Read on as three communication sciences and disorders professionals share insider tips on providing culturally informed services: Audiologist Levi Reiter points out what to absolutely avoid when providing audiology services to Orthodox Jews. Ana Claudia Harten explains the need to be aware of religious observances when providing dysphagia services to Muslims. And SLP Aletha Burnette discusses the need to consider taboos and humor when working with Apache clients.
What to Know When Treating Orthodox Jewish Clients
Audiologist Levi A. Reiter shares some simple advice that can make or break interactions with Orthodox Jewish clients.
By Bridget Murray Law
Growing up in mostly secular Marine Park, Brooklyn, Levi Reiter practiced Judaism, and his middle-class family kept a kosher home. But he wanted more—a deeper understanding of the religion's Chassidic foundations and teachings. So, while pursuing a PhD in experimental psychology at the University of Rochester, he delved into Chabad Chassidic philosophy and the writings of Rabbi Menachem Mendel Schneerson.
He and his wife began practicing—and raised their five children in—Orthodox Judaism. And, after earning his audiology certification, Reiter signed on as professor of speech, language and hearing sciences at Hofstra University. During his 33 years there, he's made his mark investigating the link between ear suction, such as that produced by kissing, and various hearing disorders.
He's also written and performed the rap song "Say What?" to popularize audiology among students. And he's sought to boost audiologists' sensitivity to cultural differences among clients. As a private practitioner on the side, Reiter sees a hugely diverse clientele and, of course, knows just how to cater to those who are Orthodox Jews. What insights can he share with other audiologists serving this population, which numbers about 1 million nationwide? We talked with him to find out.
From the perspective of Orthodox Jewish patients, what is one of the biggest challenges they may likely encounter when working with a non-Orthodox provider?
The only real challenge is nonessential, unnecessary touching between males and females. Touching an Orthodox client during the actual audiological examination is perfectly acceptable because it is necessary, but touching somebody in greeting is not. This is a biggie because, for example, it wouldn't be appropriate for a male to extend his hand to shake the hand of a female Orthodox patient when saying "Hi." She might shake his hand, but she won't feel good about it. And the same is true if a female audiologist shakes the hand of a male patient. He might shake it, but he won't be happy.
There is no biological basis for this. It's about modesty and respect for individuality.
How do you know that person is Orthodox?
There are some telltale signs: A man will wear a head covering: a yarmulka (kippah) or hat.
A woman will be in modest dress. She could look very chic, but she won't be showing her collarbone, her sleeves will cover her elbows, and her skirt will be below the knee. You don't see too many women dressed this way these days. So the dress could be a tip-off, or the patient may come out and say, "By the way, I'm Orthodox, and I don't shake hands."
I was on the NBC "Today" show recently, discussing ear-kiss syndrome, and I wondered if the anchor woman would shake my hand. But she had done her research and didn't. Otherwise, I often will just kind of give a nod to stave it off. I don't want to embarrass folks, but I've become pretty good at getting out of it.
What are some key ways for a non-Orthodox provider to put an Orthodox client at ease?
It's very simple. Don't try to shake hands and act normal.
What is the biggest mistake a non-Orthodox audiologist could make when treating an Orthodox client?
If the patient is a married female, then her hair will be covered, usually with a sheitel, which is a wig. It looks beautiful, like real hair, but it's not for attractiveness. It's esoteric and exoteric. It's a spiritual thing because a married woman's hair is special. So if the patient is an Orthodox woman, assume she's wearing a wig, and this is very important when removing the headphones during hearing testing. If the headphones are over the wig, and you're not aware, you could pull the wig off, which would be quite embarrassing to the woman, as well as to the audiologist. So what I do is to carefully spread the headphones out from the ears before pulling them up and off.
You've been involved in making programmable hearing aids—those that fit into the small part of the ear—more appropriate for the Sabbath. Explain how they are (were) not appropriate for Orthodox populations.
During the Sabbath, you are not supposed to turn a circuit off or on, and this pertains to hearing aids because they are electrical. So, if you are Orthodox, you cannot change the hearing aid settings, preprogrammed by the audiologist, during the Sabbath or Jewish holidays. But it's easy to accidentally hit the button that changes the settings. So my contribution was to develop a hearing aid where the settings program button can be disabled and re-enabled before and after the Sabbath or, say, a three-day holiday.
You worked with the company Persona Medical to create the "Emet" hearing aid, which allows you to preselect one setting for an extended time. What type of feedback have you had on this device?
In theory the idea is great and we've made progress, but there are various technical problems, so for now the project is suspended. But we're now discussing other ways of dealing with the same problem. I'm looking for an innovative company to work with on new and related ideas.
Are there other audiology devices or assistive technology that could be adjusted to be more Orthodox-friendly?
A couple of hearing aid companies are working on technology that enables the hearing aid to literally change its own setting just by sensing the environment and sound levels surrounding the wearer. This technology is out there.
Your audiology rap "Say What?" has been super popular with your students. Do you use it or other similar types of tools to teach them about the role of culture in treatment?
I now have 18 different audiology songs and raps, like ones about auditory pathologies, diagnoses, treatments, and one called "First-Year Student in the AuD Program Blues." And I'll be putting out the CD "Say What?" that will be very multicultural with the songs sung in different accents and dialects and featuring all different styles like reggae, calypso, gangsta and Yiddish. It's a way to teach about audiology and culture and get students' motivation up at the same time.
Bridget Murray Law is managing editor of The ASHA Leader.
Levi A. Reiter, PhD, CCC-A, is professor of speech, language and hearing sciences at Hofstra University and a member of the Long Island AuD Consortium. He is an affiliate of ASHA Special Interest Group 6, Hearing and Hearing Disorders: Research and Diagnostics. He also holds a rabbinical degree from Ayshel Avraham Rabbinical Seminary in Monsey, N.Y.
Uncooperative Patient? Dig Deeper
What looks like refusal to comply could be something else entirely—and recognizing this can make all the difference to treatment.
By Ana Claudia Harten
Before my career in academia, I worked with adult patients, mostly providing services in acute care settings. One particular case stands out in my mind. I always share it with my students, because I believe it clearly illustrates how confounding factors can play a role in clinical cases and affect our service delivery, and why we should always avoid jumping to conclusions.
The rehabilitation department in a hospital I worked for received a referral to conduct a swallowing evaluation on a 52-year-old patient admitted over the weekend with left facial droop, and a diagnosis of right hemisphere stroke. The contract speech-language pathologist on call attempted the evaluation twice over the weekend. Both attempts were unsuccessful, however, because of the patient's "lack of cooperation, refusing to eat."
When I arrived at work on Monday, I followed up on the order and attempted to conduct the swallowing evaluation. The patient had been NPO ("nil per os," nothing by mouth) for more than 48 hours—including medication—as staff was waiting on the evaluation results to see if oral intake would be safe for the patient. Given the patient's refusal to cooperate, the attending physician was considering tube feeding placement.
Once again, the patient refused solids and liquids, but was otherwise very cooperative throughout the evaluation. I soon realized that the patient's primary language was Arabic and that he spoke very limited English. Given the urgent need for the swallowing evaluation, I paged the hospital's Arabic interpreter to help with the rest of the evaluation. With the interpreter's assistance, I learned that the patient was Muslim and observing Ramadan, during which Muslims refrain from eating and drinking from dawn until sunset. The patient's "lack of cooperation" was, in reality, related to a religious observance, as all evaluation attempts had been conducted during the fasting period.
I was aware of the Ramadan observance, but I also knew that people who are ill are exempt from the obligation to fast. I acknowledged the patient's religious observance and then attempted to explain to him that, because he had just had a stroke, he was exempt from the obligation. I reminded him that he could still follow his religious principles by making up for the missed fasting days after he recovered.
The patient, however, disputed that he had suffered a stroke, insisting that there was nothing wrong with him. It is not uncommon for Muslims with medical conditions to insist on fasting to follow their spiritual needs. In addition, in this case the patient's reluctance seemed to be heightened by what appeared to be some anosognosia (deficit of self-awareness) from his stroke-related brain damage.
As a health care provider, I certainly needed to address the patient's religious observance as well as his medical condition. I considered two options: reschedule the swallowing evaluation for after sunset to accommodate the patient's observance or try to contact his family to reiterate with the patient that his condition would exempt him from fasting. I decided to take advantage of a family visit later that day. After we spoke, they were instrumental in persuading the patient to have the swallowing evaluation.
After we determined that an oral diet was safe, I contacted the hospital nutritionist and the patient's physician to explain the patient's overall condition and religious observance, and offered suggestions to accommodate his needs.
Clearly, the on-call SLP who had attempted to evaluate the patient made an erroneous assumption: that the patient's refusal to eat was "lack of cooperation," a common condition among patients with right hemisphere damage, rather than a commitment to religious observance. Had the SLP contacted the interpreter, this misunderstanding could have been cleared up sooner, and the patient's nutritional needs could have been addressed more quickly.
This case certainly illustrates the importance of considering cultural factors—so often highlighted in textbooks, lectures and presentations—when we assess or treat client. This case is a reminder that, in our work as SLPs, we should avoid generalizations and hasty conclusions. As health care providers, we have the responsibility to ask the right questions, keep an open mind and refrain from making assumptions without first considering all relevant factors.
Ana Claudia Harten, PhD, CCC-SLP, is associate professor of speech-language pathology at Eastern Michigan University. She serves on the coordinating committee of ASHA Special Interest Group 10, Issues in Higher Education, and is also editor of SIG 10 Perspectives. She is also a member of ASHA's Multicultural Issues Board, which consulted with the Leader on this article.
Considerations When Serving Native Americans
An Apache SLP relates her experiences working with Native American clients and shares her cultural insights.
By Gary Dunham
Aletha J. Burnette grew up on the Fort Apache Indian Reservation, a starkly beautiful land of desert foothills, fishing lakes and towering pine-covered mountains in eastern Arizona. Burnette is one of more than 11,000 members of the White Mountain Apache Tribe living on the 2,600-square-mile reservation today. Fluent in Apache, she decided, after receiving a master's degree in speech-language pathology from the University of Kansas, to return to her people. Burnette spoke with the Leader about her work on and off the reservation, the cultural forces shaping her practice, and the need for speech-language pathologists to be very aware of cultural differences when treating Native American children.
Why did you decide to become an SLP? Was there a specific person, or incident, that proved instrumental for you when making this career choice?
I have a bachelor's degree in elementary education and was a teacher for about five to five and a half years. When my boys (twin boys) entered Head Start they were screened and referred for speech issues. Beginning from Head Start through second grade they were in speech therapy. When they first told me the boys needed to be referred I was asking why and really didn't have an understanding of what speech therapy was for or what it was. I was interested in it and began to research it and asked the speech-language pathologist questions about the field. I was looking into programs at Arizona State University and the University of Arizona when a friend told me about KU's program.
Help our readers get a feel for the range of clients that you usually treat.
I work part-time in the public school district on the reservation and part-time at a hospital/clinic (Summit Healthcare) off the reservation. On the reservation, I serve students in the public school from ages 4 years to high school students. Most of the children are Apache and live on the reservation; however, with the rising number of Pilipino teachers, there have been a few students who are Pilipino that receive some services.
Very few students speak fluent Apache anymore but some do understand quite a bit. Overall, a majority of them speak and understand only English but have the dialect, syntax and errors of fluent Apache speakers. Most of the students receiving speech therapy tend to be males. I'm not exactly sure but I think the census data shows that approximately 80 percent of the population on the reservation receives some type of subsidy like food stamps. The poverty level is pretty high.
Describe a typical day on the job…What's it like for you?
I go between three schools while working in the school district. I serve children at each school by providing therapy and completing evaluations. I am also part of the Child Find Screening Team. We screen children in the areas of communication, cognitive development, fine motor, gross motor, hearing and adaptive skills. Another large part of my job consists of paperwork, which includes writing up evaluations and progress reports, and completing billing forms, METs [multidisciplinary evaluation team] and IEPs [individualized education program].
At the hospital I have an office and the patients come to me. I see mainly outpatient pediatrics and school-aged children mainly from Anglo backgrounds; however, I do have a couple of Apache kids who come for therapy. Most of those children were articulation but now I'm beginning to see more feeding issues.
In which ways does your awareness of cultural similarities and differences come into play when communicating with and treating clients?
Parents know that I have an understanding of their circumstances, and I try to work with them to schedule/reschedule appointments. I can also approach families in the community or do home visits, if needed, because I live in the community and know the people (most of them). Also, knowing what is acceptable and what's inappropriate in the culture is beneficial so that you don't offend anyone.
How has your distinctive cultural background affected your work as an SLP?
Being able to speak both English and Apache has helped me with students who speak Apache fluently and also with explaining the screening and IEP process with parents. There are some topics and areas that are taboo to the culture, therefore it's a good idea to stay away from those topics. By knowing the community, some families assume that you can also make other things happen in their child's education—for example, transfer them to another teacher, get them glasses, etcetera.
What are the key dos and don'ts for SLPs working with Apache or Navajo children? What should SLPs be especially sensitive to and looking for when working with children from Native communities?
A lot of times families will make decisions as a whole and not just the parents or mom or dad independently. There's also Native American humor and that doesn't mean the student is being rude. Native people love to joke about a lot of things and everyone has a nickname for one reason or another. We also like to tease each other and if non-natives don't understand then they may become upset or offended.
Know what the taboos in the culture are and stay away from books, games and topics that include these taboos. With the taboos, it is different in every tribe and/or culture. Therefore, I believe the SLP should become familiar with the culture they are working in and learn those "things" that are do s and don'ts. I don't really want to say or give an example because I don't want readers to think it's the same for all American Indians. It's like our language. It's different and even Apaches have different dialects from different areas.
Have you ever experienced a moment when someone has, perhaps unconsciously, made a misassumption about you because of your distinctive cultural background?
Yes. Just because I'm American Indian or have brown skin, some are shocked that I have a degree and more so a degree in speech-language pathology.
Gary Dunham, PhD, is editor-in-chief of The ASHA Leader.
Aletha J. Burnette, MA, CCC-SLP, works in the public school district on the Fort Apache Indian Reservation and at Summit Healthcare off the reservation.