Culturally Sensitive Therapy

One of my favorite parts of my job is the fact that I get to spend time with so many amazing, interesting, terrific families of children with hearing loss.  Thanks to teletherapy, “my” families now come not only from around my city, but also from around the world.  Each one brings their own unique perspective to the table.  As a therapist, how can I best meet their needs?

Though it is changing, the face of speech language pathology and auditory verbal therapy has been historically, and still is to a great extent, that of a young, Caucasian, female.  Due to the nature of the training required to obtain these certifications, that young Caucasian female also brings to the table at least a Master’s degree, an educational designation that many of her clients may not have.  There’s an inherent imbalance there.  Our professional faces do not always reflect those of the children and families we serve.  And we professionals ourselves are a diverse group, each bringing our own life experiences to the work that we do.  While every therapist’s and family’s story is different, here are some ways that I try to make my practice “a place where all families fit.”

 

Status, Roles, and Power Imbalance.  Going to see a medical professional can be an intimidating thing.  Even a patient who is well-educated with all of the resources in the world can forget a question, or make a mistake in understanding the diagnosis, or even just get lost in the maze of a large hospital complex.  Now imagine that you’re trying to navigate this system and you don’t speak the language, or you just arrived in this country a month ago, or you don’t know how to read… and you’re doing all of this with your child(ren) in tow… and you’re terrified because you just found out that your baby is deaf and all you know of deafness are horror stories of “deaf-mutes” or people isolated from society.  It’s staggering.

 

Even for parents who are natives to your country, consider what their past experiences with the “medical-educational complex” might have been.  If you grew up in a failing school district where the expectation was that you would drop out and get a menial job (if you didn’t end up in prison first), if you’ve spent your whole life being told that you “don’t speak proper English,” or if your own parents never read you a book in your life, how does it feel to come to therapy and be told by the experts that you will be charged with the task of becoming your child’s first and best teacher?  How do you feel toward people in positions of power?  How does it feel to be told that you are an equal partner in this process?  After all, it’s not like you go to the doctor and he tells you, “Sure!  You can give yourself this shot.  I’ll be right here to coach you through it!”  It’s a huge shift in mindset — one that can be very empowering to parents, certainly, but one that takes time and explanation to digest.

 

When I first meet families, I am mindful of the fact that there is real status loss, role reversal, and power imbalance inherent in our interact.  What does that mean?  Well, the status of parent means to be in charge — in charge of the child, responsible for protecting his welfare, the leader in the family.  The diagnosis of hearing loss changes all of this.  Parents who may have been confident before can find themselves powerless, awash in a sea of new information and challenging decisions.  Additionally, immigration and culture can lead to further status loss.  This parent may have been a respected community member in their home country, or may be a leader in their ethnic community here, but in the therapy room, none of that carries any weight.  Role reversal occurs here as well.  In an everyday interaction, I, a young female, would probably not be in a position of authority over most of the parents I serve.  And though I don’t see the therapist’s role of authoritative (I’m here to guide and coach!), the dynamic of the relationship can seem that way to a parent at first.  Ultimately, in any professional-patient relationship, there is a power imbalance, and that can be unsettling for families, especially at this really trying and uncertain time in their lives.

 

How do I combat this?

  • Unpack your own baggage first.  If you’ve made it to the end of a Master’s degree program, you already have more education than approximately 89% of adults in the United States.  Most of us who grow up with this privilege rarely have a need, or even the chance, to reflect on our own cultural backgrounds.  We rarely experience being in the minority or not having the education and cultural tools we need to successfully navigate the system.  It’s easy to skip through life like this.  Before you think about the family’s culture, think about your own.  What formative experiences, opinions, or biases shaped your upbringing?  What is your experience of the world?  These experiences are neither good nor bad, it’s just important to understand where you’re coming from when you’re attempting to meet families in the middle.

  • No hot seats.  Even small things, like how you position yourself and the family in the room, can make a big difference.  Instead of sitting across the table from one another, I like to be, literally and figuratively, “on the parent’s side.”  Even better is when we can be in a more living room-like environment, sitting around on comfortable couches or chairs.  When parents come in for their initial evaluations, I actually like to sit on the floor.  That’s usually where the child is, and it is a powerful, if subtle, indicator to the family that I don’t consider myself above them, and I’m anxious to jump in and get to know them and their child.

  • Names are important.  I think it’s incredibly essential to know family members’ names and to take the time to learn to pronounce them correctly (using IPA symbols can be great for this).  A person’s name is so essential to their being, and using it correctly is a sign of respect.  In therapy, I usually call family members by the names that the child calls them (“Okay, it’s Mommy’s turn,”  “Let’s ask Baba what kind of ice cream he would like,” etc.).  Culturally, for me, it’s more respectful to use titles than to address older adults by their names.  Based on your own culture and comfort level, you may feel differently.  It’s like when you go to the doctor and you call her “Dr. Smith” but she calls you “George” — I want to flip this power differential on its head.  I tell families to please feel free to call me by my first name if they choose.  I know that there’s mutual respect and caring based on how we treat each other.  I don’t need the honorific to feel that.

  • Emphasize the team.  As I mentioned above, parents are probably not expecting to hear that they will be their child’s first and best teachers on the journey to listening and spoken language.  I want them to hear this again and again and again, and I want my actions to show that I mean it.  The more parents can feel like equal members of a partnership, the more we will be able to mitigate some of the inherent power imbalances in the relationship.

 

Language.  Family language can also be a flashpoint — after all, parents come to you to learn how to teach their child language.  You’re the expert, and they may feel that their own language competence (or lack thereof) is also being assessed.  For therapists, it’s very important to understand the distinction between difference and disorder when assessing language and articulation in light of family dialect.  Many things that in the past would have been classed as “errors” are now understood to be features of non-standard but still valid dialects of English.  Parents may want their children to also learn Standard American English (SAE) to facilitate code-switching between home/neighborhood and school/professional environments, but that is their choice.  In therapy, I model sentences using my default dialect (SAE), but I treat as valid anything the parent/child says that is the equivalent of that statement in their home dialect.  For example, if we’re talking about a picture of a sad little boy in a book and I say, “Oh no!  He’s sad!” and the parent chimes in with, “He be cryin’,” that is 100% correct and an appropriate sentence in African American English (AAE).

 

And what about bilingualism?  Research shows us that oral bilingualism is absolutely attainable for children with hearing loss.  It’s exposure to fluent language models that matters, and if parents can provide a fuller model in their native language than in English, then by all means, that’s the language they should use!  Parents are often surprised to hear this, but I tell them, “At the end of the day, it’s far more important for you child to learn to talk to me than to talk to you.”  The techniques of Auditory Verbal Therapy work in any language, so if I can give parents the skills, they can translate them in a way that works best for them at home.  Interestingly, all of the techniques that we use to teach children language (repetition, acoustic highlighting, etc.) are also a great way to learn a new language as an adult!  In my work with families, I’ve found that both the parents and I have been able to pick up on aspects of each other’s language just by participating in therapy for the child.  The more that I can learn of the family’s language, the better I can serve them (and make smarter decisions about targets based on speech acoustics, grammatical rules, and other features of the home language).

 

The use of interpreters is another factor to consider when working with families who do not speak the dominant language.  Basic interpreter rules — like speaking to the client, not “through” the interpreter, asking question to, not about, the person (“Ask him how the audiology appointment went” is not the way to use an interpreter) — always apply.  I think it’s also very important to ensure that there’s an interpreter (and a good one!) at all official meetings (IFSPs, assessments, etc.) so that parents have full access to information.  Even in these meetings with an interpreter, it can be easy to lose the parents’ “voice.”  Take time in the middle of meetings to ask the parents for their thoughts, opinions, and feelings about what is going on.

 

For issues of language, I like to let the family be my guide.  Online dictionaries and translating sites cannot match the human experience.  For example, the Spanish-speaking families I’ve worked with have taught me at least five different words for the animal “pig,” based on their country of origin and exactly what type of pig we’re talking about.  If I had relied solely on the dictionary, or the single word for “pig” I learned in Spanish lessons at school, I’d be missing out!  Even for families who speak dialects other than Standard American English, I prefer to ask, “What do you call this at home?”  Some families (English speakers and others) will tell you what they say is the “correct” word and then sheepishly admit that they use something else at home.  Validate that home language!  Use it in therapy!  As with everything, if we’re giving the child access to sound and the parent the tools to bathe the child in language, it is possible for the child to learn all options, learn to code switch, and become a competent communicator across contexts.

 

Holidays.  I don’t “do” holidays in therapy.  First of all, my clients may celebrate holidays that are very different than my own, and even if the families do celebrate the same holidays, their interpretation may not be the same as mine.  I’m really conscious that, given my position of “authority” as the professional in the situation, the way I present things, for better or for worse, may be taken by the child (or parents) as the way things are.  (Think about the last time you had to convince your child that something their beloved preschool teacher said may not have been 100% correct.)  I am happy to discuss holidays and family celebrations if the child or parents bring them up, but in my lesson plans, I use neutral, seasonal activities instead (e.g. fall leaves, going to the beach, snowmen, flowers and baby animals, etc.).

 

But won’t this leave the child with huge gaps in their knowledge?  No!  If I’m doing my job correctly as an Auditory Verbal Therapist, the parents should be empowered with the tools they need to teach their child things that we do not cover in therapy.  It’s not just holidays — it’s everything!  There would never be enough time in one hour a week to teach the child everything he needs to know.  That’s why it is key to help parents learn to become their children’s first and best teachers.  It’s my job to equip them with the skills to get there.

 

I do want to know what is important to the family, though.  Instead of asking leading, biased questions like, “What do you do to celebrate Thanksgiving?” (maybe the family doesn’t celebrate it at all), or even, “Do you celebrate Thanksgiving?” (indicating that the default, “normal” answer would be “yes”), I like to ask, “Tell me what holidays and celebrations and special events happen in your family in the fall/summer/winter/spring?  And also, “What special events happen in your family at rotating times of the year? (Remember that some holidays, like Ramadan, change based on the lunar calendar, and will fall out in different Gregorian calendar months each year).  These questions help me to learn so much about the family beyond the “standard holidays” one might assume.  For some, the start of deer season is cause for a family party.  For others, the day their child was adopted is a big celebration.  You don’t see either of those marked on a standard calendar.  Other families may celebrate holidays I know of, but have their own special traditions based on their culture of origin.

 

Learn the Power of “Some.”  We humans are trained to look for patterns.  We love when things fit into logical, predictable boxes — it’s one of the reasons our ancestors were able to survive.  But we know that life is not always like that.  While it’s tempting to feel that a short summary on this culture or that culture can tell you all you need to know about interacting with members from that group, it’s just not so.  While it is helpful to do some research on the background of the families you serve, I find it much more productive to just let them tell me their stories and be my teacher, knowing that what I learn from Family A may not translate to Family B, even if they are of the same origin.  It’s never “all,” it’s always, “some.”  Likewise, children, who are trying to figure out the world around them, often make statements in therapy designed to test out their hypotheses about life on the adults in their world to determine whether or not they are valid.  Here again, we learn the power of “some.”  If a child tests out his theory, “The family needs to have a mommy and a daddy,” I can reply, “That’s right, some families do,” or the child says, “It’s gross to eat fish,” we respond, “Some people like how it tastes.”  It’s a small word, but a big message.

 

Don’t Assume.  You know what they say happens when you assume?  It makes an “ass” out of “u” and “me.”  It’s kind of funny, but also very true.  It’s easy to fall into the trap of believing that families who are not proficient in the majority language, or who have limited education, or how come from trauma and poverty, will not be the ideal auditory verbal family.  In fact, some programs still feel that certain family structures or backgrounds preclude even entrance into such therapy!  I have found that, when faced with the challenge of teaching their child with hearing loss to communicate, there are some families who take the challenge and run with it and others who are paralyzed — by grief, by indecision, by fear — and it’s not always easy to predict who will fall into which camp.  For example, one of the best AV moms I’ve ever worked with had only a third grade education in her home country and spoke very little English.  Yet, the week after we had discussed “some,” “many,” and “few,” in therapy with her child, she came back in with three baggies filled with the respective amounts of beans (the family didn’t really have toys), and her daughter knew it cold.  Another mother I know had no schooling — literally none — in her home country before moving to the US as a refugee.  She was a natural — so much so that I encouraged her to find some way to mentor other parents of children with hearing loss in her community!  On paper, neither of these mothers looked very promising.  In person, they blew me out of the water.  How different would that interaction have been if, instead of presuming competence, I assumed that they would not be able to cut it in AVT?

 

On the other hand, some families you think will soar end up needing more help.  Once I worked with a mother from an upper-middle class family, US citizens for many generations, from the mainstream American culture.  So far, so good — they’ve got all the resources in the world at their disposal.  But it just wasn’t clicking for this mom, no matter how hard she tried to implement the techniques.  Finally, one day, she broke down in therapy and told me, “You know, I pay someone to paint my nails, to clean my house, to mow my yard.  I’m just not used to not being able to pay someone to make my child better.”  It was a watershed moment for me, and a powerful lesson in how stereotypes of a “good parent” or an “easy parent” can be very, very deceiving.

 

Another tricky assumption to avoid is that of obvious versus hidden diversity.  It seems pretty clear-cut to us that the immigrant family who dresses, speaks, and worships differently than us qualifies as “diverse” and in need of cultural accommodation.  But what about the family that grew up twenty minutes down the road from you, has the same skin color, wears the same clothes?  Based on their growing up experiences — religious, economic, history of abuse/trauma, etc. — their worldview could also be quite different than your own.  Take time to get to know each family as individuals.  Let them tell you their stories and their needs.  Don’t assume.

 

You’re Going to Mess It Up.  (And That’s Okay!)  Don’t be afraid to make mistakes!  Interactions at the edges of culture and communication can be awkward for everyone involved.  I find that most families are appreciative of the efforts you make to be sensitive and understanding of their needs.  You can’t be expected to get it right 100% of the time, but if mistakes are made out of good intention and you’re willing to learn from them, then have a good laugh and move on.  Laughter can even break down barriers.  Can you imagine what it would be like to be an immigrant to a new country with limited familiarity with the language and culture?  You’d probably be making mistakes all the time.  For adults, who are supposed to “have things figured out,” it can be humiliating.  To see that the therapist, a professional skilled in the ways of the mainstream culture, makes mistakes, too, can be a great equalizer.

 

If you’ve really made a mistake, something that can’t just be laughed off, then humble yourself to sincerely apologize.  Sometimes cultural interactions can feel like a minefield, but I believe that most people — of any culture — respond to sincerity.  Acknowledge your mistake, ask for help to do it better next time, and grow from the experience.  It really isn’t as scary as you think!  Remember, too, that just as you won’t click with all of the families who match your own background, you’re not going to click with all families who are “other” either.  Give your best service, put forth your greatest effort, and try hard not to take it personally.

 

Ultimately, our lives are immeasurably enriched by every family we serve.  Whether they come from the other side of the world or their family arrived in North America on the Mayflower, each brings new perspective and growth to our practice as therapists.  How privileged we are to get to be a part of their journeys!

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