Section One
Module 1: Journeys, Cultures, Identities, and Other Definitions
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Where am I, and where do I want to go?
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After working with the material in this module, readers will be able to
explain the importance of self-awareness to client-centered, culturally and individually appropriate clinical and professional practice
compare multiple definitions of culture, compare multiple definitions of identity, and distinguish between culture and identity
define and distinguish among many culturally relevant terms, including “diversity,” “integration,” and others
This module introduces the idea of your personal and professional journey, a metaphor we will use throughout our discussions. We will also discuss some important foundational terminology, divided into two sets, and begin to work with the Your Turn segments that you will find throughout this website.
Appreciating Your Journey
Let’s start simply: Tell me about yourself! What has happened so far in your life? Who are you? What experiences, relationships, and adventures have shaped you?
Think about your daily, weekly, and annual routines. Think about the years that you spent in one place doing one thing, and the years that you spent in another place doing another thing. Think about the people who helped you, and think about your own efforts. Think about the good parts and the bad parts, the parts you would repeat in a heartbeat if only you could, the parts you have worked hard to leave behind. Think about how you made your decisions, what mattered to you, when your life felt good to you, and when your life seemed to be pushing you along in a direction that was not of your own choosing.
Let’s call your answers the journey that you took to get here.
Reflect on your journey for a moment. Parts of it have been difficult, and you might need to acknowledge those parts. If you are carrying grief or fear or anger, remind yourself that your grief or fear or anger was reasonable and necessary. (Then consider telling someone, if you need to, if you are carrying something that has become too heavy for you to manage alone. Talking can help.)
And parts of your journey have been good! Find some things about your life and your stories that you cherish. Think about some special parts that make it your life, not anyone else’s, in wonderful and meaningful ways. Enjoy your good memories of your life. It’s your journey, through your life. You are who you are, and everything about you matters.
Where you have been, what you have done, and your experiences and stories are your crucial starting points as we begin to think about client-centered, culturally appropriate, individually appropriate, multi-cultural, and cross-cultural speech-language pathology.
Then, next, let’s look forward, wherever your “forward” might be. Think about the next parts of your journey. Where are you going? Are the next steps on your future path as immutable as the past steps you have already taken?
You might have been ready to say no, but some parts of your future probably are established already! If your life includes daily or weekly rituals that matter to you, such as daily religious practices or weekly family commitments, your future will probably continue to include them. If you are a speech-language pathology student, you already know when this week’s clinic reports are due and which classes are on your schedule for next semester. If you have two children and an aging parent, much of what you will do this month is also predictable: You will make dinner for the kids, you will get your parent’s laundry done. If your clinical practice includes assessment and treatment methods that you believe in and that seem to be helping your clients, you will probably continue to use those methods.
But you were correct, if you recognized that your future is more flexible than your past. Most of your future journey through your life does remain wide open before you. Your future has at least some options, regardless of where you have been previously. In the particular context of your clinical and professional practice as a speech-language pathologist, you can always consider new possibilities.
We need all these pieces of ourselves, of our pasts and of our futures, as we start thinking about client-centered clinical practice, professional practice, and multi-cultural, cross-cultural, and culturally and individually appropriate speech-language pathology
The purpose of the materials collected on this website is to help all of us, no matter who we are, and no matter where we have been, to reflect on how we want to go forward.
Thinking about client-centered, culturally and individually appropriate speech-language pathology does not mean giving up your past, your present, or your future. It does not mean giving up your identity or your personal style as a clinician. As a matter of fact, it often means thinking even more explicitly about your very own journey, your individual identity, and your special personal style. If you are reading these modules with a group, you and your classmates or colleagues will each experience this material differently, because you are each on your own journey. That’s okay! We will celebrate you, your classmates, and your colleagues, each of you and all of you, as we work through this material. We will think about what makes each of you unique, and we will also think about the culture of speech-language pathology that we share.
More importantly, we will celebrate your clients and their journeys through their lives. We work on becoming aware of our own journeys, as we study client-centered, culturally and individually appropriate speech-language pathology, not for the sake of focusing on ourselves but because our awareness of our own journeys facilitates our awareness that other people’s journeys matter to them.
We work on becoming more aware of ourselves so we can work on understanding how all groups and all individuals develop their tendencies, beliefs, and actions.
We think about our own groups so we can work on learning about what happens when groups and individuals try to interact with each other.
And this thinking must be dynamic and cyclic; each time we discover something more about ourselves or about culture or about people or about groups, we return to thinking about our own journeys, and then to thinking about how we want to interact with others. How and why did we make our previous choices, and how and why are we making our current choices, and how and why will we make our future choices, as we work to fulfill our responsibilities to our clients, ourselves, our colleagues, the public, and our profession itself?
Lots of questions! And we will continue to ask a lot of questions. The modules collected here are designed to allow you to think about how and why you will incorporate information about groups and people and cultures and identities into your current and future work as the speech-language pathologist that you are, given your journey through your life and your career. These modules are not “how-to” seminars; I could not possibly begin to tell you how you should organize your version of your practice. That’s up to you — within a few legal and professional guidelines that we will address. The materials collected here are intended to provide you with some information that I hope you will find interesting and useful, and that you will then need to choose how to apply in a way that makes sense for you and your journey through your life. We will also spend quite a bit of time in conversations and discussions, in part because this material lends itself to conversations and in part because I find conversations more interesting than lectures (especially when I am the one doing the lecturing!).
And with that said, let’s get going. We need to start with two sets of foundational terminology, and then we can take our next steps.
Terminology, Set One: Culture, Identity, Culturally Appropriate, Individually Appropriate, Client-Centered, Clinical, Professional, and Speech-Language Pathology
Throughout these modules we will intentionally use the terms “culture” and “identity” loosely, rather than tying ourselves to any single, specific definition. I encourage you to think broadly about everything that culture and identity can mean, rather than attempting to memorize the “correct” definition.
We do need some initial shared points of reference, however, to limit our territory a little bit and to prevent any unnecessary miscommunication.
The word culture, to begin with, often refers to a group of people who can be considered tied together in some way, usually in terms of their beliefs and associated behaviors (as we will start to address in Module 2). Alternatively, the word culture can refer to the beliefs and behaviors themselves, using definitions such as those in Box 1.1.
Read the definitions in Box 1.1, and then spend a minute thinking about which cultures (or groups) you would say you belong to and about how they fit or reflect any of these descriptions. And if you think of your culture as referring primarily to your family’s racial, regional, or religious heritage, try letting the word expand a little bit in your mind. Your work group probably has its own culture, as does your sorority, and people who live with certain kinds of physical, cognitive, or neuropsychological characteristics can often meaningfully be described as having their own cultures, too.
Box 1.1. Representative Definitions of Culture
Culture can be defined in many ways, including the following.
> a group’s values, and the actions and artifacts that result from those values
> the recognized rules and unrecognized assumptions that control a group’s preferences, routines, and choices
> the knowledge and behaviors that any group of people, and the individuals in that group, assume to be necessary
> that which families and communities explicitly pass on to their children, and that which individuals implicitly absorb as true from their families and communities
> the assumptions and actions with respect to language, religion, food, dress, schooling, relationships, politeness, history, and many similar personal and interpersonal elements that lead a person to feel like, and to be accepted as, a member of a group
> an “integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions” for members of “a racial, ethnic, religious, or social group” (Cross et al., 1989, p. 3).
Identity, as a second term, differs from culture in that culture refers to groups but identity refers to an individual characteristic of a person, to how a person sees themselves, or to how a person would describe “what I am” or “who I am.” Some elements of our identities come from our cultures. You might describe yourself as part of a bilingual Spanish-English and Catholic culture (a group that shares explicit and implicit rules, expectations, values, behaviors, foods, languages, and more, as described in Box 1.1). At the same time, being a Spanish-English bilingual Catholic might be a defining feature of your individual identity, or part of how you know that you are you.
Other parts of our identities represent an individual characteristic, such as our height or age (see Module 2). Still other parts of our identities reflect our association with a subgroup that exists within a larger cultural group, such as seeing ourselves as a volunteer, an amputee, or a nonbinary person, within a culture where most people are not volunteers, amputees, or nonbinary. As these examples might have suggested, notice also that some aspects of our identities link us to subgroups that exist within many cultures and therefore represent cross-cutting cultures in their own right: a person from a Chinese American community might see herself as an artist and feel that she has more in common with Mexican and Ugandan artists, based on her identity as an artist, than she does with Chinese American non-artists. Finally, of course, a few parts of our identities are unique to us as individuals; I know that I am my husband’s wife, and that identity is an important part of who I am, and I know that I am the only person in the world who currently holds that title.
We will emphasize both culture and identity as we think about our work, because of our emphasis that high-quality clinical and professional practice must be client centered and because of the associated principle that client-centered practice must be culturally and individually appropriate for that client. I tend to describe our goal using the phrase “client-centered, culturally and individually appropriate speech-language pathology,” but many other terms capture parts of what I intend for this phrase to mean. You might enjoy thinking about what you know already about any of the terms collected in Box 1.2, or thinking about how the constructs emphasized by these terms can contribute to our general notion of client-centered, culturally and individually appropriate speech-language pathology.
Box 1.2. Related terms that can contribute to client-centered, culturally and individually appropriate speech-language pathology
> cultural sensitivity, culturally informed, culturally oriented
> culturally competent, cultural competence, culturally proficient, cultural proficiency
> culturally responsive, culturally supportive, culturally sustaining
> client-centered, person-centered, identity-centered, identity sustaining
> client’s values and preferences
The United States Department of Health and Human Services uses the phrase “culturally appropriate” to address similar ideas, and they too have defined culturally appropriate services broadly, using the shorthand “respect and responsiveness.”
Further, the Department of Health and Human Services defines culturally appropriate services as “a way to improve the quality of services provided to all individuals…. to help eliminate health inequities,” and as a way of helping us as care providers “remember that dignity and quality of care are rights of all and not the privileges of a few” (https://thinkculturalhealth.hhs.gov/clas/what-is-clas).
One way to summarize what we mean by client-centered, culturally and individually appropriate practice for speech-language pathology combines many of these constructs and also draws on words, concepts, and structures that you might (should!) recognize from the American Speech-Language-Hearing Association (ASHA) Code of Ethics (ASHA, 2023) and from ASHA’s Issues in Ethics statement about cultural and linguistic competence (ASHA, 2017) (see Module 3). Combining from and drawing on these sources, we will describe client-centered, culturally and individually appropriate speech-language pathology as follows:
Client-centered, culturally and individually appropriate speech-language pathology recognizes, respects, and responds to our own cultural and individual characteristics and to those of our clients and colleagues, in ways that hold paramount the needs of the persons we serve and that also reflect our responsibilities to ourselves, to the public, to other professionals, and to our profession as a whole.
Finally, as suggested within this definition of client-centered, culturally and individually appropriate practice, this website does use and depend on specific definitions of clinical service delivery, professional practice, and speech-language pathology.
As ASHA’s (2016) Scope of Practice for Speech-Language Pathology reminds us, speech-language pathology includes two large categories of actions, referred to as the two domains of speech-language pathology. The domains of clinical service delivery include prevention, assessment, treatment, and other activities that are undertaken primarily on behalf of an individual client or family. The domains of professional practice, in contrast, are undertaken primarily on behalf of the public, our present and future colleagues, or our profession itself: advocacy and outreach, supervision, education, research, and administration and leadership. Both sets of domains are important, and cultures and identities influence all actions in both domains. When these materials refer to “speech-language pathology,” I invite you to envisage the entire scope of your actions and responsibilities as a professional, across both clinical service delivery and the domains of professional practice.
Your Turn
Talk with a person you trust about your journey through your life and your career. How have some of the personal aspects of your journey influenced your work as a professional?
Think about the larger and smaller cultures (groups) you are part of, and think about the identities that make you who you are. Which of your identities flow from your cultures or from a subgroup that exists within or across cultures, and which of your identities represent you alone?
ASHA’s (2020) Standards and Implementation Procedures for persons seeking certification in speech-language pathology provide three definitions related to the material in this module:
“Cultural competence: The knowledge and skill needed to address language and culture; this knowledge and skill evolves over time and spans lifelong learning.
“Cultural humility: A lifelong commitment to engaging in self-evaluation and self-critique and to remedying the power imbalance implicit to clinical interactions.
“Culturally responsive practice: Responding to and serving individuals within the context of their cultural background—and the ability to learn from and relate respectfully with people of other cultures.”
Discuss how ASHA’s definitions relate to the definitions and ideas discussed in this module.
Did you notice that we are combining the notions of client-centered practice, culturally appropriate practice, and individually appropriate practice? Had you thought of “culturally appropriate” as somehow separate from “client centered” in the past? Do you see why I combine them?
You might have noticed that we are not referring to “multicultural speech-language pathology” or talking about the needs of “culturally diverse clients.” We will use the descriptors multi-cultural and cross-cultural later, to refer to some specific circumstances and practices, but think for a moment about what labels like “multicultural speech-language pathology” might imply. In some uses, they are positive, descriptive, meaningful, and important. In other uses, however, the underlying premise can be that speech-language pathology contains two kinds of practices: the basic, normal practices that most speech-language pathologists use with most basic, normal clients, and the different, special, or otherwise not basic or not normal practices that we have to go out of our way to learn, or that some of us might choose to learn as a specialty area, or that we might be required to use with some difficult clients. In some uses, in other words, the term “multicultural speech-language pathology” can start from the premise that there is normal speech-language pathology, for normal people, and that there therefore must be a special version of speech-language pathology for those we have decided to view as our “culturally diverse” clients. I strongly disagree with all such implications, as the next part of this module continues to address, and I am raising the issue here to help ensure that we all mean the same thing as we discuss client-centered, culturally and individually appropriate speech-language pathology. Our primary emphasis throughout these modules will be that all high-quality, client-centered clinical practice must be culturally and individually appropriate, for our clients, our colleagues, and ourselves, not that any particular group or subgroup of clients can be anticipated to be any more “difficult” than any other. Try discussing these distinctions with your friends, family, or colleagues. Are you drawn more or less to the term(s) client-centered speech-language pathology, culturally and individually appropriate speech-language pathology, or multicultural speech-language pathology? Why?
I have used the name “speech-language pathology” for our profession throughout this website, but not without some hesitation. Does the word “pathology” bother you? If you could start fresh and name our discipline and our profession, what might you call us? Why? How are definitions of cultures and identities relevant to that question?
Terminology, Set Two: Diversity, Equity, Equality, Inclusion, Access, Intent, Impact, Segregation, Desegregation, Integration, Responsibility, and Values
These are serious words, and you probably had a serious reaction to one or more of them. Some of them are in the news as I am writing, and some of them are probably the focus of lawsuits as you are reading.
But stand back for a moment. Let’s start by imagining two happy flower gardens.
The first garden is mostly sunny, with some shade, good soil, and adequate water. Many beautiful, healthy, happy, flowering plants are spread throughout the garden, in many different combinations and groupings, with one exception: No marigolds.
The second garden is also mostly sunny, with good soil and adequate water. It contains many beautiful, healthy, happy, flowering marigold plants.
Let’s use these gardens to explore the simple meanings of some words that are often saddled with unnecessary complexities.
The first garden, to begin with, is diverse, meaning that it contains a range of flowers that differ from each other. This garden includes many different plants and flowers, even though as a descriptive fact it excludes marigolds, here meaning simply that there are no marigolds in the first garden.
The first garden is also integrated, which means that its many plants are all mixed up: the different plants are all found all over the garden, in many different combinations and groupings. In addition, let’s assume that the plants in the first garden are happy in part because they are all being treated equitably, meaning that they each get what they need: the cacti and other sun-loving desert flowers live in the sunny spaces and get less water, the plants that need some protection from the worst of the afternoon sun get some shade, the plants that need more water get more water.
Let’s emphasize this point: The plants do not all get equal amounts of sun or equal amounts of water, in this equitable garden, because they do not need equal amounts of sun or water. The result is what we can call equity, one definition of which is “equal opportunity for optimal individual outcomes,” among the plants. Some species grow tall, some are groundcovers, some make many small pink flowers, some make a single large yellow flower, some grow better than others, and a few random plants throughout the garden end up being eaten by grasshoppers, but every plant receives the basic sun, soil, and water that match its needs and that start it off with a reasonable chance of flourishing as the kind of plant that it is.
The intent of the gardener who organized, planted, and tends these flowers was to allow each of them to grow and bloom as best it can, for each plant’s sake as an individual and also because this gardener perceives the inclusive and diverse garden to be a pleasing or positive arrangement. The impact of the gardener’s carefully equitable, and purposely unequal, distribution of resources has been to allow each plant to thrive in its own way, again resulting in a diverse and inclusive garden that the gardener perceives as beautiful.
Imagine now that a rose bush from this beautiful mixed-flowers garden lifts up its little rose-bush roots and hops over to the edge of the marigold garden. What might happen?
Based on your own experiences with immigration or emigration, or based on your opinions about many related issues, you might be excited about the potentially positive impacts on individual marigolds and on marigold culture, and on the currently marigold-less mixed-flowers garden, if the two gardens start to interact.
Equally, however, you might find yourself concerned that a large rose bush in the marigold garden might use too much water or could shade shorter marigolds in a way that stunts their growth. You might recognize that adding too many rose bushes to the marigold garden will ultimately result in its not being a marigold garden at all. And where will this all end? If the rose bush can move, what about the daisies? Would large-scale movement into or out of either of these gardens be a good outcome or a problematic outcome? For whom? Why?
Let’s imagine, in our situation, that our traveling rose bush is allowed to enter the marigold garden, but the marigolds dictate that it must plant itself in one specific corner. The marigold garden could then be described both as segregated (the marigolds are separate from the roses, within the garden) and as desegregated (the marigold garden no longer contains only marigolds). Either way, it is not a diverse, inclusive, or integrated garden; it is a marigold garden with one rose bush in the corner. And depending on how the flowers’ stories evolve from here, we will definitely need to question whether the rose bush’s future experiences will include equitable access to the resources it needs or to the opportunities we might believe it deserves.
We might also have several related final questions, as we consider these two flower gardens.
First, does any past or present gardener, flower, garden, or group deserve blame (with a negative connotation), credit (with a positive connotation), or any backward-looking responsibility of any sort for the current situation?
And then finally, separately, either because of how we got to this point or regardless of and completely ignoring how we got to this point, does any current gardener, flower, garden, or group hold any obligation or responsibility to act in any specific way, now or in the future?
People’s answers to questions of responsibility, especially future-oriented questions about a responsibility to act in certain ways going forward, tend to reflect their values and principles, as well as their beliefs about the world, about themselves, and about their roles in the world.
If our hypothetical gardener is a botanist who knows marigolds to be toxic to the other flowers, and who sees herself as the kind of person who protects other flowers from the damage that marigolds can cause, she might feel a strong responsibility to keep the marigolds separated from the other flowers. If the Marigold City Council had never thought about the impact of their traditional architecture, but has now because of the rose bush’s attempts to immigrate learned that their traditional style of fence not only protects marigolds from being eaten by rabbits but also prevents rose bushes from having access to Marigold City, their response will reflect their values, their goals, and what they believe to be the better outcome. They might feel a responsibility to continue protecting marigolds from rabbits, or they might feel a responsibility to allow roses to experience expanded opportunities in the world – or neither or both.
Did encountering these serious words in the context of flowers and bunnies help you to think about what they might mean, or were you bothered by what you interpreted as a flippant approach to a serious topic? Once again, I know that some of you will have had different reactions, and once, again, that’s okay! Let’s acknowledge from the beginning that parts of the journey we will take together, as we think about people, cultures, and identities in speech-language pathology, will be difficult for different people in different ways.
This website, and the conversations you will have with yourself and with other people about these modules, will challenge you to think about your assumptions, your values, and your perceptions, especially when your assumptions, values, and perceptions differ from other people’s. You will recognize that your personal and professional journeys, cultures, and identities influence how you approach this material, how you approach your profession, and how you think about such issues as diversity, inclusion, equity, and access not only for imaginary flower gardens but, much more importantly, for very real people, including yourself. You will also recognize that your sense of your private personal responsibilities informs and shapes not only the actions you take as a professional but also your views of our shared professional responsibilities.
These complexities are part of the journey. Part of your journey.
Thinking about client-centered, culturally and individually appropriate speech-language pathology challenges us, but I hope you will ultimately find the effort rewarding. Take your journey your way, and take the time also to speak with kindness and to listen to, respect, and learn from your classmates and colleagues’ journeys. We will not all make the same decisions, about hypothetical rabbits or about our very real clients, colleagues, and careers. We are not required to make the same decisions. But we can all strive to hold paramount the needs of our clients, our colleagues, the public, and our profession itself.
Your Turn
Discuss the question raised at the end of this segment: Did you find a metaphor of flower gardens and bunnies to be a useful way of approaching some typically difficult concepts, or did you find the metaphor to be denigrating some serious issues? Listen with kindness to each other’s reactions. (If your group agrees on one reaction, try to imagine several other reactions.)
In the previous Your Turn questions, we addressed the phrase “multicultural speech-language pathology” (which I do not use). As we said, some sources use the words “multicultural” or “diverse” to describe people, in phrases such as “working with multicultural populations” or “working with culturally and linguistically diverse clients.” Think again about what these phrases assume and what they mean, using the terminology and the definitions from this segment about flowers and bunnies. Are clients who are referred to as “culturally and linguistically diverse” in some uses of this phrase different from each other in a way that creates diversity (i.e., many differences) within their group? Sometimes they are, but do you also hear the implicit suggestion in some uses of these phrases that some people are the “regular” clients and that other people then need to be marked as the “multicultural” or “diverse” clients because they somehow “differ” from a “regular” client? The modules on this website focus on our abilities to work with all people and with each individual, and we will not refer to diverse clients unless we are referring to a large group of people who each differ from each other in many ways.
Highlight Questions for Module 1
What benefit do we hope to gain by focusing on our own journeys as a starting point for our efforts to help other people?
Provide at least three different definitions of culture (Box 1.1). If you used each of those definitions as your only definition of culture, which aspects of your clients’ lives might you fail to appreciate? If someone else were thinking about you and using only that definition of culture, which aspects of the things that matter to you would they miss?
Distinguish between a culture and an identity. How do a person’s culture or cultures relate to their identity or identities?
Consider this list of words: Diversity, Equity, Equality, Inclusion, Access, Intent, Impact, Segregation, Desegregation, Integration, Responsibility, and Values. Select many pairs of words from this list (e.g., access and impact, or equity and values), and explain what those two words have in common, how they differ, and how they might influence each other.
What have phrases such as “multicultural speech-language pathology,” “culturally and linguistically diverse clients,” and “a multicultural client” tended to mean, when you have heard them or read them previously? Why did this module describe some of the potential underlying premises and implications of these phrases as problematic? Do they strike you as problematic? Why or why not? Compare these phrases to the phrase “client-centered, culturally and individually appropriate speech-language pathology.”