Complexities of Culture and Counseling

Culture and Counseling

In her book The Spirit Catches You and You Fall Down, author Anne Fadiman recounts the life and death of a little Hmong girl living in Merced, California. Lia Lee had what Western doctors call epilepsy, and which the Hmong have a far more lyrical explanation that lends itself to the title of Fadiman's book. The most common neurological disease, epilepsy can be frightening and potentially debilitating. However, in cultures around the world and throughout time, from the Hmong to the ancient Greeks, epilepsy opens pathways to creativity and an increased understanding of the universe. Thus, as Fadiman points out, many epileptics become shamans. When Lia Lee first started having epileptic seizures, her mom Foua, speaking not a word of English, rushed her to the Merced Community Medical Center. There, doctors tended to the eight-month-old child as best they could under the circumstances. Because all she was doing was coughing when she arrived at the hospital, doctors gave her chest x-rays and diagnosed Lia Lee with "early bronchiopneumonia or tracheobronchitis," unaware that she had just recently seized. The same thing happened on more than one occasion until finally Lia Lee was rushed to the medical center in the middle of a seizure. Visible evidence at hand, doctors were then able to accurately diagnose Lia Lee's illness and prescribe a course of treatment.

That all would have been simple enough had Lia Lee's family been able to communicate with the doctors at Merced Community Medical Center (MCMC). Fortunately, the first doctor that did treat Lia Lee for her epilepsy was a resident named Dan Murphy, who had what Fadiman describes as love and deep respect for the Hmong culture. Still, potent linguistic and semantic barriers remained in place, preventing Lia Lee from receiving the treatments that would have best suited her. Thrown into the care of doctors and medical specialists who, in spite of good intentions, failed to meet the needs of Lia Lee and her family, little Lia Lee was eventually wrested from the loving arms and placed into a foster home. As a ward of the state, Lia Lee and her family suffered immensely, and for no real reason. The doctors that recommended her transfer into foster care believed that the Lee family's noncompliance with treatment was a sign of gross neglect, even child abuse. However, through her book Fadiman captures the underlying causes of the patient noncompliance: culture clash, the root of the difficulties faced by not only Hmong living in Merced but by non-whites and non-native English speakers throughout the United States. Culture clash is not limited to the language barrier, although that is a significant aspect of it and one that needs to be adequately addressed by the medical and social scientific communities. Besides language barriers, obstacles to cross-cultural communication include ethnocentricism, competing worldviews, metaphysical arguments, and a conflict of the essential philosophies and values of life. Such matters can hardly be captured by a translator, which is why linguistics is only one facet of the problem.

The Spirit Catches You and You Fall Down examines the various obstacles toward patient-doctor communication in a cross-cultural setting. Seeing what happened with Lia Lee, Fadiman advocates mandatory multicultural awareness programs in all medical communities, in fact all service communities. By incorporating cross-cultural sensitivity into their training programs as more than just theoretical, politically correct lip-service, the problems faced by the Lees could in the future be avoided. Because most communities in the United States are multi-ethnic, the message of The Spirit Catches You and You Fall Down is an urgent one. Families like the Lees experience similar situations every day in the United States. Whether they are from Mexico or Montenegro, Latvia or Laos, individuals from nations other than our own often receive inferior treatment at hospitals and by doctors who feel they know what's best. Paternalism is the problem, an attitude of subtle condescension that mars the doctor-patient relationship and undermines treatment. The Hmong provide a perfect example of the failure of Western medicine to escape paternalism and its cousin, arrogance. As Fadiman points out, Hmong culture is historically resilient and proud. Like so many ethnic minorities, the Hmong have been persecuted for centuries, driven out of their ancestral homes in mass exodus. Preserving their communities has not been easy. When Hmong come into contact with paternalism, they naturally turn their noses and shut their eyes.

Non-compliance, therefore, comes not from arrogance on the part of the Hmong, but rather, from a justified suspicion of a paternalistic medical culture, of the imposition of Western culture, Western values, Western practices, and Western beliefs upon Hmong counterparts. To assume that patient non-compliance is due to ignorance is in itself a painfully ignorant belief. The Hmong's rich, strong cultural fabric bears witness to the need to respect, not disparage, their community. When they came into contact with the American medical system, the Hmong viewed it "not as a gift but as a form of coercion," (Fadiman 37). Going to the hospital is viewed as a "dreaded last resort," (Fadiman 63). The mistrust of the American medical community actually extends to the Hmong communities in Laos, where tales of Western medicine have reached Hmong ears and where many Hmong have come also into contact with Western institutions directly. "Hmong fear and shun the hospital," according to Fadiman, and for good reason (24). Allopathic medicine devalues the indigenous beliefs of people like the Hmong, even if those indigenous beliefs have survived for far longer. Allopathic doctors have failed to bridge cultural gaps by including what Fadiman calls cultural brokers into their regular practices.

The role of the cultural broker extends far beyond that of the translator. The translator simply replaces one lexicon for another, using direct translation of words to impart simple meanings. The cultural broker, on the other hand, translates not only language but values, belief systems, cultural norms, and worldviews. The cultural broker informs the allopathic doctor about body language, gender roles, and any other information pertinent to clear unequivocal communication. Patient non-compliance often arises from miscommunication as well as from a lack of respect by the patient for the doctor. Respect is always a two-way street: in order to increase their likelihood of being treated with respect, allopathic doctors must be willing to give it in return. Therefore, one of the first steps in a program of multicultural medicine is education. Doctors who work in multicultural communities must inform themselves about the cultures with which they work.

It is impossible to treat Hmong or any other ethnic group properly without understanding their history, values, and beliefs. A culture's history indirectly informs the individual patient's history. For example, American cultural history rests on values such as self-reliance, independence, and Manifest Destiny. Not all cultures share this history. American cultural history informs American value systems: we raise our children to be self-reliant and independent rather than communal; we teach our children a sense of entitlement that stems from the philosophy of Manifest Destiny. When we encounter cultures other than our own, we should also try to peek into their shared history, the collective consciousness that drives a person's behavior. Knowledge about an individual's cultural background offers an invaluable window into the soul of the individual. Penetrate the soul of the culture, and the doctor can perceive optimal avenues for communication and cooperation. As the Hmong realize, optimal healing and well-being cannot occur otherwise.

Moreover, both patient and doctor share the same goal: healing. Therefore, both should remain fixated on that shared goal. If a Hmong patient wishes not to have a blood test, so be it. If a Hmong patient wishes to bring in the family shaman for ancillary treatment, why not allow it? Fadiman notes that shamans could be afforded the same status as priests and rabbis. For many cultures, healing is largely a spiritual matter and there is no reason to exclude spirituality from places of healing. Even if Western medicine is firmly committed to reason and verifiable evidence, spirituality will not impede a patient's prognosis.

In The Spirit Catches You and You Fall Down, Fadiman offers a set of solutions for doctors and other health care practitioners. The author recounts some interesting solutions that have been proposed and even executed. For example, on 269 the author recalls the "integrated mental health delivery service" put on by the Nationalities Service of Central California in the 1980s, which incorporated Hmong txiv neebs into the Western hospital setting. Such integrative medical practices can and should become the wave of the future for Western medicine, which suffers from a lack of cross-cultural awareness and understanding. On page 266, Fadiman offers a list of some things that can help doctors and health care professionals to increase cultural competence with the Hmong. From there, the author extends the advice to all cultures. For example Fadiman suggests that female doctors treat female patients, male doctors treat male patients. Community leaders as well as immediate family should be permitted to consult and talk with patients, serving as cultural intermediaries. Often, the patient will better understand the wishes of a community elder or shaman than the doctor, not because of a personal mistrust but because there is a huge cultural divide. When a Western doctor wants a patient to take medications or undergo surgery, the patient often refuses because of a lack of trust understanding, so community leaders can help bridge that gap. Doctors and nurses can phrase their wishes or prescriptions in words and language familiar to the patient and non-threatening. In some cases, the doctor-patient relationship can turn more poetic, more nuanced, when cross-cultural communication takes place. Fadiman offers one such instance, when social worker Francesca Farr made a house call to a Hmong family. Farr respected the Hmong traditions of speaking directly with the husband before the wife, and of phrasing requests in ways meaningful to the Hmong. Moreover, Farr brought along a cultural broker who was able to walk Farr through the process of communicating with Hmong not in their native tongue but with the nonverbal cues that are so essential in any conversation.

Race, ethnicity, language, and religion commingle to form a worldview. The corresponding worldview also informs social roles and norms, including the roles of doctor and patient. Worldview also informs concepts of healing and illness. The doctor-patient relationship, like all social relationships, is established and based on roles and role definitions. These role definitions differ between cultures just as definitions of words differ. In Hmong culture, the doctor plays a far different role than in the United States. In Hmong culture, doctors come right to the patient's home and bedside, rather than the family taking the patient to a crowded hospital. Then, the doctor attends to the needs of the family as well as to the patient. His role is authoritative but not authoritarian. He may be imbued with spiritual power. Thus, the relationship between patient and txiv neeb is one of mutual respect and understanding. The role of the doctor in the United States is much different. The doctor does not make house calls, because of financial constraints as well as the less friendly role of the doctor in modern medicine. The doctor does not perform the intake survey, other health care workers do, in a hierarchical chain of command. Thus, the patient is several rungs on the social ladder removed from the doctor, who occupies a position of supposed moral, social, and usually economic authority. Except in rare cases, the doctor does not sit by the patient's bedside in the United States, for he or she is far too busy to do what nurses do. In Western medicine, the doctor occupies a position of authority that patients dare to question. When told to take a certain pill or get a certain surgery, the patient will comply or else face criticism and scorn. When the patient is a child, his or her parents risk losing their baby, like the Lees lost theirs. In cases like that of the Lees, noncompliance is not due to stubbornness and definitely not neglect or abuse. Noncompliance is a factor of race, religion, spirituality, language, and culture. Compliance can arise through cross-cultural awareness and respect.