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Contextualizing Our Work with Families in Varying Levels of Poverty

 

As marriage and family therapists (MFTs), we are trained to understand the context of presenting problems, issues, disorders, etc. The foundational philosophies of our field, along with a post-modern lens, frame this discussion about at-risk families and those experiencing homelessness.

MFTs can begin by making “at-risk” an antiquated term. The term at-risk seems to imply individual responsibility for poverty instead of understanding the influence of the macro- and exo-system on individual lives. It is our aim to help therapists bring these systems into their treatment of families experiencing various forms of poverty by considering access to care, building a therapeutic relationship, and meeting them where they are.


Access to care

Access to quality healthcare seems to be a universal concern. However, access to care may be even more elusive for families with varying levels of poverty. As therapists, there are three key components we can consider regarding access to care (Office of Disease Prevention and Health Promotion, 2020). First is the ability for families to use the services provided in the area of care needed, usually through insurance or financial affordability. When individuals have difficulties qualifying for adequate insurance and are unable to afford services otherwise, significant issues may go undiagnosed and untreated. This area often impacts the sustainability of care due to the high cost and limitations of the insurance coverage and expendable cash (Doherty, McDaniel, & Hepworth, 2014). Families with income levels just above the poverty line who do not qualify for free insurance may have difficulty accessing insurance considering high premiums that often change yearly. Then considering the cost of living, finding extra money to help pay for uncovered, but needed treatments, is simply not feasible.

The next component is access to a location that provides the needed healthcare. The geographical accessibility is just as important as the affordability of the care. Often, mental healthcare or quality, affordable mental healthcare is limited in particular demographic areas of the U.S., especially rural and low-income areas (Hodgkinson, Godoy, Beers, & Lewin, 2017; Murphy, Vaughn, & Berry, 2013). Families experiencing homelessness generally do not have set housing, and often live in transient housing—shelters, homes belonging to family and friends—with limited access or transportation to mental health and medical facilities, as well as other social support networks, making access to quality care problematic. Having quality providers in close proximity to the communities where these populations reside would go a long way in improving access to care. Consider an individual living in an area with limited public transportation, who also may have disabilities or young children. Traveling to the bus stop can be very challenging as well as discouraging. This concern is further exacerbated for areas where the transportation is not only limited, but non-existent. Trying to figure out how to travel 10 miles or more for treatment can be daunting. This is also problematic because those who do have coverage for transportation under Medicare or Medicaid are often unaware of this available resource (Health Research & Educational Trust, 2017).

MA20-F1 Contextualizing Homeless

The third component is the trust between the provider and the individual seeking care (van den Berk-Clark & McGuire, 2014). If individuals do not trust the provider to care for them as people, to see them beyond their circumstances, it is highly unlikely they will seek the needed treatment. Healthcare providers have been found to view families in poverty as more problematic to work with and have given excessive diagnoses (Hodgkinson et al., 2017). Families are justified in their lack of trust, considering the biases towards families experiencing poverty, coupled with the limited visibility of mental health providers in the local community. Therapists can help build trust by regularly volunteering throughout the community, or even better, opening a practice that is a part of the community.

Building a therapeutic relationship

The therapeutic relationship is the foundation of the therapeutic process. It is formed by the therapist and the client being open and truthful not only during the building phase but throughout the therapeutic process (Noyce & Simpson, 2018). The relationship is free of judgment regardless of social class characterization. A client must trust the therapist, feel confident the therapist can provide therapeutic services without bias, and that the therapist is competent with the uniqueness of the concerns that brought the client to therapy. The therapist who makes an effort to understand the client regardless of social class encourages the therapist-client bond resulting in the client trusting the therapist to provide competent services (Trott & Reeves, 2018).

Our potential biases or classism can influence the therapeutic process. When the client believes the therapist can effectively provide therapeutic services regardless of social class, the client is more likely to feel accepted and accepting of the therapeutic relationship (Trott & Reeves, 2018). It has been my (YW) experience that clients respect and are more likely to invest themselves in the therapeutic process if they feel the therapist is invested in their mental well-being without judgment of their economic status. The client, regardless of economic status, deserves therapeutic services that will lead to mental wellness. It is the responsibility of the therapist to begin building the therapeutic relationship by making the client comfortable and expressing empathy and care. The therapist can begin the therapeutic bond process by allowing the client to narrate her or his story, while showing the client the story matters. The therapist can then begin to help the client own that story while helping rewrite it for the road to healing.

Meeting them where they are

It is hard to treat someone who feels misunderstood and ostracized, especially if professionals are disconnected and aloof to the existing problems. Treating those who are impacted by homelessness and are considered at-risk families requires flexibility and open-mindedness (Institute of Medicine, 1988). These populations deserve respect, and to have providers be aware of their unique needs and limitations. Poverty, along with homelessness, can and most likely may increase chances of having learning disabilities at two times the rate; and behavioral and emotional issues may be three times more likely than those living in their own homes, especially with the children (Council on Community Pediatrics, 2013).

Understanding context and the complex stressors that families experiencing poverty face will go a long way in meeting them where they are and ensuring that they do not feel alone in that space. For example, when treating a single mother with two young children with ADHD, the therapist may want to help the client find affordable childcare and be willing to see her with the children in session. For client’s experiencing homeless, therapists can provide a list of venues that provide access to showers and potentially have extra clothes available. It is vital to be aware that their need will likely extend beyond just their mental health treatment.

While having a profitable business is important, it cannot supersede caring for people and ensuring they get the help they need. When therapists are working with families experiencing varying levels of poverty, they should consider how the lack of resources can exacerbate presenting problems. It also may be helpful to consult with social workers to ensure families’ basic needs are met and they have access to resources that are available to them. Therapists can assist families with varying levels of poverty by being present in low-income areas, being willing to provide pro bono care, and being an advocate for those who cannot advocate for themselves.

Families are justified in their lack of trust, considering the biases towards families experiencing poverty, coupled with the limited visibility of mental health providers in the local community.

DeAnna Harris-McKoy

DeAnna Harris-McKoy, PhD, LMFT-S , is a Clinical Fellow of AAMFT, an associate professor at Texas A&M University Central Texas, and a couple and family therapist in private practice. She is also an AAMFT Approved Supervisor and an alumna of the Minority Fellowship Program.

Yulonda Washington

Yulonda D. Washington, MS, MFT , is a Licensed Professional Counselor with a private practice in Killeen, TX, It’s A Journey Counseling. Washington is a Student member of AAMFT.

Latisha Wilson

Latisha D. Wilson, MS, MFT , is a Licensed Professional Counselor and LMFT-Associate with a private practice in Killeen, TX, Narrations of Life Counseling Services, LLC. Wilson is a Student member of AAMFT.


REFERENCES

Council on Community Pediatrics. (2013). Providing care for children and adolescents facing homelessness and housing insecurity. American Academy of Pediatrics, 1206-1210. doi: 10.1542/peds.2013-064

Doherty, W. J., McDaniel, S. H., & Hepworth, J. (2014). Contributions of medical family therapy to the changing healthcare system. Family Process, 53(3), 529-543. doi: 10.1111/famp.12092

Health Research & Educational Trust. (2017). Social determinants of health series: Transportation and the role of hospitals. Chicago, IL: Author.

Hodgkinson, S., Godoy, L., Beers, L. S., & Lewin, A. (2017). Improving mental health access for low-income children and families in primary care setting. Pediatrics, 139, 1, 1-9. doi: 10.1542/peds.2015-1175.

Institute of Medicine. (1988). Homelessness, health, and human needs. Washington, DC: National Academies Press.

Murphy, D., Vaughn, B., & Barry, M. (2013). Adolescent health highlight: Access to mental health care (Publication # 2013-2). Retrieved from https://www.childtrends.org/wp-content/uploads/2013/04/Child_Trends-2013_01_01_AHH_MHAccessl.pdf

Noyce, R., & Simpson, J. (2018). The experience of forming a therapeutic relationship from the client’s perspective: A Metasynthesis. Psychotherapy Research: Journal of The Society For Psychotherapy Research, 28(2), 281-296.

Office of Disease Prevention and Health Promotion. (2020). Access to health services. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services#1

Trott, A., & Reeves, A. (2018). Social class and the therapeutic relationship: The perspective of therapists as clients. A qualitative study using a questionnaire survey. Counselling & Psychotherapy Research, 18(2), 166-177.

van den Berk-Clark, & McGuire, J.(2014). Trust in health care providers: factors predicting trust among homeless veterans over time. Journal of Health Care for the Poor and Underserved, 25(3), 1278-1290. https://doi.org/10.1353/hpu.2014.0115

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