REHAB Bringing Research into BRIEF Effective Focus Vol. XV, No. 8 (1993) ISSN: 0732-2623 NATIONAL INSTITUTE ON DISABILITY AND REHABILITATION RESEARCH OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES DEPARTMENT OF EDUCATION WASHINGTON, D.C. 20202 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * CULTURALLY SENSITIVE REHABILITATION "If what you [the rehabilitation counselor] are going to do to a client is unacceptable in his culture, or renders him unacceptable to other members of his culture, you can't do it, even if you consider it common rehabilitation practice." Carol Locust, Ph.D. Director of Training NARTC Racial and ethnic minorities constitute an increasing proportion of the American population and work force. People of Asian descent are the fastest growing minority group in the United States. A 1988 census study reported that the Hispanic population totals almost 20 million. There are more than 300 federally recognized American Indian tribes with a total population of 1.4 million. And people of African descent form the nation's largest minority. Members of minority groups are disproportionately represented at the lower end of the economic spectrum and in the ranks of people who are unemployed. Census Bureau data document a high correlation between low socioeconomic status and disability; research corroborates the high incidence of disability among minority groups with 14.3 percent of black males and 14 percent of black females reporting a disability, compared with 9 percent of white males and 7.8 percent of white females. Data from the 1980 census indicate a rate of work-related disability for American Indians at about one and one-half times that of the general population, a higher rate than for other minority groups. Also, while most people think that the Asian/Pacific community is well educated and well-off, in fact 12 percent of this population lives below the poverty level, and the number of Asian/ Pacific persons with disabilities is disproportionate to the population. What is the experience of members of racial and ethnic minority groups in rehabilitation? Having a disability and being a member of an ethnic minority group have often presented what many see as a "double bias." Studies show that there have been serious problems in service delivery and in success rates. Placement rates among nonwhite clients are proportionately lower than those of white clients. There is a greater tendency for cases of white clients to be closed "rehabilitated," at or above minimum wage, than for nonwhites. Of the 2.5 million Hispanics of working age who were reported disabled in 1981, only 25,000 were rehabilitated by public rehabilitation programs. Similarly, Asian-Americans, American Indians, and blacks have experienced difficulty accessing the rehabilitation system and benefiting from it; this has been manifested by low referral rates, high dropout rates, and low success rates. Cultural Insensitivity Many members of ethnic minorities, and those who work on their behalf, believe that part of the problem has been that of cultural insensitivity. Robert Davila, former Assistant Secretary of the U.S. Department of Education's Office of Special Education and Rehabilitative Services (OSERS), himself a Mexican American with a disability, has said that in order to improve the quality of service delivery, rehabilitation professionals need to learn to recognize the cultural values of minority individuals and to adapt service delivery approaches accordingly. This Rehab BRIEF focuses on the issue of culturally sensitive rehabilitation. It highlights recent research in the field and introduces the two Rehabilitation Research and Training Centers (RRTCs) devoted to this issue. CULTURAL PLURALISM The familiar metaphor of this nation as a "melting pot" has led to confusion and disagreement. Some people believe that immigrants and second or third generation Americans should become acculturated, that they should assimilate themselves into American society, believe and behave like Americans, and shake off characteristics of their cultural and ethnic backgrounds. Others believe that such acculturation is never fully possible, nor even desirable. The concept of cultural pluralism suggests that cultural diversity is, in itself, a mark of the "American" culture and that such diversity, in all of its manifestations, should not only be recognized but honored, celebrated, and encouraged. --------------------------------------------------------- BEGIN SIDEBAR: HOWARD UNIVERSITY RESEARCH AND TRAINING CENTER FOR ACCESS TO REHABILITATION AND ECONOMIC OPPORTUNITY The Howard University Research and Training Center for Access to Rehabilitation and Economic Opportunity (HURTC) is funded by the National Institute on Disability and Rehabilitation Research (NIDRR) the philosophy of the Center is that every individual, no matter how severely disadvantaged or disabled, no matter from what cultural background, can benefit from competent, appropriately designed rehabilitation services. The Center focuses on the vocational rehabilitation, sociocultural, psychosocial, economic, and medical needs of persons with disabilities, people who are economically disadvantaged, and minority populations. The Center works with African-Americans, Hispanics, American Indians, and Asian-Amencans. The program of the Center is founded on the premise that an interdisiplinary collaborative approach is the best way to respond to the needs of the targeted population. A unique feature of the HURTC is the collaboration of several of its own university units with federal and state rehabilitation agencies, private community agencies, other RRTCs, and the corporate sector; a network of support systems has been established throughout the country. For example, the following businesses and professional organizations cooperate in the HURTC venture: AT&T, IBM, Digital Equipment, New Jersey Bell, The Pilgnm Life Insurance Company, Dr. X's Corporation, the Council for Exceptional Children, AFL-CIO, American Association for the Advancement of Science, Association for Retarded Citizens and the Epilepsy Foundation. Consortium agencies include the President's Committee on People With Disabilities, Harlem Hospital, Northern Arizona University and the University of Arizona, and the National Air and Space Administration. The Howard University Research and Training Center is carrying out a number of training projects designed to promote culturally sensitive rehabilitation practice, including the following: - Special Focus Training Conference Senes, - Building Bridges to Rehabilitation Within Minonty Communities, - Pre/Post Doctoral Minonty Scholars Fellowship Program in Rehabilitation, - Minority Youth Leadership Training Project, - Increasing Access to and Utilization of Technology by Economically Disadvantaged Persons, - Information Dissemination Network Relative to Disabled Minority Consumers and Their Families, and - Parents Advocating for and Educating Parents of Disabled Minonty and Economically Disadvantaged Children and Youth. For information about any of these projects, or the work of the HURTC, contact: Sylvia Walker, Ed.D., Director Research and Training Center for Access to Rehabilitation and Economic Opponunity 2900 Van Ness Street, NW Washington, DC 20008. (202) 806-8727. END SIDEBAR --------------------------------------------------------- Whatever one believes should be true of American society, the fact is that many different cultures do coexist here and it is impossible to separate individuals from their histories or their cultures. If rehabilitation professionals wish to serve all clients effectively, it is important to recognize culturally based beliefs, values, and behaviors. Cultural elements such as language, family roles, sex roles, and religious beliefs can play a significant role in the etiology, symptom manifestation, and rehabilitation treatment of disabilities. Culture can influence beliefs about causation of illness or disability, the conditions that qualify as ' ' sickness, " the expectations about what an affected person should do, and the expected actions of others. When sociocultural elements are included in the assessment and rehabilitation process, clients can be more accurately evaluated and effectively rehabilitated than when these elements are excluded. COUNSELOR EDUCATION There is a growing movement among rehabilitation counselor education programs to include a focus on cultural differences in their curriculums. Rehabilitation counselors need to be trained to be sensitive not only to individual differences among clients but also to cultural differences. While discrimination must never be tolerated, many in the field say that it is not always best to treat clients without regard to gender, race, creed, or cultural background; such differences must be acknowledged and taken into account in order for appropriate services to be provided. Rehabilitation students and all practitioners need to develop awareness, sensitivity, and respect for other cultures and offer services that reflect the belief that clients' values, although different, are equal to their own. FOCUS ON MEXICAN-AMERICANS Hispanic clients in rehabilitation experience low referral rates, high dropout rates, and poor overall success rates, despite the fact that they are overrepresented in physically demanding jobs and incur many job-related disabilities. Mexican-Americans are the dominant Hispanic group in the United States. Julie Smart, a Mary E. Switzer Merit Fellow, recently conducted a study funded by the National Institute on Disability and Rehabilitation Research (NIDRR) to find out more about Mexican-Americans in public rehabilitation programs and to suggest ways of improving outcomes. Smart believes that Mexican-Americans with disabilities may be said to be handicapped by two conditions: the disability itself and the subordinate status that many Mexican-Americans occupy in the social and economic structure of the United States. The state/federal rehabilitation program consists of a system of laws, regulations, knowledge, beliefs, norms, values, attitudes, techniques, and procedures. Smart describes this system as undeniably part of the dominant culture, reflecting an Anglo-centric or Eurocentric world view and value system. According to Smart, one set of cultural beliefs determines the way in which services are provided, but other--often conflicting--sets of cultural beliefs held by clients can influence how these services are utilized. If a deeper understanding of the Hispanic culture and its impact on clients with disabilities could be obtained, then rehabilitation services that are more culturally relevant could be extended. Julie Smart's research focused on the issues of acculturation and acceptance of disability among Mexican-Americans. Acceptance of Disability Good health is an interest of people of all cultures. However, the ways in which various cultures view, react to, and treat disability vary. It may be said that acceptance of disability is culturally determined. Thus, attitudes and perceptions of Mexican-Americans toward disability are determined to some extent by the Mexican-American culture. Smart points out that the degree of acceptance of disability may influence an individual in his or her decision to apply for services and may subsequently enhance or retard the success of the entire rehabilitation process. She identifies several factors that may be said to be associated with acceptance of disability among Mexican-Americans and other Hispanics: - Well-defined gender roles. Many Hispanic men have been taught that it is their responsibility to provide for their families, and being strong is considered an important male attribute. Acceptance of disability may therefore be more difficult for a Hispanic male than for clients who perceive their roles less stringently. - Stoic attitude toward life. Acceptance of disability among Mexican-Americans may be affected by what many researchers identify as a culturally based attitude of resignation and acceptance of life problems. There may be less inclination to question, complain, or strive for change than among people of other cultural backgrounds. - Cohesive, protective, family-oriented society. Researchers agree that Mexican-American families play important roles in rehabilitation outcomes. On the one hand, the reaction to disability by the tightly knit, family-oriented Hispanic culture can be described as uniquely supportive and comforting. However, some have seen this cultural characteristic as overprotective and paternalistic, making independence and selfsufficiency for the Hispanic disabled person nearly impossible to achieve. - Religious views. Religion plays an important role in the definition, response, and acceptance of disability for many Hispanic clients. Smart cites research that points out that in the Hispanic world view, disability is often seen as a punishment for one's sins or for the sins of one's parents. It is important for counselors to understand that such a "theological etiology" may be ascribed to disability by many Hispanic clients. - Reliance on physical labor. Mexican-American and other Hispanic people are overrepresented in physically demanding jobs that have a high risk of illness, disability, and fatality. They also have lower levels of education. For many Mexican Americans who are disabled, options for employment or training may be very limited. -------------------------------------------------------------- BEGIN SIDEBAR: THE NATIVE AMERICAN RESEARCH AND TRAINING CENTER The Native American Research and Training Center (NARTC) was established in 1983 at the University of Arizona and serves as a national resource for American Indian communities and for people working with Indian populations. Under funding from the National Institute on Disability and Rehabilitation Research (NIDRR), NARTC investigates health and rehabilitation issues, helps determine rehabilitation and service needs, defines barriers to service, and devises innovative and culturally relevant interventions. One of the central objectives of the Center is to promote active participation and partnership of Indian communities in the Center's programs. Each year, NARTC conducts workshops, conferences, and training programs on a number of rehabilitation and healthcare issues. In addition, as part of its mandate to disseminate the results of its research and training programs, NARTC publishes a monograph series and produces training videotapes. A few of these are highlighted here and give a flavor of this Center's commitment to culturally sensitive rehabilitation practice. - We Look-You Look: Perspectives. After defining the levels of acculturation and the process of assimilation of American Indians into contemporary American society, this video discusses American Indian cultural values and philosophies. The presentation emphasizes Indian perspectives about time death, social interaction, religion, the significance of life, child rearing and behavior. - Communicating With Native American Patients. A Navajo practitioner discusses some of the communication problems that arise in the Indian client/service provider relationship as a result of cultural differences and suggests culturally appro- priate solutions to these problems. - American Indian Concepts of Health and Unwellness. Based on a monograph of the same title, this videotape presents 10 basic beliefs about health and handicaps common to the traditions of the majority of American Indian tribes and provides interesting comparisons between Indian and non-Indian attitudes and beliefs about health. - Culture and Disability. The relationship between culture and the perception of disability is discussed in this video by Jennie R. Joe, Ph.D., director of NARTC. The presentation is particularly helpful for those wishing to understand how cultural differences impact on perception and treatment of disabilities and handicaps. For more information about culturally sensitive rehabilitation practice and the American Indian community, or to obtain more information about NARTC's publications and videotapes, contact: Jennie R. Joe, Ph.D. MPH Director NARTC 1642 E. Helen Street Tucson, AZ 85719 END SIDEBAR -------------------------------------------------------- Acculturation Smart's research indicates that in order to provide culturally relevant and successful rehabilitation services, some judgment or measurement of acculturation and biculturalism must be made. This is not to say that it is better for a client to be acculturated; it says that for rehabilitation efforts to be successful, they must be culturally appropriate for each client. The more acculturated a client is, the more likely it is that traditional (Anglo- or Euro-centric) assessment tools and counseling strategies will be successful. A client who is less acculturated, that is, more closely tied to his or her home culture, may benefit more from assessment techniques and interventions that take into account his or her language, value system, and beliefs. Another telling finding of Smart's discussion concerning acculturation is this: rehabilitation practitioners tend to view acculturation as a predictor of client success. If a client retains the language and continues to embrace the cultural characteristics of his or her home country, that client may be viewed by a rehabilitation counselor as being at high risk of not reaching rehabilitation goals. Smart suggests that instead of viewing level of acculturation as a predictor of success, practitioners should view it as a tool for determining what assessment techniques and interventions might be most appropriate. Implications Smart's work with Mexican-Americans makes it clear that the rehabilitation process must be responsive and appropriate for each client. Cultural awareness and sensitivity can help practitioners and policymakers design and carry out programs that are best suited for clients whose world views and value systems are culturally different from their own. Smart suggests some important implications that could apply widely in rehabilitation practice: - Level of acculturation should become a routine part of the evaluation of Mexican-American clients. Individualized Written Rehabilitation Plans (IWRPs) could be devised and implemented that take into account level of acculturation. Also, since there are so few bilingual, bicultural rehabilitation counselors, it would be possible to make better use of them by making a determination, based in part on an acculturation instrument, of who actually would profit most by working with bilingual, bicultural professionals. - Obviously there are not enough bilingual, bicultural rehabilitation counselors in all geographic areas to serve Mexican-American clients. Therefore, more and better training about cultural sensitivity must be made available to rehabilitation counselors. - Smart recommends that two courses be added to the curriculum for rehabilitation counselors: (1) Rehabilitation Counseling With Culturally Diverse Clients. This would have both a theoretical and a clinical component. The clinical component would include a supervised practicum in which students would work with clients of different ethnic groups. Not only would the students become sensitized to the issues and concerns of these groups but they could also learn to use culturally enhancing rehabilitation techniques. (2) Training Course for the Use of Paraprofessional Bilingual, Bicultural Interpreters. Smart found during the process of gathering data that many clients who consider themselves to be bilingual express different content when speaking Spanish than when speaking English. Moreover, these clients expressed more content in Spanish than in English. The use of bilingual, bicultural interpreters would help address the needs of Mexican-American clients and also the needs of monolingual English-speaking rehabilitation counselors who work with these clients. In fact, Smart proposes two courses for the rehabilitation curriculum; the first would train interpreters to work with rehabilitation counselors, and the second would train counselors in the use of interpreters in the counseling setting. For more information about this study, contact The National Rehabilitation Information Center (NARIC), 8455 Colesville Road, Suite 935, Silver Spring, MD 20910. Ask for the NIDRR document Level of Acculturation of Physically Disabled MexicanAmericans and Acceptance of Disability, project number H133F90017. ------------------------------------------------------------------ We welcome your comments on this BRIEF and on BRIEFS put out during the past year, as well as your suggestions for topics and for improving this publication of Conwal Incorporated. Prepared by Conwal Incorporated, 510 N. Washington St., Suite 200, Falls Church, VA 22046. =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- This document was scanned into electronic form for ABLE INFORM BBS: 301/589-3563 or FTS 301/427-0280 (data); Silver Spring, MD USA Internet telnet: fedworld.gov, then dd115 from the Top Menu Internet mail: naric@cap.gwu.edu Electronic release date: January, 1994 =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-