On Becoming a Culturally Competent University

Submitted by Dr. Tolu Oyelowo, Chair – Diversity Commission

A colleague recently asked me to define culture.  My response was that culture is the lens through which we view the world, and the lens can be made up of many different filters.  The filter of family, faith, society, group affiliations, community and nationality to name a few.  What followed was a blank stare and I quickly realized that what I had just said made no sense to this individual, which got me thinking – why is it so easy for some to define their culture, and extremely difficult for others?.  I think the answer is relatively simple, if one is customarily in an environment where there is perceived uniformity, then there is a tendency to presume we are acultural.  Part of identifying ones own culture is to have it juxtaposed against other like and unlike cultures, and to experience the affirmation or rejection of ones culture as it is reflected against others.

What??? you say – well let me explain.  Imagine you are a homeopath, you were raised in a community of homeopaths, you see mostly homeopaths on television, your high school was made up of children of homeopaths, your girlfriend is a homeopath - you get the picture.  If this was the only life you knew, and someone were to ask you to define your culture, you might say ‘what culture?’ aren’t we all the same.  You have made the assumption that because everyone around you is sort of ‘like you’ there is no unique culture.  Until you start to see your (homeopathic) culture reflected against other differing cultures, you might assume you had no culture.

Okay fine, you say, but so what, after all I get along with lots of different people, and quite frankly what does this have to do with my views on health care? Good question and I will come back to the health care question in just one moment, but first indulge me as I describe a model of cultural competency.  The Developmental model of intercultural sensitivity described by Milton Bennett PHD and Mitch Hammer PHD.  This model describes three phases of intercultural competency development. Phase 1 Defense/Denial, Phase 2 Minimization, and Phase 3 Acceptance/Adaptation

Defense – One’s own culture is experienced as the only good one, and cultural difference is denigrated. Example: ‘you know those foreigners’

Denial – One’s own culture is experienced as the only ‘real’ one and consideration of other cultures is avoided either by maintaining psychological and /or physical isolation from differences. Example “Saddam who? ”

Minimization – elements of ones own culture are experienced as universal, despite surface differences, deep down, other cultures are seen as essentially similar to one’s own.  Example ‘aren’t we all deep down basically alike, and don’t we all just want to be treated with respect’

Acceptance/ Adaptation– Other cultures are experienced as equally complex, but different constructs of reality and one attains the ability to shift perspective in and out of another cultural world view. Example ‘diversity is a good thing and I know that your not making eye contact with me doesn’t necessarily mean you are hiding something, it might mean you are showing me respect or that firm handshake does not necessarily mean you are trying to crush my bones, or that wimpy hand shake does not necessarily mean you are insecure, or the fact that you like to tell stories first before making your point does not necessarily mean you are inefficient’. i.e. I am going to withhold judgment because I recognize that we have differences, and these differences might be valuable to the task.

That’s the model, and you perhaps recognize a potential value for cultural competency in relationships, but how does this connect to health care? - the common thread that unites the ‘culture of NWHSU’

First I think we will all agree that as proponents of natural health care, health care providers, and providers in training, our primary task is to model health and to sell our brand of health and wellness to the population at large – friends, family, neighbors, enemies, patients, and colleagues.  Second I think we would all agree that ideally we want to sell our brand in the most effective way.  This begs the question what does it take to be the most effective to a broad range of potential consumers?  I propose to you that one element is to be culturally competent.   

Let’s take a look at our programs.  If you are a Chiropractor in the Defense phase then as far as you are concerned, Chiropractic is the only ‘real’ choice for health care, and quite frankly it is the ‘superior’ choice and if those acupuncturists would only just ‘see the light’ then they would simply become chiropractors and practice chiropractic (which is true of course – no just kidding), but you get the idea.  Well imagine contact with an Acupuncturist, also in defense who feels as strongly that Acupuncture is the superior choice, and that Chiropractic is really an inferior second choice. What is the message that is communicated to the consumer?  Quite confusing isn’t it.  Is this perhaps a reason why as individual entities we still don’t reach the masses?  Given the strength of commitment that we hold to our different disciplines, wouldn’t you expect that everyone, and yes I mean everyone will be jumping on the band wagon of natural health care.  Collectively, we still make up less than half the utilization of health care services as a primary health care choice.  Why is that?

What if you are a Massage therapist in the denial phase – ‘Acupuncture who?  yeah, yeah, yeah – get with the program my friend, what you need is a massage – that’s the only thing that will help that sciatic pain of yours.’  Except you are conversing with a client, whose sister just went to an acupuncturist for sciatica, and guess what, they got better – so now who should the patient believe?  Is it any wonder the general public is so confused?

I propose to you that to become the most effective health care practitioners, if we are indeed in the defense/denial phase, we need to move out of this, through minimization and into acceptance/adaptation.  We need to acknowledge that the other health care cultures are equally complex, and strive to attain the ability to shift perspective into the other health views, so that we can better serve the consumer.  At the very least, we need to be willing to learn enough about ‘the other’ to enable us to intelligently educate our consumers.   To summarize, we can still hold firmly to our commitment to our chosen practices, while recognizing and intentionally assigning value to the health care practices of our colleagues. 

So, what does Acceptance/Adaptation look like?  The words that come to my mind are inclusive, dynamic, multiple voices, creativity, marketability.  In health care, it might mean a fundamental understanding and acceptance of the value of the health care professions, and the ability to identify and adapt the patients’ needs to the providers expertise.  Within the health care programs at NWHSU, it might mean that a massage therapist would chose to refer the patient to the chiropractor because they identified the spinal misalignment as a primary problem, or the chiropractor referring the patient for herbs and acupuncture  because they evidence spleen deficiency concurrent with infertility, or the chiropractor referring the patient for massage therapy because they recognize the role that stress is playing in the patient’s health outcomes, or the acupuncturist referring a patient for chiropractic manipulation because they recognize that spinal misalignment might be impacting the child’s ear infections, and so on…..

I previously discussed the developmental model of intercultural sensitivity and  gave examples of the chiropractor and acupuncturist in the ‘defense’ phase and the massage therapist in the ‘denial phase’.  How about an example of an Oriental Medicine practitioner in the minimization phase.

In the minimization phase, the thinking is that deep down we are all basically alike.  A patient presents in the office, subconsciously an assumption is made, they are basically like you, they want what you want after all that is why they came to your office, they will follow your prescription.  You prescribe some herbs send them off with a wonderful array of natures best healing concoctions and smile with joy at the improved health that your patient is soon to experience.  Much to your surprise, they don’t get better, or at least not to the degree that you had anticipated.  You are perplexed; those herbs were perfect for the patients circumstances.  Well three months later you make an offhanded comment in the waiting room about how surprised you are that the patient is not making the progress you anticipated, and his daughter informs you that he never took the herbs, actually just tossed them once they left your office.  What! You say, How could this happen? After all you carefully explained the reasons for the herbs, and why they were the right choice for this situation.  The patient had said they understood, had thanked you profusely had even referred a friend; so why didn’t they take the herbs? Perhaps because deep down they have some fundamental beliefs about health care and the utilization of herbs that are very different from yours.  In addition, they may have beliefs about your role as healer that keeps them from disagreeing with you or even challenging you directly.  So they do what works for them; remain cordial and respectful but don’t follow your plan.  The result, unanticipated, and potentially disappointing outcomes.

A statement I have heard often vis a vis the diversity initiative at NWHSU is ‘why do you keep talking about differences?’ we have more in common than we have that’s different.  My response to this is ‘How do you know that?’  Unless we are brave enough to dialogue about our differences, we truly have no way of knowing what we have in common.  To make the assumption that we are all really very much alike is really in effect minimizing the ‘others’ experience.

It is perhaps worthwhile to spend some time talking about minimization, after all this is the bridge that connects ethnocentricism to ethnorelativism or defense/denial to acceptance/accommodation.  Minimization is ‘safe’.  It means you care enough about the ‘other’ to want to form relationships, and in order to do so you are invested in the similarities.  That is great; unarticulated however is I suspect a hidden fear that focusing on differences can be divisive.  This is true – wars are fought over differences; however wars are also fought over assumptions of similarities.  Assumptions that may turn out to be incorrect!  The key to dialogue about difference is an environment that is safe, so that differences can be articulated without fear of recrimination or reprisal.

Conjure up an image of someone you know quite well, someone close to your heart, a spouse, a sibling, a dear friend, and think through the life of the relationship.  Let’s take the spouse - you meet, you find you have some things in common, you fall in love, you marry; you discover you are actually very different, you argue, you resolve the arguments, you now understand each other better, you have a deeper relationship – not based on the superficial (we are all alike), but on the deeper level – we are alike, we are also different, by learning about the similarities and differences, we now have a deeper relationship.  The same for cultural relationships (health, race, gender, age, sexuality, socioeconomic – you name it).  It is in understanding differences not in minimizing them that we find ways that enable us to best accommodate one other. 

The common thread that unites the NWHSU culture is health care – holistic health care to be specific, meaning we chose to attend to the entire being – the body, the mind and the spirit.  This means that as we engage in the healing of the body, we must pay equal attention to the mind and the spirit. Imagine a place where each of us as members of the NWHSU community were comfortable nurturing our minds, bodies and spirits.  Isn’t that an exciting thought?  Getting there might cause some tension, but arriving there would be quite euphoric. We get to dialogue without having our opinions minimized.  It does not mean that we don’t speak our minds because we are afraid we might offend, quite the contrary it means freedom and safety of expression and being, within the boundaries of respect, courtesy and caring.

Let me say this one more time cultural competency is not about losing ones identity.  It is about holding firmly to our commitments and chosen practices, while recognizing and intentionally assigning value to the commitments, identities and practices of others.  In health care what this ultimately means is that because we come from a place of knowledge we are better able to guide our patients in making optimal health decisions.  As such we are better health care providers because our patients manifest better health outcomes.

The remarkable thing about cultural competency is that it is not about ‘them’ it is about ‘us’.  Collectively when we leverage our differences, everyone wins, and the time to start to do that is now.  What does this mean to the community, well it means that when our students leave, not only have they developed intellectual skills, they have also developed life skills, it means a greater understanding of the different areas, departments, positions, schools of thought, and issues on campus, it means being human centered, it means open and honest communication and it means improved health and wellness to the broad range of populations we influence because it is based on effective service.   It is a win-win situation when we chose the words from our diversity slogan:

Celebrate Me, Celebrate You, Celebrate Us!