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Two of the things that seem to affect low levels of success for treating clients with depression are poverty and ethnic minority status. Clients who are dealing with depression, in addition to being economically and socially disenfranchised, are dealing with compounding stressors. They are statistically more likely to drop out of or disengage from treatment attempts. The research question that Swartz’s 2007 study looked at was “What can be done lower rates of drop out and “no shows” among clients with depression?”
The authors addressed this question firstly, with a qualitative literature review, and secondly, by developing an “engagement session” protocol for use with clients with low levels of motivation. After reviewing the literature on motivational interviewing (MI) and ethnographic interviewing (EI), and finding that MI in particular, is empirically supported for increasing engagement and motivation among clients with serious substance issues, the authors proposed and described the protocol for an “engagement session” that could be used at the beginning of treatment among clients with low levels of motivation.
Motivational interviewing is a technique I want to learn more about, especially given that I am currently doing my internship in corrections and want to continue to do client work with people who come from low-income and disadvantaged backgrounds like those that this article targeted with the EI/MI intervention. It is described in the article as a “client centered, directive method of enhancing intrinsic motivation for change by exploring and resolving ambivalence” (432). My instinct and first response when I sense ambivalence is to ignore it, which is not as effective as I would hope. Motivational interviewing seems to provide an effective tool to deal with ambivalence.
Ethnographic interviewing will also be important for me to learn more about, especially because I am rather shamefully, quick to judge. For instance, in my work with the young men in corrections, my initial instinct was to assume that both the client and I had the same idea about what the problem was: namely, their engagement in the criminal offence that got them incarcerated. It has been good for me to learn to take a step back and ask about the client’s judgment of things, being aware of my own bias and quick response. I hope that learning more about motivational and ethnographic Interviewing, and specifically, becoming more comfortable with ambivalence in general will help me be a better therapist, researcher and teacher.
A specific example of how I have been using motivational interviewing and ethnographic interviewing in my work with the young men at my practicum site has been during my initial interactions with the youth I serve. As all of the young men I work with are court ordered into corrections and treatment, it would appear, initially, that motivation levels may be very low. They have not actively sought treatment and therefore, their engagement in it would intuitively be lower than the “average” outpatient client.
However, levels of motivation at the outset of therapy seem to have quite a range, from “I’m never going to stop being a criminal and I’m going to die a gang member” to “I don’t ever want to come back to prison, I need to learn how to avoid police and subsequent incarceration” to “I need to change everything about my life, and the change I am going to make is going to be transformational, as opposed to a superficial in nature.” Each starting level of motivation includes different ideas about what change is, what meaningful change would consist of, and whether or not change is a meaningful pursuit. To make the last point more succinct, the value of change is not a duality; how meaningful change or growth or healing is bound to be is more accurately measured on a Likert scale.
Regarding the young men at my practicum site, ethnographic interviewing is also important. Recognizing my own self of the therapist and knowing that I am walking into the room with my Masters degree nearly completed, my white skin, my thick and trendy glasses, I am, by appearance and speech often a world apart from the adolescent, impoverished, ethnic minority and often truant youth with whom I work. While it may be easy and even not inaccurate for me to read the young gang-banger who states that he will claim his “set” until his early death as short-sighted, I may not know that in the community from which the young man comes, gang involvement is firstly, a matter of safety. When I’ve worked to meet the young men I work with in their world and ask more questions to help me understand, more often than not I’ve found that their gang involvement serves an important and needed purpose in their life and in the lives of their family members. Although they are currently incarcerated, their gang involvement protects their families.
Some of the questions I regularly use with my clients that come form a motivational/ethnographic interviewing stance include:
- On a scale of 1-10, where 10 is “100% absolutely want to complete your goal” and 1 is “no way, not even going to try at all,” where are you as far as working toward your goal? (Motivational Interviewing)
- Why are you at the number you picked and not lower? (Motivational Interviewing)
- If you felt 100% committed and had all of the time, resources and everything else you needed to work toward your goal, what would keep you from completing it? (Motivational Interviewing)
- What do you do during a typical day at home? Who do you see during a typical day? (Ethnographic Interviewing)
- Who will be important to include in your treatment? (Ethnographic Interviewing)
- What nouns do you prefer for what we are doing here, for example, counseling, meetings, sessions? (Ethnographic Interviewing)
- What do you think the problem is? What led up to the problem? (Ethnographic Interviewing)
- Have you had other encounters with social service people or mental health before? What have they been like? What did you like? What don’t you like? (Ethnographic Interviewing)
By being honest in my ignorance and working to understand where clients are coming from, what is important to them, and engaging with them in those things that they perceive as important, I build connections that help my clients not only experience growth, healing and even change on their own terms, but also leave the door open for further help-seeking in social services and become the sort of person who can question harmful and criminal behavior in such a way that leaves my clients also questioning it. When we work to know our client’s worlds, we connect in such a way that allows for and compels growth on both sides of the relationship. Therapists and clients experience change.
Swartz, H.A, Zuckoff, A., Grote, N.K., Spielvogle, H.N., Bledsoe, S.E., Shear, M.K., et. al. (2007). Engaging depressed patients in psychotherapy: Integrating techniques from motivational interviewing and ethnographic interviewing to improve treatment participation. Professional Psychology: Research and Practice, 38(4), 430-439.
After last Tuesday’s earthquake in Haiti, a flood of donation efforts began. One of the more notable ones that I heard about was the Red Cross’s donation via text message. By texting HAITI to 90999, users could donate by having $10 added to their cell phone bill. In the past week, they have raised more than 7 million dollars, solely through texted donations. When I went to the grocery store yesterday, I got prompted at the register to donate by adding money to my bill. I donated an additional $5 that way. In small donations, the Red Cross is getting the money they need to get the job done effectively and efficiently. I wonder how the proliferation of technology will change the look of philanthropy and disaster relief in upcoming years. Props to the Red Cross, not just for the amazing relief efforts they do on a continuous basis, but also for using technology in a way that allows more people to effectively contribute.
Public Radio International (Jan 18, 2010). Text donations aid Haitian relief efforts. Retrieved Jan 18, 2010 from:
http://www.pri.org/science/technology/text-donations-aid-haitian-relief-efforts1837.html
A recent study put out by the Robert Koch Institute found that rates of smoking and obesity are significantly higher among individuals from lower socioeconomic classes. I didn’t find this study to be all that surprising. Although preparing and cooking foods at home is cheaper than going out for fast food, it requires time. Even just riding the bus to and from work, at least in the Minneapolis – St Paul, MN metro area can expect to take at least 45 minutes to an hour on average. Where riding the bus is cheaper and sometimes preferable (for instance for those people who work downtown and would prefer to not pay to park), time becomes the real resource. If stopping for fattier, less nutritional fast food saves time, than the price is worth it. When it comes to smoking, I wonder if smoking becomes almost an element of self care; it is relaxing and you get a break from whatever job you work to have a smoke. I wonder if actual leisure time, free from childcare and work, might be a change agent for those negative health habits. I have no idea how implementing this sort of idea would work, but it seems interesting.
Deutsches Aerzteblatt International (2010, January 15). Poor people smoke more. ScienceDaily. Retrieved January 16, 2010, from http://www.sciencedaily.com /releases/2010/01/100115112048.htm
The Washington Post recently put out an article called “The High Cost of Poverty”. To put it succinctly, “To be poor, you have to be rich.”
Check it out:
How do the wealthy walk? That question, at least as far as how they walk with others, is one addressed by a recent study put out by the University of California-Berkley. They put participants in a room with a video camera and had them interview each other. During the interviews, researchers measured engagement and disengagment behaviors. Engagement behaviors were nodding, smiling, eye contact, and other signs of active listening. Disengagment behaviors were behavirors like doodling and fidgeting. Researchers found that participants from a higher socioeconomic status’ demonstrated more disengagment behaviors and participants from lower socioeconomic status’ demonstrated more engagment behaviors. More interestingly, when other participants were shown the videos, they were able to correctly identify the socioeconomic status’ of the videotaped participants. Assuming that factors like appearence of participants were controlled for, do these finding surprise you? Why?
Association for Psychological Science (2009, February 5). Rich Man, Poor Man: Body Language Can Indicate Socioeconomic Status, Study Shows. ScienceDaily. Retrieved February 8, 2009, from http://www.sciencedaily.com /releases/2009/02/090204121515.htm
I spent my first year out of college living in a 550 square foot one-bedroom apartment in the Phillips neighborhood of Minneapolis, MN. Although certainly not the most dangerous neighborhood in the Twin Cities metro, Phillips does have a bit of sorrid reputation. It is not wealthy; my building was across the street from Little Earth, a housing project for Native American residents. In my building with a grand total of eight other 550 square foot one-bedroom apartments, there were four different languages spoken. On my side of the block, Somaliland and Haiti were represented along with both Native America, and the America who thought President Bush was, quite literally, God’s gift to America. I fit in on my street. In spite of my white skin, I felt a sense of kinship with my neighbors. My neighbors were out of much greater challenges than college, but we were all trying to find our way to Aldis, the post office, and an independence of our own design.
As much as I enjoyed living in my Minneapolis apartment, I did have some unexpected encounters. One night, I came home from work at 5PM and looking out my side window I saw someone I didn’t recognize pull the screen off the window directly below mine. The man climbed in the window, and a woman’s voice screamed. I called the police. They came, and as it turned out, the tenant who had been renting the apartment below mine, hadn’t actually been living in it for some time. He had kept his key, but was letting some friends stay in the apartment. Due to the “Do Not Copy” engraved on all of my landlord’s keys, the window was his means of entry. The woman screaming was angry at him, but just angry, not surprised. My landlord assured me of the norm of this situation. Apparently many families and social systems in my Minneapolis neighborhood had similar arrangements, designed to prevent homelessness.
According to a recent study published by Angela Fertig and David Reingold the risk of family homelessness is more strongly related to individual than structural factors. In a longitudinal study that took place over three years and examined both structural and individual factors, homeless families are more likely to be headed by African American single mothers who have been dealt with health or safety issues (like chemical dependency or domestic violence). These families are unlikely to have lived in any particular neighborhood for five years or more, which would suggest a low rate of community supports. Anti-homelessness laws, like those against vagrancy or sleeping in public spaces, were not found to be statistically related with lowering the rate of homelessness. In the study, homelessness was defined as either being homeless at the time of the interview, or having have spent even just one night somewhere that is not meant for sleeping (a car, tent, outdoors, ect) out of necessity.
Homeless families are most likely to be led by African American single mothers. (Photo from Shake it For Shelters.)
The major alternative to homelessness the study examined was “doubling up,” or moving in with a relative or friend rent-free. The families more likely to double up were found to be Hispanic or another race, younger, high school graduates, and have family who would likely loan them a small amount of money (<$200). All of them families examined in the study had a child under three years of age. One explanation offered in the study is that when mothers give birth to a new child, they may reconsider staying in an abusive relationship. Alternately, the birth of a new child increases economic stress on any family. For families who are already living on the edge, a new child may push them over.
The study suggests some ways cities and institutions can help prevent family homelessness. Targeting their outreach efforts toward female high school dropouts who are new to the area would seem to lower the risk for homelessness. Additionally, increasing welfare and Section 8 programs was not found to increase the rate of homelessness; instead it was found to help mitigate some concerning risk factors. Length of time spent in a particular community was also found to be negatively correlated with homelessness.
Fertig, A.R. and Reingold, D.A. (2008). Homelessness among At-Risk Families with Children in Twenty American Cities. Social Service Review, 82(3), 485-510.
