Communication Across
Cultures
Marian H. Jarrett, Ed.D.
Lorelei Emma, M.A.
George Washington University
6th Annual Infant and Toddler Connection of
Virginia Early Intervention Conference 2008
Across cultures, people may differ in what
they believe and understand about life and
death, what they feel, what elicits those
feelings, the perceived implications of
those feelings, the ways they express
those feelings, the appropriateness of
certain feelings, and the techniques for
dealing with feelings that cannot be
directly expressed…To help effectively, we
must overcome our presuppositions and
struggle to understand people on their own
terms. (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 Culture
 Family
adjustment seen in context of
family systems and ecological model
Grief is a normal response to an
abnormal situation
 Grieve
the loss of the expected child
 Pregnancy images of the imagined child
 Process of grieving and adaptation is
complex and confusing for family
 Grief does not signal non-acceptance or
devaluing of the family member
Grief: A Complex, Personal
Experience
 No
typical time; some suggest 1-3 years
 Varies greatly from individual to individual
 How person copes depends on previous
coping behaviors
 Grief for a disability may become more
intense during periods of transition
Secondary Losses Compound
Initial Grief Reactions
 Families
experience stress as secondary
losses when needs are not met
 Secondary losses may challenge a
family’s ability to manage grief


Services should be family-centered,
relationship-based, and culturally competent
Consider the impact of respite services, inhome medical support and therapy, financial
assistance, and family support for this
particular family
Predominant Phases of Grief
3.
Traumatic Stress or Shock
Assimilation
Acknowledgment and Integration

Phases recycle and blend into one another

Certain feelings predominate in each phase
1.
2.
Phase 1: Traumatic Stress
 Period
immediately following diagnosis
 Numbness, shock, disturbed sleep, panic,
and despair
 Families




Make major decisions about treatment and
services
Report do not hear what doctors and service
providers say
Try to understand meaning of diagnosis
May experience relief with diagnosis
Feelings & Behaviors in
Initial Phase
 Gather
as much information as possible
 Express anger at doctors and diagnosis
 Tearful and withdrawn
 Preoccupation with imagined child
 Panic and helplessness
 Focused on immediate needs
 Frightening for siblings
Phase 2: Assimilation

Confusion begins to dissipate


Sharper realization of nature and extent of disability
Family members show highly idiosyncratic,
changing responses
 Heavily influenced by personality and contextual
factors
 Period when families experience their most
intense reactions to loss of hoped-for child
Feelings in
Assimilation Phase
 Hope
 Anxiety
and restlessness
 Depression and anxiety
 Guilt
 Anger
 Social Isolation
Phase 3: Acknowledgment and
Integration
 Greater
understanding and
acknowledgment of disability
 Greater integration of child with a disability
into the family
 Periods of distress are briefer, less intense
 Parents still report “having a bad day”
Behaviors and Feelings in
Integration Phase
 With


help, family members can
acknowledge they are feeling better
distinguish grief-related stress from other
stress
 Acknowledge
there is no “getting back to
normal.” Families are forever changed.
 Begin to see self as a parent, not just a
parent of a child with a disability
 Embed learning into daily routines
Cultural Competence in Supporting
Families Who Are Grieving
 Definition:


A set of values, behaviors, attitudes, and practices
within a system, organization, program or among
individuals and which enables them to work
effectively cross culturally.
Ability to honor and respect the beliefs, language,
interpersonal styles and behaviors of individuals and
families receiving services, as well as staff who are
providing such services.
(Division of Services for Children with Special Health Care Needs, 2005)
Cultural Competence as a Process
 Cultural
competence is not an end-state,
but a process:

Encompasses not only cultural knowledge on
the part of the service provider, but also
constructive attitudes and attention to the total
context of the family’s situation.
Barriers to Culturally Competent
Care

Institutional Barriers




Lack of diversity in health care’s leadership and
workforce
Systems of care poorly designed to meet the needs of
diverse patient populations
Poor communication between providers and patients
of different racial, ethnic, or cultural backgrounds
Personal Barriers
Betancourt, Green, & Carrillo, 2003
Development of Cultural
Competence

3 Step Process (Iterative, No endpoint)
1. Clarification of the service provider’s own values,
attitudes and assumptions
2. Knowledge of commonly held cultural beliefs and the
culturally normative interactive styles of specific cultural
groups
3. Skills that enable the individual to engage in successful
interactions
AAP, 1999; Lynch & Hanson, 2004
Self-Awareness Activity

Understanding Our Own Place on the Continua







Interdependence……Independence
Kinship (extended family)……Nuclear family
High context……Low context
Religious orientation……Secular Orientation
Authoritarian child-rearing……Permissive childrearing
Greater respect for older family members……Greater
emphasis on youth
Oriented to the situation…….Oriented towards time
Disability, Death, and Culture

When individuals are confronted with the fear and
senselessness of disability, illness, and death, culture
can:






Provide meaning for those who are grieving through its beliefs
about life after death
Define care of the body after death and burial or cremation
practices
Describe roles for grieving family members and for the
community which surrounds them
Influence how grief is expressed
Affect how grieving families interact and communicate with
caregivers
Impact how families approach decisions about interventions,
treatment, and end-of-life decisions
Beliefs and Values Influence
Grieving Process
 Beliefs


disability and infant death
medical care
 Values




about
of
Family
Religion
Education
Age
Influence of Other Factors
 Age
 Gender
 SES
 Education
 Length
of time in the US
 Level of acculturation
Communication
 10.5
million U.S. residents speak little or
no English
 Different languages = difficulty
communicating
 Even with same language, language of
disability and grief are always difficult.
(U.S. Census Bureau, 2001)
Effective Communication
 Medium
through which families and
providers negotiate the process of caring
for an infant or young child with disabilities
or a life-threatening illness
 Basic tool used to establish and maintain
relationships with families
 Essential to family-centered and culturallysensitive care
Fostering Shared Meaning
and Mutual Understanding

Shows interest and encourages parent to
continue
 Uses open-ended questions to help parents
describe their perceptions and feelings
 Uses focused questions to gain specific
information
 Paraphrases the content of parent
communication
 Validates parent’s feelings
 Remains nonjudgmental
Examining Our Own
Communication
 Unconsciously
learned ways to think, feel,
and act according to what our culture
considers appropriate
 Often unable to set aside our own cultural
values and listen to the family
 May unwittingly violate cultural
assumptions about the parent’s role,
cause of disability, or intervention options
Examining Your Own Cultural
Values, Beliefs, and Practices
 Complete
the Values Clarification Exercise
in the back of your packet.
 Read each statement, rate it, and move to
the next statement.
 There are no right or wrong answers.
Values Clarification Exercise
Review your responses.
Examine each statement by asking:


Why do I feel this way?
How might this affect my interactions with
children and families?
Social Organization
 Who
are the members of the family
system?
 Who is the spokesperson?
 Who should be included in
discussions?
 Is full disclosure acceptable?
 Who makes decisions in the family?
Showing Respect
 Can
be based on age, gender, social
position, education, economic status
and authority
 Formality of communication shows
respect
 Distinct lines drawn between
members of society in some cultures
can impeded open communication
Communication Style

Low context culture – European American


Direct, precise, logical verbal communication
High context culture – Hispanic, Asian,
African American, Native American





More informal
Rely more on situational cues
Non-confrontational responses
Well-established hierarchies
Physical cues and relationships are easily
perceived
High Context Cultures
 May
be inappropriate to ask
informally about family and disability
or medical issues
 Coming directly to decision-making
may seem rude or insensitive
 Direct confrontation and questioning
may cause discomfort and even
shame
Revert to What is Comfortable
 Low



Talk less
Speak faster
Raise the volume of their voice
 High



context communicators may:
context communicators may:
Say less
Make less eye contact
Withdraw from the interaction
Providers Must Adapt Their
Communication Style
 Slow
down and talk less
 Look for meaning in physical gestures
 Focus on the context of the family and the
interaction
 Be aware of hierarchical differences within
families and between the family and the
provider
Cultural Blind Spot Syndrome

Low socioeconomic status
 Inexperience with Western health care and
education system
 Lack of or limited formal education
 Emigration from a rural area
 Little knowledge of English
 Recent immigration to the U.S. at an older
age
 Segregation in an ethnic subculture
(Buchwald, et al., 1994)
L-E-A-R-N
 Listen
with sympathy and understanding
to the family’s perception of the problem
 Explain your perceptions of the problem
 Acknowledge and discuss the differences
and similarities
 Recommend intervention
 Negotiate agreement
Guidelines for Cross-Cultural
Nonverbal Communication

Eye contact – can be sign of disrespect, hostility or
rudeness


Body language and facial expressions – may be
interpreted differently


Observe family members and members of cultural groups
Ask for clarification of concerns, check for questions, or reword
information being presented
Silence – some comfortable with long silences; some
speak immediately


Listen to conversations between members of the same culture to
learn the use of pauses and interruptions
Silence can have many meanings difficult to assess
Guidelines cont’d
 Distance
– preferred distance is 2-3 feet in
U.S.


Give family members a choice of where to sit
Stand with room for parents to move closer or
farther away
 Touch


– norms for how and when to touch
Touching not common for South Asians and
West Indians
In some Latino cultures, touching conveys
lack of respect, especially older people
Recommendations to Facilitate
Communication

Encourage open dialogue by asking about
family relationships, values and beliefs.
 Informally determine fluency of family by
asking open-ended question.
 Encourage family to ask questions.
 Ask family questions to check understanding.
 Summarize what the parent says.
 Do not discourage family from talking among
themselves in their own language.
Recommendations to Facilitate
Communication
 Work
with cultural mediators.
 Learn and use words and forms of
greeting.
 Provide information in different forms –
oral, written, pictorial, demonstration.
 Rely on the interpreter, observations,
instincts, and knowledge to know when to
proceed and when to wait.
Working with an Interpreter
 Use
trained interpreters for important
meetings with the family.
 Allow additional time to determine cultural
values, beliefs and perspectives.
 Reinforce verbal interaction with material
written in family’s language.
 Provide an interpreter when requested by
the family even if they speak some
English.
Case Scenario
 Overview
of case
 Small group discussion
 Sharing out with whole group
References

Buchwald, D. Panagiota, V.C., Francesca, G., Hardt,
E.J., Johnson, T.M., Muecke, M.A. & Putsch, R.W.
(1994). Caring for patients in a multicultural society.
Patient Care, June 15, 1994, 105-123.
 Lynch, E.W. & Hanson, M.J. (2004). Developing crosscultural competence: A guide for working with children
and families. (3rd Ed.) Baltimore: Paul H. Brookes
Publishing Co., Inc.
 Montgomery, W. (2001). Creating culturally responsive,
inclusive classrooms. Teaching Exceptional Children,
33(4), pp. 4-9.
 U.S. Census Bureau. (2002). Number of foreign-born up
57 percent since 1990, according to Census 2000.
Retrieved July 12, 2004, from
http://www.census.gov/PressRelease/www/2002/cb02cn117.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