(p. 98) Bringing Psychotherapy to People Living in Poverty
People living in poverty continue to be invisible to society, to mental health training and practice, and to diversity initiatives. Researchers and practitioners, albeit small in numbers, have offered a wealth of information about people in poverty who either don’t receive psychological services or prematurely terminate. Our understanding of why and how this phenomenon of chronic poverty persists is explained in this chapter. Early stereotypical beliefs about people with lower socioeconomic status (SES) have had a devastating and enduring impact on attitudes toward the poor and view of their “suitability” for mental health services. For example, some common stereotypes are that (a) poor people are hard to empathize with, (b) do not permit appropriate therapeutic procedures, (c) insist exclusively on symptom relief, (d) use unbearably crude language, and (e) are apathetic with regard to treatment (Auld & Myers, 1954). “They are “extrospective . . . relatively unimaginative . . . and have lower estimated intelligence” than their middle- to upper-income counterparts (Brill & Storrow, 1960, p. 343).
Yet, as noted by Lorion (1974), there is no evidence that lower-SES individuals are less able to engage in psychotherapy than any other demographic group, and presumptions to the contrary reflect “therapists’ negative bias” (p. 345). Mental health professionals, by virtue of their education and training, may hold privileged worldviews and inadvertently work in an ineffective and oppressive manner with lower-SES individuals (Sue & Sue, 2015). However, “there is ample reason to suspect that people living in poverty stand to benefit from mental health services that are tailored to their experiences and are implemented by clinicians who have been trained to deliver them effectively” (Smith, Li, Dykema, Hamlet, & Shellman, 2013, p. 139).
While some significant changes have occurred since the earlier statements cited above were made, much work remains to be done. Lower SES has been given a place in the list of diversity variables (e.g., culture, language, gender, sexual orientation) but not a place at the table. Many who live in poverty report, through their narratives, the same experiences reported 40 years ago.
(p. 99) This chapter will discuss the invisibility of poverty and the efforts being made to uncloak this elusive problem for the mental health professions. A critical element in removing barriers is the development of cultural competence, specifically class competence. Over recent years, the mental health professions have committed to a transformational level of consciousness raising, standards of training, and reflective practice in correcting longstanding violations of equity, respect, and dignity for all persons with whom we work. It is time for classism to be recognized among the other “isms” on which we are focused. The definitions of classism, poverty, and the poor are offered to provide a shared context for the reader in understanding the frame of reference and worldview that is applicable to this population, those who work with the population, and treatments of choice:
Classism is a form of oppression, which is prejudice plus power. Classism is an intricate system that rests on domination and control of social ideology, institutions, and resources with the intended outcome of privilege for one group and the disenfranchisement of the other (Hardiman & Jackson, 2016).
Poverty is “a human condition characterized by sustained or chronic deprivation of the resources, capabilities, choices, security and power necessary for the enjoyment of an adequate standard of living and other civil, cultural, economic, political, and social rights” (UN Economic and Social Council, 2001, p. 2). Descriptors of those who live in poverty include low income, lower class, low SES, poor, economically poor, working poor, and disadvantaged (Smith, 2005).
The poor are people who have been poor all their lives, whose parents were poor, and who have a high probability of remaining poor. It is thus a social, as well as an economic, condition. This definition of “poor” does not have sharp boundaries but includes the unemployed, partially unemployed, and the lower-income members of the working class (Karon & VandenBos, 1977, p. 169).
The Scope and Description of the Problem
Prevalence of Poverty in the United States
The rate of individuals living in poverty in the United States is 13.4% (39.7 million) (U.S. Census Bureau, 2018). Poverty is particularly prevalent among people of color, who already suffer from structural and institutional discrimination. The poverty rate for Whites is 9%, whereas it is 24% for Blacks, 21% for Latinx, and (p. 100) 11% for those of Asian descent. More women than men live in poverty (14% vs. 10%), and the rate of children living in poverty is 19.7%, the second highest in the world. Almost one third (31%) of families with a female head of household live below the poverty line (National Center for Law and Economic Justice, 2014). The poverty level is the metric used by the federal government to determine who is eligible for subsidies, programs, and benefits. The poverty guidelines are updated every January to factor in inflation. In 2018, the official poverty rate in the United States was $12,400 for an individual and $25,100 for a family of four (Fox, 2018).
The functional impact of poverty on marginalized and disadvantaged individuals is staggering. People living in poverty live shorter lives. The life expectancy between the wealthiest 1% and the poorest 1% is 14.6 years, and this percentage has increased over the last 15 years (Chetty et al., 2016).
Poverty and Mental Health Status
Research has demonstrated that those in lower socioeconomic levels have diminished psychological well-being and higher rates of anxiety, depression, and substance abuse than middle-class individuals. The experience of chronic and uncontrollable life events creates a context of stress that is cumulative. Due to increased risk of social determinants of poor health and adverse childhood experiences, individuals living in poverty may be exposed to additionally detrimental levels of stress and adversity, potentially putting them at risk for poor health throughout their lives. Common stressors include inability to meet basic needs, food insecurity, unstable housing, poor transportation availability, obstacles in accessing benefits (e.g., applying for food stamps, Medicaid, job applications), potentially high levels of stress and conflict in the home, and being stigmatized. People in poverty are affected by lack of community resources, lower quality of and access to education, higher crime rates, and greater distance to grocery and supply stores. These multiple complex stressors can adversely impact their ability to work, ability to advance in education, stability in the home, and ability to parent effectively, thereby creating a bidirectional downward spiral that makes high-quality mental health services a necessity. Despite the knowledge that mental health problems most often originate through the stressors of poverty, the mental health professions have done little to develop treatments that are tailored to the poor, resulting in ineffective outcomes and discouragement for clients.
Utilization and Outcomes
People living in poverty are less likely to seek or receive mental health services (Goodman, Smyth, & Banyard, 2010). Stereotypes of the poor (e.g., lack of (p. 101) motivation, intellectual limitations, undependability, assumed responsibility for life issues) persist, and discrepancies between mental health needs, services offered, and lack of preparation by clinicians result in much lower utilization than is needed (Smith, 2005). Patients of lower SES have higher attrition rates and lower improvement rates in psychotherapy than higher-SES clients. Relevant contributing factors may include (a) conventional psychotherapy approaches do not address the needs of those in poverty and (b) biases resulting in distancing (e.g., devaluing, discounting) interfere with psychotherapy (Goodman et al., 2010). The result is underutilization and inadequate mental health services for low-SES individuals.
Research on the psychological effects of poverty suggest that the basic needs categorized as practical/logistical barriers are most frequently noted and are certainly important to survival; however, psychosocial needs are as important for people in poverty as for higher-SES populations. These factors cluster into the following categories (Smith, 2010).
The inability to provide for oneself and one’s family creates an ongoing chronic level of stress. People in poverty may be routinely overwhelmed by stress related to difficulties attaining or maintaining daily needs to sustain life for themselves and their loved ones. Time and resources are often exhausted by daily demands for survival and sustainability. Patients in this type of strenuous situation may not have the ability to consider or prioritize mental health treatment, despite their interest, desire, or motivation to do so. These stressors lead to ongoing negative affective states such as hopelessness, anger, and fear, and responses such as chronic vigilance given community violence, attributions of negative intent, and isolation (Chen & Matthews, 2003). Bureaucratic systems introduce obstacles and complexities that often pose hurdles too high to jump, such as applications for food stamps or housing, the SNAP program, and unemployment procedures. These power imbalances are often not acknowledged by authority figures but are keenly evident to those whose lives can be manipulated by powerful others. These imbalances can lead to feelings of disempowerment, alienation, hopelessness, and helplessness.
Social Isolation and Social Exclusion
Paradoxically, even in urban areas, people living in poverty can feel distanced and isolated and can experience an absence of the social connection that is a (p. 102) major element in protection against stress and serves as a predictor of emotional well-being. Views of the poor often attribute poverty to personal deficits and negative traits such as being unmotivated and lazy (Kunstman, Plant, & Deska, 2016). Poor people of color are doubly stigmatized with stereotypes of classism and racism through pejoratives such as violent, immoral, and abusive. Negative attitudes prevail toward people of all ethnicities regarding public assistance (Cozzarelli, Wilkinson, & Tagler, 2001). In essence, attitudes about the poor continue to suggest that the poor are inferior to others (Lott & Bullock, 2007). Even when low-SES individuals live in populated areas and have access to middle-class experiences, they remain isolated and excluded in the near presence of others. This dynamic occurs by the exclusion of the poor from mainstream opportunities, events, and experiences that others would take for granted and that contribute to a sense of community engagement and belonging. Some activities, such as cultural events, entertainment, and sports, are not affordable; others, such as community, school, and church events, still find low-SES individuals excluded and often invisible from being accepted as either volunteers or participants.
The inherent power imbalances between people living in poverty and authority representatives who make decisions about them represent ongoing sources of stress and are often traumatic when individuals are blamed, shamed, or abused for being poor (e.g., fear that the wrong answer will result in loss of housing, children, or access to food) (Pajak, Ahmad, Jenney, Fisher, & Chan, 2014). These experiences over time can become internalized as part of one’s identity, further disempowering and contributing to mental health difficulties (Goodman, Pugach, Skolnik, & Smith, 2013). Patients’ sense of powerlessness can lead to a sense of alienation, distrust, and distancing from professionals and can compromise engagement and rapport in psychotherapy. As Thompson, Cole, and Nitzarim (2012) noted in a participant interview, “There is a huge stigma out there . . . You must be poor for a reason because that’s a punishment for a crime you didn’t even commit. . . . If you’re down and out, you’re already thinking that the world hates you because for whatever reason you worked hard enough, but you still didn’t make it” (p. 215). Thompson et al. further report a participant stating, “You have to cater to them [therapists] and jump over their hoops because their analysis can mean taking away your kids, stopping or starting Social Security, and other stuff” (p. 215).
Interpersonal and cognitive distancing from the poor (Lott & Bullock, 2007) has, to a significant extent, become ingrained in our professional (p. 103) treatment of those in poverty, which may represent overt classist attitudes or may be inadvertent avoidance of seemingly despairing and entrenched individuals. This phenomenon is thought to occur because, unlike many other diversity variables that have positive attributes, no one wants to be poor, not those who were poor at one time nor those who have never been poor. People tend to avoid those who have what is stereotyped to have no positive attributes. As a result, interpersonal distancing from any social or civic association occurs and cognitive distancing results in not aligning with frame of reference or attempts at empathy. If we listen with respect to the voices of the poor, as we do in service to middle-class clients, we can break the silence of poverty in the treatment room and thereby “meet the clients where they are,” which is our empathic goal with all other clients.
Barriers to Service Delivery
Logistical or practical barriers are often the default explanation given as the reason why people living in poverty do not seek mental health services. Very little attention is given to the questions of why there are few if any mental health awareness programs publicly announced for this population, and why few public health efforts are made to increase health education and decrease health disparity for people living in poverty. Awareness of the other equally impactful and harmful barriers to mental health services within the research and practice communities has not been well developed. The research on non-logistical barriers is sparse; however, qualitative researchers in particular have identified variables that can be clustered and defined as the following.
Cost of treatment is a barrier for individuals who may not be able to pay or who may be embarrassed to have the financial conversation about ability to pay. Transportation may be unavailable or unreliable (e.g., limited access to reliable vehicles or gas/bus money). Patients without reliable transportation often rely on family or neighbors to take them to appointments. This reliance on others to access care often leads to no shows or an inability to plan for and adhere to regular follow-up treatment. Childcare is tenuous and often means asking favors of others, for which individuals may or may not be able to reciprocate. Poor individuals often have low-wage jobs that entail changing shifts; this makes planning for (p. 104) appointments difficult, and taking time off work can place their job in jeopardy; poor people may have no personal time for appointments; they may have to deal with other inflexible conditions; and they are likely to be challenged by the cost and time involved in public transportation (Beeber et al., 2007). People in poverty may have difficulty adhering to treatment recommendations that require financial expense and or may struggle to follow recommendations to engage in behavioral activation due to inability to afford activities or access transportation to leave the home. As noted, other barriers are critically important to access of care; however, practice barriers must be resolved or at least recognized before other barriers can be addressed.
Even if individuals in poverty can access psychotherapy services, they may still be faced with barriers that prohibit them from following through on the prescribed treatment plan. For example, a typical intervention like behavioral activation may include the encouragement of pleasurable activities. However, patients in poverty may not have the financial means to support that recommendation or treatment goal. Similarly, patients with chronic illnesses, such as diabetes, are often encouraged by a behavioral health provider to purchase healthier foods such as fresh fruits, vegetables, and lean protein. However, individuals in poverty may be living in areas where fresh food is scarce and may rely on gas stations or convenience stores as their food source. These patients are likely unable to go to the store frequently enough to purchase fresh foods and may not be able to afford those foods at all, so they buy less expensive, less healthy processed foods that are typically high in sugar, salt, and carbohydrates. This inability to access healthier food options prevents these patients from adhering to medical recommendations that promote health and wellness. Patients in poverty may be unable to follow through on a therapist’s recommendation to increase exercise, as they may not live in an area where it is safe to walk outside or may not be able to afford or access a gym. They may not have access to the internet, a television, or a computer on which to watch exercise videos.
The stigma of mental health treatment is held by many in lower-SES positions based on family bias, cultural beliefs, societal stereotyping, and self-blaming/criticism. Ethnic minorities may be suspicious of treatment given historical exploitation and persecution. People in poverty may fear that their pursuit of services could jeopardize their parental status in that saying “the wrong thing” to a psychotherapist can result in their children being taken away, their disability being questioned, and their access to resources (e.g., food stamps, Medicaid) being brought under examination beyond their control (Copeland & Snyder, 2011).
(p. 105) Social and Psychological Barriers
Low-income people primarily hold jobs in which authority figures (e.g., managers, supervisors) oversee their work and have considerable control over their work conditions. People living in poverty have experienced so many negative encounters and dismissive treatment that any interaction with those with authority and power in decision-making positions can engender fear, anxiety, and a filtering of information. Given that psychotherapists are viewed as authority figures, it is understandable that clients would anticipate negative consequences and the possibility of demeaning attitudes, devaluation, and inability to empathize.
The mental health field has consistently misplaced the rationale for lower participation, as well as lower successful outcome rates, for lower-SES individuals on stereotype bias by psychotherapists and/or actual barriers of clients and has neglected the role of psychotherapists. “Modalities of care suggested as appropriate for the lower classes may turn out to be inadvertent discrimination in disguise” (Siassi & Messer, 1976, p. 32). Although alternatives to conventional therapeutic interventions are, in fact, suggested, the recommendations for “shortcuts” and brief services is not the adaptation needed to serve the poor.
Occupation and education are among the most defining characteristics of class. Mental health professionals have attained the status of middle or upper middle class by virtue of education, even if they began their lives in working-class or poor families. Psychotherapists can fall prey to implicit bias or to overt classism, communicating distance and devaluation to patients (Appio, Chambers, & Mao, 2013; Smith, 2005). “Psychotherapists’ willingness and ability to work with the poor is compromised by persistent, unexamined classist attitudes” (Smith, 2005, p. 687). As Sue and Lam (2011) emphasize, “Despite the important influence of socioeconomic status on an individual’s life, this variable has been widely ignored. It seems that there are still biases and stereotypes that psychologists have with regard to this population” (p. 414).
People who live in poverty are keenly aware of the factors that separate them from others around them, such as clothing, jewelry, vocabulary, and the décor and furnishings displayed in the office. Appio et al. (2012) cite examples taken from participant narratives. One participant noted that even though she and her psychotherapist “got along,” she could not help but notice that all of the books on the shelves were “way over my head.” Another client noted that her counselor (p. 106) had pictures of her vacations all over the office and pictures of her playing tennis. These symbols communicated to this client that they lived in two different worlds. The participant reported, “I like vacations, too, but I will never be able to go on one.”
These examples can be reasonably attributed to implicit bias; however, psychotherapists also have expressed overt classism through beliefs that the poor as a group are disorganized; they aren’t motivated (as evidenced by not being prompt for appointments, for example); or they are cognitively limited and not able to fully participate (Appio et al., 2013). The failure to recognize the contextual and environmental barriers of the poor perpetuates a trait rather than state causal view of the problem, thereby creating additional barriers to treatment. The inherent privilege of the psychotherapist, contrasted with that of a lower-SES patient, is not typically acknowledged, discussed, or utilized as part of the therapeutic situation or relationship; however, this factor often acts as a treatment barrier.
Adherence to Conventional Psychotherapy and Inflexibility
Treatment outcomes are not as successful for lower-SES clients as others principally because of the aforementioned barriers. But when treatment plans are adapted for the context and the barriers of people living in poverty, significant improvements in retention rates as well as symptomatology are evidenced (Grote, Zuckoff, Swartz, Bledsoe, & Geibel, 2009). The adherence to conventional psychotherapy precludes meeting after business hours, accommodating walk-in appointments, meeting elsewhere than the office, allowing children in the office, eliminating no-show and cancellation policies, and assisting in making calls to agencies regarding resources and benefits. These are activities that are not typically viewed as within the scope of practice of mental health professionals but are key elements in the access of mental health services for the poor (Goodman et al., 2013).
The failure to initiate and then allow an ongoing discussion about class has the same deleterious effect as the failure to bring into psychotherapy ethnic, cultural, gender, or other diversity variables that could impact psychotherapy. Clients rely on the knowledge and skills of the clinician and think that if social class is not at least recognized, then the psychotherapist is either biased, unknowledgeable, and potentially ineffective; is distancing from the client; or is unable to align and empathize with the patient. Avoidance of open discussions about class differences also heightens the anxiety of clients, for fear of judgment engendering shame and humiliation over their plight (Appio et al., 2013). Paradoxically, psychotherapists may fear drawing attention to social class as though if they don’t speak about it, the clients won’t notice the contrast.
(p. 107) Competency
Multicultural competence is now a mainstay of graduate education and a standard requirement for accreditation. Poverty and class, however, have yet to be included in curriculum requirements and clinical training for most doctoral programs (Stabb & Reimers, 2013). Class competency should not be confused with the classism heretofore described. Competency is measured by knowledge, skills, and attitudes (i.e., interpersonal competence) that are learned through didactic education and supervised experience while in training and through consultation, continuing education, and professional development as a practicing mental health professional. Incompetency is not characterized by prejudice, bias, and discrimination that is inherent in classism; however, incompetency can also be damaging to clients when the contextual understanding necessary to be effective in working with people in poverty is not a mastered skill.
Despite years of multicultural research, practice innovations, and inclusion in the training and accreditation of graduate programs, the factors of conventional treatment applicability, classism, and the stereotypical attributions and bias against people living in poverty have not been investigated in any meaningful way (Smith et al., 2013).
Local, state, and national governmental agencies as well as other nonprofit and nongovernmental systems (e.g., hospitals, health clinics, educational systems) are central to the basic needs and availability of resources for people living in poverty. These entities have extraordinary decision-making authority and control over the lives of the poor. These power imbalances, coupled with the survival need to be compliant with these systems, are primary stressors. In addition, the pursuit of these resources can be extraordinarily difficult: (a) clients may not understand the system, (b) the multistep process in applying for food stamps requires a set of appointments, (c) applying for subsidized housing can take several years, and (d) just finding the entitlements for which one is eligible can be challenging. These are just a few examples of the impact of the power imbalance (Pajak et al., 2014). Medical and mental health services rarely have sufficient bilingual and ethnic minority psychotherapists. Often professional as well as support staff who lack training in working with low-income individuals aren’t aware of relevant barriers to compliance and are unaware of the community resources available, which then often go underutilized (Green, Kaltman, Frank, Glennie, Subramanian, & Fritts-Wilson, 2011).
When individuals are already economically disadvantaged, they can experience uniquely complicated hardship following challenging events like (p. 108) community-based or natural disasters, exacerbating their preexisting adversity. This population has an increased chance of living in subpar housing or in homes that have become devalued due to the financial inability to maintain and restore them. When a disaster occurs at a magnitude where homes and other buildings are damaged or destroyed, people in poverty struggle significantly when disaster recovery funds are awarded based on the pre-disaster value of one’s destroyed assets. These families are required to downsize and move into homes or alternative living that is supported by their low recovery funds.
Creating Cultural Competency
Awareness and knowledge of classism are foundational components of multiculturally competent practice (Zalaquett & Chambers, 2017). Cultural competency, as has been noted here, is an essential component in training and professional practice standards of care. More typically a competency section would include several diversity variables; however, competence in this chapter will focus on class and socioeconomic competence. As has been noted, class has not been reliably embedded in diversity training and has not been a focus of continued skill development in standards of practice, and research in this area has not advanced significantly beyond what has been known for 25 years. Further, institutional practice has not incorporated training or practice policies for wide dissemination throughout the profession. As a result of these deficits in training and practice preparation to work with this population, attaining a level of cultural competence often falls on individual psychotherapists to pursue. An organized developmental approach to cultural competence for practitioners who did not receive such training is an imperative for continuing education and professional development offerings. Actions that can promote cultural competence for individual practitioners are identified below.
Self-Awareness and Personal Beliefs
Practitioners should engage in self-reflection regarding their own experiences with low-SES individuals related to their own social class, noting their emotional and psychological reactions. They should endeavor to identify the occasions in which they interact with low-SES individuals, the quality of those interactions, and any stereotypical beliefs that emerge. They may believe that (a) people living in poverty have too many basic life problems to focus on mental health needs; (b) given their other problems, the practitioner cannot even make a dent in their situation; (c) mental illness is an expected life condition for these individuals (p. 109) (Smith et al., 2013); and (d) in some way, poverty is the fault of the individuals living in those conditions, and they must help themselves first (Liu, 2012).
Peer consultation, particularly group supervision, enables practitioners to go beyond their own self-reflective assessment of their cultural competence. Implicit bias is the influence of stereotyped and biased attitudes and beliefs outside of our conscious awareness or knowledge and is much more nuanced than overt classism. Peer consultation regarding the treatment of low-SES clients gives practitioners the opportunity to explore their awareness, treatment choices, the clinical relationship, and other case dynamics in an open and supportive environment.
Introduction of Class into the Psychotherapy Session
Intuitively, practitioners may not address the subject of class if clients do not include the topic in working issues for psychotherapy. They may perceive that clients aren’t aware of class differences, that drawing attention to class might make the client uncomfortable, or that psychotherapists themselves will be uncomfortable. Practitioners should know that if they notice a class difference clients surely will, and furthermore will likely be uncertain about how to express their observations. Practitioners may introduce the topic through immediacy and the here and now of the session just as they would other session variables that are obvious but unrecognized (Smith, 2005). Experiential psychotherapists might call this action “making overt the covert.” Practitioners would explore how clients feel about any perceived differences, how they think these differences could affect their psychotherapy, and what the psychotherapist can do to respect and respond to class factors.
The psychotherapy relationship is a central component in effective treatment and outcome across modalities, diagnostic classifications, and client and psychotherapist variables. Formation of a working alliance is particularly valuable with low-SES clients given their skepticism about services, self-doubts, and anticipation of emotional barriers. Development of collaboration that conveys equality and promotes trust encourages disclosures that might otherwise be seen as too (p. 110) risky (Appio et al., 2013). Attention to social class cues is a skill that can significantly advance cultural competence awareness and enhance the working alliance (Thompson et al., 2012). Just like other basic psychotherapy skills such as attending to nonverbal cues of clients and clinicians, practitioners should be alert to social class cues exhibited by clients and those that can be interpreted by clients as defining characteristics of the clinician. Social class cues from clients can include nuanced expressions of anxiety, self-consciousness, uncertainty, or embarrassment about transportation or tardiness, or a restricted range of conversation topics. Social class cue interpretations by clients of their clinicians, as noted previously, can include the décor of the office, personal photos, jewelry, conversation about free time or travel, and vocabulary. Psychotherapists’ professional surroundings typically reflect their educational and professional status. These same symbols of comfort and validation to psychotherapists can signify class privilege and “not belonging” to the poor. Psychotherapists who become aware of these inadvertent messages can begin to have authentic conversations with clients about their perceptions and how these may affect their willingness to accept services.
Advocacy has not been viewed as part of conventionally delivered psychotherapy. However, qualitative studies have demonstrated that taking an advocacy stance significantly enhances the psychotherapy experience for low-SES individuals. An advocacy stance may include strategies that support and train clients to effectively represent and assert their needs, navigate the systems around them, utilize resources, and promote community engagement. Examples of advocacy engagement include teaching life skills (e.g., assertiveness, insurance coverage negotiations), financial information (e.g., compound interest impact on loans), accessing resources (e.g., housing subsidies, Social Security Disability Income, training opportunities), and communicating directly with other health professionals (Thompson et al., 2012).
Language and Client Literacy
Practitioners will want to become familiar with colloquialisms, metaphors, and idioms that are characteristic of the regional culture of low-SES clients. For example, Appalachian people may say they feel like “a lost ball in the high weeds,” or they feel “fair to middlin’.” Psychotherapists may feel ambivalent about altering their own language use in that they don’t want to “talk down” to clients, yet it (p. 111) is important to avoid language that laypeople may not know, such as “operant conditioning,” “cognitive dissonance,” “countertransference,” or “behavioral reinforcement schedules.” In terms of literacy, the 2018 adult literacy level was determined to be an eighth-grade level of reading (U.S. Department of Health and Human Services, 2019). Practitioners often provide or recommend reading material for clients and will want to be aware of the level of difficulty both for paper documents and online recommendations. Online services are available through which materials can be evaluated for reading level.
In addition to being alert to reading literacy, practitioners will want to be aware of their clients’ health literacy, which is the ability to obtain, process, and understand health information well enough to make health-related decisions (Centers for Disease Control and Prevention, 2018). Education on how to read prescription labels, understand the importance of dosage, know what medications must be taken regularly and which should be taken as needed, how to access financial assistance for annual physical exams, and other health literacy factors should be part of health discussions with low-SES clients.
Access to Integrated Settings
When working with low-SES clients, practitioners in independent, group, integrated, or other settings can collaborate with interdisciplinary settings that would include access to social work, pharmacy, public health, and medical professionals to engage with whole-person care for their clients. Low or no-cost primary care clinics committed to serving those below the poverty line often welcome collaboration with practitioners whose clients receive medical care at these clinics. Mental health practitioners are welcomed at clinics serving low-income patients such as for conducting presentations to staff, providing pro bono services to other patients, collaborating with medical professionals, helping to improve adherence to treatment plans for patients (e.g., hepatitis C programs), and offering other behavioral health expertise that mental health practitioners bring to primary care settings. A secondary advantage of affiliation with integrated care settings is the reduction of stigma for low-income patients (Shim & Rust, 2013) in that individuals may be willing to seek primary care at an accessible and available clinic but not be willing to go to a second site for behavioral health.
Effective Strategies and Empirically-Supported Treatments
Methods and techniques that contribute to improved outcome in providing psychological services to the poor can be clustered as (a) quantitative studies (p. 112) on treatment outcome, (b) flexible evidence-based treatments, (c) qualitative studies identifying factors that make a difference to clients, and (d) recommendations for therapeutic approaches that depart from conventional psychotherapy.
Miranda et al. (2006) compared the effectiveness of cognitive behavioral therapy (CBT) versus medication in the treatment of depressed, low-income White and ethnic minority women. At a one-year follow-up, decreases in depression were found for both groups (50.9% for antidepressants and 56.9% for CBT). In a related study (Roy-Byrne et al., 2006), the effectiveness of evidence-based care across income lines was compared. Primary care patients diagnosed with panic disorder were given either CBT or pharmacotherapy, and the patient groups were divided into those living above the poverty line and those below. Initially, those living below the poverty line had much more symptom severity and comorbidity. However, reduction of symptoms was similar across the two groups, and poor individuals were just as responsive to psychotherapy as other income groups. The significance of these findings is that they further support the usefulness of psychotherapy for the poor and challenge assumptions that individuals in poverty may be less able to participate effectively and remain engaged in treatment.
Two studies examined the effects of interpersonal psychotherapy (IPT) for low-income women. The first recruited individuals with trauma histories and diagnoses of post-traumatic stress disorder (PTSD) and randomly assigned them to IPT or wait list group. At the one-year follow-up, participants in the IPT group not only demonstrated significant reductions in PTSD compared to the wait list group but also showed improved interpersonal functioning. A second study investigated the effect of IPT on women with depression. A culturally relevant version of IPT was conducted, and the participants receiving enhanced IPT-B, compared with those in enhanced usual care, demonstrated significant reductions in depression across three months and at six months showed significant improvement in social functioning (Grote et al., 2009).
Multiple studies on collaborative care treatment for depression among low-income Latino adults have been conducted. When collaborative services are engaged and patients receive medical care, medication, symptom monitoring, and relapse prevention, their depression significantly improved (Ell, et al., 2011). These and other quantitative studies demonstrate the applicability of psychotherapy to the poor, begin to dispel the longstanding stereotypes of intractability of low-income people in resistance to psychotherapy, and offer suggestions for (p. 113) interventions and culturally sensitive approaches to treatment that may yield outcomes for individuals in poverty.
Flexible, Evidence-Based Treatments
Conventional treatment interventions have not proven effective with low-SES individuals; however, evidence-based treatments that have implemented intensive outreach, transportation, flexible scheduling, convenience locations, and childcare remove many of the barriers that prevent people in poverty from a fair playing field in access to mental health services. Santiago, Kaltman, and Miranda (2013) identified the following key recommendations from their experience working with people of poverty. Flexibility in treatment schedules may vary by session given shift employment, childcare, and other barriers; flexibility should be built into the treatment plan rather than being an exception made occasionally. Tailoring treatments (e.g., flexible hours, meeting outside the office, bringing family members) to the specific needs of clients, even though it may represent a departure from standard practice, greatly contributes to overcoming the physical and logistical barriers. Substantial outreach for engagement and retention is a key element to provision of services. Many low-SES individuals are not familiar with mental health services and are not aware of the applicability or accessibility to them. Training of staff in class culture and awareness of classism changes the contextual experiences of clients coming into the therapeutic environment as well as their expectations for services. Commensurate with ongoing outreach is telephone engagement, which can be time intensive initially but has been shown (Miranda, Lawson, & Escobar, 2002) to significantly improve retention and subsequent outcome. In the same study, those who were skeptical of psychotherapy were offered an educational session that was meant to increase understanding of what psychotherapy would be like and would thereby demystify the process. All of these efforts contribute to building trust and communicating respect and transparency, which are prerequisites for successful outcomes.
Perspectives from the Poor
Given the higher dropout rate for low-income people, Pugach and Goodman (2015) studied the experiences of ten low-income women through a qualitative descriptive model. The data characterized the individuals’ responses as follows:
1. Awareness therapy was meaningful when the psychotherapist was aware of the nature of poverty and had direct exposure to poverty.
2. Practice—psychotherapy was useful when the psychotherapist was flexible, provided support, and focused on strengths rather than deficits.
3. Relational factors were important and were demonstrated by the psychotherapist listening, sharing power, and showing authenticity.
Enhancing the 50-Minute Hour
Thompson et al. (2012) examined the process of psychotherapy with low-income clients after completing six months of treatment to capture the clients’ experiences of social class in psychotherapy. The rich and insightful narratives of these interviewees illuminated several themes:
1. The psychotherapist’s ability and willingness to manage and to acknowledge social class within the room significantly shifted the balance of power and reinforced respect toward the client.
2. Social class was acknowledged as a contextual characteristic that influences the psychotherapy process. These methods include deliberate conversations regarding social class differences between psychotherapist and client.
3. Social class content was integrated into psychotherapy. Mental health treatment with people who live in poverty specifically needs to address social class-related complexities (Goodman et al., 2010).
The most important single characteristic noted by interviewees was willingness to extend the 50-minute hour in terms of flexibility, support, advocacy, and relationship building. The psychotherapist treated clients as whole persons rather than attending only to decreasing mental health symptoms. Individual acts of caring included checking up by phone between sessions (e.g., calling on the first anniversary of the death of the client’s father), expressing sympathy upon the loss of a family member, engaging in appropriate self-disclosure, giving the client small gifts symbolic of progress, informing the client of financial literacy resources or resources for reduced cost of medication, and supporting clients in filling out applications.
Some patients in poverty express appreciation for other types of flexibility in service delivery. Being rigid in no-show and lateness policies falls short of meeting these patients where they are in in their lives. Scheduling policies that allow more flexibility in absences, late attendance, and same-day work-in appointments offer the flexibility needed to support these patients, who face numerous and unexpected stressors in their daily life outside of treatment. Accessibility to individuals who are transient or experiencing homelessness is (p. 115) relevant to this population and should be integrated into the psychotherapist’s practice by developing alternate locations for sessions (e.g., arrangements with shelters, service agencies, and free or low-cost clinics for space). The level of life stress, unpredictability in daily routine, and barriers to care are significantly more complex and severe for these underserved populations and warrant extra sensitivity and consideration.
Modified Therapeutic Modalities
The Relationship-Centered Model
Goodman et al. (2007) developed the relationship-centered advocacy (RCA) model, in which mental health professionals and clients collaborate on setting goals and overcoming any barriers to achieving them. Meeting times and locations are flexible and require travel to local agencies. The psychotherapy therefore involves both psychological and systemic concerns and barriers. The RCA model entails practitioners and clients (often termed “partners” to emphasize collaboration) working together for a given number of hours per week and focusing on the immediate needs and issues of the clients. Meetings are typically at the client’s home or another preferred location. The pair work together for an agreed-upon number of weeks or months (Weintraub & Goodman, 2010). Goodman et al. offered the example that when a client felt ashamed when a store manager spoke loudly to her about items her food stamps didn’t cover, the psychotherapist could work with the client on her feelings of shame, but also collaboratively identified a way the patient could return to the store and speak to the manager about his manner to people using food stamps.
Psychotherapy must extend beyond the walls of the treatment room and beyond the focus on symptom reduction to a contextual level of awareness and advocacy. Recognition of power, who has it, and how it can be negotiated are important components of the therapeutic dialogue with lower-income clients. Reconceptualizing boundaries, selective self-disclosure, showing emotion, and other unconventional stances that are among basic tenets of feminist theory are also among the key elements of psychotherapy with people in poverty (Brown, 2009).
Relational-Cultural Therapy (RCT)
Although RCT was born out of the recognition that traditional psychotherapies did not represent women’s experiences and were often not effective with women, (p. 116) the modality has been equally applied to many groups who are marginalized by more powerful societal forces. The concept of disconnection, which is expressed in the writings of poverty as distancing, is a central dynamic in RCT. Disconnections are invalidations of those in the lower classes that give rise to shame, particularly in the presence of silence about social class (Jordan, 2010). RCT promotes awareness of power imbalances and societal and institutional systems that perpetuate oppression and link these concepts to the psychotherapy in the room. Naming and discussing client experiences and putting them in a cultural and societal context is instrumental to the tenets of RCT, feminist therapy, and effective treatment of people living in poverty.
The rise of diversity and its role in our society’s developing moral compass is relatively new. Steps forward can be viewed through the lens of training, practice, research, and settings.
Class competency is not a designated curriculum component of graduate training and with few exceptions (e.g., social work) is not taught at all. Specific didactic and clinical training experiences need to be embedded in the multicultural curriculum or taught as a separate emphasis. That is, specific course content and specific practicum experience in working with people in poverty should be clearly identified. Such curriculum should also operationalize the unique struggles of people living in poverty in urban versus rural areas. Practicum and other clinical training experiences that take place in the poor communities ensure integration of skills and healthy attitudes. Resources for Inclusion of Social Class in Psychology Curriculum (American Psychological Association, 2008) provides useful educational material, but the resources in this book do not reflect recent work. Supervision of practitioners working with people in poverty should focus on class competency, encourage awareness of and address provider privilege, and promote provider self-care and continued development in professional flexibility and patient-centered care. Supervisors also should have received formal training or continuing education, consultation, and professional development to ensure competence to supervise.
Greater attention by continuing education and professional development sponsors (e.g., American Psychological Association, National Association of Social Workers, American Counseling Association, American Association (p. 117) for Marriage and Family Therapy, and the American Psychiatric Association) to the teaching of classism, stereotyping, and prejudicial treatment is essential so that practitioners have the knowledge and skills to develop these class competencies.
Treatment research through quantitative methods continues to be vital to the area; however, increased utilization of qualitative approaches will illuminate the need for investigation into psychotherapist and client variables that impact psychotherapy usage and outcome. Effective research in the future will need to consider making the same flexibility modifications that practitioners have made (e.g., transportation, childcare, and time flexibility) if applicable and meaningful research is to be done in this area (Miranda et al., 2002). Future researchers in this area are also encouraged to study the unique experiences and treatment needs of individuals from varied levels and types of poverty and disadvantaged situations.
Successful practice with lower-SES populations will involve practitioners’ awareness of their own specific cultural identity and effort to understand the differences between themselves and their lower-SES patients.
Recognition of the importance of emotional and psychological support for mental health professionals in this work is important for the avoidance of burnout. Practitioners need access to materials and methods that promote the sustainability of this service while supporting the whole-person health and well-being of practitioners. Additionally, interprofessional alliances will promote ongoing development of clinicians while also contributing to interpersonal connectedness and the increase of the value of work with people in poverty by others.
Creative contextual and flexible mental health practices will involve becoming collaborators rather than experts with clients and require flexibility in thinking about ethical frameworks and possible reconsideration of traditional practice. Advocacy for clients on a practical clinical level and on the institutional and policy levels is important for any progress in the treatment of poor people. Advocacy on any level can be a valuable activity for providers as it allows for new challenges, learning, and diversity in professional activity and factors found to reduce burnout risk.
(p. 118) Settings and Systems
A true challenge in promoting psychotherapists’ interest in working with people living in poverty is motivation and incentive. Those who have written about, and practice with, this population are primarily motivated by values of service, compassion for the poor, and the creed “To whom much is given, much is expected.” Other than pro bono commitments, practitioners are not likely to engage with marketing and recruitment for this population. Two developments in mental health practice of recent years are changing the landscape favorably toward greater potential for services to this population.
In recent years, advocacy has become not only an accepted but an expected component of advancing mental health services. Advocacy is now a standard among many accreditation requirements, benchmark competency models, and multiple diversity guidelines. Grassroots, as well as systems, efforts to enhance Medicaid, SNAP, welfare or Temporary Assistance for Needy Families (TANF), and the Children’s Health Insurance Program (CHIP) are among the vehicles for supporting the basic needs of the poor. Such safety nets elevate the poor and bring within reach mental health services for psychological and emotional needs.
Second, integrated behavioral health care in this country has taken a transformative trajectory. Not long ago, mental health professionals faced barriers to accessing employment and integrating into medical settings and primary care facilities. For several reasons, including successful advocacy, strategic initiative, and interprofessional engagement, behavioral health is becoming a mainstay in integrated and primary care settings. Psychotherapists, as behavioral health professionals or consultants, are now part of an integrated team in which low-SES clients are seen for medical treatment, with the psychological services offered as a companion service and adjunct to medical services. This collaborative care approach opens up opportunities for clinicians that were not previously possible. In underserved rural and remote areas, rural hospitals and community health centers are more often providing integrated primary care services to patients who may have not previously had access to care in that some of these facilities treat underinsured and uninsured patients. These medical settings often provide services in a whole-patient care model by including integrated behavioral health services, resulting in improved access to mental health care for patients who would otherwise go untreated. People living in poverty in these underserved communities are now more likely to have access to much-needed treatment and resources. These clinics also may employ health care professionals such as care coordinators and patient representatives, who are trained to assist patients in overcoming barriers to care and resolving practical lifestyle and financial issues, such as housing, job insecurity, transportation, and food insecurity, and (p. 119) referring them to other resources and services (e.g., legal assistance) (Stabb & Remiers, 2013).
Training programs are beginning to affiliate with low-cost or free clinics that serve only those living under the poverty line. As an example, the first author of this chapter maintains a doctoral practicum site at a free clinic in which low-SES patients who receive medical services at the clinic are, for the first time, offered behavioral health treatment. The students and supervisors work directly with the medical staff on integrated treatment plans that greatly enhance the whole-person care of the low-SES patients.
This chapter has attempted to review the myriad problems, complex barriers, and possibilities for advancement in the welfare of those living in poverty. The invisibility of this population is profound and, once realized, cannot be forgotten. We knew 40 years ago what we know now. We only hope it is not another 40 years before we as a society, and people of conscience, will act to lift the oppression that represents the life of people in poverty.
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