With the Affordable Care Act expanding access to mental health care, APA's Committee on Socioeconomic Status is working to ensure that all practicing psychologists are ready to treat clients living in poverty. The committee is developing practice guidelines to help practitioners improve therapy with low-income clients.
Psychologists often receive little training in this aspect of diversity, says committee member Kipp Pietrantonio, PhD, a psychologist at the Ohio State University's Counseling and Consultation Service. Multicultural training doesn't give socioeconomic status nearly as much attention as race and ethnicity, sexual orientation and other factors, he points out.
Without such training, he says, psychologists may unwittingly commit micro-aggressions that make it less likely that a client returns for a second session, especially when combined with such barriers as lack of insurance, transportation and child care.
"When a person from a low-income background comes to a counseling session, they're immediately out-classed," says Pietrantonio. "They see a doctoral degree on the wall, someone dressed in white-collar clothing and an office with nice furniture they can't afford, all of which says to them, ‘I'm a middle- to upper-income person here to help you.'"
Plus, says Pietrantonio, recommendations that may be appropriate for more well-off clients may not be feasible for people struggling to put food on their tables. Psychologists often encourage clients to exercise more without considering that clients living in poverty may not have access to workout clothes, child care, a gym or even a safe area where they can run, for example.
The new guidelines will help fill this gap in training, says Pietrantonio. He urges anyone with ideas to email APA's Public Interest Directorate. "We don't want this to be the committee's guidelines but a collective look," he says.
In the meantime, there's plenty that practitioners can do to make psychological services more accessible to people living in poverty in addition to offering sliding scales, seeing patients pro bono and accepting Medicaid, says Laura Smith, PhD, an associate professor of psychology and education at Columbia University's Teachers College.
For one, psychologists can examine class biases in the same way that they develop multicultural competence in other areas. In a qualitative study that Smith and co-authors published in the Journal of Clinical Psychologyopens in new window in 2013, psychotherapists revealed that they had previously held common stereotypes of poor people as lazy, violent and dirty.
Psychologists may also assume that most poor people don't work. That's not the case, says Smith. "A lot of people in poverty today are working people," she says, citing unlivable minimum wages as a contributing factor. Mistaken assumptions can play out clinically, she says, referring to studies that suggest that psychologists may be less inclined to work with poor clients and more likely to view them as having more serious disturbances than their wealthier counterparts.
Misunderstandings can go both ways, Smith adds. Because people living in poverty often have access to psychological services only in crises, she points out, they may not be aware of the range of services psychologists offer. "The idea that you could work with a psychologist to understand yourself or your relationship better or to do some family therapy may be unfamiliar," she says.
Smith encourages psychologists who work with poor clients to take a flexible view of therapy. Clients living in poverty may need to address problems of food sufficiency, housing or other issues that more affluent clients may not have to worry about.
"These might initially seem to psychologists like concerns that are associated with social work or problem-solving rather than psychotherapy," says Smith.
In addition, behaviors that therapists may commonly interpret as resistance to treatment — not showing up for an appointment, for example — may simply be a symptom of a client's lack of access to child care, transportation obstacles or some other factor, she says.
Finally, says Smith, "Psychologists can advocate on a broader social level on behalf of people living in poverty."
Taking class into account in research
APA's Committee on Socioeconomic Status is also working to encourage researchers to take class into account in their work via a new campaign called "Stop Skipping Class."
"It's an effort to raise awareness about the importance of considering socioeconomic factors," says Committee Chair John M. Ruiz, PhD, an associate professor of psychology at the University of North Texas.
The campaign will encourage researchers to expand their demographic reporting beyond age, race and ethnicity to include socioeconomic factors and encourage journal editors to make that information an expectation. Currently, says Pietrantonio, researchers tend to recruit middle-class participants for their studies, which means that the theories and clinical practices based on those studies are "normed" for the middle class.
Psychologists shouldn't treat social class as a confounding variable to be controlled for, argue former committee member Matthew A. Diemer, PhD, of the University of Michigan and fellow committee members in a 2013 paper in Analyses of Social Issues and Public Policyopens in new window. The article, which Diemer describes as "social class for dummies," offers guidance on how to conceptualize and measure a factor that plays a central role in many of the areas psychologists research.
The "Stop Skipping Class" campaign will kick off with letters to researchers, editors and APA's Council of Editors and will eventually include webinars and online resources aimed not just at researchers but also practicing psychologists, students and members of the public interested in learning more about poverty and how to help members of their community escape its grasp.
Visit APA Public Interest for additional information.
