CULTURAL ISSUES

What is “Culture”?

What are the demographics associated with“culture”? • Age

• SES• Education• Religion• Demographic origins• Race• Preferred language• ….others…

Culture is not something that “someone else has” but is present in everyone.

It is also dynamic, shifting, and in transition.

What is your cultural make-up?

• Culture is not something that “someone else has” but is present in everyone.

– With what cultures and subcultures do you identify?• Culture is dynamic, shifting, and in transition.– Has your cultural identity changed over time?– Acculturation to new culture affected positively by:

• ++ urban• ++ high SES• + high education• + early immigration• + limited migration• + outside contacts in community

A Definition of Culture (Betancourt/Penn)• “Culture is an integrated pattern of learned beliefs and behaviors that can

be shared and include – thoughts, – styles of communicating, – ways of interacting, – roles and relationships, – values, – practices and – customs.”

• Following Shaules, 2007, culture can be both– Explicit (what can be seen, bought, used)– Implicit or “deep” (shared networks of knowledge and relationship

between families and communities)

Culture Interface (ganma metaphor, where fresh water meets sea, Penn)

• At the interface of cultures there are unique patterns of change in– Language– Religion– Beliefs– Practices– Behaviors

• These changes happen– In society– In the individual

Changing Demographics: What is a “minority group”?

“Cultural Competence” in Clinical Settings

Clinical Reality

• Each time we meet with a client, our own culture is interfacing with the client’s culture

Examples from class members….

Cultural competence in clinical settings

• Understanding of how culture affects– Beliefs– Behaviors

• How cultures interact with the culture of the health care delivery system

• Devising interventions in order to assure quality heath care

Cultural competence in clinical settings (cont.)• NOT the attainment of a set of knowledge, skills and attitudes through

training class, and NOT a discrete endpoint (“I took a class in cultural competence, so now I’m culturally competent.)

• RATHER– cultural competence is a lifelong process– training should result in:

• Humility• Reflexivity : understanding of one’s own values, beliefs, and

behaviors, prejudices and attitudes• Awareness of how power, privilege and inequalities are embedded in

social relationships in clinical settings– Cultural competence as a practical demonstration of ethical principles

of respect, beneficence, non-maleficence and justice.

Cultural competence in clinical settings (cont.)• Perhaps a healthy goal would be an underlying feeling of cultural

INcompetence– A healthy anxiety or uncertainty– Can trigger sensitive and effective communication in intercultural

situations (Daniels & Swartz, 2007)• Foster a sense of cultural safety (move beyond simple “cultural

awareness”) – “A client feels that their cultural social and human values are

respected and that an organization providing service to that client reorients its institutional practices, values, resources and governance arrangements accordingly” (Phillips, 2007)

– Ramsden defines culturally unsafe “any actions that diminish, demean, or disempower the cultural identity”

Some Practical Suggestions

Effects of race/ethnicity/culture• Biological differences (freq and cause of partic. conditions may vary)

• Perceptions of disability (e.g., pragmatics of silence in kids)

• Need/desire for Dx/Tx (Table 2-1, p. 40, values)

• Who to see for Dx (m.d., therapist, medicine man, curandero, herbalist)

• Nature of language dominance (how recently, and extensively used; can’t test alone…need to interview in context/situation of use with meaningful interlocutor; possibility of delay in both languages: LI normal until amount of exposure slows down; L2 learned late, so it is also deficient)

• Dialect vs. accent– Linguistic quality– Social prestige/power

Where do you fit?

Where does clinical culture fit?

Cultural issues in various components of Dx process

• Administrative, pre-session orientation: Be aware– “testing culture”• Non-verbal: fast and on-time; teach w/ words,

demonstration of own abilities vs. blend into group• Verbal: pseudo Q’s vs. genuine Q’s; low context vs. high

context; symmetrical vs. asymmetrical dialogue

Cultural issues in various components of Dx process (cont.)• Std. testing

– Act of testing itself is part of a culture!– Can standardized test be adapted? (No, not easily)

Direct translation (many concepts can’t be translated)Standardize existing tests on population (some concepts may not apply, though)Use tests that include minority as part of sample (too small)Modify existing tests (need full knowledge of culture; revisions can’t assure “equal credit”)Use language sample (no normative data)Use criterion-referenced measure (only if client set crit.)

• Alternatives– Ethnographic approach (see Penn), portfolio, dynamic

Cultural issues in various components of Dx process (cont.)

Testing and information sharing• Using interpreters

– Interpreter not from “enemy” culture and not from neighborhood– Explain topic to interpreter ahead of time; familiar with concepts– Talk to client– Translate w/o paraphrasing– Sit with interpreter next to client (not triangle, not “conduit”)– Have family repeat (reverse translation)– Discuss with translator afterwards

• Using cultural brokers (Penn) (May or may not also act as translator)– May include a community advisory board (MAP-A)– Accompagnateur is one example

• Communication strategies with non-native speakers– Read about culture in advance– Interact with members of the culture– Find cultural broker to learn about culture– Acknowledge (up front) the culture you are from

and fact that the team represents different cultures; respect, humility, working together for best possible outcomes for client

– Maintain loudness– Learn how to pronounce names– Learn common words and greetings, without

patronizing

ETHICAL ISSUES

Ethics for the clinical diagnostician• Continuing education• Evaluation of the diagnostic– Evaluate effectiveness of diagnostic, including

counseling (“What went well? Poorly?”)– Assess own skills– Do not claim guarantees; only prognosis

• Repetition of education, training, experience– Needs to be accurate, don’t let slide

• Give price and fee information up front

Ethics for the clinical diagnostician (cont.)

• Records– Keep them– Keep confidential– When research involved, obtain informed consent

• Note taking: Don’t hide fact you’re doing it• Referral – Required when outside your expertise– Give reasons for the referral– “Consult with” “talk with” “see”

Ethics for the clinical diagnostician (cont.)

• No criticism of other professionals– Be descriptive– Be positive

• When lying occurs:– Document what they say

• Inform them when breaking the law • Avoid friendships and social relationships with client• Termination: Don’t save discussion of it to the very

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