Journal of Religion and Health, Vol. 32, No. 4, Winter 1993

Transcultural Hospital Pastoral Care DAVID G. HAWKINS

ABSTRACT: Transcultural hospital pastoral care's subjects, the immigrant and the refugee, are

described. Differences and similarities are noted. Three difficulties--culture shock, prejudice, and ethnocentrism--are followedby principles of transcultural hospital pastoral care, the significance of hospitalization, and a case history.

Immigrant In the early 1950s I decided to attend seminary in order to practice ministry in Canada. I had time enough to reach this decision, delegate or terminate personal and business matters, m a k e my farewells, pledge promises of bonding with relatives and friends, and choose what to bring with me to Canada. My resettlement was eased by "advocates" in both country of origin and host country. Within Canada, I had a preferred destination, somewhere to go. The immigrant is typically intentional and organized. With some education and/or training, he or she is customarily adaptable enough "to t u r n m y hand to almost anything until the right thing turns up." Transition from one country to another occurs for m a n y reasons--family sponsorship, ambition, boredom, need of pastureland, pursuing patterns of crop growth and game movement, for example.

Refugee The forced flight of the refugee "is often precipitous and unplanned with no time for closures and goodbyes. Further, decisions about whom and what to bring often are not possible. ''1 The primary expulsive force is what novelist George Eliot in Daniel Deronda terms "political refugeeism." Other reasons include war's indiscriminate violence, natural disasters, genocide, psychological brutality, persecution, deprivation, and pursuit. What distinguishes the refugee "is violence resulting from conflict between state and civil society, The Rev. David G. Hawkins, B.A., S.T.M., D. Rel., R.S.W., of St. George'sAnglican Church in Vancouver, is a chaplain at VancouverGeneral Hospital. 291

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between opposing armies or conflict among ethnic groups or class formations that the state is unwilling or unable to control. ''~ Today's phenomenon is the multitude of stateless persons condemned to interminable confinement in relocation camps. They exhibit, in varying degrees, dependence, depression, indifference, or determination to survive. They represent the casualty and victim who, through accidents of birth, belonging, and location, is caught in the crossfire and the eye of somebody else's hurricane.

Differences. "A basic and age-old characteristic of man is that he often moves from one place to another. Generally because he wants to. Sometimes because he has to. These two conditioning factors mark the fundamental difference between immigrants and refugees. The former are predominantly voluntary migrants. The latter are involuntary ones. ''3 The immigrant is "pulled out" by a counter-attraction. The refugee is "pushed out" by an alien force. "An immigrant is usually going to something; a refugee is usually fleeing from something. ''4 The immigrant's primary goal is resettlement. The refugee's primary goal is survival. Similarities. Supposedly the voluntary migrant is more "normal" than the involuntary refugee and less prone to hardship. Yet Bernard concludes, "Perhaps the refugee may be more likely to be so (psychologically hurt) but the difference between his wounds and those of the immigrant appear to be those of degree rather than type. It is not that the refugee develops psychoses completely unknown to the immigrant. It is just that he may acquire them more often and perhaps more sharply. ''5 We examine three difficulties common to both. Culture shock "is that malady that occurs in response to transition from one setting to another; in which the individual is placed in an unfamiliar situation where former patterns of behavior are totally ineffective; and in which basic cues for social intercourse are absent. ''~ Other stressors include: Communication is necessary to find meaning of and obtain cues for behavior. It provides feedback for behavior modification to fit the situation. In an alien language the individual plays the role of a deaf mute who, although he hears and sees, attaches little meaning to verbal and non-verbal messages. Even when the language is known, its colloquialisms, tonal differences, and other factors may obscure meaning. Particularly with people from Southeast Asia is it necessary to distinguish between the primary language spoken in the country of origin and that spoken in the home. Mechanical differences encountered include public utilities (water, gas, telephone, electricity), clothing change, shopping, access to and use of travel facilities, household appliances, house types, and so on. Many elderly find it easier to remain within the ethnic enclave which then becomes a ghetto, rather than to risk embarrassment

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within the wider community. Some will never adjust. Elderly Punjabis in Canada ambivalently refer to their host country as a "sweet prison," from which they will never depart for "home." Isolation is inherent not only because of communication barriers but in an environment populated by strangers. Friendlessness and non-relatedness are apparent. Distance between self and others is magnified or distorted. Making friends and becoming significant to someone in the new situation becomes a lonely task. Many elderly are lonely because in the West aging appears to be primarily biological. In their countries of origin, it is considered spiritual and cultural. Customs involve reciprocal role relationships generally, and particularly sex-linked relationships. Class, status, kinship networks, and etiquette, more often than not implied rather than explicit, need to be respected. Attitudes, beliefs, and values about h u m a n life and conduct distinguish one group from another. Belief systems are not necessarily explicit statements and, because they are more difficult to isolate, are easier to infringe upon. It appears that ethnic groups of color and those in the lower socioeconomic scale either never achieve integration or maintain their own attitudes, beliefs, and behaviors. 7

Prejudice. Writing of the refugee, Zolberg identifies contributory reasons for xenophobia, racism, intolerance, and the like. "Refugee status is a privilege or entitlement, giving those who qualify access to certain scarce resources or services outside their own country, such as admission into another country ahead of a long line of claimants, legal protection abroad and often some material assistance from public or private agencies. ''8 Ethnocentrism is subtle. It shows itself in majority class assumptions, biases, and generalizations. These are often unthinkingly conveyed by health workers who, customarily middle-class and unilingual, deliver "dominant culture service models and information inappropriate or useless. ''9 Possessed of and sometimes by their biomedical culture, they "become frustrated and disappointed and tend to settle back to what they are accustomed to doing with white, middle-class patients and their families. ''1~ Brink and Saunders add, "More insidious still, the field worker is often unaware of his own attitudes and belief systems prior to entering the field and reacts according to his belief system rather than that of the host country. ''11 We have defined transcultural pastoral care, described its consumers and features common to both. Now, what is hospital pastoral care's role? Transcultural Hospital Pastoral Care: Principles. Anderson and her colleagues identify four "areas of assessment" that lend themselves to this purpose. 12 Recognition of the influence of one's own ethnicity and culture. In addition to what has already been said, consider the chaplain frustrated by an Asian

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woman's passivity and deference that conflict with his or her value of assertiveness.

Establishing the role of the patient's ethnicity in beliefs about illness. Cultures generally give their people specific concepts about the body, how and why sickness occurs, its expressions and outcomes, medication and other treatment procedures. "Some societies consider the whole self is different from 'my sore leg' or 'my sick stomach.' The former is social fact. The latter is anatomic statement. In many cultures, anatomical statement is not part of 'body knowledge.' So some peoples will report pain due to coldness or to an object that has 'entered' the body; the weakness may be explained by a supernatural 'robbing' of the spirit. Clearly the explanation of the symptom or illness will influence the behavior of the sick person. ''~" Determining differences in viewpoints of patients and clinicians about health and illness. Discrepancies will exist between the biomedical culture's perspectives and those of the ethnic culture involved. The hospital chaplain may sensitively and over time determine what the patient calls the problem, the name given to it, what causes it, why it started when it did, what it does to the body, how it works inside the body, how severe it is, what is more feared about it, what problems it causes personally and to the family, what kind of treatment is expected, what is anticipated from this.

Identifying the influence of the family on health care and identifying social and religious support networks. In many cultures, family life and its problems are personal. Questions about these are unwarranted intrusions. The significance of the extended family should never be underestimated. Multigenerational, composed of family members by birth, adoption, and marriage, it may encompass many households. A non-biologically related person may be a parent in the family network. In times of crisis, all are expected to guide and support. The extended family, then, is an emotional and an economic unit that displays, at best, affectionate connectedness, respectful separateness. At worst, its members are unhealthily stuck together. Of it, Bashir Qureshi writes, "A man will act as figure-head, security officer, wise man, family historian, arbitrator and, in some cases, commander." And we add taxpayer and caretaker. Qureshi continues, "A woman may act as culture protector, folk remedial therapist, marriage counselor, child minder, baby sitter, chief cook, home help, night nurse, health visitor and family crisis advisor. In return [she receives] the 'financial' reward of food and accommodation, as well as the 'psychologicar reward of being respected, wanted and loved. General practitioners who understand this will have a good rapport with such patients. '~4 To these principles of transcultural hospital pastoral care we add two further considerations.

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Biblical world view. Migration, flight, and the search for a continuing city (Hebrews 13:14) are central to the biblical record. Identification with, protection of, and love for the immigrant and refugee are matters of creed (Deuteronomy 26:1-11) rather than ethics. The experiences of both are chronicled in Exodus, the stories of Joseph, records of the Babylonian exile, and so on. The book of Ruth is a manual on immigration, exogamy, and displacement. It features the exiled (Naomi), the foreigner (Ruth), and the native (Boaz). According to Matthew, Jesus is a refugee child. Later he describes himself as one with "nowhere to lay his head" (Luke 9:58; Matthew 8:20). Christians and the congregations to which they belong live as aliens and strangers amid their surroundings. The first missionaries to Jerusalem are refugees (Acts 8). The Christian Gospel transforms the stranger into a newcomer. This biblical record is not of a world "churchified" but, rather, recognition of similarities and differences, of the "universal, the group-specific and the unique. '~5 "Every man." Each person, like all others in the world, shares commonalitiesmbiological, psychological, sociocultural. "We are all born helpless, we grow from dependence towards self-management, we relate to other beings and to a physical environment, we age and one out of one dies. ''1~ Each person, like some others, shares local and cultural shaping, embeddedness, formation, beliefs, customs, rituals, and values. Each is like no other and is unique with feelings, genetic code, fingerprints, perceptions, lifestyle, memories, dental and voice patterns, life history, and developmental sequence; each person comes "individually wrapped." "No other person will ever see, think, feel, celebrate, or suffer in the identical way. ''17 Hospitalization. Culture shock occurs when residence is changed, such as at the time of hospitalization. It is exacerbated when the need for this is neither recognized nor understood. "This abrupt transition from a free, independent, productive adult to an immobilized patient in a new setting can be seen as a stressor that requires not only adjustments in lifestyle but also in self-perception."ls Before we meet our patient, we briefly look again at the five environmental stresses cited above, and relate these to hospitalization. Communication--the patient is introduced to hospital language; for example, "void," "EEG," "X-ray." A procession of health care givers enter and leave the room without anticipation of the patient's "Who?", "What?", and "Why?" Mechanical differences-what buttons "work" the bed, its side rails, the TV, access to the nurses' station, the toilet's emergency signal? The use of the bedpan rather than going to the toilet is an adjustment. Walking may be restricted. The intricacies of the menu are deep. Add to these adaptation to catheters, casts, cardiac monitors, and so on. Customsmdifficult are the "patient mode" of staying in bed even when feeling "fine," the hospital gown rather than the

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patient's own apparel, rearrangement of the daily schedule, hospital procedures, protocols, and patient role behaviors. Isolation--the patient is separated out from family, friends, and work associates, especially if confined within a special care area. Visiting hours are restricted. Daily living activities are subject to the scrutiny of strangers, other patients, and staff. Attitudes and beliefs--a primary mystique is that everyone knows what is going on except the patient. Patients are low-status in the hospital hierarchy. Their questions are unheard, answered vaguely or non-directly. The status relationship may be maintained by keeping them in ignorance. A patient may react to some or all of these stressors. Is he angry because he receives coffee and not tea? (Mechanical). Does he call repeatedly for a bedpan when he urgently needs not to be alone? (Isolation). Why does he refuse medications and treatment? (Communication). Does he ask unanswerable questions? (Attitudes and Beliefs). Does the patient insist upon doing things "his way" regardless of staff time, energy, and "wear and tear?" (Customs).

A case history The room is filled with food and visitors. "The more visitors, the more respect and dignity of the person. ''19 I enter and enquire of the patient's first, second, and last name as he is not a Christian. He is non-compliant. A nurse yells at him in the belief that he will better understand her. A social worker is seen as an embarrassment to his family, and her presence reflects badly upon it. A staff member translates adequately yet fails to interpret; that is, she conveys the words' meanings yet ignores facial expressions, intonation, and gesture. The patient is withdrawn, anxious, and alienated. One of the children present is fractious. Her father slaps her. The Asian personality profile is touch, hearing, and vision. The Western personality profile is vision, hearing, and touch. So I need to be cautious about what constitutes child abuse. A colleague reported to the police that a child had severe bruising on her back. But for five days prior to her daughter's hospitalization the mother had applied the Vietnamese treatment of "spooning" (the pressure of a silver spoon up and down the child's back to remove the disease). A physician enters. "Shared privacy" takes over. "The relatives expect to be present at consultations. They believe it to be their right to receive details of the patient's illness because they then have to explain to other relatives what is happening to a member of their extended family. ''~~Decisions on medication and treatment may have to wait upon other family members' input. Indeed, there is no guarantee that Western prescriptions will be (a) taken to the pharmacy, (b) used, and (c) used without home remedies.

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The patient appears to be in agreement with the physician. This m a y not be so. He m a y be intimidated and find it difficult to leap over the physician's authority and control to put his own questions. He m a y not wish to be an equal partner in a dialogue. Perhaps he is preoccupied with his present health and sickness when the hospital staff desire him to be "future oriented." Conclusion

The chaplain can help immeasurably with clarification and interpretation. He or she will need to distinguish between the customary "melting pot" theory of assimilation (better integration) and the more realistic "tossed salad" theory; that is, each cultural element contributes its distinctive flavor to the whole. What is the relationship between the West's health care systems sturdily erected upon science and other cultures' humanistic, empathic, and even more compassionate care? "The blending of the scientific with the humanistic aspects should be kept in mind for cultures that are sharply divided on these two approaches in health care and wish to redress the inequities. ''21 The chaplain will sooner or later encounter an indigenous health care system representative of traditional health care ways. It is holistic, less expensive t h a n Western medicine, readily available, and immediately to hand. Religion is science's equivalent. Involved are parents, non-parents, relatives, and non-relatives. In contrast, the West's "culture of medicine" is dominant transculturally, funded and sanctioned publicly and privately. But one needs the other. "To meet inevitable and actual gaps in our professional health care system, both systems would seem to have a role in most cultures today. ''~2 By choice as immigrants or necessity as refugees, men, women, and children of all nations and none "go to and fro upon the earth" (Job 1:7). As long as countries produce immigrants and refugees, there will be countries to receive them. Pastoral care's mandate is to express solidarity with the newcomer by means of a transcultural and interfaith literacy. God speaks to m a n y in their own religion rather than having them abandon it for His. In other words, Christianity's nature m a y be revealed by a "good" Buddhist rather t h a n a "bad" Baptist. References

1. Thornton, S.S., "Southeast Asians: CommonThemes and DifferencesAffectingSocial Work Practice." In Adult Protective Services Practice Guide. St. Paul, Minnesota, Department of Human Services, 1991, pp. 5-13. 2. Zolberg,A., Suhrke, A., and Aguayo,S., Escape from Violence. New York, OxfordUniversity Press, 1989, p. 269. 3. Bernard, W., "Immigrants and Refugees:Their Similarities, Differencesand Needs." In International Migration, 1976, 14, 4, p. 267.

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4. 5. 6. 7.

Thornton, op. cit., pp. 5-13. Bernard, op. cit., p. 271. Oberg, K., Culture Shock. Indianpolis, Bobbs-Merrill, 1954, p. 1. Brink, P. J., and Saunders, J. M., "Cultural Shock." In Brink, P. J., ed., Transcultural Nursing. Prospect Heights, Illinois, Waveland Press, 1976, pp. 126-138. Zolberg et al., op. cit., p. 3. Thornton, op. cit., pp. 5-13. Leininger, M., "Towards Conceptualization of Transcultural Health Care Systems." In Loininger, M., ed., Transcultural Health Care Issues and Conditions. Philadelphia, Davis, 1976, p. 6. Brink and Saunders, op. cit., p. 129. Anderson, J. M., Waxler-Morrison, N., Richardson, E,. Herbert, C. M., Murphy, M., "Delivering Culturally Sensitive Health Care." In Waxler-Morrison, N., Anderson, J. M., and Richardson, E., eds., Cross Cultural Caring. Vancouver, University of British Columbia Press, 1990, pp. 256-261. Fabrego, H., "Culture, Biology and Medicine." In Rothschild, H., ed., Biocultural Aspects of Disease. New York, Academic Press, 1981, p. 88. Qureshi, B., Transcultural Medicine. London, Kluwer, 1989, p. 83. Sundberg, N., "Research and Research Hypothesis About Effectiveness in Intercultural Counselling." In Pedersen, P., ed., Counselling Across Cultures. Honolulu, Hawaii University Press, 1981, p. 140. Augsberger, D. W., Pastoral Counseling Across Cultures. Philadelphia, Westminster Press, 1986, p. 49. Ibid., p. 49; the "Everyman" profile is from Kluckhohn, C., and Murray, H., Personality in Nature, Society and Culture. New York, Knopf, 1948. Brink and Saunders, op. cit., p. 134. Qureshi, op. cir., p. 87. Ibid., p. 136. Leininger, op. cit., p. 15. Ibid., p. 15.

8. 9. 10. 11. 12.

13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Bibliography

Dumon, W. A. "Activity of Voluntary Agencies and National Associates in Helping Migrants to Overcome Initial Problems." International Migration, XV, 2/3, 1977, 113-126. Gelinek, J. "Role of Social Work and the Contribution of Voluntary Social Agencies." International Migration, XV, 2/3, 1977, 127-142. Giger, H. N., and Davidhizar, R. E., Transcultural Nursing. St. Louis, Mosby, 1991. Hesselgrave, David J. Counseling Cross-culturally. Grand Rapids, Baker Book House, 1984. Hoffman, G. "Solidarity with Strangers as Part of the Mission of the Church." International Review of Mission, January 1989, 78, 53-61. Sanghera, G., '~rhe Male Punjabi Elderly of Vancouver." Vancouver, U.B.C. School of Social Work, 1991.

Transcultural hospital pastoral care.

Transcultural hospital pastoral care's subjects, the immigrant and the refugee, are described. Differences and similarities are noted. Three difficult...
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