For many clinicians working with patients with dysphagia, the word “culture” equals the use of ethnically diverse foods and their integration into the modified diets that may be recommended for a patient. The increased importance placed on a variety of aspects related to cultural diversity and the practice of speech-language pathology is not new. In 2004, the American Speech-Language-Hearing Association (ASHA) approved a practice document entitled, “Knowledge and Skills Needed by Speech-Language Pathologists and Audiologists to Provide Culturally and Linguistically Appropriate Services” authored by members of its Multicultural Issues Board (ASHA, 2004). This document outlined the knowledge and skills that clinicians must strive to develop in order to provide unbiased and culturally appropriate services.
Subsequently, the ASHA Board of Ethics developed an Issues in Ethics statement specifically on cultural competence, writing that:
The ASHA Code of Ethics requires the provision of competent services to all populations and recognition of the cultural/linguistic or life experiences of both professionals and those they serve (ASHA, 2005, p. 1).
Most recently, members of ASHA created a policy document entitled, “CulturalCompetence in Professional Service Delivery” (ASHA, 2011). There is also a set of tools for self assessment on cultural competence (ASHA, 2005). In addition, there is a cultural competence awareness tool in an interactive web-based platform.
What is missing in the mix of documents is a direct emphasis on working with persons with dysphagia. The concepts of cultural sensitivity need to be explored more directly in the context of the clinician-patient interaction when working on assessing, managing and/or treating dysphagia, as well as in exploring the interactions with parents/caregivers and children with feeding/swallowing disorders.
This discussion becomes increasingly relevant as we live the changing demographics in the United States. At present, slightly more than one-third of our country is composed of persons classified as racial/ethnic minorities (U.S. Census Bureau, 2010a). It is projected that by 2030, almost half of the U.S. population will be composed of persons classified as racial/ethnic minorities. Needless to say, the term minority may need to be reconsidered for persons belonging to these groups (Riquelme, 2014).
Culture, however, is not a term reserved for persons of racial/ethnic minorities only. Understanding, applying, and believing in concepts of culture and its impact on all we do as persons and as professionals is of great importance if we are to be socially and professionally responsible members of this society and this discipline (Riquelme, 2013). This starts with developing our personal definition of culture. The word culture refers to integrated patterns of human behavior that include language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups (U.S. Department of Health and Human Services, 2001). So, in essence, every individual presents with many cultures (Riquelme, 2007). If the concept of culture is to be redefined for some, then one must accept that just as we belong to different social, political, and religious groups, we belong to many different cultures. The same applies to the patients, families and caregivers we work with; they too present with many cultures.
In order to provide culturally sensitive services in the context of our dysphagia practices, we must accept the fact that we, too, may engage in stereotyping, a natural cognitive process, and even racism. This is by no means an easy task for us as professionals or as members in society. Tervalon and Murray-Garcia (1998) presented a concept that espoused life-long learning and perspective-taking on the part of the practitioner. According to them, “cultural humility incorporates a lifelong commitment to self evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations” (p. 123). The dynamic between provider and patient often is compromised by various sociocultural mismatches, including the providers’ lack of knowledge regarding the patient’s health beliefs and life experiences and the provider’s unintentional and intentional processes of racism, classism, homophobia, and sexism as previously mentioned.
Now, what about the perspective of the person being cared for? Some argue that cultural competence is a bilateral process, whereas others argue it is not. Sánchez (2008) presents an argument against the bilaterality of cultural competence. He argues, based on the “difference principle” presented by Rawls (1971/1999) that the patient receiving services is not necessarily empowered to expect culturally competent services. This power differential is in line with the concept of cultural humility presented above. He further writes that, “Cultural expectations, which any member of an alien culture brings with him or her to the doctor-patient relationship, are barriers to proper medical care if and when these expectations are neither understood nor addressed” (p. 5). Noting a more comprehensive definition of culture, the patient’s perspective, or expectation, will vary by ethnicity, socioeconomic status, prior experience, setting, or any other set of possible factors. Once again, understanding each patient or client’s unique perspective and expectation is of utmost importance, and we should not assume these based on stereotyping on the part of the practitioner.
In our practices, the information gathered from the patient/family interview is essential in beginning to solve the dysphagia puzzle. Creating the proper environment in this context can be difficult. Ethnographic interviewing is an approach first presented to our profession by Carol Westby (Westby, 1990; Westby, Burda, & Mehta, 2003). Through this process, the clinician listens to the behaviors and beliefs that the patient or caregiver reports through a systematic and guided dialogue with him or her. Ethnographic interviewing conveys empathy/acceptance of the world as defined by the informant, allows the clinician to collect necessary information for generating appropriate support and clinical practice, helps equalize the power differential, provides a means for the professional to discover the culture of the family and their strengths and needs, provides a means for focusing on the perspective of the informant, helps reduce potential bias in assessment and intervention, and allows the clinician to collect data in a more ecologically valid framework (Westby, 1990).
Being aware of our surroundings, protocols, and the clinical forms we ask patients/clients to complete is another form of addressing culture from a sensitive and least-biased perspective. One should ask a number of questions of our practices. Is our office space welcoming and conducive to the celebration of everyone’s cultures? Although we may not be able to include everyone, is it conducive to individuality? Are our protocols for provision of a service least-biased? Are we flexible in our approach to completing our work? For example, if a patient wants his or her spouse to be included in the session, do we allow that? If the patient, for religious reasons, prefers our office door to remain open, do we allow that? Yet one more area to review in making the welcoming first impression is our forms. Have we worked to eliminate or reduce bias in the forms we ask the patient/client to complete? Simple things like asking for both “caretakers” of a child rather than asking for a “mother” or “father” and asking for a “spouse or partner” rather than “husband” or “wife” can make a difference. These simple things increase a sense of welcome to an office.
Once we are comfortable with the fact that becoming increasingly culturally competent is a life-long process, we can further develop the tools we have, as we search for others. From something as seemingly simple as being comfortable with asking our patient or client if he or she is comfortable, we can make a difference in our interactions, information we gather and overall clinical processes with the persons we serve.
- American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services [Knowledge and Skills]. Available from www.asha.org/policy
- American Speech-Language-Hearing Association. (2005). Cultural competence [Issues in Ethics]. Available from www.asha.org/policy.
- Riquelme, L.F. (July 2014). Cultural sensitivity and practice: Aiming for the right balance. Invited keynote address at the Bilingual Therapies 2014 Symposium, New Orleans, LA.
- Riquelme, L.F. (May 2013). Cultural Competence for Everyone: A Shift in Perspectives. Perspectives on Gerontology, 18(2): 42-49.
- Riquelme, L.F. (2007). The role of cultural competence in providing services to persons with Dysphagia. Invited manuscript to Topics in Geriatric Rehabilitation, 25(3): 228-239.
- Sánchez, C. A. (2008). Cultural (in) competence, justice and expectations of care: An illustration. Online Journal of Health Ethics, 5(1), 1–6.
- Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved 9(2), 117–125.
- U.S. Census Bureau. (2010a). 2010 census shows America’s diversity. Retrieved from
- Westby, C., Burda, A., & Mehta, Z. (2003, April 29). Asking the right questions in the right ways: Strategies for ethnographic interviewing. The ASHA Leader.
- Westby, C. (1990). Ethnographic interviewing: Asking the right questions to the right people in the right ways. Communication Disorders Quarterly, 13(1), 101–111. doi: 10.1177/152574019001300111