Cultural Humility and Motivational Interviewing: Adding Context to Change.

Diversity, inclusion, compassion, integrity and mindfulness are some of my core values as an individual, trainer and clinician. The values of inclusion, compassion and mindfulness have driven me to the mental health field and to motivational interviewing. The values of diversity and integrity drew me towards the social justice field and to facilitating diversity dialogues. Cultural Humility (CH) and Motivational Interviewing (MI) seem like a natural fit to me. They compliment each other, and when combined I think that these two concepts make each other more whole and more effective.

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Cultural Humility
Cultural Humility is a concept first popularized in the late 90's by Tervalon and Murray-Garcia (1998) who believed that the popular idea of cultural competence that had taken off in health care and educational settings was problematic. The idea of cultural competency was often aimed at teaching difference and diversity. In a way it sought to produce "experts" who were competent in understanding other cultures and identities. Tervalan and Murray Garcia found that folks practicing cultural competence were prone to making assumptions based on what they had learned through cultural competence programs. Often these assumptions can be incorrect and sometimes even offensive or harmful. Kleinman and Benson provide an example (below) that illustrates this problem with cultural competence:

"A medical anthropologist is asked by a pediatrician in California to consult in the care of a Mexican man who is HIV positive. The man's wife had died of AIDS one year ago. He has a four-year-old son who is HIV positive, but he has not been bringing the child in regularly for care. The explanation given by the clinicians assumed that the problem turned on a radically different cultural understanding. What the anthropologist found, though, was to the contrary. This man had a near complete understanding of HIV/AIDS and its treatment—largely through the support of a local nonprofit organization aimed at supporting Mexican-American patients with HIV. However, he was a very-low-paid bus driver, often working late-night shifts, and he had no time to take his son to the clinic to receive care for him as regularly as his doctors requested. His failure to attend was not because of cultural differences, but rather his practical, socioeconomic situation. Talking with him and taking into account his “local world” were more useful than positing radically different Mexican health beliefs" (Kleinman & Benson, 2006).

Tervalon and Murray-Garcia flipped the notion of cultural competence on it's head by promoting the idea that there are no experts in difference, rather we need to seek to understand others as individuals who have been shaped through experiences in a world with power differences assigned by society based on social groups such as race, class, gender, etc. The authors also place emphasis on not only identifying but also addressing the larger structural issues that cause inequalities and inequities based on one's social group. There are 3 tenants of cultural humility: 1) lifelong learner and critical self reflection, 2)  recognize and challenge power imbalances, and 3) institutional accountability (Chavez, 2012; Tervalon & Murray-Garcia, 1998).

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Lifelong Learner and Critical Self Reflection
The lifelong learner and self reflective piece of CH seems to be the most natural fit with MI. MI stresses a non-expert approach as we communicate and help others. The practice of seeing the client as the expert helps us to drop our assumptions and listen fully to another person. MI trainings and literature focus on the unique perspectives, values and goals of each individual. The sense of curiosity, interest and learning are key to the practice of MI.

In terms of self reflection, MI encourages practitioners to reflect on the power dynamic between the role of client and helper. MI proposes several "traps" that this imbalance can create, and MI encourages helpers to practice avoiding and escaping from these traps. Self reflection is key in MI because we cannot truly be present with others without a deeper understanding of ourselves and how we fit into the relationship with our client and larger world.

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Recognize and Challenge Power Imbalances
MI practitioners are taught to avoid the expert approach in attempts to equalize the power imbalance that exists between client and helper. Practices such as collaborative agenda setting, supporting a client’s autonomy and accepting the client's view of the issue also work to address power imbalances. The development of a collaborative and more equal power balance in the relationship may be the most important part of MI. The respectful partnership that is developed in MI sets the groundwork for authentic communication about difficult and uncomfortable subjects.

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Institutional Accountability
In terms of Institutional accountability, MI seems to be growing. Many MI trainers are now evolving from simply offering the 2 day MI training for direct line staff, and instead trainers are pushing an "agency change" type approach. The MI trainers who I respect most offer an array of learning strategies including a 2 day training, training leadership, follow up communities of learning, booster trainings and coding/coaching. The end goal of these multi-prong training initiatives is to create culture change at the organization, and at best a good trainer attempts to hold the organization and its leadership accountable for sustaining a climate of compassion, acceptance, partnership and evocation.

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Using MI with Cultural Humility
I know through my own experience that the MI OARS skills and the Spirit of MI are potent methods to communicate across difference. Working with clients and trainees who come from social groups far different from myself has shown me that taking a non-judgmental, compassionate stance and the evocative based skills of reflections and curious open ended questions facilitates a relationship which allows for the uncomfortable and often risky conversations about difference and identity. But MI shows us that a respectful and collaborative relationship is not enough, we must have a direction.

I propose that MI be used to work towards the change goal of not just acceptance and inclusion of others, but that a larger change goal of larger societal equity and equanimity. MI is a powerful tool for change; our society is in need of change. Society assigns power and privilege unfairly upon identities of race, class, gender, sexual orientation, and ability status among many others. Incorporating ideas of CH into MI trainings, teachings and literature will make MI more relevant and more powerful. Some examples of steps towards this end include:

1) Lean into the concept of difference and multiple identities and find ways to use MI to further the conversation.
2) Explicitly acknowledge social groups and identities in the context of imbalance, and find ways to challenge this imbalance.
3) Critically reflect on concepts of self-identity and how this fits into the larger societal context.

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As a front line clinician, a trainer and supervisor I have seen the dramatic impact that MI has had on the creation of change in behaviors for a large array of people in varying roles. MI is an incredible approach in part because it allows us to be humble when helping people from different identities and social groups. 

I believe that the partnership of MI with CH has the potential to create a more equal and fair society for all groups of people. Where MI provides the evidence based change, CH brings the larger vision of a more just, equal, and inclusive society. By combining the pragmatic evidence based skill set of MI with the larger social picture of power imbalance offered by CH we can have a bigger impact. These concepts can come together to help change peoples' lives and work towards creating needed change in the larger society.

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Chavez, V. [Vivian Chavez]. (2012, August). Cultural Humility: People, Principles and Practices [Video File]. Retrieved From: https://www.youtube.com/watch?v=SaSHLbS1V4w

Kleinman & Benson (2006). Anthropology in the clinic: the problem of cultural competency. PLoS Medicine 3(10). Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1621088/

Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Healthcare for the Poor and Underserved,9(2), pp. 177-129.