Cultural Competence and Humility in Brain Injury Rehabilitation

What is cultural competence or cultural humility?

Cultural competence is a common term used in practice but not cultural humility. Before describing each, we must first define culture. Often, we automatically think of race/ethnicity, language or traditions. However, culture also includes how and where we live, social roles, physical abilities, military experience, how we communicate, among other things. Cultural competence is a process by which individuals and systems respond respectfully to and work effectively with culturally-diverse individuals, such as persons with disabilities, to recognize, accept, respect, and value others who are different from them. Striving to be “culturally competent” may inadvertently promote stereotyping, overemphasize group differences, and give a false sense of competence or expertise. Tervalon and Murray-García coined cultural humility in 1998, as “a life-long commitment to self-evaluation and critique, to redress the power imbalances in the clinician-patient dynamic, and to develop mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.” Cultural humility views culture as unique to individuals and can be fluid and change based on context. It also defines culture as being different combinations of diversity factors, such as age, race/ethnicity, sexual orientation and more. Striving to be “culturally humble” promotes respect, places the focus on not only the other but also on self through self-reflection/self-awareness making your biases explicit, and results in flexibility and humility. It is OK with not knowing and giving the role of expert to the patient while shifting your role to student.

How to apply cultural competence or cultural humility to your clinical practice?

The concepts of cultural competence and cultural humility in brain injury rehabilitation appear almost customary and commonplace; however, practicing in this manner takes extra effort and drifting back to our comfort zone often happens when treating a “challenging patient.” By definition, to be humble is to lower yourself in importance. This may seem counterintuitive to providers with years of training and an abundance of treatment expertise; however, the likelihood of patients carrying out our recommendations is low if we do not demonstrate respect for their individual values and a willingness to embark on a collaborative journey with them. Therefore, it is recommended to think of the patient as the expert on themselves and think of our role as qualified consultants assisting them with their rehabilitation endeavors.

To be culturally humble, become curious and actively try to uncover what motivates your patient. A clinician is wise to develop hypotheses (as opposed to assumptions) about a patient’s values and traditions, and how they may influence rehabilitation-related behaviors. Asking questions that start with “What” and “How” may help us find evidence to support or refute our hypotheses (i.e., What language did you learn first? How has being Muslim impacted your life?). Keep in mind, their responses to our questions are their reality, and to be empathetic we don’t have to agree with their vantage point, we just have to understand how their perspective will influence their rehabilitation efforts and outcomes. In brain injury rehabilitation, there is much to be learned by asking about the patient’s premorbid functioning or family dynamics, and the constellation of cultural factors outlined by Hays’ ADDRESSING model. Incorporate asking about these factors and others into your initial evaluations, and clarify how such factors impact their lives within your ongoing collaborative relationship.

References

1. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved 1998; 9:117-25.
2. Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed.). Washington, D.C.: American Psychological Association.

This article was contributed by Monique R. Pappadis, Ph.D., and Carlos Marquez de la Plata, Ph.D.