Section Five
Module 18: Multi-Cultural Clinical Assessment and Intervention
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How can we be successful for everyone in multi-cultural clinical asessment and intervention situations?
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After working with the material in this module, readers will be able to
compare
Clinical assessment and intervention usually occur with one person or with a few known individuals; they are cross-cultural activities, designed in terms of specific therapeutic bridges from one clinician to one client, not multi-cultural activities. Some clinical service situations are genuinely multi-cultural, however, and the universally-oriented strategies that make multi-cultural assessment and intervention successful can also be very useful in almost all client-centered clinical assessment and intervention.
Be sure you understand the distinctions between “multi-” situations and “cross-” situations, from Module 15, before you try to read this module.
Multi-Cultural Assessment and Intervention
Do the notions of “multi-cultural assessment” and “multi-cultural intervention” sound a little strange to you? They might, at this point, if you have already read some of our earlier modules.
Assessment and treatment are individual. Assessment and treatment are designed to meet the needs of one specific person, or to meet the needs of several specific people in the context of a small group of known individuals. Thus, assessment and treatment tend to be cross-cultural situations, not multi-cultural situations, as we have defined these terms. You are correct to wonder about “multi-cultural assessment” and “multi-cultural intervention”; we will definitely continue to focus most of our clinical energy on multi-cultural screening and then on individualized cross-cultural assessment and intervention.
Occasionally, however, we do find ourselves working in the context of genuinely multi-cultural assessment or treatment situations. Treatment groups can be multi-cultural, when they contain a wide range of different people with different specific needs. In these situations, a multi-cultural logic of seeking to address human universals can be a better fit for everyone than an attempt to shoehorn too many individually-therapeutic bridges into one small space. We will consider, later in this module, the universally useful features of any good treatment group, because every group falls somewhere between what you might describe as “only a little multi-cultural” and what you might describe as "very multi-cultural” (as we addressed in Module 15).
Before we get to treatment, though, let’s think about assessment. Two assessment approaches, ethnographic interviewing and dynamic assessment, are often recommended for cross-cultural situations. They also turn out to be almost universally applicable to most assessment and treatment situations. As was true for our universal “Yes and” strategy, they meet a lot of needs, in part because they were designed to be appropriate for almost everyone, not designed to test from any specific cultural or linguistic point of view.
We will start with ethnographic interviewing, a set of techniques for helping us to understand someone else that operationalizes a universally applicable and universally appreciated question: Tell me about yourself.
Ethnographic Interviewing to Understand Individuals’ Experiences, Abilities, Interpretations, and Concerns
Ethnography refers, generally but certainly not simply, to a set of intertwined methods from cultural anthropology that seek to understand groups of people from and within their lived experiences and points of view (see Howell, 2018). Anthropologists engaging in ethnographic inquiry depend on multiple methods, for multiple reasons, traditionally including “participant-observation” or working as a “participant observer.” These terms refer to the ethnographer, who may be embedded within a group (as a participant) while also attempting to observe, record, and analyze that group’s behaviors and beliefs (as a researcher or observer).
As adapted for health research and then for healthcare practice, “ethnographic interviewing” has come to refer to conversations that do not include participant-observation (see Dowdy, 2000) but that do retain the ethnographer’s desire to understand people’s experiences and interpretations of their own lives. Many discussions of ethnographic interviewing place it in larger contexts such as qualitative research methods or focus on the “dispositions” that “underpin” ethnographic interviewing for health-related topics: “humility, a readiness to revise core assumptions…, attentiveness to context, relationality, [and] openness to complexity” (Trundle et al., 2024), among others.
In early childhood education and speech-language pathology, ethnographic interviewing procedures are recommended for many types of situations, primarily in seeking to understand a child’s world as part of understanding their developing language and other abilities. The approach has also been described using a streamlined set of relatively specific principles and question types that can be taught, learned (see Brown, 2017; Brown & Woods, 2011), and adapted to many clinical situations. Box 18.7 provides a few selected examples.
Box 18.1. Selected Basic Principles and Questions for Ethnographic Interviewing, to Use in Multi-Cultural Screening or Assessment Focused on Communicative Universals (see Brown, 2017; Westby, 1990; Westby et al., 2003)
Start by stating your (broadly defined) interest in the family’s experiences.
“I would like to understand what it’s like when you and your child are talking.”
Ask open-ended questions, including especially “Tell me about.”
“Tell me about what it’s like at home with your child.”
“Tell me about a conversation you had with your child this morning.”
Repeat the other person’s words; repeat “tell me about”; and ask for examples.
“You said he is hard to understand. Tell me about a time when he is hard to understand.”
“You said he throws tantrums. Tell me about a tantrum he threw recently.”
Seek existing solutions.
“You said he is hard to understand. Tell me about what your family members do when he is hard to understand.”
“You said he throws tantrums. Tell me about what you and your wife do when he throws a tantrum.”
Avoid anything that might be interpreted as judgmental or that will generate your views instead of the family’s views. Avoid asking why, avoid leading questions, avoid interpreting, and avoid explaining.
Instead of “Why do you think he won’t answer you?”, try “You said he won’t answer you. Tell me more about a time when he did not answer you. What does he do?”
Instead of “It sounds as if he has a hard time expressing his basic needs,” try “You said getting out the door in the morning is almost impossible. Tell me about some examples of what makes it impossible.”
Explanations of ethnographic interviewing also depend on some specific terminology, such as refering to some questions as “grand tour” questions (e.g., “Tell me about a typical day”), “mini tour” questions (e.g., “Tell me about your job”), and “specific mini-tour” questions ( e.g., “Tell me about your talking and understanding in your committee meeting at work yesterday”), among others. Westby et al.’s (2003) summary of ethnographic interviewing is almost perfect, as an accessible description with more explanations, “how to” information, and examples.
Regardless of such details as the difference between a “mini tour” question and a “specific mini tour” question, the emphasis in ethnographic interviewing remains on the interviewer’s attempt to stand back and let the client or the family describe their experiences from their point of view. The principle is similar to the material we discussed in Module 17 about asking caregivers (or clients) to describe, so we can work to understand their experiences or interpret what their experiences might mean when combined with our professional expertise (see Module 13). If you go back to Module 17 now, you will probably notice how similar much of that material was to the principles that underlie ethnographic interviewing, and we will use similar principles as we design cross-cultural assessment and intervention in Module 19.
Your Turn
Compare ethnographic interviewing to a scripted interview with pre-prepared questions. Do you see any benefits to scripted pre-prepared questions? If so, how can you incorporate those benefits into ethnographic interviewing?
If you are familiar with motivational interviewing, compare it to ethnographic interviewing. What do the two have in common? How do they differ?
Roleplay ethnographic interviews with a friend who is willing to pretend that they live under circumstances you have never experienced (maybe living with several other people in a small apartment in a big city, or living on a large corn farm in Indiana, or living alone on a houseboat in Brazil); willing to pretend that they have what they perceive as difficulties with their speech, language, or communication; and willing to pretend (without laughing!) that they are utterly convinced that the reason for those difficulties is the invisible aliens from Jupiter who routinely poison their food in the place where they live. Can you use the question types summarized in Box 18.1 to understand their experiences, perceptions, and requests without making any judgment at all and without introducing your own experiences or opinions in any way?
Dynamic Assessment to Understand Individuals’ Abilities and Needs as Learners
The label “dynamic assessment” refers to strategies that seek to assess not only what a person currently knows but also how that person responds to or can use feedback or new examples. It is related generally to Vygotsky’s classic models of learning, including his notion of a “zone of proximal development,” and it has been used for decades in everything from mathematics instruction to counseling to vocational training.
If you happen to be unfamiliar with Vygotsky, imagine your learning about any topic or your expertise for any skill as a continuum: information or skills that you have mastered, information or skills that you can not manage on your own yet but can achieve with some degree of assistance, and information or skills that are simply beyond your current abilities. The part in the middle, the things you cannot do on your own but are ready to learn, is your ZPD.
As a general strategy, dynamic assessment combines assessment and intervention, or evaluation and teaching. It is similar to what we might call stimulability testing (such as in articulation), and in some interesting ways it actually shares features with everything from old-fashioned behavioral programmed learning to errorless-learning therapy approaches. (The less common version of dynamic assessment, referred to as graduated prompting, reminds me of Rosenbek et al.’s (1973) old 8-step task continuum for apraxia therapy, because I am old!)
The commonalities among these otherwise disparate examples involve starting where clients are, or starting with what clients can do, and then giving them some support, observing everything that happens, and deciding what they need next. The mindset is not “testing,” as in comparing a client’s knowledge and abilities to a predetermined standard or norm; the mindset requires our client-centered efforts to recognize, respect, and respond appropriately to what clients bring and to what they may or may not need next in their world, precisely as most of this website has emphasized. During dynamic assessment, we are watching not only for the client’s accuracy with a task but, much more importantly, for the client’s genearalizable skills as a learner — those meta-cognitive or other abilities that will allow the learner to continue to slide the window of their ZPD forward along the continua of knowledge and skills they are developing in their worlds.
The most common strategy for dynamic assessment, as shown in Box 18.8, tends to be summarized as “Test-Teach-Retest.”
Box 18.2. Dynamic Assessment Stages and Roles, with Examples from Articulation and Tennis
Test: Teacher presents an activity; learner does the activity
> articulation: child names 10 picture cards
> tennis: player serves 10 balls
Teach: Teacher provides assistance; learner attempts to change
> articulation: child names each picture card again, several times, after the teacher’s model and/or given feedback about each production
> tennis: coach explains what the player has been doing and gives a suggestion for a change; player tries 10 serves the new way, with feedback after each attempt
Re-Test: Teacher presents an activity and encourages the learner to do it the new way; learner attempts to do the activity as they have been working on
> articulation: child names 10 picture cards
> tennis: player serves 10 balls
Notice that “test” and “retest” refer to having the client do something briefly, not to giving a long or formal test. “Observe” or “Try” would be better words, depending on whether we are assuming the professional’s perspective or the client’s.
Notice also that middle part, “Teach,” can include almost any type or style of teaching. Depending on the learners’ abilities, the teacher might explain, model, praise, reflect, recast, expand on, correct, or make additional specific suggestions to the learner throughout the Teach phase. Many descriptions of dynamic assessment also start with a specific sequence of explanations about the new activity, drawing the learner’s attention to why the change matters and when they might use it in their real-life setting. The Teach phase can be as brief as a few minutes of explanations and examples, but variations on dynamic assessment can expand the timeframe, eventually approaching what the schools call Response to Intervention programs.
Given that intervention or specialized teaching is more likely to be necessary for people who do not learn easily from quick exposures to new things, the logic behind dynamic assessment is that clients who demonstrate clear meta-cognitive or other abilities to learn during a brief dynamic assessment probably do not need intervention, if that decision makes sense given everything else we know about them, their experiences, and their abilities.
Do you see the beauty of what dynamic assessment can do, in the context of our search for client-centered, culturally and linguistically appropriate speech-language pathology, and as related to the distinction between universals and specifics in healthcare or education?
Instead of asking specific clinician-centered questions from one language and one culture (“Do you know this static fact I thought of ahead of time?”; “Do you have this specific skill that a test developer decided ahead of time to ask you about?”), dynamic assessment asks universal, client-centered questions that are directly related to our overall desire to determine who needs our assistance:
What skills do you already have for managing new information in your life?
What happens when you are given a bit of help when you are trying something new?
Are you therefore probably learning what you need, from whatever you are exposed to in your world?
Dynamic assessment has been recommended for assessment in speech-language pathology for well over 20 years (Gillam & Peña, 2004; Gutiérrez-Clellen & Peña, 2001; Austin, 2010; see also Peña’s four-part recorded training), often in the context of child language assessment and usually in the context of what some authors have called “culturally and linguistically diverse” clients (and, again, I refer to as “people” or maybe “clients”). It is often described as a secondary or informal method to be used after standardized testing, and the emphasis is often that we can use it to help us interpret a difference we have detected between our standards and a child’s abilities.
If the child demonstrates learning strategies or benefits from the brief Teach phase, then any difference between their abilities and the standards assumed by our tests is interpreted as probably merely the result of the child having learned what they have been exposed to, not an indicator of a disorder at all.
If, on the other hand, the child does not seem to be using strategies for learning (which might include anything from asking for clarification to repeating the clinician’s instructions aloud, among many others) or does not show improvement on the task even with substantial assistance, then we might reasonably conclude that the difference between our test’s assumptions and the child’s abilities could genuinely be because the child has a problem with language learning that our intervention might be able to help.
Dynamic assessment has been described, in this frame, as an important part of helping us ensure that our diagnoses are not over-identifying as having language disorders those children whose language experiences and abilities merely differ from the experiences and abilities a test developer assumed (or from our own language experiences and abilities).
From a client-centered, multi-cultural, culturally- and individually-focused point of view, however, I am going to go out on a bit of an assessment limb, here.
Ready?
We have been repeating for decades that our profession’s standardized tests were not developed for or normed on a wide-enough range of test takers, making any attempt to compare most clients’ scores to those tests almost uninterpretable.
The context within which dynamic assessment is often recommended, in other words, is a hole of our own digging! We say that we need dynamic assessment as a secondary method to help us determine whether a test score that seems “low” is a false positive or if it actually means that the client has a diagnosable condition, a problem from their point of view, and a genuine need in their own world — but we were the ones who chose to give that first test!
What if we simply skipped the stage of giving the static, inappropriate test?
I do not think it is overstating the case to suggest that the combination of ethnographic interviewing and dynamic assessment could and should be our initial, major, and primary approach to assessing all clients’ abilities and needs.
My views here are clearly influenced by my years of work in stuttering, for which we have long depended primarily on speech samples and conversations with clients, rather than on standardized tests. My views here are also definitely influenced by my years of work on the construct of reliability, which our profession’s tests often simply do not have. My journey has shaped me, in other words, and I invite you, once again, to shape your practice and your career your way. We are each on our own journeys, and we do not all need to make the same decisions.
But we do all need to provide high-quality care to all populations (ASHA, 2017)! And we do all need to do so in ways that hold paramount each client’s welfare and that recognize, respect, and respond to their cultures, languages, and identies. Dynamic assessment can be successfully incorporated into busy settings with high caseloads and is almost universally applicable as a general strategy that starts with the client and helps us understand what the client can do. If you, given your journeys, cannot make yourself give up standardized tests entirely, maybe you can treat ethnographic interviewing plus dynamic assessment as your default methods and add specific standardized tests only when their scores would help you answer a specific remaining question that you still have about a specific client.
At the very least, I might suggest keeping ethnographic interviewing and dynamic assessment on the top of your multi-purpose toolkit with the “Yes and” strategy. Give them a chance, instead of finding excuses not to. You might find them all more useful than you had initially imagined, and you might not miss the hole of our own digging at all.
Your Turn
Think about the last two or three new clients you saw in your practice. If you used any sort of standardized testing during their assessment sessions, imagine that you had used ethnographic interviewing followed by dynamic assessment as your only two evaluation procedures instead. Would your intervention plans have differed from the ones you did develop for these clients? Would you miss your standardized tests? Why or why not?