Cultural Considerations for Treatment Activities for Adults

This page can guide clinicians when selecting appropriate, individualized activities for clients from all cultures and backgrounds. It is a worksheet to find out more information about clients and their cultural and linguistic backgrounds and identify culturally sensitive, individualized, and functional activities based on some key considerations.

Primary Consideration: Is the client from a culturally or linguistically diverse background, or do they identify with a culture other than the dominant culture?

Note: Regardless of whether a person identifies with mainstream culture, the following considerations can still be used to discover clients’ individual experiences and personal views. If the answer to the question above is ‘no, my client does not come from a culturally and linguistically diverse (CLD) background,’ it is recommended to continue to ask open-ended questions addressing the considerations below to personalize clients’ treatment activities further. It is important to note that, for this worksheet, the definition of culture encompasses not only race, ethnicity, or religion but all other factors related to a person’s view of the world.

The questions below are adapted from eight questions identified by Arthur Kleinman (1981) as suggestions for identifying a person’s cultural and personal perspective on illness and injury. Answering these questions can help reveal pertinent information for both assessment and treatment planning and aid cross-cultural communication.

1. What do you call the problem?

2. What do you think has caused the problem/condition?

3. Why do you think it started when it did?

4. What do you think the condition causes? How does it work?

5. How severe is the condition? Will it have a long or a short course?

6. What kind of treatment do you think the client should receive?

7. What are the chief problems the illness/condition has caused?

8. What do you fear most about the illness/condition?

Kleinman, A. (1981). Patients and healers in the context of culture. San Francisco: University of California.

How does the client identify? What is their background? Research and identify resources for more information regarding background/culture/language. However, be cautious of over-typifying general statements about culture. Make sure that any culturally sensitive conclusions are drawn only with confirmation and approval from the client. Use professional interpreters if necessary.

Factors: Consider the client’s views and feelings on the following when choosing treatment approaches and activities:

• The personal and cultural perspective on disability/disorder and Western health care.

  1. This requires independent research on the clinician’s part and should always be verified with the client and family as applicable to their perspective. Information on many different cultures and languages can be found on this website under ‘Cultural Information.’

• Nature of disability/diagnosis and prognosis.

• Client and family wishes.

• Age.

• Bilingualism vs. monolingualism; first/native language (L1) vs. second language (L2) proficiency.

• Frequent communication partners and communication community/context in which each language is used.

• Occupation and return to work goals.

• Interests and hobbies.

• Education and literacy level (all languages, if applicable).

• Family structure.

• Payor and insurance.

The personal information necessary to answer the questions above can be gleaned through discussions with the client and family. The factors mentioned above are vital in developing treatment plans that are individualized, client-centered, holistic, culturally appropriate, and functional for clients. They can be addressed in initial intake questionnaires and interviews as part of the evaluation process. This is, by no means, intended to be an exhaustive list but rather a tool to assist in focusing efforts toward client-centered care. A conscientious clinician will use open-ended questions to discover topics that would benefit from further exploration and allow the client’s answers to guide the interview. Approaching treatment planning allows for better rapport with clients and their families, which will likely impact motivation and carry-over into daily activities. Indeed, by taking the time to learn about a client’s personal views and attitudes surrounding their condition, one can ensure therapy will contribute to the client’s overall quality of life.

Develop: Plan and develop treatment activities incorporating the above factors and considerations into the plan of care. By extrapolating the pertinent information and turning it into functional client-centered activities, the clinician draws on their expertise, creativity, and resourcefulness. As with all clients, it is good to directly ask the client and family what they feel is most important to address and pair it with current evidence-based suggestions to plan a treatment course collectively.

Using the Worksheet

Case Study #1

Mr. Flores is a 63-year-old Filipino-American who will be seen as an outpatient for speech and language services, secondary to a left hemisphere CVA that occurred three months ago.

Primary Consideration: Is the client from a culturally or linguistically diverse background, or do they identify with a culture other than the dominant culture?

Yes, Mr. Flores was born and raised in the Philippines and is bilingual in Tagalog and English. He identifies as a first-generation Filipino-American as well as a devoted Catholic. After reviewing Mr. Flores’ case history and chart, the clinician conducted a basic internet search for common cultural perspectives of Filipinos. All of the cultural information used for treatment planning was verified with the client and family through intake interviews and questionnaires.

Factors: Consider the client’s views and feelings on the following when choosing treatment approaches and activities, such as their personal and cultural perspective on disability/disorder and Western health care.

The clinician’s findings revealed that some Filipinos might believe that sickness or disorder stems from a mystic or spiritual cause. They tend to prefer or trust health professionals who either have a disability themselves or can personally relate to disorder or disability. Additionally, they may turn to alternative forms of medicine, such as faith healers. Filipinos are often very involved in the treatment and recovery of their family members, occasionally leaving their jobs to care for a disabled family member. They tend to prioritize recovery over financial stability. They may turn to faith in a time of medical crisis and view even the smallest amount of recovery as a “miracle.”

Nature of disability/diagnosis and prognosis

During chart review and discussion with the client and family, it was confirmed that Mr. Flores had a left hemisphere CVA three months ago. He has made steady progress thus far, no longer requiring a walker to ambulate and increasing his verbal output. With speech-language, occupational, and physical therapy, he should continue to improve in the upcoming months. A home program for language will be implemented with Mr. Flores, which should increase the generalization of his language skills and maximize his progress outside of the limited clinic sessions.

Client and family wishes

During intake interviews, the clinician discovered that Mr. Flores wants to return to his daily life activities, spending time with his family and friends, attending and participating in church activities, and part-time work, if possible. He is unsure about attending therapy at first. However, after a discussion among his family, they decided it would be beneficial, in conjunction with an increase in church and prayer group attendance. His eldest daughter is taking time off work to transport him twice weekly to his speech-language therapy.

Bilingualism vs. monolingualism (L1 vs. L2 proficiency)

While completing the Bilingual Aphasia Checklist, the clinician found out that Mr. Flores speaks English at work but is not in frequent contact with others on the job. He meets weekly with his boss, but other than those meetings only speaks to coworkers briefly in passing. He learned English as a child, speaking it at school in the Philippines, and has spoken it regularly since his move to the US. He does continue to speak Tagalog with his friends, members of his extended family, and wife. His children understand Tagalog but do not regularly speak it, using English as their primary means of communication. He and his family have noticed communication changes in both languages since his CVA.

Communication partners and context

The intake interview also provided us with information to answer this question. Mr. Flores communicates regularly with his wife, children, grandchildren, boss, church members, friends, and extended family. He uses Tagalog when speaking with his wife and older children and friends, and extended family. He speaks English with his boss, some of the church community, and his grandchildren.

Occupation and return to work goals

Mr. Flores informed the clinician that he works full time as a maintenance man at an office building; however, he is currently on temporary disability while he recovers from his stroke, hoping to return to work in the same capacity. He works directly for the building owner, meeting with a supervisor once a week to discuss any concerns or specific tasks for the upcoming week. He would like to continue working as much as possible to provide for and support his family.

Interests and hobbies

Mr. Flores is very active in his church and Bible group. He attends church every Wednesday and Sunday and volunteers his time doing maintenance around the church. He enjoys spending time with his wife, children, and extended family, reading to his grandchildren, and traveling back to the Philippines every 2-4 years.

Education and literacy

Mr. Flores graduated high school in the Philippines and reports he was an average student. He had considered attending college shortly after graduation but determined it was in his family’s best interest to start working. He reads fluently in Tagalog, and as such, he tends to read more news stories and books in Tagalog. He reads English fairly proficiently, at a level that is adequate for him to complete his daily responsibilities at work and to read stories to his younger children and grandchildren.

Family structure

Through an internet search and client and family confirmation, the clinician discovered that Filipino culture tends to be collectivist, with large, extended family networks. They tend to be very willing to make sacrifices for each other and those in need. Mr. Flores has an extensive and supportive network, including his family, church, and Filipino community.

Payor and insurance

Mr. Flores is dependent on his wife’s health insurance plan, which she has through her work. He is eligible for 20 combined sessions of speech therapy/physical therapy and has a small co-pay. His physical therapist has said they will not need to see him for more than five more sessions to have 15 sessions of speech-language therapy as an outpatient.

Develop: Plan and develop treatment activities keeping the above factors and considerations in mind.

Possible treatment activities

Use the Oral Reading for Language in Aphasia (ORLA) (Cherney, 2004; 2010) approach to work with Mr. Flores in his oral reading and reading comprehension skills. This versatile treatment approach can be used with Bible verses, stories, and children’s books in English and Tagalog. The members of Mr. Flores’s family that read can be trained in this technique to be actively involved in his recovery in their preferred language, more specifically, by working with him on verbal expression and reading exercises. Stimuli were discussed with Mr. Flores and his family and decided based on those discussions; since it was agreed that they were areas of importance to Mr. Flores and his family.

Use the Copy and Recall Treatment (CART) (Beeson, Rising, & Volk 2003) to develop a list of functional and personally relevant words that Mr. Flores wants to address in his treatment in both languages. This list includes family member names, Bible and church-related words, words related to work, and other functional words Mr. Flores has selected. His family will also be trained in this treatment approach to provide another avenue for maximum family involvement.

We will also work with Mr. Flores to develop scripts with him, both for church events (i.e., greeting fellow church-goers and for bible study) and his eventual return to work (i.e., a script for meetings with his boss). These will aim to increase Mr. Flores’s participation levels in the activities he has deemed necessary. Throughout treatment, we will role-play scenarios using these scripts to support him in a practical, relevant way.

Case Study #2

Fawaz is a 20-year-old Muslim male who was born and raised in Kuwait. He has been living in the US for two years, attending college. He suffered an mTBI secondary to an MVA with no loss of consciousness and is being seen in a sub-acute rehab center.

Primary Consideration: Is the client from a culturally or linguistically diverse background, or do they identify with a culture other than the dominant culture?

Yes, Fawaz is a Muslim man, born and raised in Kuwait. He speaks English and Arabic fluently.

Factors: Consider the client’s views and feelings on the following when choosing treatment approaches and activities, such as their personal and cultural perspective on disability/disorder and Western health care.

An internet search was conducted for cultural perspectives of Muslims in Kuwait. There is a vast spectrum and range of beliefs and attitudes in terms of disability and health care. The cultural perspective often depends on the type of disability, severity, age, environment. For some, the term disability connotes a more permanent state, whereas the assumption made concerning a “health condition” can be resolved and is temporary. What is often considered paramount is how the person in question functions in society; if they function well, the diagnosis or label can hold very little significance.

Nature of disability/diagnosis and prognosis

Fawaz is two months post-injury and is reporting difficulty tracking details in conversations and multitasking. He was referred by the physical therapist who was treating his neck pain and began to notice attention deficits and was easily fatigued.

Client and family wishes

Fawaz reports he does not consider himself a disabled person because he still functions independently. He relies very little on his friends and family from day today. Fawaz does report trouble paying attention in class and low energy, which he would like to address in therapy. His family in Kuwait knows of his accident, but they have not noticed any deficits or challenges in their phone communication.

Age

Fawaz is a 20-year-old student living in the dorms on campus.

Bilingualism vs. monolingualism (L1 vs. L2 proficiency)

The dynamic assessment was conducted and revealed that Fawaz is bilingual and demonstrates fluency in English and Arabic. He uses English at school and in day-to-day activities as necessary. He uses Arabic when speaking with most of his friends, family, and acquaintances at his attends the mosque.

Communication partners and context

He is frequently in communication with classmates, friends, and dorm-mates. He has regularly scheduled weekly phone conversations with his family in Kuwait. However, over the last few weeks, he has forgotten about the weekly calls, which is very upsetting to his family. Fawaz speaks English in school and with dorm-mates, Arabic with friends, family, and acquaintances at the mosque.

Occupation and return to work goals

He is a full-time student studying business. At this time, he has not connected with the Student Disability Office on campus but reports he is struggling with school and falling behind in his reading and assignments. His long-term goal is to complete his MBA and return to Kuwait, where he has a job waiting for him at his uncle’s business.

Interests and hobbies

Fawaz is a business club member, attends the mosque occasionally, mainly as a social outlet to interact with friends and other Middle Easterners. He also enjoys skateboarding and video games. Following his Muslim faith, he participates in prayer at five scheduled times throughout the day, an automatic event for him, and has been unaffected by his injury.

Education and literacy level (all languages, if applicable)

He attended a British high school in Kuwait and has always been an excellent student, and is currently on scholarship. He reads and writes in both English and Arabic fluently and at an academic level.

Family structure

He comes from a large family, and often family members rely on each other for connections in the community. There is a considerable emphasis placed on respect for elders in his family structure. The interaction between the sexes is often limited, and strong patriarchal values and practices are in place.

Payor and insurance

Fawaz’s insurance is through the University, and therefore, the number of sessions is limited to six with an expensive co-pay.

Develop: Plan and develop treatment activities keeping the above factors and considerations in mind.

Possible treatment activities

To address self-advocacy and education, we will provide Fawaz with written and verbal information regarding the nature of his injury, which is essential in raising his awareness of his deficits. An important part of treatment is providing Fawaz with resources, such as the Student Disability Center, and educating him on how these services will benefit him. The education piece in Fawaz’s situation is crucial considering his cultural perspective of disability. More specifically, making the connection between the physiological changes associated with mTBI and how they might contribute to his performance in school will hopefully increase his awareness and motivation in treatment. Finally, providing education will likely help him explain to his family why he has been missing the weekly phone calls.

Since he participates in prayer five times a day, we suggest filling out his activity log following each prayer time to establish a routine. Tying the two activities together will serve as a reminder to fill out the log and increase awareness of fatigue levels and pacing. The log will include his daily activities and corresponding fatigue levels using a rating scale. This will provide vital information for creating a pacing plan and establishing scheduled breaks.

Establishing an external memory system for Fawaz using either a smartphone or planner will be important in tracking his daily and weekly commitments, such as his weekly phone call with his family in Kuwait and due dates for school assignments. Systematically instructing the activity log and external memory system is an appropriate technique considering the nature of his cognitive challenges. The information gathered from Fawaz’s activity log can be integrated into his new system in a pacing plan, which will address his energy management.

Case Study #3

Ms. Vega is a Mexican-American woman who moved to the United States eight years ago. She has been referred for treatment for dysarthria and the decreased speed of processing, secondary to a recent diagnosis of Multiple Sclerosis.

Primary Consideration: Is the client from a culturally or linguistically diverse background, or do they identify with a culture other than the dominant culture?

Yes. Ms. Vega is originally from Mexico and speaks fluent Spanish. She speaks English only functionally while at work. As such, a clinician who does not speak Spanish should have a qualified interpreter present for all evaluation and treatment.

Factors: Consider the client’s views and feelings on the following when choosing treatment approaches and activities, such as their personal and cultural perspective on disability/disorder and Western health care.

During the interview, we discovered that Ms. Vega was using faith healers, or sobadoras, for some of the discomfort related to her MS, before her official diagnosis. Her daughter mentioned that Ms. Vega believes MS might be a physical manifestation of “wrong” thoughts or actions in the past and that she feels somewhat guilty about it, which is why she waited to seek treatment.

Nature of disability/diagnosis and prognosis

While symptoms of MS vary significantly between clients, due to the general nature of progression, we can expect that she will have periods where her symptoms will plateau, decrease or remiss, and periods of a sharp decline in function. Episodes can last for days, weeks, or months. Since the disease is progressive, the focus of treatment will be compensatory to prolong functional activities.

Client and family wishes

Ms. Vega is very family-focused. She has many family members in town, and she takes trips twice a year to Mexico with her children to visit her family there. She does not have savings or retirement, and she is worried about continuing to work to support herself and her children. Ms. Vega has a strong work ethic and would like to continue to work at the restaurant as often and as long as she can. Her family would also like to be involved in her treatment as much as possible.

Age

Ms. Vega is 37 years old.

Bilingualism vs. monolingualism (L1 vs. L2 proficiency)

She speaks and reads functionally in English to customers and vendors at work; however, her English language skills are limited to work-related topics.

Communication partners and context

Ms. Vega communicates primarily in Spanish. She considers herself profoundly religious and attends Catholic church services regularly, and as such, she has many members of the church community that she communicates with regularly. She frequently calls her family in Mexico. Ms. Vega lives alone with her son and daughter and works at her cousins’ restaurant, communicating in both Spanish and English while at work. She uses English to communicate with customers, vendors, and a few staff members at the restaurant. In public places, she visits in her activities of daily living (mainly shopping, dining).

Occupation and return to work goals

She works as a server and cooks at a family-owned restaurant. Her employers (who are also cousins) are willing to make accommodations for her to prolong her ability to work and help her financially.

Interests and hobbies

Ms. Vega enjoys attending church, cooking, reading, and dancing.

Education and literacy level (all languages, if applicable)

Ms. Vega finished 11th grade in Mexico, and she reads fluently in Spanish. However, her writing has been affected by MS. Her English literacy is limited to operative words and phrases she encounters in her daily life.

Family structure

She has a son and a daughter, ages 8 and 18, respectively. In addition, she has many supportive relatives in the area. Her mother and sister would like her and her children to return to Mexico to assist in her care.

Payor and insurance

Ms. Vega has private insurance that she pays for, but it is limited in coverage, with a high deductible and co-pays. Treatment sessions are limited to 12 sessions per year and include all allied health (PT, OT, Psych). Due to her prognosis, she is applying for disability insurance.

Develop: Plan and develop treatment activities keeping the above factors and considerations in mind.

Possible treatment activities

Due to her limited coverage for therapy and the need for services of other providers, we need to focus most of our treatment around providing education and compensatory strategies for Ms. Vega and her family members. This approach will address her communication concerns and provide ways they might be able to implement independently. To address her communication difficulties related to dysarthria, we can set up a low-tech AAC system to assist her with functional communication at work and church. Pictures accompanied by words in English and Spanish could be used as much as possible to address her communication needs both at work and in her personal life. We can work with her to develop recommendations and determine modifications to her work environment to address her communicative needs. Ms. Vega’s family could be involved in cueing Ms. Vega to use compensatory strategies such as slowing down and over-enunciating her words to increase intelligibility.

Ms. Vega has also been experiencing challenges with her processing speed, and treatment could include education to both Ms. Vega and her family on the cognitive challenges associated with MS. Her family could be trained in communicative strategies to compensate for Ms. Vega’s decreased speed of processing. They could be taught to slow their speech rate when communicating with Ms. Vega, provide her ample time to process and answer questions she is asked, shorten and simplify their utterances, and not overwhelm her with visual and auditory information. This information could also be provided to Ms. Vega’s coworkers and friends to enhance her communication in all environments.

Conclusion

This page provides several examples and suggestions for how a clinician can allow a clients’ cultural perspectives to guide treatment planning. When serving CLD populations, external research must be conducted to gather foundational knowledge regarding the clients’ backgrounds. Feel free to use these suggestions with the caveat of avoiding assumptions about the clients’ cultural identification and always confirm with the client and family before initiating any treatment activity.

Original contribution by Kelsey Fowler, Krystin Overstreet, and Faith Purnell, March 2013.