Speech therapy is experiencing a surge of interest in all things “cultural,” including cultural competence and cultural sensitivity. But what does it mean, and how do you actually practice it with your patients?

This article will help you become a more person-centered and culturally responsive therapist. It’s not about being a good person. We know that speech therapists have hearts of gold and great intentions. It’s about being able—and willing—to develop greater self-awareness.

Chung and I are with you in this process. It’s a lifelong journey that we hope you’ll join us on.

Our Experience

Chung was eight-years-old when we moved to rural, small-town America. Although it was a beautiful place to grow up, we always stuck out as the only Asians in sight. At her new school, Chung’s teacher determined that she was “behind” on reading and needed to be pulled out of class to work with a reading assistant. Even then, Chung knew that her teacher was wrong. She could read just fine—but with a slight Japanese accent. She felt afraid every time she had to see the assistant who, with a perpetual scowl and big blond hair, corrected Chung’s accent as she read out loud.

Over time, experiences like these and countless other micro-aggressions build. There’s trauma that comes from being looked down on by the majority around you. Chung and I were lucky to have opportunities to build better lives and, through counseling, unlearn our hometown’s messaging that we were less-than.

Unfortunately, many of our patients also face discrimination as they navigate the healthcare system that we are all a part of. This is not only emotionally painful for our patients, but the evidence overwhelmingly shows that discrimination leads to worse health outcomes. This is not a theory, my friend; it’s evidence-based.

Fortunately, we can do something about it! Person-centered care and culturally responsive practices are the answer.

Handouts, Worksheets, Treatment guides, Eval templates, Documentation guides, Goal banks, and much more!

Why Does It Matter?

Below is a comparison of health outcomes in the United States.

On the left are the results of the U.S. healthcare system’s biomedical model—which is not person-centered nor culturally responsive. In this model, the clinician is the expert, so they “know best”.

On the right are the health outcomes when person-centered and culturally responsive care are in practice.

Biomedical Model	Person-Centered & Culturally Responsive Care
The U.S. has the highest rate* of avoidable deaths	Lower ER visit rates
Long-known health disparities	Faster recovery
Rising health care spending	Decreased utilization of healthcare resources
Lowest life expectancy*	Increased patient, family, and care team satisfaction
Highest chronic disease and obesity rate*	Fewer clinician mistakes
Fewer physician visits*	Improved health outcomes
High hospitalizations from preventable causes

What is Person-Centered Care?

Person-centered care is when you, as the healthcare provider, actively respect a person for everything that they are. And how do you learn who a person is? You ask! And you listen.

And how do you show respect? You treat the person as a unique individual whose needs and preferences matter. Upon listening to their wants and needs, you act on helping them get those things. You treat the person equitably.

Sounds simple! But it does require a major shift towards greater awareness of your biases, learning how to listen, and adjusting how you show up for patients.

Principles of Person-Centered Care

Person-Centered Care IS	Person-Centered Care is NOT
Prioritizing a patient’s preferences.	One-size-fits all. My way or the highway.
Communicating well by confirming that they understand. Ask-tell-ask.	Tell-tell-tell. Using medical jargon. Failing to share information freely. Not asking follow-up questions.
Making decisions with the patient. Understanding what matters most to them → allowing time to think and talk about the decision → reaching a collaborative decision.	Making decisions for the patient. Considering only the speech therapy diagnosis while making goals.
Involving family and friends. Asking who they want to be involved. Supporting caregivers.	Not accommodating caregivers.
Supporting physical comfort. Assessing pain & attending to the environment (lights on/off, privacy).	Figuring it’s another discipline’s job to “deal with” physical comfort.
Emotional support. Listening and demonstrating empathy and respect.	Not providing the time and space to listen to patients’ concerns.
Smooth transitions of care. Preparing them for the transition. Communicating with other providers.	“Discharge.” Not providing timely referrals. Not creating a community of care.
Promoting self-management (teaching how to monitor symptoms, identify quality resources, self-advocate).	Doing everything for the patient (instead, meet them in the middle).

What Does a Person-Centered Clinicial Look Like?

What is Culturally Responsive Care?

We are all cultural beings. Your culture is influenced by your history, geography, society, and family. And just as each patient sees the world through their own unique cultural lens, you bring your own cultural influences into every interaction with your patients.

Culturally responsive care is a deep respect for and understanding of people’s cultures. Being a culturally responsive therapist requires that you:

• Become more aware of your own identity and biases, both conscious and unconscious
• Take your patients’ cultural perspectives, beliefs, and values into consideration in all aspects of the care you provide

Culturally Responsive Care IS	Culturally Responsive Care Is NOT
Person-centered care. Every person is unique; nobody is a stereotype of their culture.	Treating groups of people differently based upon assumed labels.
Being aware and acknowledging your unconscious biases.	Denying that you have unconscious biases.
Focusing on your similarities and shared identities.	Focusing on the differences between you and your patient (Asking Asian patients, “Where are you from?”)
Acting on your biases to reduce the potential harm to others.	Minimizing the impact of unconscious biases. Believing that you can treat all patients objectively (“I don’t see color.”)
Adjusting your behavior to reflect an awareness of and respect for cultural differences.	Believing that human behavior and values have a universal standard (“Good people never lie.”)
Considering the patient’s cultural perspectives, beliefs, and values when providing care.	Labeling differing perspectives, beliefs, or values as “good” or “bad.”
Being knowledgeable about different cultures.	Not learning about different cultures. Not questioning stereotypes.
Appreciating diversity.	Giving up your own beliefs. You can honor your beliefs and honor a differing belief.
Knowing how health disparities & discrimination affect historically disadvantaged groups.	Blaming historically disadvantaged groups. Denying that discrimination exists.
Understanding that cultures and people are dynamic. They change.	Assuming that a person from a culture will believe the same things as another person from the same culture.
An opportunity for self-reflection and growth. As Maya Angelou said: “When you know better, you do better.”	An opportunity to shame other people and tear them down for their mistakes as they learn to become culturally competent (online shaming).

Become More Self-Aware

Self-awareness is how well you understand your own:

• Strengths
• Weaknesses
• Thoughts
• Feelings
• Values
• Beliefs
• Assumptions

Be curious as you examine these parts of yourself. Practice non-judgmental attention the feelings and truths that arise. Try not to judge yourself for anything that comes up.

Self-Awareness Exercise: What Are Your Identitities?

This activity highlights the multiple dimensions of our identities. It addresses the importance of individuals self-defining their identities and challenging stereotypes.

Copy the diagram below in a notebook or journal (here’s a PDF version if you’d prefer to print it out). Write your name in the center circle. Write an important aspect of your identity in each of the satellite circles — an identifier or descriptor that you feel is important in defining you. This can include anything: Asian American, female, mother, athlete, educator, Taoist, mullet-enthusiast, or any descriptor with which you deeply identify.

Questions:

1. Write about a time you felt “included” or “respected” in relation to one of the descriptors used above.
2. Write about a time you felt “excluded” or “disrespected” in relation to one of the descriptors used above.
3. Name a sterotype associated with one of the groups with which you identify that is not consistent with who you are. Fill in the following sentence:

I am a(n)_______________but I am NOT a(n)_______________

For example, if one of my identifiers was “Christian,” and I thought a stereotype was that all Christians are radical, right-wing Republicans, my sentence would be: ” I am a Christian, but I am NOT a radical right-wing Republican.”

*This exercise is adapted from a handout on the Department of Anthropology at The University of Maryland’s website.

Self-Awareness Exercise: Privilege

Take out a journal and pen or pencil then go through this list. Each item gives you a chance to gain or lose “points.” Keep track of your points. The final number of possible points ranges from -25 to 19.

(Although useful when done solo, this exercise is much more powerful when done in a group. This way, you can learn from others and have meaningful conversations based on what you’ve learned about your own and other people’s privileges—or lack thereof.)

1. If your ancestors were forced against their will to come to the USA, subtract 1.
2. If your primary ethnic identity is American, add 1.
3. If you were ever called hurtful names because of your social identities, subtract 1.
4. If your family employed people in your household as domestic workers, add 1.
5. If they were people of color, add 1.
6. If you were often ashamed or embarrassed of your material possessions, subtract 1.
7. If most of your family members worked in careers requiring a college education, add 1.
8. If you were raised in an area where there was visible prostitution or drug activity, subtract 1.
9. If you ever tried to change your appearance, behavior, or speech to avoid being judged based on your social identities, subtract 1.
10. If you studied the cultures of your ancestors in elementary school, add 1.
11. If you started school speaking a language other than English, subtract 1.
12. If there were more than 150 books in your home when you grew up, add 1.
13. If you ever had to skip a meal or go hungry because there was not enough money to buy food when you were growing up, subtract 1.
14. If your parents took you to art galleries, plays, or museums when you were growing up, add 1.
15. If at least one of your parents was ever unemployed, not by choice, subtract 1.
16. If you have ever attended a summer camp, add 1.
17. If your family ever had to move because they could not afford the rent, subtract 1.
18. If you ever attended private school, add 1.
19. If you were ever discouraged from academic or career paths because of your social identities, subtract 1.
20. If you were encouraged to attend college by your parents, add 1.
21. If you believe that you were paid less for a job because of your social identities, subtract 1.
22. If you were raised in a two-parent household, add 1.
23. If you frequently saw characters who shared your social identities portrayed in likable ways on TV and movies, add 1.
24. If you have felt that clerks watch you more than other customers in a store, subtract 1.
25. If you were ever offered a job because of your association with a friend, mentor, or family member, add 1.
26. If you are a first-generation college student, subtract 1.
27. If your family ever had to change their last name due to mispronunciation, subtract 1.
28. If you ever had your name mispronounced, subtract 1.
29. If you have ever been afraid to walk alone at night, subtract 1.
30. If you believe that an employer turned you down because of your social identities, subtract 1.
31. If you attended an elementary school with good books and facilities, add 1.
32. If you ever had an allowance during high school, add 1.
33. If you were ever accused of cheating or lying because of your social identities, subtract 1.
34. If you have ever inherited money or property, add 1.
35. If you’ve had to rely on public transportation, subtract 1.
36. If you were ever stopped or questioned by the police because of your social identities, subtract 1.
37. If you have ever feared violence directed at you because of your social identities, subtract 1.
38. If you have been usually able to avoid places that are reputed as dangerous, add 1.
39. If you have ever felt uncomfortable about a joke related to your social identities, but not able to confront the situation, subtract 1.
40. If you were ever the victim of violence related to your social identities, subtract 1.
41. If at least one of your parents did not grow up in the USA, subtract 1.
42. If your parents told you that you could be anything you wanted to be, add 1.
43. If you have ever been whistled at, subtract 1.
44. If you have traveled overseas, add 1.

Review Questions

1. What are your immediate thoughts after completing this exercise?
2. Were some items easier to respond to than others? Which ones?
3. What did it feel like for the people who had closer to 19 points total?
4. What did it feel like for the people who had closer to -25 points?
5. What is the American Dream to you?
6. Do your social identities have anything to do with the American dream? Why or why not?
7. What might you draw from this exercise that can help you in your everyday life?
8. How can you apply what you have learned here to the work you do?

Self-Awareness Exercise: Reducing Implicit Bias

• Take the Implicit Association Tests (IAT) to help you identify your implicit biases.

Again, be kind to yourself if you realize that you have implicit biases. Suspend judgment for now.

I know that some of my results were humbling. I had a period of denial (“those Harvard researchers don’t know what they’re talking about!!”) then shame (“I’m a bad person.”)

I’m not a bad person, and neither are you. But this is important information that can help all of us approach others from a place of greater awareness and fairness.

How to Practice Person-Centered & Culturally Responsive Care

Increase Your Self-Awareness

• Self-awareness is a continual process. You’ll uncover many layers of yourself, including long-held assumptions and unconscious beliefs.
• Be open-minded. Go outside of your comfort zone. Do new things. Meet new people. Read books you couldn’t normally read. Attend events you never pictured yourself attending.
• New self-awareness may prompt change, which is typically uncomfortable and can be messy and scary. Your self-identity may change. Your friends may change. Your family’s view of you may change.

Learn About the Cultures You Interact With

• Learn more about your cultures, patient’s cultures, the educational system, political system, healthcare system, professional organization, family, etc.
• What are the underlying values, beliefs, and assumptions of this culture? How self-aware are these cultures?
• A reminder: Pay non-judgmental attention to everything you learn. Hold off on deciding whether it’s something you believe or not until you’ve had the time to really process the information.

Advocate for Yourself

• Remember that you have the right to respect and dignity.
• While we have the responsibility as clinicians to learn about our patient’s cultures, values, and beliefs, this does not mean we have to change our fundamental selves in order to make our patients feel comfortable.
• In other words, culturally competent care means adapting our behaviors and perspectives in order to help our patients reach their goals. Sometimes self-awareness may cause us to change our values and beliefs. But this is not the same things as being unheard, abused, or discriminated against because your values and beliefs are different from those around you.
• If you feel that this is happening to you, communicate as soon as possible. Use, “I feel…” sentences. Keep it about you and avoid accusations. Ask specifically for what you’d like to see. Keep the conversation open.

Looking for more? Check out The Starter Pack!

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