"Just Therapy" with Families on Low Incomes

"Just Therapy" with Families on Low Incomes
Child Welfare - April 30, 2005
Charles Waldegrave

This article addresses the inadequacies of counseling, therapy, and social work that occurs with low-income families. The author argues that many families who seek help arrive with problems that are usually assessed separately from their socioeconomic and cultural contexts. Careful questioning will often lead to the discovery that the onset of many family problems are located in events external to the family, such as unemployment, bad housing, and racist, sexist, or heterosexist experiences. They can be extremely depressing ongoing experiences that eventually lead parents and children into a state of stress that opens them up to physical and mental illnesses. This article argues that a wide body of research supports such a view and that counseling, therapeutic, and social work practices should address these issues much more directly. It also argues that practitioners have an important role to play in social and economic policy development out of respect for their clients' struggles. [PUBLICATION ABSTRACT] Word count: 3918.

citation details

When we speak of families and therapy, we tend to think in mental health or relationship categories. In this article, the term families refers to any primary intimate group, who either through genealogy or intentional commitment identify themselves as family. The term therapy in this context refers to the healing and problem-solving discourses that the helping professions carry out, including those of psychologists, social workers, counselors, psychiatrists, and nurses. A family in need of therapy may require help because of the unpredictable behavior of one or a number of household members, or because relationships between members have become disrupted in some way. If, instead of referring simply to families, we refer to poor families, we are triggered into issues of context.

Addressing the Context

What is good therapy when families are poor? How does a therapist address relationships when parents who struggle to feed their families are not able to access decent housing? Do current clinical and therapeutic courses adequately prepare students to address the therapeutic issues of poor families? The words families and therapy tend to elicit a reasonably predictable set of expectations, but if one uses the adjective poor to describe a set of particular families, those expectations become challenged.

Consider for example, how a group of therapists are likely to answer the question, "What is absolutely basic to a family or family life?" They would probably answer along the following lines: There must be at least a minimal commitment to relationship among members. There must be some evidence of emotional warmth among members. There must be some cooperative patterns of behavior that order at least some of their life together, and one would hope that there would be some evidence of what is referred to in the non-social science world as love.

Consider now how a group of community workers may answer the same question concerning what is absolutely basic to a family or family life. They would probably answer along the following lines: Families require adequate and safe housing. They require sufficient income to live out of poverty. They need to be able to access affordable health care, and they need to be able to live free from fear and harassment.

Both views, of course, are correct in as far as they go, but their emphases are quite different. One is focused primarily on family dynamics, whereas the other is focused primarily on social and economic context. The same divergence of views would probably occur if therapists and community workers were asked a further question: "What causes the problems of poorer families who visit therapists for help?"

Many therapists, when referring to particular stresses poor families face, would probably still make a list characterized by the following sorts of problems: inadequacies in communication, the loss of emotional warmth, tensions in relationships, an inability to make decisions, and difficulties resolving conflict. Community workers, on the other hand, would be more likely to refer to an alternative list of problems, such as poverty; bad housing; inadequate financial resources; and ongoing racist, sexist, and heterosexist experiences, for example.

For many therapists, the problems of all families relate primarily to individual or family dynamics. Such a view provides a contained space in which to work effectively, and that which is beyond those boundaries is the work of other professionals. Although this view limits and defines therapists' work, it unfortunately also ensures that work will be ineffective, and possibly detrimental to poor families, because it treats the symptoms of larger scale social problems as though they are the result of internal family dysfunction. The context named by the community workers is largely dismissed.

Many families who come to therapists arrive with problems that include psychosomatic illnesses, violence, depression, addiction, delinquency, marital and partnership stress, psychotic illnesses, parenting problems, relationship stress, and the like. If the therapists are sufficiently patient and persistent, they will discover after some questioning that the onset of many, although certainly not all, family problems are located in events that are external to the family. These could be events such as unemployment; bad housing; homelessness; racist, sexist, or heterosexist experiences; and the like-the same problems, in fact, that the community workers identified. These can be extremely depressing, ongoing experiences that eventually lead parents and children into a state of stress that makes them vulnerable to physical and mental illnesses.

When people come to therapists depressed and in bad housing, and therapists treat their clinical or social problems within the conventional clinical boundaries, they are simply made to feel a little better in poverty. Quite often, competent therapists are able to quite effectively help move people out of depression, but then simply send them back to the conditions that created the problems in the first place. Unintentionally, but nevertheless very effectively, they simply adjust people to poverty.

Furthermore, by implication, the therapists encourage fami lies in the belief that they, rather than the unjust social, economic, and political structures, were the authors of their problems and failures. They do this despite the knowledge we have today of structured and cyclical unemployment in most postindustrial countries, the physical and psychological pathologies associated with inadequate housing, the same pathologies associated with ongoing racist experiences, and the patriarchal determinants of physical and sexual abuse.

Further still, such therapists can be guilty of silencing the voices of poor people. Low-income families often share their vulnerability and pain with therapists, who then, because of their professional commitment to confidentiality, never pass it on to the forums that could do something about it. The therapist is often one of the only people in mainstream middle-class society to whom poor people outline their difficulties. If they feel no compulsion to address the causal factors by bringing the repeating themes of poor families (not the individual confidential stories) into the public debate or to the institutions that can change them, then the cry for help has been silenced.

Inequalities and Health

A substantial body of literature associates low-income households and inequality with physical and mental ill health. One of the most significant early research projects on the subject was carried out by Harvey Brenner (1973) at Harvard University. His research focused on unemployment and societal health. He led a large-scale study on the effects of economic recession in the United States from 1936 into the 1970s, and his results indicated that a 1% rise in unemployment is followed by 6% more admissions into psychiatric hospitals, a 4% rise in suicides, a 4% rise in state prison admissions, and 6% more homicides.

Further research by Brenner (1979) confirmed the same findings in England and Wales. Researchers tested the relationship between unemployment and suicide in eight different developed countries and again demonstrated the close link between annual variations in unemployment and suicide rates (Boor, 1980). Another study found the same relationship in New Zealand (Macdonald, Pearce, Salter, & Smith, 1982).

Since the 1980s, many local and national studies have followed Brenner's (1973; Acheson, 1998; Benzeval, Judge, & Whitehead, 1995; Crampton, Salmond, & Kirkpatrick, 2000; Dunn, Hayes, Hulchanski, Hwang, & Potvin, 2003; Kawachi & Berkman, 2003; Kawachi & Kennedy, 2002; National Health Committee, 1998; Waldegrave, King, & Stephens, 2003). They each show a distinct relationship between inequalities in society and physical and mental ill health. Poorer people die earlier and consistently have the poorest health and the highest hospitalization rates. Furthermore, when a country's population health status improves overall, the health inequalities do not decrease.

The evidence is so overwhelming that a number of major governments have set up inquiries to study the evidence and recommend new directions for national health services to address health status from the perspective of inequalities. The famous Acheson (1998) Independent Inquiry into Inequalities in Health report in the United Kingdom and the Social, Cultural and Economic Determinants of Health in New Zealand (National Health Committee, 1998) are two such examples.

Given the substantive evidence of the relationship between inequality and physical and mental ill health, it is reasonable to suggest that many of the problems that families present in therapy result from poverty, inadequate housing, unjust economic planning, unemployment, racism and so on. As such, where this is the case, one can conceive of the problems as the symptoms of inequality.

From this perspective, these symptoms, which are usually construed in mental health or social categories, should not be considered as simply personal, intrapsychic, or intrafamily disorders if they arise in association with broader structural problems in society. They can be more accurately viewed primarily as the symptoms of those structural social problems. The tighter clinical categories are secondary and only useful if viewed in relation to the primary focus.

This suggests a notion that many, although obviously not all, of the mental health and relationship problems people have are the consequences of power differences and injustice. Such a notion seldom appears in clinical literature or as a major theme in therapeutic conferences. If it did, however, researchers would do considerably more exploration and analysis regarding ethics and social justice themes as they relate to family context and would focus less exclusively on the boundaried space of individuals, couples, or families.

Therapists as Thermometers of Pain

Therapists, be they psychologists, social workers, counselors, psychiatrists, or nurses, have a critical role in postindustrial and largely secular states. They are the predominant professional group who listen to the pain of individuals and families. They work in the institutions that address pain in these societies, such as the health, welfare, and justice services. They work in the nongovernmental and community organizations that provide family support and services for abuse, poverty, housing, general counseling, mental and physical ill health, and so on. They also work privately, but are often contracted into the work of these larger organizations.

Therapists, as a professional group, are the most informed "experts" of the collective grounded levels of hurt, sadness, and pain in modern countries. Those who live in deep pain are of course the primary experts in the sadness and hurt they and their communities experience, but therapists are the professional helpers who continually witness that pain with many individuals and families and across a variety of communities week after week. As such, they carry a substantial responsibility to identify, quantify, and describe the severity and causes of it. This is ethically essential if they are committed to honoring their client group. They have a responsibility to publish and publicize the causes and outcomes of people's pain so they may be addressed in the public debate and affect policy. Good policy in this sense can address issues of well-being and inclusion in informed and effective ways.

Therapists, in this view, can be seen as the "thermometers of pain" in modern countries. Instead of withholding their knowledge in clinical vacuums, they can quantify, describe, and identify causality for all to see. If issues of housing, poverty, or race become dominant in caseloads, for example, their descriptions can inform the public by adding reality and depth and providing a more helpful basis for intelligent public discussion. On can find a good example of this in the public work many fine therapists have carried out highlighting the levels of abuse occurring in many countries, the causes of that abuse, and the policies and laws required to stop it. A parallel level of action and commitment is required in a range of other pain-causing factors therapists identify.

There are a number of critical issues along these lines that therapists could usefully ponder at professional conferences, in professional organizations, and at staff meetings that may be more useful than the endless string of case study presentations and focus on therapeutic techniques. They would center on the importance of developing record systems of the numbers of individuals and families they meet in therapy who are below the poverty income threshold in their country, for example (or in inadequate housing, or being subject to ongoing racist experiences, etc.). The summaries of those, and their colleagues' in other organizations, could be written up and placed in the public arena.

Therapists could write up the stories they see and hear in therapy for popular media outlets and advocate for social changes that will address the therapeutic problems they identify. They could also identify the failure of certain social and economic policies as the prime cause of pain and ill health to many low-income families, rather than the failure of individuals and families, as many in society often view the situation. When therapists know that certain social and economic conditions prolong ill health, they could be active in creating public awareness concerning these issues, out of respect for the needs of their clients not to have their sicknesses prolonged.

Actions like these would require a fundamental institutional shift of attitude and responsibility in the profession. To begin would not be difficult, however. For example, keeping the statistics would simply involve a few more columns in case-note sheets after some sensitive questioning. Reflective and careful analysis, however, would be required to address the social critique, based on those statistics, for placement in academic and popular media outlets. Success in achieving these goals would go a long way toward ridding the profession of the fair accusation that practitioners often silence the voice of poor people as they unintentionally help make them happy in poverty.

The profession may also choose to address some uncomfortable and more personal questions. These include:

* Has the profession of therapy been captured by a group who believe in low taxes and minimal social policies?

* Are therapists paid off to be silent, given the profound knowledge many of them have about the lives of poor people?

* Do therapists make money off people's misery and thus have no interest in reducing their problems at root?

These are tough, reflective questions, but they are the sort a professional who is entrusted with the vulnerability of people during some of their most fragile periods should be asking. It is perhaps excusable to admit one's naivete and unintentional behavior when first addressing these questions, but once admitted, it is surely unethical not to change. Societies need their reliable thermometers of pain, the mercury readings provided by the therapists.

"Just Therapy" in Poor Communities

For therapists to successfully work in poor communities, they have to take the critical context beyond the family into account. Those most in need of the health and welfare resources in most societies and communities are those who experience the most trauma, the greatest stress, and, as a consequence, the most ill health. They are usually those with low incomes, people in cultures that have been marginalized in the societies in which they live, and, most frequently, they are women. Unfortunately, therapeutic resources are spread rather thinly for this group because they are outside the mainstream and have less money.

Waldegrave, Tamasese, Tuhaka, and Campbell (2003) created Just Therapy to help therapists address the critical socioeconomic, cultural, and gender contexts of therapy. This article has focused predominantly on the socioeconomic aspect and therapists' interactions with and responsibilities to their societies. Each of these contexts, however, are very important.

It is equally important to address the context in the therapeutic process as well. A full development of this is not possible in an article of this length, however, some pointers may be helpful. It is beneficial when questioning low-income household members to sensitively address their stories about accessing necessities. Unfortunately, therapists seldom refer to this in therapeutic discourse. The adequacy of household income, quality of housing, and access to good health care are critical contexts. Families in these situations struggle and are often highly motivated to share coping strategies and survival skills. These in turn offer genuine stories for the therapist to admire, honor, and, in a sense, be in awe of.

Institutions view so many of these families in a pathological light. They are often referred to as "dysfunctional" or "multiproblem" families. This consistently negative view, combined with the sense of social failure and lower status conferred by mainstream society, can quickly become self-fulfilling. It is critical to this work to recognize where families' strengths lie and honor them. Strengths are usually found in their resilience under the sort of stress middle-income households are seldom required to endure.

Nothing is more basic, for example, to a family than a house. As such, housing can usefully become a central context in the therapeutic process. Without adequate, safe, secure housing, all families are at risk of mental or physical sickness. The meaning therapists assign to poor families' housing problems determines whether the therapist will locate the problem internally or in its socioeconomic context. If the therapist takes the former route, he or she will encourage feelings of inadequacy and self-blame. If the therapist chooses the latter, contextual route, then the focus will move toward understanding the socioeconomic context and developing smart survival strategies. It is very important to challenge the failure meanings that so many poor families adopt as a result of their constrained circumstances and the reactions of others to them.

In our work, for example, we often congratulate families for surviving overcrowded living conditions with their families still intact. Their ability to survive a housing crisis not of their own making, but of that of the housing planners, can be recognized as courageous, committed, and extraordinarily competent. Having explored their stories of resilience, resistance, and survival, we often indicate that we are not at all confident our families would have survived those circumstances as well as the clients' have. In this positive context, we are able to address the symptomatic presenting problems in context, enabling families to identify the broader structural issues that have been imposed on them. We can then help them recognize their strengths as the stepping stones to either surviving without self-blame or developing smart strategies to move to a more secure social place.

We also use metaphor to encourage a positive perspective. For example, we may say to a single parent who has struggled through many difficulties with his or her children as a result of rejection and poverty that we are amazed at the parent's ability to steer his or her canoe through the stormy waters of loss and rejection that they have experienced. "All your cargo and paddlers are still on board and you have kept them in rhythm despite the odd upset. You will reach the calm waters you have been searching for, and when you do, we are sure you will recognize just how much you have achieved." The metaphor gently recognizes the parent's achievement in what has been his or her prime life task, despite the current and past problems. It externalizes and contextualizes the difficulties that would pose serious obstacles for any family, at the same time as it encourages and touches the parent's hopes.

Focusing the Problems of Current Practice

The therapy community has served poor families badly in three ways. First, although such families are those most in need of therapeutic resources, they seldom receive such resources on their own terms. A combination of middle-class capture and preference for therapists to work above the poverty line constrains the resources available to low-income households.

Second, therapists working with poor families typically constrain themselves in narrow clinical boundaries that avoid the prime contextual factors that are so basic to the families' daily survival. This encourages the internalizing of their problems and the consequent self-blame during therapy and subsequently, if the family relapses.

Finally, this article strongly suggests that therapists would better serve poor families if they took their role in social and economic policy development seriously. As the key profession most in touch with grounded pain in society, therapists would contribute substantially more to disadvantaged families if they were active in the public debates and policy discussions that affect these families in modern democratic societies.

References

Acheson, D. (1998). Independent inquiry into inequalities in health. Available from http:// www.official-documents.co.uk/document/doh/ih/ih.htm.

Benzeval, M., Judge, K., & Whitehead, M. (Eds.). (1995). Tackling inequalities in health: An agenda for action. London: King's Fund.

Boor, M. (1980). The relationship between unemployment rates and suicide rates in eight different countries 1962-1976. Psychological Reports, 47, 1095-1101.

Brenner, M. H. (1973). Mental illness and the economy, Boston: Harvard University.

Brenner, M. H. (1979, September 15). Mortality and the national economy: A review and the experience of England and Wales 1936-76. Lancet, 15, 568-573.

Crampton, P., Salmond, C., & Kirkpatrick, R. (2000). Degrees of deprivation in New Zealand: An atlas of socio-economic difference. Auckland, New Zealand: David Bateman.

Dunn, J., Hoyes, M., Hulchanski, D., Hwang, S., & Potvin, L. (2003). Housing as a socio-economic determinant of health. In P. Howden-Chapman & P. Carroll (Eds.), Bousing and health: Research, policy and innovation (pp. 12-39). Wellington, New Zealand: Steele Roberts.

Kawachi, I., & Berkman, L. F. (2003). Neighbourhoods and health. New York: Oxford University Press.

Kawachi, I., & Kennedy, B. P. (2002). The health of nations. New York: New Press.

Macdonald, M., Pearce, N., Salter, D., & Smith, A. J. (1982). Health consequences of unemployment. In M. Abbott (Ed.), Mental Health Foundation of New Zealand/New Zealand Psychological Society symposium on unemployment. Auckland, New Zealand: Mental Health Foundation.

National Health Committee. (1998). The social, cultural and economic determinants of health in New Zealand: Action to improve health. Wellington, New Zealand: Ministry of Health.

Waldegrave, C., King, P., & Stephens, R. (2003). Changing housing policies, poverty and health. In P. Howden-Chapman & P. Carroll (Eds.), Housing and health: Research, policy and innovation (pp. 144-156). Wellington, New Zealand: Steele Roberts.

Waldegrave, C., Tamasese, K., Tuhaka, R, & Campbell, W. (2003). Just Therapy-A journey: A collection of papers from the Just Therapy team, New Zealand. Adelaide, New Zealand: Dulwich Centre.

Charles Waldegrave, MA (Waikato University, New Zealand; Cambridge University, United Kingdom), The Family Centre, Lower Hutt, Wellington, New Zealand. A similar article appears in: Flaskas, C., McCarthy, L, & Sheehan, J. (in press). Hope and despair in family therapy. UK: Brunner Routledge.

Citation Details

Title: "Just Therapy" with Families on Low Incomes
Author: Charles Waldegrave
Publication: Child Welfare (Feature)
Date: April 30, 2005
Publisher: Child Welfare League of America, Inc.
Volume: 84 Issue: 2 Page: 265-276