International Support Group for Chartered Physiotherapists

N E W S L E T T E R September 2002 No.3

Contents

Page Item

1 / Editorial
2
2 / Description of Joint ISG – Communication Therapy International Study Day
Culturally Appropriate Competence – What is it? By Marisue Pickering
5 / Disability and Culture – A CBR programme in Afghanistan by Peter Coleridge
8 / Teaching Assistant Physios in a CBR Programme in Afghanistan by Archie Hinchcliffe
12 / Job Opportunity

Editorial

This newsletter is dominated by an account of the Joint Study Day which was held on 27th July in the Healthlink Worldwide office in London. ISG4CP joined together with the equivalent Speech and Language Therapy group – International Communication Therapy to look at the subject of Culturally Appropriate Competence.

There are two reasons for this newsletter being so taken up with this. One is that it was an extremely interesting rewarding day and, since so few people were able to attend, it seems a good idea to describe it in detail so that all may benefit. The second reason is that I had asked several people to write articles and, though all promised they would, the deadline came around too quickly and they were not able to deliver. I could not extend the deadline because I leave for a teaching assignment in Poland on 15th September and by the time I get back it will be well in to October.

Never mind, we will have some really interesting articles to look forward to in our next newsletter.

The Study Day was beset by disasters in the week beforehand. Both Barbara Jennings and Lyn Hemmings had family illnesses to deal with and could not attend. At the last minute too Lesley Dawson was not well and Liz Carrington had her bag stolen at Kings Cross Station and could not come. I was the only official in the ISG to be able to attend. Luckily Heather Payne of Healthlink had everything beautifully organised and she and Mary Wickenden of ICT set up the event with seeming effortlessness.

We were so lucky to have such eminent speakers. Both Marisue Pickering and Peter Coleridge are very well known in their field. Marisue for her work with intercultural communication and Peter for his book “Disability and Development” (Oxfam 1993)

CTI/ISG4CP Joint Study Day – 27th July 2002

We joined forces with Communication Therapy International (CTI) to hold a Study Day on “Culturally Appropriate Competence” in Healthlink International on 27th July. There were three speakers looking at the topic from very different perspectives. The first was Marisue Pickering who described her model for Culturally Appropriate Competence from an academic point of view. The second was Peter Coleridge (author of Disability, Liberation and Development) who talked about development and culture in the context of the Community Based Rehabilitation programme that he was responsible for setting up and running in Afghanistan from 1995 until recently. I was the third speaker and I described my experience of teaching the assistant physiotherapists in that same Afghan programme. I focused on my own emotional responses to the Afghan culture and some of the strategies I found helped me to communicate and teach across the cultural divide.

Model for Culturally Appropriate Competence

Marisue introduced her presentation with the following two quotes

1.  “Every encounter is a cultural encounter” (Taylor, as cited in ASHA, 1998, p.1)

2.  “…..I as a human being am neither the norm nor the ideal…..one’s own society, however much loved and comfortable, is neither typical nor ideal” (Woodbury, 1991)

She then asked us to identify key people or institutes where we had learnt our cultural attitudes and what those attitudes were. The following were some examples: -

Source of Cultural Attitudes

/

Cultural Attitude from that Source

Colleague in Kenya / Work as a team
Husband / Openness to others
Friends / Mutual exchange
Missionary uncle / Stop judging and comparing
Work / Responsibility
Growing up in a multiracial society / Commonalities among people

Marisue’s 5 part model of culturally sensitive practice which she believes is applicable to work both in the international and national field is: -

1.  Basic Underlying Component: Diversity of the Social World

In every part of the social world there is diversity: culturally, linguistically, ethnically and racially. Even in a 97% white state such as Maine, U.S.A. this is true.

2.  Conceptual Component: Shared Territories

What does it mean to live productively with others within a multicultural reality? The territory we share is not the “exclusive property of one ethnicity, origin, religion, culture or language” (Flecha 1999) Nor indeed of one group of professionals. Each of us is part of the diversity mix and each has the opportunity to contribute to the development of norms. Sharing territory can provide opportunities for cultural and personal growth to occur as long as there is understanding that no one of us is the world’s standard against whom all others are to be considered ‘diverse’. We must live our differences and establish commonalities with others.

3.  Educational Component: Cultural Concepts

This means examining how cultural influences manifest themselves in daily perceptions and behaviours. These are not only the cultural influences of others but also our own. The cultural concepts that influence daily mindsets in different ways in different cultures may include: -

·  Time

·  Nonverbal communication including use of space

·  Family structure and kinship

·  Gender roles and relationships

·  Religious and spiritual practices and values

·  Educational systems and values

·  Impact of social issues (e.g. AIDS, refugees, drought, war, famine)

·  Historical understanding of events

Examining our own and others’ assumptions about these concepts will reveal arenas where major cross-cultural differences and misunderstandings can be encountered.

4.  Interpretative Component: Multidimensionality

Interpreting the experiences and behaviours of others is a particularly challenging issue. Moving beyond a single cultural interpretation of reality calls for setting aside one’s own familiar ways of assigning meaning in order to perceive from another’s cultural perspective (multidimensionality)

A multidimensional approach means seeing reality from the cultural perspective of another person rather than exclusively from one’s own. It means accepting more than one reality. We need to think in categories of “both/and” rather than “either/or”

5.  Interactive Component: Partnership and Dialogue

To bring together the concepts and skills that constitute cultural sensitivity practitioners need to think about partnership and dialogue.

“working in partnership with a team approach, developing mutual respect for all parties involved “(Sally Hartley 1998, p 282) describes the idea of partnership across the roles of clinician-client and across cultural differences

Yoshikawa (1987) chooses the symbol for infinity (¥) to suggest mutuality between two groups or individuals (p.326). Each is in relation to one another while being simultaneously independent. Independence and interdependence co-exist as the two parties strive to interact, learn and commit to action.

Such relationships are not created quickly resting as they do on seeking to understand one another’s perspectives.

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In the second half of her presentation Marisue discussed how a conceptual model of culturally sensitive practice fits within our field's discourse about multiculturalism, at least in the USA. For over 30 years, the American Speech-Language-Hearing Association has been active in helping practitioners understand the need for "multicultural literacy."

Concurrently, there has been a major focus in the professional literature on specific US populations—those often defined as "minority" or "multicultural." Thus there is important information available on cultural and linguistic aspects of Asians and Pacific Islanders, Hispanics, American Indian, and Black Americans. Additionally, specific immigrant populations, such as Korean Americans, have been discussed. This focus has helped the field understand general experiences, needs, and values of particular groups and related implications for assessment and intervention. Recent literature has suggested ways to approach clinical assessment and intervention through application of ethnographic principles. This application of cultural constructs to one's work goes beyond the focus on specific populations to consider particular principles and cultural competencies and their usefulness clinically.

Marisue and Lindy McAllister, an Australian have been working together to develop a conceptual framework to guide domestic cross-cultural and international practice (Pickering & McAllister, 2000) - a model appropriate for culturally sensitive practice irrespective of locale. This model — requires all of us to probe our own cultural assumptions and behaviours and, hopefully, as a result, confront elements of our own ethnocentrism.

Stumbling Blocks: Ethnocentrism and Experiences of Participants

Marisue uses the term ethnocentrism to encompass all forms of cross-cultural superiority. the mindset that assumes one's own culture is the only important one, or the most superior one, or the one that should be used to judge all other cultures and practices. For example, when a clinician is working with parents, an ethnocentric approach would assume that those parents share one's own child-rearing practices. Or if these practices are not shared, then the parents' different practices automatically would be seen to represent a deficit or deviant style.

Any model of culturally sensitive practice needs to speak to and strive to counteract all forms of ethnocentrism. Mariesue asked us to identify areas of difficulty when interacting with people from a different culture. The following were some suggestions: -

Our tendency to judge

Lack of awareness of local customs

Impatience with the slowness of the decision-making process when involving others

Not knowing how to handle customs that seem morally wrong

Changing offensive non-verbal behaviours

Strategies: Attitudes and Communication Skills

We then identified attitudes we try and assume when communicating cross-culturally, as well as communication strategies we follow to try to make communication successful.Examples include:

Helpful Attitudes / Helpful Communication Approaches
Avoid making value judgements / Learning language (at least in part)
Acceptance / Being clear about boundaries
Attitude of mutuality in communication / Being aware of and careful about non-verbal behaviors
Humility
Look for similarities / Observing and then mirroring others'
Give yourself and others time to . . . . . / Communication
Commitment to understanding / Expressing self genuinely and sincerely

Marisue ended with two helpful quotations:

“ . . . in spite of everything, I still believe in the power of words, in the necessity of communication" (Drakulic, 1993, p. 4). Drakulic was writing as a Croatian journalist during the war there, and she still affirmed the "necessity" of communication.

The second quote is from a Nobel Prize Winner who also is a diplomat, poet, essayist, and dissident who defected to the West. His quote reminds me that many things—such as cross-cultural communication—are a lot of work and we still have not learned how to do it to the extent we would like. It also reminds me that we have to learn about ourselves in order to do what we want to do.

" I had to return to myself, to learn how to outline my own hidden convictions, my own real faith . . . . It's a lot of work and I haven't yet learned how to do it" (Milosz, 1980, p. 14).

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Peter Coleridge’s presentation was called:

Disability and Culture – A CBR Programme in Afghanistan

He started by quoting Geertz who said:

‘Culture is the web of significance that man himself has spun.’ He then made the following key points about culture: -

·  culture is not fixed in stone. It is continually evolving.

·  Culture may not represent a consensus, but is often manipulated by those in power.

·  Culture is a key reference point for identity.

·  Social identity is learned, not fixed by biology.

·  Culture is the total manifestation of a people’s values, aspirations, and behaviour.

·  Culture is the entire context in which development happens.

People working in CBR programmes are concerned with development. But we need to think ‘Who owns the process of development?’

·  Development programmes that ignore the fact that culture is the sum total of people’s values, aspirations and behaviour are doomed to failure.

·  Planners frequently ignore cultural aspects because it is too cumbersome to consult local people.

·  But consulting is a problem: with whom do you consult? Who represents ‘the community’?

·  Especially a problem in conservative cultures where powerful men may be ‘representatives’.

An essential part of the development process is to create fora where the appropriate people can express their opinions and participate in the decision-making process.

When we come to consider disability and culture we must understand that:

Disability is culturally defined.

·  Important to define disability when a social welfare system gives benefits.

·  If no such system, no pressing need to define it.

·  Most developing countries do not have such a welfare system.

·  In the West disability is often seen as a source of discrimination.

·  This may not be the case in poor Third World communities, where poverty is a great leveler.

·  Often the degree of acceptance of disabled people is greater than in western cultures.

Disability is Defined by Relationships

·  Nobody can ‘develop’ anybody else. But we can facilitate or block others’ development by our attitudes towards them

·  We can empower or disempower them.

·  This is particularly true of anybody in the ‘helping’ professions

Disability is a medical, social and economic issue.

A CBR programme provides the opportunity for a

·  consultative,

·  listening,

·  participatory,

·  locally owned and therefore

·  locally appropriate and sustainable approach to disability.

The essential elements of a disability programme are: -

·  Epidemiology

·  Prevention

·  Medical treatment

·  Physical rehabilitation

·  Socio-economic integration

·  Capacity building

Epidemiology

This involves data collection, but data collection is complicated by problems of definition. How wide should a survey be? Large scale surveys raise expectations which cannot be fulfilled. It is best to combine data collection with programme field work.

Prevention

A CBR programme can provide strong support to an EPI programme. Physiotherapy can be a form of prevention as can awareness raising about the causes of disability.