Interrogation
|
*This is an adapted version of the article published in Focus Supplement on HIV Antibody Counseling 12(7) June 1997. It contains more detailed transcriptions of the sessions discussed in the original published version. More About Confession |
When counselors interview clients during the risk assessment
session, clients often respond with statements of remorse,
"confessions"
about past risky behavior. This confessional
dynamic can alter the relationship
between counselor and client,
potentially leading to ambiguity in communication
and blurred boundaries
in the counseling relationship. Based on a study
of audio transcripts
from 30 anonymous test counseling sessions, this issue
of the FOCUS
Supplement explores confessional interactions and presents
ways
counselors can respond most effectively to confessional dynamics when
they occur.
The Confessional Dynamic
According to Michel Foucault,
the urge to confess transgressions
to those authorized by society to
grant a "clean slate" has been
a defining feature of Western
civilization.1,2 The best known form of this
practice occurs in religious
settings, for instance in the Catholic Church,
when a person confesses
sins to a priest who offers absolution. Like the
reassurance people get
from a seronegative test result, sacramental confession
offers
"sinners" a slate that may be wiped clean again and again.
Both
are private, one-on-one discussions that focus on, among other things,
the sanctity of relationships and specific sexual practices. In a
religious
context, sexual behaviors are interpreted by the priest in
terms of venial
and mortal sins, while the HIV counselor views this
information in terms
of safer and risky behaviors.
A
confessional dynamic can occur in test counseling sessions for several
reasons. Test counseling can involve a discussion of behaviors that
people
consider "right" or "wrong" with respect to
HIV-related
risk. The process of recording a "moral inventory"
on an "official"
form can deepen the confessional dynamic and
intensify feelings of vulnerability,
anxiety, and guilt.
Because in
U.S. society, public opinion functions as an arbiter, condemning
or
forgiving wrongdoers, individuals may expect judgment from their
"confessors"
in the test counseling venue. One client,
interviewed after counseling and
testing, described her experience of the
counselor in these words: "I
expected him to go on and on and ask me
what risks I had taken and tell
me at length how wrong those things are,
and how I shouldn't be doing those
things." Expectations of
admonishment often evolve from projections
of a client's own anxieties
and self-judgment onto the counselor. Clients
may unwittingly place
counselors in the role
of confessor.
The confessional
dynamic, which involves a client's self-judgment, can make
the counselor
hesitant to explore the client's issues, resulting in a superficial
test
counseling session. By confessing, a client is saying in effect, "I
know better, it won't happen again, so don't lecture me!" Counselors
find themselves in the role of admonishing parent rather than empathic
confidant.
If the counselor asks additional questions about a risky
incident, he or
she risks being seen
as overbearing. As a result,
counselors often preface questions about risks
with phrases such as,
"The state wants to know," or, "We
ask this of every
client," so as not to seem to be singling out clients.
To avoid
appearing judgmental, counselors often depersonalize advice by
presenting
it as standard information, for instance saying, "We recommend
that
clients. . . ."3 While this strategy helps counselors provide
information and advice, it does not serve as effective client-centered
counseling,
because too often, clients receive little new insight into
their particular
situations.
When counselors initially ask why
clients are seeking HIV testing, it is
not uncommon for clients to
respond that "I've been a bad boy,"
"I was stupid,"
or "I've done some crazy things." These
statements can set up a
confessional dynamic that requires the counselor
to absolve the client of
wrongdoing. It may also make it difficult for the
counselor to follow
such statements with a productive discussion of risk
behaviors.
The following two cases illustrate how risk assessment questions can
create
a confessional dynamic. Each case is structured around a client's
confession
of feeling "stupid" as a result of previous
behaviors, and each
counselor responds differently. In the first session,
the counselor continues
to probe without absolving the client, leaving
the client feeling alienated.
In the second session, the counselor
absolves the client for his lapse but,
in order to re-establish a
cooperative dialogue, must forego any further
exploration. While these
examples are extreme ones, they illustrate a dynamic
that is present to
some degree in nearly all risk assessment sessions.
Session One: Absolution versus Denial
A 20-year-old, heterosexual woman is testing because she
has heard a rumor that one of her previous partners has AIDS. The session
has proceeded smoothly until midway when the counselor asks if the client
engages in receptive anal sex.
C: = counselor
P: = client
or patient
transcription
symbols
| 1 2 3 4 5 6 7 8 |
C: P: C: P: |
Okay. Do you
and your partners engage in anal receptive (.) sex? That's where he would put his penis in your anus. Uh (.) I've done that a couple times (.) like three times and I don't think we ever used anything. Okay. In the last year? Yeah. |
Noticing that the client has suddenly placed her hand over her stomach, an indication that the last question may have made her feel uncomfortable, the counselor asks,
| 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 |
C: P: C P: C: P: C: P: C: P: C: P: C: P: |
Okay. Are you okay?= =Mm hm. 'Cause you grabbed your stomach. HHHH I'm just thinking. What about? Well (.) you go back over all the things that you've done(.) and (.) I don't really feel ashamed (.) I just feel kind of stupid. Why stupid? Because(4) I mean all those people are gone now (.) and they're not really part of my life anymore (.) and (I've really cared) that much for them (.) and and to get something like that from somebody (2) or to give it to someone (.) is kind of heavy. What would that mean to you? (5) I'm more concerned about whether or not I could have ever given it to anyone. Mm hm. .hhhhhh (6) And it's like murder. Why? You're not pulling a trigger, but it (.) y you've given what's going to kill them. |
Session Two: Exonerating the Client
The rule of everyday conversation that confessions should result in forgiveness broken by the counselor in the Session One is demonstrated in this case of a counselor who responds by exonerating the client. The client is a 24-year-old heterosexual man testing because of an incident of unprotected vaginal sex a month earlier. When the counselor asks about the role of alcohol in the client's lapse into unprotected sex, the client responds guardedly
| 1 2 3 4 5 6 7 8 9 10 |
C: P: C: P: C: P: C: P: |
Okay. How bout alcohol? (.) >I drink sometimes<= =Okay. In the context of ssexx. I bring it up because (.) and I mean you're you sound I remember cause last time and that was a big factoHr th See? tHhat I had drunk. And you're aware of that. Yes, defin absolutely. |
| 11 12 13 14 15 16 17 18 19 20 21 22 |
C: P: C: P: C: P: |
Were there condoms around, or just you were encouraged, or we don't need to do this? or what was going on Nnn there was no condoms around actually, otherwise I would have used it [and I just [Okay you know I just felt kind of uncomfortable to bring this up (.) you [know? so let's wait and [And so you had some, now you have got anxiety and you came in a month later for Yeah HHHH |
The client's
admission of feeling uncomfortable sheds doubt
on his implied assertion
that he would have used a condom had one been available,
and offers the
counselor an opening to explore the source of the client's
discomfort in
negotiating with sexual partners. The counselor's technique
is similar to
the "good cop" approach often used by police in
interrogations.
By minimizing a suspect's role in a crime, an interrogator
makes it more
acceptable for the suspect to admit to committing the crime.
Responding to this admission, the counselor abruptly switches from good
cop to bad cop.
| 23 24 25 26 27 |
C: P: C: P: |
So you're uncomf.
you're GOING TO BE UNCOMFORTABLE FOR FIVE MONTHS, NOW! Yeah that's true So there's a tradeoff. That was real stupid of me to do |
This confession of
"stupidity" leads the counselor
to shift abruptly back to being
the good cop.
| 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 |
P: C: P: C: P: C: P: C: P: |
That was real stupid of me to do [(I usually= [No it's not= =don't but =stupid. It's not stupid. It's just I I people say that (.) It's human. Okay. It just it happens. You just need to know that it happened, that you're anxious as a result, and you're going to try to make it not happen again, but [I wouldn't [It's true I wouldn't say it's stupid. I mean I just know what I've done in my life and I HHHH You know. And I think counselors are among the bigger offenders in that sort of stuff because we hear so much and we give results and we look at stuff...And I hear you tell (.) me that you knew it was alcohol and you knew that led to it. So the next time you do that keep a couple condoms in your pocket to do that sort of thing. I mean obviously from what you from what I'm hearing (.) you're comfortable with condoms Oh yes |
The client's confession has reversed the power dynamic
and
prompted the counselor to confess his own lapses in order to restore
the
dialogue. The client's self-deprecating statement places the counselor
on
the defensive and effectively blocks any further insight into the
unprotected
incident. This is also illustrated by the fact that, although
the client
stated earlier he felt "uncomfortable bringing up
condoms," the
counselor merely absolves him, giving him a
"penance" without
confronting in a productive way the client's
problem with using condoms.
What can the counselor do in such
situations to respond and re-engage in
a constructive dialogue? The first
thing is to understand that the counselor
is not responsible for the
confessional dynamic. Confessions are not an
indication of bad
counseling. The confessional dynamic arises more from
the unequal power
relationship inherent in the risk assessment process than
from the
personalities of the client or the counselor.
One approach is to
gently confront a client's statements of guilt or remorse
by pointing out
the confessional roles that these engender. For example,
when a client
says, "I was stupid," or, "I should really
know
better," a counselor might respond:
Counselor: Let's stop for a
second. Why
do you think it's stupid?
Client: Because I knew better.
Counselor: Well that's not stupidity. Stupidity is about
ignorance.
You're totally informed. You've demonstrated that by coming
here today.
If it's not stupidity, what might be going on?
Counselors should be alert that clients may make confessional statements
as a way to preempt further discussion. A client may do this, for
instance,
by making a statement such as: "I'm never going to have
sex again!"
The counselor can ask the client how realistic he or she
thinks this is
and under what circumstances he or she might someday
decide differently.
Confessional dynamics can influence a
client's reasons for seeking a test
and keep him or her in denial about
underlying issues. For this reason,
it is especially important to help
clients explore the meaning of the test
in the context of their lives and
relationships. Return at various times
in the counseling session to the
subject of why a client is seeking a test.
Often, counselors ask this
question only at the beginning of the session,
before rapport develops.
As a result, clients tend to give non-committal
answers, such as, "I
just want to know," or, "I'm testing
because it's been a while
since my last test."
Because questions on risk assessment
forms focus primarily on risks of exposure,
clients sometimes answer that
risk is their primary reason for testing,
assuming that this is the
"right" answer. Risk of exposure, however,
may play only a
minor role in motivating some clients to test. Issues of
intimacy or new
developments in a relationship, for instance, often play
larger roles in
the decision to test, but these elements are far more difficult
to
articulate in the session. To help clients articulate unconscious
motivations
for testing, validate the fact that there are many reasons
people might
seek testing and counseling services and that risk may
represent only one
element.
Responding to Repeat Testing
Clients often use the existence of the six-month infection
window
period as a justification for routine testing. A client's doubts
about
his or her infection status often stem more from the passage of time
since a previous test than a concern over a specific incident. Such
patterns
of routine testing are usually symptomatic of unresolved issues
for which
testing can offer only temporary reassurance.
Like
recidivist sinners compelled to attend regular confession, some clients
test with consistent frequency but continue taking risks. Unable or
unwilling
to change risk behaviors, clients may unconsciously view
regular testing
itself as a form of prevention. Determine whether this is
the situation
for the client by asking if he or she plans to test again.
When a client
says he or she plans to test every six months, respond by
saying, "Okay,
but remember, it's what you do between tests that
protects you from getting
infected, not the test itself." Ask why
the client needs a clean slate
every six months. Point out that "the
test might help to reassure you,
but unless you try to look at where your
anxiety comes from, for instance,
a particular relationship, you'll
probably test again with the same doubts
about your status."
When clients feel little control over their risk behaviors, they may
use
routine testing as a way to avoid the challenge of consistently
practicing
safer sex. Clients often feel particularly vulnerable during
the risk assessment
because they can no longer undo the lapses that they
have disclosed. To
build a sense of self-efficacy among clients, validate
the steps, such as
getting tested, that a client has already taken to
protect him or herself.
Focus on future steps the client can take to
protect him or herself. In
this discussion, explore the meaning of
testing in each client's relationships.
For some clients, repeat testing can serve as a ritual of purification to deal with self-blame for "giving in" to unprotected sex, punishment for not maintaining boundaries with an abusive partner, or unresolved guilt over sex outside a primary relationship. To help clients recognize the influence of these other issues, counselors can point out the confessional tone of the narrative. Respond, for example, by saying, "From what you just said it sounds like you're really beating yourself up about this. Do you think punishing yourself is really going to help?"
Conclusion
A client's
motivations for seeking HIV testing can be complex
and difficult to
articulate. The strategies presented here can help clients
explore in
greater depth their motives for testing and how these motives
affect
decisions about risk, and help counselors recognize and confront
the
confessional dynamic before it preempts meaningful discussion within
the
counseling session.
References
1. Foucault M. The History of Sexuality: An Introduction. New
York: Vintage,
1979.
2. Delumeau J. Sin and Fear: The Emergence
of a Western Guilt Culture. New
York: St. Martin's Press, 1990.
3. Silverman D. Discourses of Counselling: HIV Counselling as Social
Interaction.
London: Sage, 1997.
4. Levinson S.
Pragmatics.Cambridge: Cambridge University Press, 1983.
*These
sessions were recorded with the consent of clients.
Author
Nicolas Sheon is a doctoral candidate
in medical anthropology at University
of California, Berkeley and has
worked as an HIV test counselor since 1993.
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