M3 — Becoming Culturally Competent

Narratives

— Stories help us relate to people, forge connections, and build relationships between story teller and listener.
— Relational activity that gathers others to listen and empathize.
— Collaborative practice, and assumes tellers and listeners/questioners interact in particular historical contexts that are essential to interpretation.
— Opens up forms of telling about experience, not simply the content to which language refers.
— Provide meaning, context, and perspective.

• Encourage holistic approach to management

• Intrinsically therapeutic or palliative

• Suggest additional therapeutic options

In therapeutic process, narratives are…

• To inspire

• To connect

• To teach

• To learn

• To share information

• To make things stick

Why do we tell stories?

Narrative Reasoning

— A mode of clinical reasoning... complex and interactive.
— The individual becomes the "actor"
— Shift perceptions from passivity to activity.
— Thinking in "stories"

Storytelling is the manner in which the client conveys the meaning of their experiences.

Storymaking is a collaborative meaning-making process in which both therapist and client work together to understand the client’s experience and enable them to move to where they want to be.

Differentiate Storytelling vs. Storymaking

Storytelling

Manner by which clients and patients convey the meaning of their experiences.

Storymaking

Collaborative meaning-making process in which therapists and clients work together to understand the client's experiences and enable clients to move from where or who they are to where or who they want to be,

Prospective Treatment Story

Story that clients were able to make.

Chart Talk

— Formal tone
— Can sound technical, clinical 
— Observable during structured situations like case conferences
— Very bare essentials, no emotions.

Break Room Talk

— Nuanced (more colorful and free)
— Rich and interpretive
— Just like a story: plot, characters, suspense, drama, action

1. Personal Narratives

2. Community Narratives

3. Dominant Culture Narratives

What are the 3 Levels of Narratives?

Personal Narratives

— Occurs within the individual experience.
— Social interactions that occur.
— Place that provides context.

Community Narratives

— Communal stories of a group of people.
— They are shared stories within a specific or common group that had the same experience
— Can be positive or negative based on the group they belong to.

Dominant Culture Narratives

— A master narrative of different groups of people; shorthand way of characterizing a group with shared experiences.

— Generally understood and shared among bigger groups of people.

People who have the capacity to share or put their story out.

Who tells the story in Dominant Culture Narratives

Illness

How the sick person and the members of the family/wider social network perceive, live with, and respond to symptoms and disability

Disease

— What the practitioner creates in the recasting of illness in terms of theories of disorder and what they have been trained to see through the theoretical lenses of their particular form of practice (How professionals frame diseases experienced by patients)
— An interpretation of the health problem within a particular nomenclature and taxonomy

• Illness Problem

• Illness Experience

• Illness Behavior

• Illness Compaints

What are the Component/s of Illness?

Illness Experience

— Lived experience of monitoring bodily processes (e.g., abdominal cramps, wheezing, painful JTs).
— Always culturally shaped.

Illness Behavior

— What ill person does in response to illness experiences

Illness Problem

Difficulties not related to symptoms themselves, but due to the symptoms

Illness Complaints

— What the ill person brings to the health professional; how the patient describes the illness to the health professional.
— Belief of the ill person and caregiver of how the illness came about (e.g., pasma, nausog)

Disease Problems

What are the Component/s of Disease?

Disease Problems

The disease is reconfigured only as an alteration in biological structure or functioning

1. Restitution

2. Chaos

3. Quest

What are the 3 Types of Narrative Structures

Restitution

— Characterized by desire to return to before
— Emphasis: Recover version of oneself prior to illness.
— Storyline: Restoration of Health
— 2-fold purpose: Individual, Culture

1. Denial

2. Sense of “magic cure”

3. Overshadows need for applicable treatment

Why can restitution prevent recovery?

Chaos

— Absence of coherent sequence.
— Emphasis: To tell events as the storyteller experiences life (no past, no future, just the incessant present as one jumbled experience)
— Storyline: Recovery is not a possibility
— Hear and listen. not fix

Quest

— Expression of belief that there is something to be gained from experience (purpose and meaning)
— Emphasis: Acceptance of impairment and disability and the desire to use it/alternative ways of being ill.
— Storyline: Realization of a sense or purpose

Cultural Competence

The process by which individuals and systems respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds in a way that recognizes, affirms, and values the worth of the individual and protects and preserves the dignity of each

Cultural Humility

Lifelong, learning-oriented approach to working with people with diverse cultural backgrounds and a recognition of power dynamics in health care

Narrative Humility

— Our patients’ stories are not objects that we can comprehend or master, but rather dynamic entities that we can approach and engage with….
— We cannot completely comprehend the totality of our patient’s stories however we have the capacity to see half of it, or at least the part that our client tries to show us.

1. Age Bias

2. Gender Bias

3. Race/Ethnicity Bias

4. Religious Bias

What are the examples of different biases?

Cultural Pre-competence Stage

Cultural Awareness falls under what stage in the Cultural Competency Continuum?

Cultural Pre-competence Stage

Being exposed different cultures and becoming more aware and accepting of the differences

1. Active Listening

2. Silence

3. Making Observations

4. Open-Ended Questions

5. Seeking Clarification

6. Encouraging Descriptions of Perception

What are the strategies for Therapeutic Communication?

1. Providing False Reassurance

2. Giving Personal Opinion

3. Giving Defensive Response

4. Showing Sympathy

5. Changing the Subject

6. Approving or Disapproving

7. Arguing

What are the strategies for Non-therapeutic Communication?

Active Listening

— Listen for total meaning
— Avoid mental distractions
— Offer more questions than solutions

Silence

— At times, it is more useful not to speak at all rather than talk
— Our client needs time to process, and silence can be utilized to allow them to think through without feeling rushed

Open-Ended Questions

— Gives a sense of control to the patient on what they want to share 
— We go into it with the goal of understanding where they are coming from
— We would want to know their experience using their own words

Making Observations

— Pointing out something that we have noticed to better understand where our patients may be coming from
— Recognizing unique cultural aspects of patient's day-to-day activities → personal context

Seeking Clarification

— If there was something the patient didn't explain well that was confusing or ambiguous
— Make sure that we understood what was said correctly to ensure we are on the same page and avoid misunderstanding
— Encapsulate and get the meaning of what they want to say
— Similar to active listening

Encouraging Descriptions of Perception

— Can be very useful for individuals with perception/sensory issues or who might be experiencing hallucinations
— Can also be useful for people with certain beliefs coming from their own cultures

Providing False Reassurance

— Reassuring without full understanding can lead to false hope.
— We must offer realistic reassurance, acknowledging that we can't guarantee improvement.

Giving Personal Opinions

— We might be undermining their decision-making skills.
— We can recommend, explore,or give options to them without imposing our personal opinions

Changing the Subject

— Abrupt changes with the topic just because we’re not ready to deal with it or don’t know how to respond.
— Avoiding the conversation

Sympathizing

Outsider stance

Empathizing

Asking questions to understand their experience