1 Services for People of Minority Cultures -- Part 2. Presented by Daniel Wong and Lucy Wong Hernandez. >> LAUREL: Good afternoon. This is Laurel Richards with ILRU in Houston and we're glad you could join us today for the second of a two part series on services for people of minority cultures. And as you can see, you're connected right now to our web page and for this webcast we've posted information in front of you there for the presentation and overview of the content, bio sketches for our two presenters and handouts in two formats and actual links to the audio part of the presentation. So you're connected not just by the web, but you're hearing the audio through one of two Media Players. One is RealPlayer and the other being Windows Media Player. And so you're hearing the audio and then in the area of the Media Player where it would be video say if a movie was playing, you're getting realtime captioning. And for those of you for whom it's not necessary and it may be getting in your way, you can minimize that without having any problem. Today's webcast is live, of course. And we also have people on standby here at ILRU, our technical assistants, because being live things can -- you can run into some problems and not quite know how to handle them. What you would do in that case is call ILRU at (713)520-0232. and call 2 for any reason. Things will happen like buffering and all of a sudden things will come to a pause -- I'm telling this to folks who are fairly new. Those of you who are experienced, just hang for a minute. But there will be a pause and if it lasts too long, then you need to just disconnect and reconnect and go through the process again. But buffering is very, very common. And it's kind of like when you put a pause on a DVD or videotape. It stops and then there is this pause and it comes back exactly where it stopped before. Or if there is any other problem -- if you get tossed off -- and you could just get disconnected for whatever reason the Internet chooses, just reconnect. If there are problems, call us here with our team of technical assistants who are just standing by and Redding to answer any requests. That's by the way, the telephone number is both voice and TTY. We're going to have a chance to have questions. If you care to make a comment or care to pose a question, and our presenters welcome those, please just E-mail them to us. Those of you using RealPlayer will see there a little note at the bottom that says click here if you wish to ask questions and it will bring up your E-mail program and it's preaddressed to ILRU probably webcast@ilru. Anyway, it's preaddressed and you put your question -- input your question and hit send and it goes. I think for Media Player at Microsoft, you probably have today dress it yourselves. It's not automated yet so just send to ILRU at ilru.org. Dawn, I believe that would get us where we need to go, right? >> DAWN: Yeah, sure will. >> LAUREL: Dawn Heinsohn is going to be the one fielding our 3 questions today, so she's the expert on all things question-related. And then just type in your question and send it to us. Now, we'll hold the questions until our presenters ask for them, but go ahead and send them in -- or observations or disagreements. We're game for all of that and we're game for anything you have to send us. And so for those of you now -- I'm going to talk a minute to those of you in the future who are going to be listening to this not live. And we have an amazing number of people who come back to the archives and for whatever reason the time right now isn't as good as another time, so they come to the archive and they printout the presentation, the slide sound program and they pull up their Media Player and they listen at their own convenience; but the same thing goes for you all. So in the future if you have a problem of any sort, don't hesitate to call. We're still here. And call that same TA number, the (713)520-0232. It's also at the bottom of the web page. And also send in questions and we'll forward them on to Daniel and Lucy and if it's on the weekend, even better. We'll work you all during the weekend, too. And the captioning for those of you in the future, the captioning will of been converted to text like a transcript of the presentation. So you've got what you need. So enough housekeeping. We'll get to today's presentation. Here we are two weeks ago we were halfway through our two-part presentation on services for people of minority cultures. Daniel Wong and Lucy Wong Hernandez are doing the presentation. They are, as you can see from their bio sketches there both extremely knowledgeable in this field on disability issues pertaining to people of -- 4 sometimes called people for whom English is not a primary language, people of ethnic diversity, people of minority populations. There are many, many pronouns or adjectives that l being used, but it's basically folks underserved or less frequently served by the programs of independent living, voc rehab, medical social work, whatever, any program like that. But the content of the presentation as we heard last time and we'll hear this time is extremely important for those of us who wish to increase our services to people of an under represented population. So I believe that our speakers today, Daniel Wong and Lucy Wong Hernandez will do a quick review of the presentation last time to get you caught up, but remember that for those of you who weren't here, in the archives, the material is there and ready for you to hear in detail if you wish. With that said, Daniel, will you be going first today, Daniel? >> DANIEL: Yes, Laurel. >> LAUREL: Welcome and I'm going to turn it over to you and Lucy. >> DANIEL: Thank you so much and thanks for of course the ILRU and Laurel and Dawn today for this opportunity to make this presentation and webcast. About two weeks ago I believe that we did the first of this two-part presentation and today we'll use -- continue the discussion of this topic and present some of the recommendations. We expect to include rehabilitation services to individuals from diverse cultures and ethnic backgrounds. I agree with Laurel there is so many terminologies and for example 5 some people use under represented populations, multicultural population, so for the purpose of this presentation and some of our publications and writings, we use individuals from diverse cultures and ethnic background. And so I say again there are so many variations describing these populations. As we indicated in our last presentation, the objective of this two-part presentation, number one, an understanding of how cultural factors play a significant role within families who have members with significant physical and mental health-related issues such as chronic illnesses, disabilities and secondary disabling conditions. Secondly, we discussed the significance of how cultural factors will contribute to the coping, adjusting, caring and managing of family members who acquire chronic illnesses, disabilities and secondary disabling conditions. And thirdly, we tried to provide a summary of cultural competence skills, recommendations for working with consumers and also their family from diverse cultural and ethnic backgrounds. As we discussed last time, we kind of identify and we also truly believe that the two so-called major rehabilitation main goals are, number one, the prevention of secondary conditions; and number two, is to improve quality of life. And we spent some time last presentation to kind of discuss these two main goals. And we also talk about five major contributors which ultimately determine whether these two rehabilitation main goals are accomplishable. Now, those five so-called major contributors -- of course there are so many 6 people can identify contributors to so-called rehabilitation success, but the five major contributors are -- we identify as, number one, medical interventions; two, psychosocial interventions; three, consumer involvement; four, community support; and the last one is family interventions. We also spent some time to kind of define what an intervention involves. So we're not going to discuss further. As Laurel mentioned, if you need more information, you can probably can get into the information that is being posted in the webcast. Now, as we know that it's important to kind of discuss all these issues because we believe that unless programs and services for individuals with chronic illnesses and disabilities are defined in a culturally appropriate way. The opportunity to make so-called real and effective changes is often lost or not even accomplishable. Other cultural variables affecting diverse populations such as values and beliefs, family structures, and attitudes toward illnesses and disabilities are critically important to the outcome of the service provided. The intend of providing services is not to catalog every human variation, every variable and the perception of health-related challenges, but rather to alert the practitioner or service provider to the fact that the way which chronic illness, disability and secondary conditions are conceptualized will have an impact on the manner in which professionals and any kind of intervention services are received and are able to serve the consumers. 7 As we said before, as service professionals, we have to recognize that individual and cultural diversity are important factors in any kind of intervention which includes counseling, family therapy, rehabilitative services and even psychotherapy. Let me pass it to Lucy and she will discuss further in more details different kind of situations. >> LUCY: Thank you, Daniel. Happy to be back to finish this Part 2 of our presentation. I believe that today we should start on slide No. 29, accepting disabilities. But before I do that, I would like to summarize just very briefly points that we touched on during the previous Part I presentation regarding disabilities. How some cultures have different beliefs about disabilities and so on. For many cultures, disabilities can be as a result of bad conduct by an individual or family member in this life or in a previous existence. They also may believe, people from different cultures, in a similar way they may believe that the disability was caused by, for example, by disobeying God and not being a good person. So some kind of a punishment is being given to you. Also perceived as the source of family embarrassment and shame, that is a very -- I would say global perception. Many families, perhaps due to the lack of information or the lack of resources in their community and so on, to enable them to achieve what their goals are may perceive the disability as an embarrassment or shameful to the family in some way. It is also attributed to super natural or natural causes. Many 8 different explanations in reference to that. Disability can also contribute to the cause of disability whether it's something based on religion or based on ingrained cultural values and so on. Public display of disability kind of weaknesses is discouraged. Many cultures try to hide as much as possible what disability may be occurring in the family or a given individual. And disabilities is viewed with significant stigma, and you'll see in a few minutes with more detail. Another issue that we have encountered as we go, you know, in our quest of studying cultures and how they perceive disability is that even to this day, you know, many families may make that drastic decision of abandoning the person with the disability. We see that a lot in other cultures. Not necessarily here in our country, but it used to happen here, too, but not as much now -- abandonment of a child with disability. That sometimes occurs. Relating to the family, just a brief summary of the points we touched and we need to elaborate a little bit more today, is how cultures view families in their unique culturally based way. What does the family really mean for that given culture group? Family is defined by immediate and extended members which may include for many cultures -- they go back many generations and those people, even though they are not present, that constitutes the family. Traditionally, senior male is the head of the household. We see that in many of the cultural groups that we study and we work with here in this country as well as in other countries. Decision-making could be a collective issue that is handled within the family, usually is not one individual but there are many 9 other immediate family members, mother, father, pair grandparents, Godparents that have a say in reference to making a decision. Decision is what we call sort of a collective mind of making decisions. This is important for service providers to understand because when we do the assessment or that initial interview with a client, we may expect for a decision right there and then and it could not be possible. This person may need to have a family meeting sort of and discuss how to arrive at a decision. Also the family is regarded as a life-long sense of moral obligations and loyalty to all family members in order to maintain the family name, for instance, honor and faith and many other variables. So that's, briefly, you know just to refresh our memory in reference to the points that we touched and slide No. 29 that I mentioned where we're beginning today gives you an idea of those points. One extra point that this slide indicates is, for example, taking care of a family member with a disability is something that is a common goal of the family. All family members are involved in that, too. Now we can move on to slide No. 30, attitudes towards life events. This is very important because as we well know disability is a life event. It's something that nowadays we take it as one of the many things that happen in life. The perception of a chronic illness and disability among diverse cultures may be affected by what many researchers identify as a culturally-based attitude of resignation and acceptance of life problems. There are -- there may be less inclination to question, for example, there are many people that do not ask questions, not to the physicians, not 10 to the case workers, not to the counselors and so on. They may not complain or they strive for changing their perception, even the perception of how people may see them or strive to change that among people from other cultural backgrounds. So this is something that we need to take into account if a person is not really speaking of, as we say here, perhaps the person is sort of like implying, you know, or giving you some information how the culture interprets the situation the person is in at that moment. This rather passive attitude for some cultures should not be misunderstood with lack of interest or feelings of guilt and resignation. On the contrary, it should be understood more from a more culturally religious, spiritual perspective of accepting the things that cannot be avoided or changed, the things that the person or the family may have actually no control of. It is more like not resisting the destiny and usually that could be interpreted through complaints and so on of self-pity. The individual may not exhibit any of those behaviors. It's more like accepting all those life events that are beyond their control. And sometimes this is difficult for us to understand, but that's just the way it is on how people perceive it and it's something that happens cross culturally as well. Appreciation of cultural variability leads to a radically new conceptual model of clinical and rehabilitation interventions, and this is what we need to keep in mind. This approach will support and facilitate our role in assisting consumers as they plan for their preferred future. Helping a person or family achieve a stronger sense of self may require resolving internalized negative cultural attitudes or cultural conflicts 11 within the family, between the family and the community or in the wider context in which the family is embedded. How that family is being perceived within that community. A part of the process involves identifying and consciously selecting ethnic values with which to reinforce through all these series of training and all the other training that people receive in their place of work, we learn about all these positive values and we need to utilize those positive values and reinforce them and use them in our favor. Now we can look at slide 31. Yes, 31. And this is in reference to other important factors that we need to acknowledge when providing services to consumers and families from diverse cultural backgrounds. For example, we have the cohesive, protective family into society. Through research we have somehow demonstrated how family members play an important role in the therapeutic and rehabilitation process and outcomes. They are very important. It's a vital contributor to any process that is being implemented with a person and they are an important factor for the services outcome. Remember going back to who is making decisions, if the family does not agree with something that is being planned, perhaps that plan will stop and then the services outcome, you know, may be in some way disturbed. At times, these cultural characteristics have been viewed by many practitioners as other protective and personalistic on the family side and limiting the client full and active participation. We see that happening a lot. With a better understanding of the cultural-based approach, the 12 consumer -- or the service provider in this case will utilize these variables to the best advantage for the consumer and the family. In reference to impact of religious views, we have to acknowledge that religion plays an important role in the definition response and acceptance of a chronic illness and disability for a large population of consumers and their families. It is important for counselors and other service providers, especially in the rehabilitation and mental health fields, to understand that a theological etiology may be prescribed as chronic illness and disabilities by many culturally diverse families. The religious beliefs that this family and consumer may have are already as scribing a clear definition to them and perhaps also an expectation of the type of services that they would like to receive or to agree to receive. Perception of physical and mental disabilities varies a lot from one cultural group to the other. Some with more emphasis than others. Physical and mental disabilities have a high prevalence among culturally diverse individuals and we know that. Many researchers are demonstrating the statistics that are rather alarming on this issue. As an example, for Hispanic population was physical disabilities among working age groups, let's say 16 through 60 years old, physical disabilities occur very frequently. In most cases due to high risk of occupational accidents and hazardous contamination as in the case of persons working for the farming industries. Mental chronic illnesses are associated with the inability to assimilate a new culture, usually manifesting itself with bouts of anxiety and depression. Sudden changes of lifestyles, you know, trying to get used 13 to the new community and the effects in many cases of alcohol and drug dependency. Some populations experience a greater array of potentially stress-inducing events than do other populations, like comparing one cultural group with another. You could see how they are adjusting and their perceptions of disabilities is totally different and just have a higher -- some groups specifically have a higher risk for mental health problems. Several aspects of the transition from one society to another, once again, for example, I'm referring to a population that we study a lot here in North Carolina which is the Hispanic population, family separation also creates a lot of mental health issues. Parents separating from their children or young people separating from their parents and so on and apparently this constitutes a hazardous situation leading to increased risk of psychiatric episodes and hospitalizations. In slide No. 32 -- we're moving along, No. 32, the impact of chronic illnesses, disabilities and secondary conditions on the family -- we put a lot of weight on this topic because it's impossible to separate each one. We mention in the previous presentation the economic burden on the family, the psychological impact or setbacks on lifestyles due to multiple stressors. We also mentioned the amount of managing and caring for the individual. One important cultural difference that we could highlight on this topic is, for example, many families from diverse cultures do not believe in having an outsider -- a personal attendant or a companion -- to care for their family member with a disability. They feel that it's their 14 responsibility and there is no need for that. And we may -- a service provider may encourage them to accept that type of a service, but perhaps that is a service that they do not reject because they want to reject it. It is something that is practically as scribed by their culture. The impact of chronic and secondary conditions in families has been very well documented based on all the -- what I just mentioned and even more factors that really impact the entire family. However, the impact of a secondary disabling condition has not been fully studied and understood. So there is little information on how this impacts the family, but we assume that because as we said previously a secondary condition sort of like -- creates a lot of frustration and puts a lot of the plans on hold, at least for awhile. This also creates a lot of stress among the family and the consumer. It is important to note the paradigm shift and this was mentioned briefly also from -- it's a paradigm shift from chronic illness, disability prevention and rehabilitation to prevention of secondary conditions and promotion of health and wellness including mental health. There are also been a shift toward the need for further culture, eth nix and environmentally relevant interventions as well as research studies on these topics which address most importantly the centrality of health to quality of life, of millions of Americans with disabilities. Rehabilitation professionals, family consumers are all involved in this positive change, this change that now we're trying to avoid and prevent a lot of issues that affect the person's rehabilitation. The family involvement we have said that is very, very important and is 15 something that we cannot avoid is always there. Related to chronic illnesses, disabilities and secondary conditions we know and we mention how this would affect everyone, especially if the person who happens to acquire the disability is one of the head of household, income and economic situation of the family or economic status and so on in some way will be affected. The onset of a chronic illness, a disability or a secondary condition within the family also affects in other ways on how the rest of the family will continue their life and how responsible perhaps the individual with the disability may feel because this interruption is actually taking place. So the perception of the condition may also influence how the family will intervene and care for the family member with the condition. To give you an example, the issue of psychiatric illnesses are perceived by many culturally diverse families as one of those most difficult to manage and most of it is perhaps the Lang of understanding or not assessing themselves of the resources available and also because of the negative stigma that is a attached to not being able to have what is called mental health, the psychiatric impairment, and also families in almost every culture worry -- they are concerned about how society perceives this type of a chronic condition. Persons with chronic illnesses and disabilities from diverse cultural and ethnic backgrounds may encounter and could be subjected to more negative events because of marginalization from the society at large, which will further intensify and impair their adjustment and coping with their conditions. 16 The psychosocial aspect of the health-related condition is affected by multiple variables such as society perception as I mentioned in the case of mental illnesses, the built environment -- if the environment is not conducive for people to be able to have quality of life, this also is a tremendous impairment. And the quality and expectation of the services and the consumer relationship with the service provided. That's pretty much in reference to those issues of family involvement. But now Daniel will discuss some other related recommendation that is we were planning to cover today. Daniel... >> DANIEL: Thank you, Lucy. That's a long description of many important variables. Let's discuss some -- this is a big topic and probably requires maybe 20 different webcasts, but we kind of tried to summarize our recommendations since this is the second of the two webcasts. Let's discuss some recommendations for training supervisors, counselors and service providers and other professionals with respect to these issues. Now, the need for multicultural sensitivity and understanding of the indication of chronic illnesses, disability and secondary condition as we mentioned in times is critical for the success of rehabilitation services and other human service disciplines and professionals. It's just essential to examine multicultural training as a cultural competence tool. I think the past years and many years people will start looking at this as a tool and how can we perfect this tool? The kind of tool we're talking about will enhance the consumer's/service provider's relationship and of course the service outcome. 17 For many people, cultural competency is understood as having the capacity and skills to function effectively as an individual, organization or service provider within the context of cultural beliefs, practices and needs presented by the consumer, the family and the communities. It's just the conscious and social reaction to what is called so-called culturally appropriate and putting all biases, if any, aside. We have to put all bias aside. And cultural sensitivity is a cognitive reaction in knowing that cultural differences as well as similarities exist without assigning values. Values such as we call better or worse, right or wrong, black and white -- onned these kind of values to those cultural differences. So we should not assign values to stigmatize the importance of cultural differences. And culturally appropriate supervision from a supervisor or consumer perspective is also critical in the delivery of service interventions in the rehabilitation services. As an educator, I believe that supervisors -- you know, professors and faculty members at the academic level or at internship agencies should be encouraged to identify issues related to individuals from diverse cultures and ethnic backgrounds from these two different perspective for the students in training and the consumer receiving services. This will allow these two different levels will allow both supervisors and supervisees to dispel any misconception of the barriers that would intervene with treatment, counseling or services and this also will allow the supervisor or the faculty member or the student to honor each other's cultural upbringing. 18 Many people believe it is hardly the service provider's job to try to change consumer's fundamental cultural belief. As we know, it is impossible and it should not be even attempted because it's unethical to attempt this and as I said, ethical principle in relationship to consumers demonstrate respect for the cultural and religious value of those they serve and of course refrain from imposing their own valued and belief on those consumers and the people that are working as a service provider. It is also recommended to avoid a position of theology and cultural value on those served or supervised. Professionals or service providers cannot avoid some engagement with consumers in effort to make sense of the chronic or disabling conditions or those of the family members. So it cannot be avoided. There has to be engagement because you're providing the services. Now, it's important to listen a tent representatively and with culturally-based understanding to acquire the competence to have the service provider to have more awareness of the range of human beliefs in the chronic illness and disability psychosocial areas. One benefit of studying cultural aspects from the service provider is that it may be possible that the consumer and the service provider will have a better or a more positive position to each other, a better understanding toward each other. Some professional provider recommendations for multicultural supervisors or faculty members to provide supervision in the academic setting. Now, this so-called recommendation includes as we mentioned before increased self-awareness, continued professional development, continued practical experience and joining 19 multicultural professionals organizations, peer supervision, join attendance to multicultural workshops by supervisor and students meaning the professors or the faculty member going to workshops together to understand better of how the views are and use of tools to assess the multicultural competency of service providers, supervisors and the student alike. If standard of multicultural competency involves identifying major life events as Lucy mentioned a few times. Relationship and cultural concepts that affect cultural identity. It's very important to remember multicultural competence takes into consideration multi-elements of cultural and ethnic differences, social conditions, the systems and an issue with enforcing their own perspective on the people that we serve. To demonstrate professionals function which include our emotional ability, cultural (inaudible) appropriate self-disclosure, positive use of power and authority and judgmental presence and clear responsible boundaries. Now, a lot of the issues that I mentioned, we believe that of course it deserves further and further explanation, but at this point I'm going to give it to Lucy to continue the discussion. >> LUCY: Thank you, Daniel. I need to open up here the discussion for training and recommendations for professional programs to have a better understanding on the diverse family because after all the main objective would be the consumer, but as I said the family is so important and it's so difficult to separate the two in today's type of service provision. 20 A culturally appropriate professional training program should begin by taking the necessary steps towards defining one's ethnic and cultural identity. I believe that that is very important. We need to know who we are and what values and beliefs we carry with us in order to be able to attempt to understand others. Investigating the trainees or students or co-workers' own racial or ethnic or cultural heritage also needs to take place and people do that individually, as a group, and so on and this is done by paying attention to their cultural roots, the social location of their upbringing. As we mentioned before, just putting it in more original context, we usually talk about the people from the north, the people from the south, in this case it's the people from the west, the people from the east and their ethnic ties and cultural context. How do we relate to the individuals around us in the different regional locations? And the movement in and out of successive social locations and cultural context in the trainer's life journey as professionals. We propose the following recommendations: Number one is for example the attitudes and self-awareness of the trainees to be evaluated to determine what training programs should be developed to provide culturally sensitive training to them in reference to maximizing their respect towards diverse cultures and issues related to chronic illnesses and disabilities and so on. For example, in the case of students or co-workers in different agencies and so on, it's very easy to arrive at the conclusion if there is a student or a co-worker who may be, let's say, Asian this person will have 21 a broad knowledge of all Asian people and this could be a mistake because we know that the Asian culture is so diverse and the Hispanic culture -- even though we tend to usually lump everyone under the same umbrella, the Hispanic culture is a very, very diverse culture as well. Not only in behaviors and values and beliefs, but also in the way that we speak and in the different variations of the Spanish language. Students and trainees should be required to demonstrate self-reflective awareness and provide culturally appropriate therapeutic assessments or interventions to consumers and their family members or significant others. So we always have to keep that in mind who we are, our own cultural values that we carry with us and what is the situation that is being presented to us. The assessment should include the immediate crisis with challenges that the consumer or perhaps the consumer's well-being is the main thing that we need to look at first of all. The relationship to illness and disability and the body image, how is this person reacting to what is going on in his or her life? The consumer's connection to personal, cultural, spiritual resources and the theological and spiritual issues presented by the individual with the disability or chronic illness during the therapeutic dialogue or the initial interview or so on. Another suggestion is that training modules with respect to the understanding of the implications of chronic illnesses and disabilities to diverse cultures should be a requirement in any curriculum for educational training and it should be a requirement in any policies or procedures that any agency may have. This is something that we cannot avoid any longer. 22 This requirement will enable trainees, co-workers, educators and so on to develop the skills to understand various culturally-based practices that are relevant to their consumers and the consumer's family members in reference to the psychological aspects in regard to cope and make the necessary adjustments with the challenges at hand that they are presenting to the service provider. So as you can see, just based on these few suggestions, there is a lot that opens up for us to think about. So now I will let Daniel continue some of the other recommendations. >> DANIEL: Thanks, Lucy. I'd like to continue other suggestions that we kind of discussed and I feel strongly is important to so-called providing service to people from diverse cull cultures and ethnic backgrounds. I would like to see the student to be trained to understand the differences and similarities among various cultures with respect to the understanding and practice of social and medical models. It seems like it's a tall order, but we discussed previously the definition of social and medical model and I believe it's important for a student to understand that some cultures are more into the social model with respect to disability and some cultures are more to the medical models. So I believe this is an important step to provide training to students. This also allows a better understanding to empower the consumers and service provider to contribute to a positive outcome and of course we're talking about rehabilitation outcome.I also believe it's critically important to identify the consumer and the immediate family members' strength and struggles -- struggle is a realistic term in the cultural context. In most cases, the service provider, the lack of understanding of 23 how people from other cultures or so-called people from minority populations struggle and what other spiritual and cultural contexts have contributed to so-called struggles and how they contribute to the strength in terms of dealing with the situation. Equally important is to validate various aspects of the crisis, including the role of cultures to persons or the struggle with respect to their conditions. I also believe it's important to develop an appropriate intervention plan based on the ability to communicate cross culturally, to choose specific techniques of the therapeutic focus and to maintaining an attitude that is culturally sensitive. I also believe that working and empowering families who have family members with chronic and disabling conditions is a critical step to encourage families to identify their needs and strengths in order for them to assist the family member more effectively. The family member needs to learn to understand the medical information and the implication of the chronic illness and disability and how it may affect other family members. We discussed it a few times how important this can be in terms of contributing to a successful rehabilitation outcome, how important a family member can play a significant role. Family members will need to learn how to assess and utilize community resources available to maximize the coping and adjustment for their family member with chronic illnesses and disabilities. And as we know that family members should always be a learner in terms of how to utilize community resources because by using -- maximizing the usage of community resources, the family member can assist the person with disability quite a lot in 24 terms of the rehabilitation outcome. I think that we also looked at the training module that should enable students and service providers to demonstrate a built to communicate effectively across a diversity of culture, ethnicity, spiritual traditions, understand and respect cultural identity with their laws and behavior and values and beliefs. Different spiritual frame of references provide appropriate and specific -- to the case guidance support and present with an awareness of cultural and context our Al issues. This is also important, but probably not the last one, but I'd like to say that the awareness of cultural or enhanced cultural differences focus on a variety of aspects such as things as relations of individuals with family and community before and after the on set of chronic illness or disabilities. Different use of time -- people perceive time differently. Different use of space, how people use space to understand each other and culturally people will see space differently. Focus on content or prior ort value placed on content or relational context. Communication -- some cultures prefer more direct communication and some prefer indirect and vice versa and sometimes indirect communication style means more than direct communication styles in some cultures. Age, gender, the role of the family and of course the socially accepted ability the make independent choices, boundary between person and public is important, public image and self image meaning how you perceive yourself. One more before I think it's probably not the last one, but I'd like 25 to recommend another one. We strongly believe the motivation of becoming culturally competent benefits the service provider beyond the need for a successful career. As I mentioned before, it's not just career, but when you truly enjoy your work. It must be clear for every student or service provider and professional that is absolutely, positively impossible for anyone to understand clearly and care skillfully for a consumer and family if one is culturally crude. Meaning everybody has no idea how important cultural factors with respect to this process. And if we are talking about crudeness, that will probably need to (inaudible) or the conscious or unconscious assumption that an individual -- and on opposite of being culturally crude becomes as many people believe culturally competent. Now, let me give Lucy back the discussion with respect to some of the issues we're going to address in our conclusion. Lucy. >> LUCY: Thank you. Yes, we'll start giving some information to conclude our lengthy discussion of two sessions. One of the things that comes to mind is, for example, the challenge of understanding the culturally diverse family with health and disability issues in a life-long journey and the destination to this life-long journey in reference to the process of providing services. This is a tremendous challenge, not only for the expectations that we may have on the service provider, you need to learn, you need to learn and learn, but also to be able to implement those lesson that is are learned. So it's quite a challenge that we are posing here on the service provider and also on the family and consumers because it goes both ways. They are equally responsible to be culturally competent towards each other. And this is what I call the life-long journey. I 26 mean, we never stop getting information and facing different challenges and trying to come up with the solutions to those challenges. Also the effort to become cultural competent in order to have a better understanding of the implications of chronic illnesses and disabilities and now secondary conditions are a vital part of our profession. Even if we're not working directly within the health care field, we still need to have some knowledge, some basic knowledge that will give us some kind of a guidance to understand where the consumer and his or her family member are in reference to the condition that is being presented and how can a professional or service provider can best provide the services that are needed. In addition to positive impact of the services on individual -- the individual with a disability and the family is a challenging one in reference to now we are making things more complicated. Now we're telling you about all these cultural issues that also we need to take into consideration. Well, we need to do that, but we need to do that case by case. We don't need to pretend or to be challenged with the fact that we need to learn so much. We usually discuss cultural competence and that's a very complicated topic. We cannot expect that we will be culturally competent on every culture, but at least we can expect to become more culturally sensitive and competent in reference to those cultures that we work with most often. All efforts and methods used to deliver human services including rehabilitation services must point to the direction of achieving quality of life for the consumer and of course if the consumer is impacted with this 27 improved or enhanced quality of life, the family will be impacted as well. And I believe that at the very beginning of our presentation, Part I, and today Part 2, quality of life was one of those main issues. It's what we expect -- what everyone expects consumers and society in general for people to be able to achieve once a person goes through the process of rehabilitation. So maybe Daniel now has some final words and, Daniel, anything to add? >> DANIEL: Lucy, thanks. The thing that I can think of is some discussion points. What does it take -- that's what we are thinking about. Regarding the competency, I'd like to kind of use one of my own personal examples to kind of open up people's mind about how the term competency is all about. I came hereafter high school in the past 20 or 30 years I've been in this country. So every time when I return to my hometown, regardless of my own so-called first language that I can say is very fluent, no problem with communication, but every time I return to my hometown, the first few days or even the first week I feel totally lost. Even I speak fluidly in my first language and of course knowing the place and understanding the people and the simple cultural indicators that people always talk about food and clothing and body language and I don't have any problem with that, but the first few days of my visit I feel very incompetent. So I always often challenge this term competency, how much we can assume that a person is competent about something and expressly we are really talking about a very, very diverse population here in the U.S. with people from all over the world and so that's a tall order in terms of being so-called culturally competent and I agree with what Lucy just mentioned, 28 that you need to strive to learn more to understand the people that we work with or ultimately, I believe, the major point that is most important is try to be as sensitive to other cultures as possible. So my thinking now is to look at how we can be more culturally so-called -- you know, the humility of being a cultural learner and also can think critically about being a good human being. And then the ability to remain open minded, imaginative and that's important to be a good professional and receptive and curious about things that we have never experienced and never thought of and never encountered in our life. Overcoming all obstacles to the delivery of effective quality culturally-based services. There is a lot of barriers of course, and regardless of your professional, your line of work -- of course there are so many barriers to overcome if you deal with people from diverse culture and ethnic backgrounds. And again to overcome confusions about other people, other cultures and to become defensive, fearful to new things and of course you have to overcome your own ignorance about other people and, you know, truly try to be someone that is willing to learn new things every day and to embracing engaging intercultural services. As I mentioned before, the most important thing that we'd like to say is be a student of culture for life and I hope people from all over the world have our same view with respect to being a life-long learner in cultures and other things, too. So Lucy, do you have anything to add? >> LUCY: Well, I guess that we covered a very wide topic. Just like what Daniel just said, the hope is that this information that we have shared with you and is in the archives now for other people to access it 29 will help create a more enthusiastic frame of mind to continue learning and striving to provide the best possible services to persons with chronic illnesses and disabilities and their families and to continue building up the harmony of this comprehensive and diverse cultural society that we have. So I have nothing else to add. But we will entertain any questions if there are any questions for us or anything. >> LAUREL: Dawn, you have some questions that may have come in. >> DAWN: I have three questions so far. What technique should be used in order to involve the immediate family members in the process of service provision? >> DANIEL: Lucy, you want to answer that? >> LUCY: That's an interesting one. This is a question that I've heard before from many service providers. Needless to say that there are many instances in which the family help or assistance is needed and sometimes it's not found because of the busy life that people have going to work and so on and not being able to attend to appointments or meetings with the service provider, but I always caution people not to think that the family is not interested. One good technique is to go the extra hour or the extra mile, you know, and try to initiate some kind of a dialogue whether it's through a phone conversation after hours that are not necessarily the working hours or perhaps, you know, a letter or in some cases -- and I know especially in rural areas -- service providers go out into the community and do make house calls and house visits and try to start some kind of communication. That's one of the techniques. The other technique is that I usually recommend is once you become more and more 30 knowledgeable about the cultural differences to try to utilize that as much as possible. If you feel that it's a difference, then try to overcome that. One technique is also to observe certain behaviors that are more accepted within one culture than within another and so on. And of course always trying to address your questions to whomever the individual who may make the decisions is within that family. I think that's have, very important. >> DANIEL: One thing I'd like to add is often that when we work with people from other cultures or other countries, the translation part is a major issue I believe in many agencies because we were kind of aware for many years now that some service provider -- if they get the immediate family member involved in the process of service provision, they usually do not have the interpretation of other language capacity and that poses a major, major issue. I believe that this issue has been addressed in many different articles and research studies and the problem if you do not have good interpreters to help the so-called family member to interpret the conversation or communication between the service provider and the consumer, it's a major problem. So ethically we have to discourage the consumer to be the interpreter or their little brother or sister to be the interpreter for the parents. So that's a very important issue that I believe the service provider has to remember to take that so-called language barrier seriously and that is something that we cannot ignore. >> LAUREL: Daniel, this is Laurel. That's very reminiscent of the issues pertaining to working with people who have deafness and rely on interpreters for communication of importance of not relying on the consumer 31 to interpret for himself. It's the issue of language and almost a spin put on meanings of words. It's a very critical issue. And with the ADA there are issues pertaining to requiring interpreters in certain formal situations, certain informal situations and I don't believe such a requirement -- an actual legal requirement exists, does it, for whose family members or themselves speak other languages? >> LUCY: I think that, yes, there definitely is a requirement directly from the department of health and human services. There is a policy that is encouraged for all service providers to utilize that explains -- I believe it's 14 standards on how to provide -- how to avoid language barriers and how to provide culturally and linguistic services. >> LAUREL: Good. >> LUCY: And one of the things that they encourage is definitely to utilize the expertise of professional language interpreters rather than calling on somebody passing by or a friend or whatever. You need to be able to have those interpreters at hand that are knowledgeable of the language of a jargon that we use in a given field. >> LAUREL: That's very good. >> LUCY: Yeah, because talking about, for example, issues of rehabilitation, whether it's medical or vocational, talking about issues of independent living you need to be -- to be familiar and to have the understanding and the comprehension of what those terms in that field really intend and that is important to have qualified interpreters. >> LAUREL: Yes, go ahead, Daniel. >> DANIEL: I want to add that sometimes when we do some work in 32 terms of personal issues, for example, that people with psychiatric disabilities or behavior, that if they bring in their family members or friends and even disregard the credentials of the person, even the person is an interpreter, it doesn't matter because that issue of personal information culturally speaking is very difficult for -- some cultures are very much -- feel ashamed of some personal problems and that's a major issue that I think that we have to avoid because a qualified interpreter should be a third party person and should not have anything to do with the person. >> LUCY: And definitely. And that relates to something that Daniel mentioned earlier about the direct and indirect communication. A well trained interpreter, a well trained translator will pick up on those issues and rephrase the questions in a way that will give you the information that you're looking for without being too invasive on something that the person may consider -- the consumer may consider to have a negative stigma attached to it. >> DANIEL: You know, actually we found in the academic world perhaps the regulations that Lucy mentioned from the department of health and human services hasn't been really trickled down in terms of dissemination to even the educators and the people that are so-called training service providers to work in the human service field or the rehabilitation service field. So often they don't even know that that's something that's not just a requirement, it's a mark of professionalism. It involves ethical issues. >> LAUREL: Would it be possible for us to get from you the -- 33 perhaps the website for that. >> LUCY: Sure. >> LAUREL: I'm totally ignorant of that. I didn't know that existed. And Dawn, we can get that and post it on this website if possible. >> LUCY: I will send that you information, yeah. I use it a lot for presentations that usually have the majority of the audience are people involved in the health care field. >> LAUREL: Good. I have just a couple of questions related still to the interpreter issue. Of course my background being in independent living I understand certification of people who are interpreters -- sign language interpreters and I understand there are degrees of training and then there is meeting certain requirements to be certified. I'm not aware -- I'm not as familiar with foreign language interpreters who would serve a similar purpose. Are there -- and you were talking about ones that are skillful in the knowledge area. How does one obtain those? >> LUCY: Oh, you mean like when there is a registry or organization that provides? >> LAUREL: Yes. >> LUCY: Definitely there are the translating agencies. There are quite a few. They are very common nowadays and I can also send you that information. You find them by regions, cities and so on. They are certified language translators. >> LAUREL: I'll be darn. 34 >> LUCY: Just like the ones they use in the court system, family court and so on. It cannot be just anyone that happens to be bilingual. As I said, you need to be knowledgeable of the jargon, the language that is being spoken. And those are the certified for medical, certified for legal, certified for community-based agencies and so on. >> DANIEL: So Chinese is my first language, but I cannot be a certified interpreter. >> LUCY: Only if you are trained. >> LAUREL: I see. Well, English is my first language and I couldn't even come close. Now, so for that -- so these are like small businesses that are recognized in this area to have -- >> LUCY: Yeah. Many of them are small businesses and they do translation even for the closed captioning translation into other languages. >> LAUREL: And so we might be able to get that -- there might be a site or something we could -- >> LUCY: It would be wonderful if we had a directory whether it's national or at least statewide. I'll look into that and see. These quite a business opportunity right there. >> LAUREL: I think it is. We'll advertise it on our website and do a Google. The second one is going back to the issue of different cultures and what would be perceived by let's say someone like myself who is from Texas and just basic middle class and I would see perhaps a passivity just as a 35 real tough job to work with somebody like that, and according to the presentation it's not necessarily -- I mean, that's my interpretation. I'm bringing my own interpretation to that, and you had talked about how certain -- that people have qualities and values that can be used to facilitate a kind of action that you want to facilitate. I didn't quite understand how that might work if there was an illustration. >> LUCY: Right. For example, when people appear to be really passive as relates to care and they also have other cultural-based qualities that you may be able to utilize to overcome that passive attitude that you see. The reason that some people appear to be very passive, it's based on spiritual and religious beliefs more closely because you should not complain about the things that God intended for you and you should be complacent to everything. Almost like pretend that nothing really serious happened. Continue your life, but you know very well as a good professional that deep down there are a lot of problems going on. >> LAUREL: Oh, yes. >> LUCY: And you need to address that psychosocial aspect of the individual, so you need to be able to utilize the other resources that once you become more culturally competent or culturally sensitive you learn in order to bring out those issues that are perceived as complaints, but actually there are those challenges that as a service provider you need to empower the consumer to overcome. >> LAUREL: Now, that's exactly right. I was thinking when you were talking about directing questions and so forth at the family member who is in effect the head of the household, how people at centers for 36 independent living who are trying to build strong advocates out of the individuals with disabilities and to encourage self-determination, it's a different -- if I hear you correctly, we have to approach that sort of from the left field and looking at that in a different way. >> LUCY: Or indirectly as we call it because even the same -- our perception, our understanding of independent living, you know that it's very different from culture to culture. You mention that to a family from another country, whether it's Asia, Africa or Latin America and they understand that you're telling their children to move a way from home. >> LAUREL: Yes, that's right. >> DANIEL: You know, let me say quickly, one time we were attending an independent living international conference in D. C. and then we heard the delegates from Japan, you know, translate independent living to living independently. >> LUCY: And of course that created a problem. Some families may not appreciate the fact that you're telling their children, you know, to move out of the house. >> LAUREL: You know, I use that frequently as a synonym for independent living but within the context of not intending it to be threatening. I guess looking for a higher quality of life. >> LUCY: That's right. Fulfilling your dreams or something. >> LAUREL: Are there -- for those of us who are in effect laypeople and not as -- not yet as well entrenched with these issues related to cultural capacity and appropriateness, are there some readings that you might recommend or articles that those of us who are interested 37 right now in going through another course in college? >> DANIEL: We'll compile some books and articles and some research that regardless -- interesting findings that we've been doing with our teams for this research project and some interesting findings that we kind of put it together and publish and also a lot of good information out there and as I said, this issue of competency, because of my upbringing and Lucy is Hispanic, and so I think I pretty much know a different culture, but I kind of hesitate to tell people that as I mention that every time we return to my homeland, it really takes me a few days just to understand the meaning of the language and the body language and the gesture of people. >> LAUREL: That's very interesting. I'm sure it's true. It's a surprise I would think the first time especially. >> LUCY: You need a little bit of time for submersion into the culture. >> LAUREL: This has been just a terrific set of two presentations and the challenges though that you've put in front of us are really a bit sobering I think is the best word and these resources that you will send back to us that we can post such as the health and human service guidelines and maybe the readings and certainly the agencies by which we might be able to find qualified language interpreters. This is very good. Hearing the first half of the presentation, I was getting a little bit discouraged, but the training and then the way to make up for our lapses of understanding that just come naturally is a little bit more heartening. >> LUCY: Thank you. >> LAUREL: But thank you very much for the presentation and 38 we're running a tad toward our closing time so I'd like to thank you both for being here and for communicating this and we look forward to the next time we do one or two or five. And for those of you all in the audience, we're glad were you able to join us today. We have an evaluation form that is on the website. You can click on it and it will come up and you can give us feedback. We take the feedback very seriously, not just in terms of the presentation and the content, et cetera, that's important, too, but we're also very interested in the navigation of the website and how we can make it more accessible to those of you who need greater access or ways we can make it better or more user friendly for lack of a better word. So please do complete the evaluation. And then in closing, I just want to say that this has been a presentation in collaboration with the rehabilitation research institute on under represented population, that's a NIDRR-funded program. It's located at Southern University under the direction of Alo Dutta and Madan Kundu. Thanks to them for making this an important -- so important part of their project that they wanted to fund initiatives such as this. Also NIDRR -- the funding for these kinds of activities are prescribed through Title II of our wonderful Rehabilitation Act where it asks -- in fact it demands that NIDRR fund projects that ensure the widespread distribution in usable formats of practical research information that's generated from NIDRR projects and so we're grateful for that provision and we thank NIDRR for honoring that obligation. So we at ILRU invite you to come back for our next webcast. We have coming up one that June Kailes is going to present on disasters and how to 39 handle them. She's just been in the part of California that's been affected by the fires. I'm sure she'll have a new spin on how to handle disasters. We have one coming up on accessing federal funds to address the housing needs of people with disabilities. So we have -- please come back to the web page calendar to see the upcoming webcasts. Don't forget about the archives. We have many, many that have been done over the last several years and they are worth hearing and we welcome any kind of feedback you can give us including future topics, topics you'd like to hear about. So in closing, I want to thank our webcast team that includes Rob Dickehuth who is with the Center for Collaborative and Interactive Technologies at Baylor College of Medicine and our realtime captioner, Marie Bryant, and here at ILRU our webcast team includes: Marj Gordon, Sharon Finney, Marissa Demaya, Maria del Bosque, Tanjauna Arnold, and Dawn Heinsohn who handled the questions today. So thanks for participating with us and we look forward to you being with us on our next webcast. Good afternoon. >> LUCY: Thank you, Laurel.