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Grief Perspectives
Scholar's Corner
Resource Review
Your Professional Library

Building Cultural Competency

by William G. Hoy
I was a young clinician when I first encountered the work of Steven Covey (1989), famous for his Seven Habits of Highly Effective People. He stated his fifth habit as, “Seek first to understand, then to be understood.” Though I have certainly not always remembered to put the habit into practice (which probably means it is not really a habit!), the principle has served me well. My job as a caregiving professional has always been fundamentally to seek first to understand the stories and concerns of my patients and only then to help them understand whatever I think is important in their health. I generally think the same principle holds when we are working cross-culturally.

As typically used, the term cultural competence refers to one’s ability to interact effectively with individuals from a wide variety of cultural groups, assuring that the needs of diverse people are met. When we think about it in a health care or human service setting, generally we are thinking about how to approach people different than ourselves without expecting them to respond in the same ways we do to the same set of circumstances. Especially as I have interacted with colleagues in health care over the last couple of years with a couple of emergency department visits, two orthopedic surgeries, and more than a year of physical therapy, those interactions for me have been from the perspective of trust. I have gotten to know most of my providers and some of them I had relationships with before they became my doctors. That is not the experience of many individuals who come to the health care system from outside of the so-called “dominant” culture.
Many different cultural issues complicate how we provide care to patients, families, and communities at the end of life and in bereavement. Whether one typically is “told” about the seriousness of an illness is a cultural issue as well as a legal one; whether a patient (or family) expresses trust or mistrust of the caregiving system is another issue deeply steeped in cultural background. While there are many “skills” that are needed for practitioners to become culturally competent, I think the starting point has much more to do with character or values than the development of skills. In other words, it is our values that cause us to approach a person different from ourselves in a culturally competent way rather than any set of skills we have developed. Over the last few months, I have been thinking about three of those values though I am quite sure the list could be a great deal longer: respect, teachability, and compassion.
Respect is the first of these vital values. Respecting people from other cultures means believing in the deepest place of my heart that their ways are as appropriate for their background and their appraisal of the situation as are mine. This is the hardest value for me to embrace; I generally think there are “best ways” to approach dying patients and their families (such as with truth-telling) that might not be culturally respectful. Though some faith practices do not square with my personal theology, I can choose to see the beauty in them anyway, following Covey’s habit of “seeking first to understand…” Carl Rogers, the creator of client-centered counseling theory used to say that we must meet the person where he or she is; this is especially true when working cross-culturally.
In addition to respecting customs for the value they hold in the hearts and minds of individuals, respect also includes seeing individuals, families, and communities for what they are: individuals, families, and communities. It is not fair to say, “African Americans believe…” or “First Nations people hold this to be true…” Instead, our descriptions must always be accompanied by qualifiers: “Some African Americans believe…” or “In my work with First Nations people, this is the practice I have observed among most First Nations people.” No cultural group is a monolithic whole and to describe it as such is to commit one of the gravest of all cultural errors: stereotyping.
Asking myself questions such as the following helps me avoid stereotyping, eliminate assumptions, and deepen my respect for others: What is beautiful, artistic, or aesthetically pleasing about this custom/ceremony? How does this custom grow out of a particular belief? If I held this belief, would this ceremony help me to articulate that belief? When I consider what I think is true, does something in this group’s customs actually picture it better than my own practices? Is there something I can borrow from this cultural group to apply with my own beliefs and practices?
Teachability, the second value I find particularly important in cultural competence is generally defined as the ability to be taught. However, I think the word is much bigger; in fact, I think teachability refers to a willingness and readiness to learn. In the professions, we talk about the importance of life-long learning and teachability is clearly a component of that. We have all met people who believe they have learned all they need to learn.
The teachable individual asks questions with a real desire to understand. Especially among some Eastern Europeans (such as Romani people), as well as among some very traditional Welsh and Irish, it is important that a window be opened as a person nears death to allow the spirit to escape the building. My Kenyan friends will sometimes sell part of their land—a great challenge for subsistence farmers—to afford the appropriate funeral for a deceased parent. For us to exhibit teachability, we must see those customs as steeped in story and tradition, viewing them as appropriate behaviors in light of a particular belief system.
Teachability says my patient or my client is my teacher; he or she is the best authority on what is important for this chapter of his or her life and my role is to learn as much as I can and to support the individual in the quest to make meaning of this experience. When we take pre-med students with us to Kenya, we talk to them about the importance of “leaning in,” absorbing as much of the cultural experience as they can even when it is uncomfortable and seeking to learn all they can. While respect seems to be developed in asking myself questions, teachability is developed as we curiously ask others to help us learn about their cultural beliefs and practices.
Finally, I apprise that compassion is a necessary value in cultural competence. The Merriam-Webster Dictionary has a particularly robust definition to the word: “sympathetic consciousness of others' distress together with a desire to alleviate it” (“Compassion,” 2018, n.p.). To be “sympathetically conscious” is to bring all of our awareness to the sufferings of others. This is most important for those of us who are part of the “dominant society” working cross-culturally; many others have not had the same opportunities as we have. When acting with compassion about the patient who refuses to comply with the “non-compliant patient,” compassion considers, “Does a language barrier prevent her from understanding what I mean?” or “Does something in her life story make it hard for her to trust a person in health care?”
Many years ago, I happened upon a truism from educator of counselors, Larry Crabb and I have never forgotten the phrase: “All behavior is motivated.” Compassion understands there is a motivation to the belief and behavior I am seeing, even if the story that creates that motivation might be completely hidden from my view. If I am to live with compassion, I must make this awareness part of my appraisal of the decisions patients/clients and their families are making.
A discovery I have made in recent years about my own approach to cultural differences is that all the skill development I can attain will still not make me culturally competent. Only a change of attitude can accomplish that. It would seem that an ongoing effort to develop respect, teachability, and compassion in our own approach to people who are different will go a long way toward developing appropriate responses to cultural differences.
Compassion. (2018). Merriam-Webster dictionary of the English language. Retrieved from
Covey, S.R. (1989). The seven habits of highly effective people: Powerful lessons in personal change. New York, NY: Simon & Schuster.

The Author: For more than three decades, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide effective care. After a career in congregation, hospice, and educational resource practice, he now holds a full-time teaching appointment as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas.

Resource Review

Because cultural practices are so closely tied to religious beliefs, understanding the faith perspectives of large population groups can be a starting point in conversations with individuals about their preferred cultural practices. One vital source for learning about current beliefs and practices is the Washington, D.C.-based Pew Research Center ( The center conducts public opinion polling, demographic research, media content analysis and other empirical social science research without taking political or partisan positions. Their work is deeply respected by social scientists and the center’s data are widely quoted in the social science literature. At least three of the center’s eight core research areas grapple specifically with issues related to culture: Religion & Public Life; Hispanic Trends; and Social & Demographic Trends. While much of the center’s material is focused on the U.S., the Pew Global research area examines cultural and religious trends in Canada, the U.K., and other countries where this newsletter is read.
Your Professional Library
Matlins, S.M. (2000). The perfect stranger’s guide to funerals and grieving practices: A guide to etiquette in other people’s religious ceremonies. Woodstock, VT: SkyLight Paths.
Though not a new book, Stuart Matlin’s little gem, The Perfect Stranger’s Guide to Funerals and Grieving Practices is a must-have for anyone tasked with attending the funeral or providing support to a family from a culture other than one’s own. Most people face such activities with great anxiety; Matlin’s book goes a long way to reducing the fear factor.
With each of the 38 religious groups in the United States and Canada Matlins overviews, he briefly summarizes their history, notes the estimated number of adherents and offers a perspective on a few salient points: What should I wear to the service? Is it okay to send flowers or take food? How should I participate in the ritual? What can I expect to happen during the service?
Matlins addresses these questions with common groups like Roman Catholics and Buddhists, to be sure. But he also devotes chapters to some of the lesser-well-known groups like Baha’i ,Christian Science and Seventh-day Adventist.
Lists of characteristics always carries with it the risk of stereotyping by assuming that because I have learned a few important “general points,” I actually now understand this group. But with this caveat mentioned, the book is a great starting point for asking good questions and understanding beliefs and customs different from our own.
Research that Matters
Shahrour, T.M., Mochen, S., Siddiq, M., Hammasi, K.E., & Alsaadi, T. (2018) Suicide attempters in Abu Dhabi: Is criminal prosecution associated with patients’ guardedness? Death Studies, 42:10, 636-639, doi: 10.1080/07481187.2017.1421280
For more than two centuries, nation-states have been in process of de-criminalizing suicide attempts, eventually seeing the attempter as in need of psychiatric intervention. In 45 nations, attempted suicide is still a criminal offense including the United Arab Emirates (UAE) where an attempted suicide is punishable by imprisonment of up to five years and substantial fine.
In this study, the researchers examined all 364 patients who were admitted with suspected self-injury to emergency departments at the three government hospitals in Abu Dhabi. By law, private hospitals must transfer any patient presenting with symptoms of self-injurious behavior to the governmental hospitals. The research team interviewed each patient using a general mental status exam and watched especially for evidence that the patient’s “story changed” between initial admission and interview. Using the results of the examination, the research team established that patients who were legally charged with a suicide attempt were 1.6 times more likely to be guarded (changed story, provided narrative as alternative to the suicide attempt, etc.) than if the patient was not charged. Although all patients can be charged, only 39.2% were actually charged with suicide attempt.
On the basis of their data collection, the research team concluded that there was a substantial changing of story on the basis of whether or not the patient would be charged and that this can substantially mask the need for psychiatric intervention. If suicide attempts are treated as accidents, the researchers surmise, many suicidal individuals will be overlooked.
Clearly, there are many cultural issues in this study. First, there is still substantial “shame” related to suicide in countries where suicide is not viewed as an illegal act, so we do not get a “pass” in the places where the majority of this newsletter’s readers live and practice. Furthermore, it would be interesting to examine similar demographic groups in countries where suicide is not a criminal act to discover how “shame” might be a contributing factor to the desire to not report suicide attempts. It is also an almost certain fact that narratives evolve in the retelling so one must also consider that the additional interviews to which the charged patients were subjected might also have caused their stories to shift.
Readers working in cultures where suicide is decriminalized (Canada, Australia, the U.S., and the U.K. among them) must be ever-vigilant, however, in attending to patients with possible suicide attempts whose home culture is one where suicide is a criminal act. There would seem to be an implied tendency for these patients to be less than forthcoming about their own mental health issues, even when reporting these issues to health and human service providers in a decriminalized country.

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