Multicultural clinical interactions.

All clinical interactions, no matter where they occur, involve multiple cultures. Appropriate and therapeutic care that is satisfying to patients and their families and, at the same time satisfying to care providers, can occur only if this multiplicity of cultures is taken into account. This paper uses the example of a Pacific Islander with a spinal cord injury to explore illness explanatory models and some of the cultural dimensions of clinical interactions. Cultural brokerage, intercultural sensitivity programs, and programs like the Pacific Basin Rehabilitation Technician program are introduced as examples of strategies for dealing with multicultural situations.

Culture is an integral part of everyone's life. It is a part of every personal encounter and every interaction--including every clinical interaction. As Hoeman (1989) points out, the provision of care and rehabilitation services to every patient, no matter what their ethnic background might be, involves multiple cultures. This multiplicity of cultures presents many challenges to care and service providers. Appropriate and therapeutic care can only occur if the multiplicity of cultures is considered. If this issue is not addressed, both the patients and the care provider may find the clinical interaction less than satisfying.

There are many definitions of culture. Central to most definitions is the idea that culture is the learned, shared, patterns of beliefs, values attitudes, and behaviors characteristic of a society or population (Ember and Ember, 1988). Common styles of clothing or housing are not culture; they are products or evidence of culture. However, not all beliefs, values, attitudes, and behaviors are cultural. If they are not shared with others, they are not cultural; they are idiosyncratic, and may instead reflect an individual's personal adaptive style or personality.

The ideas presented here are not specific to people with only certain kinds of illnesses or injuries nor are they relevant only for certain populations. They are applicable to a much wider range of situations, and should form a base upon which culturally appropriate care and rehabilitation programs are developed. This approach is as relevant to the development of medical systems as it is for the development of care plans for individuals.

This paper offers a brief and general introduction to some of the cultural dimensions of clinical interactions. It also introduces some strategies for dealing with multicultural situations. These strategies include cultural brokerage, intercultural sensitivity programs, and an approach used by the Pacific Basin Rehabilitation Research and Training Center (PBRRTC) to help deal with the multicultural aspects of providing care, or more specifically, the provision of rehabilitation services in the Pacific Basin.

The Culture of Clinical Interactions

In every clinical interaction there are at least three cultures and medical systems involved: (a) the personal or familial culture of the provider, (b) the culture of the client or patient, and (c) the culture of the primary medical system. In many cases, especially when people come from non-Western backgrounds, there is a fourth culture--the traditional medical culture (Figure 1).

The amount of overlap in knowledge of each culture or cultural system can vary considerably among the participants in a clinical encounter. The greater the shared knowledge, the less likely there are to be misunderstandings; but, when participants have little knowledge of the other cultures or systems involved, some problems are almost assured. However, problems can often be averted, or solutions developed, simply by being aware that there is this interplay of cultures.

All people bring their own peculiar cultural baggage, much of it associated directly or indirectly to health, to their clinical interactions. Like the baggage people carry on a trip, some of it is essential and some is useless for this occasion. People acquire their cultural baggage as they are socialized into their worlds. As people grow up, they learn about appropriate behavior and about health and illness from all the people they interact with--parents, teachers, and health care providers--and people learn from personal experience. People learn explanations for illness--what makes people ill or causes injury. People learn about appropriate health seeking behavior--what people need to do to stay or become well. People learn about illness behavior--how to behave when they are ill or injured. And, people learn the language of health and illness--they learn words for body parts and bodily sensations and illness names.

Patients and clients go through the same process as care providers, but they may acquire very different knowledge, beliefs, values, and attitudes, especially if they have grown up in a different society. If they have also grown up in a different physical environment, it is even more likely that these beliefs, values, and attitudes will be different, for culture often reflects a society's relationship with its environment. As a result, when people are ill or injured, they may behave quite differently from the way people from other backgrounds behave or expect people to behave.

In the process of becoming health professionals, care providers go through another socialization process. They are socialized into a new medical culture, one that may involve somewhat different knowledge, beliefs, values, and attitudes than the culture of their childhood. As this new culture is acquired, the old is not simply replaced with the new. Some of the old will be retained; some of the new will be added on; and in some cases a synthesis occurs, a blending of the old and new. This new medical culture is now a part of the cultural baggage care providers take to clinical interactions.

Western biomedicine is the medical system which grew out of the medical traditions of Europe and is based on a biological model. It is the primary medical system of the United States. People who grow up in societies where Western biomedicine is practiced usually have some knowledge of this culture; however, the degree of awareness varies considerably from one person to another. Knowledge of this medical system comes from personal interactions with the system and exposure through the experiences of others, educational programs, and popular mass media.

However, there are very few, if any, societies where Western biomedicine is the only available medical system. Almost every society has one or more traditional, indigenous, or alternative medical systems. IN the U.S. we also have such alternative medical systems as chiropractic, naturopathy, herbalism, and spiritual healing and the laying on of hands. All of these are based on conceptual models or theories which differ to varying degrees from Western biomedicine.

When there is more than one medical system available to a society it is called medical pluralism. Pluralistic medical settings provide alternatives for care, alternative ways of thinking about and responding to illness and injury. Medical pluralism can have an effect at both the micro-level (the individual) and the macrolevel (the society). The medical knowledge of some individuals might resemble that of biomedicine and for others it might more closely resemble another traditional medical culture. The medical system of a community may, in some societies, resemble Western biomedicine. In others, it may more strongly resemble the indigenous medical system, but in fact it may be neither. More often a kind of synthesis occurs--a unique blending of all the available medical systems. This is usually more obvious in developing communities like those we find in the Pacific, but in fact this blending occurs almost everywhere.

Thus, in every clinical encounter one or more medical systems are involved. The participants in this encounter may, or may not, share knowledge of all the systems involved. The shaded area in Figure 2 indicates the area of shared knowledge between the care provider and the patient in one hypothetical case. This is the kind of situation which might occur if the participants in the interaction were raised in the same environment. Figure 3 suggests a situation where there is little shared knowledge. This is not an unusual situation. It often occurs when service providers go to another country or ethnic community to work without receiving an orientation, or they go unaware that culture influences their own behavior. It seems to be especially difficult for caucasian Americans, especially medical and service providers, to see the influence of culture on their actions in clinical encounters. They tend to see themselves, and co-workers and patients from their own culture, as acultural. People who have been enculturated into Western biomedicine often have difficulty recognizing biomedicine as a cultural system which influences their behavior. Anthropologists themselves have only recently begun to explore the culture of biomedicine. Good examples of these explorations are seen in Hahn & Kleinman (1983) and Lock and Gordon (1988).

It is not necessarily the lack of shared knowledge which is potentially troublesome; this can be overcome. More often it is the lack of awareness or willingness to accept that alternative beliefs, values, and attitudes, and even medical systems, may be involved. This can lead to a lack of empathy and an inability to see the problem from the patient's point of view. As a result, there may be an inability to devise solutions which are satisfying and "sensible" to all the people involved.

Explanatory Models

The way the different cultures can come together is illustrated in an all too common example from the Pacific. A young man climbs a coconut tree to harvest coconuts, something he has done almost every day since childhood. On this particular day he falls from the tree, something which has probably happened at least a few times before. But this time he injures his back and cannot move his legs.

How would a Western trained physician or health care provider explain this young man's inability to move his legs? The explanation might be that the young man is experiencing paraplegia due to a traumatic spinal cord injury sustained during the fall. The care provider might go on to provide more specific details about the injury, such as: the anatomy and physiology involved; how such injuries cause paralysis; the type of care that will be necessary; and what is the most reasonable prognosis. The care provider has offered an "explanatory model" for this situation (Kleinman, 1978, 1980; Kleinman, Eisenberg, & Good, 1978).

Explanatory models are always cultural constructions. They are a product of one's cultural knowledge and experiences. They deal with one or more of five issues: (a) etiology or causation, (b) symptoms, (c) pathophysiology, (d) course of the illness (including the appropriate illness behavior and level of severity of the disorder), and (e) treatment (Kleinman, 1980; Kleinman et al., 1978). The explanatory model provides a template for dealing with and understanding the situation. An explanatory model, particularly the etiological part of the explanation, attempts to answer some fundamental questions. Why this person? Why this illness or injury? Why now? And now, what should be done?

The young man and his family generally have very different answers to these questions; they usually have a very different explanatory model. They may, or may not, accept any of the care provider's explanatory model. Their model may be completely different or it may be an expansion or modification of the care provider's model. Again, as Joe (1978) also points out, their model or explanation will be a product of their culture and their experiences.

For example, they generally accept that the injury was the result of the fall, but instead of labelling it a spinal cord injury they may call it a broken back. However, critical questions remain unanswered (and are often left unanswered in biomedical explanations)--Why this person? Why now?

It is not uncommon for care providers to suggest something like: the young man was just not as alert as usual, maybe he had too much to drink the night before. For some this is a satisfying answer, but for others it still does not answer the critical questions. On other occasions he has climbed coconut trees after drinking but he did not fall out of the tree. He has fallen before but he never broke his back. Among some Pacific Islanders, as among many other groups throughout the world, other explanations are possible, including things like the accident was divine retribution for some misdeed or behavior of the individual or someone in his family. Some might attribute it to sorcery. For others, the accident is seen as this person's fate, something beyond human control, something which must simply be accepted and endured. Whatever the explanation, it will affect how the person and his family respond to the injury.

When thinking about the rehabilitation of this person, care providers must also remember that for many people every illness or injury event has only two possible outcomes--full recovery or death. Thus, the very idea of rehabilitation, as Western trained care providers use the term, may be incompatible with the patient's and patient's family's cultural beliefs or explanatory models. It may be difficult for the person with the injury, and his family, to accept that many of the changes in this person are permanent. This kind of belief can make it difficult for them to understand the goals of rehabilitation.

It is also important to remember that in many societies, illness events are rarely individual events. They are more often social events. At the very least, the family, as it is culturally defined, will be involved. Often the entire community will also be involved. Because one individual fell from a tree and was injured, the entire community may have to come together. Not only will they come together to provide support for the injured person and his family, but they may feel they have to resolve interpersonal problems or their relationship with the spirit world if they want the person to get well and they want to prevent others from becoming injured.

Approaches

There are a number of ways to approach the problems of multicultural interactions. The suggestions offered here are neither exhaustive nor mutually exclusive. They will also not resolve all potential problems, but they can help. One way to approach the potential problems of multicultural interactions is to decrease the degree of disparity in those cultures. Cultural brokerage, as outlined by Weidman (1982, 1983), can be employed to mediate in the interaction, or the number of cultures involved can be decreased.

Weidman defines cultural brokerage as "the process of establishing meaningful, strategic, or significant linkages between cultural or sub-cultural sysems" (1982, p. 211). In cultural brokerage, the degree of disparity between cultures is decreased, in part, by providing people (care providers and consumers) with information about one another's cultures and medical systems. This can be a good approach and is useful for a variety of situations. But, although this kind of information and intercultural sensitivity training can be very effective and very appealing, the "cookbook" approach must be avoided. The cookbook approach, compiling a list of information on the beliefs, values, attitudes, and behaviors characteristic of a society or population and then assuming this information applies to all people associated with that society or population, ignores all the diversity within a population. The Pacific Islander who has always lived on his home island is quite different from the Pacific Islander who was born and raised in Hawaii or the U.S. mainland. At best, this kind of information provides a starting point.

A better approach is to provide access to some basic information and then help people develop strategies for acquiring the necessary additional information. For example, Kleinman et al. (1978) suggest some questions which can help care providers learn about the patient's and the family's explanatory model (Figure 4). In addition, care providers can ask the people they work with to teach them more about their culture. This can help care providers expand their general knowledge of the culture and at the same time it can help identify which aspects of the culture are of particular importance to this person and the person's family. Service providers who have come to me for advice on how to deal with the cultural diversity of their client populations report feeling more effective and more satisfied with clinical interactions when they have used this approach.

Providing culture brokers, individuals who can mediate between, and communicate across, the culture can be very useful. All health care providers can become cultural brokers, but all cultural brokers do not have to be health care providers.

Cultural brokers can be especially useful in developing nations or ethnic communities where service providers from outside are not familiar with the culture of their patients and are not likely to remain in the community for long periods of time.

Another approach is to decrease the number of cultures involved. Sometimes the best approach is for the patient and care provider to be from the same culture. However, many communities either do not have appropriately trained, local personnel or they do not have enough. One obvious solution is to train people in the community, to provide them with the necessary technical knowledge and skills, and then allow them to provide care in the most culturally acceptable manner possible. These people can act as a bridge between the cultures of introduced medical systems and Western trained health and rehabilitation professionals and the culture of the patient and the community (Stubbins, 1978). They can act as cultural brokers as they provide care.

Following the recommendations of a committee of advisors (including advisors from the Pacific), the Pacific Basin Rehabilitation Research and Training Center (PBRRTC) developed a program to support and assist the development of local medical systems for the delivery of rehabilitation services in the American associated communities in the Pacific (Micronesia and American Samoa). This program includes the provision of technical training for a variety of rehabilitation service providers, including medical officers, nurses, and a group of people now known as rehabilitation technicians.

The Rehabilitation Technician Program is a critical part of PBRRTC's work, and it is the program which most closely fits the model just outlined. It involves providing assistance and technical training at the paraprofessional level to members of these communities--people who are locally identified, committed to their community, and who also share the culture of their clients. The technicians provide important services to their communities and in some cases are the principle rehabilitation person on the island. It is not always easy to work in multicultural situations. And yet, every day these rehabilitation technicians negotiate between the culture of Western biomedicine and the culture of their community and at the same time try to provide necessary services.

But while the interaction of cultures may be especially obvious and pronounced in the rehabilitation technician's case, that is one part of their situation which is not really unique. All clinical interactions, whether they happen in Micronesia or Honolulu or any other place involve the interaction of multiple cultures.

Conclusion

In today's world, care providers are constantly involved in multicultural interactions. Interactions with people from very diverse backgrounds are likely to become even more common as more and more people, especially migrants from other countries, choose to maintain their distinctive cultural identities.

These multicultural interactions can be frustrating and too often result in a sense of dissatisfaction and disharmony for both the care provider and care receiver, but these interactions can also be challenging and exciting. This paper briefly outlined some conceptual frameworks and approaches which can help resolve some of the difficulties presented by multicultural situations.

One important step in resolving or avoiding the potential problems of multicultural interactions, and one of the first steps in establishing a satisfying and productive healing relationship, is the acknowledgement that multiple cultures are involved, and that both care providers and care receivers are bearers of culture. This is fairly easy to do when the participants in the interaction obviously come from different cultural backgrounds, i.e., they speak different languages. It is more difficult to do when the participants have grown up in seemingly similar environments and appear similar.

While it is often useful to decrease the number of cultures involved by providing situations where the provider and receiver are from the same culture, this is not always possible. Thus service and care providers are encouraged to explore the illness or disability experience from the service receiver's perspective and to use patients and their families as cultural informants. They are encouraged to use other cultural brokers when necessary and available, and to become cultural brokers themselves.

This paper encouraged care providers to be culturally sensitive to all patients and provided some information how to be culturally knowledgeable and sensitive. It ends, however, with caveat: When there are difficulties in intercultural interactions, is culture always the explanation or is it sometimes used as an excuse? In other words, while culture is an important part of all clinical interactions, it is only one possible explanation of problems and dissatisfactions.

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