Talk therapy is Not universally meaningful
It is ethnocentric to think “western therapy dialogue” is somehow universally meaningful and effective. In fact, it often simply confuses people who expect a healthcare professional to act like an authority figure who instructs them to change their behavior. Being asked about “intrinsic motivation” and “levels of ambivalence” may not seem relevant even if simpler language is substituted—as it would have to be!
Self-Reflection Does Not Always Come Easily
Consider that in many cultures people are not encouraged to talk about themselves to the extent that Americans generally are. Motivational interviewing (MI) involves answering direct questions about oneself—personal experiences, desires, fears, resistances, etc. MI takes for granted that people can be self-aware when asked to be. It requires that people share in self-reflection openly.
Patient Literacy and Health Literacy
Patient literacy/health literacy and the ability to speak English will impact how MI can be used in primary care settings. Thought must be given to keeping questions and concepts simple. Even with fluency in English, many people won’t be able to grasp complex concepts without a lot of explanation. MI hinges on active participation by the patient, but this may be expecting too much from a lot of people- especially those from traditional non-western cultures who also have little education.
Using MI techniques steers conversation in a very specific way. In many cultures, people use figurative language. Often, answers are given as a story. A doctor might expect a motivational interview to unfold in a very linear fashion. Stories and digressions can frustrate the process. Filling the gaps in conversation with additional questions or steering the interview with leading statements may only promote agreement on the part of the patient who will nod and smile in an effort to please the doctor. Care must be taken to allow for thoughtful silences. Head nods must be clarified using open ended descriptive questions to arrive at “real” understanding.
People from some cultures may have trouble answering hypothetical questions. In cultures with strong oral traditions, answers and explanations tend to be driven by direct experience. Hypothetical questions may confuse or even annoy some people because of the belief that truth can only come from first-hand experience. 3 The developers of MI say that hypothetical language is less threatening for patients who are less ready to change. Also, “Imaginative leaps are possible if you have good rapport with your patient.” While this may well be true with mainstream Americans used to functioning in our healthcare system, it is not necessarily true for a recent immigrant or refugee, especially one learning English. Some motivational interviewing questions should be rephrased or even avoided for reasons of culture and language difference. Questions like these may need to be phrased more appropriately:
“If you decided to change, what do you think would work for you?
“Let’s imagine for a moment that you did _____. How would your life be different?”
“If you were in my shoes, what advice would you give yourself about _____? (The shoe idiom should also be avoided.)”
Motivational Interviewing by Marcia Carteret M. Ed.
Copyright 2015 All rights reserved.
