It is highly likely that you took a “multicultural” course in graduate school. It is also likely that you heard terms like cultural “competence” that led you to believe that you were obtaining a level of professional competence for working with families who are different than you. However, it is also likely that you, like us, did not actually feel “competent” once you began working in the field. Perhaps you became painfully aware of your own lack of knowledge about different cultural groups, noticed inherent privilege you walked around with, or felt personal pain related to the oppression you’ve faced in life.
Falicov1 proposed a model called Multidimensional Ecological Comparative Approach (MECA) which seeks to embrace the dialectical tension of: 1) having knowledge about different culture groups and 2) acknowledging that we can’t know all of the different aspects of each culture given how different cultural identities interact to create unique ecological niches for families/individuals. Ecological niche refers to the particular location of a person’s cultural identity given their multitude of experiences – socioeconomic, race, religion, immigration status, education, marital status, children, etc. We need to hold in dialectical tension this knowing (e.g., many Latino immigrants adhere to traditional family values) and not-knowing (e.g., how individuals enact traditional family values when they are third generation Latino immigrants who are U.S. college graduates) in order to manifest a clinical and personal skill called cultural attunement.
The not-knowing stance can be likened to cultural humility, a popular concept in family medicine. Cultural attunement then is a personal and professional skill requiring the uncomfortable holding of two dialectical truths – knowing things and not knowing things about the cultural realities of the people we treat – and then enacting curiosity and empathy to understand the client/patient.
|Two dialectical truths - knowing things and not knowing things |
In collaborative care, cultural attunement is vitally important for improving health disparities for people of color 2. The ecological niche inherently challenges stereotypes of different cultural groups through critical examination of the dynamic nature of cultural identities for a given individual – including the patient and other care team members (e.g., family therapists, physicians, social workers, etc.). The outcome of such examination could be improved interdisciplinary communication that manifests into better patient-centered care. To explore the various ways cultural attunement is imperative in collaborative care, the following case study is offered. As an intern, within Saint Louis University’s Medical Family Therapy program, I (Ariel) had the opportunity to work in a collaborative care setting with many such professionals.
A Latino family came into the clinic identifying a 36-year-old female, Maria, as the patient in need of care. Maria (who spoke limited English) and one other female family member (acting as a translator) were brought back to an exam room while the rest of the family remained in the waiting room, per instruction of the clinic staff. Maria complained of leg cramps, which made walking difficult though was unsure of the cause of her pain. She went to a chiropractor however who did not help the pain.
Upon examination, the team of doctors and staff found no major issues with her leg. When explaining this to Maria, she became emotional and began sobbing loudly. Many members of the team were very unsure about what was happening since it was believed that good news was being delivered. As the medical family therapist, I (Ariel) was called into the room to meet with Maria due to her emotional response to the seemingly good news. During this time, I found out that there was extensive family in the waiting room, many of whom Maria had requested join her in the exam room to also meet with the doctors and staff.
While I had some knowledge about Latino culture there were still many aspects of this family’s unique ecological niche that were unknown to me. I invited back the entire family and they shared that their father had passed away recently due to complications with his leg after receiving inadequate medical attention. The family feared that this same issue was occurring with Maria. Thus, they felt it was vital to have an opportunity to discuss these concerns with the doctors. It became clear that Maria’s sadness in response to “seemingly good news” was entirely reasonable given her and her family’s fear of receiving poor medical attention and suffering the loss of another beloved family member. I then met with the family and the medical staff to share this new information and the doctor returned to the room to explain the results of the testing with the entire family.
|Many aspects of this family’s unique ecological niche were unknown to me|
This clinic serves many low-income and minority patients. Since I (Ariel) am a black woman, I am often seen as an expert on the lives and cultures of many of the clients that are seen in the clinic. And while I have some knowledge of these cultures, the uniqueness of every family, patient in a given ecological niche is generally unknown to me. At one point, the lead doctor made the final decision saying it was best to have one female family member come into the room to increase Maria’s comfort. And while there were several reasonable arguments for this decision, I saw the inherent gender and professional power imbalance. Given the existence of patriarchy in some Latino cultures it seemed to me that it would be most beneficial to have a male family member present to speak with the male doctor.
In retrospect, the family’s disclosure to me of their father’s death and concerns about medical treatment likely occurred due to cultural attunement happening between us. Several contextual factors seemed to promote this: the removal of the male doctor, allowing the male family members to enter the room, and my own status as a person of color. Dialogically, I assumed both a knowing (inviting in the family) and a not-knowing position (being curious about the emotional response) enabling the family to tell their story and for me to hear it and respond. This is the essence of cultural attunement.
|Cultural attunement in collaborative care requires holding difficult conversations about the nature of presumed “knowing”. |
When exploring cultural dynamics as part of a care team, it is important to note the implicit and explicit hierarchical differences between the care team members and between patients and providers. Explicit titles and job descriptions and implicit cultural norms and identities define our ecological niche making possible the interaction of a given cultural script (i.e., white, male medical doctors are given final authority on treatment because they appear to “know” more). The result is a genuine lack of cultural attunement between collaborative care team members and between patients and professionals. Creating cultural attunement in collaborative care settings will likely require reevaluating the way our medical community operates and holding difficult conversations about the nature of presumed “knowing”.
Medical and mental health professionals are often presumed experts (“knowing”) in their chosen field. Likewise, people of color who are professionals are often presumed experts on all other people of color (“knowing”). Both presumptions of “knowing” can be highly detrimental to relationships because they overrule “not knowing” curiosities and shut down conversation that seeks to understand the ecological niche of both professional and patient. It is equally as important to create an environment where “not knowing” is valued, and where there is a safe space to ask culturally pertinent questions to both patients and team members (e.g., clarification about cultural language, possible gender or racial dynamics at play etc.) that would promote cultural attunement and, likely, improve patient outcomes.
1. Falicov, C.J. (2014). Latino families in therapy (2nd ed). New York, NY: The Guiliford Press.
2. Johnson, R. L., Saha, S., Arbelaez, J. J., Beach, M. C., & Cooper, L. A. (2004). Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. Journal of general internal medicine, 19(2), 101-110.
Katie M. Heiden-Rootes, MA, LMFT, PhD
Recent PhD graduate of Saint Louis University’s Medical Family Therapy program in St. Louis, MO. Clinically active at Ascend Family Institute in Rogers, Minnesota as a marriage and family therapist, supervisor, and Clinical Director. Also, teaching at St. Mary’s University of Minnesota in their COAMFTE accredited MFT Program. Research and clinical interests includes clinical effectiveness with racially and sexually diverse families; couples sexual and emotional health; and parent-child relationships in transracial adoption and foster care.
Ariel N. Hooker Jones, MSW, LCSW
Current doctoral student at Saint Louis University’s Medical Family Therapy Program in St. Louis, MO. Recent coordinator and family therapist at the Center for Counseling and Family Therapy at St. Louis University and recent medical family therapy intern at a community clinic providing free medical services for low-income patients in the metro St. Louis area. Research and clinical interests include counseling with minority and underrepresented families and couples; parent-child engagement and play therapy; and play as a protective factor within families exposed to violence.