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Les Liaisons Dangereux

Les Liaisons Dangereux:

Humanistic Psychotherapy with the

Economically Disadvantaged.

 

Sharon R. Kahn, Ph.D

 

Dangerous Liaisons:

Psychotherapy with the Economically Disadvantaged

Sharon Kahn, Ph.D

[A version of this paper was originally presented at the Annual Meeting of the Eastern Psychological Association in Boston, on March 31, 1995].


Abstract:


Psychotherapists negatively stereotype economically disadvantaged patients as less suitable for various treatment modalities than all other patients. This stereotype enmeshes psychotherapy within an unexplored matrix of socio-economic status (SES). Failure to examine this matrix may create a system where patients suffer negative therapeutic effects while therapists confirm their pre-existing beliefs. This paper will illuminate this matrix through the theory of Abraham Maslow and illustrate treatment issues through case material.

Dangerous Liaisons:

Psychotherapy with the Economically Disadvantaged

Sharon Kahn, Ph.D

 

Introduction:

Psychotherapy literature manifests insufficient sensitivity to the confounding impact of patient socio-economic status (SES) on psychotherapeutic diagnosis, treatment, and outcome. Extant literature indicates unarticulated and uninterpreted transference and countertransference enactments emerge when patients have either a higher or a lower SES than their therapist. However, certain countertransference enactments emerge that are unique to psychotherapy with lower SES patients. Lower SES by itself may be viewed by clinicians as a trait of psychopathology. Therapists tend to negatively stereotype lower SES patients as more likely than upper SES patients to present in crisis, somaticize concerns, miss sessions, demand concrete advice, utilize denial of feelings, etc., in therapy. Therapists are also likely to believe that lower SES patients, because of their social class standing, require special treatment approaches or are unsuitable for other types of treatment. Finally, while higher SES patients may present for treatment either in sliding-scale clinics or in private practices, lower SES patients are likely to be treated only in the clinic setting and are assigned to less experienced or training therapists there. Therapists' stereotypes about low SES may create countertransferential difficulties, increase patients' risk for premature termination, and exacerbate the potential for negative therapeutic effects.

Method:

In this presentation, I will review representative literature on therapy with lower SES patients. The constituents of social-class will be defined according to Hollingshead's criteria. The enmeshment of various therapeutic parameters within social class, capitalism, and culture, will be delineated and explored through the theories of Abraham Maslow Additionally, I will present a case from my work with economically disadvantaged clients at a psychoanalytically oriented training clinic. The case presented will deal with the twice weekly, two year psychodynamic treatment of an elderly Caucasian female, Josephine. Josephine was an unemployed graphic artist, financially dependent upon Medicaid, and later, Social Security. Nosologically, she presented with borderline personality disorder and had several episodes of major depression over the course of treatment. She had paranoid fantasies and was a social isolate. In the presentation, I will discuss how Maslovian constructs guided the creation of specific parameters employed in her treatment, describe countertransference/transference interactions, and relate treatment outcome. Finally, I will compare and contrast treatment experiences with fee-for-service and Medicaid patients.

 


Results:


Assumptions about the unique difficulties of treatment brought by lower SES patients were not validated by my experience at this clinic. Over the course of treatment, Josephine showed enhanced ability to more functionally resolve interpersonal difficulties. She showed decreased paranoid ideation. Being socially isolated was more ego dystonic to her after treatment ended. Individual psychodynamic therapy, however, failed to enhance her economic status. Furthermore, clinic patients who present with borderline personality disorder, regardless of their SES were more similar in their psychodynamics than not. Somatizing, presenting in crisis, wanting advice, missing sessions, denial of affect, etc., are not SES specific in a clinic.

Discussion:

A humanistic psychodynamic framework that takes into account the theories Abraham Maslow is a definite asset in helping the therapist gain entry into and identify with the intrapsychic world of lower SES patients. This paper will explore the effects of socio-economic status as it intersects with standard tenets of psychodynamic psychotherapy through illustrative case material. Economically disadvantaged clients present treatment opportunities for psychotherapists in the clinical setting. However, they also present empathic dilemmas rarely encountered by therapists in professional practice. Therapists may feel overwhelmed by their clients' chaotic lives and unable to attune to them. Literature reviewed indicates the need to invoke fresh perspectives for such clients based on theories formulated by both Abraham Maslow. Real change is contingent upon a recognition of the interplay among individual, societal, economic, and political forces. Statistical and demographic information will be presented, along with treatment issues, countertransference/transference interactions, and treatment effects.

1. MEthod of payment is not an adequate indice of ability to work

2. SES is fluid for both therapist and patient

3. Economic factor not totally controllable (it is a memoment in which you meet the patietn).

 

Develop a thesis statement: Fluidity/Expectations based on current SES erroneous and theme of hierarchy of needs, status of movement.

One reason for a lack of literature on the psychological treatment of the economically disadvantaged is the lack of acknowledgment of class and status issues by psychotherapists. Another is the relative lack of access the economically disadvantaged have in receiving outpatient psychotherapy. However, one group of economically disadvantaged patients can have regular access to outpatient psychotherapy services---those who receive Medicaid entitlements. The Medicaid patient pays no fee for their session, suffers no fiscal penalty for missed sessions, and receives reimbursement for carfare at the end of the session. When the Medicaid client misses a session, the therapist is penalized because Medicaid will not reimburse for sessions not held. Not surprising, therapists become frustrated with this arrangement, as the usual motivator, paying for missed sessions, can not be applied to this clientele. Over time and across occurrences, frustration leads to stereotyping Medicaid recipients as undesirable psychotherapy patients who lack both motivation and psychological mindedness to engage in therapy. The lack of a fee is interpreted as giving them a lack of incentive. Poverty is viewed as a component of their psychopathology. The Medicaid patient may be more at risk to be transferred in a clinic from therapist to therapist, either because of therapist frustration or because the therapist leaves the clinic for private practice. This is an environmental failure which may impede their psychoemotional progress.

Although Medicaid has paid for therapy treatment for over a quarter of a century, little has been written specifically about therapeutic outcomes with this population. In 1993, Psychoanalytic Dialogues,3, had a special issue which focussed on psychotherapy with the urban poor. However, in few papers was poverty recognized as a complicated biopsychosocial predicament, which affects these patient's self-esteem, family relationships, and relationships with their environment, and, which in turn, affects the environment's relationship to them. Poverty is more than chronic, concrete, financial distress. Karon & Vanderbos, 1977, were two authors who acknowledged this issue. The free for service aspect is not what makes the Medicaid patient so unusual in the treatment setting. Many patients receive psychotherapy for free through insurance coverage, parents, or spouses. Few therapists have written about the unsuitability of such patients just because their fee is paid by a third party. Such patients are usually better educated than Medicaid patients, are members of the middle or upper middle classes, and, overall, are more similar in background to their psychotherapists. Thus, in psychotherapy, middle class patients are easier for a therapist to identify with, in contrast to the economically

disadvantaged. This problem has also been referenced as a special case of stranger anxiety, as "the poor...may remain strangers to many therapists..." (Lawrence, 1982, p. 250). Class and status inequities between therapist and patient may lurk unexamined in the treatment of Medicaid patients.

Perhaps it is not so much the patient but the therapist who requires a special treatment approach. Therapists may have negative feelings about economically disadvantaged patients in general or about Medicaid patients in specific. (Karon & Vandenbos, 1977;Lorand & Console, 1958). It is not an uncommon for therapists to believe that paying a fee enhances the chances of a positive treatment outcome. (Bloch & Rubenstein, 1987). Payment also enhances the self-esteem and status and the therapist. (Bloch & Rubenstein, 1987). Some authors have confirmed the equations of money with livelihood, status, and prestige. (Drellich, 1991, Horner, 1991, Lerner, 1991, Pasternak, 1988, and Shainess, 1991). However, outcome research indicates neither significant differences nor negative effects between for free and for fee therapies. (Friedman, 1991; Herron & Sitkowski, 1986; Karon & Vandenbos, 1977; Lorand & Console 1958; Schneider & Watkins, 1990; Scott, 1958; and Yoken & Berman,1984) Friedman (1991), a psychiatrist in private practice, described four patients whom he treated for free. Patients' progress ranged from those who because of treatment could live independently of long-term care institutions to those who completed doctorates. Lorand & Console (1958) reported on a larger population of patients treated with orthodox psychoanalysis and found that after 2 1/2 years of free treatment, patients demonstrated better social skills, increased their work ethic, identified themselves with the middle class, and secured more prestigious employment compared to their pre-therapy states. Only in certain types of treatments, such as behaviorally based weight loss programs, or with certain populations, such as students using a campus health center, was it found that patients who paid a fee made more progress than those who did not. (Stanton, 1976; Wesch, et al 1987). However, an empirically validated research base is spare, and these conclusions rest upon a scanty literature reliant on anecdotal reports, case studies, analog situations, and single session therapies.

The negative countertransference therapists often have towards the Medicaid patient is further complicated by the patient's overt rejection of the therapist's latent professional credo. Woven into the manner in which psychotherapy is conducted are many aspects of Western middle-class ideology which have not been openly acknowledged. Such aspects include the weekly fee-for-service hourly session. The client is expected to verbalize their internal feelings and thoughts, come to sessions regardless of feelings, manage their daily affairs so the environment does not thwart their timely arrival, and pay for missed sessions. The Medicaid client does not necessarily fit easily into this framework. Clients present in crisis, recognize somatic concerns, utilize denial of feelings, fail to keep regularly scheduled appointments, and may value the presence of the therapist only to the extent that they remain in a crisis. Medicaid clients expect the focus of treatment to be helpful advice and problem solving. (Altman, 1994; Bergman, 1994, Goldensohn, 1981; Jones, 1974; Olarte & Lenz, 1984; Perez-Foster, 1993; Shen & Murray, 1981).

Abraham Maslow was a psychologist who clearly delineated the need to acknowledgement both class and status issues in psychotherapy. His theories encompass the total environment of the patient/therapist dyad, enhance the therapist's ability to understand their patient's internal world, and increase the therapist's ability to engage the patient in a manner geared to the patient's level of comprehension. Thus, utilizing their formulations would be an enormous aid in treating the Medicaid client. Before I continue, I would just like to offer a brief introduction to the thoughts Maslow relevant to examination of class and status in psychotherapeutic dyads.

How can psychotherapy alone influence an individual who may remain forever marginalized in society? In a capitalistic society, income bears little correlation to occupational utility. For example, both home health care aides and physicians require training, provide valuable services, and work long hours, but their professional prestige and salaries differ.

Maslow's concept of a hierarchy of motives is another asset to boost the power of the therapist's lens to connect with patients. (See Table 1). As can be seen in table 1, an individual's needs can be ordered in a hierarchical fashion. This hierarchy is one of "relative prepotency," that is, the needs are not equal in the forces they generate within the individual. (See chart) Need fulfillment and need deprivation result in characteristic activities or preoccupations.

 

Table 1: Maslow's hierarchy of motives.

Motivation: Interpretation: % Satisfied: Deprivation

Self-actualization Be all that you can be. 10 Metapathology

Hobbies for pleasure (lack values

Concern for others no fulfillment

no meaning in

life)

 

Esteem Respect for individual 40 Doubt,depreciation, lack confidence

 

Belongingness Integration into social groups 50 Defensive, shy

& Love Love: affectionate overaggressive

relationships

 

 

Safety Being cared for, 70 Fear, insecurity,

shelter, security dread

Most people spend their

lives attempting to

satisfy this

Physiological Food, water, 85 Fatigue

oxygen, sleep malnutrition loss of energy

sexual obsessions

 

 

 

 

 

 

 

Needs are rarely fulfilled 100%--the more a need is fulfilled, the more strongly the next level need will emerge.

 

 

 

 

 

 

Maslow's five step hierarchy can be conceptualized as a "steps and stairs" approach for adult intrapsychic development. "Steps and stairs" are a metaphor used by some psychologists in teaching others about the Piagetian cognitive stages. Just as with Piagetian stages, nobody arrives at the top of Maslow's hierarchy without first having transversed all four lower levels. Nobody "skips" a motivational stage. Some people remain on lower levels longer; others climb faster and go higher. Lower level needs become more potentially pressing if they begin redux to be chronically unsatisfied. Therefore, motivational levels are fluid, as life circumstances set the stage for an individual's ascent and descent. Little lifespan oriented research has been executed which either uses or attempts to validate Maslow's hierarchy. It is possible that the higher level motivations require not only certain environmental prospects but certain cognitive capacities as well.

In using the Maslovian hierarchy to illustrate fundamental human motives, one soon sees there is more than a class and status differential between the therapist and the Medicaid patient. There is also a motivational difference represented by their diverse locations on Maslow's hierarchy. In all probability, the therapist is on level 3, love and belongingness, and may be nearing or on level 4, esteem. This gives the therapist a different perspective than that of the Medicaid patient, who may still be struggling to fulfill safety needs or even physiological needs. This difference can become a source of conflictual points of view, as the differential placement on the hierarchy offers each not only a different scene but represents different ways of conceptualizing the self and the environment. Lower level needs are always more urgent and thus potential higher-level needs are neither invoked nor recognized by the patient in a meaningful manner. For example, Altman, 1993, wrote of how a therapist perceived a patient's applying for government entitlements as "giving up," and being enticed by the "tantalizing object." The therapist's formulation of an external event emphasizes the symbolic level. And it may well be quite accurate on that level. But on the more immediate level, it lacked attunement to the physical world of the patient. Applying for welfare for such a patient may represent an active step to care for herself, to ensure some level of both safety and biological need satisfaction on a constant basis. The therapist who ignores motivational level differences and attempts to invoke insight and relatedness will probably fail to engage the patient and may create a "confusion of tongues," (Ferenczi, 1933) where patient and therapist are at cross purposes with each other--the patient, struggling with concrete safety needs versus the therapist, conducting sessions on an abstract level.

Maslow was not merely conceptualizing physiological needs as lacking a meal but of chronic deprivation. Unsatisfied physiological needs are not just concretely manifested as hunger pangs, thirst, weariness, etc. Unsatisfied physiological needs create a complicated concatenation of factors influencing affects, perceptions, memories, emotions, and cognitions. For example:

...when individuals are hungry they change

not only in their gastrointestinal functions, but ...perceptions change (food is perceived

more readily...) Memories change (a good meal

is more apt to be remembered...) Emotions change

(more tension and nervousness) The context

of thinking changes ( a person is more apt to

think of getting food than of solving an

algebraic problem). (Maslow, 1970, pp.3-4).

Those to whom hunger is merely a few hours of deprivation tend to belittle its significance for those who are chronically unfulfilled in this need. And if this is true just simply for hunger, imagine how an individual's perception changes when the product is vastly more complicated as is chronic poverty, where physiological and safety needs are daily unsatisfied. Only real success at filling these unmet physiological and safety needs ensures changes in perception and motivation. It is just as difficult for a middle class therapist to empathize with their Medicaid patient's potent and chronic need deprivations as it is for the patient to understand the more abstract potentials of therapy. A patient who lives in poverty may not even "know" or be "aware" of these more intangible needs invoked by therapy. It is difficult for them to connect how therapy, as tantalizing as it might be, will help them fulfill their pressing lower level needs. Further thwarting the ability of a therapist to attune to this patient is many psychotherapies are grounded on the notion of an optimal frustration of needs. These concepts were originated upon a population of upper middle class patients. However, for those who conduct psychotherapy with the economically disadvantaged, it would be more helpful to consider that "gratification becomes as important a concept as deprivation....for it releases the organism from the domination of a relatively more physiological need." (Maslow, 1970, p. 17). When patients and their therapists are at different motivational levels, there may be little attunement between them, regardless of the nature of the therapist's training:

Of course...[Freudians, existential therapists, Rogerians, personal growth psychologists] can be said to be overpsychologizing and under sociologizing...they do not stress sufficiently in their systematic thinking the great power of autonomous social and environmental determinants, of such forces outside the individual as poverty, exploitation, nationalism, war and social structure..." (Maslow, 1968, pp. 12-13:)

Maslow offers an important theoretical window into the world of the economically disadvantaged patient. He demonstrates a potential difference in perspective between an individual functioning on the higher level and the individual still struggling to satisfy lower level needs. The third level of Maslow's hierarchy, that of love and belongingness, may the most optimal place for a patient to be at for traditional therapeutic work. Treatment planning might be meaningfully conceptualized by using the Maslow hierarchy to concretize what level both the patient and the therapist are at and which presenting problems may be manifestations of deprivation.

Clinical Experiences with Medicaid Patients:

I would like to use Maslow as points of reference for conceptualizing my work with economically disadvantaged patients. I treated seven Medicaid patients in my three years at an outpatient psychotherapy clinic. (See table 2).

Currently, 35% of the patients seen at this clinic have their sessions paid for by Medicaid or SSI benefits. As can be seen in Table 2, none of these patients matched the societal stereotype of the welfare recipient. They were not teenage mothers. They did not descend from a family culture of government entitlements. Socio-economic status of origin ranged from poverty level to upper-middle class. Six had severe personality disorders. Six are female, six Caucasian. Three of the patients had college degrees. One of these patients secured a full time job after two years of treatment and discontinued her Medicaid. Two were terminated from Medicaid for reasons that remain ill-understood. Two are elderly. Three have physical disabilities. All had a work history.

If therapeutic success is defined as patient's coming regularly for session and forming an attachment to their therapist, then it can be said that therapy with Medicaid patients who have attained Stage III in Maslow's hierarchy, regardless of their socio-economic or educational background, was successful. In my caseload, that would be three patients. These patients were also more likely to have been transferred from therapist to therapist at the clinic. Therapy was, at best, a limited success. These patients retained their rigid, uncompromising, borderline or narcissistic character structures. Sessions focussed on concrete issues of deprivation: problems with entitlements, problems with landlords, problems with foodstamps. When relationship issues arose, the level of discussion remained concrete and for a variety of reasons, the patient could not or would not go beyond the "he say, she say" aspects of the situation. Thus, these patients demonstrated limited capacity for understanding themselves or their difficulties with the environment on an insightful level. The therapist attempted to help these patients problem solve, reality test, cope, modify, and negotiate with their environment. Through their therapies, they received a stable, comforting relationship. They obtained a base of empathic soothing from an authority figure. They apparently felt the genuine interest and concern felt towards them by their therapist. As Fromm realized: Even in those cases in which a patient may not
get well, at least one condition is fulfilled in a good analysis, and that is that the analytic hours, if they

have been alive and significant, will have been the

most important and the best hours that he ever had in

his life." (Fromm, 1994, pp.40-41).

There was much to admire about the creative abilities of these Medicaid patients. They were not bundles of ambulatory psychopathology. Josephine was quite the gourmand: she described mouth-watering recipes she devised from her frugal shopping basket, she had a green thumb and maintained an astonishing variety of herbs and flowers in her window sill garden, she sewed, and she was well read. Maisie was able to budget, negotiate, and wheedle with others to give her child a stimulating, enriched environment and a good education. She was occasionally able to create an internalized image of the therapist if great urgency arose. For example, an altercation with a neighbor ended with both being summoned before a court arbitrator. Before she went to court, she called her therapist and discussed strategies. While awaiting her turn, Maisie forced herself to stare out of the window and focus on the neutral object of an automobile in the parking lot, fantasize about what it would be like to own such an automobile, and repeat to herself like a mantra: "My therapist says--don't let Hilda get your goat." She succeeded in remaining calm and focussed with the arbitrator under this stressful circumstance.

Donna suffered from physical and intellectual limitations. She suffered severe early developmental trauma as an emotionally abused and scapegoated handicapped child. Her ability to reality test was quite limited and her low intellectual level caused her to operate at a very concrete level. She received psychotherapy and medical services through SSI. She presented with an odd physical appearance--her corrective glasses magnified her eyes noticeably out of proportion to her face, she had nystagmus, she walked with an awkward gait and she displayed poor posture. Yet, she was capable of passing the civil service test and held a job as a file clerk. She was also ambitious. She had a tuneful voice, took vocal lessons, performed in unpaid showcase opportunities, and aspired to be a working artist. She was also capable of making an attachment, coming regularly to sessions, and showing empathy to others on concrete and solvable issues. For example, when her therapist was recovering from influenza and had a fit of coughing in session, Donna silently took out some lozenges from her purse and insisted the therapist take several. If therapeutic success is defined as patient's coming regularly for session, attachment to the therapist, insight, and, entry into full-time, meaningful employment, then it can be said that therapy with Medicaid patients who have attained Stage III in Maslow's hierarchy, have a middle class background and college training, was successful. In my caseload, that would only be one patient, Beth. Beth was an artist with Usher's syndrome. After a year of therapy, she adjusted to her reality: her husband was not ambitious and was content to receive Medicaid entitlements. Her ability to obtain large grants to create her artwork was uncertain. Furthermore, the galleries where she had once exhibited her work were closing due to financial problems. She went to the library, researched new careers, applied to graduate school and received scholarships, and after her first year in school, found a full-time professional job that enabled her to support herself and her husband. However, she could no longer afford psychotherapy for herself.

Unfortunately, not every Medicaid patient emerges from psychotherapy with even the limited success of being able to engage in a relationship by coming regularly for sessions and by forming an attachment to the therapist. Patients who were in Stage 2 of the Maslovian hierarchy at the time of their presentation were least likely to meet these two criteria. A reasonable hypothesis, which is also aligned to Maslovian theory, is that patients require a stable environmental base where they can leave, return to, and operate in autonomy within, to be able to competently take up the task of adult to adult attachment in psychotherapy. In my caseload, three patients were unable to form a psychotherapeutic connection with their therapist. Concetta, for example, for reasons that remain unclear, was terminated from Medicaid a month after she started psychotherapy. She was ashamed of her poverty and her inability to even pay a lower than usual fee and did not return the therapist's telephone messages or letter.

Walt and Pauline both lived in Medicaid shelters and needed more than weekly or twice weekly outpatient psychotherapy sessions could provide. These two patients would have done better if Medicaid could have provided them with a stable community of lucid individuals in contrast to the transient populations of very low-functioning, very psychopathic populace they daily saw. Walt was in denial of his bi-polar psychopathology and did not take his medication. He had been a successful entrepreneur but lost all his money and assets, probably as the sequelae of manic episodes, and landed on Medicaid. In his first session, he boasted about his two prior suicide attempts and seemed proud that he had not told his prior private practice therapists about these. He was passive-aggressive and refused to engage in expectable hygienic practices.

Pauline had numerous documented physical health problems of which she was in denial. She also had passive-aggressive dynamics. Pauline's treatment consisted of her arriving promptly for session and talking very softly, very circumstantially, and without cessation. These traits, in combination with a slight English accent she developed working abroad as a secretary in an international business conglomerate, created severe difficulties in her being understand on a literal level. Her constant theme was being victimized by men. She constantly bemoaned the therapy's lack of efficacy but would not cease her orations to allow the therapist an entry into her intrapsychic world. After the sixth session, the therapist had to change the day sessions were scheduled for from Mondays to Tuesdays. Although the therapist clarified when this switch would occur several weeks in advanced and reminded the patient of it in the last session, Pauline showed up the next week on the usual day, only to find her therapist away. She was so enraged by her misunderstanding of when her psychotherapist was rescheduling sessions that she screamed at clinic personnel and later at her therapist and terminated treatment.

Conclusion:

Psychotherapists need to reconsider the significance of what therapy means for a patient, in a manner which is attuned to both the patient's and the therapist's current life circumstances. Psychotherapist's need to be alert to the potential misalliance created by their training and inclinations to treat external events on the symbolic level versus the Medicaid patient's frustrations in conquering the real privations of everyday life and potential inability to engage in the relationship above a concrete level. Engagement with a patient on this level does not necessarily mean the patient is not benefitting from the service, nor that they are unsuited for psychotherapy. A psychotherapy where the patient remains fixated on a concrete level of reality does not mean that the patient is not making intrapsychic progress nor that the therapist cannot understand the patient on a symbolic level nor utilize the communications in a psychodynamic fashion. It does require the therapist's ability and willingness to translate this symbolic understanding to the patient in a meaningful, concrete way. It may also require that the psychotherapist be attuned to the patient's ego strengths or talents, praising, prizing, and refining what is there. It may require a psychotherapy attuned to patient ego assets over patient ego deficits.

Psychotherapists need to revitalize a treatment matrix based on theories formulated by Abraham Maslow. Class, status, and motivational differences can be barriers in achieving an empathic accord with the Medicaid patient. The therapist may be used to treating patients who live financially stable and orderly biological existences. The very real traumas and stressors of poverty: bureaucratic obstacles in receiving benefits, budgetary constraints against realizing dreams, housing restrictions, fiscal insolvency, physical handicaps, landlord unresponsiveness, physical dangers, educational and vocational limitations, ethnic/racial prejudices and biological survival, may remain unrecognized and unvalidated by the therapist, who is then ill-prepared to formulate a realistic treatment plan for these clients. Instead, the therapist may feel exploited by such patients and this becomes a source of countertransferential difficulties. Change may be contingent upon a recognition of the interplay among individual, societal, economic, and political forces. Psychotherapists who envision the patient's location on a Maslow Hierarchy may more easily attune to the patient's internal world and structure a therapeutic situation which can engage them and make them feel recognized. Psychotherapy with a Medicaid patient is often more frustrating for the therapist. However, for the patient, it may offer the needed stability to begin to satisfy their lower level needs adequately.

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