Partner Abuse, Volume 1, Number 1, 2010 programs and practice Guiding as Practice: Motivational Interviewing and Trauma-Informed Work With Survivors of Intimate Partner Violence Motivational Interviewing and Intimate Partner Violence Workgroup Over the last five years, a new paradigm has emerged in social services. Numerous social service providers are now being asked to provide treatment within a framework of trauma-informed care. Trauma-informed services recognize the pervasive impact of current and previous violence on the everyday lives of many clients. Such services prioritize the establishment of a safe, trusting relationship where trauma can be disclosed. Trauma-informed services also account for the potential effects of clients’ experiences of violence and trauma on their relationship to treatment and to treatment providers. This article describes trauma-informed services and the potential that Motivational Interviewing (MI), an evidence-based, client-centered, and guiding communication style, holds for utilization within trauma-informed work. A case vignette is provided which demonstrates primary MI skills that can be used to create a climate of safety and trust, and effectively elicit and strengthen clients’ motivation for change. A discussion of the case and ethical aspects associated with MI in trauma-informed work is also provided. In addition, suggestions are made as to the potential MI holds for further use with traumatized clients. KEYWORDS: intimate partner violence; substance use; ethics; practice; motivational interviewing There is increasing awareness of the necessity to provide trauma-informed services to improve the system of care (including substance use disorder [SUD] treatment, mental health treatment, and domestic violence services) for women who have experienced violence (Elliot, Bjelajac, Fallot, Markoff, & Reed; 2005; Finkelstein et al., 2004; Harris & Fallot, 2001; Salasin, 2005). Trauma-informed services are delivered based on the recognition of how violence impacts individuals’ lives and development and they reflect this awareness in all levels of service delivery (Elliot et al., 2005). From the trauma-informed perspective, some client behaviors that have been conceptualized by other approaches as maladaptive and /or representing 92 © 2010 Springer Publishing Company DOI: 10.1891/1946–6560.1.1.92 Motivational Interviewing 93 a pathological noncompliance with sound treatment strategies and recommendations are better understood as reactions to unresolved trauma that can become threatening to the client in the change process (Saakvitne, Gamble, Pearlman, & Tabor Lev, 2000). While the focus of our project and specifically the vignette we provide revolves around female survivors, we acknowledge the fact that men (Archer, 2000; Houry et al., 2008; Próspero & Miseong, 2008) and transgendered people (Zaligson, 2007) also experience intimate partner abuse. The emotional impact of domestic violence on men, while not as severe as the impact on women, is not negligible; and recent research finds that the effects of psychological abuse and control are comparable across gender (Hines & Malley-Morrison, 2001). Motivational Interviewing (MI) has been shown to be effective for both male and female consumers for a variety of behavior changes (Miller & Rollnick, 2002; Rollnick, Miller, & Butler 2008; Rubak, Sandboek, Lauritzen, & Christensen, 2005). Consequently, we propose the MI intervention in this article as applicable to all survivors regardless of gender identity or sexual orientation. The effects of exposure to trauma and /or intimate partner violence (IPV ) may lead to difficulty in establishing trust with providers, caution in what is disclosed, and sensitivity to shame and guilt. Trauma-informed services are those that respect the needs of survivors as affected by their history with traumatic experiences and provide interventions in ways that are safe and quick to build rapport. These are different from trauma-specific services, which are those services designed to specifically address the trauma and its related problems (Harris & Fallott, 2001; Huntington, Moses, & Veysey, 2005). Through collaborative relationships with survivors, the goal of trauma-informed services is to help set the stage for addressing current trauma-based symptoms, as well as the concerns that caused the client to seek help initially. The purpose of this article is to describe theoretical and practice intersections between trauma-informed IPV practice and MI, a communication method designed to engage clients and help them strengthen their own internal motivators for change. It describes how many of the fundamental components of MI complement traumainformed work. A brief vignette is also provided to demonstrate the general tone and process of an MI interview with an IPV survivor. MOTIVATIONAL INTERVIEWING AND TRAUMA-INFORMED WORK Motivational interviewing is “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change” (Rollnick, 2008) in regards to a targeted or chosen behavior. The purpose of MI is to create a nonjudgmental, supportive environment for survivors as they move through various stages of behavior change, and to guide them in exploring and ultimately strengthening their motivation for health-promoting change. Meta-analyses have found that the use of MI (by itself or in conjunction with other 94 Motivational Interviewing and Intimate Partner Violence Workgroup treatment modalities) improves client adherence to the change process and retention in treatment (Arkowitz & Burke, 2005). Preventing treatment dropout is an important issue when working with trauma survivors, thus making MI a helpful adjunct to other skills service providers might use to engage this client population. At the heart of the approach rests the spirit of MI (discussed later), which includes a variety of processes to establish a client–helper environment, including collaboration, evocation, and support for the autonomy of the client (Miller & Rollnick, 2002). MI involves practicing specific skills, including assessing motivation, confidence, and readiness for change; asking open-ended questions; using reflective listening and summaries; exploring ambivalence in regards to change (when relevant); avoiding the temptation to confront (and therefore amplify) resistance; and eliciting and responding to client language suggesting desire, ability, reasons, need, and /or commitment to change. Many similarities exist between MI and trauma-informed practice (see Table 1). Both focus on strengths and self-efficacy, while emphasizing collaboration, empowerment, respect for choice, and understanding of the survivor’s perspective. The development and maintenance of collaborative relationships are at the core of MI and trauma-informed work. A key premise of MI is that motivation for change is “formed in the context of relationships” (Rollnick, 2008, p. 6), and that the way in which we communicate can influence motivation for change. When providers try to persuade, shame, or blame people into change, they often evoke all of the individual’s reasons not to do it. Similarly, in trauma-informed practice, relationships and human connection are central to healing. MI and trauma-informed practice both seek to empower individuals by supporting their self-efficacy and by enhancing their confidence that change is possible. When negotiating the goals of trauma-informed work and MI, the focus needs to be on behaviors that survivors can control, including but not limited to behaviors associated with self-care, safety planning, health, social supports, addictions, and employment. Wahab (2006) suggests that when considering the use of MI with survivors involved in violent relationships, it is vital to keep in mind that IPV occurs within the context of a relationship. Individuals in abusive relationships have control only over their own behaviors; they cannot control the behaviors of their partners, nor should they be encouraged to do so. Despite taking action and changing one’s behaviors, a violence-free life cannot always be secured. A key concept in MI is that the service provider (SP) needs to resist the “righting reflex”—the desire to make better, fix, or prevent harm (Miller & Rollnick, 2002)—before the client has specifically asked for such assistance or given permission to provide it. When working in the area of IPV, the urgency and pull to protect and persuade survivors to make changes can be heightened, particularly when their life and relationship circumstances are deemed life-threatening by a provider. For example, SPs can inadvertently replicate controlling behaviors that survivors have experienced in the past by pushing for the survivor to leave their abusive partner (Wahab, 2006). Such desire to protect an IPV survivor can have a paradoxical effect in that the more the SP argues the case for change, the more the natural response for the client is to provide Motivational Interviewing 95 TABLE 1. Relationship of Trauma-Informed Work to Motivational Interviewing Trauma-Informed Practice Motivational Interviewing (Miller & Rollnick, 2002) Emphasis on safety, respect, and acceptance while avoiding treatment that might retraumatize (Elliot et al., 2005; Jennings, 2004). Emphasis on respect, empathy, and acceptance while avoiding confrontation. Emphasis on listening to and believing the survivor (Jennings, 2004). Emphasis on reflective listening to ensure accurate understanding. Emphasis on understanding the person and her symptoms in the context of her life experience, culture, and society (Elliot et al., 2005; Jennings, 2004). Emphasis on individuals being the experts in their lives. Emphasis on collaboration, power sharing, and empowerment (Elliot et al., 2005; Jennings, 2004; Saakvitne et al., 2000). Emphasis on collaboration, power sharing and empowerment. Emphasis on suspending judgment through asking “what has happened” to the person rather than “what is wrong” with the person (Harris & Fallot, 2001; Jennings, 2004; Saakvitne et al., 2000). Emphasis on suspending judgment through exploring experiences and perceptions rather than labeling. Emphasis on strengths, highlighting adaptations over symptoms, and resilience over pathology (Elliot et al., 2005). Emphasis on supporting self-efficacy through affirmations that highlight strengths and positive coping skills. Emphasis that recovery can only take place within the context of relationship (Elliot et al., 2005; Jennings, 2004). Emphasis on relationship as foundational to the change process. Emphasis on maximizing choices and survivors’ control over recovery (Elliot et al., 2005). Emphasis on supporting autonomy and increasing perception of choice. the other side of the argument (Miller & Rollnick, 2002), and to disengage from services (Grauwiler, 2008). APPLICABILITY OF MI IN TRAUMA-INFORMED HELPING The “Spirit” of MI MI creates a collaborative climate1 in which client motivation for change can emerge and grow by evoking the client’s own desire, ability, reasons, and needs for change, and 96 Motivational Interviewing and Intimate Partner Violence Workgroup by supporting both the client’s decision-making authority in regards to change, and her or his autonomy in all other aspects of treatment planning. Such is the environment most trauma-informed providers also nurture to maximize the likelihood that clients will engage in the helping process and not feel threatened or controlled by it. Beyond its methods and strategies, however, empirical evidence suggests much of the operant mechanism by which MI works has to do with the therapeutic alliance that is created when the principles that guide provider decision making are strictly adhered to (Moyers, Miller, & Hendrickson, 2005). Several elements of the MI approach with potential for contributing to helpful trauma-informed IPV work are outlined in the following. Listening and Empathy Skillful and strategic use of reflective listening to obtain and express empathy is fundamental to MI and trauma-informed work. The purpose of reflective listening in MI is to assist the clients to hear important, change-liberating elements of their thinking (and speech) and to assist the clients to think through what is reflected to them. Listening to survivors can have a powerful impact. In one study using MI in street outreach with female sex workers, researchers found that what participants remembered most was the respectful listening they experienced (Yahne, Miller, Irvin-Vitela, & Tonigan, 2002). They especially noted that they were not labeled or judged. Affirmations Reflecting strategic affirmations in MI is a powerful way to build self-efficacy and trust, and to express empathy (Miller & Rollnick, 2002). Identifying key moments to use affirmations in conversations with survivors in genuine ways to mine for experiences that highlight self-worth and self-efficacy is a key skill. Skillful traumainformed practitioners who also have training in MI are especially competent in identifying “opportunity sightings” for the use of reflections to affirm and reframe thoughts, feelings, behaviors, and circumstances as skills and strengths. Exploring Ambivalence Although not always the case, often those affected by IPV are conflicted between their motives for maintaining the status quo and for pursuing change. As long as such motives compete, and as long as a survivor is unable to achieve resolution of such conflict, one will remain stuck. “Ambivalence is a reasonable place to visit, but you wouldn’t want to live there” (Miller & Rollnick, 2002, p. 14). One technique used in MI for working on resolving ambivalence about change is called values clarification (Wagner & Sanchez, as cited in Miller & Rollnick, 2002), whereby the MI practitioner works to highlight discrepancy by exploring with the clients ways in which their current life conditions conflict with their core values or life goals. In this way, MI is well suited for work with survivors, as it allows them to move Motivational Interviewing 97 in and out of ambivalence, exploring the various and often complicated circumstances in their lives, with the intended goal that the clients arrive at their own desired goals and methods for change. Focus on Change Talk A fundamental purpose of MI involves eliciting (from the survivors) their own desires, reasons, abilities, needs, and, ultimately, their commitment to pursuing change, otherwise referred to as “change talk” ( Miller & Rollnick, 2002). There are a number of methods by which MI practitioners elicit change talk. Such methods help prevent providers from being enmeshed in the “blaming trap” (Miller & Rollnick, 2002). MI does not concern itself with blame, but rather it emphasizes evoking the survivors’ will to change behaviors and circumstances that are within their control. Such a focus is often helpful in working with trauma survivors, who may become stuck in emotional pain and a sense of helplessness, rather than a focus on their capacity for change ( Miller & Rollnick, 2002, p. 63). A BRIEF MI DISCUSSION CONSISTENT WITH THE TRAUMA-INFORMED APPROACH The following vignette is presented to demonstrate the use of some fundamental MI skills and concepts with an IPV survivor in the context of a nonresidential domestic violence agency. Provider: Hello Sarah. How have you been doing since we last talked? [Open-ended question] Sarah: Oh pretty good, I guess. Provider: So things have been going well. [Reflection] Tell me a little more about that. [Open-ended question] Sarah: Hmmm well things were okay during the week but the weekend was pretty bad. Provider: It sounds like things have been up and down [Reflection]. I have to say, it’s great to see you here today though, despite the weekend you’ve had. It would be easy to have just avoided coming in today I’m sure. Your perseverance is a good sign that you’re able to keep focused on your goals. [Affirmation and support for self-efficacy] Sarah: Well, I’ve never really thought I had much perseverance. Provider: You sound upset about what happened over the weekend. [Reflection, including affect] Sarah: I was with the kids all day Saturday and Saturday night. We got invited to a party at a neighbors to watch football and the kids could play with their kids I said to my husband “let’s go” so we did … I had a few beers. 98 Motivational Interviewing and Intimate Partner Violence Workgroup Provider: You needed a break from everything. [Reflection] Sarah: Yes, I know I talked about how I should drink less and how drinking seems to make things worse at home but it was just a few beers. Provider: Thank you for your honesty about what happened. [Affirmation] You went to a neighbors’ party and had a few beers. [ Reflection] Sarah: Yeah but one of the guys said some things to me and got my husband upset so when we got home, before I could even get the kids to bed, he started yelling. He had more than a few beers so he was really loud and threatened to hit me … but he didn’t. Provider: Things got out of hand when you got home and it was really frightening. [ Reflection, including affect] Sarah: (crying) I don’t know what to do. Provider: This isn’t the kind of marriage or home life you want for yourself and your kids. [Complex reflection, including client’s desire for change] Sarah: Right. But he is a good father and he has a good job. I don’t have any money to support myself and my kids. Provider: You love your kids a lot and want to take good care of them. [Reflection, including affirmation] Sarah: I really do, but I guess sometimes what they see isn’t very good for them. And I started thinking about it after he passed out Saturday night—it was just an innocent party and I was enjoying myself and to have to deal with this. … Provider: You want to have a life where you can enjoy going to your neighbor’s and talking to other people without getting threatened at the end of the night. [Reflection including client’s change talk—desire for a better life] Sarah: Right. He apologized on Monday and said it won’t happen again. And then I got upset and he just wants to act like it never happened. Provider: He wants to forget about it.[Reflection] Sarah: Yes, but this is how things go. I’m getting pretty tired of always being upset, or worried, or scared. Provider: This is wearing you out and you wonder how much longer this will go on. [Reflection] Sarah: Yes, what if it’s forever? What if it never changes? I don’t want my children to live like this forever. I don’t know what to do. I don’t know if I could leave him. Provider: Let me see if I have this right. Your week was going pretty well but then the weekend came and what seemed like a simple get together at a neighbor’s turned into your husband getting upset and yelling and then threatening to hit you. You wonder how long this will go on and you wonder Motivational Interviewing 99 about the impact it might be having on your kids. You also worry some about your drinking. You’re not sure if you could leave your husband and at the same time you want to feel safe and you want your kids to feel safe, so you’ve thought about the possibility of leaving. [Summary, including illumination of ambivalence and reflection of key issues that may serve to strengthen discussion about the desire, ability, reasons, and need for changes in her home / parenting and relationship situation] That’s a lot to be dealing with. [Affirmation] So, thinking about all of this: Where does that leave you? [Openended key question to elicit change talk] Sarah: I don’t know. (silence) … It’s like a cycle, like you told me about. I know something has to change … maybe if I could start saving a little bit of money I could go ahead and get my teaching credential that I’ve been putting off. I had some courses completed when we got married but I don’t know how he will react. I’d like to finish my education. I need to figure this out. I have to figure out what I want. Provider: You remember that we talked about the cycle of violence and you don’t want to be stuck in a situation like that. One possibility you have thought about is saving some money and getting your teaching credential. [Reflection of desire for change/goals] What else do you need at this point? What do you think you’ll do next? [open-ended questions to elicit change talk and to focus on the client’s autonomy] DISCUSSION OF THE CASE SCENARIO Central to MI is the collaborative nature of the working relationship between the provider and survivor. In this brief conversation the SP sets the tone for a collaborative working relationship by recognizing Sarah as the expert on her life and experiences. By using an open-ended question to ask about how she has been doing, the SP invites Sarah to control the initial direction of the session. The SP uses reflections to convey accurate empathy about what Sarah has experienced and therefore facilitates the building of trust and rapport. The use of reflective listening by the SP also serves to help Sarah hear important elements of her thinking, feeling, and experience and to help guide the conversation in the direction of Sarah’s desire for change. Trust and rapport are enhanced by offering an affirmation of Sarah’s honesty in revealing that she had been drinking alcohol, in spite of previous discussions about the possible negative consequences of this behavior. As Sarah talks about the violence, the SP does not continue to ask questions or focus on the specifics of what happened. Instead, she reflects the discrepancy between what Sarah was hoping for in the situation (“You want to enjoy going to your neighbor’s ”) and what did happen (“ Things got way out of hand and it was really frightening ”). In this way, the SP also reflects Sarah’s ambivalence about her relationship but does not take a position about what Sarah should do. No arguments for change are made, and this gives Sarah the opportunity to explore and work on 100 Motivational Interviewing and Intimate Partner Violence Workgroup resolving her own ambivalence. By avoiding arguing for change, which would most likely elicit a defensive position from Sarah, the counselor leaves room for Sarah to bring up her own concerns around the need for change. Sarah begins to ask the kinds of questions that can produce change talk. This is a signal to the SP that Sarah is potentially moving in the direction of change. The SP then uses a double-sided reflection to capture both sides of the ambivalence, as she summarizes everything the client has shared. The SP also uses empathy in the summary (“ That’s a lot to be dealing with”). The summary is followed by an open-ended key question: “So, thinking about all of this: Where does that leave you?” When Sarah answers the question by stating that she does not know and becomes silent, the SP resists the temptation to give advice or to offer solutions for her. Instead, the SP demonstrates a belief in Sarah’s self-efficacy and autonomy and waits for her to expand on her answer. By doing so, new information is revealed. Sarah introduces the possibility of becoming more independent by completing a previous educational goal. The provider reflects this one option back to Sarah, again resisting the urge to tell Sarah what choices she should make, and asks about what else is needed. It is important to note that the interviewer provides guidance in the session, focusing Sarah on specific issues by choosing what content is reflected. At the same time, by using this approach, whatever plan is eventually reached, it will be based on Sarah’s goals, abilities, motivations, and values, and not on the SP’s “prescription” of what she or he feels may be best. When working with issues where there is a history of risk for IPV, it is crucial to address safety concerns for both the client and any children involved. In the example, as the provider and Sarah move forward, the SP can ask permission to give Sarah feedback about any concerns for Sarah’s safety and ask permission to collaborate on a plan to create a strategy for responding to potential future violence. By asking permission, the provider maintains the collaborative nature of the working relationship and demonstrates respect for the client’s autonomy. A NOTE ON ETHICAL COMPLEXITY AND “ITCHES” Practitioners of MI are not unaccustomed to wrestling with the potential ethical “itches” that rightfully manifest when there is less than total congruence between the aspirations of a provider in an MI session and those of a client. MI is described as a “guiding” approach to strengthening motivation for positive change toward a (specified) target behavior (Rollnick et al., 2008). Depending on how the concept of “guiding” is understood, and depending on what “target behavior” is identified and by whom, many people who work with trauma survivors are cautious, if not downright leery, about the concept of guiding, especially when guidance may involve conflicting agendas between provider and survivor. Rollnick et al. (2008) suggest that interviewer aspirations for client behavior change, while perfectly understandable and natural in those who want to be helpful, can be problematic in maintaining the foundational (autonomy-supporting) spirit of Motivational Interviewing 101 MI. The tendency to want to “rescue” the client contradicts the practice of MI and other ethical approaches to trauma-informed work. Often the concepts of “ steering ” or “ navigating ” are used in such a way as to suggest that it is the role of the provider to “ keep one eye on the compass ” and on the intended destination, in order to know whether the general trajectory of the treatment is “on track” or “on target.” Although guidance-oriented metaphors are helpful for general explanations of the MI method, they may also oversimplify the ethical dilemmas faced by many of those who use MI in a trauma-informed context. An MI provider works to supply direction and movement to the interview by differentially reflecting the survivor’s statements and by eliciting specific types of change talk to guide the conversation in the general direction of a goal. The question for many professionals is how to support clients’ autonomy without imposing the provider’s aspirations for the client. With its emphasis on supporting client autonomy and “gently steering” toward goal-oriented change, MI can be a helpful antidote to the phenomenon of the “privileging leaving ” bias (Wahab, 2006) when working with survivors of IPV. CONCLUSION Trauma-informed work and MI converge around a number of important principles, theoretical concepts, and skill sets. MI serves as a useful template to guide the ethical practice of those who work with survivors of IPV and other forms of trauma, and we contend that the very heart of the mechanism that drives MI is the free will that is sparked when true collaboration meets with the evocation of clients’ desire for change, along with respect for their autonomy in decision making. It is the experience of the authors that MI provides important and useful principles that serve to inform SP guidance of survivors who have trauma backgrounds. It also provides a foundational skill set that can be easily and objectively measured so as to ensure fidelity with the practice and to support legitimacy of research that involves its practice. As an interviewing style that is both person-centered and guidance-oriented in its practice, MI enables SPs to carry out the intentions and goals of trauma-informed practice. It has been our collective experience, in using MI to inform our work with survivors of IPV and other forms of trauma, that this approach holds much value in preventing the imposition of helper bias and control onto survivors. This is an important contribution to the training of those who work with such populations, given that the “righting reflex” is often alive and well (and well-intentioned) but thwarts progress in those who have experienced victimization. MI provides a useful framework for how to guide trauma survivors without imposing pressure to conform to externally imposed behavior change requirements that may resemble or contain elements of the abusive and confrontational tactics that have been used against them in the past. The need for working collaboratively with clients ensures that providers are “walking the walk” and not just “talking the talk.” So as not to see MI as a technique, or a trick, or a skill that can be “done” to clients to make them do what the SP thinks is best for them, providers who seek to use MI to 102 Motivational Interviewing and Intimate Partner Violence Workgroup work in a trauma-informed manner must be well trained and therefore able to practice the MI approach with fidelity. Clearly, more research is needed to investigate the effectiveness of this change facilitation approach when used with those affected by IPV and other forms of trauma. Such clients need to be asked how they respond to the approach and followed to determine how MI influences functioning in major life areas of client functioning. NOTE 1. These three concepts (collaboration, evocation, autonomy), collectively, are often referred to in the literature as the “Spirit” of MI. REFERENCES Archer, J. (2000). 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(2006). Motivational Interviewing: A client centered and directive counseling style for work with victims of domestic violence. Arete, 29(2), 11–22. Yahne, C. E., Miller, W. R., Irvin-Vitela, L., & Tonigan, J. S. (2002). The Magdalena Pilot Project: Motivational outreach to substance abusing women street sex workers. Journal of Substance Abuse Treatment, 23(1), 49–53. Zaligson, J. (2007). LGBTQ survivors in domestic violence shelters: Discussions with providers about clients, homophobia, and outreach. Conference Papers—American Sociological Association, Annual Meeting, pp. 1, 21. Acknowledgments. The MI and Intimate Partner Violence Workgroup was formed at the annual international meeting of the Motivational Interviewing Network of Trainers ( MINT) in October 2008. The purpose of this group is to further knowledge and practice of Motivational Interviewing in the context of trauma-informed and intimate partner violence work. The following members coauthored this article: Paul Burke, M.A. Paul Burke Training & Consulting Group, BC, Canada Charlotte Chapman, MS, LPC Women’s Center, University of Virginia, Charlottesville, VA Melinda Hohman, Ph.D. San Diego State University, San Diego, CA Trevor Manthey, MSW WIMHRT, Washington State University, Spokane, WA Katie Slack, MSW SDSU Research Foundation, San Diego, CA 104 Motivational Interviewing and Intimate Partner Violence Workgroup Dee-Dee Stout, MA City College of San Francisco, San Francisco, CA; Responsible Recovery, Emeryville, CA Cristine Urquhart, MSW, RSW British Columbia Centre of Excellence for Women’s Health, Vancouver, BC, Canada Stéphanie Wahab, Ph.D. Portland State University, School of Social Work, Portland, OR Carolina Yahne, Ph.D. University of New Mexico, Albuquerque, NM Special thanks to Dr. Allan Zuckoff who also contributed thoughts to this project. Correspondence regarding this article should be directed to Stéphanie Wahab, PhD, Portland State University, School of Social Work, P.O. Box 751, Portland, OR 97207. E-mail: wahabs@pdx.edu PAPER Would it be ethical to use motivational interviewing to increase family consent to deceased solid organ donation? Isra Black,1,2 Lisa Forsberg1,2 1 Centre of Medical Law and Ethics, King’s College London, London, UK 2 MIC Lab, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Correspondence to Isra Black, Centre of Medical Law and Ethics, King’s College London, Strand, London WC2R 2LS, UK; isra.black@kcl.ac.uk Received 2 March 2013 Revised 13 August 2013 Accepted 25 September 2013 Published Online First 14 October 2013 ABSTRACT We explore the ethics of using motivational interviewing (MI), an evidence-based, client-centred and directional counselling method, in conversations with next of kin about deceased solid organ donation. After briefly introducing MI and providing some context around organ transplantation and next of kin consent, we describe how MI might be implemented in this setting, with the hypothesis that MI has the potential to bring about a modest yet significant increase in next of kin consent rates. We subsequently consider the objection that using MI in this context would be manipulative. Although we cannot guarantee that MI would never be used in a problematically manipulative fashion, we conclude that its use would, nevertheless, be permissible as a potential means to increase next of kin consent to deceased solid organ donation. We propose that MI be trialled in consent situations with next of kin in nations where there is widespread public support for organ donation. In this article, we explore whether it would be ethically permissible to use motivational interviewing (MI) in conversations with families about deceased solid organ donation. After briefly outlining what MI is (1) and providing some context around organ transplantation and family consent (2), we describe how MI might be implemented in this setting, with the hypothesis that it has the potential to bring about a modest yet significant increase in family consent rates (3). We subsequently consider the objection that using MI in this context would be manipulative (4). Although we cannot guarantee that MI would never be used in a problematically manipulative fashion, we conclude that its use would, nevertheless, be permissible as a potential means to increase family consent to deceased solid organ donation. We propose that MI be trialled in consent situations with next of kin in nations where there is widespread public support for organ donation. WHAT IS MI? To cite: Black I, Forsberg L. J Med Ethics 2014;40: 63–68. MI is ‘a collaborative conversation style for strengthening a person’s own motivation and commitment to change’.1 Initially developed for use with unmotivated problem drinkers,2 MI has a robust evidence base over a wide range of applications,3 4 and is ‘effective both in reducing maladaptive behaviors […] and in promoting adaptive health behavior change […] for use when client Black I, et al. J Med Ethics 2014;40:63–68. doi:10.1136/medethics-2013-101451 ambivalence and motivation appear to be obstacles to change’.5 MI has been shown to be efficacious as a short, single-session intervention. In most of the 200-plus randomised controlled trials where the efficacy of MI has been tested, the MI intervention has consisted of one or two sessions. In summing up the MI research, Miller and Rollnick conclude ‘MI has been tested most often as an intervention of 1 to 4 sessions, and even with relatively brief consultation of 15 minutes or less’.1 Other reviews have found short interventions to be as effective as long interventions.6 Two complementary components of MI, clientcentredness and directionality, are thought to be active in successfully influencing behaviour, although a complete theory explaining how MI brings about behaviour change has yet to be developed.5 The client-centred component emphasises empathy and ‘MI spirit’. Empathy involves ‘an active interest in and effort to understand the other’s internal perspective, to see the world through her or his eyes’.1 MI spirit ‘(a) is collaborative […], (b) evokes the client’s own motivation rather than trying to install [sic] it, and (c) honors the client’s autonomy’.5 MI requires practitioners to evoke the client’s own reasons for and against change, and to understand and accept them. MI emphasises collaboration and power sharing in interactions between client and practitioner, requiring the latter to refrain from assuming an expert role, and accepting that the final decision in favour or against change rests with the former. Finally, MI requires the practitioner to reinforce the client’s perception of control and ability to choose. The directional component of MI consists in the practitioner ‘selectively eliciting and reinforcing the client’s own arguments and motivations for change [emphasis added]’ (‘change talk’),7 while taking care not to evoke ‘sustain talk’, which favours the behavioural status quo.5 Thus, ‘MI departs from traditional conceptions of client-centred counselling […] in being consciously goal-oriented, in having intentional direction toward change’.7 ORGAN TRANSPLANTATION AND FAMILY CONSENT Organ transplantation is an effective means of managing end-stage solid organ failure. Transplant recipients have a reduced risk of mortality and improved quality of life compared to patients receiving alternative treatment.8 Transplantation 63 J Med Ethics: first published as 10.1136/medethics-2013-101451 on 14 October 2013. Downloaded from http://jme.bmj.com/ on October 2, 2021 at Northern Illinois University. Protected by copyright. Public health ethics may also offer significant benefits in terms of cost effectiveness for healthcare providers.9 However, ‘[i]n virtually all [the countries where transplantation is practised] the questions constantly being posed are where and how enough organs for transplantation are going to be obtained’.10 In respect of deceased donation, debate over how to meet the shortfall of solid organs has centred on the legal framework for transplantation, in particular, the effect of a switch from an explicit consent, ‘opt-in’, regime (eg, UK, USA), to an ‘opt-out’ regime under which individuals are required to register an objection in order to prevent donation upon death (eg, Belgium, Singapore, Spain).11 While there is evidence of an association between opt-out systems and increased organ donation, it has been advanced that ‘factors other than [opt-out contribute] to the variation in organ donation rates’.12 Adoption of opt-out legislation may therefore only be one element in a framework approach that addresses organ need.11 13 Whether legislation takes the form of opt-in or opt-out, one factor that exerts significant influence on donation rates is family objection.14–16 This is notwithstanding survey evidence that demonstrates, in nations such as the USA and UK, high levels of public support for organ transplantation.17 18 Rosenblum et al11 analysed the legal regimes of 54 nations, of which 25 had enacted opt-out legislation and 29 had enacted opt-in legislation. The authors found that 21 of 25 nations with opt-out legislation ‘allow the next-of-kin to object and prevent a potential donation’.11 In the four remaining opt-out nations ‘health professionals do not override the deceased’s registered wish to be a donor in the case of an objection from next-of-kin but will respect an objection if there is no such record’.11 All 29 nations with opt-in legislation require family consent where the deceased’s wishes are unknown.11 In 25 of 29 opt-in nations, family consent is required even where the deceased has a validly registered wish to donate, and in the remaining four opt-in nations, family objection may prevent donation notwithstanding a legal right to retrieve.11 In practice, family objection may account for a large percentage of potential donors not becoming deceased organ donors.19 20 In many countries, rates of family refusal greatly exceed the proportion of people who are opposed to organ donation. Commenting on their findings from a qualitative study of relatives who refused to donate a deceased relative’s organs, Sque et al write … many participants who had positive views of donation, and who knew of the similar views held in life by their deceased relatives, declined donation. Understanding what influenced participants to decline donation despite having positive views may help us to understand why populations that generally support organ donation and transplantation have high refusal rates. Of course, respect for strongly held beliefs and values that militate against donation renders unfeasible a consent rate of 100 per cent among families approached to donate. Nevertheless, there may be room to increase family consent rates,11 12 and a number of modifiable factors have been associated with improved rates, in particular, the provision to, and understanding of, information by families, who makes the request, and the timing and setting of the conversation between requestor and next of kin.16 21 Indeed, it may well be that the procedure for requesting family consent has a crucial influence on rates of donation. As Vincent and Logan write 64 It is a consistent finding among other work that a sensitive and empathetic manner (or lack of) during family discussions is a discriminator between donor and non-donor families, and that those families who feel pressurized or feel that staff are uncaring are less likely to donate.16 With this in mind, an MI-based procedure for consent to organ donation may be an excellent candidate for increasing family consent rates. In the next section, we outline why and how MI might be successful in this setting. MI AND FAMILY CONSENT TO ORGAN DONATION MI is used to help individuals resolve ambivalence in the direction of change.3 Before discussing why and how MI could work in the context of family consent to organ donation, it is helpful to outline how MI might (hypothetically) work in a setting where its efficacy has been demonstrated: alcohol use.i 22 A problem drinker might be ambivalent about cutting down. He may take pleasure in drinking, yet is aware that his (excessive) alcohol consumption is taking its toll on his work and family life. If he does not reduce his alcohol intake, his professional and social situation is likely to worsen considerably over time. MI might be used to elicit and strengthen his motivation in favour of change, possibly leading him to reduce alcohol use. Similarly, next of kin may be ambivalent about whether to donate the organs of a loved one. This ambivalence is often conceptualised as a kind of ‘dissonance’ or psychological inconsistency in the decision maker.23 24 Thus, on the one hand, the potential donor’s family may believe that organ donation is good (this would seem likely in nations where public support for organ donation is high). On the other hand, support for donation may be displaced in concrete situations by a number of reasons, such as dissatisfaction with the person and/or process by which consent to donation is sought.21 Even where organ procurement practice is optimal, next of kin may have reasons associated with the loss of a loved one that count against donation. Such reasons may emanate from a desire to protect the integrity of the body,23 25 and individual responses to grief. Where the reasons that count in favour of donation are outweighed by reasons that count against it, family refusal to donate is likely. MI may help next of kin resolve this ambivalence about donating a loved one’s organs in favour of donation, by evoking and reinforcing statements that point toward consent, while avoiding dwelling on utterances leaning toward refusal. At least in terms of what the practitioner does, the family consent to donation context is arguably analogous to the alcohol use context. Would the consequences be similar for the problem drinker and the next of kin decision maker? Most of us would accept that it would be better if the drinker reduces his alcohol consumption. He might enjoy a better family and work life, which would benefit those around him too. Conversely, not cutting down would have opposite negative consequences. In the family consent context, it is relatively uncontroversial to claim that donation is better for recipients and their families. We might also claim that it would be better for the decision maker. In two separate studies, Sque et al23 24 found that, on the one hand, relatives who consented to donation ‘remained supportive of their donation decision’ over time, and, on the i For example, as a brief intervention for heavy-dependent or low-dependent drinking, MI has been found to produce low to moderate effects in reducing alcohol consumption when compared with no treatment or other interventions respectively. Black I, et al. J Med Ethics 2014;40:63–68. doi:10.1136/medethics-2013-101451 J Med Ethics: first published as 10.1136/medethics-2013-101451 on 14 October 2013. Downloaded from http://jme.bmj.com/ on October 2, 2021 at Northern Illinois University. Protected by copyright. Public health ethics other hand, some experienced ‘feelings of guilt and selfishness’ following a refusal to donate the organs of a loved one.23 It is submitted that the structure of the ambivalence and its consequences in the organ donation setting is sufficiently similar to other contexts in which MI has been successfully employed. Moreover, since the evidence base suggests that MI is efficacious in ‘small doses’, we advance that it might feasibly be applied to organ donation situations—circumstances in which the requestor has a limited window of opportunity to gain family consent. However, we concede MI might not work in all situations in which family consent to organ donation is sought. For example, two people of equal qualifying relationship under the relevant legislation may both wish to respect the deceased’s wishes, but interpret facts about his or her wishes differently. This factual uncertainty may lead to different conclusions (consent, refusal), though neither one necessarily opposes donation in principle. Since such situations do not really involve the kind of ambivalence that MI is designed to resolve, using MI is unlikely to be any more successful that other strategies for requesting organ donation from next of kin. Notwithstanding the preceding limitation (and perhaps others), MI might yield modest yet significant effects in gaining family consent when favourable attitudes to donation conflict with other factors pointing against it. This possibility provides a strong reason in favour of trialling MI in this setting, since more frequent family consent would increase the number of transplantable organs. However, independent of the possible benefits, it might be argued that it would unethical to use MI to guide next of kin toward consent to organ donation, since this would be manipulative in a way that is problematic. MANIPULATION Understanding and applying a concept of manipulation is by no means straightforward.ii An objection to some practice on the grounds that it is manipulative involves a descriptive claim that (1) A induces B to w, and an evaluative claim that (2) A does this in a way that is unethical.26 When considering procedures for gaining family consent in the context of organ donation, this indeed appears to be the structure of the objection. For example, the ‘presumptive approach’ is a technique that has been developed in order to increase consent rates.27 This approach relies on the assumption that most individuals, given the opportunity, will save lives, and that organ donation is a morally unproblematic way of saving lives.27 Requestors use ‘value positive’ language, such as stating that a majority of individuals in a similar position would consent to donation, as well as presumptive statements, such as ‘[w]hen you decide to donate’,27 and ‘[i]f you do not have any more questions, I will now guide you through this process’.28 Truog criticises the presumptive approach on the grounds that language typically employed by requestors is often ‘clearly misleading or even manipulative’, which in turn ‘undermines many of the core elements of informed consent’.28 29 As a matter of law and ethics, we typically take valid consent (sufficiently well informed, competent and voluntary) to be a manifestation of autonomy. Truog argues that when consent is undermined by the (manipulative) presumptive approach, the individual’s autonomy is violated. Therefore, the presumptive approach is unethical, as well as its progeny, the ‘dual advocacy’ approach.29 30 ii Thanks to T Martin Wilkinson and the handling editor at JME for pointing this out. Black I, et al. J Med Ethics 2014;40:63–68. doi:10.1136/medethics-2013-101451 Would MI use in organ donation conversations induce next of kin to consent—is it descriptively manipulative? Would gaining consent in this way be unethical—would MI use here be manipulative in an evaluative sense? In respect of the first question, MI interventions are designed bring about behaviour change. Miller writes ‘we hope that our treatments are manipulative; that is, that they effectively alter behaviour [original emphasis]’.26 The explicit focus on selectively ‘eliciting the client’s own change talk and taking care not to reinforce counter-change talk [emphasis added]’,7 demonstrates that we think what the practitioner does will influence the client’s subsequent behaviour.5 For example, Miller found that ‘the very style with which one delivers a treatment or even speaks to a problem drinker during a single counselling session can predict a substantial share of the variance in his or her drinking behaviour a year later’.26 31 32 Indeed, we would not be proposing MI as a strategy to increase family consent to organ donation if we did not think it might be effective in achieving this. Any measure that sought to increase consent to organ donation that was not manipulative in the descriptive sense would be a grave waste of resources. In respect of the second question, the influence MI has on behaviour might be ethically problematic if it could be used to overbear individual autonomy. Miller and Rollnick have argued that MI is not manipulative in an evaluative sense, since its causal role in behaviour change consists in highlighting the contrast between status quo behaviour(s) and deeply held values and beliefs; individual autonomy is not undermined as an incident of change. They write ‘unless a current “problem” behaviour is in conflict with something that the person values more highly, there is no basis for [MI] to work’.33 Similarly, in earlier work, Miller advanced that: The core processes of [MI] … are designed to help the person experience the ambivalence, consciously see and feel the conflict between the problem behavior and that which is truly more important. The process is an inherently internal one, invoking intrinsic motivation … enduring change of this kind [cannot] be engendered by trickery or by imposing someone else’s values.26 However, it is somewhat implausible to suggest that people only respond to core values when they change their mind or behaviour. While this may be true in the contexts for which MI was originally developed, it may not be true generally. It seems reasonable to think that the selective reinforcement of many utterances in a client-centred manner, not just those which relate to supposedly core values and beliefs, might influence behaviour.iii If it were only true that MI worked when an individual held a relevant core value in favour of change, there would be no concern when MI were employed in contentious settings such as sales. However, Miller and Rollnick, citing the work of Cialdini, recognise that ‘psychological knowledge and techniques, including [MI], can be used to exploit, to pursue one’s advantage and gain underserved trust and compliance’.1 It appears, therefore, that MI might be used to influence individuals in instances when their core values are not in play. This, however, would not necessarily overbear or even undermine autonomy, if the individual held a relevant preference that was reinforced. iii eg, We are not necessarily acting on a core value when, following your successful use of MI, we choose to buy a convertible, rather than an estate, which would have made transporting Nigel, the Labrador, practical. 65 J Med Ethics: first published as 10.1136/medethics-2013-101451 on 14 October 2013. Downloaded from http://jme.bmj.com/ on October 2, 2021 at Northern Illinois University. Protected by copyright. Public health ethics The claim that MI works on intrinsic motivation (in some broader sense than core values or beliefs) is perhaps supported by evidence that MI is not 100% effective in producing the desired behavioural outcome. In clinical trials where practitioners have been proficient in MI, change has not been observed in every client.34 Thus, it is hypothesised that if an individual’s preferences and behaviour are consistent, MI will not work. For example, next of kin religious objections to organ transplantation may align with a refusal to donate. Even if the practitioner is successful in evoking change talk, it may not be sufficient in quantity or strength to produce behaviour change. This evidence suggests that some preferences cannot be overcome, and thus, MI does not overbear autonomy. However, it cannot be guaranteed that it is impossible to initiate change through the introduction of preferences that are not the individual’s own. It might be true that MI is not manipulative in the evaluative sense in that it cannot be used to induce behaviour change that is inconsistent with an individual’s core values and beliefs. However, without sufficient prior knowledge of the individual, it may be difficult to establish that the motivation for change was not internalised during the intervention. Therefore, proof that MI has not overborne an individual’s autonomy, and is thus not problematically manipulative, might be epistemically inaccessible, or at least difficult to gather. Blatant attempts to instil motivation, such as advice giving, warning, confronting, leading questions, conditional threats, however, will be MI inconsistent and can be detected. The extent to which a practitioner adheres to the MI method can be measured using a variety of validated treatment fidelity instruments.35–37 The use of instruments to ensure treatment integrity can safeguard against attempts to undermine individual autonomy, such as using more manipulative (and possibly less successful) strategies, perhaps such as the presumptive approach. However, we are unsure whether more subtle forms of manipulation that might overbear autonomy necessarily will be detected. Since we cannot be completely confident that MI use would never undermine individual autonomy in a problematically manipulative way, it might be argued that what the requestor should do is counsel next of kin in a neutral way, that is, that the counsellor should not attempt ‘to influence the client to take a particular path’.1 Instead, the requestor should ‘help the person make a difficult decision without influencing the direction of choice’.1 However, counselling with neutrality is a flawed strategy. It is unlikely that MI practitioners would be able to maintain neutrality throughout the interaction. Miller and Rollnick concede that neutrality may require ‘a still higher level of clinical skilfulness than the directive variety of counseling, because one must avoid inadvertently tipping the scales in one direction or the other’.33 MI is not easy to learn, and it may take a substantial period of time to acquire the skills necessary to influence client behaviour using directional MI.38–40 It appears unrealistic, therefore, to think that requestors would be able to use neutral MI in conversations with next of kin over organ donation. Truax found that even Carl Rogers, the father of client-centred psychotherapy, was unable to avoid reinforcing certain client utterances, and was unaware that he was doing so.41 Requestors’ views would more likely colour the direction of the conversation, probably in favour of consent to donation. Moreover, requestors would be unlikely to know if they were being neutral, given the very limited accuracy of self-assessments of practice.38 42 It is less ethically problematic for requestors to inform next of kin that an approach aimed at securing consent to donation will 66 be employed than to claim that requestors will not steer next of kin in the direction of consent, or that they will use a completely client-centred technique, when in all likelihood they will be directing unawares. The latter approach risks violating autonomy, insofar as the intervention to which next of kin consent would not be that which they receive. For any conversation around family consent to organ donation, including those which used MI, it would be important for requestors to be upfront about the goals and the methods used, and to gain valid consent. First, consent to discuss organ donation should be given, and it should be made clear that having a conversation about donation in no way commits next of kin to consent to donation; both consent and refusal are fine. Second, the requestor should disclose that their position is that organ donation is a good thing, and that their role is to explore how next of kin feel about donation in order to see whether their view aligns with that of the requestor.iv It should be stressed that consent to the conversation can be withdrawn at any time, and if it is, donation will not occur. Having these requirements would ensure that individuals were properly informed of the nature of the intervention, and also, through gaining valid consent, avoid adding an autonomy violation on top of a potentially problematically manipulative procedure. We have conceded that MI is descriptively manipulative, and we cannot guarantee that MI would never be problematically manipulative, insofar as it might be possible to use MI to instil preferences in favour of a particular decision, which would overbear individual autonomy. Is this risk of unethical manipulation unacceptable in the context of next of kin consent to organ donation? We submit that in countries where support for organ donation is widespread, and most people hold the relevant preference in favour of donation, the risk of unethical manipulation would be relatively insignificant. Indeed, MI might help next of kin take decisions that are in accordance with more longstanding preferences. Are we going to allow a few potential autonomy violations to stand in the way of saving of many lives?v This appears very unreasonable. Assuming high levels of support for organ donation, the situation in which MI might be used unethically to manipulate a few next of kin would be quite different to that of organ conscription, which many people find objectionable, and which would, therefore, involve frequent autonomy violations. Moreover, in cases in which the potential donor has an established wish to donate, any wrongful manipulation of next of kin should be weighed against the violation of the deceased’s interests.vi In such circumstances, manipulation of next of kin is not a freestanding wrong; there are various competing interests in the organ donation context, and some must necessarily yield to others. We submit that the balance should come down in favour of the potential donor. Furthermore, in cases where the potential donor’s wishes are unknown or ambiguous, Wilkinson has argued that next of kin ‘do not have the status of consenters, but only the lesser status of people who ought not to be distressed’.43 As such, violations of their autonomy might be less ethically problematic. iv Thanks to Bob Truog for this point. Of course, we are not claiming that a few autonomy violations would be justified in pursuit of some greater good if those violations were accompanied by serious additional harm. vi Thanks to T Martin Wilkinson for raising the need to discuss the potential donor’s interests. v Black I, et al. J Med Ethics 2014;40:63–68. doi:10.1136/medethics-2013-101451 J Med Ethics: first published as 10.1136/medethics-2013-101451 on 14 October 2013. Downloaded from http://jme.bmj.com/ on October 2, 2021 at Northern Illinois University. Protected by copyright. Public health ethics That is not to say, however, that the preceding claim undermines the case for using MI rather than other highly manipulative procurement practices. All others things being equal, it is better to employ the means of achieving one’s ends that involve the least interference with the autonomy of others. MI could potentially be unethically manipulative in a few cases, whereas, the presumptive/dual advocacy approaches, for example, involve something close to misrepresentation or falsehood as a matter of routine, and would thus involve interference with autonomy in almost all cases. The success or failure of organ procurement regimes in large part depends on public trust, and health professionals stand in a position of power vis-à-vis next of kin. Little is known about current strategies employed in conversations with next of kin about organ donation. This lack of accessibility could undermine confidence in the transplantation system. Moreover, if it became widely known that requestors employed unethical approaches in order to gain family consent, such as the presumptive/dual advocacy approaches, this would be quite likely to result in a net reduction of organs available for transplantation.28 43 MI is attractive because its methodology is explicit, it contains a client-centred component, and fidelity can be monitored even in a clinical setting.39 40 CONCLUSION In this paper, we argued that MI, an evidence-based, clientcentred and directional counselling style, might successfully be employed as a strategy to increase rates of family consent to organ donation. We considered an objection to the use of MI in this setting based on manipulation. Although MI is clientcentred, we cannot guarantee that it would never be used to overbear individual autonomy through the introduction of preferences that were not the individual’s own, and thus be unethically manipulative. However, we advance that the risk of problematic manipulation would be relatively low in countries in which organ donation enjoys widespread public support, since most individuals would hold the preference for donation. Moreover, when we consider the interests of potential donors with an established wish to donate, the relative weakness of family interests in situations where the potential donor’s wishes are not explicit, and the potential good brought about by donation, some problematic manipulation may be acceptable, provided that interference with autonomy is kept is to a minimum overall. Although we know relatively little about existing organ procurement strategies, MI may be an ethical candidate for use in conversations with next of kin about donation. No doubt implementing MI in this setting would be challenging. However, given the potential for a modest yet significant increase in rates of family consent, it might be worth giving MI a try. Acknowledgements We would like to thank Penney Lewis, James Wilson and Lars Forsberg for their insightful comments on an earlier draft. We owe a considerable debt to T Martin Wilkinson, Bob Truog and a third anonymous reviewer, who pointed out many places where the paper needed improvement. Thanks also to the participants of a Centre of Medical Law and Ethics Staff Seminar in December 2011, and those who attended the Third International Conference on Motivational Interviewing in June 2012 where this paper was presented. Both authors would like to acknowledge the considerable support of the Fondation Brocher. Contributors Both authors contributed equally to the preparation of the manuscript, and approved the submitted version. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Black I, et al. 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J Med Ethics 2014;40:63–68. doi:10.1136/medethics-2013-101451 J Med Ethics: first published as 10.1136/medethics-2013-101451 on 14 October 2013. Downloaded from http://jme.bmj.com/ on October 2, 2021 at Northern Illinois University. Protected by copyright. Public health ethics [sil.] 00:00:05Ladies and gentlemen, let’s have a warm round of applause for our very own Dr. Gerald Corey. 00:00:10Gerald Corey Author, Professor Emeritus California State University at Fullerton 00:00:30GERALD COREY I want to begin by thanking those who got me here because I’ll tell you about a year ago when I got the invitation, I was checking my e-mail and it said, we’re inviting you to be a keynote speaker, I almost fell off my chair. I did! And I said, what keynote? So, I considered a distinct honor and a real privilege to be able to be here as a keynoter. And my hope is that my message can reach many people. And I also want to start by acknowledging someone, a very important person who is up here in spirit with me and that’s Marianne Schneider Corey. My best friend. My best colleague and my best wife for 46 years. The only wife I’ve had. So, I’m just going to ask her to come up here, so you can see what she looks like. 00:01:40[sil.] 00:01:50GERALD COREY One thing I would like to do today is talk about the theme of how the counselor as a person in a profession are so tied up that you can’t separate the two, that who you are as persons intermittently affects how we work as professionals. And our professional life no matter what it is whether a counselors, counselor educators, whatever setting we work in, I think what’s critical is that professional life impacts our personal life. I just don’t know how to separate the two. And what I would like to do in the next… Alright, stop biting me. In the next in the time I have until 10:30 is talk about maybe ten different themes about the intersection between the counselor as person and professional. One of the first areas that I want to address briefly is the counselor as person and profession and the importance of the personhood of the counselor. It seems so simple and yet you know I don’t think it’s given nearly enough attention in the literature and in our teaching. Maybe it’s becoming more so, but I think there is a lot more attention given to knowledge and skills and content and trends and all that’s important. But I think if we forget the importance of the personhood of the counselor we’re forgetting the most important thing. And there is some abundant research that supports the idea that the counselor as person is one of the most critical, not the most, but one of the most critical variables in therapy outcomes. So, I ask you for a moment, I wanted to talk about some personal characteristics of what makes for a effective counselor. And may be you can just ask yourself for a moment what characteristic do I have that I most value, that I think is my greatest asset as a counselor or a helper or a social worker or an agent? And may be just think what is that one trait, they’re probably a number of them and they intersect. But you might think about that and I’ll list just a few. One is for me is having curiosity, a real sense of interest in the client. So a curious spirit another having some interpersonal skills. You know you would think the counselors are interpersonally skilled and yet I worry sometimes that we have technicians, the unskilled helper. Gerry Egan wrote a book called the Skilled Helper and sometimes I think we have counselors who are unskilled as a person. Another is that they really care, not that they just intellectually care, but they’re really compassionate individuals that they involve themselves in the lives of others. Another, and I think this is very important that they show respect, genuine respect for people who are different from them and who differ in many significant ways perhaps. Another is that they have courage and they’re willing to take risks that they don’t worry if they make a mistake, that they don’t think that, you know, mistake is failure. They can at least think, okay, so I made a mistake, how can I retrieve from that, recoil from that. I’ve got all these microphones here, so one of it will work. Another one is, I think they have a healthy sense of self-pride. Now in… they have a German expression that Marianne often says and it’s called Eigenlob Stinkt, and what that means is self-love stinks or self-praise. And yet, you know, I think, it is important to have a healthy sense of self-pride that’s a characteristic (inaudible ) with an effective counselor. Another one is that we have social interest going beyond self. And Adler talked about that and that to me is a very, very vital component of a good counselor. Another one that I… I’m just rattling these off thinking, you know, what ones would you want to reflect on more and how might you want to develop some of these for yourself? One of them is avoiding perfectionism. That’s a biggie, I think. Sometimes people say Gerry how do you manage to write and do the things you do? Because I think I am no longer worried about perfectionism. I realized that we have editors and then we have second tries. So, I think if we get too hung up on being perfect, the perfect counselor making the perfect intervention, we’re not going to do anything. So, I would hope we could free ourselves up. There is a book that was written and I don’t know who wrote it, may be Dreikurs and is called The Courage to be Imperfect. The idea that, you know, if we make mistake it’s not fatal. Another is a sense of humor. I don’t see enough of that in books and counselor training. I don’t see enough written about the ability to laugh at ourselves, never, never, never at a client in a demeaning sort of a way. But I think it’s great when the rapport eventually builds and the clients can, you know, and counselor can laugh together, that I think is healthy. Another one is personal presence. That to me, I think is really critical and that we can show up. And I want to talk more about that later when I talk about self-care. Another is the ability to make maybe significant connection with our clients. Really connection, I don’t mean just intellectual connection, but somehow where there is a meeting, an (inaudible ). Erving Polster one of the men I most admire and his wife, late wife Miriam Polster, they’re Gestalt therapists who really I think did the most of modernized Gestalt therapy. Erving Polster is a great example of a person who is really present. When he sits with a client and does an interview or a counseling session with the audience this large, he is right there with that person. He is not thinking what is going to say and that he’s fully in contact. So, I think the ability to make significant connection is critically important. And in addition to that the ability to disconnect. I think that’s critical, because if we stay connected and the client leaves the office, then I think we’re gonna to be ineffective of we take all of our clients home psychologically with us, because then we’re gonna wear ourselves out. So I asked you to just the kind think for a moment, what characteristics do you want to work on? I don’t think we have to be perfect human beings. I think our clients will give us a lot of room for making a lot of mistakes and a lot of latitude. Another area that I’d like to talk a bit about is the counselor as… By the way there are so many books written on the subject of becoming an effective counselor. One I see Sam Gladding in the second row, he wrote a great book called Becoming a Counselor: The light, the Bright, and the Serious and is published by ACA and second edition too. And the other colleague of mine, Jeffery Kottler writes about four books a year. He wrote a book called On Being a Therapist. And there are many books I think on the subject of becoming and being a therapist. So, we have lot of resources. I want to say something secondary. I want to get into as the counselor, as a ethical person and talk a bit about ethics. You know I don’t see how we can separate ethics from our being and our own personal philosophy and value system. I think ethics to me is how we live our lives and that’s reflected in how we treat our clients. And I have some notes just I want to be sure to cover some key points. But the speaker yesterday talked about complex problems and complicated problems. And I think ethics presents a lot of complex problems and there are no simple answers, there’re very many ethical issues that are posed to us. So, what I strive to teach my students when I teach an ethics course as I do every year at California State University of Fullerton is I try to get them to think outside of the box in a way and not so much in legalist terms and not so much in terms of thinking about, will I get sued in risk management perspective. But a lot more in terms of, how can I do the best for the largest number of clients that I’m going to see? And you know ACA’s 2005 code that Barber Hurley(ph) is sitting next to Sam Gladding in the second row too. She and others had a lot to do with revising the 2005 ACA code. And they did a tremendous job I think in really revamping the code. And one piece of the code is aspirational ethics as opposed to mandatory ethics. And what I try to do with my students is to get them to think not so much about what you need to do minimally to avoid getting into trouble, but what do you need to do to reach your client in the most significant profound way. So, one thing comes to my mind is, by the way I am so impressed with so many of you who are students. Marianne is too, we talked about this last night, we said we are just so impressed with all the students we meet and I never get tired of having students come up to Marianne and me; “Oh, will you take a picture with us.” And sometimes you’re so timid and you’re …you’re so apologetic and (inaudible ) and I love it, this is the only time of the year I can ever get famous. All the rest of the time people are trying to get rid off me. So, I’m just so impressed and so is Marianne with the spirit that so many of you as graduate students have. And it really, I think makes this both so hopeful about the future of counseling. And I’m just delighted to see how many students show up at the conferences. We’ve asked, how many of you are students? And 90% of the hands went up. I can see out there. How many are students? Turn around and look at that. Oh, my gosh! Look at that, fantastic! There are a few non-students, that’s good, that’s good. So I’m going to be talking a lot to students in the rest of time I have to. You know, what role does… do ethics codes play in your being an ethical counselor? I want to address that a bit. I think you ought to know the code, not by memory surely, but at least you ought to have it and if you have any ethical struggle you ought to at least know what did the code say, that would be I think important. But you know, I think, ethics is not a simple matter of taking the code book out, I think ethics is much deeper that the codes give us a blueprint, a general framework, but it certainly doesn’t answer or address the complexity of the problem that we meet. And I mentioned just a moment ago about aspirational ethics. I want to give just one example of it. I may give others, but… Many of you are students, might like to get personal counseling and yet you can’t afford it, and I think this is an area where season counselors could and probably should give at least part of their work to students on a much, much reduced basis or even pro bono. We’re asked in our ACA code to give something for those who couldn’t afford it , but need our services. And I think that’s a different way of thinking about ethics than, well what happens if I touch a client? What happens if I see a client on the street that I know? See, I think, I know, I’m not at all a fan of rule-based ethics, but much a more a fan of reflective ethics and ethics that are part of our basic personality structure. The thing I try to get my students to think about too is the ability to deal with grayness, gray, ambiguity in ethics. So many times, the first day my students say, well what will I need to do to not get into trouble or while I’m talking this class is I want to be sure that you know I don’t get in trouble with the licensing board or with the ethics committee. And I think that’s not a way to think, otherwise we’re gonna be practicing scared. And I don’t think that’s a particularly healthy way. One more comment about ethics and becoming an ethical person is I think it’s a developmental perspective, no matter how long we’re in this business. I think, we can always think how could I meet new ethical challenges in a new way and look at it from a fresh light? So, maybe it gives us an opportunity to look at some of our ethical dilemmas, in another way as we season. So, I don’t think it’s a question that we’ve got all wrapped up once we get our masters or doctorate. Moving branching off from ethical person, I’d like to talk about ethics briefly from a multicultural perspective. And what that might imply in terms of you and me as a practitioner. Recently, we went to the McCallum Theatre in Palm Springs and Bill Cosby was there. And he drank four bottles of water in his two hours of presentation of having the group laugh and what not. So, I’ll try to limit myself to one. I’m functioning on empty. Usually, I have a modest breakfast, two eggs, baken, bagels, cereal, fruit, orange juice, coffee, I’m kind of forgetting, but that’s a modest breakfast. This morning I didn’t have time, so I just had cereal and fruit and coffee and orange juice, half a banana and some cereal granola, but that was a very modest. But dinner I stock up on. And I’ve got a… Marianne is a fantastic cook and people look at me and say; “Gerry, how can you stay like you’re with that kind of meals? Do you eat that way every night?” And I say; “Well, if I can.” In fact, we went on a cruise once and I’m looking here and I can see Bob Wubbolding right in the front row. And Bob and Sandy, Marianne and me, we went on this cruise to Alaska over the Caribbean. And Bob started writing everything I ate down. He did! And then when he wasn’t with me he would say; “Gerry what did you have for snack? How many yogurts did you have? What else did you have?” And he kept this list very dutifully and at the end of it he sent me an e-mail with this whole list of all the things I had. And then co-presented on the topic and Bob started off by saying; “Put an overhead projector here.” And he said; ”This is a colleague of mine that ate all of this in one week.” And I think there are about 20 eggs, 48 strips of bacon. And he said; “Guess who he is?” Okay, that’s a digression. And I shouldn’t digress, but I’ll come back to it. As long as I’m on that digression, I’m proud to say that my father-in-law, Heinrich Schneider, rest his soul. He was a great man. He bought me a weeding outfit, when we got married in Germany, the Cathedral of Worms, 46 years ago. And I looked at the thing and I said; “That’s great, but can I wear it to teaching, to go to school.” And I made some points with him. He was very impressed that I wouldn’t just wear a suit once and then discard it. And I still have it. And when one of our daughters got married, I said; “You know I love… I don’t wanna wear a damn tuxedo and pay $40 or whatever it cost.” I said; “Why can’t I wear my wedding suit.” And I got in it and I fit in perfectly you know. So, she said; “Well, you can wear it to the rehearsal dinner. But Brian really wants you to wear a tuxedo.” So I wore the damn tuxedo and looked like a penguin. But, you know, you wanna get (inaudible ). I want to say a few things about an extension of the counselors and ethical person from a diversity perspective. The ACA codes 2005 have a new, it’s built in, every section has something to do with multiculturalism and diversity. So when you talk about diagnosis, there are something in there about how this fits from a multicultural perspective, which I think is very good. And I think what I want to say about this. I’m thinking of, how we bring our personal baggage or cultural baggage frequently into our interactions. There is a very wonderful podcast that Dr. Courtland Lee made recently and it’s on multiculturalism and diversity. And I listen to three times in my car going in and he talks about cultural baggage that we all bring into our work. And our job as counselors, he says, and I think that’s very important part of ethics, that we become a layer of our biases and prejudices and our stereotypes and our own cultural encapsulation. Awareness is so critical, because that’s the beginning of change. So I think that’s the key piece for me. Another is, Paul Peterson would say, and he has done a lot for multicultural movement. He wrote a book for ACA called Handbook of Multicultural Counseling. Paul would always say and still says in his workshops “Counseling, a diversity can be your friend. It doesn’t have to be your enemy and so welcome diversity and work with how it plays out in your interchange.” And I think all exchanges are multicultural in many respect. So, I think it’s important to kind of pay attention to our client to find out what aspect we should focus on, you know, rather than going into the session and saying; “Ah, I noticed you’re different from me in this respect.” Why not allow the differences to emerge and encourage the client to talk about what it’s like to be in this encounter? And then if the client says something like; “Well. I wonder if you’re gonna understand me?” And say; “Well help me out how might I have difficulty.” Well, I’m man and you’re woman and I wonder if we’re gonna be able to bridge that gap or there is age difference or there is cultural difference. You know, I used to worry when Mariana and I were asked to go to another country like Ireland. We went there five times already and we loved it. But I was a little worried, because Mariana is German and I’m… Can I still be heard if I sit this far back? I can, okay. Mariana is German and I’m Italian. And, you know, I kind of wondered, how’s that gonna mix with Irish? And you know, after I stopped worrying so much about would we head it off, I found if we were ourselves, we did get along just quite well in many regards. I think, our culturally different clients are gonna expect this to know everything about them. They are not. And I think they’re very tolerant in us even making cultural (inaudible ). If we have a good heart and a good spirit and we really are invested in not imposing our view of the world on them, I think that’s the critical piece. So often sometimes I think, we all, I know I do, sometimes I think, if the whole world will think the way I do it will be a hell of a lot better place, God help us. But sometimes I think, you know, I try to control universe and I’m not very good at it. But I think in some ways, we might think, may be we have the answer for our clients. And I think that’s unfortunate, because I don’t think our job is to give our clients answers, but to help our clients find their own answers within the framework of their culture. I think that’s critical. Oh, there is a shelf here that I didn’t see! I don’t have to put everything up here. You know, another piece before I leave the multicultural aspects of you being an effective counselor is our willingness to change our role as a counselor. I think a lot of times we’re trained in counselor programs to work with the individual, okay, in an individual setting, one-on-one and I hate to say this, but I think this model might be a little archaic. And I think there might be other models that are more effective and maybe that we ought to be thinking about, how can I take counseling out of the office and into a border context? Particularly, how can I take counseling out of the one-on-one office and go into the community with it? And I think that demands a different role for a counselor. For example, I think counselors are called upon to be applicants at times and to be change agents and to help clients that don’t have a voice to find a voice. The speaker yesterday talked about speak out. I think that was one of our six points. And I think a lot of clients sometimes and lot of us whom we start are afraid to use our voices. And so maybe a counselors job, particularly when we work with a diversity perspective is to help our clients find the voice that’s within and have the courage to be able to speak and say what they think. And a lot of people aren’t used to that I think. You know, one more think that occurs to me that I’ve here is cultural sensitivity is not limited to any one group. I think, every person in this audience including all of us, I think have a mandate to become culturally competent and culturally effective. And I don’t think it is a finished product. I think, it’s an ongoing life long kind of endeavor. And I think, sometimes we get way to hung up on our differences and forgetting that we swim in the same tide. Existentially, we all worry about some of the same universal issues about finding meaning in life, the fact that we’re gonna die eventually, how we deal with freedom and responsibility and the anxiety that brings. And Dr. Clemmont Vontress got an award and he’s gonna become a fellow and Dr. Lindy, your president acknowledged Dr. Vontress in terms of the contribution he made in her life as a mentor. And by the way, I very much liked to your article where you said; “You hope everybody in the profession finds one person to mentor.” And I think that was a great line in terms of you carrying forward whatever you’ve gotten from somebody else and giving it to others, giving others hope, giving others inspiration, giving other a sense that they can do it, particularly when they doubt that they can do anything. So, I think we’re all called in one way or another to be mentors, and we’re all mentees in some ways. I get a great deal from students. I really mean that. The best reviewers that we have in our books are students reviewers. And some of the best colleagues that I have are former students and some of them are right here in the audience, having doctorates, and writing and doing all sorts of things. But Dr. Vontress makes one very important point that I hope we remember, maybe we ought to focus more on our commonalities rather than our differences. And I’m thinking of a homily I heard in Palm Springs while back from, an Irish priest who is very radical and he really thinks outside the box. And he was criticizing the traditional church for the role of women have in the church or don’t have. And he was criticizing so many things that needed criticism. And he made a line and he said; “You know, we need unity through diversity.” And I like that line, Unity through Diversity and Unity and Diversity, that we don’t wanna all look alike, sound alike and… woo… alright. One more point before I move to another topic of boundaries is, I’d like to suggest that maybe the client might be a… our client… The community might be our client, that may be I mentioned taking counseling outside of the office. There is some good books on this. One is Mark Homan’s book, it’s called Promoting Community Change (inaudible ). And Mark Homan is a social worker and he talks about how you can work with groups within the community to empower them to bring about change, rather than just doing delivering services. So, Mark is saying our job as change agents should be to help people become self-sufficient. And I like that idea, that notion. I certainly wasn’t trained in it. I had never had much it all in that. And I think rather than just making a difference in the life of an individual maybe what can we do to touch community. Because so many people I think won’t come to an individual counselor’s office for a number of reasons, they’re intimated, they don’t believe in it. But maybe it’s our job to go outside and reach them where they are, by going where they’re living, maybe in churches or whatever happens to be, live with them and do our work out there. I’m gonna shift topics now. This is a very important piece. As far as I’m concerned it’s on managing personal boundaries and professional boundaries. It’s still part of becoming an ethical counselor. By the way, I was talking to somebody about this particular topic, about becoming an ethical counselor and she said; “Why do you say becoming an ethical counselor?” Hmm… You might think for a moment How would you answer that? Just think while I drink. You might think How would you…
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