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.