Friday, October 28, 2011

Motivation or Manipulation?

As much as our profession values self-determination (i.e., everyone having the power and freedom to make their own choices in life), we're also put in the position of trying to prevent or minimize damage (to our clients or others) from destructive choices. It's an ethical dilemma.

We try to rationalize our way out of the dilemma by saying that we defer to clients' self-determination only in very specific circumstances: when it's life-or-death (suicide, homicide, or complete inability to care for self), or when a vulnerable population may be harmed (children, the elderly, persons with disabilities - including individuals whose psychosis is interfering with safety).

There seems to be no end of debate about the moral and legal nuances involved here, but that's not what I want to focus on. What I'm thinking about today is the way I intervene differently according to the risk involved.

Motivational Interviewing (MI) is considered best practice for substance abuse, as well as other "problem behaviors." Essentially, it assumes that people often enter treatment with some ambivalence - that part of them sees the behavior as a problem and wants to change it, while another part is comfortable with the behavior and doesn't want to change it. MI tries to strengthen the first part of the ambivalence, for example by "developing discrepancy" (i.e., highlighting the divergence between the behavior and the client's values and goals), and selectively reflecting "change talk" (i.e., highlighting things clients say from the first part of the ambivalence, while purposefully not reflecting back things that come from the second part of the ambivalence).

Part of the justification for this approach, from the perspective of self-determination, is that the clinician is following the client's lead by encouraging movement toward a change that the client has said s/he wants (at least partially), drawing on the client's self-identified motivators (e.g., goals and values). For this reason, I like MI as an approach...when there's time to do it without the problem becoming lethal.

On the other hand, I have a high-risk client who is teetering on the edge of suicidality. He isn't actively least, not today. As a result, he doesn't meet hospital level of care. However, he's holding onto the idea of suicide as a back-up plan, just in case things get worse, or don't get better. He's also severely depressed, and therefore not particularly verbal. He's not spontaneously coming up with any "change talk," and only occasionally reveals motivations in either direction. (I assume ambivalence because he is still alive, in spite of persistent SI).

I could wait and see - wait for change talk to come - but that feels too risky for me. I'm trying to develop some discrepancy - something that matters to him that's incongruent with suicide. The only thing, so far, is concern about his suicide damaging his children.

In trying to build some commitment to life, I admit I stooped to what felt like manipulation - elaborating on how his suicide might harm the kids (the only motivator he's identified), asking about what he'd be sad to miss (alas, even walking his daughter down the aisle at her wedding is not a good reason to live, in his mind), and even trying to cast doubt on his idealized image of going to heaven (shamelessly capitalizing on the Catholic belief that people can't go to heaven if they commit suicide, in spite of my personal belief to the contrary).

Yes, definitely seeming more like manipulation than motivation. Yet, that's what it took for me to feel like I'd done everything I could to keep him alive for another week. There are no guarantees, of course, but I'm cautiously optimistic because what he got out of all that was the (baffling, to him) sense that I care what happens to him, even after death. Maybe knowing that will be enough.


  1. Very interesting thoughts,Nat. Nice analysis. You raise significant questions about life itself and its value - at least I thought so. I like the issue of control; rarely discussed. Nice blog series! Bill K.