Section Five
Module 18: Multi-Cultural Clinical Assessment and Intervention
-
How can designing our clinical approaches by thinking about human universals help us provide effective assessment and intervention for all clients?
-
After working with the material in this module, readers will be able to
explain what it means for a clinical approach to be “universal” or “multi-cultural”
use a “Yes and” response to operationalize the construct of recognizing, respecting, and responding to all persons’ universal and specific needs
use ethnographic interviewing to complete effective, personalized, whole-person assessment with all clients
use dynamic assessment to complete effective, personalized, whole-person assessment with all clients
use principles from culturally responsive group therapy to facilitate effective therapy situations for all clients
Multi-cultural clinical approaches start from human universals, rather than from cultural specifics, and therefore allow us to work appropriately with almost anyone. This module discusses four multi-cultural or universally-oriented strategies for assessment and intervention: the “Yes, and” response, ethnographic interviewing, dynamic assessment, and principles from culturally responsive group therapy.
Be sure you understand the distinctions between “multi-” situations and “cross-” situations, and the constructs of universal needs and specific needs, from Module 15, before you try to read this module.
(Re)Defining Multi-Cultural Assessment and Intervention
Before we move into discussing individual assessment and treatment methods for individual clients, let’s make sure (again) that we all mean the same thing, when we say “multi-cultural assessment” or “multi-cultural intervention.”
We do not mean, to be clear, that some of our clients are “regular” clients and some of our clients are “multicultural” clients.
Some of our clients might initially seem to differ from us more or less than others do, yes. But none of your clients are the same as you, and none of your clients are so different from you that you have to label them as “other,” abandon everything you might otherwise have done as a clinician, and use special different or difficult techniques as you work with them.
You do not have a “regular” client at 10:00 and then separately have a. “cuturally diverse” client at 11:00.
What you have is a person at 10:00, with whom you share some cultural, linguistic, or individual features to some greater or lesser extents, and another person at 11:00, with whom you share other individual, linguistic, or cultural features to some lesser or greater extents. What you need for both of them, given that neither of them is you, will actually primarily be your cross-cultural knowledge, skills, and practices. No matter where each of them is, you will start from where you are and work to build a single cross-cultural bridge that meets that single person’s individual needs. We will address some specific requirements and methods for this sort of individualized and client-specific work in the next module, when we discuss cross-cultural clinical methods.
“Multi-cultural” assessment and intervention means something else.
Multi-cultural, in this context, refers to Leininger’s original notion of recognizing the human universals in health care, and the associated philosophies of universal-design decisions for architecture or physical products. Multi-cultural clinical approaches are those approaches that were developed based on human universals, or that are intended to meet everyone’s shared and universal needs, rather than designed starting from any single culture’s unique elements or specific preferences.
Universally-oriented, multi-cultural screening methods, as we discussed in the previous module, start from universal assumptions such as that adults come to understand the toddlers and preschoolers in their lives, not from culturally specific assumptions that any particular child should have learned any particular morpheme. Universally-oriented, multi-cultural assessment and intervention methods, similarly, start from universally applicable human needs or from our universal need to understand how all clients function in their worlds, regardless of the specific features of that world.
The rest of this module describes four such universally-designed and therefore widely applicable or multi-cultural approaches for assessment and intervention in speech-language pathology. The first is a mindset that is also a truly universal response: “Yes, and.” We will then address two assessment approaches, ethnographic interviewing and dynamic assessment, and discuss ideas from culturally responsive group therapy.
The methods combined in this module have in common that they were designed and intended to be appropriate for a wide range of clients, not developed starting from the assumptions of any one culture. They also have in common that they can be useful for multi-cultural groups as well as for single individuals, an idea we will return to throughout this module.
Is that what you meant by “multi-cultural assessment and intervention”?
Your Turn
Who or what had you previously thought of the phrase “multicultural clinical approaches” as referring to? Compare your ideas and your colleagues’ or classmates’ ideas to the definitions provided here, in Module 1, and in Module 15. (Notice that I will continue to use the hyphen, multi-cultural, to emphasize that we are always working with people from many cultures.)
Find at least four or five uses of terms such as “multicultural speech-language pathology” in other books, articles, or websites. How do their uses of the term compare to the discussion provided here?
One (Almost) Universal Strategy: “Yes, and”
Let’s start our consideration of universally appropriate, multi-culturally oriented clinical practices with an absolute classic: “Yes, and.”
You have probably heard of the “Yes, and” response as an improvisation technique or as an assignment in a theatre class. In these settings, “Yes, and” requires two or more partners to improvise a scene using a rule that everything anyone suggests must be accepted and built upon. The second actor’s response must be some version of “Yes, and,” regardless of what the first actor has offered.
If Alison has asserted in an improvised scene that it is raining, for example, Bertie cannot retort that it is not raining. Bertie must accept Alison’s assertion (“Yes”) and then do whatever he can to build on it (“and”).
Similarly, if Bertie’s response is “Yes, and here come the ducks,” Alison must incorporate Bertie’s ducks into her reality.
She might try, “Yes, and it looks like they are having fun dancing!”
She might try, “Yes, and can you read that sign the little one is carrying?”
She might even jump to, “Yes, and I’m sure glad we brought our hunting rifles!”
Either way, she’s stuck with Bertie’s ducks. And Bertie, in turn, will have to build on Alison’s reply, whether or not he had originally pictured his ducks as dancing, sign-carrying, or otherwise.
“Yes, and” as an acting lesson serves two important purposes.
First, it allows actors to practice listening and responding to their fellow actors. To be able to say “Yes, and,” the listener needs to be listening and absorbing and accepting (i.e., respecting) what their partner has said.
Second, the strategy allows actors to practice their ability to build a single shared reality.
Imagine watching a play that consisted primarily of one actor announcing one thing and another actor immediately contradicting it. Unless the playwright had chosen this arrangement for a specific reason, the audience would find the result essentially unfathomable. Acting requires working together to create a single, collaborative, shared reality and to convey that reality to an audience. Listening, absorbing, accepting, and building together are critical skills that determine the actors’ later ability to be successful together in their work.
“Yes, and” serves the same purposes in clinical conversations with clients, especially but not only those whose backgrounds and assumptions differ noticeably from yours, for the same reasons.
One of our goals in client-centered, whole-person, culturally and individually appropriate clinical service delivery is to recognize, respect, and respond to our clients’ needs, but in multi-cultural situations we cannot possibly have prepared to match every client’s needs specifically — just as Alison could not have known ahead of time that Bertie was going to add ducks to their scene, and Bertie could not have known that his simple little ducks were about to become brain-surgeon ducks on pink roller skates.
Your other goal as a culturally and individually appropriate clinician is to develop a respectful therapeutic relationship and a shared, collaborative reality that will help each client, whether your interaction will be for a minute or two during a quick screening or for many months (or years).
“Yes, and” supports and allows these goals, whether you are preparing for multi-cultural speech-language pathology or enjoying your improvisation classes.
In speech-language pathology, as in acting, “Yes, and” is useful because provides a single, learnable behavioral framework that operationalizes the otherwise somewhat abstract notions of recognizing, respecting, and responding to other people. It should be your first response to almost anything your clients or their families come up with, whether you were expecting them to go there or not and whether what they said is what you would have said or not. It literally, in two simple and learnable words, allows us to recognize (“Yes”), respect (“Yes”), and then respond to (“and”) our clients, regardless of whether we perceive them as a little bit like us in some ways, very different from us in many ways, or anything else. It is a universal, multi-culturally appropriate phrase that starts from, and exemplifies, our basic belief that our clients and their families are all universally human and all deserve equitably high-quality clinical services designed to meet their needs.
Regardless of any other specific suggestions, options, or techniques you might learn or use for multi-cultural, cross-cultural, or any other clinical situations, keep the universal “Yes, and” strategy nearby.
Your Turn
Play with “Yes, and.” Have some fun generating (non-clinical, non-professional) conversations that allow you to practice the universal skill of accepting and building on anything the other person says, whether you agree with them or not and whether you expected them to say that or not. Be careful that your version of “Yes, and” does not communicate “Yes, but here’s my repetition or defense of my view”; the goal is genuinely to accept Bertie’s ducks, and to incorporate Bertie’s ducks into the reality you are creating together, whether you thought there were ducks or not.
Generate one or two professional variations on “Yes and” to have ready and that fit your specific style as a clinician. Among many others, you might think about any of these possibilities:
Claro que sí. Y también podemos…
True. So then from there, we can also…
I see how you are looking at it. So I could…
Thanks for explaining your views. Also, I think we might include…
Ah, so you did [xxx]. We can also try…
Okay, I see how you did that. How about if we also…
“Yes, and” is useful literally, as a phrase to be spoken. It is also useful as a mindset, and it helps in many ways with our goal of providing the best possible communication care to all populations and in diverse, multi-cultural groups. But are you aware that your reaction to some people might be closer to a negatively framed or emotional “No, that’s not right” than to a positively framed or accepting “Sure, you are more than free to be who you are”? If you know that large men on motorcycles scare you, or if you know that you react to some clothing choices as “trashy” rather than as “clothing,” how can a “Yes, and” mindset help you to be prepared to pivot quickly to accepting and supporting each new client in a multi-cultural clinical situation?
As wonderful as “Yes, and” can be, have you also been thinking that sometimes we need to say “No, because”? No, I can’t go to the movies, because I have to study. No, I will not let you climb that tree, because I am your mother and I know it is unsafe for you. No, I will not allow you to speak to me that way, because I am a valuable human being who deserves my own dignity. Even, very seriously: No, I cannot agree that the way you treated your elderly parent in that situation was appropriate, because it meets our society’s definition of elder abuse and I am actually required to report it to the county. Regardless of our emphasis on recognizing and respecting other people, use “No, because” when you must. You have your necessary boundaries, and you are not required to accept racism, sexism, cruelty, or any other abuse or unacceptable behavior.
(Yes, and…. let’s now go back the other direction. As difficult as some interpersonal situations can be, remember, too, that the shared universal in a clinical situation is not that you and the other person are there to agree on hairstyles, politics, or religion. You are there to do speech-language pathology together, for the client’s benefit, and ASHA requires us to provide high-quality services to all populations. If a client has asserted something you fundamentally disagree with, you might be able to use “Mm-hmm, and here is our next activity” to communicate, essentially, “Yes, you said that thing, and I disagree strongly but the more important point in this situation is that we are now moving on with our therapy session.” We will think more about “remembering why we are here” throughout Sections Five and Six.)
Ethnographic Interviewing to Understand All Individuals’ Experiences, Abilities, Interpretations, and Concerns
As we continue to think about multi-culturally appropriate or universally-designed approaches for clinical service delivery, let’s consider a set of techniques that can be useful for initial assessment, for goal-setting, and in our continuing relationships with all clients: ethnographic interviewing. You might notice, as we discuss this technique, that in many ways it is little more than an extended variation on “Yes, and”!
Ethnography refers, as a bit of background, 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 and then potentially identifying clinical goals with their families. 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 18.1 provides a few selected examples.
Box 18.1. Selected Basic Principles and Questions for Ethnographic Interviewing (see Brown, 2017; Westby, 1990; Westby et al., 2003)
Start by stating your (broadly defined) interest in the client’s or family’s experiences.
“I would like to understand what it’s like when you and your child are talking.”
“My goal is understand your experiences as a communicator.”
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.”
“Tell me about talking at work.”
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.”
“You said it depends on who is in the room. Tell me about some examples.”
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.”
“You said you get frustrated with yourself. Tell me about what you do when you get frustrated with yourself.”
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. Use the other person’s words and “tell me about” instead.
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.”
Instead of “That must be hard,” try “You said you ‘really struggle to find words when Mr. Jones is in the meeting.’ Can you tell me more about what the meetings feel like when Mr. Jones is or is not there?”
Successful ethnographic interviewing obviously begins with and incorporates many of the larger principles we have already discussed, including the universal assumptions that all people’s interpretations of their own lives are valuable and that all people deserve to be approached with a basic underlying kindness and respect. Ask your questions in ways that convey kindness and respect, regardless of whether you agree with, approve of, or have ever experienced the situations or the feelings the client is describing. The entire goal is to let them tell you what they experience, how they perceive it, and how they respond to it, and for you to come to understand their experiences and views.
Keeping this goal in mind (“Let them tell me”) might help if you are struggling to understand the last point in Box 18.1, that we should avoid “why” questions, avoid interpreting, and avoid explaining. For other reasons, in other conversations, you might reasonably ask why, if you are seeking to understand a client’s reasoning. The common problem with asking why is that the question can often be perceived as judgmental, heard more as “Why in the world would you believe or do such a silly thing?” than as “That’s interesting; please try to tell me why, because I genuinely care about understanding you.” In some other kinds of conversations, you might use precisely these latter words, and a gentle tone of voice, precisely to avoid giving the former impression. In ethnographic interviewing, however, the rule is simpler: just stick with asking for descriptions and examples, through which you should be able to come to understand the client’s reasoning.
Interpretations and explanations are similar. Many other counseling and interviewing traditions use them, and they can be used quite effectively. You have probably rephrased, paraphrased, labeled, or explained for your clients many times, for many positive and helpful reasons. In the ethnographic interviewing paradigm, however, we are carefully seeking to understand the client’s interpretations, explanations, and current solutions, not trying to impose or even to offer our own views. Ethnographic interviewing does not seek to help clients learn from us; it seeks to let us learn from them. If they need information from you later, they will ask, or you can present information or your professional interpretations within a separate conversation. If nothing else, there’s an important trust issue here: If you start the conversation by stating that you want to understand your clients, and you then shift to acting as if you want them to understand you, you are revealing yourself to be dishonest, uninterested in their views after all, or even hopelessly self-centered.
Ethnographic interviewing also differs from other interviewing strategies in that it depends on some specific terminology that is not common in other kinds of interviewing or counseling. Some ethnographic interviewing questions, for example, are referred to as “grand tour” questions (e.g., “Tell me about a typical day”), “mini tour” questions (e.g., “Tell me about your job”), or “specific mini tour” questions (e.g., “Tell me about your talking and understanding in your committee meeting at work yesterday”), among others. If you will be doing research or writing about ethnographic interviewing, or if you want to refer to your approaches as following Westby’s (1990) description of ethnographic interviewing for early childhood education or speech-language pathology, these details will be important for you. For many of us, however, in most day-to-day clinical practice, these specific labels are less important than the possibilities they represent. As long as you are asking broad and then slightly narrower questions, repeating the client’s own words and repeating “Tell me about,” it will usually be less important that you can use some of the specific terminology. (If you are interested in the details, Westby’s (1990) paper is comprehensive and Westby et al.’s (2003) summary is easily accessible.)
Regardless of such details as the difference between a “specific mini tour” question and a “guided mini tour” question, in summary, 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. It was designed to be a universally applicable method for gaining information about what clients know, do, and believe, not designed to test a client’s knowledge or abilities against a predetermined or language-bound list of pre-selected morphemes, syntactic structures, or anything else. If you are asking your questions based on your knowledge of universally appropriate speech or language expectations for all clients (see Module 17), and based on your genuine respect for their experiences and their views of their world, ethnographic interviewing will get you a long way. These techniques can help us understand what any client can do, what they value, how they perceive their lives, and what they might perceive as helpful assistance or a reasonable goal for going forward. It is a wonderful and useful assessment approach that deserves to be better known and more widely used in our profession.
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?
Practice asking variations on the questions summarized in Box 18.1 using a social communication style (tone of voice, pragmatics, body language) that conveys criticism, disbelief, or contempt. Then practice asking the same questions using a social communication style that conveys warmth, acceptance, and kindness. (And, obviously, be ready to use the latter in all your clinical interactions!)
Roleplay an ethnographic interview with a friend who is willing to pretend all of the following for you without breaking character or laughing.
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; anything that would be completely new to you).
They have what they perceive as difficulties with their speech, language, or communication.
And they are utterly convinced that the reason for their difficulties is the invisible aliens from Jupiter who routinely poison their food in the place where they live.
Imagine that you are meeting this person for the first time and know nothing about their living situation, background, experiences, or beliefs. Can you use the question types summarized in Box 18.1 to understand your friend’s experiences, perceptions, and requests without making any judgment at all and without conveying your own experiences with, or opinions about, aliens from Jupiter?
Dynamic Assessment to Understand Individuals’ Abilities and Needs as Learners
Ethnographic interviewing helps us understand what clients have experienced, what they do, what they can do, and how they interpret their lives and their needs.
Another important multi-cultural or universally appropriate assessment approach, known as dynamic assessment, refers to strategies that 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” (ZPD), 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 and skills that you have mastered are at one end. Information or skills that you can not manage on your own but can achieve with some degree of assistance range across the middle, from “almost mastered” through “working on it” to “I still need a lot of help with this” (or, in terms that might be familiar to you, from stand-by assist through min, mod, and max assist). At the far end lie the (visible) information and skills that you are aware of but that are beyond your current abilities (followed by the invisible information and skills that are completely beyond the current scope of your knowledge about this topic). The part in the middle, the things you cannot yet do on your own but can do with support and 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 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 when they are given that support, and deciding what they need next. Dynamic assessment is an assessment strategy, but the mindset is not “testing,” as in comparing a client’s knowledge and abilities to a predetermined fact, standard, or norm. Instead, the universally oriented mindset includes everything that the best possible versions of teaching or coaching include: We watch for, recognize, respect, and respond appropriately to what clients bring and to what they may or may not need next in their world, as the learners that they are. During dynamic assessment, furthermore, we are watching not only for the client’s current accuracy with a task but, much more importantly, for the client’s generalizable 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 18.2, 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, again, 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 much 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 task, the learner’s abilities, and the teacher’s theoretical orientations, the teacher might explain, model, praise, reflect, recast, expand on, correct with a hand-over-hand prompt, or make other 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. Each phase of a dynamic assessment sequence, including the Teach phase, can be as brief as a few minutes, and multiple dynamic assessments about different topics or skills can easily be accomplished within one session with a client. (Variations on dynamic assessment can also expand the timeframe, eventually approaching the weeks-long systems that schools call Response to Intervention programs.)
How, then, do we interpret the information we obtain during a dynamic assessment session?
Dynamic assessment gives us at least two kinds of information.
First, we evaluate the client’s responses to the assistance we offer during the Teach phase. Behaviorally, as we make quick suggestions, does the client try to do the task a different way, or succeed in changing their speech, language, or other behavior? Cognitively, does the child ask for explanations, attempt to verbalize their own potential explanations, or make further suggestions or discoveries on their own? Emotionally, does the child appear excited, engaged, and interested as we make suggestions for change? If so, the child is demonstrating the ability to benefit from minimal guidance, the kind of guidance that life probably provides, and is less likely to need formal intervention.
Second, we evaluate the difference between the client’s performance during the first Test phase and their performance during the Re-Test phase. Have they improved, given only the quick suggestions, models, or other feedback we provided during the Teach phase? If so, the client is again demonstrating the ability to benefit from minimal guidance, the kind of guidance that life probably provides, and is probably less likely to need formal intervention.
Overall, notice that we interpret the results of dynamic assessment by assuming that intervention or specialized teaching is more likely to be necessary for people who do not learn easily from quick exposures to new things. Clients who demonstrate improvement and/or 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. Clients who do not improve during the dynamic assessment process, however, or who do not seem to demonstrate an ability to engage in learning from bits of information, probably will need more help, possibly in the form of formal intervention, if they need to be moving from their current knowledge and abilities forward to their next possible level of knowledge and abilities.
Combining Ethnographic Interviewing and Dynamic Assessment for Universally Designed, Client-Centered, Multi-Cultural, and Culturally Appropriate Assessment
Let’s put ethnographic interviewing and dynamic assessment together. Do you see the beauty of what they can do for all clients, in the context of our search for client-centered, whole-person, culturally and linguistically appropriate communication care, and as related to the distinction between universals and specifics in healthcare or education?
Ethnographic interviewing and dynamic assessment avoid culture-bound or clinician-centered questions that are based on the specifics used in one language or one culture. They do not ask, “Does your family do things in this particular way that someone else decided ahead of time to call the correct way?” They do not ask, “Do you have this specific skill that a test developer decided ahead of time to ask you about?” They do not ask, “Do you use this one morpheme that is important to me but that may or may not be relevant to your dialect?”
Instead, both ethnographic interviewing and dynamic assessment ask universal and therefore client-centered questions about clients’ experiences and abilities.
What is happening in your life?
What do you think about, and how do you feel about, what is happening in your life?
What skills do you already have for managing your life and 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 managing your life and learning what you need, from whatever you are exposed to in your world?
Because of its many strengths, dynamic assessment in particular 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,” as we said at the beginning of this module). 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, or to help us understand if a low test score should be interpreted as a valid indicator of a disorder for that child.
If the child demonstrates learning strategies and/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 helpful strategies for learning, and does not show improvement on the task even with substantial assistance, then we might reasonably conclude that the low score is meaningful, or that the difference between our test’s assumptions and the child’s abilities should genuinely be interpreted as suggesting that the child has a problem with language learning (which our intervention might be able to help).
Notice that 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 whole-person, 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 many clients’ scores to those tests almost uninterpretable. Some test developers are trying, but on the whole, I think it is well established in our field that our commercial tests show problematic reliability and validity, especially when we attempt to interpret scores from those tests as if they were meaningful for clients who simply do not reflect the groups whose scores were used to “norm” the tests. (See Wood et al.’s (2025) recent addition to this literature, if you happen to be unfamiliar with the problems.)
Because of the problems with standardized tests, dynamic assessment is often recommended as a secondary procedure to use next. The outcome of dynamic assessment can help us decide, as we said above, whether the difference between the test’s norms and the child’s abilities should be interpreted as a true problem for that child or simply a difference between the test’s norms and the child’s experiences.
The context within which dynamic assessment is often recommended, in other words, is an entirely unnecessary 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, instead of calling on dynamic assessment as a secondary approach, we simply skipped the stage of giving the static, inappropriate test in the first place?
I do not think it is overstating the case to suggest that the combination of ethnographic interviewing plus a few cycles of dynamic assessment could and should be our initial approach to assessing all clients’ abilities and needs. And yes, I mean instead of, not after, the use of most standardized or commercial tests.
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 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 identities.
Here is my conclusion and my suggestion: Ethnographic interviewing, dynamic assessment, and our careful observation of clients’ abilities in the context of our truly universally-oriented expectations that recognize and respect their lives can go a long way toward allowing us to provide all clients with client-centered, whole-person communication care. And this conclusion and this suggestion are not my new idea or my original suggestion; substantial research has demonstrated that dynamic assessment not only can be successfully incorporated into busy settings with high caseloads but, even more importantly, that it can serve as an almost universally applicable general strategy that starts with the client and helps us understand what the client can do and therefore what the client might need — which is, remember, the fundamental and basic reason we do any assessment or set any clinical goals in the first place.
Can you, given your journeys through your clinical career, make yourself give up standardized tests entirely, or does that choice strike you as coming from too far out on too fragile a limb?
Conversations such as this one often get stopped at “but my district requires” or “but my client’s insurance company requires,” both of which are solvable systemic questions. Until they are solved, maybe at the very least more of us could use ethnographic interviewing plus dynamic assessments as our first, default methods and then add carefully selected standardized tests only when the scores from those instruments would help us answer a specific remaining question that we still need to answer before we can decide how to help a specific client.
Or maybe, even if you can’t make yourself give up commercial tests, you might at least keep ethnographic interviewing and dynamic assessment toward the top of your multi-purpose toolkit, with the “Yes, and” strategy, and use these strategies more often.
Give them a chance, instead of finding excuses not to. You might not miss the hole of our own digging, and our solid tree branch out here turns out to be a fairly sturdy and supportive limb after 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. What might you have learned from ethnographic interviewing and dynamic assessment that you did not learn from the approaches you used? 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?
If you did use only informal assessment procedures with your last two or three new clients, were they ethnographic interviewing followed by dynamic assessments, maybe plus speech/language samples or observations, or did you use something else? Do you ever use standardized tests in your practice? Why or why not?
Multi-Cultural Treatment, Management, or Intervention
Finally, as we finish thinking about universally applicable or multi-cultural clinical approaches, let’s think about treatment or intervention.
As we have said repeatedly, almost all intervention must be cross-cultural, not multi-cultural, given the way we are defining these words. Our task in intervention is to meet a specific client’s needs, a task that almost always requires us to build a specific cross-cultural bridge to that client.
There is at least one situation, however, in which intervention can be truly multi-cultural, meaning that it includes a wide range of people from a wide range of different backgrounds at the same time: Group therapy.
Imagine working with a group of clients. They might have in common little more than that they attend the same elementary school. Even more broadly, your weekly videoconference group for adults with aphasia and their family members could include people who do not live near each other and who span a wide range of medical histories, cultural backgrounds, ages, family shapes, first and later languages, economic circumstances, religions, and so on, to any greater or lesser extent along any numbers of dimensions.
Regardless of any of these variables, your goal as the facilitator of the therapy group must always be to ensure that each member of the group gets what they need as an individual. As clinicians, we develop and meet individualized goals with each client, even if our therapy for that client uses a group-therapy model for service delivery. We build individual, cross-cultural bridges to each person, and we also try to facilitate at least some bridges between group members, because our goal is to help each person with their individual therapy goals.
At the same time, however, as we recognized in distinguishing between “cross-” efforts and “multi-” efforts in Module 15, we cannot possibly build all the bridges at the same time in the same space. Carefully personalizing for each of 8 people in a group cannot mean that they each spend 7/8ths of their time listening to details meant for someone else. As we have said, the many differences between “cross-” situations and “multi-” situations include that working appropriately with a group requires its own approaches.
Try reading Box 18.3, which collects many suggestions for culturally-responsive or culturally-oriented group therapy. The emphases might not be what you are looking for, in part because these ideas were developed originally for clinicians facilitating overtly culture-forward psychological or emotional counseling groups. As adapted for any group therapy situation, however, these approaches can help us act in one universally-oriented way that meets each individual’s universal and shared human needs to feel understood, empowered, appreciated, and respected. Try thinking about how you could adapt these ideas to your practice, as you read Box 18.3, or thinking about what variation on this idea you would appreciate if you found yourself the client in a group or individual therapy situation.
Box 18.3. Selected Principles, Strategies, and Examples for Conducting Culturally Responsive or Multi-Culturally Oriented Cognitive or Emotional Group Counseling, With Examples for Speech-Language Intervention Sessions
Seek to support each client by actively fostering a positive environment that is accepting of their cultures and identities. Because you cannot be aware ahead of time of all clients’ specific and detailed needs, start by fostering a positive environment that is accepting of all cultures and identities (see Kivlighan, 2023).
Be empathetic to other people’s needs. Be aware of, sensitive to, and accepting of human diversity.
Be honest with yourself and with all other group members (see Brinson & Lee, 2005).
Provide new group members with information and guidelines about accepting cultural diversity and about expecting cultural respect.
“There will be people in the group whose family background or other personal history will differ from yours. Our meetings are intended to be positive and accepting for everyone. Please be prepared to listen with respect to all the other members of the group, especially if they seem to look different from you, think differently from you, or act differently from you. You can also expect that everyone else will listen respectfully to you.”
Serve as a leader and as an exemplary participant, not as an aloof authority. Describe and model cultural humility and the other culturally-influenced behaviors you expect group members to display.
Listen as every group member is talking (rather than focusing on your notes or searching through your materials to prepare the next activity).
When speaking to any group member or to the group as a whole, use a polite and kind tone of voice (rather than using a frustrated tone to insist that group members should speak kindly to each other).
When a group member has described a cultural detail that is new to you, respond with explicit cultural humility and explicit acceptance of diversity (“I did not know that about your family’s background! That’s cool, and it’s also cool that different people do it differently.”)
When you do not understand a member’s point, or when you are aware that other members might disagree with a member’s point, respond with explicit support, explicit cultural humility, and explicit acceptance of diversity. Say, “Thank you for sharing. I am interested in your views. Can you tell us more, to help us understand what you need?” or “Thank you for sharing. I can tell other people have other opinions, but that’s okay. Everyone can have their own beliefs about this topic.” (Or, if needed, if the individual is monopolizing the group: “Thank you for sharing. I am interested in your views, so let’s definitely plan to come back to that, I made a note. For now, does anyone else want to address the question we had raised?”).
Regardless of the specific type of group (skills development, support groups, relapse prevention, and many others) or the leader’s philosophical orientations, effective group leaders display all of the following attributes toward all clients, encourage all group members to develop these attributes, and facilitate group interactions based on these attributes.
Personal warmth with professional boundaries (i.e., professional warmth with personal boundaries)
A positive and life-affirming demeanor; positive and life-affirming words toward ourselves and toward all other people
Active listening
Balanced confidence and humility; balanced consistency and spontaneity
An awareness of our own tendencies as human beings, and an acceptance of other people’s tendencies as human beings
The ability to differentiate between our own old personal issues, other group members’ old personal issues, and the group’s current issues, and the ability to keep the conversation focused on the group’s current needs while also respecting background concerns
Trustworthiness, and the ability to trust other people
Only kind humor, used only to create supportive connections; only warm curiosity, used only to provide connective support
Empathy for other people, and an understanding that other people’s experiences and resulting needs are important to them.
Make the implicit explicit and positive. Name any cultural or identity-related issues or occurrences in the group; state directly that they will be viewed positively and dealt with in accepting ways.
“I see immediately that we have a range of different family backgrounds in this group tonight! I’m glad. All of you are welcome here.”
“Mark, I heard that you started to mention your husband while you were talking but then you seemed to back away from that. Please feel safe to share this part of yourself, that you have a husband, if you want to. We will all respect that part of you in this group.”
Use explicitly developed group agreements, to prevent the implicit imposition of any subgroup’s assumptions onto the whole group. Where you must impose one version of any culturally-influenced variable, explain your reasoning.
“I know we all have different assumptions or preferences about food or drinks during group. This building has a rule about no food in any of the classrooms, to help keep the rooms clean for everyone and to prevent bugs, so I need everyone to follow that rule. What about drinks? Do you all think we should allow ourselves to have coffees or sodas or other drinks during group?”
“Our group is scheduled to meet from 2:00 to 2:45. I will start exactly when this clock on this wall says exactly 2:00 and stop exactly when this clock on this wall says 2:45, so everyone can know when group will happen and so I can be ready for my 3:00 group. Will anyone have any trouble arriving before the clock says 1:55?”
Express cultural humility explicitly, seeking to develop honest and supportive relationships. Use “I think I know; how about you; how does that influence us now?” phrasing to improve your own knowledge, to educate other group members, to respect the person you are assuming is from any given culture, to help group members make the links between their backgrounds and the current issues, and to keep the group’s focus on it’s current learning issues.
In an example situation, families from different cultural backgrounds might struggle to understand each other’s choices or respond differently to your suggestions about how to communicate clearly and firmly with adults with dementia when their safety is at risk. Try: “I think I know that sometimes some people grow up assuming that it is inappropriate to question an older person, and sometimes other families expect their adult children to take on the authority role as the parents age. How about each of you, what was true in your family? How does that influence our lesson tonight about safety communications with your parents?”
Address cultural and identity-related issues openly, if possible, rather than automatically redirecting or attempting to avoid them. Decide when it is appropriate to present generalized cultural or identity-related information or history, when it is appropriate to invite group members to describe their individual experiences and beliefs, and when discussions are not serving the group’s therapeutic purpose and need to be actively tabled.
“I’m think I’m hearing here that Ydira has seen several members of her family stopped by the police, while Zadi seems less familiar with that experience, is that right? To the best of my current knowledge, Ydira’s experience is common for Black people in the U.S., and that is definitely a difference between you — which is why we say often here that everyone’s individual experiences are true for them and that we are not all required to have lived the same lives or to believe the same things. Ydira, is anything else about your experiences important for the group to understand this evening as part of today’s lessons? I will ask Zadi the same question next.”
Seek to develop an honest, supportive, and therapeutic relationship with each group member that includes their cultural background as one of many important variables. Help all group members to develop supportive relationships with each other, and help all group members to keep the group’s interactions therapeutic.
Facilitate honest reflections about culture, ensuring that those interactions remain positive, kind, and helpful.
Do not expect people to teach the individuals who have hurt them, do not expect individuals to speak for their entire culture, and do not allow individuals to speak for any other entire culture.
Encourage reflections on culture, while also respecting the decisions of group members who do not want to discuss their cultural or personal history.
Repeat often that everyone’s individual experiences are true for them and that no one’s individual experiences negate anyone else’s.
Acknowledge differences explicitly, and use “Yes, and” to keep the focus on the content of the meeting’s lessons or therapy goals.
Incorporate discussions of culture into how you address the group’s therapeutic goals, but do not allow individuals within the group or the group’s conversations overall to focus on large societal or historical complexities that your group cannot possibly solve.
Use evidence-based practices and a strengths-based approach, to highlight student strengths and to bring empowerment to students involved in the intervention. Adapt practices as needed, given the complexity and individuality of the students (see Goforth & Pham, 2023).
Seek to understand each group member’s current strengths, abilities, and goals in the context of their cultural, familial, and other backgrounds. Ensure that each group member understands their own current strengths, abilities, and goals. Ensure that the group experience builds on each member’s strengths and helps them to progress toward meeting their goals. Use individual progress-monitoring data, even if intervention occurs in a group setting.
Long list, and do you also see the larger points?
Some therapy groups focus on being about culture, being actively culturally responsive, or being explicitly culturally oriented, using principles and practices such as those described in Box 18.3. This focus might not characterize your individual speech or language therapy sessions at all.
At the same time, because these principles and practices were developed to be universally welcoming or applicable for essentially all cultures, they are almost universally appropriate!
We do not need to be conducting something that we think of as a Culturally-Focused Group Therapy Session, for example, to understand the importance of using only kind humor, and using humor only to create supportive connections, rather than allowing any humor that enters our therapy sessions to be discriminatory, taunting, targeted, or intended to diminish anyone’s sense of self. Any treatment session, of any size or with any client, will benefit from the use of strengths-based, evidence-based practices, appropriately adapted for each client’s needs and tracked with appropriate individual progress-monitoring data. And there is no circumstance within which we would ever want to approach any single client by saying anything other than “You matter, your background matters, and I am here to help in ways that I intend to be helpful for you given who you are, where you have been, and where you are going.”
So, again, we will achieve most of this goal, as we provide treatment or management or other intervention options with clients, by focusing on therapy as a cross-cultural situation, not a multi-cultural situation. But if you use group therapy sessions, you will need at least some of the explicitly multi-cultural ideas from Box 18.3.
And even if you do not use group therapy sessions, as we said for “Yes, and,” ethnographic interviewing, and dynamic assessment, the principles and practices that were originally developed for multi-cultural and culturally-focused group therapy provide a wonderful starting place for essentially all therapeutic interactions, with any single client or with all clients, precisely because they were developed from an inclusive, universal, caring, human, and therefore individually-supportive point of view.
Your Turn
Talk some more about Box 18.3. Which parts did you like instantly? Which parts are you less sure about? Use a 16-Questions matrix to reflect on your reactions.
Think about the last few individual-therapy sessions you conducted that you think went fairly well. Which parts of the ideas from Box 18.3 were you using, either automatically or as a conscious effort or decision? Do you think that was part of why those therapy sessions went well?
Think about some clients whom you would perceive as coming from cultural backgrounds or incorporating individual identities that are very similar to yours. The ways you would interact in individual therapy sessions with these clients would probably reflect the ideas in Box 18.3: You would probably be warm, accepting, and sensitive to their culturally-based preferences not to schedule appointments on certain holidays, as one example. You would probably address culture directly, in many ways, from telling an adult that it was nice to see them at temple or at the protest last weekend to bringing a Santa Claus coloring activity for a child. How could you use the ideas in Box 18.3 to ensure that all your clients, no matter how similar or different you think your backgrounds might be, receive equally warm, accepting, culturally sensitive services from you?
Think about some clients whom you would perceive as very different from you. Which cultural factors or individual identities made you assume that this imaginary person differed from you? Do any of those factors make that person any less deserving of receiving the best possible warm, accepting, culturally sensitive clinical services from you? If you were imagining that they differed from you in only a few key ways, probably related to their race, religion, age, or sexuality, can you also imagine that they might have also been almost identical to you in every other way? How do these questions relate to the suggestions provided in Box 18.3 for group therapy or affect your application of the ideas from Box 18.3 for individual therapy?
Remember that ASHA requires us to provide the best possible, high-quality clinical services to “all populations” (ASHA, 2017). If you are resisting that idea, as you think about Box 18.3, can you reflect on why? (Would another 16 Questions matrix help?)
Highlight Questions for Module 18
Explain what it means for a clinical intervention approach to be “universal” or “multi-cultural,” as this module discussed those terms.
Explain the “Yes, and” response. Explain its use as a way to operationalize the otherwise potentially abstract constructs of recognizing, respecting, and responding to all persons’ universal and specific needs.
Describe the principles and practices of ethnographic interviewing (Box 18.1). How can ethnographic interviewing help us to complete effective, personalized, whole-person assessment or to develop appropriate clinical goals with all clients?
Describe the principles and practices of dynamic assessment (Box 18.2). How can dynamic assessment help us to complete effective, personalized, whole-person assessment or to develop appropriate clinical goals with all clients?
When or why have ethnographic interviewing and dynamic assessment been recommended in our profession, historically? What case did this module make for using ethnographic interviewing and dynamic assessment as our primary assessment methods with all clients? What approaches or methods will you use to complete initial and ongoing assessments of clients’ abilities and needs in your practice, and why?
Describe some of the many principles and practices used in multi-culturally-focused or actively culturally-oriented group therapy (Box 18.3). How can these ideas help us to provide effective, personalized, whole-person communication care for all clients, in all individual or group intervention sessions?
Module 18: Copyright 2025 by Compass Communications LLC. Reviewed November 2025.