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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.
My husband and I have been married for just over two years now. One of the things that we really like to do together is go for walks. We walk through our tree-lined neighborhood, holding hands, and chat about our days, the weather, all of that average, mundane stuff that relationships are made of. I treasure those walks.
While we are walking, we rarely get a second glance. A neighbor or two might glance up and smile in greeting or extend an “ ‘Evening” but rarely do we get much more than that. I’m okay with that. We aren’t out for a walk to be recognized or announce anything about ourselves to anyone else. We are simply strolling at dusk, anonymous and happy.
While we are walking, we are anonymous. We are just a couple, like any other.
Another couple might be walking at the same time we are walking. They, too, might have been together for over five years and be highly committed. They may presently struggle with many of the same things young couples struggle with: defining their couplehood, maintaining family of origin relationships and navigating emergent adulthood. They, too, may someday plan on buying a house, planting a garden and raising children.
When this couple walks, though, they are not anonymous. They may be gay or lesbian, biracial, or have any the other characteristics that seem to require explanation. In short, they deviate from “the norm.”
Over the past year, this has really struck me. When I’m thinking about what being oppressed and privileged means, I think that one of the primary clues that I’m thinking about a category of privilege is that it does not require explanation. When my husband and I walk at dusk, I feel like I can rest assured that nothing is assumed about us. We could be liberal or conservative, parents or childless, in touch with our families or not.
As far as I know, holding my husband’s hand is not regularly construed as an overt political statement.
One of my assumptions is that all people have been both recipients of privilege and victims of oppression. Where in your life are you oppressed? Where in your life are you privileged? If you are having trouble defining these areas, think about the parts of your life and context that demand explanation. What does that mean?
*Many thanks to Dr. Terri Karis and Dr. Bruce Kuehl, two professors at the University of Wisconsin-Stout, who got these ideas rolling.
Individuals and systems are bound by context. For instance, although according to surveys, higher rates of domestic violence are demonstrated among African Americans than whites, when the confounding effects of poverty and racism are eliminated, that difference between ethnicities also disappears (Hamel, 2005, 30). Ethnicity as a contributing issue, therefore, is ruled out in the etiology of domestic violence and instead, classism and racism stand indicted.
As competent researchers and practitioners, we look for confounding contextual factors that speak against narrow viewpoints such as those that would suggest that “African Americans are violent” (Hamel, 2005). In short, in our investigations of individual trees we don’t miss the forest or the dirt or the sky. We want to see the detail, as well as the whole picture.
In Gender-Inclusive Treatment of Intimate Partner Violence: A Comprehensive Approach, Hamel describes individuals dealing with “psychopathy,” as “essential untreatable” (54). Although I understand the pragmatic intent of treating immediate issues of violence with an attitude of triage, I am unsure how perpetuating such worldviews positively impacts the likelihood of developing treatment methodologies in the future.
As an MFT, I believe that one of the primary limitations that competent therapists deal with is an awareness of the confines of our own sight. We can only see that which we think is possible to see. In our educational system, it is vital that we learn both the importance and efficacy of triage, but also employ significant questioning whenever an individual or their diagnosis is deemed “untreatable.” Certainly, in the present moment, some individuals live with diagnoses that are unresearched, difficult and/or impossible to treat. Antisocial Personality Disorder, the “psychopathy” Hamel refers to falls in this category. However, that is only for the present moment.
As the future of mental health and the future of many individuals without the resources, knowledge or connections to advocate for themselves or their loved ones, we have a responsibility to read any claims of “terminal” with both a skeptical eye that questions the details of validity and a wide angle lens that notices the wider contextual factors that may be contributing to that claim. For instance, Robert Foltz, a research whom I much admire, wrote regarding the treatment of Conduct Disorder (an established pre-cursor to Antisocial Personality Disorder, or “psychopathy”), its “likely that that brain changes in youth with psychiatric disturbances are actually the product of their life experiences rather than the cause of their symptoms” (2008, 7).
I appreciated Hamel’s description of assessment of domestic violence. I especially appreciated the focus toward practitioners evident by the straight-forward counsel regarding assessment tools and biases to notice. I did take issue with his description of “psychopathy” as untreatable, not because it is untrue, but because there simply are not treatments yet. It is possible to describe the extreme limitations in providing treatment for specific diagnoses without effectively describing them as terminal. In the education of future counselors, even simply stating “right now, there is not a treatment” is preferable, because it includes the “right now.”
Foltz, R. (2008). Behind the veil of conduct disorder: challenging current assumptions in search of strengths. Reclaiming Children and Youth. 16(4). 5-9
Hamel, J. (2005). Gender-inclusive treatment of intimate partner abuse: A comprehensive approach. Springer Publishing Company: New York, NY.
For Trees We Will Not Sit Under 