Section Five

Module 17: Preparing for Multi-Cultural Clinical Service Delivery

  • How can we prepare to be ready for anything?

  • After working with the material in this module, readers will be able to

    • use a general “Yes and” strategy in multi-cultural clinical situations

    • create online and physical clinical spaces that are accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities

    • create clinical intake forms that are accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities (cf. ASHA Certification Standard IV-C, and in preparation for practicum assignments addressing Standard V-B)

Multi-cultural clinical practices seek to be appropriate for all people, for the situations in which many cultures and identities are involved or when we cannot match our work to any specific client’s cultural needs or expectations. Module 17 presents one widely applicable general strategy and then addresses some of the work that we do to prepare for all clients, before we meet any clients.

Be sure you understand the distinctions between “multi-” situations and “cross-” situations, from Module 16, before you try to read this module.

One (Almost) Universal Strategy: “Yes And”

Have you ever played with “Yes and”?

“Yes and” is a widely known (and widely parodied) strategy from acting classes and improvisational theatre. And it is a terrific, multi-purpose, widely applicable strategy to have with you in almost all multi-cultural situations.

In acting and improvisation, “Yes and” requires two or more partners to improvise a scene using a rule that everything anyone suggests must be accepted and built upon. The second actor’s response must be some version of “Yes, and,” regardless of what the first actor has offered.

If Alison has asserted in an improvised scene that it is raining, for example, Bertie cannot retort that it is not raining. Bertie must accept Alison’s assertion (“Yes”) and then do whatever he can to build on it (“and”).

Similarly, if Bertie’s response is “Yes, and here come the ducks,” Alison must incorporate Bertie’s ducks into her reality.

She might try, “Yes, and it looks like they are having fun dancing!”

She might try, “Yes, and can you read that sign the little one is carrying?”

She might even jump to, “Yes, and I’m sure glad we brought our hunting rifles!”

Either way, she’s stuck with Bertie’s ducks. And Bertie, in turn, will have to build on Alison’s reply, whether or not he had originally pictured his ducks as dancing, sign-carrying, or otherwise.

Regardless of any other specific suggestions, options, or techniques you might learn or use for multi-cultural clinical situations, keep the universal “Yes and” strategy nearby.

“Yes and” as an acting lesson serves two important purposes.

First, it allows actors to practice listening and responding to their fellow actors. To be able to say “Yes and,” the listener needs to be listening and absorbing and accepting (i.e., respecting) what their partner has said.

Second, the strategy allows actors to practice their ability to build and convey a single shared reality.

Imagine watching a play that consisted primarily of one actor announcing one thing and another actor immediately contradicting it. Unless the playwright had chosen this arrangement for a specific reason, the audience would find the result essentially unfathomable. Acting requires working together to create a single, collaborative, shared reality and to convey that reality to an audience. Listening, absorbing, accepting, and building together are critical skills that determine the actors’ later ability to be successful together in their work.

“Yes and” serves the same purposes in clinical conversations with clients whose backgrounds and assumptions differ from yours, for the same reasons.

One of our goals in client-centered, culturally and individually appropriate clinical service delivery is to recognize, respect, and respond to our client’s needs, but in multi-cultural situations we cannot possibly have prepared to match each client’s needs specifically — just as Alison could not have known ahead of time that Bertie was going to add ducks to their scene, and Bertie could not have known that his simple little ducks were about to become brain-surgeon ducks on pink roller skates.

Your other goal as a culturally and individually appropriate clinician is to lay the groundwork for future development of a respectful therapeutic relationship and a shared, collaborative reality that will help each client, whether your interaction will be for a minute or two during a quick screening or for many months (or years).

“Yes and” supports and allows these goals, whether you are preparing for multi-cultural speech-language pathology or enjoying your improvisation classes.

In speech-language pathology, as in acting, “Yes and” is a wonderful general strategy, intended to be personalized and adapted, not the script for any specific play. At the same time, “Yes and” is useful because it does provide a single, learnable behavioral framework; “Yes and” is two specific words that can help us begin to operationalize the otherwise somewhat abstract notions of recognizing, respecting, and responding to other people. Once you have it in your pocket, you will find yourself using “Yes and” often, in many different ways.

Your Turn

Play with “Yes and.” Have some fun generating conversations that allow you to practice the universal skill of accepting and building on anything the other person says, whether you agree with them or not and whether you expected them to say that or not.

Generate one or two professional variations on “Yes and” to have ready and that fit your specific style as a clinician. Be careful that your version of “Yes and” does not communicate “Yes, but here’s my repetition or defense of my view”; the goal is genuinely to accept Bertie’s ducks, and to incorporate Bertie’s ducks into the reality you are creating together, whether you thought there were ducks or not. Among many others, you might think about any of these possibilities:

  • Sí, claro. And also

  • True. So then from there, we can also

  • I see how you are looking at it. Let’s also

  • Thanks for explaining your views. Also, I think we can include

  • Ah, so you did x. We can also try

  • Okay, I see how you did that. How about if we also

As wonderful as “Yes and” can be, have you also been thinking that sometimes we all need to say “No because”? No, I can’t go to the movies, because I have to study. No, I will not let you climb that tree, because I am your mother and I know it is unsafe for you. No, I will not allow you to speak to me that way, because I am a valuable human being who deserves my own dignity. Even, very seriously: No, I cannot agree that the way you treated your elderly parent in that situation was appropriate, because it meets our society’s definition of elder abuse and I am actually required to report it to the county office. Regardless of our emphasis on recognizing and respecting other people, use “No because” when you must. You have your necessary boundaries, and you are not required to accept racism, sexism, cruelty, or any other abuse or unacceptable behavior.

(Yes, and…. let’s now go back the other direction. As difficult as some interpersonal situations can be, remember, too, that the shared universal in a clinical situation is not that you and the other person are there to agree on politics or religion. You are there to do speech-language pathology together, and ASHA requires us to provide high quality services to all populations. If a client has asserted something you fundamentally disagree with, you might be able to use “Mm-hmm, and here is our next activity” to communicate, essentially, “Yes, you said that thing, and now we are moving on with our therapy session.”)

Before We Meet a Client: Designing our Websites, Intake Forms, and Physical Spaces

Multi-cultural clinical practice starts before we meet any of our clients! Let’s think about the first electronic and physical ways that potential clients interact with us before we meet them as human beings. Your website might be the first interaction that clients have with you, so we will start there.

Multi-Culturally Welcoming Webpages

Websites and webpages are complex structures with many elements. For our purposes, we can focus on only five.

Content refers to the information itself and to the visual and auditory elements that are used to present that information. If you are trying to convey the location of your office, the relevant content on your webpage might include your address shown in printed words, a description such as “near the 12th Street YMCA in Midtown,” or an image of a map with your location marked.

Function refers to the goal of any page, screen, section, menu, item, or link. The goal of one section on one page might be to provide information about you or about your services; the goal of the button at the top might be for clients to be able to send you a message or schedule a free initial consultation with you.

Design or style refers generally to the overall look and feel of the site: the colors, fonts, images, sounds, and resulting emotional reactions. Some webpages use bright colors, lots of white space, and photographs of smiling people; others use dark colors, dark images, dark sounds, and images of angry faces.

Accessibility asks whether users can interact with the website in a way that allows the intended information to be communicated and the intended function to be achieved. A webpage’s visual content is accessible if people can see it; it is inaccessible if the fonts are too small, the colors are too muddy, or the advertisements cover half the page. A website is accessible, as a whole, if all the information is available to people who use either vision or hearing but not both, and if all the functions of the webpage can be achieved by people with a range of physical, cognitive, and other abilities.

Inclusion asks about potential users’ emotional experiences with the site, or to the group of people that the website is aiming to create. Your goal might be to present information about your practice to everyone in your community in a way that draws people in and makes them feel that your clinic will be welcoming and helpful for them. Inclusion refers to whether your website achieves this goal.

Many of these aspects of web development and design will be handled for you by your web hosting service or website building software, or by your colleagues in an information technology office at the district level or for the entire hospital system. Nevertheless, it is important for each of us to be aware of these issues, in part because the website services and products we use must meet legal accessibility requirements (related to being part of a state or local government entity or a business serving the public; see Module 3; and see the information about web accessibility under the Americans with Disabilities Act provided at the ADA.gov website).

Most importantly, and most generally, the law requires that our professional websites be constructed such that the information and the intended function of each element is equally accessible to all users, including people with the full range of human abilities in the visual, auditory, cognitive, and motoric realms. Much of this work is achieved through behind-the-scenes programming that, again, your web hosting provider will control, such as in ensuring that the website’s primary navigation menus remain visible when the screen’s text has been zoomed to a larger size. (If you do your own web design, you are probably familiar already with the many relevant technical complexities and solutions, as described in such sources as Waddell et al., 2002, and Gilbert, 2019; if you are not familiar with the technicalities but are interested, these books or any introductory web design textbook might help.)

Even given an appropriate web hosting service, however, many accessibility issues remain our own responsibility, whether we are creating our own multi-culturally informed websites or working with our facility’s or district’s web professionals to design and improve the single speech-language pathology paragraph on a larger website. In either situation, you will need to draw on your knowledge of all dimensions and continua, and your knowledge that all human characteristics and abilities exist on continua, to think about content, function, design, accessibility, and inclusion for your multiculturally welcoming speech-language pathology website in terms such as the following (and as many others as you can think of).

Visual abilities. Use shorter paragraphs, larger fonts, and fewer non-functional decorative elements. Use color contrasts that people with different levels of color vision can perceive (avoid red on green or vice versa, and avoid blue on yellow or vice versa). Use sharp contrasts throughout; one of my own routine visual complaints, because of my own visual abilities, is what I refer to as web designers’ illegible “grey on grey” color choices. Take the time to write complete and meaningful alternative text for all photos, pictures, and other visual elements; if you allow an AI or natural-language computer system to create your first draft of such text, read it and fix it. And be aware of how your webpages will function with text-reading software or if they have been zoomed in or otherwise adjusted for visual accessibility; experiment with the accessibility settings on your phone and your computer, if you have never had reason to use them (or try reading your webpages with your sunglasses on and with the screen’s brightness turned to its lowest level, if your vision is not usually limited).

Auditory abilities. Websites present primarily visual information, but be sure to provide visual alternatives to any auditory information. The most common problem is missing or inaccurate captions for videos; again create and check your own, rather than depending on automatic captions. Experiment with your website with your computer sound turned off, if you usually acquire information aurally, and make sure users who depend on the visual modality can access the same information.

Cognitive and neuropsychological abilities. Think about the function and the accessibility of your website for persons with a wide range of abilities in visual tracking, visual attention, sustained attention, working memory, and the need for predictability. Think about the function and the accessibility of your website for people who find it easier or harder to ignore extra links, noises, or visual materials and for people who will be frightened or distracted by sudden flashes or noises. As multi-cultural professionals, we pay for professional web services, rather than asking our clients to work through the complexities of intrusive advertisements that interfere with our website’s basic function of explaining to everyone what services we offer, where we are located, and how to contact us. If your website serves other purposes, such as providing background explanatory information about speech and language conditions, again be sure that people with a wide range of cognitive, emotional, and neuropsychological abilities will be able to access that information.

Motoric abilities. Finally, multi-cultural websites are designed assuming that people with a range of motoric abilities should be able to interact with them. Draw on your knowledge of alternative and augmentative communication systems, draw on your knowledge from your collaborations with occupational and physical therapists, and imagine users who have a wide range of motoric abilities. Specific motoric access requirements for websites include navigation and selection by keyboard, for people who do not use mouse technologies. Selection buttons and links should be large, with space between them, to accommodate people with manual tremors or who use potentially less fine-grained selection devices such as head-worn pointers. Forms that rely on typing are more physically accessible to almost everyone than forms that require fine-grained selections from long dropdown lists, including that typing fields are accessible for people who use speech-to-text computer access methods.

In addition, as you create the content and the style of your webpage or website, be aware of the overall message that your choices are communicating to all users of your website. If your intent is a multi-cultural site that will feel equally safe and equally welcoming to “all populations” (as required for us by ASHA, 2017; see Module 3), your photos, symbols, and colors need to convey and respect a wide range of human possibilities without falling back on any tokenism or stereotypes (a topic we will address in more detail below for our physical spaces).

And the specific words we include on webpages, of course, also convey our multi-cultural inclusivity and respect. Some words are legally required: If you are a covered entity under HIPAA or subject to other federal regulations, you must provide the current prescribed nondiscrimination statement (see Module 3, and use the U.S. Department of Health and Human Services website for current guidance and the required format of the statement).

Well beyond the legal minimums, multi-cultural websites are also phrased to be positive and inclusive throughout. Person-first language remains the generally preferable default for a website intended for the general public, and we must describe abilities, backgrounds, and identities in positively framed ways. If you list the services you provide, for example, try “Services available to help all people of all ages with speech sound production, speech fluency, voice production, expressive language, receptive language, and social communication” rather than “Services for speech disorders, voice disorders, and language disorders.”

And because we welcome all clients from all backgrounds, use explicit words on your website to say so; include a phrase such as “We welcome inquiries from everyone” or “All clients from all backgrounds and with all individual identities are welcome at Sunflower Speech Therapy.”

Your Turn

Analyze your school’s, hospital’s, or practice’s website. Use the ideas from this segment and other information from throughout this website. Does your website recognize, respect, and respond to the many cultural and individual dimensions we have been addressing? How might an architect or another person with skills in universal design change your website, if that person were approaching your website as a product to be developed according to their principles?

Web design and programming professionals distinguish among accessible web design, inclusive web design, and universal web design in several overlapping ways. Try searching online for several definitions of these terms, for websites and programming, and comparing them to each other. How do the different definitions you found relate to our basic emphases on recognition, respect, and responsiveness for all human dimensions, backgrounds, abilities, characteristics, and identities? Does what you found lead you to think any differently about “multi-”, “cross-”, “transcultural,” or “universal design” (from our Module 16)?

Multi-Cultural and Identity-Affirming Intake Forms

The next step that a potential client might take with you, again before you have met them in person (or in a real-time video conference), will often be to fill out a shorter or more comprehensive intake form. How should we design our intake forms, if our goal is client-centered, culturally and individually appropriate speech-language pathology?

Intake forms are written surveys (either on paper, electronic, or online) that begin our attempts to build a personal relationship with a future client, but they are designed and used at stages where we know almost nothing about that client. Like our websites, therefore, intake forms must be multi-cultural, focusing on universals more than on specifics, and appropriate for everyone who completes them. Intake forms are not individually designed bridges that carry us directly to a single client; they are multi-purpose tools.

Intake forms, therefore, must reflect our awareness that people from all cultures, with the full range of human abilities, and with all identities will be trying to fill out our forms. Our intake forms are built on our awareness of and respect for the many dimensions, continua, and options that characterize both groups and individuals.

If you are creating or revising intake forms for yourself or for your practice, consider all of the questions summarized in Box 17.1, and discussed in greater detail below, as you design your forms and their questions.

 Box 17.1. Culturally and Individually Appropriate Considerations as We Design Clinical Intake Forms

Toward which healthcare or educational function am I asking this question?

Do I need that information from everyone?

What other information do I need?

Does everybody have that?

Is everybody’s answer among the options?

Am I asking this question in way that reflects my respect for all possible answers?

Which languages do I need my forms in, for this community?

Will everyone who completes this form have approximately the same emotional experience with it?

Think about each of the questions presented in Box 17.1. Do you see why each one matters, or how each one can help us think through what we are asking people to do before we meet them?

One of the first principles of survey design is to understand the purpose of the survey and of each question on it. In speech-language pathology intake forms, we seek information from potential clients for the purposes that HIPAA summarizes as treatment (i.e., client care, including screening, assessment, and intervention), payment, and our own internal healthcare business operations. As you design a form, therefore, it can help to be sure in your own mind which of these purposes the form as a whole is meant to address and the purpose each question is meant to address. Some information is necessary. But if your answer is that this information does not help you serve the client, or that you might need the information to understand some clients’ experiences and needs, then think carefully about why you are asking every client.

At the same time, we are also thinking “What did I not think to ask that I should have asked?” or “What other information do I need?” Use Morgan’s (1996) axes of identity from Module 2 to think through any information your forms might be missing that you do need from every client to be able to serve them appropriately. Reasonable additions or changes to common forms might include asking about all languages and dialects the client and the family would like to incorporate into their services (see Section Two; this is very different from asking for the client’s primary language or asking clients to name only one of their languages as a single language used at home).

Thinking “Does everybody have that?” and “Is everybody’s answer among the options?” helps us recognize any limitations in our own imaginations. Based on our recognition and respect of the full range of family structures and living situations, for example, our forms do not ask for a child’s “mother’s name.” We ask instead for the name, contact information, and relationship to the child of the person filling out the form, or we ask for similar information for up to 3 or 4 adults who share responsibility for the child and will be involved in the child’s care, with an open-ended blank for “relationship.” There is also no need to ask for home phone, cell phone, work phone, primary email address, and secondary email address. The universal need is “How can we contact you?” or “How should we send you the bill?” And we probably do not need to ask for every client’s physician, religion, or marital status; do you see why?

For the questions you do need to ask, the next step is to think carefully about how clients will answer. Forms designed with checkboxes or drop-down options collapse the human experience into a few categories, rather than recognizing, respecting, and responding to the continuous dimensions that define groups and individuals. The checkboxes also tend to include the options that met the form designer’s assumptions or reflect the form designer’s knowledge, with all other possibilities collapsed into an answer labeled “Other.”

Multi-culturally appropriate forms, in contrast, use open-ended questions, with blanks for the client to fill in, rather than checkboxes or drop-down suggestions that divide people into those who fit into one of the “correct” categories and those who are “othered” by the form. Alternative phrases, such as “Prefer to self-describe,” try to avoid putting people into a box literally labeled “Other,” but respondents who have to self-describe in such a system have been othered nonetheless. If anyone’s answer will not be among the options you provide, have everyone self-describe.

A system of checkboxes, whether on paper or on a computer screen, might initially seem more expedient for clients or for staff, but it is only easy for clients whose answer is at the top of the options, clients who see well, clients whose attentional abilities allow them to scroll long lists, and clients whose motor abilities allow them to select precisely from within a long list. (If you live in Alabama or Wyoming, you have a different experience with clicking your state in an online form than people in Mississippi and Missouri have.) It is much easier for a client to write an answer to the open-ended question “How would you like us to address you?” than it is for that client to search through the boxes for “Title” that include Mr., Ms., Mrs., Miss, Mx., and Doctor, pause, and ultimately click “Other” and write “Abbie,” “Rabbi Avril,” or “La señora Aragón.” The goal of multi-cultural practice is to do our best to recognize, respect, and respond to all potential clients’ needs, thinking about human universals, not trying to list all the specifics. Be sure you are not designing a form that will metaphorically be asking everyone to climb over all the bridges you were trying to build to other people; remember, “multi-” work is not about trying to build all the bridges in the same space. (Most of us who live in mid-alphabet states have learned to get around the 50- or 52-item checklist by typing our state’s abbreviation; it’s faster.)

On the whole, your intake forms have several goals. They should gather the information you need to begin developing a therapeutic relationship with this client (or to begin the process of determining whether one is needed). They should be easy for anyone to complete, regardless of that person’s cultural or personal identity or background. And everyone who has completed your multi-culturally appropriate intake form should come away feeling that you care about their individual answers and are prepared to meet their needs as a unique, respected, and worthwhile human being.

One more note: Be aware that shorter, more focused instruments meet the needs of clients with a wide range of language, cognitive, visual, motor, and other abilities. They are also more likely to provide you with more complete and therefore more useful information (because respondents are known to provide more valid and more reliable responses to shorter surveys than to longer ones). Multi-cultural, accessible, inclusive intake forms will probably be structured as a series of shorter forms, each designed to focus on one type of information (client care, payment, or our own internal operations), not as one overwhelmingly long instrument.

Your Turn

Analyze one or more of your clinic’s intake forms. Use the questions in Box 17.1 and other information from throughout this website. Were your intake forms designed in a way that recognizes, respects, and responds to the many cultural and individual dimensions we have been addressing? How might an architect or another person with skills in universal design change your intake forms, if that person were approaching your intake form as a product to be developed according to their principles?

Function and Décor for Physical Spaces

You are finally meeting some clients! After they have navigated your website, your appointment processes, and your intake forms, many clients will come meet you for the first time in your physical space. The considerations for physical space are very similar to the considerations for online spaces; we will again think about content, function, design, accessibility, and inclusion.

Function of the Space

At the basic level of both content and function, your entry and waiting spaces need to serve the universal purposes of entry and welcoming, both physically and emotionally. They need to do so for a wide range of people, including those whose cultural backgrounds differ from each other’s and from yours, and including for those whose abilities and needs in the areas of mobility, vision, hearing, problem-solving, attention, visual or auditory (over)stimulation, need for other people, and fear of other people might differ from your individual preferences or initial assumptions.

Depending on the location or style of your physical space, therefore, you might start by considering all of the ideas listed in Box 17.2, when you have the opportunity to design or modify a multi-culturally welcoming entry and waiting room.

 Box 17.2. Functional Characteristics of Multi-Culturally Welcoming Clinical Entries or Waiting Spaces

Large simple signage, easily visible from the street, parking lot, or elevator lobby

A physically accessible front door that a person in a wheelchair, a person moving slowly with a cane, or two or more people assisting each other physically can manage

A well-lit front door with no overgrown bushes or potentially frightening shadows

Minimal but clear signage inside about where to check in

A two-level check-in desk or counter that is high enough for tall adults and low enough for people in wheelchairs, arranged to allow privacy for individual clients and also with enough space to be welcoming to couples or families who come in together

Space in the waiting room for persons with wheelchairs, strollers, or service dogs to maneuver, and for people afraid of or allergic to dogs to avoid them

Chairs of different sizes, including some that are sturdy enough for relatively large people and some that are smaller and with strong arms to help older people push themselves up

Clear line-of-sight and clear pathways between and among your entry door, your check-in counter, your waiting chairs, and the entry to your treatment spaces (to allow physical mobility without tripping hazards; to give clients the emotional safety of knowing what will happen next and knowing how to get out; to allow clients with children to see them at all times; and to allow clients with vision, hearing, or speech concerns to know that you are calling them and to respond in a way that you can see if you cannot hear their response)

Enough light, no unnecessary sounds, and no clutter on the walls, counters, or tables (to reduce anxiety in clients with a range of neuropsychological abilities) 

In addition to the suggestions provided in Box 17.2, be aware that television monitors have become ubiquitous in most waiting rooms but can be problematic. It is almost impossible to ensure that the images on the screen will be consistently welcoming and appropriate for everyone, and the extra visual and/or auditory noise will compete with necessary conversations, especially for your clients with hearing, attention, or anxiety issues.

You might have noticed that medical spaces tend to be more sparsely furnished and more neatly kept for infection-control reasons than independent clinics and school-based spaces. If you work somewhere other than a medical space, consider emulating your medical colleagues. You might buy more storage bins, or another large cabinet, to minimize the visible clutter that clients need to physically maneuver around, that clients with attention or anxiety issues need to cognitively work through, and that children will only be tempted by.

Decorating the Space

After the functional elements of your physical space are in place, then you can consider its style, or how to decorate it. Either of two general principles can be useful, if your goal is a multi-cultural space that feels equally welcoming and equally physically and emotionally comfortable to everyone: either use everyone’s second choice, or seek to actively contradict multiple stereotypes.

The “everyone’s second choice” principle requires us to identify our first choices, recognize that other people’s first choices would differ, and settle on a second choice that everyone finds acceptable (it is a variation on seeking the universal, and it is a compromise solution to a potential conflict; see Module 26).

If I were to decorate a room, for example, my first choice might be to use photographs of my own children. I am also aware, however, that pictures of my children would be no one else’s first choice. Using those photographs could also (inaccurately!) communicate to potential clients that my practice values families with children, values White children, or values families with the financial means to vacation in California more than it values other children or other families.

The “everyone’s second choice” principle would lead me, instead, to select something along the lines of flower prints for my professional waiting room. Flowers are not my first choice, but they are fine, and I think I know that most people find pictures of flowers universally acceptable (if perhaps not their first choice either).

“Everyone’s second choice” decorating decisions lead to the many perfectly acceptable pale blue waiting rooms in the world with abstract art or landscape photographs of generic mountain ranges. They are no one’s favorite, but they reflect reasonable attempts at universal decisions that everyone will perceive in approximately the same way and that actively exclude no one.

Another approach to multi-culturally welcoming decorating requires actively contradicting multiple stereotypes. In this situation, rather than starting from my own first choice, I might start with an active attempt to display multiple people, to actively show and communicate my belief that all people are welcome in my waiting room.

The danger with such an approach goes back to the definition of stereotype as one fixed image that oversimplifies a complex, dynamic reality (from Module 9).

What have I done if my attempt to actively show multiple people results in a waiting room with three large pictures, each of which shows an easily recognizable “type” of person doing something that “people like that usually do”? Rather than achieving my goal of making everyone feel welcome, I will have managed only a tokenism that perpetuates limiting and problematic stereotypes. People who do identify with part of what they see will wonder if that is all I think of their entire culture, while people who do not identify with any of my three pictures will wonder if they belong in the waiting room, given that they are not in the pictures.

Decorating by actively contradicting multiple stereotypes attempts to solve this problem by communicating a genuinely multi-cultural message that all people can be and do all things, purposefully controverting stereotypes about which people are “supposed to” do which things.

If you choose to decorate with images of people, seek to include as wide a range of novel combinations as you possibly can.

Tokenism remains a danger whenever we are selecting a small number of pictures for a small number of walls, but an active attempt to contradict multiple stereotypes might lead to three large paintings in your waiting room: one that shows a Black man with a bright pink cochlear implant helping Japanese children make tortillas; one that shows an older woman in a sari laughing with a younger man with facial piercings in a sharply pressed business suit at the top of a roller coaster; and one that shows an athletic teenager with darker skin and a running blade on his prosthetic leg who is helping a lighter skinned child select a book from a library shelf that is clearly labeled “Gender Books: Find Your Rainbow.”

Do these combinations sound fanciful? Perhaps, and they would be hard to find at your local poster store! But the soundness of the principle remains: If you choose to decorate with images of people, the overall message of the display should be one of novel combinations and possibilities, not one that reinforces narrow stereotypes or that allows some people, but not all, to recognize themselves in your decorations.

Finally, as you finish decorating your waiting room, be aware that the same principles apply to any other physical objects you might choose to incorporate.

If you choose to provide reading material in your waiting room, for example, try thinking universally and in creatively multi-purpose ways. Selections from the many available lists of international wordless picturebooks for children, for example, can be among the best options for (almost) everyone, because of their intentional breadth. They might not have been your very own first choice, as our first principle recognized, but they can be a simple way to select one option that meets most people’s underlying need to be occupied and calmed for a few minutes (i.e., it’s a universal design decision). The International Board on Books for Young People maintains lists of its recommended international wordless picturebooks, which do not require familiarity with any language or dialect, as well as books that are either for or about people with a range of physical and cognitive abilities.

One last note: Let’s avoid religious and political materials or symbols entirely (see Module 25), and let’s avoid anything intended to be frightening, even if you think of it as “fun scary.” We will make unintentional mistakes (see Module 26), but multi-culturally appropriate decoration seeks, as a general rule, to be universally welcoming and inclusive for everyone, not divisive, challenging, playing favorites, or in any way frightening to anyone.

Your Turn

Think about the functional elements and the decorative elements of any clinical waiting room or other business that has been new to you recently. Did you feel good when you walked in? What examples did you see of universal design principles used well (decisions that seem to have been intended to meet the higher-order, category-level, human need in a creative way that was not tied to any one specific preference)? What might you have changed about that space, either in function or in decor?

Highlight Questions for Module 17

Explain the “Yes and” strategy. Why does it serve as a good multi-purpose tool for multi-cultural clinical situations?

Explain some of the characteristics of accessible, inclusive, respectful, or multi-culturally welcoming webpages. Why do our clinical webpages need to reflect these characteristics?

Explain some of the characteristics that make clinical intake forms accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities. Why do our intake forms need to reflect these characteristics?

Explain some of the characteristics that make a physical waiting room or other space accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities. Why do our physical spaces need to reflect these characteristics?