Section Five
Module 18: Multi-Cultural Clinical Assessment and Intervention
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How can designing our clinical approaches by thinking about human universals help us provide effective assessment and intervention for all clients?
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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 allow us to work appropriately with everyone, both as we engage with groups that include many different people and also in one-on-one situations. This module discusses four broadly applicable strategies for our multi-cultural clinical practice: 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
Let’s start by making sure we all mean the same thing, when we say “multi-cultural assessment” or “multi-cultural intervention.”
You might have previously encountered terms such as “multicultural practice,” “multicultural speech-language pathology,” “working with multicultural populations,” or “working with culturally and linguistically diverse clients.” As we have discussed, many of the materials intended to support this kind of “multicultural practice” might be useful in some ways, but they often consist of little more than repetitions of stereotypes or isolated oversimplifications about complex groups of people (the Columns-and-Rows Problem).
As we have also discussed, phrases such as “multicultural approaches” or “multicultural practice” also often manage to serve a distinctly more complex or insidious purpose: to divide our clients and our clinical approaches into two groups. In this view of the world, the “regular,” “typical,” or “straightforward” clients, on the one hand, those who are not “multicultural,” would be those for whom we need only our “regular” clinical approaches. Because of our profession’s history in the U.S., let’s also go ahead and be honest that these clients are often implicitly assumed to be White, financially stable, cisgender, heterosexual, if not religiously Christian then at least culturally Christian, educated or growing up in educated families, and monolingual speakers of one of the northern or western American Englishes.
Our “diverse” or “multicultural” clients, in this view of the world, would then be everyone else. Read the Table of Contents in a “multicultural speech-language pathology” book; it’s probably little more than a list of the groups perceived as “other” by some members of American society or by some past members of our profession. There are chapters about people who are not White, but no chapter about “working with White people.” There are chapters about religions other than Christianity, but no chapter about “working with English-speaking Christian families.” People who are gay, nonbinary, transgender, bi-/multilingual, and/or users of dialects or languages other than the northern or western American Englishes are reduced to single chapters. The overall message is that people who do not fit the author’s or editor’s sense of “typical” are so different from our “regular” clients that we need to learn and use special techniques to be able to help them — or, as an alternative, the message might be that the ability to work with bi-/multi-lingual clients or any other specific group of non-White, non-“typical” clients is a specialty area, reserved for professionals who have gained additional education or certification from specialized training programs.
I utterly reject these divisions and implications and descriptions, for many philosophical and practical reasons. None of that is what I mean, when I refer to multi-cultural clinical practices for speech-language pathology.
Remember, as we have said repeatedly, that every person and every group exists somewhere along the full range of many continua, in ways that intersect and interact dynamically. Some of your clients might initially seem to differ from you less than others do, or might seem to differ from you on fewer continua, but none of your clients, I guarantee it, none of them, are the same as you. And, equally importantly, none of your clients, none of them, I guarantee it, 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.
There is no line in the sand beyond which you will stop using your “regular” clinical approaches and switch to using your “multicultural” clinical approaches.
You do not have a “regular” client at 10:00 and then separately have a “multi-cultural” or “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 a different person at 11:00, with whom you share other individual, linguistic, or cultural features to some lesser or greater extents. We always have something in common with every client, and we always differ from every client, in a range of cultural, linguistic, and individual ways. And regardless of how similar or how dissimilar you might be, your clients all need and deserve your very best whole-person, client-centered, personalized, culturally and individually appropriate clinical services and support.
Multi-cultural speech-language pathology, in summary, is not a set of special techniques we pull out when we have decided that someone is “different enough” to warrant “multicultural practices.” Multi-cultural speech-language pathology is no more than, and no less than, how we meet everyone’s shared and universal needs, preferably in the specific way that they prefer, given that everyone is similar to us and also simultaneously different from us.
What does that mean, exactly? What exactly are we supposed to do at 10:00 tomorrow morning and then do again with another client at 11:00?
It does not mean, to be clear, that we treat everyone the same way. Of course we don’t.
It does mean that we tend to use cross-cultural (not “multicultural”) practices, cross-linguistic or multi-lingual (not “multicultural” or “bilingual”) practices, and other “cross-” approaches that help us develop the specific bridges we need to individual people, given that no other person is exactly the same as we are.
It also means, interestingly, that we can look to the approaches that have often been described as good for “other” or “different” or “culturally diverse” clients and recognize that we could (and perhaps should) be using those approaches more often and with almost everyone.
The solution to the artificial and incorrect division between “regular” clinical approaches for “regular” clients and different, special, multicultural clinical approaches for “other” clients, in other words, turns out to be not that we use “regular” approaches with everyone, but that, in a very interesting way, we consider using the “other” approaches much more often than we might otherwise have thought.
Here’s what I mean.
Many of the approaches that our profession has developed but then sidelined as its “multicultural” approaches are wonderful, client-centered, family-centered, whole-person, personalized, evidence-based, culturally and linguistically appropriate approaches. They are good for helping a wide range of people with a wide range of speech, language, literacy, or communication needs. They embody Leininger’s principle of focusing simultaneously on both human universals and the individually-specific ways that each person realizes those universals. They were designed to work with a range of people, or to satisfy universal needs without privileging any group’s specifics, and they therefore turn out to be useful for a much wider range of people than our profession might have given them credit for.
They also help us avoid the impossible task of trying to decide when a person is a “regular” client versus a “multicultural” client, or trying to decide when a person is “enough like us” that we can use “regular” methods versus “so different from us” that we need to stop thinking of them as a person and treat them as an “other.”
The rest of this module describes four of these universally designed and multi-culturally applicable approaches.
We will start with a truly universal response (“Yes, and”). We will then address three clinical approaches that deserve to be at the top of our clinical toolkits for all clients and all families: ethnographic interviewing, dynamic assessment, and culturally responsive group therapy. All three of these methods are often recommended for “other” clients or described as how we can work with clients we have decided are “multicultural” (in the use of that word that I reject). More importantly, however, and as this module will emphasize, all three of these approaches were designed to be culturally neutral, or culturally universal, or universally applicable, or appropriate for people from any background. This feature turns out to make them ideally suited for working with any client, whether we see that client as like us, or somewhat like us, or not like us at all, or anywhere in between. They are multi-purpose, or multi-cultural, or universally applicable, approaches.
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?
How does it make our practice simpler if we assume that all people are both similar to us in some ways and also different from us in other ways (rather than assuming that some people are similar to us while other people are different from us)? Does this approach also make our work more complicated in any way? Why or why not?
Two of my grown children are identical twins. If I were for some reason to serve as their clinician, the three of us might appear to be the most homogeneous combination of one clinician with two clients ever assembled. But we are not! They differ from me in age, economic circumstances, education, gender identity, and work history, among other variables. They are living through a long-term familial and generational trauma that did not affect me in nearly the same way. They also differ from each other, not just from me, in some large and even cultural ways, even though they are identical twins, because of the choices they have made and the personal and professional backgrounds they are developing for themselves as adults. I can easily imagine a person who might look very different from one of the twins on the outside who would have much more in common, in serious ways, with that twin than the twins have with each other. (In fact, they each have some very close friends who meet that description.) How does this story relate to questions about when we need “multi-cultural” clinical practices or why all of our clinical practices, with all of our clients, need to be cross-cultural, whole-person, client-centered, personalized, and culturally and linguistically appropriate?
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 two 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. 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 “appropriate,” 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, 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-cultural or universally designed approaches for clinical assessment and intervention, let’s consider a set of techniques that can be useful both for initial assessment 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. 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 suggest our own views. It’s not a learning opportunity for them; it’s a learning opportunity for us. Stick with repeating the client’s precise words and asking them to tell you more. If they need information from you later, they will ask, or you can present information or your professional interpretations within a completely different 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. Both papers provide explanations, “how to” information, and examples.)
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 or syntactic structures. If you are asking your questions based on your knowledge of universally appropriate speech or language expectations for all clients, 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 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 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 introducing your own experiences with, or opinions about, aliens from Jupiter in any way?
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 “at least I have gotten started” (or from stand-by assist through min, mod, and maximal assist). At the far end lie the (visible) information and skills that you are aware of but that are simply beyond your current abilities, followed by the (invisible) information and skills that are 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 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.
How exactly is all this accomplished, or what does dynamic assessment actually include?
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, or the teacher’s theoretical orientations, 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 and trials, and multiple dynamic assessments about different topics or skills can usually be accomplished within one session with a client. (Variations on dynamic assessment can expand the timeframe, eventually approaching the weeks-long systems that schools call Response to Intervention programs.)
How do we interpret the information we obtain during a dynamic assessment session?
First, we evaluate the client’s response 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, provide 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 feedback we provided during the Teach phase? If so, again the client is 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, 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, in other words, 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 (Or, Climbing Out on an Assessment Limb to Help All Clients!)
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 speech-language pathology, 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 that happen to be 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 may or may not be at all 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 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.
My conclusion and my suggestion is that 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 care. And this conclusion and this suggestion are not my 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 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 their scores 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. 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 used only informal assessment procedures, 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.
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. Sometimes the “bridge” feels almost imperceptible, a simple hop across a quiet stream to meet a client who feels very much like us. Sometimes it feels like we need a large, multi-laned, and heavily engineered construction, several long steel beams, and enormous amounts of concrete to get from where we are and what we have experienced to where a client is and what they need. Either way, and everywhere in between, we do whatever is necessary to meet our clients where they are and then to create individualized and specific intervention plans with them.
There is at least one situation, however, in which intervention can be truly multi-cultural, meaning including a wide range of people from a wide range of different backgrounds: Group therapy.
Imagine working with a group of 5 or 8 people, or more. They might have a diagnosis in common, or they might have in common that they are approximately the same age and attend the same elementary school, or they might have almost nothing in common. If the group meets online, they might not even live in the same community. A support group for adults with aphasia and their family members, for example, could conceivably span a wide range of medical diagnoses, cultural backgrounds, ages, 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 any therapy group is always to ensure that each member of the group gets what they need.
How are you going to meet that goal?
By building individual, cross-cultural bridges to each person, and between group members, so you can help each person with their individual therapy goals. Yes. Over time. And as part of what you do.
But how, exactly, are you going to manage to build all those different bridges to all those different people in the same place at the same time?
This point, the “What exactly are you saying I should do tomorrow morning at work?” point, is precisely where the switch to multi-purpose, multi-cultural, and universal client-centered thinking becomes necessary, because part of the answer is that we cannot possibly build all the bridges in the same space at the same time.
Remember, the “Yes, and” strategy, ethnographic interviewing, and dynamic assessment all work for everyone not because they were designed to be all the bridges, to test every phoneme and every morpheme and every syntactic structure from every dialect of every language, but because they were designed from a universally-oriented point of view. We do not start by setting ourselves the impossible task of learning specific assessment methods specfically designed for each column of people we might describe as different from ourselves. We start by learning, and using, a set of multi-purpose or universally applicable set of adaptable approaches (as we discussed in Module 15 for transcultural nursing’s emphasis on universally-applicable principles and universal design’s emphasis on all people’s shared needs).
In the same way, as we shift from assessment to intervention, we can use a few universally thoughtful and adaptable approaches as the basis for our work with any single client, or with any group.
In fact, just as we have been thinking about how all assessment with all clients might benefit from being structured around the methods that were originally developed in our field for clients who had been positioned as “multicultural” or “different,” I think it is reasonable to assert that all therapy can benefit from being structured around the methods that are often described as culturally responsive group therapy.
Stick with me here. I know I’m out on another clinical and metaphorical limb. What does it mean to say that all therapy can use approaches from multi-cultural group therapy?
Let’s try this.
Read Box 18.3, which presents several examples of principles and strategies for clinicians conducting culturally responsive or culturally-oriented group therapy. Beyond the obvious little tweaks, would any of these ideas be completely inappropriate if you were working with only client?
Box 18.3. Selected Principles, Strategies, and Examples, for Conducting Culturally Responsive or Multi-Culturally Oriented Cognitive or Emotional Group Counseling
Actively foster a positive, culturally accepting, and identity supporting orientation (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 before their first meeting.
“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 a model 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 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, cultural humility, and acceptance of diversity: “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 we will not try to change your opinion about this. 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
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
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 current needs while also respecting background concerns
Trustworthiness, and the ability to trust other people
Kind humor used only to create supportive connections; 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. Use explicitly developed group agreements, where possible, 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 see immediately that we have a range of different family backgrounds in this group tonight! Cool. 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 bit of yourself, that you have a husband, if you want to. We will all respect that part of you in this group.”
“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. We will start exactly when the clock on the wall says exactly 2:00 and stop exactly when the clock on the 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?”
Address cultural and identity-related issues openly, rather than attempting to avoid them. Decide when it is appropriate to present generalized cultural or identity-related information or history and when it is appropriate to invite group members to describe their individual experiences and beliefs.
Respect the decisions of group members who do not want to discuss their cultural or personal history.
Facilitate honest interactions, but do not expect individuals 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.
Repeat often that everyone’s individuals 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.
Focus on the group’s immediate needs, not on solving large historical complexities. Use the wisdom of the group to brainstorm temporary solutions
“I’m hearing here that Ydira has seen several members of her family stopped by the police, while Zadi has not had that experience. I think I know that 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. Ydira, would you like to share any more about your experiences, or no? Then I will ask Zadi the same question next.”
Express cultural humility explicitly. eeking to develop honest and supportive relationships. Use “I think I know; how about you; how does that influence us now?” phrasing to educate other group members, to respect the person you are assuming is from any given culture, and to help group members make the links between their backgrounds and the current issues.
In an example situation, families from different cultural backgrounds might seem to be misunderstanding each other’s choices or struggling with your suggestions about communicating 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 parents expect their adult children to take on the authority role. How about you, what was true in your family? How does that influence our lesson tonight about safety communications with your parent?”
Seek to develop an honest, supportive, and therapeutic relationship with each group member. Help all group members to develop supportive relationships with each other.
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.