Motivational Interviewing in a Multicultural Setting

Motivational Interviewing in a Multicultural Setting

Lawrence, Massachusetts is a city rich in cultural diversity and heritage. The Latino population alone boasts seventy three percent and continues to grow (Brown et al, 2013). This brings unique challenges to the therapeutic setting that relate directly to Latino cultural values. There are also challenges that Latinos face that are correlated to substance use. Literature states that Latinos are more likely to binge drink and use drugs more heavily (Franklin & Markarian, 2005). Lawrence also has a very young Latino population, resulting in the highest proportion of the population being under five and eighteen years old in Massachusetts (Jaysane & Center, 2002). This is imperative to note in a city that reports a high level of substance use among youth. Of many of the challenges that Latino’s face with substance use, they are one-third less likely to enter residential treatment in the state of Massachusetts (Caroll et al, 2009). This illustrates a community that has a great need for substance use treatment, yet is currently having that need unmet. As a social work intern, I will have the opportunity to practice with Latino clients and families within my community through in home therapy services. Therefore is vital, as a social worker, to better know the Latino clientele within Lawrence and the distinct factors that might set them apart from other clients within therapeutic settings.

Latinos in Therapeutic Settings

Latinos represent a very diverse group each having a unique history of social, political, and economic factors that have caused their migration into the United States, or their families migration. This diversity continues to manifest across ethnicity, race, generations, language, but especially nationality. Many Latinos identify first and foremost by their country of origin and will often differentiate, “I am Puerto Rican” over the official “I am Latino”. However, though individuals hold this diversity ascribed to their subgroup, many Latinos share core cultural values that are based on mutual experiences such as migration history, access to education and employment, as well as socioeconomic status. Due to acculturation and other psychosocial stressors, language, and poverty, Latinos may be particularly vulnerable within treatment and treatment organizations (Caroll et al, 2009). These shared experiences can impact communication styles such as the willingness to disclose sensitive information which in turn impacts the clinical setting as traditional therapy models often assume direct disclosure from the client. This creates a dysfunctional environment in which Latino clients, ones that do not follow Westernized norms, risk finding therapy to be invasive and opposing with their core cultural values. Therefore it is vital for social workers to consider cultural differences within the clinical setting. Mental health services among foreign-born, monolingual Spanish-speaking Latinos remains low when compared with bilingual Latinos born in the United States (Anez et al, 2008). This is because mental health providers are challenged to develop cultural and Spanish friendly services that will effectively address the needs of a diverse Latino community.

Substance Use Factors

Substance use is a significant problem among Latinos, who represent the largest ethnic minority group in the United States. However, treatment-related disparities have been identified as being relevant to Latinos. Specific factors that have been identified as contributing to these disparities include the following: cultural and language barriers, poverty, stigma, the lack of bilingual and bicultural staff, and the lack of treatments that are receptive to Latinos’ needs (Anez et al, 2008). The necessity for trained professionals who have the ability and empathy work with the distinct needs of Latinos is great within the therapeutic process. These noted discrepancies are of great concern because it is well documented that Latinos “… have increased morbidity and mortality rates, high incidences of suicide, school dropout, alcohol use, illicit substance use, and HIV infection (Anez et al, 2008).” Regardless of an apparent need for mental health services very few members of the Latino community actually seek professional help. It appears that these services are not considered to be a primary source of support. In fact, fewer than one in eleven Latinos contact mental health specialists, and often seek services from a primary care provider first (Anez et al, 2008). This illustrates a client group that is currently at an unmet need for alcohol and drug use treatment. Latino clients might have a reason; clients frequently complain that they feel abused, intimidated, and harassed by non-minority personnel (Sue, 2006). Latinos as a group are largely marginalized within greater society; it does not help to do so within the therapeutic setting. Many social work theories originate from a monocultural standpoint, when social workers unconsciously inflict these standards without regard for other cultures, they may be engaging in cultural oppression (Sue, 2006). Social workers must enter the therapeutic setting aware of their own prejudices in order to learn and grow from them.

Latino Youth in Therapy

Lawrence reports a high level of substance use among youth. In 2002, a survey was conducted within the city which collected the responses of 2,206 high school students resulting in respondents revealing that the majority of substances used are alcohol (52.9 percent), inhalants (39 percent), cigarettes (25.2 percent), and marijuana(19.9 percent) ( Jaysane & Center, 2002). The reported substance use rates among Lawrence youth can increase the risk of dropping out of school for many, as the drop-out rate of high school within the city has been very high in current years. Rates as much as fifty percent of high school classes dropping out between their freshmen and senior years have been reported ( Jaysane & Center, 2002). There have been a number of factors attributed to the drug use of Latino youth. For example, the role of the family has been identified as being the most important component of addiction treatment for the client. It has been shown that parent’s attitudes, and the use of drugs, play a key role in the drug use behavior of twelve-seventeen year old Latino youth ( Franklin & Markarian, 2005). Adolescents in particular have a potential ambivalence when it comes to quitting substances. However Latino youth also share an additional cultural ambivalence attributed with the Latino identity.

Motivational Interviewing in a Multicultural Setting

Motivational interviewing (MI) is a client-centred counselling approach that uses certain techniques in order to produce motivation to change among ambivalent clients (Miller and Rollnick, 2013). Latinos can be considered ambivalent clients as a result of cultural and systemic factors that are experienced collectively as a group. Ambivalence in this sense can be defined as needing to make a change, but seeing little to no reason to do so (Miller and Rollnick, 2013). MI has been found to be highly effective in the treatment of substance use disorders. However, many Latino’s do not seek needed treatment for substance use. There have been a number of cultural values that have been reported to affect the therapeutic relationship to varying degrees; the three most prominent being personalismo (personal relationships), respeto (respect), and confianza (trust) (Anez et al, 2008). MI is a therapeutic model based upon respect and trust as it is a collaboration which honors the client’s experiences and individual perspectives. Latinos have also been reported to work towards engaging in pleasant conversational exchanges, and to avoid unpleasant ones, often trying to avoid conflict. MI permits the integration of these cultural values within the therapeutic setting, as it also avoids argumentation within the therapeutic relationship. This method differs from other more challenging styles that might advise a client about changes that need to be made, instead MI creates a more cooperative therapeutic setting where the Latino client’s internal motivation is drawn out and explored. This means that the counselor is not leading sessions or dictating the client in anyway. Instead the counselor’s role is to guide the client, listen to the client, and offer knowledge when needed. This method is ideal when working within the Latino community, especially when most therapeutic approaches have shown to cross with their core identity. Clients are experts on themselves; no professional can know them better than they know themselves (Miller and Rollnick, 2013). If the counselor has the ability to show the Latino client their support of the clients personal expertise, it can create a positive relationship and rapport within the therapeutic setting, and in turn creates a catalyst for change.

Motivational Enhancement Therapy

Motivational Enhancement Therapy (MET) has been proven to help individuals resolve ambivalence around engaging in treatment as well as stopping substance use. The approach persuades change quickly through motivational methods. Research found on MET methods suggests that its effects depend on the type of drug used by participants as well as on the goal of the intervention. For example, MET has been used successfully with people who are addicted to alcohol and who want to reduce their problem drinking (Caroll et al, 2009). Brief motivational interventions (BMIs) such as this have also been identified as being particularly effective methods when working with Latino adolescents who have substance use disorders, in fact, “Brief motivational interventions (BMIs) have been identified as particularly promising for use in efforts to reduce or eliminate adolescent [alcohol and other drug] use problems (Cordaro, 2012)”. The client-counselor relationship and the counselor’s ability to engage with the Latino adolescent, has also been found to be a key factor within the motivational therapeutic setting. First impressions count as the initial therapy session appears to be significantly correlated to the client’s dropout from the intervention (Cordaro, 2012). In summary, the ability for the counselor to build rapport with the client from the first session is one of the most important factors when working with the Latino community, in particular with youth.

Client Approach

This coming fall I will begin an internship providing in-home therapy services with Lahey Behavioral Health in Lawrence, Massachusetts. I will unquestionably have the opportunity to work with Latino clients and families within the community. When working in family systems, I might come across a situation in which a client within that system might have a substance use issue that needs to be addressed. When addressing the substance use issue with either an adult or an adolescent, the first impression and rapport is extremely important during the initial session, as it has been shown to be linked to successful client engagement. My focus for motivational interviewing would rely on building a positive and strong relationship with my Latino clients so as to build enough trust to persuade towards change talk. It is important for me to note that Latino clients hold an admiration for older adult’s that is attributed to the life experience and a general perception that their wisdom holds significant value, younger generations are taught to respect their elders and greet adults with a courteous “Senor” or “Senora” (Anez et al, 2008). Pretending my client is significantly older than I am I would approach therapy in the following way. First I would begin by asking the client how they would like to be addressed, this would provide the client the ability to structure a conversation around names or nicknames that their friends or family call them, or possible formal titles such as “Senor” or “Senorita”. It is also important for me as to be able to address the client respectfully, and to take a careful note of pronunciation. I would structure questions around cultural values, such as being a buena genta (likeable person), family values, respect, trust, and personal relationships (Anez et al, 2008). . In terms of being a likeable person, I could structure a question such as, “How important is it for you to be viewed as someone who is likeable?” this shows me the importance that the person holds on their image and how others view them. I would also be interested in knowing how the client interacts in interpersonal relationships outside of therapy; this can be achieved by asking, “When you are first getting to know someone, what helps you feel comfortable?” or “What does it take for you to develop trust with someone?”. This can help me gain an understanding of the client’s strengths, stressors and coping mechanisms. I would also ask, “How do you handle conflict?” or ““Can you tell me about a moment when your trust was broken?” This can give me an understanding of how the client handles and copes with hard situations, or if the client has a resistance to talking about hard situations within a therapeutic setting. I would further ask the client what their expectations of trust are within our therapeutic setting, summarizing the session with a shared agreement using the values of trust put forward by the client. This shows the client that I value trust and the client as an expert.

Over the course of many sessions I would continue to understand the client’s value system as well as where they stand in terms of change talk. Open-ended value questions would give me an insight into what really matters to the client. I would ask the client what they value the most in life, which can sometimes help to be a motivation for change. This can especially be motivating if the client values their family, a child, being employed or having an education. Once the client has reached the point of talking about their values, I would spend time using a number scale in order to help guide conversation around where my client is in terms of changing, making sure to have all documents used with the client translated if fits the clients need. The clients identified goal during this time might be to reduce the amount of the substance used. Once a goal has been identified and set with the client, I would continue to guide the client into conversation with questions such as how life was like before drug use; questions about the future, as well as what advantages and disadvantages are in terms of their current drug use patterns. I would summarize that session with a collaborative treatment plan that the client feels is realistic for them, and will continue to check up on how the client is doing with the treatment plan during each following session, making additional adjustments along the way and talking about the process.

Summary

The community of Lawrence, Massachusetts is home to a large proportion of Latinos and the population continues to grow, bringing with them unique challenges especially pertaining substance use and therapy. Latinos drink and use drugs more heavily, a trait that often cascades to younger generations. Latino clients are in need of substance use help, however they are less likely to enter treatment, leaving the need largely unmet. As a social work intern, who will be conducting in-home therapy for families within the city of Lawrence, it is my responsibility to ensure that the cultural values of my clients are integrated into the therapeutic setting. As a Latina social worker, clients might not be as resistant to my therapeutic methods as they might to a non-Latino social worker. As a Latina, I understand and share many core cultural values with Latino clients. Because of this, I might have the ability to build a stronger rapport, one that is essential during the beginning stages of the client-counselor relationship. However, I do not speak fluent Spanish. In fact I only have the ability to speak a limited amount of words, and a few phrases. This largely limits my ability to work with clients who are predominantly in Spanish speaking households, as I am not bilingual. There is also the possibility that I might be looked down upon because I do not speak Spanish, as if I have betrayed my culture and heritage. It is important for me to be aware that these opinions exist, and to notice that they might come up during counseling sessions. If they do I would do my best to redirect the questions back onto my client in a calm and collected manner. In general, MI is the best approach when working with Latino clients as it has been proven to work with ambivalent clients as well as clients with substance use disorders. MI also fosters an environment that is inclusive towards the cultural values of Latinos, and fosters the collaborative therapeutic process between the client and counselor. When the cultural values of the Latino community are taken into consideration, it fosters change, and retains client engagement within therapy.

References

Añez, L. M., Silva, M. A., Paris Jr., M., & Bedregal, L. E. (2008). Engaging Latinos Through the Integration of Cultural Values and Motivational Interviewing Principles.Professional Psychology: Research & Practice,39(2), 153-159.

Brown, N., Chesbro, T., Lee, D. H., & Puza, H. (2013). Lawrence, Massachusetts Greenway Plan. University of Massacusetts, 1-50.

Carroll, K. M., Martino, S., Ball, S. A., Nich, C., Frankforter, T., Anez, L. M., et al. (2009). A Multisite Randomized Effectiveness Trial of Motivational Enhancement Therapy for Spanish-Speaking Substance Users.Journal of Consulting and Clinical Psychology,77(5), 993-999.

Cordaro, M., Tubman, J. G., Wagner, E. F., & Morris, S. L. (2012). Treatment Process Predictors of Program Completion or Dropout Among Minority Adolescents Enrolled in a Brief Motivational Substance Abuse Intervention.Journal of Child & Adolescent Substance Abuse,21(1), 51-68.

Franklin, J., & Markarian, M. (2005). Substance Abuse in Minority Populations.Clinical Textbook of Addictive Disorders, 321-339.

Jaysane, A. P., & Center, M. P. (2002). The Community Context of Health in Lawrence, Massachusetts.Lawrence, MA: Merrimack College.

Miller, W. R., & Rollnick, S. (2013). The Spirit of Motivational Interviewing.Motivational Interviewing:Helping People Change(3rd ed., ). New York, NY: Guilford Press.

Sue, D. W. (2006). Principles and Assumptions of Multicultural Social Work Practice.Multicultural Social Work Practice. Hoboken, N.J.: Wiley.