WORK A Journal of Pre'i'ention,
Assessment & Rehabilitation
ELSEVIER
Work 6 (1996) 61-65
Sounding board
Cultural sensitivity: integrating cultural concepts into clinical practice * Dianna Good! MSOT Student, Boston UniL'ersity, 15 Green Street, Wate/Town, MA 02172. USA Received 17 September 1995; accepted 21 September 1995
Abstract
This paper draws insight from an assorted compilation of health care literature for the purpose of attaining a comprehensive perspective on issues encountered by health care professionals working with a culturally diverse clientele. The primary intent of this article is to provide clinically useful information geared toward enhancing quality health care services for people of various cultural backgrounds. Definition of difficulties experienced by practitioners and clients, as well as practical suggestions which may reduce ineffective treatment methods and increase successful treatment outcomes for individuals from diverse cultural identities are discussed. Deliberation of cultural issues will be limited to the African-American, Anglo-American, Asian, Hispanic and Native American Indian cultures.
Keywords: Diversity
In all health care professions, a comprehensive view of each client's cultural background as defined by values, beliefs and accepted behaviors, is needed to insure understanding and appreciation
-« The opinions expressed in this section may not necessarily represent the views of the editor, the publisher or the editorial board but are intended to stimulate discussion or to provoke a response. Readers who wish to comment on the ideas put forth in 'Sounding Board' should address their comments to the editor. I Tel.: + 16179261898.
of client diversity. When these constructs are integrated into a holistic approach to clinical practice, cultural sensitivity is maintained. A culturally sensitive treatment approach using a broad-based view of cultural influences, coupled with a focused view of the individual client and how specific methods of treatment clash or blend with the client's culture, allows health care professionals to modify treatment methodology to best serve each client. Culturally sensitive individualization of treatment methodology increases the ability of the client to relate to both the health
1051·9815/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. SSD11051·9815(95)00154·D
62
D. Good / Work 6 (J1)961 6/-65
care professional and the treatment methods used, thus increasing the likelihood of therapeutic goal accomplishment. Numerous authors support the theoretical presumption that integration of culturally sensitive client-centered concepts into clinical practice increases successful treatment outcomes (Kleinman, Eisenberg and Good 1978; Sue, 1981; Krefting, 1991; Pedersen, 1991). Pedersen (1991) indicates that a clinical approach to treatment which encompasses a broad view of client culture has several functional outcomes. One benefit noted was a better match of client expectations, which are grounded in cultural values and behavior. In addition to allowing health care practitioners to design treatment plans which utilize behavior accepted in the culture of the client, such treatment modification permits the matching of outcome goals set by therapists with those of the client. Research supports the notion that when a broad view of each client's culture encompassing ideologies underlying treatment expectations of clients is not taken into account, unsatisfactory treatment outcomes occur (Anderson, 1986; Kleinman, 1987). Poor results stem from a mismatch between treatment expectations of clients and therapists as well as a mismatch between treatment expectations and actions required during treatment. This phenomenon was demonstrated in research done by Anderson (1986). Her study indicated that Chinese families caring for children with chronic illnesses were likely to discontinue the use of rehabilitative procedures when treatment became uncomfortable for their child. In this study, normalization was the outcome goal determined for each child. Problems arose because the culturally biased definition of 'normal' differed between families and therapists. The families of these children held the comfort of their children in high esteem, and incorporated this value into their ideology of normalization. The health care professionals, however, defined normalization using standardized measures of physical, social, and psychological development which did not take comfort level into account. According to Anderson, the result of this interaction was dissatisfaction with the therapeutic outcome for both clients and health care professionals. These problems
were not caused by treatment methods which were inappropriate with regard to the children's illnesses, nor did the discontinuation of treatment result from a lack of understanding concerning treatment administration. These problems were the direct result of a deficit in knowledge, and clinical application of knowledge, concerning interactions between the cultures of health care professionals and their clients. Many health care professionals are caught off guard by the myriad of unexpected or subconscious cultural interplays encountered in the workplace. Unfortunately, a lack of preparation for such inevitable interactions may leave health care workers feeling frustrated and confused. Problems such as the one described by Andreson are likely to escalate as the number of people immigrating into the United States increases. The Bureau of the Census (1990) has projected that by the year 2000, 30% of the United States population will be comprised of people from AfricanAmerican, Asian, Hispanic, Native American Indian, and other non-white backgrounds. This calls for a closer inspection of treatment methodologies used in the health care profession, and how they can be geared toward clients of various cultural identities. In order to examine how these clients may be served best, it is beneficial for practitioners to gain a general overview of values, beliefs, and behaviors which are acceptable in the cultures of their clients as well as identify how their own culture influences clinical decision making. Deliberation of general characteristics of the AngloAmerican, African-American, Asian, Hispanic, and Native American Indian cultures will be presented in this review. These characteristics are not presented for use as a 'cookbook' approach to treatment. This pertains to treatment in which the health care practitioner takes an approach based on the notion that all members of a nationality will adhere to the same values, beliefs, and behaviors. Because each client's experiences are influenced by many variables such as age, sex, and level of enculturation (Pedersen, 1991), this should not be the method of clinical application. However, a general overview of basic cultural values, beliefs, and behaviors is helpful when determin-
D. Good / Work 6 (1996) 6/-65
ing whether standard treatment methods might need to be modified. The health care practitioner may first want to examine the ways in which their own culture affects treatment. Although the employment of minority health care workers is rising (Miller, 1994), the majority of the health care workers in America are of the AnglO-American descent. Many traditional values held by Anglo-Americans can be traced to the basic foundation of the American health care system. This presents a problem when using many standardized methods of treatment. One such underlying value promoted by the Anglo culture is that of independence (Banks, 1977; Ivey, 1981; Pedersen, 1988; Atkinson, Morten and Sue, 1989; Kinebanian and Stomph, 1992). When using standardized treatment methods practitioners must identify when they are promoting independence, and which culturally diverse clients may be negatively affected by this value. Sue and Sue (1990) indicate that the Asian culture has very family-centered values, while the African-American community values a sense of 'people-hood'. Wells (1994) writes that unity is a family value of African-Americans. She indicates that the length of time children depend on their parents within the family structure is prolonged in the Hispanic culture. Wells (1994) explains that the elderly as well as children are cared for by the family in the Hispanic culture. The Native American Indian culture exhibits the value of family unity through dependence upon other members of the household which often house three generations (Wells, 1994). For these reasons, it is recommended that the clinician include the client's family in clinical decision making and treatment. Clinicians may also want to follow through on this recommendation by inviting family members to sit in on therapy sessions. Because individual roles vary in different cultures, the therapist may want to inquire as to whether there is a designated person who cares for the needs of the client, even if the client is capable of learning to care for himself or herself. Through these modifications of treatment, independence which is usually stressed by the health care system may become a less emphasized part of treatment. This allows for an
63
emphasis on group care and the family dependence required for role fulfilment in many cultures. In addition to the independence valued by the Anglo culture, there is a strong belief that modern medicine is the most successful and perhaps only means of curing illnesses. This proves contradictory to the beliefs of many minority clients. In fact, 72% of respondents in a survey conducted by Kraut (1990) not only used alternative health care treatment but did not tell their physician that they engaged in other health care practices. Although many African-American clients consult only modern health care practitioners, some also USe more traditional forms of healing. Wells (1994) reports that Asian clients may be receiving services from spiritual healers or diviners in addition to western health care professionals. The concepts of Yin-Yang, hotj cold theories, herbs and meditation are among other forms of health care received by Asian individuals according to Wells. She explains that Hispanic clients may prescribe to hotjcold theories, folk practitioners, herbalists, practitioners of Espiritism or Santeria, in addition to western medicine. Native American Indian clients as well as other minorities are known to receive health care services in nontraditional forms. Wells notes that health care practices of this population may include medicine men, singing, chanting and rituals. Although health care practitioners from the Anglo-American background are often ethnocentric in the belief that western medicine provides better health care support than other non-traditional forms, it is clear that these other forms must be taken into consideration. Rankin and Kappy (1993) report that 'The ensuing conflicts between ethnic and allopathic medicine can result in low rates of utilization of allopathic care among some patients, reduced adherence to professional advice, and increased morbidity.' Rather than attempting to persuade clients not to use other forms of health care, health care workers may inquire about which alternative forms are being used, and consider how these practices may be incorporated into therapeutic methodology. Consideration should be taken concerning whether traditional forms of treatment will inter-
64
D. Good / Work 6 (J996) 6/-65
act negatively with non-traditional forms and modification of treatment should be made when needed. Good communication is essential not only for determining if the minority client is using alternative health care forms, but it influences every aspect of the therapeutic relationship. It is imperative that practitioners understand communication techniques and accepted behavior patterns surrounding communication in the culture of their clients. Anglo-American health care professionals are likely to shake hands when greeting a new client, use direct eye contact during conversation (Katz, 1985), and get straight to the point when doing business. These behaviors may clash with the commonly accepted behaviors of their clients from different cultural backgrounds. For example, the African-American client may use eye contact only when speaking and look away from the speaker when the health care provider is speaking to them (Wells, 1994). Wells states that the African-American client is more likely to use non-verbal behavior and nod the head rather than make eye contact to indicate listening. She also points out that asking a client if they are finished may be taken as rushing the client to complete an activity. It is suggested that the health care practitioner inquire as to whether the individual needs more time instead of asking if the individual is finished. Asian clients, like African-American clients may display non-verbal behavior which differs from that of the Anglo culture. Wells (1994) reports that women in this culture do not shake hands with either gender. Other conflicts include touching strangers which is considered inappropriate and making direct eye contact which may be shameful. Hispanic clients, unlike Asian clients, may be more prone to touch people with whom they are speaking. They may stand close to others while engaging in conversation, and avoid direct eye contact as a sign of respect. Hispanics may engage in prolonged small talk before getting down to business, and avoid discussing personal information with strangers (Wells, 1994). Native American Indians may also exhibit signs of dis-
comfort when asked personal question. They may consider it prying if the health care professional inquires about family matters. Another form of non-verbal behavior used in the Native American Indian culture which is not found in the Anglo culture consist of bowing the head as a sign of respect (Wells, 1994). A sensitivity to these forms of verbal and non-verbal behavior on the part of the health care practitioner will decrease the likelihood of miscommunication. The cultural characteristics given within this review are neither all inclusive nor entirely limited to the particular cultures indicated. They are presented as a guide to help increase awareness of health care professionals as to the complexity surrounding culturally sensitive practice. These guidelines are provided for the benefit of producing more satisfactory treat!TIent outcomes in a culturally diverse health care field. As Sapadone (1992) has indicated: 'A culturally competent therapist reinforces the beauty of culture, incorporates it into therapy, and is open to different ways of engaging the patient in treatment.' This can only be accomplished through the education of health care practitioners concerning their own cultural as well as the culture of their clients. References Anderson. J.M. (1986) Ethnicity and illness experience: Ideological structures and the health care delivery system. Soc. Sci. Med. 22(11). 1277-1283. Atkinson. D .• Morten. G. and Sue. D.W. (1989) Counseling American Minorities: A cross-cultural perspective. Debuque. IA: W.e. Brown. Banks. W. (1977) Group consciousness and the helping professions. Pers. Guid. J. 55. 319-330. Ivey. A.E. (1981) Counseling and psychotherapy: Toward a new perspective. In: Marsella. A.J. and Pedersen. P.B. (Eds.). Cross-Cultural counseling and psychotherapy. New York: Pergamon. Katz. J. (1985) The sociopolitical nature of counseling. Couns. Psycho!. 13.615-624. Kinebanian. A. and Stomph. M. (1992) Cross-cultural occupational therapy: a critical reflection. Am. J. Occup. Ther. 46(8). 751-757. Kleinman. A.. Eisenberg. L. and Good. B. (1978) Culture. illness. and care: Clinical lessons from anthropologic and cross-cultural research. Ann. Intern. Med. 88(2). 251-258.
D. Good / Work 6 (/996) 6/-65
Kraut. A.M. (J 990) Healers and strangers - immigrant attitudes toward the physician in America - a relationship in historical perspective. J. Am. Med. Assoc. 263. 1807-1811. Miller. S.M. (1994) Race in the health of America. In: Lee. P.R. and Estes. L. (Eds.). The Nation's Health (4th edn.>. pp.359-372. Pedersen. P. (J 99)) Multiculturalism as a generic approach to counseling. J. Counsel. Dev. 70(1), 6-12. Pedersen, P.B. (1988) A handbook for developing multicultural awareness. Alexandria. VA: American Association for Counseling and Development. Rankin, S.B. and Kappy, M.S. (1993) Developing therapeutic relationships in multicultural settings. Acad. Med. 68(1 I), 826-827.
65
Sapadone. R.A. (J 992) Internal-external control and temporal orientation among Southeast Asians and white Americans. Am. J. Occup. Ther. 46(8). 713-719. Sue. D.W. (198)) Counseling the culturally different. New York: John Wiley & Sons. Sue. D. W. and Sue. D. (J 990) Counseling the culturally different Cnd edn.). New York: John Wiley & sons. U.S. Department of Commerce. (J 990) Bureau of the Census: Current population reports. Washington DC: Government Printing Office. Wells. S.A. (1994) A multicultural education and resource guide for occupational therapy educators and practitioners. Rockville. MD: American Occupational Therapy Association.
Assessment & Rehabilitation
ELSEVIER
Work 6 (1996) 61-65
Sounding board
Cultural sensitivity: integrating cultural concepts into clinical practice * Dianna Good! MSOT Student, Boston UniL'ersity, 15 Green Street, Wate/Town, MA 02172. USA Received 17 September 1995; accepted 21 September 1995
Abstract
This paper draws insight from an assorted compilation of health care literature for the purpose of attaining a comprehensive perspective on issues encountered by health care professionals working with a culturally diverse clientele. The primary intent of this article is to provide clinically useful information geared toward enhancing quality health care services for people of various cultural backgrounds. Definition of difficulties experienced by practitioners and clients, as well as practical suggestions which may reduce ineffective treatment methods and increase successful treatment outcomes for individuals from diverse cultural identities are discussed. Deliberation of cultural issues will be limited to the African-American, Anglo-American, Asian, Hispanic and Native American Indian cultures.
Keywords: Diversity
In all health care professions, a comprehensive view of each client's cultural background as defined by values, beliefs and accepted behaviors, is needed to insure understanding and appreciation
-« The opinions expressed in this section may not necessarily represent the views of the editor, the publisher or the editorial board but are intended to stimulate discussion or to provoke a response. Readers who wish to comment on the ideas put forth in 'Sounding Board' should address their comments to the editor. I Tel.: + 16179261898.
of client diversity. When these constructs are integrated into a holistic approach to clinical practice, cultural sensitivity is maintained. A culturally sensitive treatment approach using a broad-based view of cultural influences, coupled with a focused view of the individual client and how specific methods of treatment clash or blend with the client's culture, allows health care professionals to modify treatment methodology to best serve each client. Culturally sensitive individualization of treatment methodology increases the ability of the client to relate to both the health
1051·9815/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. SSD11051·9815(95)00154·D
62
D. Good / Work 6 (J1)961 6/-65
care professional and the treatment methods used, thus increasing the likelihood of therapeutic goal accomplishment. Numerous authors support the theoretical presumption that integration of culturally sensitive client-centered concepts into clinical practice increases successful treatment outcomes (Kleinman, Eisenberg and Good 1978; Sue, 1981; Krefting, 1991; Pedersen, 1991). Pedersen (1991) indicates that a clinical approach to treatment which encompasses a broad view of client culture has several functional outcomes. One benefit noted was a better match of client expectations, which are grounded in cultural values and behavior. In addition to allowing health care practitioners to design treatment plans which utilize behavior accepted in the culture of the client, such treatment modification permits the matching of outcome goals set by therapists with those of the client. Research supports the notion that when a broad view of each client's culture encompassing ideologies underlying treatment expectations of clients is not taken into account, unsatisfactory treatment outcomes occur (Anderson, 1986; Kleinman, 1987). Poor results stem from a mismatch between treatment expectations of clients and therapists as well as a mismatch between treatment expectations and actions required during treatment. This phenomenon was demonstrated in research done by Anderson (1986). Her study indicated that Chinese families caring for children with chronic illnesses were likely to discontinue the use of rehabilitative procedures when treatment became uncomfortable for their child. In this study, normalization was the outcome goal determined for each child. Problems arose because the culturally biased definition of 'normal' differed between families and therapists. The families of these children held the comfort of their children in high esteem, and incorporated this value into their ideology of normalization. The health care professionals, however, defined normalization using standardized measures of physical, social, and psychological development which did not take comfort level into account. According to Anderson, the result of this interaction was dissatisfaction with the therapeutic outcome for both clients and health care professionals. These problems
were not caused by treatment methods which were inappropriate with regard to the children's illnesses, nor did the discontinuation of treatment result from a lack of understanding concerning treatment administration. These problems were the direct result of a deficit in knowledge, and clinical application of knowledge, concerning interactions between the cultures of health care professionals and their clients. Many health care professionals are caught off guard by the myriad of unexpected or subconscious cultural interplays encountered in the workplace. Unfortunately, a lack of preparation for such inevitable interactions may leave health care workers feeling frustrated and confused. Problems such as the one described by Andreson are likely to escalate as the number of people immigrating into the United States increases. The Bureau of the Census (1990) has projected that by the year 2000, 30% of the United States population will be comprised of people from AfricanAmerican, Asian, Hispanic, Native American Indian, and other non-white backgrounds. This calls for a closer inspection of treatment methodologies used in the health care profession, and how they can be geared toward clients of various cultural identities. In order to examine how these clients may be served best, it is beneficial for practitioners to gain a general overview of values, beliefs, and behaviors which are acceptable in the cultures of their clients as well as identify how their own culture influences clinical decision making. Deliberation of general characteristics of the AngloAmerican, African-American, Asian, Hispanic, and Native American Indian cultures will be presented in this review. These characteristics are not presented for use as a 'cookbook' approach to treatment. This pertains to treatment in which the health care practitioner takes an approach based on the notion that all members of a nationality will adhere to the same values, beliefs, and behaviors. Because each client's experiences are influenced by many variables such as age, sex, and level of enculturation (Pedersen, 1991), this should not be the method of clinical application. However, a general overview of basic cultural values, beliefs, and behaviors is helpful when determin-
D. Good / Work 6 (1996) 6/-65
ing whether standard treatment methods might need to be modified. The health care practitioner may first want to examine the ways in which their own culture affects treatment. Although the employment of minority health care workers is rising (Miller, 1994), the majority of the health care workers in America are of the AnglO-American descent. Many traditional values held by Anglo-Americans can be traced to the basic foundation of the American health care system. This presents a problem when using many standardized methods of treatment. One such underlying value promoted by the Anglo culture is that of independence (Banks, 1977; Ivey, 1981; Pedersen, 1988; Atkinson, Morten and Sue, 1989; Kinebanian and Stomph, 1992). When using standardized treatment methods practitioners must identify when they are promoting independence, and which culturally diverse clients may be negatively affected by this value. Sue and Sue (1990) indicate that the Asian culture has very family-centered values, while the African-American community values a sense of 'people-hood'. Wells (1994) writes that unity is a family value of African-Americans. She indicates that the length of time children depend on their parents within the family structure is prolonged in the Hispanic culture. Wells (1994) explains that the elderly as well as children are cared for by the family in the Hispanic culture. The Native American Indian culture exhibits the value of family unity through dependence upon other members of the household which often house three generations (Wells, 1994). For these reasons, it is recommended that the clinician include the client's family in clinical decision making and treatment. Clinicians may also want to follow through on this recommendation by inviting family members to sit in on therapy sessions. Because individual roles vary in different cultures, the therapist may want to inquire as to whether there is a designated person who cares for the needs of the client, even if the client is capable of learning to care for himself or herself. Through these modifications of treatment, independence which is usually stressed by the health care system may become a less emphasized part of treatment. This allows for an
63
emphasis on group care and the family dependence required for role fulfilment in many cultures. In addition to the independence valued by the Anglo culture, there is a strong belief that modern medicine is the most successful and perhaps only means of curing illnesses. This proves contradictory to the beliefs of many minority clients. In fact, 72% of respondents in a survey conducted by Kraut (1990) not only used alternative health care treatment but did not tell their physician that they engaged in other health care practices. Although many African-American clients consult only modern health care practitioners, some also USe more traditional forms of healing. Wells (1994) reports that Asian clients may be receiving services from spiritual healers or diviners in addition to western health care professionals. The concepts of Yin-Yang, hotj cold theories, herbs and meditation are among other forms of health care received by Asian individuals according to Wells. She explains that Hispanic clients may prescribe to hotjcold theories, folk practitioners, herbalists, practitioners of Espiritism or Santeria, in addition to western medicine. Native American Indian clients as well as other minorities are known to receive health care services in nontraditional forms. Wells notes that health care practices of this population may include medicine men, singing, chanting and rituals. Although health care practitioners from the Anglo-American background are often ethnocentric in the belief that western medicine provides better health care support than other non-traditional forms, it is clear that these other forms must be taken into consideration. Rankin and Kappy (1993) report that 'The ensuing conflicts between ethnic and allopathic medicine can result in low rates of utilization of allopathic care among some patients, reduced adherence to professional advice, and increased morbidity.' Rather than attempting to persuade clients not to use other forms of health care, health care workers may inquire about which alternative forms are being used, and consider how these practices may be incorporated into therapeutic methodology. Consideration should be taken concerning whether traditional forms of treatment will inter-
64
D. Good / Work 6 (J996) 6/-65
act negatively with non-traditional forms and modification of treatment should be made when needed. Good communication is essential not only for determining if the minority client is using alternative health care forms, but it influences every aspect of the therapeutic relationship. It is imperative that practitioners understand communication techniques and accepted behavior patterns surrounding communication in the culture of their clients. Anglo-American health care professionals are likely to shake hands when greeting a new client, use direct eye contact during conversation (Katz, 1985), and get straight to the point when doing business. These behaviors may clash with the commonly accepted behaviors of their clients from different cultural backgrounds. For example, the African-American client may use eye contact only when speaking and look away from the speaker when the health care provider is speaking to them (Wells, 1994). Wells states that the African-American client is more likely to use non-verbal behavior and nod the head rather than make eye contact to indicate listening. She also points out that asking a client if they are finished may be taken as rushing the client to complete an activity. It is suggested that the health care practitioner inquire as to whether the individual needs more time instead of asking if the individual is finished. Asian clients, like African-American clients may display non-verbal behavior which differs from that of the Anglo culture. Wells (1994) reports that women in this culture do not shake hands with either gender. Other conflicts include touching strangers which is considered inappropriate and making direct eye contact which may be shameful. Hispanic clients, unlike Asian clients, may be more prone to touch people with whom they are speaking. They may stand close to others while engaging in conversation, and avoid direct eye contact as a sign of respect. Hispanics may engage in prolonged small talk before getting down to business, and avoid discussing personal information with strangers (Wells, 1994). Native American Indians may also exhibit signs of dis-
comfort when asked personal question. They may consider it prying if the health care professional inquires about family matters. Another form of non-verbal behavior used in the Native American Indian culture which is not found in the Anglo culture consist of bowing the head as a sign of respect (Wells, 1994). A sensitivity to these forms of verbal and non-verbal behavior on the part of the health care practitioner will decrease the likelihood of miscommunication. The cultural characteristics given within this review are neither all inclusive nor entirely limited to the particular cultures indicated. They are presented as a guide to help increase awareness of health care professionals as to the complexity surrounding culturally sensitive practice. These guidelines are provided for the benefit of producing more satisfactory treat!TIent outcomes in a culturally diverse health care field. As Sapadone (1992) has indicated: 'A culturally competent therapist reinforces the beauty of culture, incorporates it into therapy, and is open to different ways of engaging the patient in treatment.' This can only be accomplished through the education of health care practitioners concerning their own cultural as well as the culture of their clients. References Anderson. J.M. (1986) Ethnicity and illness experience: Ideological structures and the health care delivery system. Soc. Sci. Med. 22(11). 1277-1283. Atkinson. D .• Morten. G. and Sue. D.W. (1989) Counseling American Minorities: A cross-cultural perspective. Debuque. IA: W.e. Brown. Banks. W. (1977) Group consciousness and the helping professions. Pers. Guid. J. 55. 319-330. Ivey. A.E. (1981) Counseling and psychotherapy: Toward a new perspective. In: Marsella. A.J. and Pedersen. P.B. (Eds.). Cross-Cultural counseling and psychotherapy. New York: Pergamon. Katz. J. (1985) The sociopolitical nature of counseling. Couns. Psycho!. 13.615-624. Kinebanian. A. and Stomph. M. (1992) Cross-cultural occupational therapy: a critical reflection. Am. J. Occup. Ther. 46(8). 751-757. Kleinman. A.. Eisenberg. L. and Good. B. (1978) Culture. illness. and care: Clinical lessons from anthropologic and cross-cultural research. Ann. Intern. Med. 88(2). 251-258.
D. Good / Work 6 (/996) 6/-65
Kraut. A.M. (J 990) Healers and strangers - immigrant attitudes toward the physician in America - a relationship in historical perspective. J. Am. Med. Assoc. 263. 1807-1811. Miller. S.M. (1994) Race in the health of America. In: Lee. P.R. and Estes. L. (Eds.). The Nation's Health (4th edn.>. pp.359-372. Pedersen. P. (J 99)) Multiculturalism as a generic approach to counseling. J. Counsel. Dev. 70(1), 6-12. Pedersen, P.B. (1988) A handbook for developing multicultural awareness. Alexandria. VA: American Association for Counseling and Development. Rankin, S.B. and Kappy, M.S. (1993) Developing therapeutic relationships in multicultural settings. Acad. Med. 68(1 I), 826-827.
65
Sapadone. R.A. (J 992) Internal-external control and temporal orientation among Southeast Asians and white Americans. Am. J. Occup. Ther. 46(8). 713-719. Sue. D.W. (198)) Counseling the culturally different. New York: John Wiley & Sons. Sue. D. W. and Sue. D. (J 990) Counseling the culturally different Cnd edn.). New York: John Wiley & sons. U.S. Department of Commerce. (J 990) Bureau of the Census: Current population reports. Washington DC: Government Printing Office. Wells. S.A. (1994) A multicultural education and resource guide for occupational therapy educators and practitioners. Rockville. MD: American Occupational Therapy Association.
