The age of managed care has brought with it an emphasis on performance review, utilization review and accountability. Federal and state requirements are pushing toward standardization of services. As substance abuse counselors, we called our own shots for so long that we now find it difficult to deal with the new accountability. We have focused so much on the one-size-fits-all method that we could hardly even say the words "individualized needs." For those who did not fit the package because of gender, age or culture, we did the best we could. Today, we are required to ask: "What is good quality care for this client? What does the client really need? What will work for this client?" In this outcomes-oriented atmosphere, we can no longer regard culture as some elective or specialized aspect of counseling, nor can we choose to see it as the liberal turf of the more politicized and socially conscious provider. What can we do?
As experienced clinicians, most of
us are aware that the clinical picture of a client is influenced by
many factors, such as the client's age, gender, socioeconomic
background, educational background and even the client's
ethnic-cultural background. The essential and central awareness that
is most often lacking among us is that our culture controls our
lives, not just the client's life. Culture is the internalized
perspective that each of us has developed during our lifespan.
Culture is the result of the integration of everything we have ever
learned from every person or group with whom we have interacted, or
from whom we have learned something. Every experience and every
memory that has touched our thinking and feeling contributes to our
culture. The clinical picture of the patient is colored by his or her
cultural background. But the process of assessment is influenced not
only by the cultural background of the patient, but also by the
cultural background of the clinician, whose perceptions,
interpretations and assumptions may confuse or bias the assessment.
One of the most difficult, common experiences I have in my profession is encountering the implicit assumption of many of my colleagues that there is a single absolute standard for normal behavior. There appears to be a lack of awareness that the criteria for normal behavior changes from country to country, place to place, time to time, person to person and even situation to situation. Fortunately, within the clinical/medical profession, culture has finally been recognized as an important consideration in diagnosis and is now formally included in the DSM-IV. Culture, the very heart and soul of life, is finally being recognized as a major contributor to the dynamics of human development and well-being. Culture can no longer be ignored as the very heart and soul of counseling.
My task in this article is not to discuss culture and psychopathology. I leave that to those professionals of far more formidable expertise, such as the recent guide edited by Wen-Shing Tseng, M.D. and Jon Streltzer, M.D.1 I wish to simply invite you to move beyond the popular politically motivated definition of cultural-diversity training as race-relations training, to a more comprehensive and clinical understanding of culture as it pertains to your professional responsibilities and your client's recovery. I am referring here to expectations and values that control behavior and have been learned through a diversity of sources including ethnography, demography, status, and formal and informal affiliations accumulated by each and every individual throughout a lifetime of experiences. The cultural contributors we carry inside us attribute meaning to everything inside and outside of us, teach us assumptions that shape our expectations and control our behavior, with or without our awareness.
Everyone has culture. Our culture teaches us everything we know and don't know about ourselves and the world around us -- language, behaviors, rules, expectations, the way we understand others, the way we make decisions, the way we make choices, what is real, what is healthy, what is possible and what our limitations are. Culture even defines what is safe and what is dangerous. It defines what is hope. Culture not only tells us where home is, it tells us what is "home."
Donald Batchlder, who once headed the country program in Mozambique for Save the Children, is fond of telling the story of "The Green Banana." It can be found in a number of publications.
The story starts on a steep mountain
road in the interior of Brazil. Batchlder's old jeep began to leak,
10 miles from the nearest mechanic. The overheated engine forced him
to stop at the next settlement, which consisted of a small store and
a few houses. People gathered around, as people do, to look. Three
streams of hot water spouted from holes in the jacket of the
radiator. A man standing near him said that the problem was easy to
fix. He sent a boy for some green bananas. He assured Batchlder that
everything would work out. "Green bananas," he smiled. Everyone
agreed.
Not wanting to appear ignorant, Batchlder made no comment on the bananas, and instead remarked on the huge rock formations that rose up all around them. The helpful man pointed to a slender pinnacle of dark rock that was taller than the rest and said, "That rock marks the center of the world." Batchlder looked to see if the man was serious. Concluding that the man was very serious and wanting to be respectful, Batchlder refrained from comment. "Everyone around here knows it," the man continued.
At that point, the boy returned with the green bananas. The man sliced one in half and pressed the cut end against the radiator jacket. The banana melted into a glue against the hot metal, plugging the leaks. An hour later, Batchlder reached his destination and a mechanic. The surprised mechanic asked him where he learned about the green bananas. When Batchlder named the settlement, the mechanic asked if they had shown him the rock that is the center of the world. Batchlder affirmed that they had. The mechanic told Batchlder that his grandfather came from there, and that it is the "exact center" and everyone around there knows it.
Batchlder, being a North American, had never thought about the benefits of green bananas. He also had always assumed that the center of the world was New England (his grandfather's place of origin). He did not understand the significance of the experience in Brazil until sometime later, when he was able to let go of his own learned perspective and assumptions. In the preface to the book, "Beyond Experience: The Experiential Approach to Cross-Cultural Education,"2 Batchlder concludes this story with this comment: "The gradual lesson that filtered through to me was the simple concept that every place has special meaning for the people in it; every place represents the center of the world."
Batchlder realized that everyone has a special place where they are known, where they know others, where things have meaning, where their ways of conveying those meanings are understood, and where they themselves have identity and meaning. A place where their behavior, expectations and hopes are understood and make sense. The place that taught them how to see and how to be. Batchlder saw someone else's center.
The task we have for ourselves is similar: to allow the revelation of another person's center. By recognizing our own learned perspective, assumptions and values, an opening is created in our mind and heart that allows us "to see." The cultures of our clients, as Batchlder would say, are "full of unexpected green bananas." Our responsibility is to help them open their own possibilities for discovery, mutual acceptance, understanding and participation in a wider world. This first requires that we get out of the way and have the willingness to see. To do this, we need awareness of our own center, for the biases inherent in each of us determines the interpretation we give to all people, places and things. Second, it requires that we have the knowledge to identify and understand the center of their world. As counselors, our interpretation could result in an inappropriate and inaccurate diagnosis, or a misguided treatment plan. We need accurate knowledge and comprehension about cultures and cultural dynamics, avoiding stereotyping and prejudicial perspectives. And lastly, we need the skills to do the right thing, match the right treatment plan to the right services and match the real needs to the right treatment. We need specific counseling and interviewing skills to address such issues as verbal and nonverbal language and the stress barriers present in such encounters. This three-tier approach to training will give us the ability to take responsibility for and command of our reactions, reduce the effects of our biases and remove the filters. With this done, it will be easier to focus on the client and the client's needs.
References
Catitonaugh-Rosalinda Ramirez is currently coordinator of women's substance abuse programs for the state of Georgia and provides training and consultation for the state DUI/risk reduction program. She has worked with adult substance abusers, particularly with pregnant and post-partum substance abusers and felony offenders. As a Georgia Red Cross volunteer Emergency First Responder, she served as a multilingual medical volunteer and medical coordinator during the 1997 Summer Olympics.