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To Have and Have Not: Feeling Empowered to Manage HIV (Regardless of Social Class)

As a mental health professional and licensed clinical social worker, one of things I do with a new patient is to take a thorough “psychosocial assessment” – basically, his or her life story in one hour or less. I ask about family history, history of current symptoms (depression, anxiety), current medications, work history, health experiences, education, social support, hobbies, and cultural background. But I also ask about his or her current and past socio-economic status; what “class” did he or she grow up? I ask this because I think the issue of money in American society is one of the most emotionally-laden, and can shape – positively or negatively – a person’s experience of the world.

Add to this the challenge of living with HIV/AIDS, and I think the stakes go even higher.Many current studies show how, in general, people in the U.S. with HIV who are middle class or higher in terms of income or other resources are generally doing better – at least physically – than those of lower-income classes. Why is that? Presumably, it’s because of differences in access to food, shelter, clothing, transportation, information, medical clinics, medications, and expert/specialist care. I think that part of living with HIV successfully means feeling empowered in society, which people of the higher economic classes generally do and those of the lower economic classes don’t. Why is this? I think it’s part of the old-fashioned but still all-too-real social ills like sexism, racism, xenophobia (fear of “foreigners”) and homophobia. It is clear (because it is reflected in the current epidemiological data) that poor people, women, people of color, younger people, and immigrants are having a worse time gaining access to the kinds of resources that help other people in the U.S. with HIV live more stabilized, happier, healthier lives.

Whenever one of my patients presents with symptoms or challenges in his or her life that are keeping him or her from “full social and occupational functioning” (one definition of “mental health” used in the field), I look for what resources – internal or external – can be rallied to help this person achieve treatment goals. Using “internal” resources means things like changing the perception or meaning of a problem, raising self-esteem, gathering motivation, identifying and modifying fears, and changing unhelpful thoughts. External support resources (as described in a recent study being conducted through the Medical College of Wisconsin and UCLA) are things that provide emotional support (friends, relatives, support groups), informational support (physicians, therapists, books, Internet, librarians, treatment advocates, newspapers, pamphlets, newsletters), or tangible support (job income, welfare, Social Security, disability income, food stamps, home-delivered meals, home health aid). In mental health treatment, part of solving problems means identifying, accessing, accepting, and maintaining internal and external resources, and using them to improve functioning.

So if a person is among the lower economic classes, he or she faces an additional challenge in living with HIV because there is, unfortunately, a two-tiered system of medical care in the United States – one for people who have things like health insurance and access to (usually big-city) specialists, and one for people who must “make do” with whatever public assistance provides. While this issue is rife with complex political and social justice implications, it usually boils down to how we, as individuals, manage living with HIV both physically and emotionally. For people who rely on public assistance for their health care (such as non-profit community clinics, AIDS Drug Assistance Programs, Medicaid, Medicare, etc.), the internal resources of motivation, hope, empowerment, and courage become all the more important. We need to advocate for ourselves at every opportunity to fight the helplessness, depression, and frustration that can come with being a “have-not” in the otherwise affluent United States. We need to do what we can to fight helplessness by voting in elections for AIDS-friendly candidates, writing letters to our elected officials to express opinions important to us, speaking up at Town Hall meetings, making connections with others to form strength in numbers, and even participating in boycotts, non-violent social protests, or civil disobedience.

Depression tends to be at its worst when people feel badly about something while at the same time feeling helpless to change it. Taking an action, however small, to challenge one’s inertia contributes to feeling empowered and efficacious, which in turn leads to more action. These things do wonders to promote self-esteem and fight the “depression of oppression” on an individual level; they might even ultimately challenge the line between “haves” and “have-nots” in the world of successful HIV management.

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