HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals

SOCIO-ECONOMIC MARGINALITY AND ITS RELATIONSHIP WITH PSYCHOLOGICAL FUNCTIONING: HOW CAN FAMILY THERAPY HELP?

  • Laura Rocchietta TofaniNeuropsychiatric Unit, Ivrea Hospital (TO), ASLTO4, Italy
  • Poverty and mental health
  • trauma treatment and systemic therapy
  • socio-economic sensitive family therapy

Abstract

The ACE research has proved that adverse experiences, among which poverty, have a long-lasting effect on health, behaviors, life potentials. The impact of resource deprivation on adaptation to reality, with abundance of stress and traumatic components, has been the subject of many studies and the WHO has stated that poverty is the first risk factor to counteract in order to support physical and mental health. The paper analyzes data from statistics and various elements from literature review on poverty and on mediating variables between poverty, psychosocial adjustment and mental distress in order to detect family and individual psychological “key elements” to consider for a useful case-conceptualization and a good therapeutic plan.

Based on the author’s clinical experience in a Neuropsychiatric Unit for Children and Adolescents, interventions are proposed to address typical aspects, like the trans-generational lifestyle that contemplates economic emergency as normal, shame, hopelessness and reactive anger, learned dependency and avoidance of action (…).Theoretical aspects, data from research and perspectives on treatment are therefore considered.

Key - Words : Poverty and mental health, trauma treatment and systemic therapy, socio-economic sensitive family therapy

Introduction

Poverty is a reality that all cultures in all continents have to face.

We would like to open this paper with a citation from one of the last articles written by Rolf Carriere, UNICEF Country Director in Asia: “…Although we do not usually think of poverty as a form of violence, it, too, harms and hurts—indirectly and largely—unintentionally. But structural violence is not inevitable because ultimately it is caused by human agency. Built into the structure of the world sociopolitical–economic system, it adds another dimension to the genesis of trauma. According to The World Bank, world-wide, some 1.22 billion people lived in extreme poverty on $1.50 a day in 2010; in all, 2.4 billion lived on less than $2 a day that year. Most suffer from hunger or chronic undernourishment: around 842 million people […] worldwide, some 202 million people were unemployed in 2014 […] 45 million of whom are in the developed economies.The number of child laborers in 2012 is 168 million […] These are obviously traumatizing circumstances: poverty as a pervasive and insidious social-global reality constitutes a traumatic condition of chronic adversity with devastating consequences for mental health” ( R Carriere, 2014, p. 189).

The ACE research, where the acronym ACE stands for Adverse Children Experiences, has stated that adverse experiences, among which is poverty as a trauma, have a long lasting effect on health, behaviors, life potentials. The World Health Organization (WHO) has approved a Comprehensive Mental Health Action Plan (for the period 2013-2020), in which it is stated that poverty is the first risk factor to counteract in order to support physical and mental health.

The DSM-5 International Classification System, on the other hand, has stated that traumatic situations are at the origin of about 50 syndromes and sub-syndromes classified in DSM-5. Since persistent economic stress is a trauma, in order to develop effective interventions, psychotherapists have to consider this cause of significant stress or trauma among other traumatic experiences of individuals and families.

The focus of this brief paper is therefore against the risk of “psychological repression” in the therapist’s mind with regard to the theme of “poverty”.

In this paper  we will examine statistical reports and conduct a literature review of research on poverty and social marginality to help systematize aspects connected to relative long-term poverty and its cumulative impact on mental health, and the therapeutic work we can do in an impoverished world to counteract the psychological effects of this aspect of human life.

Absolute poverty and literature poverty

A body of research and literature deals with the influence and impact of resource deprivation on adaptation to reality. The worst risks are related to situations with problems in various subsystems, given  the abundance of stress and traumatic components.

We will start by defining some organizing concepts.

Absolute poverty can be defined as a situation in which basic needs are only met with great difficulty and intermittently, for instance, according to the standards of living in Western Europe, meals with proteins are available only every three or four days, and/or there are no heating possibilities and/or no stable place of living.

Relative poverty can be defined as a situation in which basic goods and services are available approximately at a percentage of 50% of the average level,  compared to other inhabitants in that  geographical environment and culture.

We will examine only the situation of families living in relative poverty. Absolute poverty refers to people living in shelters, usually not directly helped and cured by the National Health Service, while we have families in relative poverty coming to public Health Services and even in private practice when their financial breakdown is still recent.

Wherever a family therapist works, three types of poverty can be usually distinguished.

A first situation of limited resources can be detected in a certain percentage of the population during massive economic crises, after abrupt changes with traumatic economical impact.  A family’s socio-economic condition can suddenly change after job events that cannot be foreseen, for instance after a job loss following a company failure or when employment contracts do not guarantee sufficient financial support and benefits.

In a second case we can have chronic poverty with socio-economic marginality, which is often based on a trans-generational lifestyle that contemplates living always in economic emergency. Not rarely, these families are “multi-problem families” (Rocchietta Tofani, 2002).

As a third possibility we have poverty connected to mental illness, because of the cumulative effect of psychiatric illness on individual and family socio-economical situations, since it limits the possibility of using personal resources and competencies.

In brief, we can have poverty connected to mental impairment or poverty connected to situations deriving from the socio-economic system, its rationale and its crisis.

This consideration guides us to the following theoretical problem: the distinction, in the socio-psychological debate, between two basically different explanations of the cause of poverty and psychosocial marginality: “social causation” on one side and “social selection” on the other side.

According to the first explanation (social causation), fewer resources are considered to generate the stress that statistically causes psychological or psychiatric problems. Social selection, on the other hand, considers a condition of fragile mental health as a condition which prevents the individual from using his/her personal potentials and generate a situation more characterized by job loss, limited income due to low education as a consequence of unstable application or inappropriate behavior or other mechanisms determining a downward mobility, sometimes exacerbated by serious family dysfunctions.

The question is: are these two explanations independent of one another? Do we witness socio-economical stress causing mental distress and sometimes mental pathology, or, differently, mental distress and mental disorders generating poverty in individuals and families? In other words, is the economic system the cause of mental distress and of poverty or are mental problems the cause of poverty?

Data on poverty levelsand dynamics related to povertywill be analyzed and theoretical aspectsfrom literature review regarding the influence of resource deprivation on psychosocial adjustmentwill help to evaluate and answer this and other key questions,among which whether it is “systemic thinking” to isolate the dimension of material poverty and,above all, what  use of this knowledge a therapist can make during therapy.

Data from Statistical Reports

According to the Italian Institute of Statistics (ISTAT) 2015Report, absolute poverty in Italy strikes about 7,5% of the total population and this number has tripled since 2008, due to the serious economical crisis which started almost ten years ago. Relative poverty concerns 8 million people, or about 15% of the Italian population.

According to the Eurostat Report, 28,4% of the Italian inhabitants is at risk of poverty and social exclusion. Italy comes between two extremes along a wide range: Bulgaria on one side, with 48% relative poverty, and France, with 18%. In Europe, absolute poverty concerns 43 million people, and relative poverty 128 million inhabitants.

According to the US Bureau of Census and to the 2015 Official Poverty Report in the USA, the official poverty rate is 13,5%, and concerns an estimated 42 million people, people who live below the “poverty line”. Even if statistics in the USA are organized in a different way and the definition of poverty follows parameters that are slightly different from those used in Europe, and even if it is not therefore easy to compare data, the numbers are very high, anyway, and the line below which we can consider a family, a couple or an individual as living in poverty is usually clear to observers.

Key questions and answers

We pointed at some important questions before. One question was: “Is it systemic thinking to isolate the dimension of material poverty to study its impact for therapeutic purposes?” The answer is yes: if we think in terms of processes and complex cumulative effects and if we proceed in our analysis considering contributing factors, intervening factors or influencing factors, determining which are most important, that is a systemic way to study a phenomenon.

About the second important question —which was: “How strong is the link between poverty and mental health and what causes what?— we will observe whether  these two explanations, social causation and social selection, interweave and how.

In order to give an answer to these questions and to consider on which guidelines we can base our therapeutic work with poor families, we have chosen four important contributions from four areas of research on poverty and common mental health, mental distress and psycho-social adjustment.

A first area of contribution for therapeutic guidelines

The first area of contribution is connected to research on the impact of poverty on children.

One of the most significant contributions is a survey carried out by the University of Wisconsin in 1995, inside a National Longitudinal Survey of Youth ( Korenman, 1995). About 6000 children in the State, all five years old, were examined. The clinical evaluation included administering the Wechsler Scale and the Revised Behaviors Profile. Researchers found double developmental deficit and double performance deficit in children experiencing long term poverty versus children experiencing only recent poverty, recent poverty being defined as a condition of lack of material goods and opportunities only in the last year before they were tested. Such deficits were not explained in terms of differences in maternal behavior during pregnancy, in maternal education, in family structure or other similar variables. The contribution represented by this study would strongly support the explanation of social causation: the socio-economic variable, independently of other variables, is statistically linked to damage on both the behavioral and the cognitive aspect of individual functioning.

A second area of contribution is connected to the effects of a significant improvement of a family’s financial position on mental well-being. As the best example we cite a study conducted by a Family Investment Program in North Carolina (Costello et al., 2003). The project was carried on from 1993 to 2000 among 1500 children from wealthy families and chronically poor families. All children were in the 9-13 age range.

The importance of the study lies in that the variable of poverty was almost treated as a laboratory variable, it could be measured as a controlled variable in a “quasi” experimental study. The research was carried out in an Indian reservation where a Casino had opened and, in exchange, all Indian families were guaranteed a share of the Casino’s annual income. Each person belonging to the Indian community received the same amount of money, therefore each Indian family received a contribution which allowed financial relief and support in proportion to the number of family members. As a consequence, each family had the same economic chance to improve its financial position and all families living below the poverty level had the same possibility to exit from the condition of poverty. For four years before the beginning of the financial contribution, families and children belonging to these families were monitored and different parameters were evaluated (socio-psychological variables, parenting style, family attachment style, cognitive competencies, externalizing and internalizing problems in parents and offspring…).  Before the onset of the experimental conditions with the increase of income due to the contribution, children in poor families showed 59% more behavior disorders than children in wealthy families. For four years after the beginning of the financial contribution, 14% of the Indian families managed to escape the condition of poverty. The articulated analysis of the effect of this important change was the following: levels of behavior disorders of children of ex-poor families fell almost to the same levels of behavior disorders as wealthy children, as in children who had never known poverty. Again the importance of the social causation explanation emerges. Even more interestingly, mediating factors between improvement of the economic possibilities and the change in proportion of externalizing problems were evaluated — among these, parental intrusiveness, maternal depression, hyper-protectiveness. The only factor responsible for 77% of the change in children behavior was quality of parental supervision, which meant effective parental control and guidance. This finding is of particular interest because it points at an area on intervention which is of fundamental interest for a family therapist to support resiliency in kids and adolescents in poor families.

A third area of contribution is connected to research on mediating factors, as performed in the research mentioned above. A very useful study is a meta-analysis conducted by Murali and Oyebode, from the University of Birmingham (Murali e Oyebode, 2004). It centers on psychological intervening factors between poverty and psychological distress or disorders.

Mediating and intervening factors individuated by authors were strictly connected to therapeutic elements typically considered and treated in Family Therapy:  shame, stigma and resignation and humiliation from poverty, constituting a threat to the Self and to the identity, hopelessness and reactive anger, all linked to family dynamics and “meanings”.

A fourth area of contribution is intercultural reports. A particularly useful analysis for the purposes of this paper was conducted by Harvard researchers Patel and Kleinman in 2003. The authors conducted a meta-analysis of surveys in developing countries in all Continents. Findings reported by the authors suggest that the association between poverty and common mental health and common mental disorders is a universal one, occurring in all societies irrespective of their level of development. These studies validated the universal link between poverty and common mental disorders. According to these authors, poverty and common mental disorders interact with one another in setting up in vulnerable individuals a vicious circle of poverty and emotional behavior and/or psychiatric problems. So what we can state is that the relationship between social causation and social selection is circular, as we could foresee as systemic therapists.

Functioning in families with long-term relative poverty: elements for case conceptualization

Our considerations concerning common psychological variablesand aspects of family functioning in case of long-term relative poverty will rely not only on the results obtained from the literature review and the findings of the four studies we cited but mainly on the authors’ clinical experience in almost three decades of interventions, often conducted on multi-problem families in the National Health Service, in a Neuro-psychiatric Unit for children and adolescents.

If we consider the subjective experience of individuals in socioeconomic marginality, we often find feelings of shame, hopelessness and impotence, reactive anger against the personal condition of poverty and a learned avoidance of action against this personal condition.

A second aspect we can underline is the habituation to a trans-generational life style which contemplates economic emergency as normal, or living on Social Welfare as the “life-system”.

A third central and crucial aspect is habituation to ignoring social constraints. If people usually fight against a downward mobility in the socio-economic position for one or two years after the onset of a condition of poverty, when the hope of improvement begins to fade, people begin to consider “normal” not to pay taxes, to ignore their duty about bill payments or tickets, to live on the contributions from Social Services or volunteer associations, as in the following case-vignette.


In one of the families which underwent the kind of treatment we are recommending in this paper, both parents had a poly-traumatic life history and a chronic poverty history in their family of origin. The mother came from a household characterized by the presence of alcoholism and assisted violence; the father came from a family characterized by instability of relationship: all six of his brothers had broken families scattered around the world. There were four children, two with minor disabilities. Social problems were clearly  represented by the fact that they  didn't pay the rent, didn't pay electricity bills, their car had been taken away because the annual road tax was unpaid. The apartment run by the father was in a chaos, absence of hygiene was a problem. Atypical organizational patterns were conditioned  by the personality structures of the two parents. The family was in conflict with Social Services, and therapy begun when mother and children were in a socio-educational c ommunity, on a charge of neglect.


Family intervention: basic areas to consider for the therapy plan

We can begin to illustrate premises and recommendations specifically designed to address the abovementioned key elements: trans-generational life style that contemplates economic emergency as normal, shame, hopelessness and reactive anger, learned dependency and avoidance of action.

First of all, it is important to think that certain  “paradigms” are not useful, because organizational patterns, function, roles in families presenting the organizational aspects and dynamics  illustrated above  are atypical and “built” not only around personality structures of the parent/parents but also on actual possibilities with respect to job and living conditions.


For instance, in the family just mentioned the husband was at home looking after the children and the house while the wife had two jobs far away from home. This kind of organizational pattern was not the aim of the intervention because it was connected to an ambivalent avoidant attachment pattern in the mother and to a personality disorder in the father but was at the same time the only possibility for the family to have an income and survive. Often work for women is more available than jobs for men, or a woman can be  more able to adapt to a working environment or, as an extreme situation, parents can decide to give birth to a new child because this would help to avoid getting fired and losing a source of income.


Apart from avoiding mistakes by strict applications of the normal paradigms like “….divide the couple if the husband does not work and exploits the wife …”, which are the main areas around which to organize a good treatment plan? Of course we illustrate directions of intervention that can be carried on in parallel or at a different moment, according to clinical judgment and in an interconnected way.

It is always important to check, as a first step, for problems in specific areas and carry out  specialized interventions if necessary, i.e. with respect to alcohol abuse, violence in the family, psychiatric problems, attachment difficulties  …, if present.

As a second step, it is important to facilitate contact of the family with the Court and other Institutions to restructure the family’s perception of its own stigmatized position in the social environment,  to counteract the feeling of being stigmatized  that we have found also in the literature.


As an example, in the family described above, once the attachment relationship between parent and children had been evaluated as a positive one, the therapist  helped the mother to interact with  the Court in order to facilitate her in showing  in the most comprehensible way her position and plans, in a legal context in which the mother was not able to express herself properly. This allowed to change the perception of professional help by the family and to positively conclude the period of observation of mother and children inside the socio-educational community.


A third step can be described as the challenge against impotence and avoidance of action through “trauma work” specifically around the problem of limited financial resources and difficulties connected to that. For instance, we can decide to process the moment at which living in economic emergency began (i.e.: when the idea of poverty as a “destiny” was born? or that poverty is someone else’s fault and cannot be fought against?).In other cases, it is meaningful to process specific difficult events, as the first time the electricity or water supplies were cut off, or the first time the family asked for food bags or second-hand dresses.

To process episodes connected to the impact of poverty with techniques specific for traumatic situations, it is useful  to unblock dysfunctional reactions to emotional pain and open the mind to new attitudes.  In the abovementioned case example, the therapist used an interweave of family therapy and EMDR, an approach that has been recognized as useful in traumatic reactions in numerous guidelines, but any other effective  approach with the same impact can be integrated.


The mother of the case example could process her memories of neglect and assisted violence, the father had to “review” and process his feelings regarding relationships and his way to perceive any kind of obligations and limits as unbearable.


In the long term and with a cumulative effect, relief from personal traumatic experiences can counteract the idea of impotence toward change as a lifelong philosophy. Of course a therapist cannot change the financial situation, but working toward progressive improvements of the mental well-being can eventually, as a consequence, sometimes also have a positive impact on the socio-economic situation.

To stimulate protective factors in children, reflexive and explicative interventions specific  to promote mentalization  can help in the attempt to break the cycle of poverty. This is in agreement with the observation in the studies we reported on  parental management   as best protective factor.

Considering the importance of the narrative about the self, a last area of intervention regards the possibility to connect to trans-generational family resources and stimulate new visions and action for  new narratives that must be “validated” in the outer world . Family members can be helped to re-organize their action in real life in order to have new experiences and have them recognized as valuable in the society, with an effect on self-esteem.


In the family we cited as an example, during therapy the wife's sensation of impotence turned into action and into a better feeling of power when, after processing traumas of her previous life,  she found the strength to devote herself to struggle in the Unions of her job area, obtaining better conditions for herself and her co-workers. Her husband’s shame for his position of a jobless man and his anger for critical judgments he was receiving even if he was taking care of the family as best he could, after processing some traumatic event in his infancy, turned into pride when he decided to give the second-hand computers that he had found in the local recycling stations presents to African refugees who were locally taught by volunteers how to use computers.


The attention to the areas addressed in this proposal of intervention on poverty does not prevent adopting useful intervention at a group level with multi-problem families (i.e. Asen Multifamily therapy), or different forms of Community Work, stimulating social connections/ connectedness.

In general, to develop socio-economic sensitive family therapy interventions we need therapists “trained” in family evaluation within a socio-economic frame and, above all, therapists “trained” in civic awareness.

Conclusions

In the discussion of the issue of this paper we came across some important questions for our therapeutic work. The first regarded whether it is systemic thinking to isolate the dimension material poverty and to specifically work on it. The answer we have given is yes, if we think in term of processes in complex cumulative aspects. The second question concerned how strong the link is between poverty and mental health, if it is better explained by social causation or social selection and which mediators or influencing factors are more important. We have found that mediators we enucleated have to do with our work in Family Therapy, and the answer we can give to this question is that the link between poverty and psychological distress is strong and mediated by risk factors and protective factors connected to family dynamics and family narrative, with concept and tools already “in the DNA of family therapists”.

We have learned to focalize on important common stressful psychological aspects due to poverty  (to be carefully considered during the assessment phase), to recognize key targets to evaluate in an interconnected way when working on chronically poor families in a condition of relative poverty (both poverty as a long term context and poverty as an event of traumatic discontinuity), and to develop resources and resilience through systemic family therapy intervention, possibly interweaved with specific trauma approaches or techniques for effective and efficient results.

As always in our “professional mission”, therapists must be respectful of unusual and painful situations of adaptation to reality but, above all, able to stimulate coping with adversities, resiliency and useful competences.

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Retrieved from http://www.who.int/mental_health/action_plan_2013/en/

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