You are scheduled to evaluate a 58 year-old male today with a physician’s order of potential cognitive deficits. You identify that the patient is in rehab after having a leg amputation. The patient is a bilingual (Spanish-English) speaker, so you use an interpreter for your evaluation. You ask a few questions regarding the patient’s activities of daily living (ADLs) and learn that he is pretty independent. You ask the patient “Do you feel like there are any differences in your thinking or organizing since you arrived here?” The patient states “Well…maybe I guess, it is hard to remember all the information I have received.”
You get ready to evaluate the patient and prepare some cognitive evaluation tasks that will help capture the patient’s strengths and areas of need. You begin by asking the patient some orientation questions (e.g., “What city are we in?, “What is the name of the place you are in right now?”). Then, you have them complete some working memory tasks (e.g., backward digit span tasks) to get some insight into how they may perform with everyday life tasks that require working memory, such as remembering to write down an upcoming doctor’s appointment on a calendar. Finally, you give them a clock drawing task to measure their visuospatial skills and because it is a good indicator of cognitive deficits. The patient performs poorly on almost all tasks. You pick him up on your caseload and diagnose the patient with a cognitive deficit, and write your report along the lines of “Patient is a 58 year old male with mild to moderate cognitive deficits in the areas of memory, organization and orientation.”
Sounds familiar if you are a speech-language pathologist (SLP) in the health care setting, right? Let’s discuss what the SLP missed in this case. The client arrived to the United States (U.S.) approximately 3 weeks ago after realizing he needed an emergency surgery following an accident involving his leg. He had grown up and lived in Costa Rica his entire life. He was independent with ADLs, which included managing finances with cash and working full time as a farmer. He enjoyed farming and had been farming almost his entire life. He had to leave school early to help his family maintain the farm, and he had been doing that ever since. When asked, “Tell me about how the leg surgery may impact your daily life.” He describes that he is going to have difficulty with completing things he is used to doing on his own (e.g., bathing, dressing, farming). However, he describes that his family is very supportive and his daughter is taking time off from work so that she can take care of him and help him as needed.
Given the above information, the evaluation is incomplete because it doesn’t capture the whole client. It is difficult to answer spatial orientation questions in a place you just arrived to, especially in an entirely new country. Clock drawing tasks, by nature, assume prior knowledge of a clock. Some individuals from other countries may not be familiar with the analog type of clock we ask clients to draw during this task. Finally, working memory tasks are biased amongst populations of low education level (Souza-Talarico, Caramelli, Nitrini, & Chaves, 2007). That is, there are correlations between education levels and working memory performance (Souza-Talarico et al., 2007), thus individuals with lower education levels may perform poorly on working memory tasks without having true working memory deficits.
Gathering an in-depth interview focused on the client’s history, story and goals prevents misdiagnosis, is more productive, and ultimately, makes us better clinicians by assisting us in identifying cultural biases that may exist in our assessment process.
So how do we do this?
What is ethnographic interviewing?
Ethnographic interviewing is defined as the process of unfolding the client’s story and perspective of the interview topic by allowing the client to guide the interview (Bateman, 2002). Ethnographic interviewing styles integrate the SLPs knowledge on swallowing and communication disorders with the family or client’s perspective of disability (Westby, Burda, & Mehta, 2003). The SLP using an ethnographic interviewing style approaches it with an open mind, ready to gain insight from their client or client’s family into their goals, values, and beliefs (Westby et al., 2003). One of the most important parts of the assessment and treatment process includes building rapport with your client and this therapeutic alliance begins with the interview. By understanding what is important to clients during the interview, the SLP can begin to design an evaluation and treatment plan that is client-centered and ultimately, can begin to build the foundation of the client-clinician relationship.
The story introduced above was one of my first experiences with a culturally and linguistically diverse client during my externship placement. It reminded me of the importance of taking the extra 15 minutes at the beginning of every session to really get to know the person you are working with. I learned that these extra 15 minutes can mean providing an appropriate and thorough evaluation and creating treatment goals and plans that are functional and motivating to the client.
What are some key components of the ethnographic interview?
- Use open ended questions, including beginning with a ‘grand tour’ question that will guide the client to tell their own story.
- The grand tour question sets the tone for the rest of the interview. You want to ask an open-ended question that will help you understand the client’s overall perspective about the problem or reason for visit. This question will help you then probe further into the client’s opinions and other cultural factors/aspects that may impact your evaluation or treatment plan.
- An example of a grand tour question: “Tell me about a typical day for you and your family.”
- Ask for examples.
- Asking for examples can help the interviewer understand more about the specific ADLs the client participates in. It is also a great way to ask for clarification or for more information.
- An example question: A question you may ask after the client’s family states that their child has difficulty organizing her work: “Can you give me an example of a time your child had difficulty organizing her work?”
- Don’t reword what the client says, but instead clarify or ask for more information by restating exactly what they say.
- Rewording what the client says may lead the SLP to include something biased in their response (what their opinion may be on the topic). Restating what the client says, instead helps the SLP avoid biased questions while at the same time, dig deeper and gather more information about the client.
- An example:
Caregiver: “She has been having trouble making friends at school.”
SLP: “She has been having trouble making friends at school?”
Caregiver: “Yes…it seems as though she doesn’t know how to insert herself into conversations or doesn’t know how to find common interests with others.”
- Ask one question at a time.
- This helps the interview process feel less overwhelming and helps with clarity.
- Avoid ‘leading’ questions and ‘why’ questions.
- These types of questions are by nature, biased and may make the interview process feel more interrogative-like. You want to ask questions that will help your client feel comfortable and the types of questions you ask matter.
- For example, instead of asking “What are the communication concerns you are having?,” the SLP may ask, “Tell me about your communication on a typical day.”
- Sit next to your client.
- Yes, it matters! Think about a time you went to a doctor’s appointment and the doctor was asking about your mental health or how you are feeling day to day…how inclined are you to share when they aren’t even facing you or are across from you sitting in front of a computer?
(Westby et al., 2003).
How can the ethnographic interview help you during assessment and treatment?
The ethnographic interview works to reveal important aspects of individuals’ cultural beliefs and values that play an important role in the treatment process. As described previously in the example at the beginning of this post, it can also guide the treatment process and help the SLP decide if treatment is even necessary.
What are some key cultural aspects that the ethnographic interview can reveal and what should the SLP explore?
- What is meaningful to the client and their family?
- How does the client learn?
- What terms does the client use?
- How is progress defined?
- What is the client’s communication style?
- What specific ADLs does the client participate in?
- What events or play items are important to the family/client?
- What kinds of food or liquid does the client consume?
- What is the client’s family dynamic like? Are they a part of collectivist culture? Will family involvement and education be important for this client?
- What is the client’s attitude towards health care professionals and the health care system, in general? Will this attitude change the way I approach my client or ask questions to make them feel most comfortable?
- Consider asking open ended questions versus ‘yes’ or ‘no’ questions if your client views health care professionals as superior. This will limit bias in their answers. An example: Instead of asking “Do you want therapy conducted in English?,” the SLP may ask, “Tell me about what languages you speak at home.”
- What is your client’s view on ‘homework time’ or play? How may this impact my recommendations?
- Who is the client’s primary caregiver? Who lives in the home?
- What does the client need from you, as the SLP?
Ultimately, ethnographic interviews during the evaluation and throughout the treatment process help clients and their families feel included and like they are active participants in the process. This feeling and inclusion helps build a relationship between the clinician and the client that is open, meaningful and collaborative (e.g., Sells, Smith, & Moon, 1996; Todd, Joanning, Enders, Mutchler, & Thomas, 1990).
Conducting ongoing ethnographic interviews throughout the treatment process can also improve cultural competency of the SLP. In a study with students learning Spanish as a second language, students conducted ethnographic interviews with individuals a part of a variety of Latino cultures. The author found that ethnographic interviews improved students’ attitudes towards Latino cultures, desire to learn about other cultures, in addition to widening awareness of their own culture (Bateman, 2002).
Now, a question to think about. What is the most important skill an SLP can have?
In our graduate programs, we all learn those essential skills necessary to be clinicians, such as problem solving, critical thinking, clinical knowledge abilities, etc. What we are not taught explicitly is how to build rapport and identify what is meaningful to each client and/or family to make the most functional treatment plan for them.
Building a therapeutic alliance is probably the most foundational skill because it will
- make therapy meaningful to the client,
- align directly with principles of neuroplasticity such as “salience matters,” and
- contribute to our client’s motivation and willingness to participate in therapy.
How can we have therapy without client engagement and buy-in?
There is no “one size fits all” approach to therapy and truly skilled therapy is the identification and inclusion of the cultural values and beliefs that are important to each individual client you will work with. A truly skilled SLP needs to adjust their clinical knowledge and skills to best fit the values and beliefs of the person they are working with.
How do you do this?
Yes, you answered it!
The ethnographic interview.
Bateman, B. E. (2002). Promoting openness toward culture learning: Ethnographic interviews for students of Spanish. The Modern Language Journal, 86(3), 318- 331. doi:10.1111/1540-4781.00152
Moxley, A., Mahendra, N., & Vega-Barachowitz, C. (2004). Cultural competence in health care. The ASHA Leader, 9(7), 6-22. doi:10.1044/leader.FTR3.09072004.6
Riquelme, L. F. (2004). Cultural competence in dysphagia. The ASHA Leader, 9(7), 8-22. doi: 10.1044/leader.FTR5.09072004.8
Sells, S. P., Smith, T. E., & Moon, S. (1996). An ethnographic study of client and therapist perceptions of therapy effectiveness in a university-based training clinic. Journal of Marital and Family Therapy, 22(3), 321-342.
Souza-Talarico, J. N., Caramelli, P., Nitrini, R., & Chaves, E. C. (2007). The influence of schooling on working memory performance in elderly individuals without cognitive decline. Dementia & Neuropsychologia, 1(3), 276–281. doi:10.1590/S1980-57642008DN10300009
Todd, T. A., Joanning, H., Enders, L., Mutchler, L., Thomas, F. N. (1990). Using ethnographic interviews to create a more cooperative client-therapist relationship. Journal of Family Psychotherapy, 1(3), 51-63, doi:10.1300/j085V01N03_04
Westby, C., Burda, A., & Mehta, Z. (2003). Asking the right questions in the right questions: Strategies for ethnographic interviewing. The ASHA Leader, 8(8), 4-17. doi:10.1044/leader.FTR3.08082003.4
About the author
Sandra Guevara is a graduate student in the department of Hearing and Speech Sciences at the University of Maryland. She is a member of the Cultural and Linguistic Diversity Emphasis Program (CLD-EP) and the Bilingual Certification Program. Her clinical and research interests include bilingualism and neurological communication and swallowing disorders across the lifespan.