Communication Across Cultures

1. Communication Across Cultures Marian H. Jarrett, Ed.D. Lorelei Emma, M.A. George Washington University 6th Annual Infant and Toddler Connection of Virginia Early Intervention Conference 2008

2. Across cultures, people may differ in what they believe and understand about life and death, what they feel, what elicits those feelings, the perceived implications of those feelings, the ways they express those feelings, the appropriateness of certain feelings, and the techniques for dealing with feelings that cannot be directly expressed…To help effectively, we must overcome our presuppositions and struggle to understand people on their own terms. (Irish, Lundquist, & Nelson, 1993, p. 18)

3. Agenda • Introductions • Part 1: Grieving Process • Part 2: Communication • Part 3: Case Scenario Discussion • Part 4: Questions and Group Discussion

4. Children and Families and Culture • Family adjustment seen in context of family systems and ecological model

5. Grief is a normal response to an abnormal situation • Grieve the loss of the expected child • Pregnancy images of the imagined child • Process of grieving and adaptation is complex and confusing for family • Grief does not signal non-acceptance or devaluing of the family member

6. Grief: A Complex, Personal Experience • No typical time; some suggest 1-3 years • Varies greatly from individual to individual • How person copes depends on previous coping behaviors • Grief for a disability may become more intense during periods of transition

7. Secondary Losses Compound Initial Grief Reactions • Families experience stress as secondary losses when needs are not met • Secondary losses may challenge a family’s ability to manage grief • Services should be family-centered, relationship-based, and culturally competent • Consider the impact of respite services, in-home medical support and therapy, financial assistance, and family support for this particular family

8. Predominant Phases of Grief • Traumatic Stress or Shock • Assimilation • Acknowledgment and Integration • Phases recycle and blend into one another • Certain feelings predominate in each phase

9. Phase 1: Traumatic Stress • Period immediately following diagnosis • Numbness, shock, disturbed sleep, panic, and despair • Families • Make major decisions about treatment and services • Report do not hear what doctors and service providers say • Try to understand meaning of diagnosis • May experience relief with diagnosis

10. Feelings & Behaviors in Initial Phase • Gather as much information as possible • Express anger at doctors and diagnosis • Tearful and withdrawn • Preoccupation with imagined child • Panic and helplessness • Focused on immediate needs • Frightening for siblings

11. Phase 2: Assimilation • Confusion begins to dissipate • Sharper realization of nature and extent of disability • Family members show highly idiosyncratic, changing responses • Heavily influenced by personality and contextual factors • Period when families experience their most intense reactions to loss of hoped-for child

12. Feelings in Assimilation Phase • Hope • Anxiety and restlessness • Depression and anxiety • Guilt • Anger • Social Isolation

13. Phase 3: Acknowledgment and Integration • Greater understanding and acknowledgment of disability • Greater integration of child with a disability into the family • Periods of distress are briefer, less intense • Parents still report “having a bad day”

14. Behaviors and Feelings in Integration Phase • With help, family members can • acknowledge they are feeling better • distinguish grief-related stress from other stress • Acknowledge there is no “getting back to normal.” Families are forever changed. • Begin to see self as a parent, not just a parent of a child with a disability • Embed learning into daily routines

15. Cultural Competence in Supporting Families Who Are Grieving • Definition: • A set of values, behaviors, attitudes, and practices within a system, organization, program or among individuals and which enables them to work effectively cross culturally. • Ability to honor and respect the beliefs, language, interpersonal styles and behaviors of individuals and families receiving services, as well as staff who are providing such services. (Division of Services for Children with Special Health Care Needs, 2005)

16. Cultural Competence as a Process • Cultural competence is not an end-state, but a process: • Encompasses not only cultural knowledge on the part of the service provider, but also constructive attitudes and attention to the total context of the family’s situation.

17. Barriers to Culturally Competent Care • Institutional Barriers • Lack of diversity in health care’s leadership and workforce • Systems of care poorly designed to meet the needs of diverse patient populations • Poor communication between providers and patients of different racial, ethnic, or cultural backgrounds • Personal Barriers Betancourt, Green, & Carrillo, 2003

18. Development of Cultural Competence • 3 Step Process (Iterative, No endpoint) 1. Clarification of the service provider’s own values, attitudes and assumptions 2. Knowledge of commonly held cultural beliefs and the culturally normative interactive styles of specific cultural groups 3. Skills that enable the individual to engage in successful interactions AAP, 1999; Lynch & Hanson, 2004

19. Self-Awareness Activity • Understanding Our Own Place on the Continua • Interdependence……Independence • Kinship (extended family)……Nuclear family • High context……Low context • Religious orientation……Secular Orientation • Authoritarian child-rearing……Permissive childrearing • Greater respect for older family members……Greater emphasis on youth • Oriented to the situation…….Oriented towards time

20. Disability, Death, and Culture • When individuals are confronted with the fear and senselessness of disability, illness, and death, culture can: • Provide meaning for those who are grieving through its beliefs about life after death • Define care of the body after death and burial or cremation practices • Describe roles for grieving family members and for the community which surrounds them • Influence how grief is expressed • Affect how grieving families interact and communicate with caregivers • Impact how families approach decisions about interventions, treatment, and end-of-life decisions

21. Beliefs and Values Influence Grieving Process • Beliefs about • disability and infant death • medical care • Values of • Family • Religion • Education • Age

22. Influence of Other Factors • Age • Gender • SES • Education • Length of time in the US • Level of acculturation

23. Communication 10.5 million U.S. residents speak little or no English Different languages = difficulty communicating Even with same language, language of disability and grief are always difficult. (U.S. Census Bureau, 2001)

24. Effective Communication Medium through which families and providers negotiate the process of caring for an infant or young child with disabilities or a life-threatening illness Basic tool used to establish and maintain relationships with families Essential to family-centered and culturally-sensitive care

25. Fostering Shared Meaning and Mutual Understanding Shows interest and encourages parent to continue Uses open-ended questions to help parents describe their perceptions and feelings Uses focused questions to gain specific information Paraphrases the content of parent communication Validates parent’s feelings Remains nonjudgmental

26. Examining Our Own Communication Unconsciously learned ways to think, feel, and act according to what our culture considers appropriate Often unable to set aside our own cultural values and listen to the family May unwittingly violate cultural assumptions about the parent’s role, cause of disability, or intervention options

27. Examining Your Own Cultural Values, Beliefs, and Practices Complete the Values Clarification Exercise in the back of your packet. Read each statement, rate it, and move to the next statement. There are no right or wrong answers.

28. Values Clarification Exercise Review your responses. Examine each statement by asking: • Why do I feel this way? • How might this affect my interactions with children and families?

29. Social Organization Who are the members of the family system? Who is the spokesperson? Who should be included in discussions? Is full disclosure acceptable? Who makes decisions in the family?

30. Showing Respect Can be based on age, gender, social position, education, economic status and authority Formality of communication shows respect Distinct lines drawn between members of society in some cultures can impeded open communication

31. Communication Style • Low context culture – European American • Direct, precise, logical verbal communication • High context culture – Hispanic, Asian, African American, Native American • More informal • Rely more on situational cues • Non-confrontational responses • Well-established hierarchies • Physical cues and relationships are easily perceived

32. High Context Cultures May be inappropriate to ask informally about family and disability or medical issues Coming directly to decision-making may seem rude or insensitive Direct confrontation and questioning may cause discomfort and even shame

33. Revert to What is Comfortable • Low context communicators may: • Talk less • Speak faster • Raise the volume of their voice • High context communicators may: • Say less • Make less eye contact • Withdraw from the interaction

34. Providers Must Adapt Their Communication Style Slow down and talk less Look for meaning in physical gestures Focus on the context of the family and the interaction Be aware of hierarchical differences within families and between the family and the provider

35. Cultural Blind Spot Syndrome Low socioeconomic status Inexperience with Western health care and education system Lack of or limited formal education Emigration from a rural area Little knowledge of English Recent immigration to the U.S. at an older age Segregation in an ethnic subculture (Buchwald, et al., 1994)

36. L-E-A-R-N Listen with sympathy and understanding to the family’s perception of the problem Explain your perceptions of the problem Acknowledge and discuss the differences and similarities Recommend intervention Negotiate agreement

37. Guidelines for Cross-Cultural Nonverbal Communication • Eyecontact – can be sign of disrespect, hostility or rudeness • Observe family members and members of cultural groups • Body language and facial expressions – may be interpreted differently • Ask for clarification of concerns, check for questions, or reword information being presented • Silence – some comfortable with long silences; some speak immediately • Listen to conversations between members of the same culture to learn the use of pauses and interruptions • Silence can have many meanings difficult to assess

38. Guidelines cont’d • Distance – preferred distance is 2-3 feet in U.S. • Give family members a choice of where to sit • Stand with room for parents to move closer or farther away • Touch – norms for how and when to touch • Touching not common for South Asians and West Indians • In some Latino cultures, touching conveys lack of respect, especially older people

39. Recommendations to Facilitate Communication Encourage open dialogue by asking about family relationships, values and beliefs. Informally determine fluency of family by asking open-ended question. Encourage family to ask questions. Ask family questions to check understanding. Summarize what the parent says. Do not discourage family from talking among themselves in their own language.

40. Recommendations to Facilitate Communication Work with cultural mediators. Learn and use words and forms of greeting. Provide information in different forms – oral, written, pictorial, demonstration. Rely on the interpreter, observations, instincts, and knowledge to know when to proceed and when to wait.

41. Working with an Interpreter Use trained interpreters for important meetings with the family. Allow additional time to determine cultural values, beliefs and perspectives. Reinforce verbal interaction with material written in family’s language. Provide an interpreter when requested by the family even if they speak some English.

42. Case Scenario Overview of case Small group discussion Sharing out with whole group

43. References Buchwald, D. Panagiota, V.C., Francesca, G., Hardt, E.J., Johnson, T.M., Muecke, M.A. & Putsch, R.W. (1994). Caring for patients in a multicultural society. Patient Care, June 15, 1994, 105-123. Lynch, E.W. & Hanson, M.J. (2004). Developing cross-cultural competence: A guide for working with children and families. (3rd Ed.) Baltimore: Paul H. Brookes Publishing Co., Inc. Montgomery, W. (2001). Creating culturally responsive, inclusive classrooms. Teaching Exceptional Children, 33(4), pp. 4-9. U.S. Census Bureau. (2002). Number of foreign-born up 57 percent since 1990, according to Census 2000. Retrieved July 12, 2004, from http://www.census.gov/Press-Release/www/2002/cb02cn117.htm

44. Contact Information • Please feel free to contact either presenter with questions, comments, request for further information/resources, or to provide them with additional information/resources: • Marian Jarrett: mjarrett@gwu.edu • Lorelei Emma: loreemma@gwu.edu