The Client-Centered Approach and the Me-Centered Cultural Gap - 11/11/06

So, this week has been enormously eventful, on both sides of the Atlantic. As all of you know, in the States, the Democrats swept the mid-term elections and took control of the House and Senate. Rumsfeld retired. I think we can all be proud of the level of functioning of our democracy, whether you are a staunch supporter of the American Left or not.

Here in Russia, the process of democracy continued to erode at its own slow and grinding pace. A new election law that has already passed its first reading in the Duma has been ammended to remove minimum turnout requirements, thus eliminating the legitimacy of voter boycotts. The law removed the ballot option of "against all" and allowed the government to strike candidates from the ballot that are deemed "extremist" by a court (which as I mentioned in a recent post was defined by another new law on extremism to include "public slander of a government official related to his duties"). More importantly, the new Borat movie, "Cultural Learnings of America for Make Benefit Glorious Nation of Kazakhstan" was literally banned from Russian theaters: the first instance since Perestroika of a non-pornographic film being banned.

The good news is that I'll actually get to see the movie, because I'm taking a quick trip back to the States for med school interviews. My top choice school invited me to interview next Friday, and since med schools have rolling admissions, I jumped at the chance. I have since arranged two other interviews. Only after all was arranged did I find out that none of these schools actually have rolling admissions policies. Oh well, I can't wait to consume a good slice of pizza/some greasy diner food/Thai food/good coffee and use a washer and dryer.

The other main event for me this week was on Wednesday when I conducted a training I have spent the last week and a half developing on counseling skills. For the last month and a half, I have been working bit by bit with the Tzentr Meditsinskoi Profilaktiki Goroda Samary, the Samara City Center for Profilactic Medicine, who has formed a small case management program with funding from Population Services International (PSI). So far, I have had two aims for my work with them: to learn about what the program is already doing and to introduce myself as someone with valuable experience and an earnest desire to help.

This work has been made difficult by the absence of any precedent or clear pretense for what I am doing here. Somehow, even though I had been preparing my trip for over a year back home, no one had told the people in charge or working in the program that I was coming. My main point of contact with PSI is the volunteer coordinator. It is not a large organization in Samara, but somehow, from him to the head of the organization to the woman working with the case management program, the message never got to the program itself that a young, idealistic case manager was coming to town to help out. Ultimately, I was introduced to the program by the head of PSI, Samara at a round table on case mangement, at which I ended up speaking. Since then, I have had to start from scratch, making efforts to meet with the leader of the program, the case managers and the outreach workers.

This awkward introduction, the often-present sensitivity of Russians to those from currently "dominant" countries in the West and the language and cultural gap have all made this early period very difficult. I have been trying very carefully to walk the thin line between being here to volunteer my time, effort and experience, and being here to tell them how to do their job. While I do hope to help them improve their program, I do not want to come off as though I think I know everything, just because I have spent a year in a functional program in New York. Indeed, I am sure that I do not know how hard it is to do what they are trying to do in the context of Russia, where social services are merely a vestige of the Soviet sytem that have been robbed of their funding, there is an almost non-existent civil society trying to fill in for that gap, and most of their clients have insurmountable needs to begin with. Furthermore, the extreme vulnerability of the populations they hope to serve (commercial sex workers and injection drug users) must make the work enormously trying for the workers on the ground.

In any case, the culmination of this early period came on Wednesday of this week, when I conducted a training I offered to prepare on "the Psychological Aspects of Case Management." Since I have still been unsuccessful in seeing the case managers actually work with clients, it was difficult for me to assess the appropriate level of the training. Furthermore, since it was only agreed upon as an experimental, one-time, hour-and-a-half training, I wanted to try to cover as much theory as possible, in leu of trying to go into detail into any one topic (which would be ineffective if it were an isolated event). So I decided to try to introduce the basic principles of the client-centered approach, and to do a few basic excercizes to see how they would translate into practice, in the hopes that this would pique enough interest to go into more detail later in further trainings. At the meeting in which I had volunteered to do the training, I asked the case managers if they were familiar with Maslow's theory of the hierarchy of human needs (commonly referred to as Maslow's pyramid). They said they had not, so I figured that would be a good place to start.

I spent a week developing a PowerPoint presentation that described the hierarchy of human needs, the gap that often exists between the goals of the program/case manager and those of the client, the use of reflection and empathy to help people learn more about their own wants and feelings and the 'stages of change' model of behavior change. I prepared two excercises which would give the audience practice using empathy and reflection and evaluating a client's readiness to change his or her behavior, a hand-out on the basics of building trust and relationship with a client and an evaluation form for the training. I went over all the materials [see me preparing them, below] with a couple native Russian speakers and made sure that everything made sense. I was set to give the training for what I thought would be an audience of 10 to 15. Oh, and the whole thing was going be in my shoddy Russian.

As it turns out, there were only five people that showed up on time (within 15 minutes of on time, that is), and one of them left before the first excercise. The theory part went well [see right], though I think it was probably quite grating on the ears of the attendees to hear me massacre their language and to slowly go over what they could read on the screen in a few seconds (I also did see one of the two case managers have a whole conversation by text messages during this time).

When it came time for the excercises, however, everyone seemed kind of stunned. Since there were only four people present, we decided for the pairs to take turns. No one wanted to go first. I had to pick. The scenario was fairly simple: the first person was supposed to describe a situation in which she felt happy, sad, angry or scared, and not to talk about how she felt initially, only about the situation. The second person was supposed first to reflect what the first person said back to her, in order to indicate that he was listening and that he wanted to know more, and then to express empathy, by guessing how the client was feeling in this situation.

First, the case manager, who was supposed to describe the situation, began to describe her feelings before she even got to the situation (thus eliminating the purpose of the excercise -- to practice merely guessing what people are feeling without trying to advise them). Then, we tried it again with a different emotion, and the outreach worker (who was playing the clinician), simply began advising her about what to do (though he had excellent, sympathetic tone and gestures). After a brief discussion about their attempt, the second pair did not want to go, and said that they got the idea. I didn't want to push, so continued with the material about behavior change. During this time the director of the program arrived with a guy who is the driver/outreach worker.

When it became time to do the second excercise, the program director volunteered to go first, but her partner (the driver/outreach worker), who was supposed to play the part of the clinician was completely unclear of what to do. Gauging that he was not the only one in the room unprepared to practice the new theory with the excercize I decided it might be useful if I gave an example. So I sat down with the program director (who was playing the part of a commercial sex worker new to the industry) and set about attempting to assess her interest in moving toward less risky work.

So there I was, having never specifically worked with a commercial sex worker (at least not with the goal of reducing her risk of HIV infection -- all my clients were already positive), role-playing with the director of the program, trying to ask open questions and express empathy in Russian [see above]. Even though it only probably went on for about three minutes, it felt like forever. After this, people were already tired and ready to go home, so we just discussed it a little and people started to get ready to go.

Reflecting on it now, I am so filled with doubt. I honestly cannot get a get a sense of what, if anything, I managed to accomplish with this training or if it was at all useful to these workers. They told me that they found the whole thing interesting and helpful and repeated this on their evaluation forms. However, I can't help but suspect that they were just humoring me, that they see an enthusiastic kid from a different country trying his darndest to be helpful and nobody wants to tell him that he looks like an idiot with unrealistic ideas. On all three of the evaluation forms that I got back, the participants said they were completely ready to use the skills from the training in their work.

The woman at PSI who works with the program was present for the training and told me the next day she thought it was useful, but that the people in the program have a long way to go before they can really use these skills with clients.

This, indeed was clear. First of all, the program right now isn't even set up to do any of the longitudinal kind of work in which counseling skills really pay off. As the program is designed now, they see the client once or twice, refer them to a bunch of doctors, maybe a lawyer, and that is it. That is their contact with the client. They make goals on their service plans and then they accomplish the goals. But the goals are all short term: refer client to a doctor; refer client to rehab.

Second of all, it became clear during this training that the case managers have some pretty judgemental attitudes toward their clients. When I asked in the beginning, why clients don't often reduce their risk behavior on their own they replied "laziness." Everyone in the room at the time agreed (except me).

And then of course, I never expected this training to be anything but an introduction to these ideas in the first place.

But I can't help but wonder if I'm even on the right track here. I noticed a duality in the way the participants answered questions that keeps coming back to me. As part of the introduction, I asked, "What do our clients often want?" Their answer was automatic, "They want to recieve better medical services." "They want consultation about how to lower their risk." As though the clients simply want what we are giving. When I said that in my experience, people (especially people in the commercial sex industry or with drug habits) often are more worried about making sure there is food on the table, a roof over their heads and drugs in their arms, they agreed and said that they didn't think clients really want to have a better, healthier lifestyle, that they were too lazy. Of course, I went on to try to explain that laziness is actually just what it looks like from the outside when we are not psychologically ready to do something. Who knows if they were in any way convinced. Who knows if I even really believe that, through and through. I had written these questions into my introduction specifically to get a sense of how they viewed their clients. It was interesting to see, because it was as if there was a switch that flipped off, the second I recognized out loud the reality of clients' lives. Suddenly their official capacity was not required and they were free to place the onus on the clients.

I worry that the switch simply flipped back on by the end of the lecture so that their agreement with the principles of empathy and the client-centered approach to behavior change was simply acquiescence to what they saw as a new form of official rhetoric. That this will have no bearing on their work with their clients. I am worried that no matter how many trainings I prepare, no matter how many suggestions I make to enrich the quality of service to the clients, the program will keep going just as it did before I got here, because I am not an Authority, so what I say does not matter. In a system as vertically oriented as the vestigial Soviet social programs, this is to be expected. I worry most of all, however, that they are right to ignore me, that their clients cannot really be helped in the way that the funders of the program and I hope, and that my vision for this program, seen from across such a wide cultural gulf, is actually just a mirage, a reflection from the depths of the abyss that lies between me and a true understanding of the clients this program serves.

Before I left for here my therapist in New York said something to me that I found very helpful. He said, "bravery is not running into a burning building to save someone's life without fear. That is the myth we have about bravery. Taking on dangerous tasks without fear is just stupidity. Bravery is running into a burning building to save someone's life despite the fact that you are terrified out of your wits." I'm not saying that it is brave for me to continue to try to help this program. But it helps me to keep in mind that it is a good thing that I have so many doubts. That these doubts are what keep me from being an idiot.

For now, I feel at least that this was a good place to start. If nothing else it will help the people working in this program to get a sense of how I see case management and to trust that I mean well.

For tonight, I'm just excited to go home for a week so I can get a fricken haircut.

No More Elections (for Mayor of Samara) – 11/1/06

And just a few days ago I was so hopeful about democracy in Russia because of the results of the mayoral election...

Then, on Monday, The Moscow Times reported that a new political party had been formed, called "A Just Russia." It is the new "opposition party" created by the merger of three old parties that had a couple people in the Duma, the Party of Life, Rodina and the Pensioners' Party. As a result, Russia now effectively has a two party system. At the formal announcement of merger, Mironov, the leader of this new party declared boldly,"We will follow the course of President Vladimir Putin and will not allow anyone to veer from it after Putin leaves his post in 2008."

That's quite a strong statement of opposition. This guy Mironov ran in the last presidential election, and said, "i'm not running against president Putin, i'm running with president Putin... because when our leader goes into battle, we can't let him go alone." He is, quite clearly, the biggest Kremlin puppet around. After reading this article, I went back to check for which party Tarkhov had been the mayoral candidate (somehow this had not occured to me to be important, before), and it was the Party of Life. So, basically, the victory I described was that of one Kremlin stool over another.

This was a real killjoy. My excitement about the democratic process was shot out of the sky.

But today, it got buried deep in the ground. The Moscow Times reported today that the Kremlin is pushing forward a new bill that "would allow the abolition of elected mayors in big cities -- the only powerful officials still outside the Kremlin's direct control." The justification? "'Public officials answer to the public for providing services,' Mokry, chairman of the Duma's Local Administration Committee, said at a news conference. 'If that is not being done properly, then the state has an obligation ... to take the responsibility onto itself.'" I thought the People were supposed to be the ones who bear that obligation. I guess I had it backward. Silly me. The name of the guy being quoted, Mokry, means 'wet' in Russian. I wonder if it also means 'slimey.' Looks like I am back in the camp of the Russia cynics.

This move to the cynics' camp was helped by the fact that on Tuesday, I got a shtraf [a ticket], for crossing the street. I'm not joking, these police officers apparently had some quota to fill so they stopped their car in the street in front of Samara's biggest mall, MegaCiti. There is a place in the street [see left] which still technically does not have a crosswalk, even though there is a concrete path on one side of the street that connects to a concrete path on the other side, which quickly turns into a crosswalk that goes through the parking lot. There are no signs anywhere instructing pedestrians to do anything (let alone not cross here). The police did not direct the group of people I was walking in not to cross, but after we crossed asked four of us (all students) for our documents. He then gave us official shtrafs (rather than taking bribes which is what they usually do). It was very surreal. This path connects the University to the mall [see right], so something like 10 people cross the street in this location every minute. Wave after wave of people crossed the street right in front of the police officers while they were giving us tickets.

This was just another stark example of the way the legal system works in Russia. Technically, almost everything is illegal, so the government can choose when it wants to enforce what law with whom. This can be motivated by politics (as in the case of Khadarkovsky), by the desire of an individual official to make a career for himself (as in the case of the FSB agents that have visited my friend Susie twice at work now to see if they could catch an American not properly registered "on Russian soil") or by lack of an understanding of what better to do (as in this case). This will now be the case even for mayors just doing their jobs.

Oh, well! Look at these pretty pictures I took on a bike ride I went on the other day.