Poverty sensitivity as a diversity factor for group psychotherapists in medical settings: Ten strategies for cultural competence
Ronn Johnson Ph.D.
Creighton University School of Medicine and Creighton University Medical Center
Correspondence concerning this article should be addressed to Ronn Johnson, Creighton University School of Medicine, Werner Center for Health Science Education, 2616 Burt Street, Omaha, Nebraska, 68178, United States. Email: ronnjohnson@creighton.edu
Keywords: poverty sensitivity, group psychology, and cultural competence
Poverty sensitivity as a diversity factor for group psychotherapist in medical settings: Ten strategies for cultural competence
Introduction
Poverty is a complex cross-cutting sociodemographic experience that has no racial, gender, or diverse community restrictions. For example, poverty encompasses a diverse prevalence pattern, as noted by its disproportional presence in Native American, rural, and urban communities. Over 40 million people in the United States meet the criteria for poverty (Nicholson, 2023). Poverty also coincides with different forms of discrimination assessed through interconnected oppressed social domains (e.g., employment, education, housing, and contacts with the criminal justice system). Understanding poverty and a collection concomitant issues is an even more pressing concern during healthcare delivery. For example, Galea & Vaughan, (2019), suggested gainful employment is a prerequisite for securing higher-quality healthcare. That care is exacerbated by joblessness. Individuals meeting the criteria for poverty are also less likely to carry insurance, postpone care, or avoid seeking healthcare altogether, which can fuel unwanted chronic health outcomes.
Poverty sensitivity is a critical cultural competence for better healthcare and health outcomes for the diverse underresourced communities highlighted above. While initially slow to recognize the relevance of diverse cultures for decades, the gold standard for best psychological practice now includes the need for psychologists to develop cultural competence (Sue, 2003). That is, there is a Clarion Call to move away from approaches that overly stress technical expertise void of models that fail to integrate the lived experience of historically oppressed groups or reflexively over-diagnose deficits. There remains a substantial poverty knowledge gap when it comes to delivering responsive care that allows access to group treatment for historically under resourced communities. (Castro-Ramirez, et al., 2021; Corcoran, 2023; Ziadeh, 2020). Regarding cultural competence, group psychology is a sub field of psychology that focuses on comprehending, respecting, and responsively engaging multiple diverse patients simultaneously. A core evidenced-based disciplinary feature of group therapy within a medical setting involves care for patients with underlying health issues. At a minimum, a group in this context is designed to reduce a sense of isolation by extending support to diverse patients presenting with co morbid medical conditions.
Group 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. To be effective, a group psychologist’s self-reflections must include responsiveness observed through sensitivity to cultural orientations and the lived experiences of historically marginalized communities. Poverty is a variable of adverse demographics that results in cascading vulnerability to psychosocial risks (Stepanikova & Oates, 2017; Chen et al., 2019). Two areas prioritized here as exemplars are self-reflective awareness and responsiveness to poverty. First, a commentary on poverty sensitivity highlights culturally appropriate group practice. Second, ten resources are recommended for cultivating awareness, knowledge, and skills for optimal care for poverty sensitivity within a group context.
A reflective group psychological practice and culturally responsive guidance for poverty sensitivity
Competence is evidenced through continuing education, formal 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 group psychologists 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 group psychology. Poverty is a multi generational psychological reality disproportionately found in the lived experience of historically under resourced populations (e.g., Black Indigenous People of Color or BIPOCS and rural communities) (Gans, 2011; Winship et al., 2021; Tickamyer et al., 2017). As a sketched personal example of self-reflective group psychology practice, the author highlights here one poverty and BIPOC understanding journey. This includes what was learned and modified through diversity-saturated, clinically supervised group psychology posts. That process witnessed an ethical integration of poverty in care to enhance the utilization and efficacy of group psychological services. The journey includes 15+ years as a rural Head Start psychologist, establishing mental health clinics in unde 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 that 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 explicit biased assumption. That is, a belief that most healthcare providers are attuned to cross-cultural constructs in everyday use, prevalence rates, and motives and can 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 group psychologists
A historical assessment of poverty reveals that it is an aggregated or destabilizing stressful diversity factor. Poverty is an unevenly shared complex state or an inadequate living condition resistant to mitigation as a sociodemographic variable. Poverty affects groups of 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. Compared to other underrepresented groups, Indigenous Americans continue to be one of the most underserved populations. For example, 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 practiced certainty as a clinical health 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 preexisting healthcare access barriers for these populations (Andrilla et al., 2018).
Poverty complicates mental health and other medical issues that must be immediately addressed for the long-term benefit 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 non-biased and culturally informed practice decisions. Even so, Chatlani (2023) reports that approaching 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 socioeconomic level.” These poverty-related circumstances also buttress the relevance of group psychology as a viable care option for extending care to more people. Disappointedly, these provider compensation circumstances translate into patient panels with more attractive insurance coverage or patients who can self-pay for services. Such health service reimbursement options are not widely available for those 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 people experiencing poverty 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 a mitigating role group 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 need to be geographically positioned to engage low-income people readily. Moreover, telehealth is fraught with other logistical-related problems (e.g., low technological literacy, poor internet connections, and patients needing access to required technology). Still, from a group psychology practice standpoint, these patient cases underscores the role of continuing education (CE). Understanding barriers like socioeconomic circumstances to care for low-income patients and heightened awareness of self are critical to achieving poverty sensitivity.
Practice-relevant recommendations for group psychology
A list of 10 recommended resources for developing poverty-related sensitivity includes a didactic and experiential options framework for group psychologists, assuming preexisting expertise in evidenced-based group treatment. One takeaway message functions as a dispositional prerequisite required to advance cultural competencies or, in this case, poverty sensitivity. A self-reflective practice refashions ingrained beliefs about poverty. A self-reflective practice means awareness must translate into assessing a group psychologist’s perceptions of unexamined diversity knowledge gaps stemming from formal training, biases, clinical internships, political persuasions, post-doctoral experiences, supervision, and CE selections.
Ten resources are offered for consideration in the development of poverty sensitivity as a diversity-related factor emerged:
1) Review APA guidance on the Deep Poverty Initiative;
2) Review the APA Guidelines for Psychological Practice for People with Low-Income and Economic Marginalization;
3) complete online APA training (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);
4) complete in-vivo poverty simulation seminars.
5) consult a senior colleague with extensive group psychology experience working with diverse patients and poverty;
6) complete a self-directed reading journey (e.g., Poverty in America;)
7) volunteer to work at a county shelter;
8) review the AMA policy on poverty, wages, and health.
9) psychotherapy aimed at mitigating provider dispositions that function as barriers to developing cross-cultural competence (Rosenfield, 2020; Bager-Charleson, 2018; Fantini, 2016;)
10) Practice mindfulness and perspective-taking concerning poverty. Developing cultural competencies associated with poverty sensitivity is an unending professional journey. It requires motivated cross-cultural practice efforts advanced through continuous learning, self-reflection, and receptiveness by the group psychologist.
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