Here’s a funny question: Are you the exact same person as any of your clients?

(No. Of course not.)

Here’s a pile of “what if” variations: What if the client plays with toy cars and you don’t? What if the client has two dads and you don’t? What if the client eats with a fork and you eat with chopsticks? What if the client covers her hair with a scarf or a veil and you don’t? What if the client likes Beethoven symphonies and you prefer a niche subgenre of death metal? What if the client’s family is White, Black, Christian, and/or indigenous to the regions now known as the southwestern U.S., and yours is not? What if the client’s mother tells you the child loves the LemonSheep brand toys, you have never heard of LemonSheep, and your favorite toy when you were a child was your dollhouse?

(Same answer. I structure my clients’ therapy programs in ways that I intend to be useful for them, not as if I were the client. For these examples, I would bring toy cars for the child’s session, invite both the dads into the session and use the word “dads” as a plural form that was never necessary in my own family, and make sure the patient has a fork for our dysphagia sessions. I do not play any music during speech therapy, but I could certainly use Beethoven symphonies as a topic the client can discuss during her fluency practice… or, well, why not, I can have the client play some parts of a symphony she likes on her phone, and then we can discuss it! If the client has religious obligations for Friday evenings, Sunday mornings, or some other specific time, I will schedule their therapy sessions at other times or on other days. I will ask the child to tell me about this LemonSheep toy, because it is new to me, and I will believe what she is telling me. I will search online after the session to learn more, and I might buy some LemonSheep toys to have in my clinic or at least print something free about LemonSheep to use as a gameboard or coloring activity in our next session. I might tell the child about my dollhouse, as a way to share a bit about myself, but I would never drag my own dollhouse into the session with this child and insist that she has to play with it.)

Easy enough? Is that what you already do? That is cross-cultural or cross-identity communication care. You do it already. And you, correctly and appropriately, do it with clients who are very similar to you in many ways, clients with whom you would say you share some but not all cultural or identity details, and also clients who differ from you in some, more, or many ways.

It is not difficult to notice or ask what a person likes or is comfortable with, believe their answer whether it would be your answer or not, and respect it or act on it. This is why you choose the Batman coloring page instead of the Star Wars coloring page for the child who says they like Batman, or why you take a range of coloring pages and let the child choose. This is why you ask clients to tell you about stories or movies they like, instead of insisting that they should do their language practice by telling you all about your favorite movie.

You do this all the time, with all your friends and with all your clients — or at least with most of them.

Why, then, do some clients feel complicated? Why do we spend so much time discussing the “complexities” of cross-cultural and culturally appropriate care? Why do we find ASHA’s requirement that we are to integrate “each individual’s traditions, customs, values, and beliefs” into their service delivery to be difficult sometimes? Why did we finish Module 18 by asking about clients or populations we might find difficult? Why do we all harbor some “but what about” questions — some exceptions or limits that we might want to place on the values or beliefs we are willing to accept into our therapy sessions?

Many reasons. It might be related to our cross-cultural mindsets. It might be that we need more cross-cultural information, or it might be that we need to try some different cross-cultural methods.

This module addresses these three topics, starting with ASHA’s general instructions and required mindsets for culturally responsive care — and including thinking about what bridge building actually means.

ASHA’s Cultural Responsiveness Materials: General Instructions and Required Mindsets for Cross-Cultural Bridge-Building

ASHA’s materials on cultural responsiveness provide clear instructions for all clinical interactions: “Audiologists and speech-language pathologists (SLPs) practice in a manner that considers the impact of cultural variables as well as language exposure and acquisition on the individual and their family.” Clinicians are “responsible for providing culturally responsive and clinically competent services during all clinical interactions.”

Notice the reference to “all clinical interactions.” This requirement parallels ASHA’s (2017) requirement that we provide high-quality services to “all populations.” All. Once again, everything about culture, language, and identity applies to all our clients and all our practice, not to any subset of people. Cultural responsiveness, including high-quality cross-cultural bridge building, refers to and includes all clients, all potential clients, everyone we are serving, everyone we should be serving, and all our interactions with them.

And ASHA provides a long list of instructions, presented as the cross-cultural and bridge-building actions that we as professionals are required to take with each client and with every client. Read Box 19.1.

What do you think of these requirements?

Are parts of it simple and obvious, as we discussed above? Of course we respect each individual’s age; that means bringing preschool toys for preschoolers and bringing a magazine for adults. Of course we integrate the client’s customs and treat each person as an individual; we bring forks for clients who use forks, we ask clients to tell us about their favorite movies or their hobbies, and we do not require Christian clients to come to therapy on Sunday mornings.

And yet, if we allow you to be honest, might you also have some lingering or more complicated questions, as we started to recognize at the end of the previous module?

• What does “demonstrating respect for each individual’s… sexual orientation” actually require us to do? How does this requirement interact with “demonstrating respect for” our own religious beliefs? What about a clinician’s personal religious belief is that homosexuality is a sin? Is she required to say “both your dads” to the child, and find a picturebook that shows a family with two fathers to use in that child’s therapy, if she does not believe that gay men should be raising children at all?

• What does “integrating each individual’s… beliefs into service delivery” actually require us to do? What if the clinician is a woman, and the client makes it clear that he does believe women should work outside the home? What if the clinician is a darker-skinned woman, and the hospital patient comments to his visiting friend that he questions the professional qualifications of all darker-skinned women?

• What if a clinician views women in many Middle Eastern countries as repressed or abused? Imagine a clinician who sees a client’s heavy veil as a symbol of a seriously problematic oppression, not as a simple piece of fabric or as a positive expression of the client’s faith and family. This clinician might be very uncomfortable with, or even overtly angered by, the client’s husband’s assumption that he will be in the room during her therapy. Can that clinician at least ask him to wait in the waiting room?

• What if we simply do not know? Are we really expected to integrate all the complexities of another person’s culture, ethnicity, religion, or socioeconomic status into our therapy, when we simply do not know all the details? Don’t we run the risk of oversimplifying or mistaking an individual’s culture, ethnicity, religion, or socioeconomic needs in ways that could end up being insulting, stereotyping, rude, or just plain wrong?

Sometimes working with someone who is not me, who differs from me, is easy. I grab the toy cars and I start the session.

But sometimes, let’s be honest, sometimes it is not easy at all. Sometimes we are very aware that our starting point, on our side of the canyon, is nowhere near the client’s starting point, on their side of the canyon. Sometimes we look down at the chasm we are trying to cross and we see sharp rocks, raging waters, and other elements that we perceive as truly challenging to our personal, emotional, or professional safety. Sometimes this client and I come from such different backgrounds, carrying such different assumptions, that it seems almost impossible to imagine being in the same room with them, much less to design and implement a therapy program that centers their traditions, customs, values, or beliefs — maybe because I am aware that I do not know nearly enough about those traditions or customs, or maybe because I find those values or beliefs to be genuinely problematic.

How do we navigate the cross-cultural bridge-building in these cases?

There are several important parts to this answer.

First, we draw on all the background information, all the history, all the models, all the standards, and all the metaphors. Everything from all 27 modules of this website can be relevant, as can much more information from a vast array of professional resources. Use everything you know.

Second, we draw on all our abilities as clinicians and as human beings. You know how to help people. You are already a good friend, a good parent, a good clinician, a good neighbor. Use those abilities.

And ASHA’s basic answer, general instruction, and required mindset, as facile as this might sound, is that we do it. We value it, so we figure it out.

The items in Box 19.1 are requirements that apply to our work with all clients and with every client. There are no “unless” statements in Box 19.1. There are no “except if” statements. We are to respect every client’s cultures, identities, beliefs, abilities, and preferences, and we are to integrate every client’s traditions, customs, values, and beliefs into their therapy. ASHA’s required mindset, general instruction, and basic requirement are that we provide high-quality care to all populations, that we build an appropriate cross-cultural bridge to every client, and that we do so by respecting and integrating what that individual person needs us to respect and to integrate, because every client deserves the best possible individually-appropriate communication care.

So, yes, if they like toy cars or Beethoven symphonies, they will probably talk in their sessions about toy cars or Beethoven symphonies. And if their world includes two dads, or a synagogue, or volunteering for a certain political party, they will probably talk in your clinical sessions about dads, or synagogues, or political rallies. And yes, your related actions need to demonstrate your respect for their right to have these preferences, customs, and beliefs. ASHA does not give us the option of saying “I can’t work with a person who believes X, because I believe Y,” or “I can’t work with a person with THAT identity or from THAT background, because of my personal identity or my background.” On the whole, ASHA does not even give us the option of saying “I will only serve as your clinician if you refrain from expressing your beliefs” (with some exceptions; we will come back to this). And ASHA’s explicit answer to “What if we don’t know"?” is that we are required to go learn: We have a “responsibility to achieve and maintain the highest level of professional competence and performance,” and we have a responsibility to “enhance and refine [our] professional competence and expertise through engagement in lifelong learning.”

So that is part of the answer: We do it. We figure it out. We build a cross-cultural bridge to every client, because we differ in at least some ways from every client, because we are required to provide all clients with high-quality care, and because every client deserves the carefully individualized care that our best-served client would receive.

And let’s keep going, too, because there is also more to think about. Another important part of the answer involves reflecting for a moment on what bridges are and what bridge building actually means.

Take a minute, stand back, and give the bridge itself a bit of space in your mind.

Think about building and using a cross-cultural therapeutic bridge to a client.

Bridge building is a useful metaphor for many reasons. Part of the idea, of course, is that we need to connect to each of our clients.

But don’t stop there. The point of a bridge is not merely to connect.

The point of a bridge is to connect two points that are in different places. No one is the same as you. None of your clients are you. It is one of those obvious and silly starting points that become more complex, and more serious, the more you think about it. It’s okay that we differ from our clients. It’s okay that our clients differ from us. Of course they do, because of course they do, and they all deserve our best possible services.

Equally, bridge building recognizes that the two different points are not going to move. Bridge building does not mean lassoing the opposite bank and pulling it toward you like a cartoon character. Bridge building does not mean that the client on the other side of the canyon will manage to pull your side across or make it indistinguishable from their side. Bridges are not necessary when we could eliminate the distance instead or if the gap is going to disappear tomorrow. Bridges are built because there is a space, in full recognition of the fact that there is a space, and in full recognition of the fact that there will remain a space.

The bridge-building metaphor also implies, as we keep thinking about it, that the people on both sides of the river now have a safe way to go back and forth. Building a bridge does not include, much less require, that you fall into the river. The bridge prevents you from falling into the river! A bridge is a structure that allows people to navigate a crossing safely, in either direction and in both directions. Crossing a bridge to work with a client implies that we have safely avoided the rocky pitfalls that the differences between us might otherwise have represented, and it also implies that we will return safely to our own side 45 minutes later.

From a slightly different perspective, remember also that building a bridge does not include or require allowing yourself to be slugged in the stomach when you get to the other side. There is a huge difference between a client who believes things you do not believe and a client whose actions are closer to slugging you in the stomach. The vast majority of clients whose beliefs differ from yours, to be clear, the vast and overwhelming majority, have no desire or intent to hurt you. They are simply living their life on their side of the bridge. If something genuinely unacceptable does happen as you work with them, however, you are allowed to respond; none of the requirements or metaphors that shape cross-cultural service delivery require you to become the actual literal target of anything you perceive as an attack. Remove yourself from that situation (in a way that does not jeopardize your client’s safety) and ask someone you trust for help, if you ever do find yourself in this situation.

But if you and a client are merely on opposite sides of a chasm, no matter how large or complex that chasm might seem, remember also that building a bridge to provide her with culturally and individually appropriate communication care is about providing her with communication care. You are not trying to re-shape a client’s culture, identity, religion, beliefs, or values to make them match yours. You are not required to change your culture or identity to match hers. The two of you as a dyad are not tasked with solving any longstanding world conflicts. You are two people, who are not each other, doing a communication-care session together, each of you playing your role as either the client or the clinician.

We are required, in other words, to respect our clients’ cultures and identities in the context of their communication care plans and sessions and to integrate their traditions, customs, values, and beliefs into their communication care plans and sessions.

This mindset, which might be phrased as “Remember why we are here,” might help, if you are still feeling uncomfortable about anything that Box 19.1 implies. We are not expected to rearrange canyon walls. We are not expected to become our clients. We are not expected to agree with our clients. We are not even required to like our clients. Our bridges help us to navigate safely the real and probably permanent differences we have with all clients, and they do so toward a single and very specific purpose: to help us provide every client with the high-quality, respectful, individualized, cross-cultural communication care they deserve.