TABLE 3.

Providers’ perceptions of impacts of disadvantage and cultural difference on client outcomes

Category	Quotation
Impact of structural and socioeconomic disadvantage	Example 1: “[Poverty] impacts clients and families dramatically. The clients who do not have to worry about anything related to finances at all solely have the ability to focus on their recovery without having to make decisions about prioritizing time to do one thing over another.” Example 2: “Socioeconomic disadvantage impacts the people in our programs as it creates a constant state of instability. . . . When one’s focus is on securing the basic things they need to live, they are not able to focus on other things that are important along the recovery journey. It also refocuses the goals that arise during meetings with professionals from counseling to process or work through their experience, to more case management to address tangible or pressing matters.”
Impact of cultural, racial, and ethnic differences	Example 1: “Some individuals of various religious beliefs do not align with the medical model of treatment and are at times resistant to interventions.” Example 2: “I have witnessed that my clients of Asian descent do not generally have families that agree with their taking medication for psychosis or accept the diagnosis of schizophrenia spectrum disorders, nor do they tend to participate in the clients’ treatment.”
Influence of structural and socioeconomic disadvantages on disengagement	Example 1: “It seemed to me that the people who were most likely to disengage from the program were those facing serious, immediate risk related to socioeconomic factors (i.e., housing, poverty). I believe this was related to the fact that they saw the program as more focused on wanting them to ‘engage in treatment’ as defined by the program rather than meeting practical needs related to housing and money.” Example 2: “From my experience . . . there is no question that the degree of socioeconomic disadvantage experienced by clients has a strong impact on the likelihood that they will maintain a relationship with the program.”
Influence of race, ethnicity, and culture on disengagement	Example 1: “I think that [disengagement is higher for] African American clients and families, for so many reasons. Historical oppression at the hands of government and ‘treatment’ centers, lack of providers that are from the community, lack of treatment modalities that are tooled specifically for communities of color . . . almost too many reasons to list.” Example 2: “The main migrant populations . . . are Micronesian and Filipino. The Micronesian migrants suffer particularly from marginalization. . . . It’s my impression that we don’t even see many of these people because there are many barriers to engaging with treatment (lack of knowledge of health systems, lack of resources, differing cultural conceptualizations of psychosis).”
Intersectional impact of disadvantage and minority racial and cultural backgrounds	Example 1: “With migrants . . . we do not have a good enough understanding of their cultures, preferences, way of life, values . . . and they feel the disconnection because they are a visible minority [group]. They have this added stress. For our indigenous peoples that have left the reserves, they have often left situations of poverty, abuse, substance abuse and are trying to build a happy life, but they also feel that disconnection, not always having the possibility to live ‘their culture and traditions.’” Example 2: “Race and minority status are discussed in many stories in the news, and [clients] are talking about the discrimination they have faced. Similar to these civil rights issues are the civil rights issues related to mental health, and many of our clients are treated as second-class citizens. Having more than one minority status or something that can marginalize someone is a huge stressor and likely affects how much individuals engage in services/connect to others/feel understood.” Example 3: “SES [socioeconomic status] has a huge impact on our clients . . . and intersects with cultural factors, such as distrust of White, mainland interventions and institutions, which is rationally based on a long history of being mistreated by these institutions.”