Introduction And General Considerations

Writing and, in turn, reading a chapter such as this is fraught with difficulties. It is difficult to write about cross-cultural issues, in this case the clinical interview, from a general point of view that is relevant to most, if not all, cultural groups encountered clinically. Even if one is limited to the cultural groups that are most common in the United States (African Americans, Hispanics, Asian Americans, Native Americans), there are serious questions about whether one can (or should) generalize across groups or across social classes. Recognizing these difficulties one can still attempt to discuss general problems, issues, and approaches. Furthermore, as I will do in this chapter, one can single out a cultural group, in this case Mexican Americans, and use it as an example.

Also, I have always found learning about interviewing from a book to be difficult. Probably the best way to learn how to be a good interviewer is to

Handbook of Multicultural Mental Health: Assessment and Treatment of Diverse Populations Copyright © 2000 by Academic Press. All rights of reproduction in any form reserved.

watch good interviewers (and bad ones, too). Observing different styles and techniques can then be gradually blended into one's own style. As described later, the three most basic elements in becoming a good interviewer are (a) attaining a constant attitude of care, (b) having empathy, and (c) having compassion for those to whom we provide mental health care. This is not to say that techniques and reading are unimportant, but these should build upon the above stated three basic underlying ideal attributes of a good health care professional.

Thus my focus in this chapter will be on the general and of necessity is derived from my own training, experiences, and present clinical work. I am a physician and psychiatrist. My psychiatric training was at an institution with a pervasive classic psychoanalytic orientation, although I am not a psychoanalyst. Almost all of my clinical work has been in psychiatric outpatient clinics of a county hospital system for the medically indigent in a city (San Antonio, Texas) where over 60% of the population is of Mexican origin (Mexican Americans or Chicanos). For these reasons the individuals that I see are usually moderately to severely ill, often have comorbid medical conditions, may be taking medications, and are called patients not clients. About a third speak predominantly Spanish; somewhat less than this were born in Mexico. Thus, I see recent immigrants from Mexico as well as multigeneration Texans of Mexican descent. Of interest is that many of the latter still speak Spanish a great deal—sometimes exclusively—although not necessarily "Mexican" in customs.

Finally, I elected not to make this a reference rich-work. I have done this elsewhere (Martinez 1982,1993, 1994). Instead I chose to make this an experience-based chapter in the hope that this would be equally, if not more, meaningful. The most common clinical interview that I conduct is not entirely structured nor is it nonstructured, but rather a combination of some structured components designed to gather specific information, such as the presenting problem, symptom presentation, history, insight, cognitive functioning, and the like. The nonstructured part is where I ask questions in order to pursue a particular matter or direction during the interview based on previously elicited or observed behavior. In this respect, the clinical interview is a dynamic process, individually tailored to each patient. This is not too much unlike the process of obtaining psychological and psychiatric information when conducting a structured clinical interview with a defined probe module, as in the case of the Composite International Diagnostic Inventory (CIDI) wherein, depending on whether a question is answered affirmatively or negatively, the interviewer follows up with a different defined set of questions.

The need to be evaluating information while conducting the interview is an important part of the clinical interview. I have labeled this the "stepping-back" process, and by necessity it is a reoccurring process throughout the clinical interview. It is precisely this stepping-back process that makes the cross-cultural clinical interview particularly interesting and challenging for the clinician.

Othmer and Othmer (1994) identify five phases of the Clinical Interview:

1. Warm-up and screening

2. Follow-up on preliminary impressions

3. Psychiatric history and database

4. Diagnosis and feedback

5. Prognosis and treatment

I will utilize these five phases of the Clinical Interview to present some of my observations and experiences with respect to conducting culturally competent cross-cultural clinical interviews. It is my understanding that cultural competence in conducting a clinical interview, or in any other aspect of the delivery of mental health services, is not a place but a developmental process. It is also my understanding that the fundamental basis of developing this competency lies in respect for others, their ways of life, their religious practices, their worldviews, and their individual autonomy.

II. WARM-UP AND SCREENING A. Language of Interview

There are several things to keep in mind when initiating a cross-cultural clinical interview. These are the same irrespective of whether the interview is for diagnostic, assessment, psychotherapy, pharmacological management, or any other purpose.

The first is for the clinician to determine in which language to conduct the interview, assuming that the clinician knows more than one language. When either the clinician or the patient speak more than one language, a language has to be decided upon to start with. This may simply be a matter of selecting the language that the patient speaks best, or feels most comfortable with, and that can also be understood and spoken by the clinician. This selection sometimes occurs spontaneously or intuitively at the time the two individuals meet or initiate contact. The selection may be determined for good then without any future deviations. However, in a significant number of cases there needs to be somewhat more attention paid to this issue initially and in a few cases it (the language of the interview) persists as a recurring and, sometimes nettlesome, problem.

If the patient and clinician have more than one language in common, then they have to settle on one language for most if not all of the interview. Usually this determination can be made simply by asking the patient which language is preferred or is most comfortable. It is also acceptable for the therapist to guess which language might be the patient's choice and proceed to use it but remain alert to discomfort or awkwardness in the patient if the guess is wrong. With individuals who are recent immigrants or with many elderly minority patients, it may be safe to initiate conversations in what is considered the native language for that group on the assumption that English is not their primary language.

In my experience I have not sensed that a "wrong" guess on this matter of choice of initial language has adversely affected the remainder of the interview. My tendency is always to err on the side of using Spanish initially with patients who either look Hispanic or have Spanish last names, Exceptions are younger patients, especially adolescents, and patients that I know for certain do not speak Spanish well or at all. Also, I always ask the patient which language he or she prefers because many Hispanics are equally fluent in both languages but usually have a preference. I do not usually impose the use of one language or the other, and I have encountered patients who are clearly more dominant in Spanish (they still speak English with an accent) yet they insist on speaking English. I will accede to their wish at least initially as I assess the possible underlying motivation for this behavior. In most of these cases I determine that this insistence on using the less than best language is part of an overall attempt at denial or avoidance of painful experiences or emotions or an effort to control the interview and guide the interviewer away from certain areas. Sensitive insistence that the more appropriate, although direct and powerful, language be used may suffice to overcome this resistance.

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