20Q: Important Aspects of Diversity and Culture in Speech-Language Pathology Services

From the Desk of Ann Kummer

The United States was founded by people from various countries around the world. These original immigrants came with differences in language, race, culture, and religion.  Since the birth of our country over two centuries ago, the United States has become even more racially and ethnically diverse. I think most adults would say that it’s good that the U.S. population is racially and ethnically mixed and that this diversity is part of our strength. However, diversity introduces its own set of challenges, particularly in the workplace.

Because of the increasing diversity in our population, the ability to understand, communicate with and effectively interact with people across cultures is more important than ever before. Therefore, I am thrilled that my friend, Marlene Salas-Provance, has submitted this 20Q on diversity and cultural competence as it relates to speech-language pathology services!

Here is more information about Dr. Marlene Salas-Provance:

Marlene Salas-Provance, PhD, MHA is professor and Vice Dean in the Arizona School of Health Sciences at A.T. Stills University.  Dr. Salas-Provance is an ASHA Fellow and recipient of ASHA’s Multicultural Award and International Achievement Award.  She has taught a university course in cultural diversity and interpreter training for over 25 years to speech pathology graduate students. She is also the Founder and CEO of Bilingual Advantage, Inc., which is an organization designed to improve the healthcare and education of multicultural populations by providing quality bilingual and multicultural services for the medical and educational community. For the past 15 years, Dr. Salas-Provance has worked clinically with children with cleft palate in Spanish-speaking countries around the world and has included graduate students in this work.  She recently (2019) co-authored a textbook on Culturally Responsive Practices in Speech, Language and Hearing Sciences, Plural Publishing.

This course will review key information needed to provide services to diverse populations.  Information will include the importance of self-reflective practices to address our cultural knowledge and understanding, best practices for use of interpreters, use of appropriate methods in assessment and treatments, and important professional issues related to working effectively with this population.

This is a really great article!
Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q:  Important Aspects of Diversity and Culture in
Speech-Language Pathology Services

Marlene Salas-Provance

 

1. Why is it important to examine our views of individuals from cultures different from our own?

As we look to understand our diverse clients, patients and students, we must first turn the mirror on ourselves and reflect on our personal views of cultural differences from a broader perspective.  How do we really “feel” about individuals that act, think, look and have traditions different from our own? And how do we “show” those feelings?  Is our understanding of others based on stereotypical knowledge alone?  We have all heard ethnic stereotypes, such as, Brits are icy, Frenchmen are arrogant, Spanish men are macho, Asian children are studious, the poor are ignorant, and all African Americans dance well.  By using stereotypes, however, we reveal our lack of knowledge about these individuals and show how little we really know about them. 

2. What is beyond stereotypical knowledge?

Maybe we don't engage in stereotypes, because we have neighbors from an ethnic group different from our own and have seen their behavior up close (while they drive by our house, for example), and we can disregard stereotypical descriptions.  We observe, but we don't engage.  It may be that we want to learn more about individuals from cultures different from our own and increase our participation in their world.  At this level of our cultural development, we may become more appreciative of the sacred nature of the Native American dance and make an effort to visit a pueblo and observe this ritual and respect the individuals engaged in this native practice.  We may immensely enjoy the food and dance of the Latino people and look forward to enjoying their community festivals.  We enjoy these “events” and feel enriched by our experience in their world.  Being engaged in these ways with individuals different from ourselves is important, but it is not enough.

3. What happens when we “value” individuals from all cultural groups?

If we truly “value” individuals from all ethnic, cultural and linguistic backgrounds then we see their innate good, we want equality and justice in all ways for all people.  We may support legislation that will increase funding to study the health of diverse groups, for example, or conduct research on indigenous native groups and identify their positive impact on the world, such as nontraditional healing practices. In our practices, we may make a concerted effort to identify a cultural broker to assure that we are providing evidence-based practices, or we go the extra mile ourselves to prepare well for our treatment sessions.  Through a hierarchy of cultural knowledge we can meet our goal of providing culturally responsive practices.   In fact, we all take the journey from stereotypical knowledge, to peripheral communication knowledge, to event knowledge that ends with value knowledge on a daily basis.  Cultural responsive practice is a dynamic process, not a target we hit and then we’re done.  Can you take this journey and reflect on your place along this journey with a particular situation?

4. Why should we consider diversity and multicultural issues in our work?

The clients, students, and patients we serve in the United States and around the world represent individuals from diverse cultural and linguistic backgrounds.  I know that in your daily work there is not a day that goes by when you do not need to adapt your knowledge and skills to meet the needs of an individual who speaks a language different than your own or has had cultural experiences that vary from yours.  Your international work requires you to adapt to cultures and languages so unique that the task may seem impossible.  But, there are personal reflections, strategies, and processes that you can use to successfully provide the assessments and treatments needed for these diverse populations.

5. What do we mean when we say that “self-reflection” will help us meet the needs of our diverse patients?

I believe that no matter how hard we try not to, we all have biases.  As a professional, the most important way we can address this fact is to identify those biases in ourselves, sometimes implicit, and address them head-on.  I will give some examples of biases that can be a challenge to eradicate.  If an individual has been in this country for many years, we may feel that they should know English well, if not the parents, then the children, for sure.  This feeling may cause us to have resentment towards the patients which can affect the type of service we provide.  The fact that an individual does not speak our language will require us to work harder to adapt to this difference and require us to identify additional strategies for assessment and intervention.   These may be techniques we would normally not use, and increase the time needed to prepare for the patient.  These are subtle adjustments, but yet, they can affect the standard of care we provide.  All of us have been reared in a certain way that has dictated our views on child-rearing.  If we have a therapy parent that brings all their children to the therapy session we may resent that the mother cannot focus on the child in therapy.  Many families may not use babysitters due to various reasons, including a desire to be with all their children at all times, a lack of trust in strangers to care for their children, financial resources to pay caretakers, among others.  It is important to understand these diverse views on child-rearing and work with the family to help us adapt our views to their reality.  Our self-reflection should be expansive as we prepare to work with diverse clients.  We must consider all aspects of our student, client or patient that could be a source of misunderstanding or bias for us and lead to a poor standard of care.

6. How do you feel when you do not know the language of your client?

Like you, I have been in clinical environments where I did not know the language of my patient. This is frustrating and frightening at the same time.  This is a time when knowing how to use and access an interpreter is critical.  Once you are in a position to communicate with your patient, which is the first step in the successful provision of services,  there are special considerations and techniques in assessment and intervention that can be used to provide evidence-based services and meet your student, patient or client’s unique needs.  We will review some of these later in the discussion.

7. What does using an interpreter have to do with trust?

I have found that using an interpreter in my work is one of my greatest challenges.  I am fortunate to know the Spanish-language, but I have been in many other language-rich environments different from my own, where I required the services of an interpreter.  When I initially use an interpreter, I feel, in a somewhat uncomfortable way, that I am somehow relegating my scope of practice to a stranger.  Because I am not familiar with the language, I have to trust that my interpreter is relaying my exact words to my patient and informing me in return of my patient’s exact words.  The clinician/interpreter dyad is one that requires great trust and this trusting relationship must be established.  The comfort level between the interpreter and clinician increases with time.

8. What choices do we have when using an interpreter?

So many times a person who “knows the language” is pulled in to interpret at the last minute eliminating the opportunity to establish the all-important trusting relationship.  This scenario for selecting an interpreter should be our last choice.  There are now telephonic and internet opportunities for communicating from one language to another, but these methods, although sometimes the only option we have, fall short of the best we can do.  What is the best we can do?  Just as there is a code of ethics for our profession there is similarly one for professional interpreters.  Identifying individuals you can train or have been trained by someone else to be professional interpreters is the gold standard. 

9.  Are there some specific strategies I can use with my interpreter to develop this relationship?

Here are a few strategies (others can be found in Hitter & Salas-Provance (2019) that serve as a start to establishing a trusting and knowledge-based relationship between yourself and your interpreter.

1. Be aware that there are Dos and Don’ts for the professional using an interpreter as well as for the interpreter.
2. Do spend time before your session training your interpreter.
3. Do use the BID (Briefing, Intervention, and Debriefing) process in your interpreting situation to organize and assure a successful interpreting event.
4. The interpreter should interpret exactly what the professional says.
5. The interpreter should not add or subtract any of the patient’s conversation.
6. The interpreter should not take on the professional’s role.

10. How do we address the needs of the bilingual child with a speech or language disorder?

I was what could be called a “simultaneous” bilingual or dual language learner.  I learned Spanish and English together as a product of my parents speaking predominantly Spanish and my older brothers and sisters speaking Spanish and English while abruptly being pushed towards English.  They were in the era when they were punished for speaking Spanish in school, thus forcing them to become fluent English speakers quickly.  I was fluent in both English and Spanish as a preschooler.  Unfortunately, as we see in many children, my expressive Spanish language skills deteriorated over time, although my receptive language remained strong.  In fact, I took Spanish courses in college to shore up my Spanish speaking skills.  Later, as a professional, I was able to immerse myself in the Spanish language through my clinical work in Spanish-speaking countries, thus regained my verbal fluency in Spanish.  As you can see, being bilingual is not a direct path.  Fortunately, I was able to traverse both languages easily and did not have a disorder that affected my ability to learn the languages.  For some young children whose first language is not English, the language learning pathway can be more difficult. They may present with delayed language in their first language and may have difficulties learning the second, which is usually English in this country.  Past advice has been to stop exposure to the first language.  However, this is no longer recommended.  It is critical for parents to continue to speak the first language to offer a strong foundation from which the second language can be nurtured and developed.  It is important to identify if there is a disorder in one language alone or in both languages.  Some assessment tools will be familiar to professionals testing young children such as the Preschool Language Scale (English/Spanish), but there are also new assessment tools to screen bilingual children’s receptive skills through vocabulary testing, and a broader diagnostic tool to test across language skills such as syntax, pragmatics, and phonology. (See, new assessment tools by Iglesias et. al., 2019).  Either a skilled bilingual clinician or an interpreter will be needed.

11. What is our most important objective in conducting assessments with culturally and linguistically diverse individuals?

One of our most important objectives in conducting assessments is to be sure that we are fair and unbiased across all individuals.  It goes without saying that the individual must be tested in their native language, to allow them the opportunity to perform to the best of their ability.  This again, may require the use of a trained interpreter.  It is best to test in both languages as a bilingual child most likely will have mixed dominance, with strengths in one area such as syntax in English, but strengths in vocabulary in Russian.  It is imperative that a decision not be made to test the child in English because they appear to “be doing well” in English and speaking “mostly” in English.  Even if the child is dominant in English, there will be stored information in the first language that should be tapped.  A bilingual child with a suspected speech or language disorder must be tested in both languages to get a true profile of the child’s skills allowing us to make the appropriate recommendations for services.

Ethnographic interviewing may also be an important piece of the evaluation due to the cultural diversity and its influences. These methods are based on allowing the parent to explain their experience with their child and their concerns setting up natural and authentic communication between the family members and the examiner, rather than the examiner asking a series of questions that can be sterile and thus miss valuable information. For example, with children, the parent can discuss their child-rearing practices that influence language learning in the home. This will allow the clinician to identify the cultural richness and influence, thus allowing us to consider the child’s development within the particular cultural foundation, for example.

12. What strategies can be used in conducting assessments with culturally and linguistically diverse individuals?

In attempting to provide unbiased assessment, it may be necessary to allow more time to respond, give the test over a number of days, repeat the instructions, or provide additional cuing, among others.  Individuals from diverse groups also may have unique cultural experiences that may not be included in standardized assessment protocols; likewise, tests may include items that have not been part of their cultural experience.  Therefore, it is critical to know if the reason a test item is missed is due to lack of “experience” with that concept or the result of a more global learning impairment.  Simply speaking in the following example, if you are asked to identify the picture of a combine (farm equipment for harvesting), but you were raised in the city and have never seen this item, you would miss the item, not for lack of ability to learn names of objects, but the lack of experience with this particular item.  To identify whether a learning component could be responsible for the error, one could engage in a common testing strategy called dynamic assessment. We can identify the ‘learning potential’ of the individual along with their skill level.  We could teach the concept of a combine first, then, at a later time, repeat the test question.  If the response is correct after the teaching segment, then it was more likely an experience factor.  If there is still a problem, however, then you can consider the possibility of a learning disorder of some type.

13.  Why is it important to know the level of acculturation before we begin intervention?

Be knowledgeable about the effects of culture on the disorder.  Is the individual strongly acculturated or more mainstream?  We cannot make assumptions based on name, facial characteristics, or clothing, among other visual cues.  We need to get the potential for cultural impact clear before beginning our intervention protocols.  Does the individual’s culture dictate a more conducive environment for treatment?  Ask questions such as, should there be certain family members included or excluded from the therapy, is there a patriarchal or matriarchal family dynamic that you should be aware of as a male or female clinician, is there a level of trust or mistrust that you can ascertain from the diverse individual, or are there cultural aspects such as time, personal space or speaking rules (turn-taking, loudness, eye-contact) to consider, among others.

14. How can we identify the best setting for treatment?

We need to consider the many different options where we can elicit authentic conversations that will lead to successful treatment outcomes.  It may be a one-time event in the therapy setting or over many sessions, outside of the therapy room, alone or with other family members, possibly in the individual’s natural environment such as their home, church, family event, and other activity in which they are engaged.  Although this may be time-consuming, the results of this effort can be significant.  The sterile clinical environment (across the table/bedside therapy) may, in fact, be what is appropriate for the individual’s needs at the time.  However, the professional must look for ways to expand this environment to meet the needs of culturally diverse individuals, even though staying in the more sterile clinical environment may be easier and more convenient. Consider the individual’s capabilities to engage in their best narrative conversation and adapt the environment accordingly. 

15. Why is it important to train the interpreter who will assist you in the intervention stage?

If the individual speaks a language different from your own it will require an investment in your time to train an interpreter and to build a relationship so that you can trust that your intervention will be appropriately carried out and the individual will receive maximum benefit from your treatment. 

16. Is there something unique about the materials we use?

Of course, materials should be culturally appropriate and reflect the world of your student or patient.  Using correct and appropriate written language may require the assistance of the interpreter or a cultural broker who can also help identify appropriate subject matter and culturally relevant visual assists in both pictures and objects.

17. Where can I get more training to work with diverse students, clients, and patients?                               

I keep learning all the time and look for opportunities to do so from others. The ASHA website provides an exceptional ASHA Practice Portal on cultural competence https://www.asha.org/Practice-Portal/Professional-Issues/Cultural-Competence/.  Take the time to find information that will help you in your clinical practice, in your research endeavors or in your advocacy efforts.  A significant number of resources on cultural diversity and multiculturalism can be found throughout the ASHA website, starting with a self-assessment on cultural competence https://www.asha.org/practice/multicultural/self/ .

18. Where can I find other professionals who work with diverse groups?

I have been fortunate to be a member of the Special Interest Group 14, Cultural and Linguistic Diversity https://www.asha.org/SIG/14/ and Special Interest Group 17, Global Issues in Communication Sciences and Related Disorders https://www.asha.org/SIG/17/ .  Both of these groups provide you with a dynamic network of individuals who engage in interesting dialogue of cases, by asking thoughtful questions and providing practical solutions https://community.asha.org/home .  The SIG groups provide superior information through their PERSPECTIVES JOURNAL, another way to learn new information and earn CEUs.  Reach out within your own organizations for others engaged in similar work, but reach across fields as well.  Interprofessional practice provides a wealth of knowledge for your own work.  However, your contributions to other fields are critical in this area, as well.

19. Why are the CLAS Standards important?

Interpreters are a difficult resource to access.  Or you may be one of the fortunate individuals whose organization abides closely to the CLAS Standards (National Standards for Culturally and Linguistically Appropriate Services in Health Care) and provide a sufficient number of interpreters for your organization's needs.  The standards were set by the US government, Office of Minority Health in 2001, to assure that organizations meet the healthcare needs of the diverse population of today.   There are 14 Standards that refer to issues of Culturally Competent Care, Language Access Services (which speaks specifically to use of interpreters) and Organizational Supports for Cultural Competence.  Standards are set as mandates, guidelines or recommendations.  The Standard related to interpreters is set as a mandate.  Go to https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf   for complete information.   Organizations that receive federal funding are obliged to abide by these standards.  A review of these standards with your immediate supervisor may be helpful. 

20. What other ways can we meet our need for interpreters?

The reality is that many organizations are falling short of this CLAS Standard mandate.  It may be difficult to find an interpreter when needed, but the office of Institutional Equity and Diversity (Title VI, Title VII, and Title IX) may have information.  There also may be an opportunity for a speech assistant to be trained as an interpreter and take on these additional duties.  Trained interpreters can also be contacted through the National Council on Interpreting in Healthcare.  Their website also provides information regarding interpreter training opportunities nationwide https://www.ncihc.org/.

References

Hytter, Y.D., & Salas-Provance, M.B. (2019).  Culturally Responsive Practices in Speech, Language, and Hearing  Sciences.  San Diego, CA: Plural

Iglesias, A., Peña, E., de Villiers, J., & Bedore, L. (2019, November). Standardized Assessments Designed for Bilingual Children Work:  BESA & QUILS:ES.  Oral Seminar presented at the yearly meeting of the American Speech, Language & Hearing Association, Orlando, Florida.