Introduction
Psychologists operate within a complex array of intersecting demands from structural barriers imposed by a health care system that overlaps with ethnoracial, ethical, personal, and poverty-related factors. Poverty functions as a persistent economic experience of exclusion from access to resources required to reach the capacity to achieve a minimum quality measure of living. A gold standard for self-reflective psychologist’s includes responsiveness displayed by a keen sensitivity to cultural orientations and lived experiences. Poverty is a variable of adverse demographics that results in cascading vulnerability to psychosocial risks (Stepanikova & Oates, 2017; Chen et al., 2019). Three areas prioritized here as exemplars of self-reflective awareness and responsiveness to poverty. First, there is a review of a self-reflective practice example and culturally relevant guidance. Second, a commentary on a poverty sensitivity case highlights culturally appropriate practice. Finally, resources are recommended for cultivating awareness, knowledge, and skills for optimal care within a poverty sensitivity context.
Reflective Self-Practice and Culturally Relevant Guidance for Poverty Sensitivity
Competence is evidenced by education, training, and relevant supervised clinical experiences (Yarhouse & Johnson, 2013). Recognizing the ethical limits of competencies aligns with a self-reflective practice because it advances an instructive framework for accountability and professional growth (APA, 2017). Historically, one of the lingering challenges for the profession and individual psychologist remains how an ethos of diversity should be inculcated in practice. This means providing care that reflects sensitivity to culturally-specific factors (e.g., age, disability, gender, poverty, rurality, etc.).
To further unpack self-reflective practice, poverty sensitivity and Indigenous Americans were selected as examples of how these diversity-related matters influence professional psychology. Poverty is a multigenerational psychological reality disproportionately found in the lived experience of historically under-resourced populations (e.g., Black/Indigenous/People of Color [BIPOCs] and rural communities; Gans, 2011; Winship et al., 2021; Tickamyer et al., 2017). As a sketched personal example of self-reflective practice, the professional psychological work of the author highlights one poverty- and BIPOC-understanding journey. This includes what was learned and modified through diversity-saturated clinically supervised posts. That process witnessed an ethical integration of poverty in care as a way of enhancing the utilization and efficacy of psychological services. The journey includes 15+ years as a rural Head Start psychologist, establishing mental health clinics in under-resourced communities, juried scholarly activities, serving as executive director of an annual national health conference devoted to Indigenous Americans, and now working with highly diverse immigrant patient populations in a rural medical setting. Reflections revealed how these experiences shaped social justice-based practice viewpoints (e.g. advocacy, empathy capacity, culturally-appropriate care to reduce disparities, and fairness) on poverty.
Another self-reflective observation on understanding was an explicitly biased assumption. That is, a belief that most health care providers are attuned to cross-cultural constructs in common use, prevalence rates, motives, or able to articulate how poverty impacts BIPOCs and rural communities as a disparate diversity factor (Heard-Garris, 2021; Sue, 2019; Tickamyer et al., 2017).
Culturally Relevant Guidance on Poverty for Professional Psychologists
Over 38 million people in the United States meet criteria for poverty; the Supplemental Poverty Measure also found the highest rate of childhood poverty of most industrialized nations (United States Census Bureau, 2022). A historical analysis reveals poverty functions as an aggregated or destabilizing stressful diversity factor. Poverty is an unevenly shared complex state or an inadequate living condition that is resistant to mitigation as a sociodemographic variable. Poverty affects BIPOC populations inequitably in rural and urban communities. These groups share an intersecting characteristic of disparity evidenced by restricted access to healthcare that translates into poor health outcomes. For example, compared to other underrepresented groups, Indigenous Americans continue to be one of the most underserved populations. About 27% of Indigenous Americans live in poverty, and more than 40% reside in rural communities (Ehrenpreis & Ehrenpreis, 2022; US Census Bureau, 2022). Comparatively, Indigenous Americans have a higher prevalence of chronic medical conditions. Poverty exposure is a practice certainty for a psychologist in a university-based family medicine department strategically located in a catchment area that draws a blend of immigrant, Indigenous American, rural, and urban patients. Unsurprisingly, a rural psychologist scarcity compounds pre-existing healthcare access barriers for these populations (Andrilla et al., 2018).
Poverty complicates mental health and other medical issues that must be immediately addressed for long-term beneficence of patients (Soobader & LeClere 1999; Knifton & Inglis, 2020). The APA World Poverty Day statements echo concerns outlined here and health provider insensitivity (e.g., reduced empathy and cognitive dissonance from people experiencing poverty). For psychologists, APA has stated positions on working to address poverty and seeking to protect access to mental health care for low-income individuals. These aspirational diversity-related statements are well-intentioned as providers strive to make unbiased and culturally-informed practice decisions. Even so, Chatlani (2023) reports that almost two-thirds of psychologists have seldom treated low-income people, much less assisted those confronting housing instability reflected in the estimated 600,000 people who are unhoused. Developing cultural competencies requires a poverty-relevant self-assessment. APA (2023) reported that psychologists are less likely to “work with low income and economically marginalized patients (LIEM), come from affluent backgrounds, and do not consider expanding their services outside their own socioeconomic level.” These provider compensation circumstances translate into patient panels with more attractive insurance coverage or patients who can self-pay for services. Unfortunately, such health service reimbursement options are not widely available for those living in poverty.
There are also vulnerabilities to unshakeable, biased-based, or fixed health provider beliefs that coincide with an overuse of heuristics. Any provider’s negative stereotypes about impoverished people can have an unwanted impact on the quality of care delivered (Liu et al, 2007; Smith 2005;2009). These provider issues have resulted in less attunement to the mitigating role psychologists might assume in appropriately addressing issues fueled by poverty (Arpey et al., 2017; Shah & Oppenheimer, 2008; Yager et al., 2021). Even with telehealth options, psychologists are not geographically positioned to readily engage low-income people. Moreover, telehealth is fraught with other logistical-related problems (e.g., low technological literacy, poor internet connections, and patients lack access to required technology). Still, from a practice standpoint, the case example provided underscores the roles CEUs, understanding barriers like socioeconomic circumstances to care for low-income patients, and heightened awareness of self are of critical importance when it comes to increasing poverty sensitivity.
Case Vignette
Donald, a 67-year-old presented with a downward trajectory earmarked by vulnerability. His life course included a person with an alcohol use disorder, persistently unhoused, born down the socioeconomic ladder, long-term low-grade depression, and chronic medical problems. As a child, he recalled always being hungry, sleeping in shelters, and “sickly, but I could never see a doctor.” School was an uneven experience, but his non-verbal intelligence was in the high average range. Academically he reported, “I did the school stuff when I could attend, but I was so unhappy. I just wanted to be left alone. Everyone thought they could help me, but I never trusted anyone.” At the age of 10 a friend of his grandmother who suffered from schizophrenia began sexually abusing him. In ninth grade, he started to withdraw. The patient reported, “I thought there was no reason to go on,” though he denied homicidal or suicidal behaviors.
Although he identified as BIPOC, he was biracial (Choctaw and African American) and once lived on a reservation. He was the product of a rape from a mother who earned a living through compensation from her sexual companions and suffered from an inhalant use disorder. He never knew his biological father. Social services separated his four siblings (all from different fathers), so they never grew close. Donald’s turbulent childhood interfered with his ability to hold meaningful jobs or develop a strong work ethic.
The aggregated or accumulative effects of chronic health problems prompted him to come to the Emergency Department where he had 265 visits in 2023. He received follow-up care through Family Medicine at a university-based medical center. He developed relationships with a nurse, social worker, and physician assistant. He called them “my family because they treat me like a real person.” Despite these healthcare contacts, Donald reported medical mistrust and was reluctant to seek assistance beyond these providers. They persuaded him to see Dr. Andy Brown (psychologist) at the Open Door Mission. Dr. Brown used Cognitive Behavior Therapy for Chronic Pain (CBT-CP) to focus on dysphoria, pain, and alcohol relapse in a self-medicating effort for relief. Donald restarted Alcoholics Anonymous meetings.
Dr. Brown was mandated by the Board of Psychology to complete 200 hours of community service as a condition of probationary license reinstatement two years after a fraud conviction. He subsequently seeks board-certification. Even though Dr. Brown grew up poor, his personal and professional values reject poverty roots reminders. He came from an impoverished rural community but gained admission to an Ivy League school and later became a tenured professor. Still, his reflexive resentment of impoverished people stems from a blend of a “bad case of imposter syndrome and internalized stigma about being poor growing up.” These reactions were magnified in college where affluent classmates, and later psychology colleagues caused him to feel invalidated. Dr. Brown’s subtle microaggressions, desensitized cognitive schema (i.e. collections of thoughts that make him culturally insensitive), and worse – an overt distaste for the patient – posed difficulties with their working alliance.
Overtime, Dr. Brown persevered through active listening, supervision, and collaborative work with the interprofessional team. In addition, his poverty sensitivities sharpened by seeking consultation from a senior colleague with significant expertise with this patient population, opening conversations with a colleague about biases, and completing relevant online APA trainings. The consultation guided him to consider pursuing issues (e.g. address the patient’s medical mistrust and health literacy) that resulted in cultural credibility with the patient. At the same time, Dr. Brown also assumed more of an advocacy role to address residual patient sociodemographic circumstances previously identified. There was a notable decline in Donald’s scores on the orally administered PHQ-9 over twelve sessions, and his Emergency Department contacts reduced significantly.
Commentary on the Clinical Case
The case vignette demonstrates how poverty sensitivity is not singularly a patient issue but mirrored in psychologists. Psychologists’ prejudice is not a rare phenomenon when it comes to poverty-related stigmas and implicit biases (Dovidio et al., 2016; Jones, 2022). The undeniable baseline assumption makes it difficult to sidestep a concern over the reality of two visions of diversity. First, for providers, poverty can function as a desensitizing diversity factor or dampens attunement to it. Second, how people perceive poverty is essential as some providers possess a strong reactive negative sense of self reflected in a suboptimal level of tolerance for the diverse patients they serve. For example, the case included adverse childhood experiences (ACEs) and low social support. The case also revealed a psychologist susceptible to biases or reactive discomfort fueled by having to deal with poverty (Eunjung et al., 2022). That is, a psychologist’s lack of awareness of underlying motives or absence of a scoping understanding of poverty proved antithetical to patient beneficence. These behavioral characteristics were unrecognized, much less understood for the effect they had on the care provided by Dr. Brown. To achieve desirable clinical outcomes, the collaborative interprofessional relationships with Family Medicine providers, and professional development efforts enabled a more competent foundation for the preferred patient care.
Practice-Relevant Recommendations for Professional Psychology
An abbreviated list of recommended resources for developing poverty-related sensitivity includes a didactic and experiential options framework. A self-reflective practice refashions ingrained beliefs about poverty. For example, the reflexive assumption that there is a quick-fix process runs contrary to the need for ongoing pursuit of cross-cultural competence or that past professional growth efforts are sufficient / still valid. Securing cross-cultural knowledge does not necessarily convert into a preference for practicing in a culturally competent manner that optimizes outcomes for diverse patients (Isaacs et al., 2016). A self-reflective practice means awareness must translate into assessing a psychologist’s perceptions of unexamined diversity knowledge gaps stemming from formal training, biases, clinical internships, post-doctoral experiences, supervision, and CEU selections.
Ten resources are offered for consideration in the development of poverty sensitivity as a diversity-related factor emerged:
- Review APA guidance on the Deep Poverty Initiative.
- Review the APA Guidelines for Psychological Practice for People with Low-Income and Economic Marginalization.
- Complete online APA trainings (e.g. Implicit Bias: Reducing Clinicians’ Implicit Prejudices and Implicit Stereotypes in Clinical Practice; Building an Equitable Practice: The Case for Cultural Humility and Emotional Intelligence; Healing Power of Native American Culture; Addressing Social Justice Issues as Clinical Psychologists: Advances in Assessment and Treatment).
- Complete in-vivo poverty simulation seminars.
- Consult a senior colleague with extensive experience working with diverse patients and poverty.
- Complete a self-directed reading journey (e.g., Poverty in America).
- Volunteer to work at a county shelter.
- Review the American Medical Association’s policy on poverty, wages, and health.
- Seek psychotherapy aimed at mitigating provider dispositions that function as barriers to developing cross-cultural competence (Rosenfield, 2020; Bager-Charleson, 2018; Fantini, 2016).
- Practice mindfulness and perspective-taking with respect to poverty. Developing cultural competencies associated with poverty sensitivity is an unending professional journey. It requires motivated cross-cultural practice efforts that are advanced through continuous learning, self-reflection, and receptiveness on the part of the professional psychologist
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Ronn Johnson, PhD, ABPP
Board Certified in Group Psychology and Clinical Psychology
Correspondence: RonnJohnson@creighton.edu