Cultural medicine, counselor perspective and counseling approach   6 comments

Aside from this reading being very educational in a domain in which I have little experience – and that could actually be very relevant to me – I found the many variables Rapp and counselors seem to juggle regarding amniocentesis and beliefs/misconceptions about the procedure and pregnancy quite intriguing.  Off the cuff, these variables include the gender dynamics of cultural contexts, the educational and ethnic background of patients, superstitions and specific personal experiences each prospective mother might be dealing with, religious orientations, language-barriers, family-, age- or race-related genetic issues, financial concerns, personal biases or preferences, and probably many I’ve left out.  I think Rapp sums it up nicely when she says, “Thus, the “choice” any pregnant woman makes to take or reject the test, and to keep or end any specific pregnancy, flows from the way that both pregnancy and disability are embedded in personal and collective values and judgments within which her own life has developed” (pg. 91). 

At first, I thought, well, code switching (pg. 82) is the obvious answer for dealing with such diversity.  Yet, the more I read, I started to question not only the efficacy of such a strategy, but also the author’s perspective as a participant observer.  Code switching really seems to me to be a characterization of what we do naturally (and unconsciously) – we try to speak to people on their level, or in such a way that we think we will be understood.  We, or in this case, the counselors, respond intuitively through what really amounts to our own personal stereotypical or preconceived lenses – sometimes with responses that seemed a bit condescending to me (i.e. “I’m not pregnant, you are. Remember that”).  I don’t really think there is such a thing as “value-neutrality” when it comes to counseling, or speaking for that matter.  The second we open our mouths, we either betray our point of view as to a preferable course of action, or at the very least, our perceptions/hidden opinions of our audience.  This might be with our words, our body language, or our tonality.  I think we saw this in our prior readings.  Rapp herself characterizes at least some of the counselor responses she observed as “hardly value-neutral” (pg. 90).  So, why pretend?

What I really think bothers me is that Rapp gives many, many examples of spontaneous responses recorded from pregnant women and/or their significant others, and seems to use these as the basis for either characterizing who they are, or otherwise forming judgments about their motives, influences, and understanding – at least for the sake of her discourse – when really, they could have just been “stupid” questions or comments, formed under the stress or anxiety of the moment.  I think this is especially true when concerns are voiced.  There were several instances, where I questioned her own objectivity, but overall, she did seem to recover well.  I can’t help think that given time to think and reflect, the responses and concerns voiced by patients might be quite different.  My confidence was restored when I read, “In order to break the medical framework and find out more about how women and their supporters discussed prenatal testing and its implications in the contexts of their daily lives, I chose to follow some test takers home” (pg. 102).

Is it ethical for a counselor/medical professional to simply say what they think, even if it will likely influence a patient’s decisions?  Can it ever be considered professional to just be honest, open and forthright about how one feels when one is acting in a professional capacity (medically speaking)?  What are the negative potentialities of taking such an approach, if it will potentially end or save a pregnancy/unborn fetus?

Posted September 27, 2010 by jardaneh in Uncategorized

6 responses to “Cultural medicine, counselor perspective and counseling approach

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  1. Kev – what an awesome question….Is it ethical for a counselor/medical professional to simply say what they think, even it will likely influence a patient’s decisions? While I have a hard time thinking of this question as a pregnant woman, I can definitely see the value of this in my life pre-preggers.

    I will have to say that I am lucky to have very truthful medical professionals in my life – who have made it possible for me to avoid having total knee replacements at 2 times in my twenties alone….by being very honest with me and have absolutely influenced my decisions.

    However, as I reflect upon several of my friends and their medical issues, I am VERY glad some of their counselors and medical professionals AREN’T honest and can’t (and won’t) simply speak their mind.

    I have a very close friend who lives a very unfulfilled life due to family issues and an overly-stressful job. About 8 months ago, she just “disappeared” and didn’t show up to work for a few days. I started to get worried and called some of the local hospitals, and finally got an answer – she was Baker Acted. She is doing much better today, and has learned a LOT from her counselors….however…if they have heard many of the stories and endured her countless hours of crying and woe is me stories (which they are all warranted but can take a toll on those who are not “involved”)…an off the cuff remark such as those you talk about with the pregnant families could have been something along the lines of “wow, your life does suck” or “jeez, I would have thought about suicide, too, if I were you….”….and I can only imagine what that would have done to her psyche. If those counselors would have been open about their true thoughts of her and her situation, I am sure their influence would have ended her life. (yes, I know this example is drastic but it has such an impact on me…personally…sorry for the long story!)

    I am thankful for professionals who know when to be candid – and when to refrain for the patient’s well being. I am glad that you posed this question – and as I am looking more into Rapp’s chapters, I am going to carry it with me because it really made me reflect on the dual nature and choice of influence counselors and medical professionals make daily.

  2. Kevin –

    Your question is relevant to both medicine and teaching, so I think it’s worth considering for our curricular units, particularly when ethical issues are discussed.

    Generally, I think people can tell when a speaker is being opinionated vs. not. However, I also believe that adults are generally capable of weighing the opinions of others along with their own to better evaluate multiple sides of a complex decision (and I know of very few medical decisions that wouldn’t be considered ‘complex’).

    As Terie showed above, honest practitioners can score major ethos points by being up-front. There’s something to be said for that, especially when a patient is to trust a provider.

    I remember in my classroom, any time an election came up, I took a couple days of class to draw my students’ attention to the issues, the ballot design, and the results. At 15, my students generally didn’t know or care about politics, but I wanted to get them interested so that, by 18 or their government class, things wouldn’t seem so foreign.

    Anyway, I would often be hard-pressed to separate my views from the “factual reporting” I tried to do. It was easy to laugh at/with me as I reported the results of party-line elections, smiling when my party was victorious and grimacing when the students in my class who associated best with the opposition saw their candidate win. It was fun, and it was light-hearted. But it made a difference: I would start by saying what an issue was. Only after I was sure the students understood the issue at stake would I share my thoughts about it.

    Of course, as a public teacher, I had strict limits over what I should and should not share with my kids. The potential influence I had always made me paranoid. If I were sharing my personal beliefs or opinions about an issue, I made it abundantly clear to my classes that I was stepping out of lecture mode and into personal sharing mode.

    The situation for medical practitioners strikes me as similar. They are expected to be helpful, informative, knowledgeable, and generally unbiased…until we need help making a decision. I would say that the answer to your first question is a wholehearted “yes”, *provided the patient clearly knows the difference between medical advice and personal opinion.* Both can be extremely valuable in difficult cases such as we saw throughout Rapp.

    I’m going to be working on the Palliative Care curricular unit, and I see a strong connection here, too. One of the curriculum points is “Identify major areas for consideration in end-of-life care in special populations – pregnancy (death of mother/fetal survival, survival of mother/fetal demise); neonates & infants; children; the elderly; cognitively impaired; mentally ill.” How can a practitioner weigh in on “major areas for consideration” without infusing the commentary with an opinion? Should we expect them to? I think not, so long as the patient knows where medicine ends and opinion begins.

    • Chris writes: “Generally, I think people can tell when a speaker is being opinionated vs. not. However, I also believe that adults are generally capable of weighing the opinions of others along with their own to better evaluate multiple sides of a complex decision (and I know of very few medical decisions that wouldn’t be considered ‘complex’).”

      I appreciate much of the sentiment in your post, but I have to disagree here. I think that very often and for various social, political, and cultural reasons, opinions can be misrepresented as fact. It has historically been a man’s judgment about female experience that has dictated laws governing reproductive rights. Rapp even provides evidence of this when she briefly describes practices outside the U.S. regarding amnio: “In England, by contrast, 3/4 of the obstetricians surveyed in one study replied that they required women to agree in principle to terminate an affected pregnancy before they perform amniocentesis” and in Germany and Hungary they “see no problem with directive counseling” (33).

      I know that you point out that it is important for counselors to make clear where their opinion begins. . .but what if they do not consider their religious convictions to be opinions but righteous factoids. . .we can get into some pretty contentious territory here about which I am clearly very opinionated 🙂

      • Oh, don’t worry. I completely agree with you. About as soon as I hit “Publish” button, I realized that was a bit too strongly worded. I think I would like to *believe* that people know the difference between statistic and opinion. I do wonder whether doctors could be expected to be explicit: “This is my opinion, but…” Again, though, you’re absolutely right—my idea of an opinion might be dramatically different than that of someone else. Thanks for calling me out on this. 🙂

  3. Hi Kevin:

    It is not ethical or even helpful for a counselor in this situation to provide opinion about the testing or about continuing a pregnancy simply because the consequences of the decision will not be carried by that counselor. It is too easy to assert one’s own view of right and wrong when one can walk away after the conversation.


    • @Elle-well said. @ Chris: It seems also to be the role of the teacher to get students to be critical of and for themselves, so that even when they would rather we accepted their regurgitation of our ideas instead of our “coaching” them in strategies that will lead them to think for themselves–we do them a better service by challenging them to think for themselves, as you point out in your example about how and when to reveal your own “opinion” in the classroom.

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