November 1, 2013 Columns

SIGnatures: Evolving Expressions of Culture

Providing effective treatment requires that clinicians constantly work to understand clients' many cultures, and to question assumptions not just about gender, race and ethnicity, but also about age and life stage.

Special Interest Group 15, Gerontology

How many cultures do you belong to? A hospital-based speech-language pathologist may belong to many: the group of professionals that works with adults with neurological impairments and communication and swallowing disorders; the group that carries specialization and board recognition in swallowing; the group that works in acute-care hospitals; the group that likes to dance socially; the group that likes to drink alcohol socially; the group that likes to eat out at a variety of restaurants; the group that enjoys travel; the group that enjoys kayaking; the group that enjoys entertaining for dinner parties; the group that enjoys dressing well; the group that believes in being there for family; the group that believes in helping others; the group that likes the color purple; the group that loves a person of the same gender; the group that enjoys the beach; and the group that enjoys concerts in the park. This person alone is part of 16 different groups, or cultures.

How are we, as care providers, supposed to know about all the cultural groups of this colleague, not to mention those of our patients, clients and students?

To start—if we are to be responsible members of our society and discipline—it is vital that we understand, apply and believe in concepts of culture (see box on page 53) and their impact on everything we do as people and professionals. Unless we genuinely care for and show interest in people, the treatment process may break down and result in misdiagnosis or negatively influence treatment outcomes.

How can sociocultural mismatches compromise the provider-patient dynamic? First, the provider may lack knowledge about the patient's health beliefs and life experiences, as Melanie Tervalon and Jann Murray-Garcia noted in their 1998 article, "Cultural Humility Versus Cultural Competence," in the Journal of Health Care for the Poor and Underserved. Second, the provider may bring unintentional or intentional processes of racism, classism, homophobia or sexism to the interaction. Thus, according to Tervalon and Murray-Garcia, no clinician can expect to achieve cultural competence as a discrete endpoint. Instead, cultural competence is a lifelong commitment to learning, constantly working to bridge cultural gaps and questioning cultural assumptions.

But this assertion brings us back to the central question: How can we be culturally competent if everyone around us is a part of many dynamic and ever-changing cultures? For example, when does a patient enter the culture of "older adults"? In American society, this group may be defined by chronological age—namely, turning 65. However, many 70-year-olds do not consider themselves "old." So, the "older adult" culture is defined by the people identifying with that label and not by the imposition of a particular government-defined age.

Another way to view this concept is the fact that people like and dislike things throughout the continuum of life. A person who was included in the "lovers of loud music" culture 10 years ago may not enjoy loud music any longer, and so is not a member of that culture. We may view a person's culture, then, as dynamic and evolving, continuously changing based on preferences and life experiences.

The client's perspective

So far, this discussion has focused on the practitioner and the practice of caring for someone, but what about the perspective of the person being cared for? Some argue that cultural competence is a bilateral process; others argue it is not. In his 2008 article in the Online Journal of Health Ethics, Carlos Alberto Sánchez presented an argument against the bilaterality of cultural competence. He argued—based on John Rawls' "difference principle"—that the patient is not necessarily empowered to expect culturally competent services.

The patient's perspective or expectation varies by ethnicity, socioeconomic status, prior experience, setting or other possible factors. Take, for example, a clinician who meets a client for the first evaluation session and immediately begins to ask questions, so as to quickly complete the interview and record all necessary historical information. The clinician then goes on to test the client, and subsequently bids him or her farewell. But note that the clinician hasn't allowed the client to voice his or her concerns and perspectives regarding communication and swallowing. Has the clinician gleaned a sense of this problem's impact on the client's life? Did the clinician assume that the patient was aware of the diagnostic process? Did stereotyping on the part of the clinician influence this session? Did the clinician assume that because the patient was older, that maybe he or she expected to develop a communication or swallowing disorder?

Cultural competence: How to get there

Providing culturally competent care requires several paradigm shifts for practitioner and client alike.

  • Be aware of ethnocentrism, the belief that one's way of life and view of the world are inherently superior to others and more desirable. Ethnocentrism in health care may prevent professionals from working effectively with a patient whose beliefs or culture does not match their own worldview. An ethnocentric care provider or client may hinder the processes of assessment, treatment or management of a communication or swallowing disorder. An example of ethnocentrism is the clinician who can see only his or her recommended treatment plan and does not entertain other options presented—if allowed—by the patient/client.
  • Be aware of essentialism, which defines groups as "essentially" different, with characteristics "natural" to a group. Essentialism does not take into account variation within a culture, and can lead health care professionals to stereotype their patients. The clinical practice of an essentialist focuses on beliefs about groups instead of observations of individuals. This situation is disadvantageous to the practitioner and the client. The essentialist viewpoint needs to be replaced with an ethnogenetic one, which recognizes that groups, cultures and the individuals within them are fluid and complex in their identities and relationships. An example would be any situation in which the practitioner automatically identifies a person as being a part of a group without obtaining confirmation.
  • Be aware of power differences that reflect an imbalance in client-provider relationships. Interestingly, those with power often are not aware of its daily effects. Some ethnic groups may feel powerless when faced with institutionalized racism and other forms of privilege enjoyed by the dominant group. Examples of this imbalance may include the patient's perception that the clinician has all the answers, or a sense of the clinician's superiority due to his or her advanced education. Tervalon and Murray-Garcia refer to power differences in their discussion of cultural humility: Without knowing about power differences and their effects, health care professionals can perpetuate health disparities.

Although one frequently thinks of a patient as being from a different ethnicity or race, these concepts apply to all cultural groups, including people older than 65. This age group may feel vulnerable for many social and economic reasons, as indicated in a 2002 study looking at healthy aging and expectations from older adults.

Conducted by Catherine A. Sarkisian, Ron D. Hays and Carol M. Mangione and published in the Journal of the American Geriatrics Society, the study found that, "More than 50 percent of participants felt it was an expected part of aging to become depressed, to become more dependent, to have more aches and pains, to have less ability to have sex, and to have less energy." The sample consisted of 429 randomly selected community-residing adults age 65 to 100 (mean age 76). After adjusting for sociodemographic and health characteristics using multivariate regression, the authors found that older age was independently associated with lower expectations regarding aging, as was having lower physical and mental health-related quality of life. Moreover, having lower expectations regarding aging was independently associated with placing less importance on seeking health care.

Clinicians, in reflecting on the broadness of cultural diversity at a personal and professional level, may ask, "How do I achieve cultural competence?" There is no set formula, but there are several readily available strategies and tools:

  • Develop a definition of what constitutes culture that is comfortable for you. We should think of it as a "living definition" to allow for possible change, or redefinition, as we grow.
  • Consider the concept of cultural humility and accept that becoming culturally sensitive and competent is a lifelong process.
  • Recognize our own implicit biases, stereotypes and possibly racist notions. These may be thoughts or feelings we wish to deny, but must accept to work through them (see "Not All Bias Is Obvious—Even Our Own", and the Implicit Association Test). Some are not as clear as others, and through our cultural awareness, we may discover them. Once these biases are at the surface of our thoughts, we can work through them.
  • Use ethnographic interviewing techniques, introduced by Carol Westby. A clinician employing this process draws out behaviors and beliefs from the patient or caregiver through a systematic and guided dialogue. (See "Asking the Right Questions in the Right Ways," The ASHA Leader, April 29, 2003)

Once we are comfortable that becoming culturally competent is a lifelong process, we can further develop the tools we have, as we search for others. But will we ever be fully culturally competent? I do not think so. We may, however, strive to become culturally aware and engage in the lifelong process of learning and exploration regarding the cultures of the many groups to which we all belong.

This article is adapted from "Cultural Competence for Everyone: A Shift in Perspectives," in the May 2013 issue of SIG 15's Perspectives on Gerontology.

Luis F. Riquelme, PhD, CCC-SLP, BRS-S, is an associate professor of speech-language pathology at New York Medical College and director of Barrique SLP at New York Methodist Hospital in Brooklyn. He is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; 13, Swallowing and Swallowing Disorders (Dysphagia); 14, Communication Sciences and Disorders in Culturally and Linguistically Diverse Populations; 15, Gerontology; and 17, Global Issues in Communication Sciences and Related Disorders.

cite as: Riquelme, L. F. (2013, November 01). SIGnatures: Evolving Expressions of Culture : Special Interest Group 15, Gerontology. The ASHA Leader.


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Culture: What's it all about?

"Culture" refers to integrated patterns of human behavior that include language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups, according to the U.S. Department of Health and Human Services' definition. Culture goes beyond race and ethnicity, and it is up to the practitioner to define culture more broadly and include religious beliefs, lifestyles, special interests—even choice of supermarkets.


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