Real World Clinical Blog: Poverty as Trauma, Social Work as Cure
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
In March 2016, the American Academy of Pediatrics declared poverty as the single most pressing, chronic health issue facing children in the U.S. In fact, the number of children living in low-income, poor families has increased from 39% in 2008 to 44% in 2014. Recent ground-breaking research has shown that poverty is likely the largest determinant of adverse health experiences throughout the lifespan. The lifespan itself is greatly reduced by the presence of poverty, often deep poverty, during early childhood.
A simple questionnaire that assesses the presence of adverse childhood experiences has been distributed to adults throughout California and, more recently, in Philadelphia. The questionnaire is 10 questions - when tabulated, it gives someone their ACES score. An ACES score, which is a representative number of childhood trauma, acts as an uncanny predictor of adult physical and mental health suffering.
The manifestations of early childhood trauma range from increased rates of diabetes and cancer to inarguably disturbing rates of depression, anxiety, and PTSD. High ACES scores also seem to occur in tandem with childhood poverty. Childhood poverty typically leaves children living in environments that are infiltrated with toxic and chronic stress. This stress is the byproduct of families living in abject scarcity, often hunger, significant violence, and with constant feelings of heightened fear and terror.
Although we are well aware of the immutable vulnerability of the developing mind from the ages of 0-3, this vulnerability actually seems to extend to the age of 6. The more stress there is in the childhood environment, both inside the home and outside of it, the more the developing mind is compromised. Children living in chronic, chaotic, and toxic stress operate mainly out of the base of their brains, where the HPA axis exists. Operating and surviving from this neurobiological realm prevents the development of executive functioning, which is born out of the frontal lobe. Development literally cannot occur because of the child’s effort to regulate the stimuli of a stressful environment. Beyond the age of 6, the possibility of developing successful frontal lobe functionality becomes increasingly difficult.
Of course, as social workers, we know all this. Perhaps we were taught it, or perhaps we bear witness to it daily. Either way, we know and we know it deeply. Maybe we don’t literally know that only 14% of Philadelphia fourth graders are at the proper reading level, but we do know that our children are drowning in their own cortisol and adrenaline. Maybe we don’t literally know that more than 62 people were shot over Memorial Day Weekend (2016) in Chicago, but we know that our children are often too scared to risk their own vulnerability to the possibility of attachment. We know that our clients are suffering. And make no mistake about it, the people suffering the most are our clients.
When allowing ourselves to think clearly about the nearly depraved state of inequality that currently exists in our country, it is hard to remain engaged and determined. Of course, policy changes are essential, and we won’t heal without them. However, the most basic social work interventions are the precise leverage in the war that is being waged against poor people. How do we develop frontal lobe functionality? How do we reduce cortisol levels? How do we keep people from acting out of impulse rather than deliberation and intent? The answer to all of these questions, all of the time, is through relationship.
The cornerstone of clinical social work practice is the relationship, again and again, over and over. The relationship, meaning the presence of a steady attachment figure that offers empathy, curiosity, and warmth, shifts neurobiology. It doesn’t just shift it. It also lends to the development of more complex cognitive and affective functionality. In the presence of a steady, mirroring relationship, the brain calms down in profound ways. This calm, almost like a fertilizer, lends to the development of meta-cognition and reflective functioning. Reflective functioning, the opposite of the fight or flight response, requires the use of the frontal lobe and allows for decision making.
Aside from theoretical orientation, specific interventions, treatment planning, or goal making, the relationship itself is what is actually curative - and curative in profound ways. For every way that our society is structured to annihilate the evolution of authentic equality, the clinical social work relationship offers an antidote. Is it a sufficient antidote? Certainly not. But does it penetrate growing minds, creating the possibility for secure attachment experiences? Yes, absolutely.
By showing up, asking good questions, maintaining eye contact, meeting consistently, and seeing people holistically, we begin to help people experience themselves as cohesive wholes. When feeling overwhelmed by the pain around us, it is utterly essential to remember that it is exactly what we have been trained to do that can turn tides. The tide changes might not be immediately obviously or fully satisfying, but all corrective attachment experiences are cumulative. We are piecing together an extended release treatment that will emit its effects, in the minds of our clients over time, often unbeknownst to our searching eyes.
Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.