Communication Across Communication Across CulturesCultures

Marian H. Jarrett, Ed.D.Marian H. Jarrett, Ed.D.Lorelei Emma, M.A.Lorelei Emma, M.A.

George Washington UniversityGeorge Washington University66thth Annual Infant and Toddler Connection of Annual Infant and Toddler Connection of Virginia Early Intervention Conference 2008Virginia Early Intervention Conference 2008

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

Agenda

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

Children and Families and CultureChildren and Families and Culture

Family adjustment seen in context of Family adjustment seen in context of family systems and ecological modelfamily systems and ecological model

Grief is a normal response to an Grief is a normal response to an abnormal situationabnormal situation

Grieve the loss of the expected childGrieve the loss of the expected child Pregnancy images of the imagined childPregnancy images of the imagined child Process of grieving and adaptation is Process of grieving and adaptation is

complex and confusing for familycomplex and confusing for family Grief does not signal non-acceptance or Grief does not signal non-acceptance or

devaluing of the family memberdevaluing of the family member

Grief: A Complex, Personal Grief: A Complex, Personal ExperienceExperience

No typical time; some suggest 1-3 yearsNo typical time; some suggest 1-3 years Varies greatly from individual to individualVaries greatly from individual to individual How person copes depends on previous How person copes depends on previous

coping behaviors coping behaviors Grief for a disability may become more Grief for a disability may become more

intense during periods of transitionintense during periods of transition

Secondary Losses Compound Secondary Losses Compound Initial Grief ReactionsInitial Grief Reactions

Families experience stress as secondary Families experience stress as secondary losses when needs are not metlosses when needs are not met

Secondary losses may challenge a Secondary losses may challenge a family’s ability to manage grief family’s ability to manage grief Services should be family-centered, Services should be family-centered,

relationship-based, and culturally competentrelationship-based, and culturally competent Consider the impact of respite services, in-Consider the impact of respite services, in-

home medical support and therapy, financial home medical support and therapy, financial assistance, and family support for this assistance, and family support for this particular familyparticular family

1.1. Traumatic Stress or ShockTraumatic Stress or Shock2.2. Assimilation Assimilation 3.3. Acknowledgment and IntegrationAcknowledgment and Integration

Phases recycle and blend into one anotherPhases recycle and blend into one another

Certain feelings predominate in each phaseCertain feelings predominate in each phase

Predominant Phases of GriefPredominant Phases of Grief

Phase 1: Traumatic StressPhase 1: Traumatic Stress

Period immediately following diagnosisPeriod immediately following diagnosis Numbness, shock, disturbed sleep, panic, Numbness, shock, disturbed sleep, panic,

and despairand despair Families Families

Make major decisions about treatment and Make major decisions about treatment and servicesservices

Report do not hear what doctors and service Report do not hear what doctors and service providers sayproviders say

Try to understand meaning of diagnosisTry to understand meaning of diagnosis May experience relief with diagnosisMay experience relief with diagnosis

Feelings & Behaviors in Feelings & Behaviors in Initial PhaseInitial Phase

Gather as much information as possibleGather as much information as possible Express anger at doctors and diagnosisExpress anger at doctors and diagnosis Tearful and withdrawnTearful and withdrawn Preoccupation with imagined childPreoccupation with imagined child Panic and helplessnessPanic and helplessness Focused on immediate needsFocused on immediate needs Frightening for siblingsFrightening for siblings

Phase 2: AssimilationPhase 2: Assimilation

Confusion begins to dissipateConfusion begins to dissipate Sharper realization of nature and extent of disabilitySharper realization of nature and extent of disability

Family members show highly idiosyncratic, Family members show highly idiosyncratic, changing responseschanging responses

Heavily influenced by personality and contextual Heavily influenced by personality and contextual factorsfactors

Period when families experience their most Period when families experience their most intense reactions to loss of hoped-for childintense reactions to loss of hoped-for child

Feelings in Feelings in Assimilation PhaseAssimilation Phase

HopeHope Anxiety and restlessnessAnxiety and restlessness Depression and anxietyDepression and anxiety GuiltGuilt AngerAnger Social IsolationSocial Isolation

Phase 3: Acknowledgment and Phase 3: Acknowledgment and IntegrationIntegration

Greater understanding and Greater understanding and acknowledgment of disabilityacknowledgment of disability

Greater integration of child with a disability Greater integration of child with a disability into the familyinto the family

Periods of distress are briefer, less intensePeriods of distress are briefer, less intense Parents still report “having a bad day”Parents still report “having a bad day”

Behaviors and Feelings in Behaviors and Feelings in Integration PhaseIntegration Phase

With help, family members canWith help, family members can acknowledge they are feeling betteracknowledge they are feeling better distinguish grief-related stress from other distinguish grief-related stress from other

stressstress Acknowledge there is no “getting back to Acknowledge there is no “getting back to

normal.” Families are forever changed. normal.” Families are forever changed. Begin to see self as a parent, not just a Begin to see self as a parent, not just a

parent of a child with a disabilityparent of a child with a disability Embed learning into daily routinesEmbed learning into daily routines

Cultural Competence in Supporting Cultural Competence in Supporting Families Who Are GrievingFamilies Who Are Grieving

Definition:Definition: A set of values, behaviors, attitudes, and practices A set of values, behaviors, attitudes, and practices

within a system, organization, program or among within a system, organization, program or among individuals and which enables them to work effectively individuals and which enables them to work effectively cross culturally.cross culturally.

Ability to honor and respect the beliefs, language, Ability to honor and respect the beliefs, language, interpersonal styles and behaviors of individuals and interpersonal styles and behaviors of individuals and families receiving services, as well as staff who are families receiving services, as well as staff who are providing such services.providing such services.

(Division of Services for Children with Special Health Care Needs, 2005)(Division of Services for Children with Special Health Care Needs, 2005)

Cultural Competence as a ProcessCultural Competence as a Process

Cultural competence is not an end-state, Cultural competence is not an end-state, but a process:but a process:

Encompasses not only cultural knowledge on Encompasses not only cultural knowledge on the part of the service provider, but also the part of the service provider, but also constructive attitudes and attention to the total constructive attitudes and attention to the total context of the family’s situation. context of the family’s situation.

Barriers to Culturally Competent Barriers to Culturally Competent CareCare

Institutional BarriersInstitutional Barriers Lack of diversity in health care’s leadership and Lack of diversity in health care’s leadership and

workforceworkforce Systems of care poorly designed to meet the needs of Systems of care poorly designed to meet the needs of

diverse patient populations diverse patient populations Poor communication between providers and patients Poor communication between providers and patients

of different racial, ethnic, or cultural backgroundsof different racial, ethnic, or cultural backgrounds

Personal BarriersPersonal Barriers

Betancourt, Green, & Carrillo, 2003Betancourt, Green, & Carrillo, 2003

Development of Cultural Development of Cultural CompetenceCompetence

3 Step Process (Iterative, No endpoint)3 Step Process (Iterative, No endpoint)

1. 1. Clarification of the service provider’s own values, Clarification of the service provider’s own values, attitudes and assumptionsattitudes and assumptions

2. Knowledge of commonly held cultural beliefs and the 2. Knowledge of commonly held cultural beliefs and the culturally normative interactive styles of specific cultural culturally normative interactive styles of specific cultural groupsgroups

3. Skills that enable the individual to engage in successful 3. Skills that enable the individual to engage in successful interactionsinteractions

AAP, 1999; Lynch & Hanson, 2004AAP, 1999; Lynch & Hanson, 2004

Self-Awareness ActivitySelf-Awareness Activity

Understanding Our Own Place on the ContinuaUnderstanding Our Own Place on the Continua Interdependence……IndependenceInterdependence……Independence Kinship (extended family)……Nuclear familyKinship (extended family)……Nuclear family High context……Low contextHigh context……Low context Religious orientation……Secular OrientationReligious orientation……Secular Orientation Authoritarian child-rearing……Permissive childrearingAuthoritarian child-rearing……Permissive childrearing Greater respect for older family members……Greater Greater respect for older family members……Greater

emphasis on youthemphasis on youth Oriented to the situation…….Oriented towards timeOriented to the situation…….Oriented towards time

Disability, Death, and CultureDisability, Death, and Culture When individuals are confronted with the fear and When individuals are confronted with the fear and

senselessness of disability, illness, and death, culture senselessness of disability, illness, and death, culture can:can:

Provide meaning for those who are grieving through its beliefs Provide meaning for those who are grieving through its beliefs about life after deathabout life after death

Define care of the body after death and burial or cremation Define care of the body after death and burial or cremation practicespractices

Describe roles for grieving family members and for the Describe roles for grieving family members and for the community which surrounds themcommunity which surrounds them

Influence how grief is expressedInfluence how grief is expressed Affect how grieving families interact and communicate with Affect how grieving families interact and communicate with

caregiverscaregivers Impact how families approach decisions about interventions, Impact how families approach decisions about interventions,

treatment, and end-of-life decisionstreatment, and end-of-life decisions

Beliefs and Values Influence Beliefs and Values Influence Grieving ProcessGrieving Process

Beliefs aboutBeliefs about disability and infant deathdisability and infant death medical caremedical care

Values ofValues of FamilyFamily ReligionReligion EducationEducation AgeAge

Influence of Other FactorsInfluence of Other Factors

AgeAge GenderGender SESSES EducationEducation Length of time in the USLength of time in the US Level of acculturationLevel of acculturation

CommunicationCommunication

10.5 million U.S. residents speak little or no 10.5 million U.S. residents speak little or no EnglishEnglish

Different languages = difficulty Different languages = difficulty communicatingcommunicating

Even with same language, language of Even with same language, language of disability and grief are always difficult.disability and grief are always difficult.

(U.S. Census Bureau, 2001)(U.S. Census Bureau, 2001)

Effective CommunicationEffective Communication

Medium through which families and Medium through which families and providers negotiate the process of caring providers negotiate the process of caring for an infant or young child with disabilities for an infant or young child with disabilities or a life-threatening illnessor a life-threatening illness

Basic tool used to establish and maintain Basic tool used to establish and maintain relationships with familiesrelationships with families

Essential to family-centered and culturally-Essential to family-centered and culturally-sensitive caresensitive care

Fostering Shared Meaning Fostering Shared Meaning and Mutual Understandingand Mutual Understanding

Shows interest and encourages parent to Shows interest and encourages parent to continuecontinue

Uses open-ended questions to help parents Uses open-ended questions to help parents describe their perceptions and feelingsdescribe their perceptions and feelings

Uses focused questions to gain specific Uses focused questions to gain specific informationinformation

Paraphrases the content of parent Paraphrases the content of parent communicationcommunication

Validates parent’s feelingsValidates parent’s feelings Remains nonjudgmental Remains nonjudgmental

Examining Our Own Examining Our Own CommunicationCommunication

Unconsciously learned ways to think, feel, Unconsciously learned ways to think, feel, and act according to what our culture and act according to what our culture considers appropriateconsiders appropriate

Often unable to set aside our own cultural Often unable to set aside our own cultural values and listen to the familyvalues and listen to the family

May unwittingly violate cultural May unwittingly violate cultural assumptions about the parent’s role, assumptions about the parent’s role, cause of disability, or intervention optionscause of disability, or intervention options

Examining Your Own Cultural Examining Your Own Cultural Values, Beliefs, and PracticesValues, Beliefs, and Practices

Complete the Values Clarification Exercise Complete the Values Clarification Exercise in the back of your packet.in the back of your packet.

Read each statement, rate it, and move to Read each statement, rate it, and move to the next statement.the next statement.

There are no right or wrong answers.There are no right or wrong answers.

Values Clarification ExerciseValues Clarification Exercise

Review your responses. Review your responses.

Examine each statement by asking:Examine each statement by asking: Why do I feel this way?Why do I feel this way? How might this affect my interactions with How might this affect my interactions with

children and families?children and families?

Social OrganizationSocial Organization

Who are the members of the family Who are the members of the family system?system?

Who is the spokesperson?Who is the spokesperson? Who should be included in Who should be included in

discussions?discussions? Is full disclosure acceptable?Is full disclosure acceptable? Who makes decisions in the family?Who makes decisions in the family?

Showing RespectShowing Respect

Can be based on age, gender, social Can be based on age, gender, social position, education, economic status position, education, economic status and authorityand authority

Formality of communication shows Formality of communication shows respectrespect

Distinct lines drawn between members Distinct lines drawn between members of society in some cultures can of society in some cultures can impeded open communicationimpeded open communication

Communication StyleCommunication Style Low context culture Low context culture – European American– European American

Direct, precise, logical verbal communicationDirect, precise, logical verbal communication

High context culture High context culture – Hispanic, Asian, – Hispanic, Asian, African American, Native AmericanAfrican American, Native American More informalMore informal Rely more on situational cuesRely more on situational cues Non-confrontational responsesNon-confrontational responses Well-established hierarchiesWell-established hierarchies Physical cues and relationships are easily Physical cues and relationships are easily

perceived perceived

High Context CulturesHigh Context Cultures

May be inappropriate to ask informally May be inappropriate to ask informally about family and disability or medical about family and disability or medical issuesissues

Coming directly to decision-making Coming directly to decision-making may seem rude or insensitivemay seem rude or insensitive

Direct confrontation and questioning Direct confrontation and questioning may cause discomfort and even may cause discomfort and even shameshame

Revert to What is ComfortableRevert to What is Comfortable

Low context communicators may:Low context communicators may: Talk lessTalk less Speak fasterSpeak faster Raise the volume of their voiceRaise the volume of their voice

High context communicators may:High context communicators may: Say lessSay less Make less eye contactMake less eye contact Withdraw from the interactionWithdraw from the interaction

Providers Must Adapt Their Providers Must Adapt Their Communication StyleCommunication Style

Slow down and talk lessSlow down and talk less Look for meaning in physical gesturesLook for meaning in physical gestures Focus on the context of the family and the Focus on the context of the family and the

interactioninteraction Be aware of hierarchical differences within Be aware of hierarchical differences within

families and between the family and the families and between the family and the providerprovider

Cultural Blind Spot SyndromeCultural Blind Spot Syndrome

Low socioeconomic statusLow socioeconomic status Inexperience with Western health care and Inexperience with Western health care and

education systemeducation system Lack of or limited formal educationLack of or limited formal education Emigration from a rural areaEmigration from a rural area Little knowledge of EnglishLittle knowledge of English Recent immigration to the U.S. at an older ageRecent immigration to the U.S. at an older age Segregation in an ethnic subcultureSegregation in an ethnic subculture

(Buchwald, et al., 1994)(Buchwald, et al., 1994)

L-E-A-R-NL-E-A-R-N

LListen with sympathy and understanding isten with sympathy and understanding to the family’s perception of the problemto the family’s perception of the problem

EExplain your perceptions of the problemxplain your perceptions of the problem AAcknowledge and discuss the differences cknowledge and discuss the differences

and similaritiesand similarities RRecommend interventionecommend intervention NNegotiate agreementegotiate agreement

Guidelines for Cross-Cultural Guidelines for Cross-Cultural Nonverbal CommunicationNonverbal Communication

EyeEye contactcontact – can be sign of disrespect, hostility or – can be sign of disrespect, hostility or rudenessrudeness

Observe family members and members of cultural groupsObserve family members and members of cultural groups

Body language and facial expressions Body language and facial expressions – may be – may be interpreted differentlyinterpreted differently

Ask for clarification of concerns, check for questions, or reword Ask for clarification of concerns, check for questions, or reword information being presentedinformation being presented

Silence Silence – some comfortable with long silences; some – some comfortable with long silences; some speak immediatelyspeak immediately

Listen to conversations between members of the same culture to Listen to conversations between members of the same culture to learn the use of pauses and interruptionslearn the use of pauses and interruptions

Silence can have many meanings difficult to assessSilence can have many meanings difficult to assess

Guidelines cont’dGuidelines cont’d Distance – preferred distance is 2-3 feet in Distance – preferred distance is 2-3 feet in

U.S.U.S. Give family members a choice of where to sitGive family members a choice of where to sit Stand with room for parents to move closer or Stand with room for parents to move closer or

farther awayfarther away Touch – norms for how and when to touchTouch – norms for how and when to touch

Touching not common for South Asians and West Touching not common for South Asians and West IndiansIndians

In some Latino cultures, touching conveys lack of In some Latino cultures, touching conveys lack of respect, especially older peoplerespect, especially older people

Recommendations to Facilitate Recommendations to Facilitate CommunicationCommunication

Encourage open dialogue by asking about Encourage open dialogue by asking about family relationships, values and beliefs.family relationships, values and beliefs.

Informally determine fluency of family by Informally determine fluency of family by asking open-ended question.asking open-ended question.

Encourage family to ask questions. Encourage family to ask questions. Ask family questions to check understanding.Ask family questions to check understanding. Summarize what the parent says.Summarize what the parent says. Do not discourage family from talking among Do not discourage family from talking among

themselves in their own language.themselves in their own language.

Recommendations to Facilitate Recommendations to Facilitate CommunicationCommunication

Work with cultural mediators.Work with cultural mediators. Learn and use words and forms of Learn and use words and forms of

greeting.greeting. Provide information in different forms – Provide information in different forms –

oral, written, pictorial, demonstration.oral, written, pictorial, demonstration. Rely on the interpreter, observations, Rely on the interpreter, observations,

instincts, and knowledge to know when to instincts, and knowledge to know when to proceed and when to wait.proceed and when to wait.

Working with an InterpreterWorking with an Interpreter

Use trained interpreters for important Use trained interpreters for important meetings with the family.meetings with the family.

Allow additional time to determine cultural Allow additional time to determine cultural values, beliefs and perspectives.values, beliefs and perspectives.

Reinforce verbal interaction with material Reinforce verbal interaction with material written in family’s language.written in family’s language.

Provide an interpreter when requested by Provide an interpreter when requested by the family even if they speak some English.the family even if they speak some English.

Case ScenarioCase Scenario

Overview of case Small group discussion Sharing out with whole group

ReferencesReferences Buchwald, D. Panagiota, V.C., Francesca, G., Hardt, E.J., Buchwald, D. Panagiota, V.C., Francesca, G., Hardt, E.J.,

Johnson, T.M., Muecke, M.A. & Putsch, R.W. (1994). Caring Johnson, T.M., Muecke, M.A. & Putsch, R.W. (1994). Caring for patients in a multicultural society. for patients in a multicultural society. Patient Care,Patient Care, June 15, June 15, 1994, 105-123.1994, 105-123.

Lynch, E.W. & Hanson, M.J. (2004). Lynch, E.W. & Hanson, M.J. (2004). Developing cross-Developing cross-cultural competence: A guide for working with children and cultural competence: A guide for working with children and families. (3families. (3rdrd Ed.) Baltimore: Paul H. Brookes Publishing Co., Ed.) Baltimore: Paul H. Brookes Publishing Co., Inc.Inc.

Montgomery, W. (2001). Creating culturally responsive, Montgomery, W. (2001). Creating culturally responsive, inclusive classrooms. inclusive classrooms. Teaching Exceptional Children, 33Teaching Exceptional Children, 33(4), (4), pp. 4-9.pp. 4-9.

U.S. Census Bureau. (2002). Number of foreign-born up 57 U.S. Census Bureau. (2002). Number of foreign-born up 57 percent since 1990, according to Census 2000. Retrieved percent since 1990, according to Census 2000. Retrieved July 12, 2004, from July 12, 2004, from http://www.census.gov/Press-Release/www/2002/cb02cn11http://www.census.gov/Press-Release/www/2002/cb02cn117.htm7.htm

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