Cultural Knowledge and Counseling
Acquiring cultural knowledge at the population and individual levels can help a genetic counselor develop a healthy respect for the diverse needs of individuals who identify with this group, and to be more culturally informed and sensitive when helping clients work through their emotions and decision making challenges. While genetic counselors must be aware of health disparities in the populations we serve, we have noted the extraordinary diversity encompassed within the “Asian American population.” When reviewing statistics and studies on health disparities, consider the implications for individuals included in these reports. How general or specific are the layers of cultural descriptors of the participants? Given the spectrum of diversity of individuals within populations, health disparities population information may carry little meaning or helpfulness for working with specific clients.
Regardless of the client’s background, it is always important to focus on the individual’s specific background, values, and practices. For example, instead of letting your assumptions drive the conversation (“Yunhua and Biao are traditional Chinese names, so the couple must be Chinese and they are probably not very acculturated…”), let the client lead the conversation (“Tell me about yourself and your family background…”). Genetic counseling practice is enhanced by becoming familiar with a variety of cultural issues, traditions, health beliefs, attitudes, lifestyles, and values. In that way, the influence of each client’s cultural diversity can be more effectively woven into the psychosocial assessment and counseling aspects of the genetic counseling process.
Providers must take responsibility for continuously building their cultural knowledge. The client cannot be expected to completely educate the counselor about his or her culture (McAuliffe, 2009). Also, as health care professionals, we reflect on the similarities between our own cultural affiliations and those of our patients, while respecting and appreciating the differences. This self-evaluation process is essential for establishing and maintaining meaningful connections with clients.
Eastern and Western Cultural Values
Currently, the genetic counseling model is largely based on Western approaches to medicine and counseling. However, a Western approach may not always be the preferred counseling method. For example, the table below defines some of the many factors that can be important to individual clients. Use the table as a tool for considering how often you think about alternative worldviews.
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Eastern (agricultural) systems:
Traditional society values |
Western (industrialized) systems:
Modern society values |
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Family/group oriented |
Individual oriented |
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Extended family |
Nuclear/blended family |
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Multiple parenting |
Couple parenting |
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Primary relationship: parent-child bond |
Primary relationship: marital bond |
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Emphasis on interpersonal relationship and harmony |
Emphasis on self-fulfillment and self-development |
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Status and relationships determined by age and role in family |
Status achieved by individual’s efforts |
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Well-defined family members’ roles |
Flexible family members’ roles |
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Favoritism towards males |
Increasing opportunities for females |
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Authoritarian orientation |
Democratic orientation |
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Suppression of emotions |
Expression of emotions |
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Fatalism/karma |
Personal control over the environment |
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Harmony with nature |
Mastery over nature |
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Cooperative orientation |
Competitive orientation |
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Spiritualism |
Materialism, consumerism |
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Past, present, and future orientation |
Present, future orientation |
Source: Lee et al., 2002
Health Beliefs
Cultural diversity can manifest as a diverse array of behaviors among ethnic and racial groups. A counselor can misinterpret a client’s behavior based upon his or her assumptions, when in actuality the client’s reaction may be culturally grounded. For many Asian families, explanations of the causes of health problems are influenced by their religious and spiritual beliefs (Yu-Wai-Chiu & Lee, 2004). Healing is spiritual as well as scientific (Yee et al., 1999). Asian clients have blamed birth defects on foods consumed during pregnancy, as punishment for a sin performed in a previous life, the act of angry spirits, the evil eye, and/or a curse (Mittman et al., 2004). Often, the mother can be held solely responsible for the pregnancy outcome, and birth defects are blamed on her (Mittman et al., 1998). These beliefs can affect coping and choice of treatment strategies; Asian patients may deny their illness or view it as being related to personal factors even though they fully understand that the illness has a biological cause (Chin & Bigby, 2003). It is important to assess what an individual believes to be the cause of illness. Doing so will help the counselor gain a better understanding of the patient’s belief systems and coping mechanisms and allow the patient to feel they are being heard.
Cultural assessment tools can be used to help the counselor focus on the problem from the patient’s perspective, so that appropriate counseling, interventions, and support can follow. The following tool is commonly cited in the literature. How would you adapt these questions for use in the genetic counseling session with Yunhua and Biao?
Patients’ Health Beliefs Assessment Guide (also known as Kleinman’s questions):
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What do you think caused your problem?
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Why do you think it started when it did?
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What does your sickness do to you?
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How does it work?
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How severe is your sickness? Will it have a long or short duration?
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What kind of treatment do you think you should receive?
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What are the most important results you hope to receive from this treatment?
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What are the chief problems your sickness has caused you?
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What do you fear most about your sickness?
Source: Kleinman et al., 1978
Family
In general, Asian Americans highly value the family unit and the reputation of the family. A person’s actions reflect not only on that individual, but also on their nuclear and extended family. This value, often termed collectivism, refers to the perception of the self that is fixed between social roles and relationships. The self is de-emphasized; focusing on others and the welfare of the family or community is emphasized (Le & Stockdale, 2005). For example, many Asian American parents often place emphasis on their children doing well in school and succeeding in all aspects of life. The performance of the child is considered a reflection (positive or negative) on the whole family. Furthermore, feelings of shame may be felt intensely by members of collectivist cultures because of their social consequences (Yeh & Huang, 1996). In many Asian societies, individuals with visible birth defects might experience shame and rejection from their families and friends. In some cultures having a family member with visible anomalies can even affect the marriage eligibility status of his/her relatives. Consequently, having a child with a birth defect can be quite devastating to Asian Americans, due to the nature of the defect and the potential implications on the reputation and emotions of the entire family (Mittman et. al, 1998). It follows that decision-making, including important health care decisions, typically involves many members of the family, particularly elders (Kaiser Permanente, 1999). In some Asian groups, the eldest male may be the dominant figure for speaking and decision-making. Given the importance of collectivist values to many Asian American clients, it is important to extend a welcome to any member of the family in health care settings.
Communication
Problems with intercultural communication are not limited to language differences, but are also due to differences in thought patterns, values, and communication styles (Chan, 1992). In some cultures, public expression of feelings may not be socially acceptable (Mittman et. al, 1998). Asians generally place high value on self-control and suppression of their emotions (Yu-Wai-Chiu & Lee, 2004). In fact, any form of direct confrontation and verbal assertiveness might be considered rude and disrespectful (Leong et al., 2008). Therefore, many Asians tend to be reserved in verbal and emotional expressiveness, especially when they are in the presence of authoritative strangers (Yu-Wai-Chiu & Lee, 2004). Asian clients may avoid self-disclosure and public displays of emotion during counseling (Kuramoto, 1994). While Euro-Americans tend to use direct and precise words for the primary means of communication, Asian Americans may rely on nonverbal cues and other subtleties to deliver a message (Leong et al., 2008). They may not express their needs directly (Yu, 1999).
Acculturation
A patient’s values and religious beliefs and his/her adherence to traditional values and practices are based on numerous factors. One of these factors, acculturation level, can be a critical cultural moderator in psychosocial assessment. Acculturation involves adaptations to a minority individual’s behavioral, cultural, and social values and beliefs because of contact between the individual’s ethnic society and the Euro-American’s dominant society (Leong et al., 2008). Recently arrived immigrants may possess traditional cultural values and traditions that can be very different from Western cultures (Yu-Wai-Chiu & Lee, 2004). On the other hand, some recent immigrants may be more inclined to embrace many western beliefs from the outset. Asian immigrants who have resided in the U.S. for greater lengths of time may or may not have adopted Western culture or retained elements of traditional beliefs and values. Therefore, it is important to distinguish degree of acculturation from length of stay in the U.S. (APA Guidelines, 1990), and explore these factors with each client on an individual basis, without making assumptions.
Within the Asian American cultural context, family constancy, equilibrium, duty, obligation, and appearance of harmonious relations may be important factors. Differing levels of acculturation within families may also prove to be a stressor. Respect for elders is a common tradition that involves the extended family in decision making. In dealing with situations where multiple family members are involved, assessing the acculturation levels of individual family members may be needed, as disharmony and conflict may arise due to differing beliefs and values. “Acculturation is not a single, unitary process, but rather one in which a given individual may adopt different aspects of the dominant culture at different rates and with differing degrees of ease or acceptance of doing so. Because of this, a formal or informal assessment of acculturation by one set of criteria must be used with care in making assumptions about other aspects of acculturation” (Weil, personal communication).
►Exercise
Members of one cultural group have been reported to develop sensitivity and skills working with another culture by immersing themselves in that culture (Kavanagh et al., 1999; St. Clair & McKenry, 1999). It is reported that cultural immersion enables participants to overcome their ethnocentrism, increase their cultural awareness, and integrate cultural beliefs into health care practices (St. Clair & McKenry, 1999). Take some time to learn more about one or more aspects of Asian American culture by reviewing the resources at the end of the case and by getting involved in activities in your community.
