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Barriers, bridges and beyond : understanding perspectives in linguistically and culturally diverse clinical… Simmons, Noreen Rosalind 2007

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BARRIERS, BRIDGES AND BEYOND: UNDERSTANDING PERSPECTIVES IN LINGUISTICALLY AND CULTURALLY DIVERSE CLINICAL INTERACTIONS by NOREEN ROSALIND SIMMONS B.Sc., University of Mangalore, 1995 M.Sc, University of Mangalore, 1998 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Audiology and Speech Sciences) THE UNIVERSITY OF BRITISH COLUMBIA August 2007 ©Noreen Rosalind Simmons, 2007 Abstract This study attempts to understand how monolingual English-speaking Speech-Language Pathologists (SLPs) and their Linguistically and Culturally Diverse (LCD) Indo-Canadian adult aphasic clients manage clinical interactions when they do not share the same language and/or culture. The specific objectives were to describe and explain participants' perspectives on the barriers they encountered, and the strategies they employed to overcome the barriers, and to develop a substantive theory that elucidates how SLPs manage such LCD clinical interactions. A symbolic interactionist theoretical perspective and grounded theory method were used to explore the clinical interaction experiences of eleven monolingual English-speaking SLPs, five adult Indo-Canadian aphasic clients, six family members, and five interpreters. Data were collected through interviews, observation, and field notes. Concurrent data collection and analysis was undertaken throughout the study. Constant comparative analysis, which included open, selective, and theoretical coding, was used to construct the substantive theory. The core category that emerged, 'coordinating communicative goals,' described the basic social process that was involved in clinician-client LCD interactions. This core category captured two stages and three conditions that participants encountered during clinical interactions. The two stages were 'encountering challenges in clinical interactions' and 'using strategies to overcome challenges.' The three conditions were 'linguistic barriers,' 'cultural barriers,' and 'involvement of family members and/or interpreters.' The two stages explained the processes used by participants during clinical interactions, and the three conditions were factors that impacted the stages. i i The findings indicate that participants coordinated their respective communicative goals in clinical interactions by going through an iterative process of confronting challenges and implementing strategies to overcome some of those challenges. The findings from this study have important implications for research, clinical practice, education, and policy aimed at helping SLPs provide linguistically and culturally appropriate services to LCD clients. TABLE OF CONTENTS Abstract •• ii Table of Contents iv List of Tables .. ix List of Figures x Acknowledgements • • xi Dedication ••• xiii CHAPTER ONE: INTRODUCTION 1 •1.1 Background to the problem ...1 1.2 Statement of the problem 3 1.3 Purpose of the study 5 1.4 Research questions 6 1.5 Theoretical basis and method for the study 6 1.6 Significance of the study , 7 1.7 Summary '. 7 CHAPTER TWO: LITERATURE REVIEW 9 2.1 Introduction . • 9 2.2 Linguistic issues for linguistically and/or culturally diverse students 11 2.2.1 Components of language 13 2.2.2 Summary of linguistic issues 25 2.3 Cultural issues for linguistically and/or culturally diverse clients 26 2.3.1 Language and culture 27 2.3.2 Culture .' , ...30 2.3.3 Cross-cultural differences in health care 31 2.3.4 Cross-cultural research in communication sciences and disorders 38 2.3.5 Summary of cultural issues ..' '....41 2.4 Assessment issues • 41 2.5 Intervention issues.. ...48 2.6 Chapter summary . 51 CHAPTER THREE: THEORETICAL FRAMEWORK 53 3.1 Introduction -53 3.2 Overview of symbolic interactionism 53 iv TABLE OF CONTENTS (Continued) 3.3 Underlying assumptions of symbolic interactionism. 56 3.4 Concepts associated with symbolic interactionism 59 3.4.1 Self -60 3.4.2 Objects.... '. 61 3.4.3 Society -64 3.4.4 Act... ; • 66 3.5 Application to the present study 66 3.6 Limitations of symbolic interactionism 68 3.7 Chapter summary 69 CHAPTER FOUR: METHOD :. —70 4.1 Introduction • • 70 4.2 Research design and rationale 70 4.2.1 Theoretical perspective: symbolic interactionism 71 4.2.2 Symbolic interactionism and grounded theory 72 4.2.3 Grounded theory method 72 4.3 Inclusion and exclusion criteria 74 4.4 Ethical considerations "76 4.5 Recruitment procedures 77 4.6 Settings • 78 4.7 Data collection tools 78 4.7.1 In-depth interviews • 79 4.7.2 Observations • • 80 4.7.3 Field notes • 81 4.7.4 Reflexive journal 81 4.7.5 Post-interview summary form ....83 4.8 Data analysis .........83 4.8.1 Constant comparative analysis 83 4.8.2 Coding 84 4.8.3 Theoretical sampling..... 89 4.8.4 Memoing 90 4.9 Rigor • 92 v TABLE OF CONTENTS (Continued) 4.9.1 Data triangulation • 93 4.9.2 Criteria for rigor in grounded theory 93 Fit '.' 94 Work. ..... .. .........94 Relevance '. .... 1—-.-95 Modifiability 95 Parsimony and scope 96 Reflexivity and relationality 96 4.10 Chapter summary 98 CHAPTER FIVE: FINDINGS 99 5.1 Introduction 99 5.2 Overview of the substantive theory 102 5.3 Encountering challenges in clinical interactions : 106 5.3.1 Linguistic barriers •• • 106 Linguistic competency of clinicians and clients 106 Problems with access and use of resources . . . . . . I l l 5.3.2 Cultural barriers • .....116 Difficulties with assessment resources 116 Cultural differences between clinicians and clients 118 Perceptions of disability, treatment and caregiving ...119 Knowledge of speech language pathology ...122 Assertiveness in health care settings ..124 Food preferences 125. Gender issues..... 126 Age.. .. 128 Decision-making 129 5.3.3 Involvement of family members and/or interpreters 131 Increased time and effort .............131 Challenges in building rapport .133 Impact on quality of assessment and treatment ....135 5.3.4 Summary of encountering challenges in clinical interactions. 142 vi TABLE OF CONTENTS {Continued) 5.4 Using strategies to overcome challenges.: ...142 5.4.1 Strategies to overcome linguistic barriers .143 5.4.2 Strategies to overcome cultural barriers 151 5.4.3 Integrating family members and/or interpreters ;'. 156 Strategies to overcome challenges with time and effort ..........156 Strategies for building rapport ..................158 Strategies for managing the impact of involving family members 161 Strategies for integrating interpreters 165 5.4.4 Summary of using strategies to overcome challenges .....169 5.4.5 Chapter summary 170 CHAPTER SIX: DISCUSSION... 173 6.1 Introduction 173 6.2 Overview of the key findings ...173 6.2.1 Linguistic issues 174 6.2.2 Cultural issues ....181 Perceptions on disability, recovery and treatment 183 Assertiveness in clinical settings .....185 Gender and age preferences 187 6.2.3 Language and culture , 189 6.2.4 Involvement of family members and/or interpreters... 190 Building rapport 191 Involving family members in clinical interactions ........195 Involving interpreters in clinical interactions 198 6.2.5 Contributions to theory 204 6.3 Implications 206 6.3.1 Clinical practice... 207 6.3.2 Education 210 6.3.3 Future research 211 6.3.4 Policy 212 6.4 Limitations of the present study..... ...213 6.5 Chapter summary ..................216 T A B L E O F C O N T E N T S (Continued) 6.6 Conclusions and final refllections 217 References 221 Appendix A . 247 Appendix B ; 248 Appendix C i.249 Appendix D 250 Appendix E 252 Appendix F 254 Appendix G 256 Appendix H 258 Appendix I 260 Appendix J 262 Appendix K 264 Appendix L.. . . 266 Appendix M 269 viii LIST OF TABLES Table 5.1 Demographic information: Speech-Language Pathologists Table 5.2 Demographic information: Indo-Canadian aphasic clients Table 5.3 Demographic information: Family members ... Table 5.4 Demographic information: Interpreters... LIST OF FIGURES Figure 5.1 Basic social process: Coordinating communicative goals Acknowledgements First, I thank God for his all his blessings and grace, and with whom nothing shall be impossible. I am indebted to all my participants who gave their time to speak to me about their experiences. Without their participation the outcome of this study would not have been realized. I would like to especially thank my supervisor Dr. Jeff Small who was incredibly patient throughout my doctoral study. You provided the attention, support, and assistance whenever I needed it. You have always encouraged me to think critically, provided your insightful comments, and taken every step to make this dissertation possible. It is because of you that I have become more systematic and focused in my approach to conducting and analyzing research. My sincere appreciation to Dr. Carolyn Johnson, Dr Wendy Hall, and Dr. Alison Phinney. Thank you for agreeing to serve as dissertation committee members. Dr. Johnson - for the valuable feedback and guidance at the initial stages of my doctoral program. Dr. Hall - to whom I will always be grateful for the fact that you inspired me to conduct this dissertation. You were a constant support and provided insightful guidance throughout the dissertation process. It was a privilege collaborating with you towards achieving this professional milestone. Dr. Phinney -1 valued your expertise in qualitative research and adult participants. I appreciate the time and input you both (Dr. Hall and Dr. Phinney) provided especially during the final stages of my dissertation program. Many aspects of my data collection would not have been possible without the assistance of Vancouver Coastal Health Authorities and the Fraser Health Organization. My special thanks to Tracey Findlay and Caroline Marcoe for spending time in helping me recruit participants. Thank you Rina Prabakar for providing quality service to me as a bilingual interpreter. Dr. Judith Johnston my mentor, you have indeed been an inspiration to me everyday. Your ideas have stimulated me immensely and I will always cherish our times together. Thank you for all your support and confidence in me. Sue Bryant my friend - thank you for always being there for me. xi You will never know how much I appreciate your caring and helpful nature. Iowe special thanks to Susan Lane, my boss and colleague at the BC Family Hearing Resource Centre for her unconditional support. You made my juggling between work and school so much easier. Thanks to my husband Neville, who served as a rock throughout each stage of my personal education and professional growth. I love you for knowing when to be supportive, encouraging, challenging, and when to say, "Just get it done." Without you I would not have been able to do this. This is our degree! To mom and dad - 1 have no doubt I would never be the person I am today without marvelous parents like you. I can never thank you enough for your love, encouragement and support. I am immensely grateful for the values you have instilled in me and for the person you allowed me to be. My brother, my best friend, who always believed in me. You were there day or night to provide me the emotional support and guidance. Thank you, Brian! To my wonderful grandmas and in-laws - You have been a source of unfailing love and patience. Especially to my mother-in-law, who constantly sent e-mails of motivation and encouragement during the final days of my dissertation. You stood by me no matter what. Thank you so much. Kaizer - our puppy dog for just being you and bringing us so much joy and happiness. Finally, I would like to thank my friends, colleagues, and extended family who encouraged and uplifted me during my doctoral journey. DEDICATION To my husband - Neville You have always wanted the best for me - this journey and success is ours! CHAPTER ONE: INTRODUCTION 1.1 Background to the problem Assessment and treatment of adult clients with communication disorders is challenging for speech-language pathologists (SLPs) due to the nature and complexity of the different types of disorders, the language modalities affected, and the variability in recovery patterns. The process of assessing and treating clients is further complicated when clinicians interact with linguistically and/or culturally diverse clients (De Bot & Makoni, 2005; Wallace, 1996; Wyatt, 2002; Young & Westernoff, 1999). Linguistically and culturally diverse (LCD) clients frequently encounter cross-linguistic and/or cross-cultural clashes with their monolingual clinicians because of lack of a shared language and/or culture (Holland & Penn, 1995). Greater travel opportunities and immigration in recent years have led to increased cross-linguistic and cross-cultural clinical interactions (Grosjean, 1997). This is particularly true in North America, where immigration levels are high and immigrants make up a significant portion of the population, especially in urban areas. The province of British Columbia (B.C.) has the third largest rate of immigration in Canada and is well known for its linguistic and cultural diversity (Citizenship and Immigration Canada, 2002). The Greater Vancouver Regional District, where the present study was undertaken, has many minority groups, including Chinese, South American, and Indo-Canadian groups, who have been present in Vancouver for over 80 years. Findings from a recent survey study conducted by Simmons and Small (in preparation) indicate that twenty percent of SLPs' adult clientele with communication disorders in B.C. are bilingual/multilingual. Interestingly, although the level of immigration and the number of bilingual clients is high, routine standardized assessment and treatment procedures developed for Euro-Canadian 1 native English-speaking clients still remain predominant in clinical practice regardless of clients' language background (ASHA position paper, 2004; Roseberry-McKibbin 2002). This may be due to the fact that a large number of SLPs are from the predominant culture, with most speaking English as their only language (Simmons & Small, in preparation). Since languages other than English are commonly used in Vancouver (Statistics Canada, 2001), assessment and treatment of an increasing number of clients who do not speak English as their first language becomes potentially problematic. The American Speech and Hearing Association (ASHA, 2004) position paper on 'Knowledge and skills needed by speech-language pathologists and audiologists to provide culturally and linguistically appropriate services' (developed by the multicultural issues board) and the Canadian Association of Speech Language Pathologists and Audiologists (CASLPA, 2002) position paper on 'Speech-language pathology and audiology in the multicultural multilingual context' state that linguistic and cultural skills form basic competencies that SLPs need to develop in order to provide services to linguistically and/or culturally diverse clients. Kritikos (2003) conducted a survey study in the United States to identify the competencies of SLPs in language assessment of bilingual/bicultural individuals. He found that there was a mismatch between the number of bilingual clinicians and the number of bilingual clients, wherein the number of bilingual clients outnumbered the number of bilingual clinicians. Kritikos also documented that a majority of clinicians reported a lack of competence in assessing a client whose language they did not speak, without the presence of an interpreter. Because linguistic and cultural competence is rapidly becoming a major service quality issue in the field of speech-language pathology, clinicians who wish to provide the best possible care to an increasingly diverse population require skills and knowledge in the management of such clients. 2 1.2 Statement of the problem As different parts of the globe get more and more connected due to the ease of travel and immigration patterns, health care professionals in North America will be more likely to have daily encounters with clients who vary in their proficiency levels in English, speak another language, and/or come from a different culture. SLPs are often challenged and frustrated when dealing with LCD clients because they do not speak the clients' language, and/or are unfamiliar with their culture (Holland & Penn, 1995; Huer & Sanz, 2003; Roseberry-McKibbin, 2002). As a result, the quality of health care services can become compromised since clinical interactions depend to a large extent on SLPs' and clients' abilities to communicate effectively. In the last several decades, most literature and clinical training offered in North America in the discipline of communication sciences and disorders has been oriented towards a predominantly monolingual English-based clientele (Bates, Devescovi & Wulfeck, 2001; Miller, 1984; Restrepo & Silverman, 2001; Roseberry-McKibbin, 2002). Consequently, appropriate assessment and treatment procedures suited to the needs of clients from LCD backgrounds are lacking (Goldstein, 2000; Huer & Saenz, 2003; Roberts, 2001; Roseberry-McKibbin, 1994; Wyatt, 2002). SLPs encounter problems when managing such clients because they do not speak the language/languages of their clients or have limited skills in the client's language and/or culture (Holland & Penn, 1995; Huer & Sanz, 2003; Roseberry-McKibbin, 1994, 2002). Although the American Speech and Hearing Association (ASHA, 2004) and the American Psychological Association (APA, 2003) as well as some clinical researchers, such as Goldstein (2000), Roseberry-McKibbin (1994; 2002), Battle (2000), and Wyatt (2002) have advocated for guidelines to increase the language skills and cultural knowledge of clinicians regarding LCD 3 clients, accomplishing such a goal is difficult because it is not possible for SLPs to be familiar with all the languages and/or cultures of their clients. Research studies investigating cross-linguistic or cross-cultural differences have been predominantly based on quantitative methods, for example, survey investigations and quasi-experiments. Although the contributions of quantitative research to our understanding of cross-linguistic and/or cross-cultural differences are important, there are certain limitations. Cross-cultural investigations in quasi-experiments typically involve a previously studied cultural group taken as the control group, and a new cultural group as the experimental group (Cook & Campbell, 1979). Such investigations result in identifying similarities and/or differences, but they do not provide a deeper exploration of the cultural beliefs or practices that are unique to the culture group under investigation. One of the major limitations of this research is in addressing issues that emerge from interpersonal interaction. Interpersonal interactions entail the interplay of the language and cultural backgrounds of the interlocutors and how these variables influence each interlocutor's communication style (including non-verbal behaviour) (Robinson, 2002). The naturalistic exploratory nature of qualitative research, on the other hand, provides the opportunity to account for these complex variables and explain how they shape the clinical processes involved in the management of LCD clients. Qualitative research has the potential to help us understand meanings that participants give to different events or processes, and describe the social context within which the events or processes occur (Denzin, 2001). A qualitative approach therefore, facilitates exploration of the dynamic social process of interaction between clinicians arid their clients in an open, flexible fashion within a natural environment (Damico, Simmons-Mackie, Oelschlaeger, Elman & Armstrong 1999). 4 The few existing qualitative investigations of linguistically and culturally diverse clients with communication disorders have focused either on asking the right questions to ESL clients/family members to obtain information (Westby, 1990), or assessing clients' narratives (Gutierrez-Clellen & Quinn, 1993) and the verbal aspects of discourse in clinician-client interaction (Scollon & Scollon, 2001). These studies have contributed to our understanding of various communication styles in interactions; however, they do not provide an understanding of the barriers encountered and the specific strategies implemented by individuals involved in LCD interactions. Furthermore, since LCD clinical interactions involve two or more individuals (i.e., the clinician, client, family member and/or an interpreter), there is currently a lack of understanding of the clinical interaction processes when multiple individuals are involved, and of the outcomes of such interactions. To date, there appears to be no published study that has investigated the linguistic and cultural issues that influence the quality of clinical interactions between monolingual speech-language pathologists and their LCD adult aphasic clients. The literature that discusses the management of LCD clients in the field of speech-language pathology focuses on children or adolescent populations with language learning disabilities. There is, therefore, a gap in our understanding of the challenges and strategies associated with linguistic and cultural diversity in adult populations with communication disorders. The paucity of research in this area is undoubtedly one reason speech-language pathologists often have inadequate knowledge and understanding to effectively manage LCD clients (Simmons & Small, in preparation). 1.3 Purpose of the study The purpose of my study is to understand how monolingual English speaking SLPs and their LCD adult aphasic clients manage clinical interactions. One of the largest LCD groups in 5 B.C. is the Indo-Canadian community. The Canadian Broadcasting Corporation reported that there are over 125,000 speakers of Punjabi (one of the Indo-Canadian languages) in British Columbia which makes it the third most commonly spoken language in this province (CBC, 2007). Therefore, the present study targets Indo-Canadian clientele. The specific objectives of my study are to describe and explain participants' perceptions of barriers encountered, and the strategies employed to overcome the barriers, during clinical interactions with Indo-Canadian adult aphasic clients, and to develop a substantive theory that will help understand how SLPs may better manage such clinical interactions. 1.4 Research questions The overarching research question in this study was: How do SLPs and adult aphasic clients manage clinical interactions when they do not share the same language and/or culture? The specific questions that further directed the study were: 1. What are the linguistic and cultural elements that facilitate or impede clinician-client interactions? 2. What actions and processes are involved in clinical interactions? (e.g., How is rapport built and what is the process of conducting an assessment?) 3. What are the consequences of the actions and processes? (e.g., Does lack of the same language and culture obstruct the clinical interaction process i.e., assessment and treatment?) 1.5 Theoretical basis and method for the study My study makes use of a symbolic interactionist theoretical perspective and grounded theory method to understand how clinicians arid LCD clients manage their Clinical interactions. Grounded theory draws from the symbolic interactionist tradition, arid together they serve to 6 guide the investigation and to provide a framework within which the findings can be interpreted. The symbolic interactionist framework allows me to identify and interpret dynamic interaction processes, actions, and shared meanings constructed in a given context (Charmaz & Mitchell, 2001). The inductive process of discovery and theory development in grounded theory relies on a natural social setting to study actions and interactions of individuals regarding their multiple experiences of the phenomenon of interest (Charon, 1985). I will discuss symbolic interactionism in detail in chapter three and grounded theory method in chapter four. 1.6 Significance of the study The findings from my study will enhance our understanding of the increasingly complex linguistic and cultural issues that SLPs and clients face when communicating without a common language and/or culture. My study will clarify some of the sources of misunderstandings when there is no common language and/or shared culture and provide insights into the strategies employed by participants to overcome barriers to successful communication in LCD clinical interactions. Such knowledge is important for the purpose of increasing the awareness and skills of clinicians who provide services to LCD clients, thereby enabling clinicians to more effectively meet the client's needs. 1.7 Summary In this chapter, I have described the increasing numbers of LCD adult aphasic clients in North America and the challenges encountered by SLPs in assessing and treating these clients. I mentioned the frequent mismatch between monolingual SLPs and their LCD clients, and the concomitant lack of assessment and treatment materials in the clients' lahguage(s). I provided a brief account of the lack of qualitative research conducted in cross-linguistic and cross-cultural interactions, and the need for further research to understand how clinicians and their clients 7 manage these interactions. I outlined the study purpose and study questions, and then briefly described how a qualitative grounded theory investigation drawing upon a symbolic interactionist framework is well-suited to explore and understand LCD interactions between Indo-Canadian clients, family members, interpreters, and their monolingual SLPs. Such an investigation will provide insights into some of the barriers encountered and strategies employed by individuals in LCD interactions. Following this introductory chapter, the second chapter serves as a review of the literature on issues that arise in interactions involving LCD clients. The third chapter describes the theoretical framework, symbolic interactionism. The fourth chapter incorporates grounded theory methods and ethical considerations applied in the current investigation. The fifth chapter provides a description of the findings. The sixth and final chapter includes a discussion of the findings vis-a-vis the current literature, noting the limitations and implications of the present study. 8 CHAPTER TWO: LITERATURE REVIEW 2.1 Introduction As different parts of the globe get more connected due to the ease of travel and immigration patterns, health care professionals in North America will have more frequent encounters with clientele who vary in their proficiency levels in English, speak another language, and/or have a different cultural background. Clinicians can be challenged and perplexed when dealing with linguistically and/or culturally diverse (LCD) clients because the client's language and/or culture are unfamiliar to them. As a result, the quality of health care services can be adversely affected since clinical interactions depend upon the ability to communicate effectively. Assessment and treatment procedures during clinical interactions with LCD clients in the discipline of communication sciences and disorders have been particularly affected. Providing services to LCD clients has become an increasingly important issue that has gained considerable attention in recent years due to many challenges encountered by clinicians during clinical interactions. Appropriate assessment and treatment procedures suited to the heeds of clients from LCD backgrounds are lacking (Goldstein, 2000; Huer & Saenz, 2003; Roberts, 2001; Roseberry-McKibbin, 1994; Wallace, 1996,1997; Wyatt, 2002), as most literature and clinical training offered in communication sciences and disorders is oriented towards a predominantly monolingual English-speaking Euro-Canadian clientele (Bates, Devescovi & Wulfeck, 2001; Miller, 1984; Restrepo & Silverman, 2001; Roseberry-McRibbin, 2002). Speech-language pathologists (SLPs) encounter problems When managing LCD clients because the lack of a common language and a shared culture can cause difficulties in interacting, arriving at a diagnosis, and planning treatment for these clients (Holland & Penn, 1995; Huer & Sanz, 2003; Roseberry-McKibbin, 1994, 2002). 9 Although the American Speech and Hearing Association (ASHA, 2004), the American Psychological Association (APA, 2003), and an ASHA position paper (1998), as well as some clinical researchers (such as Goldstein, 2000; Roseberry-McKibbin, 1994, 2002; Battle, 2000; Wallace, 1997; and Wyatt, 2002) have recognized, advocated for, and/or provided guidelines to increase the language skills and cultural knowledge of clinicians to better meet LCD clients' needs, accomplishing such goals has proved challenging because there are relatively few bilingual/multilingual clinicians, and it is impossible for SLPs to be familiar with each client's native language and/or culture. The many variables and complexities involved with providing SLP services to LCD clients have made exploration of the challenges difficult and resulted in sparse empirical literature on the management of such clients (Roberts, 1998; Roseberry-McKibbin, 2002). The limited SLP education and empirical literature that are available on the management of cross-linguistic and cross-cultural clients in the discipline of communication sciences and disorders focuses on the management of children or adolescent populations with language learning disabilities. For example, Roseberry-McKibbin (2002) in her book 'Multicultural students with special language needs: Practical strategies for assessment and treatment,'' provides an array of beliefs, practices, and specific strategies that could be implemented with different LCD populations with communication disorders. However, her book is based on little empirical exploration of beliefs and little empirical data supporting the use of specific linguistic strategies when working with LCD populations. In this chapter, I review relevant literature related to the linguistic issues clinicians encounter when they assess and treat clients who are LCD. I also discuss the skills and the proficiency required by SLPs to manage clients whose language(s)/dialects(s) they do not speak. 10 Following discussion of the linguistic issues, I address some of the cultural factors that impact clinical management of LCD clients. Then I review some of the problems SLPs encounter with current assessment procedures used for LCD clients. I conclude this chapter by discussing relevant literature regarding intervention with LCD clients. As mentioned above, since most of the empirical literature regarding LCD clients in the discipline of communication sciences and disorders has concentrated on children and adolescents, much of the literature reviewed in this chapter is based on these populations. The challenges encountered and strategies used with LCD children and adolescents are in many cases applicable to the adult LCD clientele, and where they are not, differences are noted. 2.2 Linguistic issues for linguistically and/or culturally diverse clients One of the key tools for human communication and interaction is language. Language in very simple terms can be described as a tool used for the basic purpose of communication (Finegan, 1999; Foss & Hakes, 1978). It is composed of a semiotic system of codes, signs or symbols that link to meanings, and these are shared and understood by individuals who speak a particular language (Sapir, 1966). Learning a language involves not only learning a set of symbols and their combinations as these relate to meaning making, but it also involves the appropriate use of language with different interlocutors in different contexts (pragmatics). Language may be used to exchange information, build relationships, or simply interact, all of which form intrinsic aspects of human behaviour (Trudgill, 2000; Sapir, 1966). Successful communication is dependent upon individuals' ability to perceive, to interpret, and to understand each other's signs or semiotic representations in similar ways (Warfel, 1962; see Oiler, 1989, for further discussion). 11 When SLPs and their clients do not share a common language, conducting speech and language assessments and intervention becomes challenging. Moreover, LCD clients who do speak English may vary in their English proficiency level. In such cases, it is the task of the SLP to determinethe proficiency level of the client in English in order to carry out assessment/treatment in English, and/or to implement alternative procedures such as the use of interpreters for translation. In addition to the client's English proficiency level, SLPs must be aware of their own competency in the client's language(s) or dialect(s) and have sufficient knowledge regarding the general linguistic and sociolinguistic issues required to perform an evaluation. The American Speech and Hearing Association (ASHA, 2004) compiled a list of skills and knowledge required by SLPs to manage LCD clients. Skill domains include: sensitivity to linguistic and cultural differences that affect assessment, treatment, and management of the client; advocacy for and empowering consumers, families, and communities at risk for or with communication disorders; ability to identify the appropriate service providers for clients; and ability to distinguish typical from disordered language. Knowledge domains include: typical language development in simultaneous and sequential bilinguals; normal processes of second-language acquisition including language transfer; language attrition; differences between an accent and a dialect, and between a language and a dialect; patterns of language recovery following neurological insult; and grammatical constraints on code-switching and code mixing (code-switching and code mixing involve alternating or shifting a word or sentence between two or more languages by individuals who are fluent in those languages). Despite ASHA's guidelines, acquiring knowledge and skills for a particular LCD group, such as Indo-Canadian clientele, is challenging. The Indo-Canadian LCD population has great 12 linguistic diversity due to the many different languages and dialects spoken within the Indian subcontinent. The Constitution of India has recognized 22 official languages, and many other regional and tribal languages (Raymond, 2005). According to Devi (2002), "there are 1,652 mother tongues according to the 1961 Census of India, out of which more than 400 are tribal languages." Many of these languages have originated from different language families, such as the Dravidian, Indo-Aryan, Tibeto-Burman^ and Austro-Asiatic, which do not share common linguistic features with each other. Devi (2002) attributes some of the multilingual and multicultural challenges that SLPs encounter on a daily basis within the Indian context to the various languages and dialects spoken within India. The issue of language variation being a barrier to communication and interaction is manifested by a number of challenges related to the different components of language. Phonology, morphology, vocabulary, grammar, pragmatics and discourse are components of language that differ in every language. Before SLPs assess and treat a client in a specific language, they need to be aware that LCD clients will vary in their skills in the different components of language. Below I discuss several of the cross-linguistic differences identified for components of languages. 2.2.1 Components of language Phonological differences. Phonology is the study of the sound system of a language. Each language varies with regard to its inventory of speech sounds, and its allowable sound combinations (Pauwels, 1995). Clients Who speak English have different ways of combining and producing sounds than do clients who speak other languages such as Punjabi or Hindi. Often LCD clients accustomed to producing sounds in their native language and environment generalize these productions to the English language. That is, they produce sounds and their 13 combinations in English based on the way they are produced in their native language. For example, individuals from the Philippines who speak Tagalog often substitute /p/ for If I sounds in English (e.g., 'pive' for 'five' and 'pish' for 'fish') because HI is not found in the Tagalog phonemic inventory. It is only during an interaction between individuals from more than one linguistic background that awareness is created of the sound differences in the production of speech. People refer to the differences in their interlocutors' speech as an accent. Phonological differences between the languages of LCD clients have been investigated in a few populations such as African-Americans (Mufwene, 1998; Wright, 1997; Wyatt, 1997), Appalachian English speakers (Buck, Maynard, Seyried & Garn-Nunn, 1996; Garn-Nunn, 1999), and Hispanic Americans (Brice, 2002; Goldstein, Fabiano & Washington, 2001; Giles, 1995; Levey & Cruz, 2004). For example, Mufwene (1998) in his book describes the African-American vernacular English (AAE), which is an English dialect spoken by many African-Americans in the USA. He discusses the different sound productions in African-Americans' speech that make it distinct from Standard American English (SAE) production. Some examples are the production of the initial Ithl = d (i.e., 'them' becomes 'dem'), final /th/ = f (i.e., 'mouth' becomes 'mouf'), deletion of middle and final Ixl (i.e., 'all right' becomes 'aiight,' 'star' becomes 'stah'), and final consonant deletion ('live' becomes Ti'). According to Mufwene, although AAE is a variation of SAE, it has its own set of phonological rules that are unique to the dialect. Mufwene's information on phonological differences across dialects indicates that SLPs should be aware of the different phonological rules and constraints across dialects (and languages), and the transfer and use of these rules and constraints from one dialect (or language) to another. Such knowledge could enable SLPs to identify and attribute such differences to dialect and language variation rather than to classify them as disordered speech. 14 The ASHA office of multicultural affairs (2006) put together phonemic inventories in Arabic, Vietnamese, Mandarin, Cantonese, Korean, and Spanish. ASHA (2006) discusses the advantage of having access to such charts in specific languages as it can help: identify sounds in a client's phonological system for languages other than English; determine phonemic influences of a client's native language on his/her English; identify sounds from the client's first language that may not exist in English; identify sounds in English that do not exist in someone's native language; and recognize that similar sounds across two languages need not be used in the same way. For example, some of the phonemes found in English that are not found in Arabic are /p/, hi, Igl Izl; some of the consonants found in English that are not found in Korean are /w/, hi, and /z/. Although ASHA has made available the above phonemic inventories, awareness and familiarity regarding the correct production of these sounds is key to effective phonological assessments. In addition, it is important for SLPs to keep in mind that the phonemic inventories developed in specific languages often do not include the language variations and dialects spoken by individual clients. The phonemic inventories compiled by ASHA represent only a very small portion of the LCD populations in North America. There is a great need for knowledge of phonemic inventories and accents in other LCD populations. For example, a literature database search for phonemic inventories in the Indian languages came up with only one result. Manjulakshi (2003) compiled a phonemic inventory for the Kannada language for vowels and consonants. Kannada is spoken in the state of Karnataka by about 30 million Indians (Mallikarjun, 2001). Kannada like many other Indian languages has eleven dialects of which eight were included in this phonemic inventory. The development of the phonemic inventory in Kannada, although useful for managing Indian clients who speak Kannada, does not necessarily assist in understanding the 15 sounds of the other Indian languages. A s Devi (2002) says, since the phonemic inventory of no two Indian languages is identical, their phonotactic (allowable sound sequences) and other phonological rules and constraints w i l l differ, and thus, knowledge of one phonemic inventory does not help in understanding another Indian language. A lack of knowledge about the phonological differences across languages has potential implications when clinicians assess and treat L C D clients. Phonological differences could be mistakenly classified as errors leading to misdiagnosis and/or inappropriate targets for treatment. Unless there is further empirical research and literature on accent and phonological differences, the chances of acquiring such knowledge is limited. Morphology. Morphology is the study of the system of word-forming elements and their analysis and arrangement in a language. A morpheme is the smallest unit of linguistic meaning, and it may consist of an entire word (e.g., hair, and) or be an element that is part of or added to a word (e.g., the prefix " -un" in the word "unfriendly"). Morphology that is related to the inflectional variation, of single morphemes is called inflectional or grammatical morphology. Inflectional morphology in English primarily consists of prefixes and suffixes which play a syntactic role in the sentence (morphosyntax). For example, in the sentence "Sam was painting a picture" the suffix 'mg' is an inflection indicating progressive aspect of the verb "paint". Other inflectional forms could be '-ed' and'-s (painted, paints). Derivational morphology, on the other hand, can have implications for lexical meaning and grammatical class. For example, the morpheme (suffix) -able changes a verb such as "depend" into an adjective "dependable." Similar to phonology, morphology also has rules and constraints that differ across languages. L C D clients w i l l l ikely have different morphological rules and constraints in their native language, and they may also vary in their morphological abilities in their second language. 16 Paradis (2005) conducted a study on ESL children and native English speaking children with specific language impairment (SLI). The children's accuracy and error types in producing the following grammatical morphology were examined in spontaneous and elicited speech: third person singular [-s], past tense [-ed], irregular past tense, 'be' as a copula and auxiliary verb, 'do' as an auxiliary verb, progressive [-ing], prepositions in and on, plural [-s], and determiners 'a' and 'the.' Some of the errors ESL children made were 'earned' instead of 'came'-over regularization, and T don't have best friend'-deletion of the determiner 'a.' The results from Paradis'study indicated that ESL children's accuracy rates and error patterns with the grammatical morphemes were similar to the same-age monolingual children with SLI, in both spontaneous and elicited speech. Paradis concluded that results such as these might falsely indicate that ESL children are language impaired. The use of English standardized tests with non-native English speakers can thus yield erroneous results and lead to inappropriate conclusions. Similar to Paradis' study, Bland-Stewart and Fitzgerald (2001) confirmed that normative data used for mainstream English speaking children cannot be used with bilingual English/Spanish-speaking children. Their investigation involved comparing the normal monolingual morphological development of Brown's classification of grammatical morphemes (developed in English) with bilingual Hispanic preschoolers. Results from their study indicate bilingual children's mastery of the grammatical morphemes at later ages than monolingual English speaking preschoolers. These two studies, although conducted on children, have important implications for adult ESL/bilingual clientele. The use of normative monolingual benchmarks with LCD clients is inappropriate because it could lead to inaccurate diagnosis and management of these clients. Thus, the knowledge of differences in grammatical morphology 17 across languages is important for SLPs working with adult LCD clients in order to distinguish between language differences and language disorders. Vocabulary. Speech sounds of a language map onto words, which make up each speaker's lexicon (vocabulary). The mapping between word forms and meaning (lexical-semantics) varies from language to language in that each language usually uses a different string of speech sounds for a particular meaning (e.g., 'dog' = [dawg] in English but [pero] in Spanish) (Pauwels, 1995). When words and phrases are literally translated from one language into another language, the literal translation may often take on a different meaning to a listener who is unfamiliar with the language (Banks & Banks, 1991). For example, English speakers may end a conversation by saying TT1 see you soon' or 'Bye.' However, the commonly used phrase in the Kannada language when ending a conversation is, when directly translated into English, 'Alright, I'll come.' Although it makes little sense when translated to an individual unfamiliar with the Kannada language, it does have an appropriate underlying meaning in the context of the language produced. Users of the Kannada language will interpret its actual meaning as 'I'm leaving right now, but I'll be back soon.' Because such differences exist across languages, SLPs and interpreters should be aware of these differences in meanings when directly translating between languages. Evaluating vocabulary and semantic knowledge is particularly challenging for SLPs working with LCD clientele. Vocabulary often reflects individual experiences and the home language (Penna, 2001). Often LCD clientele obtain poor scores compared to the native English-speaking clientele on lexical-semantic assessments such as the Peabody Picture Vocabulary Test - IIIB (Dunn & Dunn, 1997), the Receptive One Word Picture Vocabulary Test(Gardner, 1985) and the Expressive One Word Picture Vocabulary Test (Gardner, 1990). LCD clients' lack of 18 familiarity with the vocabulary or the tasks in these assessment batteries results in lower scores compared to native English-speaking clientele for whom the tests were developed (Penna, 2001). Pena, Bedore, and Rappazzo (2003) investigated Spanish-speaking, English-speaking, and Spanish-English bilingual children's performance on a battery of semantic tasks (e.g., associations, categorization, functions, and similarities and differences) in Spanish and English. Each of the tasks included items that evaluate comprehension and production abilities. Their results indicated that although children in all three groups achieved similar levels of performance on the assessment battery, there were differences across all three groups, wherein bilingual children had a different pattern of performance compared to their monolingual counterparts (e.g., bilingual children performed better in English on some tasks, e.g. linguistic concepts, and better in Spanish on other tasks, e.g. functions). According to Pena et al., the unique configuration of semantics in each language, and differences in lexical production skills across the two languages, explained bilingual children's different pattern of performance. Findings from this study indicate that vocabulary tests designed for a monolingual language group may not be appropriate for a bilingual language group, and that bilingual clients should be assessed in both their languages with tests developed specifically for them rather than using tests that were designed for monolingual clients. The findings also imply that LCD clients need to be evaluated across a variety of semantic tasks in order to gain a more complete understanding of their lexical-semantic knowledge. There are gaps in our knowledge regarding assessing vocabulary skills in child LCD clients who speak more than one language. Unless there are procedures developed to accurately assess the vocabulary skills of LCD clients, these clients will continue to be misclassified as being delayed in language development. Challenges in assessing vocabulary in child LCD clients 19 has potential implications for adult LCD clients. Namely, adults can range in their vocabulary skills from being minimally competent to having native-like competency in their second language. Unless and until steps are taken to develop appropriate tests to measure vocabulary skills in the second languages of adult LCD clients, or to develop alternative procedures to understand their vocabulary, skills, SLPs will continue to encounter challenges when assessing such clients. Grammar. Another commonly encountered problem with language for LCD clients is the transference of the structural rules (syntax) or constraints of a native language to the second language. Grammar is the system that enables a language user to combine Words and phrases into sentences (Pauwels, 1995). Like phonological and morphological rules and constraints, each language has its own rules and constraints for word order and sentence structure. Word order and sentence structure differences and errors are commonly noticed by clinicians who work with LCD populations (Goldstein, 2000; Roseberry-McKibbin, 2002; Wyatt, 2002). In English, 'word order' is a reliable cue to grammatical relations in a sentence. For example, the word order in English is Subject-Verb-Object (S-V-O), 'boy hit cat,' while the word order in the Tulu language (a language spoken in Southern India) is Subject-Object-Verb (S-O-V), 'boy cat hit' (Brigel, 1872). A client in the process of learning English may apply the word order of Tulu to English. Such differences in grammar, and the resulting transference of rules and constraints between languages, are not only prone to affect communication due to alteration of meaning, but may also be perceived by the SLP as ungrammatical during assessment of the client in English. Thus, LCD clients' syntactic errors may occur due to the lack of proficiency in English, the manner in which English was learned (e.g., informal vs. formal context) (McDonald, 2000; De Groot and Kroll, 1997), and/or the syntactic rules and constraints 20 of the first language being applied to the second language. For these reasons, understanding grammatical differences between languages has important implications for SLPs when they assess as well as plan therapy for LCD clients. In an investigation by Sanders, Neville and Woldorff (2002), native Japanese and native Spanish late-learners of English, monolingual Japanese, and monolingual English speakers were asked to determine whether specific sounds fell at the beginning or in the middle of words in English sentences. Tasks involved identifying sounds in semantic sentences, syntactic sentences with English syntax but little meaning, and acoustic sentences that had little meaning and little syntax of English. Examples of each type follow: Semantic sentence: In order to recycle bottles you have to separate them,' Syntactic sentence: In order to lefatal fcokkers you have to thagamate them,' Acoustic sentence: "Ah ilgen de lefatal feokkerth ha maz di thagamate fon.' The sound to be identified by speakers in these sentences was /bo/. The investigators were interested in finding out to what extent each group of participants could benefit from lexical, syntactic, and stress-pattern information during speech segmentation (i.e., determining where one word ends and the next begins in continuous speech). Results from their study indicated that late-learners employed lexical information to perform the segmentation task similarly to native English speakers; however, they did not use syntactic information to the same extent as native English speakers. Although both groups of late-learners of English used stress pattern as a segmentation cue, the extent to which this cue was relied upon depended on the stress-pattern characteristics of their native language. Sanders et al's findings not only indicate that learning a second language later in life has differential effects on the components of a specific language but also suggest that SLPs working with LCD clients should be cautious when making diagnostic decisions based on 21 the evaluation of any one particular component of language. While some components may resemble native-like performance in English, others may be more problematic. McDonald (2000) provides further support for cross-linguistic syntactic differences in his investigation on children. In his study, native Spanish early and late acquirers of English as well as native Vietnamese early and late acquirers of English made grammaticality judgments on sentences in English. The findings showed that native Spanish early acquirers were not distinguishable from native English speakers, whereas native Spanish late acquirers had difficulty with all aspects of grammar except word order. Native Vietnamese early acquirers had difficulty with those aspects of English that differ markedly from Vietnamese. For example, they had more generalized problems, similar to those of native Spanish late acquirers. Thus, native language appeared to make a difference for early acquirers, whereas a later age of acquisition caused a more general problem. The results from this study indicate that the closer the native language is to a second language the fewer the difficulties there are in processing, and the later the acquisition, the greater the demands on grammatically processing the second language. McDonald's study suggests the need to be aware of the relation between the language structures and the age of acquisition of a client's second language because these could have potential implications when assessing and treating ESL clients. The studies discussed above provide information on how the different components of language develop to different degrees at different ages. Such knowledge has important implications for SLPs working with LCD clients/Knowing the age of acquisition of a client's second language and the cross-linguistic differences in the different core components of language (phonology, morphology, and grammar) can provide SLPs with information that will help determine the language proficiency of clients whose first language is not English. 22 Pragmatics and discourse. Pragmatics, the social and contextualized use of language, is one of the most important language components in clinical interactions between professionals and their LCD clients. According to May (1993, p. 42), "pragmatics is the study of the conditions of human language uses as these are determined by the context of society." An understanding of how individuals use language in a context to socialize and interact is essential as it provides knowledge about factors that contribute to functional communication. Analyzing the speaker's intention and the effect it produces on the listener can provide information as to whether the communication was successful or not (Searle, 1979). A lack of understanding of intentions between clinicians and clients often leads to misunderstandings, frustrations, and disputes during the clinical interaction process (Damico & Damico, 1993). While pragmatics is a more general level of classification of linguistic communication, discourse forms a more narrow classification of linguistic function. The term discourse analysis involves the linguistic analysis of naturally occurring connected speech within a given context. Whereas the previously mentioned components of language are concerned with units at the sentence level or smaller, discourse is concerned with larger linguistic units that span sentences, units one typically finds in conversational exchanges and written texts (Stubbs, 1983). A number of investigators have argued that discourse tasks are more sensitive in identifying functional communicative abilities of clients than are assessments of the core language components (Damico, 1985; Scollon & Scollon, 1995; Ulatowska & Chapman, 1994). However, few have actually utilized discourse measures to evaluate LCD adults who have aphasia (Wallace, 1996). Some of the important functions that discourse assessment can have in diverse clinical settings relates to exploring issues such as clients' topic initiation, maintenance, and termination, turn 23 taking rules, and repair strategies, which clients may or may not employ when breakdown occurs in clinical interactions. Ulatowska et al. (2001) were interested in comparing discourse abilities between neurologically normal African-American adults and African-American adults with mild to moderate aphasia following left hemisphere stroke in order to explore the relationship between discourse ability and clinical measures of language impairment and functional communication in the African-American adults with aphasia. Specifically, Ulatowska et al. (2001) wanted to find out: 1) whether neurologically normal African-American adults differ significantly from African-American adults with aphasia on a language impairment measure and a functional communication measure 2) whether discourse ability in neurologically normal African-American adults differs significantly from discourse ability in African-American adults with aphasia and 3) what the relationship is between participants' performance on a language impairment measure, a functional communication measure, and discourse tasks. Ulatowska et al. administered the Western Aphasia Battery to obtain language impairment measures, and the ASHA Functional Assessment of Communication Skills for Adults to obtain information on the functional communication abilities of participants. Understanding the lessons conveyed by fables, and interpreting proverbs, were specific tasks used to evaluate discourse abilities. The neurologically normal group performed significantly better than the adults with aphasia on the language impairment measures, the functional communication measure, and the discpurse tasks. Although no significant differences between groups were observed on a picture description fable task or in performance on a multiple-choice proverb task, fables and proverbs appeared to be more effective than the language impairment measures and functional communication measures in eliciting natural language from both groups of African-American participants. The participants' production of rich contextual scenarios and biblically-derived responses that conveyed didactic meaning were indicative of their socio-ethnic ;• background. The investigators concluded that fable and proverb discourse tasks may be valuable supplemental measures for characterizing communicative competence in African-American adults who have aphasia. Such discourse tasks are sensitive to the socio-cultural influences of language and may therefore be better functional indices of these clients' communicative abilities and disabilities than are standardized language impairment measures (Holland, 1983; Ulatowska & Chapman, 1994). The results of this study indicate the need for further investigation of discourse patterns in other LCD adult aphasic populations. By providing a better understanding of the socio-ethnic influences on the language used by LCD clients, such research would potentially contribute to more appropriate assessment and treatment of LCD clients. 2.2.2 Summary of linguistic issues In this section, I discussed the individual components of language skills as used by individuals who speak more than one language. The literature has made important contributions in understanding the cross-linguistic differences that may be present in one or more language components. The cross-linguistic differences identified in LCD children across different cultural groups have important implications for clinicians working with adult LCD clients. Namely, the challenges encountered with LCD child clients are just as relevant and prevalent when working with LCD adult clients (e.g., the lack of appropriate assessment tools, making informed clinical judgments, and the complexity of assessing different components in a second language). Thus, there is a need for developing knowledge about cross-linguistic interactions across different language components in specific culture groups of LCD adult clients. 25 Before concluding this section, it is important to note that just as an individual's ability in one language interacts with or has an influence on his/her performance in another language (e.g., Ll-native language and L2-second language), the different components or levels within one language interact with and influence each other. This has implications for how clinicians determine and view clients' communication challenges. De Bot and Makoni (2005) refer to dynamic systems theory in an attempt to account for the dynamic, interactive, and interdependent nature of language use, acquisition, change, and attrition. They state that not only do language subsystems interact, but changes in one of the subsystems can have an impact on other subsystems (e.g., a change in the phonological subsystem can affect the morphological subsystem). De Bot and Makoni's (2005) discussion on language as an interactive dynamic system has important implications for understanding linguistic issues associated with adult LCD clients with communication disorders. Following their line of reasoning, no one component of language should be assessed or treated in isolation because the operation of one component has consequences on how information is processed in other component. This interactive view of language, while expensively studied in monolingual English speakers, has rarely been explored in the context of individuals with multiple languages, and not at all with adult LCD clients. Thus, in order for SLPs to be better prepared to address the linguistic issues that may interfere with assessment and treatment of LCD clients, research on how the language components relate and interact within and across two languages is needed. 2.3 Cultural issues for linguistically and/or culturally diverse clients One of the important functions of language in society is to represent and transmit culture. Culture, in turn, as a semiotic system, has an influence on how language is used. Thus, while it is convenient to address each system in isolation, it fails to capture how the two are interdependent. 26 I begin this section by discussing the importance of the relationship between language and culture. Then I provide a brief description of culture, followed by some issues that have been identified in the health care literature that arise when there are cross-cultural differences between clinicians and clients. Lastly, I discuss some of the relevant literature on cross-cultural interactions within the discipline of communication sciences and disorders. The purpose of this discussion is to indicate the importance of cultural factors that influence clinical interactions between health care professionals (including SLPs) and their LCD clients. 2.3.1 Language and culture Language and its analysis are limited in providing an understanding of the underlying meaning of what has been communicated. This is because language, as a semiotic system, interacts with other systems such as social conventions and cultural backgrounds to enable individuals to assign meaning to forms. A number of linguists and anthropologists have argued that the meaning of what is said can be accurately understood only when it is interpreted in relation to one's culture (Finegan, 1999; Sapir, 1966; Whorf, 1956), and therefore, an understanding of culture and its relationship to language is essential to understanding interpersonal communication. According to Sapir (1966: 8, 9), "The components of language, the symbols used with experience (of individuals), must be associated with whole groups [of people] rather than with the single experiences themselves. For something to be communicated it needs to be referred to a class which is tacitly accepted by the community as an identity." Thus, language as it is constrained by socio-cultural conventions, involves more than just a set of arbitrary symbols and their associated meanings used for communication and interaction. It is an expression of one's own ways of thinking, which in turn are intimately related to one's culture (Landar, 1966). 27 Whorf (1956), a student of Sapir, had extensive experience with the American Indians and the Hopi culture, and extended Sapir's views by stating that speakers have their own ways of structuring and expressing themselves. One of Whorf's investigations examined the structural differences between the Hopi and the English languages. He reported that the concept of time and its dimensions were different in both languages. Namely, the Hopi language does not have grammatical concepts to represent past, present, and future like the English language. Rather, it has specific words that represent time in relative terms. According to Whorf, without an understanding of an individual's thought (influenced by language and culture), understanding concepts of time and its different expressions in English-speaking and Hopi-speaking individuals would be very difficult. Language structure and expression are closely tied to the way individuals think, and thinking is shaped by the individual's experience with his/her environment. Language thus shapes one's thoughts, and thoughts are influenced by one's culture. Sapir's and Whorf's views of language and its relation to culture have been summed up together and have come to be known as the "Sapir-Whorf hypothesis." The hypothesis is often described as consisting of two associated principles: I) linguistic determinism and 2) linguistic relativity(Whorf1956). The first principle states that our way of thinking is determined by our language, and the second states that people who speak different languages perceive and think about the world quite differently. According to the Sapir-Whorf hypothesis, speakers of different languages should perceive and understand the same situation in different ways. Language is a part of the individual, who is a part of a specific social environment, and language learnt in that environment shapes the way the individual views the world. The Sapir-Whorf hypothesis has been contested by many linguists who have argued that thought is independent of language (e.g., Pinker, 1994), or that thought determines language (e.g., 28 Gumperz & Levinson, 1996). According to these linguists, the way we think and perceive things in the world determines the way we learn concepts, and language does not limit such a capability. Others view language and thought as interdependent. For example, language is a tool for thought and cognitive processes influence how language is used (e.g., Bates, Devescovi, & Wulfeck, 2001; Caselli, Bates, Casadio, Fenson, Fenson, Sanderl & Weir, 1995). Many researchers have recognized limitations in strong form of the Sapir-Whorf hypothesis. For example, if language were to solely determine one's thoughts, communication between individuals from different linguistic and/or cultural backgrounds would be almost impossible (i.e., if they did not share the same language). However, despite the language barrier, cross-cultural communication does take place successfully. For example, in the Kannada language there are many specific words for an aunt (depending upon the family) such as 'father's elder sister,' 'father's younger sister,' 'mother's elder sister,' and 'mother's younger sister.' Despite these specific words for aunt in Kannada, speakers of the English language still are able to understand that such differences exist because English has equivalent word combinations. If language were to determine thought, English speakers might have difficulty in understanding such concepts. However, since this is hot the case, the argument that language solely determines one's thought has to be questioned. According to Carroll (1963: 12), "individuals who speak different languages sort out and distinguish their experiences differently according to the categories provided by their languages." That is, even though the concept of "aunt" may be realized differently in different languages, each language provides means for accommodating to this difference. Thus, individuals from different linguistic backgrounds are indeed able to understand concepts that are not present or vary in their native language. 29 Due to the flexibility, freedom, and independence of an individual's thinking, one person will differ from another in his/her ways of thinking, although they might have had similar experiences (Mead, 1934). This is because an individual's interpretation of things in the world helps give meanings to them (Blumer, 1969). However, these interpretations and meanings given to concepts and things in the world are mediated through cultural experiences. Thus, culture influences one's thought processes, and is expressed in one's language. Much of what is explored so far of language and its relation to culture has been reported by individuals who have investigated or have been exposed to cultures other than their own (Bonvillain, 1997; Novinger, 2001; Sapir, 1966). This is because it is often not until one steps outside of one's native language and culture that one views language and culture as something to reflect on. 2.3.2 Culture Culture comprises the values, traditions, customs, beliefs, and practices that a group of individuals have in common. It represents the shared characteristics of a community, especially characteristics that distinguish one community from other communities (Hudson, 1996): The term culture encompasses a variety of concepts like a 'set of norms for doing things together,' and 'knowledge, experience, meaning, beliefs, values, attitudes, relationships, hierarchies of status, and role expectations' (Novinger, 2001, p. 14). For example, beliefs regarding illness, values for family relationships, and attitudes towards speech disorders can be different across different cultures. As mentioned earlier, language and culture are so closely knit that attempts to describe them separately necessarily comprise the description of each and how one influences the other. Sapir (1956, p. 156) explains that "the content of every culture is expressible in its language, and there are no linguistic materials whether as to content or form which are not felt to symbolize 30 actual meanings, whatever may be the attitude of those who belong to other cultures." Because language involves speakers and listeners engaged in the production and comprehension of content and form, it is the primary means for the definition, expression, and transmission of cultural information. In other words, culture represents people's worldviews through language. Although the interdependence of language and culture is now widely embraced in the research community, it is nevertheless acknowledged that individuals may vary on the strength of the relationship that holds between specific languages and specific cultures. For example, on the one hand, there are bilingual and bicultural individuals who feel equally at home in either language/culture. On the other hand, some bilingual individuals identify much more with one than another culture. Hence, the importance of examining the interface of language and culture becomes particularly salient with individuals who identify with more than one language and culture, and in contexts where individuals do not share the same language and/or culture. The interrelationship between language and culture indicates that language cannot be fully understood without exploring individuals' cultural beliefs, values, and practices. Likewise, individuals'perspectives on their beliefs, values, and practices are shaped by their communication with others. The interdependence of language and culture is an especially important and complex issue in cross-cultural interactions in health care due to the multiple languages and cultures represented, as well as the health care needs of the client. 2.3.3 Cross-cultural differences in health care Since language is both molded by cultural practices and is the most important means of communicating culture (Taylor, 1986), identifying cultural differences and providing culturally sensitive speech-language services to LCD clients are important. Although researchers generally highlight the importance of investigating either cultural (Agar, 1994) or linguistic (Bates, 31 Devescovi & Wulfeck, 2001) factors in order to understand bilingual individuals' needs, there is a need for investigations that explore both in the context of interactions between SLPs and LCD clients. In addition, investigations are needed that explore linguistic and cultural factors in particular cultural groups in order to unravel the underlying relations between linguistic abilities and a specific individual's culture. Although SLPs may be aware of linguistic differences in their clients, they may not regard cultural differences as being as important during Clinical interactions (Goldstein, 2000; Wallace, 1997). For this reason, the cultural values, attitudes, beliefs, and practices of a client are often not taken into account by SLPs providing services to LCD clients (Roseberry-McKibbin 2002; Sue & Padilla, 1990); There is a need for SLPs to understand that clients who do not share a common language and/or culture with their clinician bring into the clinical interaction differing perspectives, needs, and goals based on their own values, beliefs, attitudes and practices. Differing cultural backgrounds and views between clinicians and clients, especially regarding health care issues, can impede successful communication and interactions (Pauwels, 1995). Moreover, lack of understanding of the client's beliefs and practices can often result in problems with assessing, diagnosing and managing LCD clients (Grooters, Hill & Long, 1997). Trembath, Wales and Balandin (2004) identified some challenges speech-language pathology students experienced in cross-cultural clinical contexts. Students placed in SLP practicums in India, Nepal, Bangladesh, Thailand, and South Africa were required to maintain personal journals to account for their experiences, including gaps in their knowledge and skills for cross-cultural interactions, use of resources and tools, and perceptions of individuals involved in interactions. Their results indicated that students were not prepared for either professional or personal encounters with clients in a cross-cultural context. According to the investigators, future 32 students preparing to undertake such placements need to attain at least some cross-cultural clinical competencies and gather information on the culture(s) of the clients they will be serving before being placed in cross-cultural clinical contexts. Trembath et al.'s study has potential implications for the current North American clinical context wherein there is a need for SLP students to have greater cultural awareness and sensitivity before they graduate and begin providing services to an ever-growing LCD clientele. It is also corroborated by Simmons and Small's (in preparation) survey findings which indicated the need for more education and training for students as well as practicing SLPs on linguistic and cultural issues in practice. Some of the cultural differences that could have a significant impact on clinician-client communication are the clinician's and client's perspectives regarding illness (Assanand, Dias, Richardson & Waxier-Morrison, 1990; Bebout & Arthur, 1997; Ensink and Robertson, 1999), differences in communication styles (Ito and Maramba, 2002), differences in establishing rapport (Bolton, 2002), and the different ages of the clients and clinicians (Paradis 2002, Roberts, 2001; Roseberry-McKibbin 2002). I briefly discuss these potential cross-cultural differences between clinicians and clients below. Perspectives regarding illness. Clients and clinicians' perceptions regarding illnesses, their causes, nature, severity and management may differ (Bebout & Arthur, 1997). Following are a few typical examples cited in different health-care discipline publications regarding cross-cultural differences. Hindu South-Asian clients have been described as perceiving mental illness as a reincarnation of 'karma', which means fate (Assanand, Dias, Richardson & Waxier-Morrison, 1990; Hoch, 1990). They may seldom believe that psychological or psychiatric management can cure mental illness. Ensink and Robertson (1999) describe African psychiatric patients as perceiving their illness to be either due to 'God's will' or their 'nerves' and preferring 33 treatment from indigenous healers rather than psychiatric facilities. Bebout and Arthur (1997) described Cantonese speaking Americans who perceived that if they 'tried hard' they could improve speech disorders like dysfluency, cleft palate and misarticulatibn. Such clinical investigations and reports make important contributions to the literature by increasing our awareness of the underlying beliefs that could be a barrier between a clinician a client prior to and/or during clinical interactions. The findings from these studies also imply that there could be many other mediating beliefs such as LCD clients' perceptions regarding stroke, aphasia, and seeking services. Understanding the LCD clients' views on illness and health care has the potential to increase SLP sensitivity to cross-cultural differences and thereby improve outcomes by providing services in a manner that accommodates to clients' varying perceptions of illness. Communication styles. Different cultures have different communication styles and views as to how language is to be used in different social contexts (Pauwels, 1995). With regard to the clinical context, Ito and Maramba (2002) reported that many Asian and Asian-American clients preferred an authoritarian directive clinician who gives concrete suggestions. For example, clients preferred clinicians who recommended treatment methods for them rather than discussed treatment options with them. In general, clients perceived higher levels of satisfaction with the health care when clinicians communicated in ways analogous to their own. Ito and Maramba concluded that successful therapeutic relationships require constant negotiation of clients' and clinicians' beliefs around clinical interaction. Understanding differences in communication styles between clinicians and clients, tolerance and understanding towards others, and a desire by clinicians to employ strategies that overcome communication barriers may help minimize cross-cultural misunderstandings during clinical encounters. 34 The educational and clinical literature on cross-cultural communication styles in health care reporting different styles of communication between health care professionals and clients has been limited to date. Moreover, since investigations are culture specific, it is not possible to make straightforward generalizations to other cultural groups for whom we have limited understanding of their communication styles and preferences. Further research is needed, therefore, to understand specific communication styles in specific cultures so that clinicians will have the information they need to adapt their communication styles to each client. Establishing rapport. Rapport is important in interpersonal interactions to maintain a collaborative relationship without which communication and interaction may be adversely affected. Establishing rapport in cross-cultural interactions is even more vital because individuals need to work together and build a relationship of trust when there are language and/or cultural barriers. Despite rapport being one of the most important aspects of effective clinical interactions, there seems to be little emphasis placed on it in the health care literature. There are very few clinical investigations within health care professions that explore rapport between clinicians and their LCD clients. One study by Bolton (2002) investigated the experience of psychiatrists working with non-English speaking patients and their families, who were from a different cultural background than the clinicians. Based on his qualitative ethnographic study, he stated that some of the key concerns in clinical interactions are establishing a basis of trust, understanding patients' problems, and trying to make a difference in the client's life. Bolton noted that often linguistic and cultural barriers create challenges in client-clinician interactions, and therefore, the task of each health care professional is to identify the specific needs of the each patient in a given clinical interaction. 35 Empirically based knowledge of the factors that positively or negatively affect rapport during SLP clinical interactions has yet to be generated. Understanding such factors should facilitate the quality of interactions between clinicians and LCD clients. Age. Age plays a significant role in both within- and cross-cultural clinical interactions. The educational health care literature reports preferences by clients to have clinicians who are older than them. However, there has been limited research on this issue for specific cultural groups (Roberts, 2001; Roseberry-McKibbin 2002). In addition, age rarely stands alone as factor but is usually connected with other issues like power and authority associated with an individual's age. For example, clients from Asian cultures-Chinese, Japanese, Filipino, and Indian—may prefer a clinician who is older than them, but this is likely mediated by each culture's relative attribution of power and authority to older individuals (Pauwels, 1995; Robinson, 2002). Further research is needed to identify and explain potential implications of age preferences for clinicians, especially those working with older LCD clients. Identifying whether older LCD clients prefer older clinicians, the reasons for such a preference, and understanding its effect oh the clinical interaction would contribute to our knowledge of the effects of age as a cultural factor in clinical interactions. Apart from the above cross-cultural differences (perceptions of illness, communication styles, establishing rapport, and age), researchers have also reported cross-cultural differences involving a preference for doctors over other health care providers (Battistone, 1998), attitudes about the importance of intervention (Holland & Penn, 1995), and the roles of different individuals in the clinical process (Mattes & Omark, 1984). Other variables include the attitudes of clients and family members towards monolingual clinicians from a different culture (Holland 36 & Perm, 1995), the dress of the clinician (Roberts, 2001), end-of-life care practices for older adults (Deshpande, Reid & Rao 2005), and beliefs about being treated in an unfamiliar language. Although these publications provide interesting reading and anecdotes based on clinical experience, the information is not based on empirical research, and therefore, points to the need for systematic investigations to be undertaken. Most of the cross-cultural literature in health care discussed above addressed only one cross-cultural difference such as perception of illness or Communication styles. Often with LCD clients a combination of cross-cultural factors exert an impact on the quality pf clinical interactions. Very few clinical investigations have undertaken the task of exploring or identifying multiple cross-cultural factors in the same study. For example, how do age, gender, and perception of illness work together in influencing cross-cultural interactions. The following study by Herselman (1996) is one such exception and has important implications for the present study. Herselman (1996) conducted a comprehensive ethnographic investigation that involved in-depth interviews to investigate doctor-patient relationships between Xhosa-speaking South African patients and their Western medical practitioners. The investigator identified socio-cultural differences between doctors and patients wherein perceptions about health care differed drastically. Doctors had vague ideas about alternative methods of treatment such as sorcery and witchcraft, while patients were unfamiliar with Western medicine and the biomedical system of hospitals. Problems with language differences were identified. Doctors reported patients lacked adequate vocabulary to indicate problems such as depression. Herselman also identified defensiveness among patients due to discomfort in a clinical setting, leading them to be reticent or emotionless and inclined to withhold information from the doctor. In addition, the submissive and passive nature of clients was perceived negatively by their doctors during interactions. In 37 this study, cultural issues of illness ascribed to supernatural entities (e.g., ancestral spirits or witchcraft), deference to the doctor, and defensiveness as a protective measure in clinical interactions, were shown to adversely affect communication between doctors and their patients. Herselman's findings indicate the need to conduct more investigations that identify multiple cross-cultural factors in clinical interactions involving specific LCD culture groups. Identifying the unique cultural beliefs and practices of specific cultural groups, and attempting to understand the influence of these beliefs on behaviors in clinical interactions, have the potential to assist clinicians in managing the client in ways that are acceptable to LCD clients. 2.3.4 Cross-cultural research in communication sciences and disorders Most of the literature on cross-cultural communication in the profession of communication sciences and disorders has focused on immigrants who are students or adults adjusting to a different culture. The majority of the literature on cross-cultural interactions of clinicians and clients within the profession of communication disorders consists of either anecdotal, descriptive single-case studies or studies of a randomly selected series of cases (Roberts, 1998; Roseberry-McKibbin, 2002; Wyatt, 2002). The few studies that have addressed individuals with disabilities or the communication and cultural differences between clinicians and clients have mainly focused on children (Roseberry-McKibbin 2002). Some of the cross-cultural investigations of normal developing children include understanding mother-child interactions in Canadian and Italian families (Girolametto, Bonifacio, Visini, Weitzman, Zocconi & Steig, 2002), mother-child interactions in Chinese and Canadian families (Johnston & Wong, 2004), and mother-child interactions in Indo-Canadian and Euro-Canadian families (Simmons & Johnston, in press). Distinct differences in beliefs and practices about talking to children were identified in these studies, and the findings have implications for SLPs working with LCD children who have communication disorders. For example, Simmons and Johnston (2007) in their survey study identified differences between Indo-Canadian mothers and Euro-Canadian mothers regarding talking to children. Results showed that there were clear cross-cultural differences between the two groups regarding perceptions of language learning—-Indo-Canadian mothers preferred direct, explicit, and adult-centered methods of language teaching rather than child-centered, indirect methods of language facilitation. In addition, twice as many Indo-Canadian mothers indicated that it was very important for their children to know about family and family relationships. The investigators concluded that SLPs need to adapt their practice by modifying current methods and incorporating Indo-Canadian norms such as including story telling instead of reading a book, and involving extended family in sessions. Other communication disorder professionals have put together videotapes as resource materials for understanding LCD clientele. Examples include: "Understanding cultural diversity: The perspectives of minority professionals" (Brislin, Stauss, Molina-Willhock, Loretto & Cullen 1994), "The challenge of providing health care to American Indians" (Brislin et al., 1994)," "Understanding cultural diversity: Providing health care to Hispanic immigrant children," (Perez, 1998), and "Understanding cultural diversity: The importance of culture in building therapeutic relationships" (Beardsley, 1999). These videotapes were developed with the assumption that watching the tapes could potentially increase the awareness of clinicians about cultural differences and thereby assist them in providing culturally appropriate services to LCD clients. Some researchers and professionals suggest using certain strategies in LCD interactions including the use of simple language (Holland & Penn, 1995), allowing patients to express themselves fully, and providing specific instructions as well as explanations about assessment and treatment procedures (Cheng, 1994; Pauwells, 1995; Roseberry McKibbin, 2002; Wyatt, 39 and treatment procedures (Cheng, 1994; Pauwells, 1995; Roseberry McKibbin, 2002; Wyatt, 2002; Battle, 2002). Other clinical researchers have recommended methods such as making sure the client understands what is being done to meet his/her needs (Bolton, 2002; Robinson, 2002), understanding and accommodating to the client's beliefs and practices, and having an understanding of one's own perceptions, values and beliefs and how these affect the interaction process (Battle, 2002; Cheng, 1994; Roseberry Mckibbin, 2002; Johnston & Wong, 2002; Wyatt, 2002). Wallace (1997) put together a comprehensive guide for clinicians entitled "Multicultural neurogenics: A clinical resource for speech-language pathologists providing services to neurologically-impaired adults from culturally and linguistically diverse backgrounds." The author provides information about the types of disorders, the assessment tools available for LCD adult clients, and the management of different LCD groups. In addition, the author compiled many single case studies that illustrate how to manage clients from different cultural groups, including African-American, Caribbean-American, and native Hawaiian. Although this book provides extensive information on managing diverse clientele, there is a lack of systematic empirical evidence for many of the recommendations in these reports. Wallace (1997) indicates the need for further investigations and exploration of issues facing SLPs and their adult LCD clients with communication disorders. The cross-cultural literature in communication sciences and disorders indicates an awareness in the field of the influence that culture has in shaping the beliefs and practices of LCD clients. However, despite preliminary efforts by researchers, there is still a lack of empirical work on the clinical management of Clients from specific cultural groups. One likely reason for the paucity of research is the difficulties in planning and implementing cross-cultural 40 investigations. Nevertheless, in order for clinicians to be better informed and positioned to adapt their clinical management to specific cultural groups, further research is warranted. 2.3.5 Summary of cultural issues In this section, I reviewed the relationship of language to culture, and the importance of taking into consideration the cultural backgrounds of clients during clinical interactions. I discussed some of the cross-cultural literature in health care that has identified differences in perspectives on illness, differences in communication styles between clinicians and their clients, the importance of establishing rapport, and age preferences. Then I reviewed the educational and clinical research conducted in the field of communication sciences and disorders. The findings from this literature suggest that clinicians' lack of knowledge about cross-cultural differences between them and their clients can cause challenges when assessing and treating clients. However, more empirical investigation is required since much of what we know is based on clinical anecdotes. Because clinical interactions in many practice contexts are becoming more linguistically and culturally diverse, additional knowledge about cross-cultural differences will serve to educate and sensitize clinicians about factors that may facilitate or hinder clinical interactions involving specific cultural groups. This is especially true in the case of adult LCD clients with aphasic communication disorders. Thus, the present study explores how linguistic and/or cultural issues influence interactions between SLPs and Indo-Canadian aphasic clients. 2.4 Assessment issues While linguistic and cultural issues arise for many health care professionals when interacting with LCD clientele, SLPs face specific challenges associated with assessment and intervention for these clients because their work focuses on communication. There is a dearth of 41 standardized tests and intervention strategies suitable for the LCD population (Goldstein, 2000; Huer & Saenz, 2003; Paradis, 2002; Roberts, 2001; Roseberry-McKibbin, 1994; Wyatt, 2002). The scarcity of these tools makes evaluations of language problematic. Failure on the part of the SLPs to understand what the LCD client's communication challenges are can lead to misdiagnosis (Vasquez and Clavijo, 1995) and/or difficulties in providing effective interventions. In this section, I first discuss some of the challenges encountered when using English standardized assessment tools with LCD clients. Then I review some of the methods used by SLP researchers to develop assessment tools for LCD clients. Following this I distill the findings from the limited research on SLP assessment procedures with LCD adult clients. One of the major problems with most standardized assessment tools is that they have been developed for Euro-Canadian native English-speaking clients (Bates, Devescovi & Wulfeck, 2001; de Bot & Makoni, 2005; Restrepo & Silverman, 2001; Roseberry-McKibbin, 2002). The test items are often biased in that they do not include items that are linguistically and culturally appropriate for many LCD clients (Battle, 2002; Cheng, 1989; Laing & Kamhi, 2003; Molrine & Pierce, 2002; Quails & Munoz, 2005; Roberts 2001). For example, clients from the Indo-Canadian culture may not be able to name the picture stimulus of the beach-front house in the Western Aphasic Battery test because it is unfamiliar to them. In addition, the assessment tools that have been developed in the languages of LCD clientele require professionals who have adequate proficiency in the client's languages(s) (Deal-Williams, 2002). The challenge of interacting with LCD clients is further complicated because SLPs need to have the time to determine the client's proficiency level in their language(s) in order to provide appropriate SLP services. Although best practice guidelines that require the use of unbiased assessment and intervention procedures with LCD clients have been proposed by the American Speech and 42 Hearing Association (2004) and the Canadian Association of Speech Language Pathology and Audiology position paper (2002), providing services to such clients is challenging because of the scarcity of clinicians who speak the languages of LCD clients. Despite the challenges associated with assessing LCD clients, attempts have been made by some SLP researchers to develop assessment tools for them. Some of these are standardized tests developed in specific languages (Garcia & Desrochers, 1997, Paradis 1987), whereas others are non-standardized assessment procedures (Leonard & Weiss, 1983). Other methods are multicultural assessment and intervention strategies such as language sampling (Cheng, 1989; Goldstein, 2000; Roseberry-McKibbin, 2002; Wyatt, 2002), which is a performance-based assessment procedure wherein a language sample is obtained in a specific context; dynamic assessment procedures (Gutierrez-Clellen & Pena, 2001), which involve an interactive approach where a pretest, intervention, and posttest are conducted to identify the ability of the client to learn and respond to intervention; and pragmatic approaches (Penn, 1993), such as assessing functional communication in a variety of real life situations (e.g., ordering a pizza, conversation at a dinner table). Pierce and O' Malley (1992) developed performance and portfolio assessment measures for LCD clients. Such assessment procedures are similar to dynamic assessments in that the client is assessed on her/his ability to learn. Makoni, Lin and Schrauf (2005) used story telling and narratives as a diagnostic tool to assess older ESL clients. Ulatowska, Olness, Wertz, Samson, Keebler and Coins (2003) investigated performance on a standardized aphasia test and an analysis of discourse in older African-American clients. They reported that the functional discourse measures captured grammatical features in the client's communication that could not be captured by the standardized tests. The authors concluded that including functional discourse measures in addition to standardized assessments contributes to better diagnostic outcomes for 43 clients. The implications of Ulatowska et al.'s findings are that English standardized assessment tools cannot be considered valid tools to assess LCD clients' language and communication abilities. In addition, many of these standardized tests do not include a normative LCD population during their construction, which makes their use with LCD clients problematic. With most of the attention on assessment of the LCD population being focused on children, there is very little information on how to assess LCD adults with communication disorders, particularly aphasia (Holland, 1995; Paradis, 2002; Roberts 2001). Some efforts in developing LCD aphasia assessment procedures include translating and modifying English standardized assessment tools. Paradis (1987) developed the Bilingual Aphasia Test for French-English speaking bilinguals (BAT). Since the time of its original inception, additional versions of the BAT have been developed in more than 60 languages. Despite this, the BAT is not used as widely as it could be due to its length and cost (i.e., it takes a long time to administer, and clinical settings need to have a copy of it in each language seen in the clinic). The Western Aphasia Battery (WAB-Kertez, 1982), another standardized assessment tool commonly used by SLPs, was originally developed in English and then translated into a few other languages, including Japanese (Sugishita, 1986), Korean (Kim and Na, 2004), and Hebrew (Soroker, 1997). Pachalska (2003) adapted the WAB and the Boston Diagnostic Aphasic Examination into Polish. However, she reports technical difficulties with translating and using standardized test materials in Polish due to differences in the language structure of Polish and English. According to her, Polish does not have the same canonical word order as in English, and individuals speaking Polish relied on noun and verb endings to complete a sentence. In addition, translated materials made it difficult to judge the degree of agrammatism in aphasic clients. 44 An investigation mentioned earlier confirms some of the problems with English standardized tests used with LCD clients (Ulatowska et al., 2001). The WAB was administered to African-Americans who were neurologically normal or who had mild to moderate aphasia. Two out of thirty six neurologically normal participants performed slightly below the cutoff score for aphasia (i.e., below 93.8), and eight out of thirty six participants with aphasia performed above the cutoff score. Of the 8 participants with aphasia who exceeded the 93.8 normal cutoff score for the WAB AQ, 3 were classified with anomic aphasia, 2 were unclassifiable, and 3 exceeded the classification criteria and were classified as not aphasic on other assessment tools such as the Boston Diagnostic Aphasic Examination (Goodglass & Caplan, 1983) and the Functional Assessment of Communication Skills for Adults (Frattali, Thompson, Holland, Wohl & Ferketic, 1995). According to Ulatowska, Wertz, Chapman, Hill, Thompson, Keebler, Olness, Parsons, Miller and Auther (2001), these findings bring the normal AQ cutoff score of 93.8 (provided by Kertesz (1979) for determining normal performance on the WAB), into question. In addition, they also state that the sensitivity of the WAB in differentiating, as well as identifying types of aphasia, is not entirely accurate across language and cultural groups. Thus, although the WAB may be able to differentiate between some groups of people who do and do not have aphasia, determining whether a specific African-American person does or does not have aphasia based on his or her WAB AQ or CQ score may be problematic. Molrine and Pierce (2002) also investigated group differences between non-brain damaged Euro-Canadian and African-American adults on three tests of aphasia-—the Boston Diagnostic Aphasia Examination (BDAE - Goodglass & Kaplan, 1983), the Minnesota Test for Differential Diagnosis of Aphasia (MTDDA - Schuell, 1965), and the WAB (Kertesz, 1982). 45 Tasks included sentence completion, repetition, oral reading, confrontation naming, and paragraph retelling. Although the results of their study showed no statistically significant differences between Euro-Canadian and African-American adults on the structured tasks of the above tests, there were statistically significant differences on the less structured tasks such as paragraph retelling, in which discourse ability on a specific topic was required. According to Molrine and Pierce, narrative recounts of African-American adults did not contain the necessary quantitative and qualitative detail across the paragraph subtopics, and this resulted in poorer scores. The authors explain that the differences between groups were due to African-American English discourse style differences rather than grammatical or phonological differences between dialects. The studies reviewed show that methods used to assess and evaluate LCD clients need to be culturally appropriate. Relying entirely on standardized measures developed for mainstream English speaking clients can lead to erroneous judgments and diagnosis. Methods of analyzing discourse styles can help identify linguistic problems as well as provide information on socio-cultural influences on performance. This information can be used by SLPs in identifying the various styles of discourse in LCD client populations and tailoring their communication approaches to meet the client's needs for assessment and treatment. Although standardized assessment tools have been developed in a number of languages, there is a lack of SLPs in many clinical contexts who know a particular language and can administer the assessments in that language to LCD clients. ASHA (2004) developed a database for bilingual and multilingual clinicians to register in so that assistance could be obtained for specific LCD clients. However, despite these efforts, the database for clinicians shows only 3% of the SLPs in the USA report being bilingual. Similarly, Kritikos' (2003) national survey study 46 on SLPs in the United States indicated that 85% of them lacked competency to assess a client whose language they did not speak. Thus, the need for clinicians who speak the languages of LCD clients is as great as the need for appropriate assessments in the languages of LCD clients. Beyond the development of assessment tools, some SLP researchers have suggested strategies to improve clinical interactions with LCD clients. For example, Paradis (2002) and Roberts (2001) reported that, when available, clinicians use the services of other clinicians who speak the same language(s) of the client and belong to the same culture. Others have advocated for training interpreters (ASHA position paper, 1998; Langdon & Cheng, 2002; Roberts, 2001; Roseberry-McKibbin, 1995; Young & Westernhoff, 1999) and/or family members to assist with providing services to the client (Holland & Penn, 1995). Overton, Fielding, and Simonsson (2004) and Paradis (2002) recommend assessing both languages of the client with the help of interpreters. ASHA (2004) suggests assessing strengths and weaknesses in the client's first language and second language by a collaborative team that includes the family, interpreter and other professionals. These anecdotal reports and recommendations need to be substantiated by empirical research. Unless steps are taken to develop standardized tools and/or provide effective alternative assessment procedures for LCD clients, clinicians will continue to encounter problems due to a lack of understanding about clients' communication abilities, confusion regarding a language disorder or a second language difference, and inaccurate diagnosis. Moreover, an accurate understanding and diagnosis of the clients' communication challenges is required to provide effective intervention. The challenges with assessment tools for LCD clients and the limited research conducted on developing appropriate assessment tools suggest a need to develop alternative methods of 47 assessments for LCD populations. One such method would be to explore how SLPs conduct assessments when there are no assessment tools available in the client's language(s). My study may identify such assessment methods, which could potentially assist clinicians in conducting assessments with LCD clients who have communication disorders. 2.5 Intervention issues Challenges with LCD clients extend beyond assessment and evaluation problems. Some of the clinical reports on barriers to appropriate intervention attribute these to the lack of knowledge and awareness of the clinician regarding how to manage LCD clients (Battle, 2002; Cheng 1989; Goldstein, 2000; Holland, 1995; Roseberry-McKibbin, 2002), clients' lack of knowledge about the disability/disorder (Morgenstern, Steffen-Batey, Smith & Moye, 2001; Manton, Patrick, & Johnson, 1994), clients' lack of access to services (Harris, 1999), and clients' beliefs about alternative medicines or remedies (Saenz, Huer, Doan, Heise & Fulford, 2001; Harris, 1999). In this section, I review literature that addresses the barriers to providing intervention to adult LCD clients. Then I discuss some treatment strategies used to manage LCD clients. The limited research on understanding the barriers in providing SLP services to LCD clients is particularly evident when it comes to issues around intervention. Morgenstern et al. (2001) in their survey study reported some of the barriers to providing general medical treatment to Mexican-American stroke clients. Survey responses from Hispanic and non-Hispanic American clients were analyzed to identify barriers to acute stroke therapy and stroke prevention. Results indicated statistically significant differences between groups. Hispanic-American clients less commonly recognized that acute stroke therapy existed, were less likely to acknowledge a time frame necessary for acute stroke treatment, and were more reticent to call emergency 48 services. Results also showed that non-Hispanic American clients expressed less confidence in their ability to prevent stroke, more distrust in the medical establishment, and more concern that money impedes their access to medical care. Thus, the clients' beliefs and lack of understanding regarding stroke issues led to barriers in their accessing appropriate treatment. The findings of this study indicate the need for clinicians to be aware of LCD clients' understanding of stroke treatment, prevention, access to services and management. In a review of SLP services used by older African-American adults, Harris (1999) reported that SLP services are under-utilized by this ethnocultural group. She discussed the importance of clinicians understanding the problems related to accessibility and affordability of health services for this group. She also recommended investigating the acceptability of methods of practice for LCD clients, noting that acceptability is "implicitly experienced, filtered through the prism of culturally determined cognitions about health and assistance" (p. 25). Since seeking help for health-related problems is influenced by socio-cultural experiences, understanding acceptability of services as a potential barrier for particular LCD groups is important. For example, clients and their family members may not want to seek speech-language therapy services because of their cultural beliefs that such services will put the client through greater stress beyond that due to his/her current health challenges. In addition to barriers to seeking intervention, there is a need for clinicians to be aware of the LCD populations' preferences regarding different types of intervention. For example, Saenz et al. (2001) provides SLPs with a review of the Vietnamese culture including information on Vietnamese history, attitudes towards disabilities, family structure, and medical traditions. Some of the treatments the Vietnamese clients used included plants and animals for medication. Other traditional remedies included spiritual intervention for perceived harmful spirits. Since there is 49 very little information about the Vietnamese community with regard to communication disorders, the authors suggest that SLPs be knowledgeable about the above beliefs and practices when discussing alternative treatments with Vietnamese-American clients. Apart from gaining knowledge about LCD clients' socio-cultural differences, SLPs also can make use of specific tools such as the augmentative and alternative communication (AAC) devices with these clients during intervention. The use of AACs are of particular assistance when spoken language is a barrier to communication. AAC depends on ways other than speech to enable communication by and with individuals who, are severely physically and/or communicatively challenged. Some of the techniques and materials used in AAC make use of specialized gestures, sign language, Morse code, communication aids such as charts, bracelets and language boards, pictures, drawing special symbols, electronic devices or any combination of the above (Beukelman & Mirenda, 1998). Although AAC has received considerable attention in the past few years, there has been a lack of empirical research on AAC with LCD clients (Bridges* 2004), and thus, limited understanding of the effects of AAC in a LCD clinical context. The potential for clinicians and LCD clients to benefit from using AAC technology when interacting during SLP intervention suggests such research would be worthwhile. Huer (2000) conducted a study to examine the cross-cultural perceptions of three aided graphic symbol sets used in augmentative and alternative communication (Blissymbols, DynaSyms, and Picture Communication Symbols) across four groups of normal adult participants from four different cultures: Chinese, European American, African-American and Mexican. Graphic symbols with translated referents (in English, Mexican Spanish, and Mandarin Chinese) from a 41-item lexicon were rated on a 7-point scale of iconicity (the correspondence between form and meaning as some symbols are more concrete, while others are more abstract). 50 Results suggested that individuals from different cultural/ethnic groups perceived graphic symbols differently. For example, differences in the mean translucency (the clarity) ratings for the three graphic symbol sets were identified for the four culture groups. Huer's findings suggest that graphic symbols used in AAC devices be developed with specific cultural groups in mind, and that the use of AAC symbols that were designed for mainstream English speaking clients with LCD clients could result in lack of recognition, decreased translucency, and/or less effective intervention outcomes for LCD clients.. 2.6 Chapter summary The lack of a common language and/or culture between the clinician and the client can create many challenges during clinical interactions. As indicated in this chapter, some of the challenges are identifying the extent of the client's deficit in the various components of language—phonology, morphology, semantics, syntax, discourse and pragmatics. Given the close relationship between language and culture, the lack of an understanding of the clients' views on the disorder and their practices regarding seeking SLP services can also impact clinical management of clients. The lack of a common language and/or culture between clinicians and clients contributes to limited assessment and treatment options for adult LCD clients. Despite an increasing demand for appropriate assessment and treatment procedures to improve diagnostic accuracy and treatment outcomes, using existing procedures, developing new tools, or adapting current methods of intervention are still a challenge due to the lack of research, the scarcity of bilingual/bicultural clients, and increasing diversity in many parts of the world. Unless steps are taken to address these gaps and needs, there will be under-utilization of services and lack of effective services provided to LCD clientele. 51 The present study attempts to understand some of the linguistic and cultural issues that affect clinical interactions involving one particular group of aphasic LCD adult clients, Indo-Canadians. My study will do this by obtaining perspectives of the individuals involved in the interactions—clinicians, clients, family members, and interpreters. Their perspectives will help to understand different person's perspectives on linguistic and/or cultural barriers as well the strategies they use during clinical interactions. In so doing, this knowledge should be useful in clinical decision-making, improving diagnosis and treatment plans, and facilitating more satisfying communication between clinicians and Indo-Canadian clients. 52 CHAPTER THREE: THEORETICAL FRAMEWORK 3.1 Introduction This chapter describes the theoretical framework for the present study—symbolic interactionism. In this chapter, I provide a brief overview of the intent and history of symbolic interactionism followed by the underlying assumptions of the approach. Then, I describe some of the important concepts of symbolic interactionism such as self, objects, society, and the act. Following a discussion of the important concepts, I describe the application of symbolic interactionism in the present study. I Conclude by discussing some of the limitations of symbolic interactionism for this study. Symbolic interactionism is an appropriate theoretical perspective for this study because it focuses on how individuals interact symbolically with one another and oneself as they develop and negotiate meanings in interpersonal interactions. 3.2 Overview of symbolic interactionism Symbolic interactionism is a theoretical perspective that serves as a lens to explore how individuals understand and come to know the world that they live in. It focuses on how individuals and groups interact to develop meanings about objects, events, and situations in the world. For example, an individual with a stroke develops meanings about living with a stroke by interacting with other individuals who have had a stroke and through interpretation of his/her own perception and understanding of a stroke. According to Blumer (1969), individuals do not merely react to each other's actions, but interpret and attach meaning to actions during interactions. Symbolic interactionists believe that individuals symbolically represent actions that take place between individuals. These actions are given meaning, interpreted, and constantly change over the course of time as individuals interact; they are socially constructed. 53 The term symbolic interactionism was coined by George Herbert Blumer in 1937 (Blumer, 1969, Charon, 1985; Franklin 1982; Lai, 1995). Blumer was inspired by the work of his teacher Herbert Mead, who is said to have laid the foundations for symbolic interactionism. During the late nineteenth century and the early twentieth century, Herbert Mead (1934), a pragmatist from the University of Chicago, described human beings as socially interacting organisms, inseparable from society. At about the same time as Mead was theorizing, sociologist Georg Simmel proposed that individuals were socially and psychologically formed by a composition of various interactions that they have had with other individuals in their life experience (Levine, 1971). According to Simmel, daily interactions or "acts of sociation" (as he described them) between people made up society and the 'self in individuals. For Simmel, society is comprised of organized patterns and forms of social interactions between and among individuals to meet the practical needs of daily life and to satisfy emotional or physical needs. Simmel and Mead argued that the individual and society were inseparable and had to be studied in relation to each other. The pragmatic and sociological traditions from which symbolic interaction draws focused on the co-created meanings in the social environment within which individuals interact, rather than the individual per se. Thus, everyday interactions offer the most fundamental unit to understand social and practical problems. Because social interactions form the most basic characteristic of man, if one wants to understand situations, activities, individuals and their behavior, one has to begin at the level of everyday interactions (Mead, 1934; Levine 1971, on the works of Simmel). Mead expanded on the notion of the 'self by stating that the self is made up of two components—the "I" and "me." The "I" is the response of an organism to other individuals. It is the answer which the individual makes to others when he responds toward them. The "me" is the 54 socially organized responses of an individual. It is the self as conceived or viewed by other individuals. It reflects the laws and the mores and the organized codes and expectations of the community. According to Mead, if the 'self did not have these two components there could not be conscious responsibility, and there would be nothing novel in experience. It is the freedom and flexibility of individual responses to varied experiences, situations, and interactions that makes actions and interactions unique. The "P and the "me" in the self lead one to think, understand, interpret, and act in a social environment. Blumer expanded on Mead's perspective of symbolic interaction by developing it into a systematic sociological approach that depicts the nature of human society. Blumer's thinking has formed the basis for present day understanding of symbolic interactionism (Blumer, 1969; Charon, 1985, 1989). According to Blumer, "symbolic interaction is the peculiar and distinctive character of interaction as it takes place between human beings. The peculiarity consists in the fact that human beings interpret or define each other's actions instead of merely reacting to each other's actions. Their response is not made directly to the actions of one another but instead is based on the meaning which they attach to such actions" (1969, p. 180). Human beings perceive self, have conceptions of self, and communicate with self to act towards self, for the purpose of reflecting, evaluating and/or modifying future actions (Blumer, 1969). The symbolic interactionist perspective focuses on individuals and their ability to think and symbolically create and connect meaning to their actions and interactions. Symbolic interactionism is intended to provide a pragmatic description of social life—how human action, interaction, and communication is achieved through the power of symbol creation (Charon 1985; Fine, 1993; Katovich, 2003; Maines, 1997). Symbolic interactionism as a theoretical perspective illuminates causes for individuals' actions. By unraveling causes, interactionists attempt to better understand 55 how individuals think, solve problems, and take actions, as well as make choices across different situations. In addition to Blumer, some of the major contributors to symbolic interactionism have been Anselm Strauss (1975; 1978), Erving Goffman (1959; 1967), Howard Becker (1986), Manford H. Kuhn (1964; 1967), Norman Denzin (1989), Sheldon Stryker (1980), and Tamotsu Shibutani (1961). Although these individuals consider themselves symbolic interactionists, their contributions differ in their empirical paradigms (e.g., positivist, interpretivist) and/or focus of their investigations (e.g., small group interactions, social structure, and organizations). The present study makes use of Blumer's approach to symbolic interactionism as it provides a framework to explore small group interaction processes within a natural setting. 3.3 Underlying assumptions of symbolic interactionism The underlying assumptions of symbolic interactionism should be viewed through the lens of the goal of this study, which is to explain small group interactions. The assumptions will demonstrate that the symbolic interactionist perspective focuses on small group interactions to capture inter-subjective meanings and experiences of interacting individuals, without institutionalizing or assigning individuals to specific roles in interactions prior to conducting an investigation. Therefore, symbolic interactionism is applicable to potentially problematic interactions, such as ones involving linguistically and/or culturally diverse individuals. Despite the differences regarding the philosophical paradigms and foci of investigations within the symbolic interactionist framework, many interactionists do believe and share the underlying assumptions of the approach. As Maines (2003) suggests, much of the scholarly work in symbolic interactionism has developed based on the underlying assumptions of the approach. 56 Blumer (1969, p. 2) provides a clear and succinct description of the underlying assumptions of the symbolic interaction perspective. These assumptions are: 1. Human beings act towards things based on the meanings that those things have for them 2. The meaning of such things is derived from, or arises out of, social interaction with individuals 3. These meanings are handled and modified through an interpretive process used by the individual in dealing with what he/she encounters The first basic assumption of symbolic interactionism suggests that all individuals attribute meanings to objects, situations, behaviors, and other individuals around them. According to Blumer, these meanings are ascribed based on how individuals define their current (or past) experience with a particular object, behaviour, situation, or another individual. Individuals decide whether they will act towards an object, another individual, or situation and then organize their actions towards it. For example, rehabilitation centres and hospitals can be perceived as institutions with organized patterns of social interactions wherein clients seek care for their physical and emotional needs. Based on interactions with people in the rehabilitation centers and hospitals, clients develop different perceptions of themselves, the people in rehabilitation centers, and how they (clients) fit in it. The second assumption explains how individuals in the real world create meanings. Blumer expands on meaning creation by stating that meaning arises through social interaction. Interactions always involve two or more individuals and their activity. Actions of other individuals are instrumental in the formation of meaning for any given individual. Symbolic interactionism is, therefore, interested in individuals' joint actions in their activity. The focus is 57 on finding out what happens when "people do things together" (Becker, 1986), and how collective creation of meaning gets constructed (Fine, 1993). Hence, according to Blumer, it is not the inherent meaning that is present for any object or thing, or the meaning that arises from the reaction of psychological processes (such as perception) that are responsible for meaning creation. Meaning develops out of a process that individuals go through while interacting. For example, individuals from different cultures have gestures such as shaking hands or bowing to greet other individuals. These gestures will probably not be interpreted in the same way by individuals from different cultures because the meanings of these gestures develop while individuals interact with others in a particular social context. In the second assumption, Blumer (1969) is referring to the development of meaning by means of a shared system of communicating and interacting. Language is an example of a conventional system in which symbols or signs (e.g., words, grammatical forms) are developed, shared and employed by a group of individuals. Individuals arrive at and derive meanings for symbols in language and other semiotic systems through the process of interaction. Ferdinand de Saussure, a Swedish linguist who is also know as the father of modern linguistics, supports Blumer's second assumption insofar as he states that social or cultural influences shape the development of language (Saussure, 1906, reprinted in Oiler, 1989). According to Saussure, the linguistic community is responsible for establishing and maintaining shared meanings. The third assumption explains that the interpretive process is crucial to how meanings arise for individuals during social interaction. Blumer (1969) indicated that individuals do not just react and respond directly while they communicate and interact. Rather, there is an interpretive process that occurs before an individual actually responds to given situations or behaviors. During the process of interpreting, individuals take into account certain relevant 58 aspects of a particular situation, which may be activities of others, anticipated activities of others, past experience, goals, interests, values, or any combination of these. Within the process of interpretation, an individual is also communicating with him/herself. Blumer is referring here to the thoughts of an individual. In other words, thought, based on language, involves interpretation by which individuals come to modify meanings. Different individuals think, interpret, and give different meanings to situations based on their own thought processes. For example, different families of clients with aphasia can have different meanings for aphasia. While some families perceive aphasia to be a communication problem due to a neurological impairment, others perceive and interpret aphasia as the voluntary decision of the client to communicate or not. Blumer's description of the three basic assumptions emphasized the distinct and unique capability of humans to think, use language, and create meaning. Language, thought, and meaning are all used to communicate and interact, but they do so in a complex way. Although Meltzer, Petras, and Reynolds (1975) suggested the process involved in symbolic interaction is the interaction between various minds and their meanings to eventually make up human societies, interactions involve a more complex process. Symbolic interactionism not only focuses on the negotiation between individuals during interactions in order to understand how they develop and modify meanings for particular objects, actions, and situations, it also examines how the individual experiences himself/herself from a particular or generalized standpoint of the social group. 3.4 Concepts associated with symbolic interactionism ' In this section, I examine the major concepts associated with symbolic interactionism, including the self, objects, society, and the act. 59 3.4.1 Self The self is understood through the symbolic interactionist perspective as what one thinks of oneself, how self has been treated and evaluated by other individuals, and how self interacts with and is influenced by others individuals (Lai, 1995). The self can be described as an individual's thought processes, wherein he/she is free to perceive, interpret, and create his/her own meaning for situations or contexts according to his/her experiences with the social world (Mead, 1934). By responding to one's own thought processes, an individual develops an internal evaluation of self, as well as responses to other individuals and objects in the environment. As discussed earlier, the self is constituted by two components—the "T' and the "me" (Mead, 1934). Without the "I," individuals would not be able to think, interpret, and make personal judgments, while without the "me," he or she would lack socially organized responses to others. The self can be seen as an interaction between language, meaning, and thought within an individual. In a way, it is internal talk wherein individuals can think, reason, and make decisions. Fine (1993) further elaborates and explains that meanings are given by individuals through an individual's choices, mediated by the relationships, situations, and culture in which he/she is embedded. For example, individuals from different socio-cultural backgrounds can have different meanings for a stroke. For one, stroke may be perceived as a mental illness to be treated by medication. For another, stroke may be perceived as supernaturally caused, and cured only through prayer and repentance for past sins. An individual's thought process is influenced not only by current situations, contexts, and interacting individuals, but also by an individual's past and future actions (Hall, 1987). In addition, thought and the internal self are not only affected by real experiences but also by imagined experiences that are constructed during the thinking process. For example, many Indo-60 Canadians are strongly influenced by their religious and cultural backgrounds. Many of them believe in the continuation of traditions and rituals such as fasting on Tuesdays and offering prayers to particular gods in order to achieve a happy and healthy life. Such practices may have been carried on from generation to generation. If an individual has failed to carry out such a practice and he/she is afflicted by a stroke, he/she may perceive that the lack of following a particular ritual could have led to the affliction. The meaning created by the self is in a constant flux, gradually undergoing change over time due to individual experience, but all within a larger and relatively stable framework of society (Mead, 1934). The concept of self helps to focus the present exploration of individuals interacting in a clinical context (aphasic clients, speech-language pathology clinicians, family members, and interpreters). For example, clients who are unsatisfied with clinical sessions may respond adversely to further clinical treatment (the "I"), while other clients may react by discontinuing services or seeking help elsewhere (the "me"). 3.4.2 Objects In addition to the interactions with oneself (one's thoughts), individuals have encounters with different things (e.g., objects, people) in their environments (Charon, 1985; Kuhn, 1967). These objects do not have intrinsic meaning (Blumer, 1969), but are given meaning by individuals when they act upon and interact with them (Lai, 1995). Objects exist in the context of social relationships where symbolization occurs (Mead, 1934). That is, individuals assign meaning to different objects they come across in the environment based upon their experience during interactions with those objects. For example, food (an object) has different meanings in different cultures. In some cultures, food is assigned a symbolic function that represents a time for socializing. In many cultures, sharing food can represent an act of showing love. These 61 symbols represent something that is significant, social, and that helps the individual interact with objects (Charon, 1985). The meanings associated with symbols affect an individual's actions towards an object and also include how others act or refer towards the object (Blumer, 1969). Symbolic meaning given to objects is similar to the linguistic sign described by Saussure (1906). According to him, a linguistic sign is made up of a concept (or meaning) and a symbol (or form). While the concept is what is being signified, the symbol is the signifier. Saussure argues the signified-signifier relationship is arbitrary in that in almost all instances there is no logical or inherently motivated relationship between the linguistic signifier and the signified (e.g., the meaning of 'table' takes many different word forms across languages, and [table] is no better a form than [mesa]). Extending this notion of flexibility between the symbol and meaning to culturally derived meanings (versus Saussure's reference to word meanings), one could posit that individuals who do not perceive the assigned symbol of food as an act of love (meaning), and consequently decline an offer of food, would be misinterpreted as acting in hostility towards the individual who offered it out of love. Individuals use symbols in both concrete and abstract ways, usually with a specific intention and purpose to interact and communicate. As mentioned earlier, language is one example of a symbolic or semiotic system, wherein individuals communicate by using words and sentences based on shared rules to represent objects and meanings in their environment. Saussure (1906) mentions that the words and sentences represent just names or signs given to objects, but that it is the symbol and its association with the meaning within a social group that makes language a symbolic or semiotic system. Since an individual is part of a larger group or society, the basis for classifying and interpreting the 'symbols' for the objects arises from within the 62 context of a larger group. Objects are thus products that have been assigned meaning based on an individual's own experience and interpretation (oneself) within the conventions of a larger group. It is through the use of these symbolically meaningful objects that individuals are able to extensively and creatively communicate and socially interact with each other. Blumer (1969) claimed that the objects individuals come across in their environment can be classified into one of three categories: 1) Physical objects. According to Blumer, physical objects are anything physical that an individual comes across and interacts with in his/her environment. Symbolic interactionism can help to explore and understand differences between individuals in the underlying meanings they associate with physical objects. For example, participants in clinical settings often interact with physical objects such as assessment tools. Standardized assessment tools have symbols (with specific meanings), such as the names of picture stimuli that represent different meanings. Clients and speech-language pathologists (SLPs) from different cultural backgrounds may perceive, interpret, and give meaning to the picture stimuli based on their own linguistic and cultural experiences. 2) Social objects. Individuals interact with other individuals who are part of their environment at different points in their lives. These other individuals, according to Blumer, are seen as social objects. For example, friends and family of an aphasic client would be seen as social objects of the client. Individuals interacting with other individuals or social objects are to some extent influenced by them (Charon, 1985). Individuals create meaning based on their interpretations of their interactions with the same individual in the same or different contexts or with different individuals, in the same or different contexts. Similar to the concept of "the self," meanings created in these social interactions with others have the potential to gradually undergo 63 change (Charon, 1985; Hall, 1987). This change is based on interaction with others, and adjustment and modification of meaning based on real and imagined past, present, and future experiences. It is essential to keep in mind that the other individual in the interaction is not merely a recipient, but an individual who is active, having his/her own thoughts, ideas, thinking and reasoning abilities. Symbolic interactionism thus takes into account the created meanings within an interaction which derive from the symbols assigned to those meanings by each individual as influenced by the self as well as the other individual(s). 3) Abstract objects. In addition to physical and social objects, individuals are also capable of constructing their own principles, rules, philosophies, and ideas. These objects are abstract, according to Blumer (1969), because they are intangible and are dependent upon the different experiences of each individual. Abstract objects are influenced by the self, physical, and social objects that individuals encounter in their daily interactions (Blumer, 1969; Lai, 1995). The concept of abstract objects could apply to clinical descriptions of rapport. SLPs and their clients can perceive and give different meanings to rapport. When SLPs interact with clients they may or may not modify their own meanings of 'rapport' based on the clients' and family members' perspectives. 3.4.3 Society Blumer (1969) referred to the activities that individuals do together as "joint actions." The joint actions and interactions that take place between individuals lead to social networks and connections between groups of individuals. According to symbolic interactionists, social networks or connections among groups of individuals develop based on the shared meanings, values, beliefs, and practices that make up "society" (Blumer, 1969; Lai, 1995; Meltzer, Petras & 64 Reynolds, 1975). Meanings are created, developed, and modified collectively in interactions with other individuals in a society. Because the essence of society lies in the ongoing processes of actions and interactions, societal institutions and other large-scale organizations are viewed as arrangements of people who are linked by their respective actions (Blumer, 1969). Hall (1987) described society as a group that seeks to routinize and standardize situations by establishing generally accepted and shared, habitual, taken-for-granted ways of understanding, communicating, cooperating, and doing. Common responses and organized attitudes with reference to property, religion, education, and the relations of family make society possible (Mead, 1934). Since society operates as a group (or a series of groups), and an individual is a part of it, an individual attempts to conform to the group and live a social life by sharing the meanings of other individuals who are part of his/her society (Hall, 1987; Maines, 1997). Society thus can be seen as organized patterns of interactions between individuals, while their beliefs, norms, and practices, commonly referred to as culture, can be described as shared characteristics of a group of individuals (Blumer, 1969). Because the purpose of the present study is to understand the inter-subjective aspects of interactions among individuals from different social networks and cultural groups (having different symbol systems, meanings, and beliefs), symbolic interactionism offers a useful theoretical lens through which the socio-cultural context that shapes the joint actions of individuals can be examined. For example, a clinician could perceive lack of eye contact by a client from a different socio-cultural group as a lack of interest in participating in sessions. However, the lack of eye contact for the client may signify respect towards the clinician. Once the clinician is made aware of the different meanings for eye contact, he/she could re-adjust his/her perspective on eye-contact with clients from different socio-cultural groups. Symbolic 65 interactionism provides direction to identify negotiation among individuals as a process representing how they construct, adjust, modify and change their lines of action for better or worse communication and interaction. 3.4.4 Act 'The act' refers to on-going actions undertaken by individuals in an interaction, and it forms the basic unit for social psychological investigation and is the most fundamental concept of symbolic interactionism (Mead, 1934). Actions taken by individuals during interactions lead to the creation and/or modification of meaning (Blumer, 1969). Meanings are modified through further interpretation of actions between individuals in social interactions. Exploring actions provides some insight about underlying meanings and processes in social interactions (Herman & Reynolds, 1994). Individuals act or take actions according to the symbolic meanings that they give to self, others, objects, and society (Blumer, 1969). In other words, individuals decide to do something or take actions based on the meanings they perceive and assign to a given concept, situation, object or individual. For example, certain cultures perceive males as the breadwinners and heads of families. Such meanings are often accompanied and reinforced by actions of individuals and groups that restrict females' access to these roles. In response, females may individually and collectively take actions to promote a change in socio-cultural norms regarding the meaning of breadwinner. 3.5 Application to the present study The theoretical framework of symbolic interactionism will allow me to explore how participants define clinical interactions when communicating and interacting with others with whom they do or do not share a common language and/or culture, and how they adjust their lines 66 of action in response to others. The theory provides concepts such as self, objects, society, and act that can help me identify and interpret participants' perspectives about clinical interactions. A symbolic interactionist framework encourages me to view participants as active dynamic organisms responsible for the creation and evolution of meaning. The theory sensitizes me to consider participants' actions in terms of how they communicate internally with themselves, externally with other participants and objects, and how they interpret their interactions. By examining how each participant interprets particular objects, actions, interactions, or situations in developing meaning, I will, as Blumer (1969) put it, be able to 'see as they see them.' Symbolic interactionism allows me to consider how the complex aspects of 'the self are manifested in participants and influence the interaction and communication with other participants, and how these influence and are influenced by objects. Meanings that participants develop with respect to other individuals and objects in the clinical interactions will also be influenced by the larger society that serves as their reference group. Symbolic interactionism sensitizes me to the intricate relationships between individuals and the larger society (Charon, 1985). An understanding of individuals and their relation to a larger society is important as it provides information about the context within which meanings were created, influenced, and interpreted, and its affect on social interactions. Considering participants within the same social group coming in contact with members of other social groups will provide opportunities to consider how social factors mediate lines of actions during clinical interactions. Lastly, the methodological position of symbolic interactionism according to Blumer (1969) warrants a qualitative enquiry that can explore natural social settings in order to understand the process of developing and modifying meanings in interactions. In addition, the 67 method used with symbolic interactionism should be able to capture the interpretive process of participants' experiences. In this respect, the grounded theory method fits well with symbolic interactionism, as together they enable the researcher to explore and explain the meanings participants construct during the process of diverse clinical interactions. 3.6 Limitations of symbolic interactionism Despite the strengths of symbolic interactionism and its application in the present study, the approach has some limitations. One limitation stems from differences in whether meaning has been explored from an intrinsic or an extrinsic point of view (Hall, 1990). My study uses Blumer's approach to symbolic interaction by seeking to understand how participants define, change or adjust meanings in micro-level clinical interactions (intrinsic point of view). Although symbolic interaction will help in identifying cultural meanings, these meanings will be derived from a relatively small group of participants and may not be generalizable to other participants from the same cultural background. Since all human beings are influenced by culture and society, which are in turn constructed through social interactions (LaRossa and Reitzes, 1993), the present study provides only an indirect account of how participants' views of their interactions are influenced by culture, society, and social structures (extrinsic point of view). Another limitation is my potential influence as a researcher on participants' views and meanings. Because I share some of the same socio-cultural background of the participants, there may be more potential for such an influence to be present. However, since symbolic interactionism accounts for the co-creation of meanings between individuals, my influence on the participants will be documented and incorporated in the present study. 68 3.7 Chapter summary In this chapter, I have provided an overview of symbolic interactionism as a theoretical framework, described its historical development, and summarized its key assumptions and concepts. I have also discussed its application in the present study. Knowledge of the origin and underlying concepts of the approach provides a lens for conceptualizing and conducting my study. Despite the few limitations of symbolic interaction, the fit between symbolic interaction and the method of grounded theory lends support to selecting it as a framework to investigate small group clinical interactions. Symbolic interaction w i l l sensitize me to meanings given by individuals, and meanings created and modified in interactions. B y making connections with the individual and society, a symbolic interactionist approach w i l l provide an account of the social construction of meaning, including how cultural factors shape those meanings. 69 CHAPTER FOUR: METHOD 4.1 Introduction This chapter is divided into three sections that describe the rationale, the research design, procedures, data collection, and the methods of data analysis for the present study. In the first section, I explain the research design and rationale. Then I briefly describe the fit between the theoretical perspective of symbolic interactionism and the grounded theory method, which were used for this study. Following description of the theoretical perspective and method, I describe ethical considerations, recruitment procedures, participant selection, and the settings. In the second section, I describe the data collection methods of interviewing, field notes, and a reflexive journal. In the third and final section of this chapter, I describe the data analyses procedures, rigor, and the manner in which I report the outcomes. 4.2 Research design and rationale My study utilized a symbolic interactionist theoretical perspective together with the grounded theory method to explore how speech-language pathologists, Indo-Canadian aphasic clients, their families, and interpreters manage clinical interactions when clinician and client do not share a common language and culture. I employed a qualitative research design, using methods such as interviews, in order to obtain detailed and in-depth information on participants' experiences (Creswell, 2003; Dillo & Wolter, 2004). Interviews provide rich data for detailed analyses and emphasize holistic forms in order to produce contextual understandings of the phenomenon under investigation (Mason, 2002). Holistic forms not only allow identification of the actions and processes that participants experience, but also an understanding of the factors that underlie and/or influence these actions and processes. For example, interviews allow for 70 exploring how participants' perspectives are mediated by cross-cultural beliefs and attitudes, and how these influence a process such as decision making in a clinical context. 4.2.1 Theoretical perspective: Symbolic interactionism Symbolic interactionism views all individuals as active participants and creators of meaning while they interact. Research from this perspective focuses on understanding the processes by which participants' meanings are developed. As described in the previous chapter, the major concepts of symbolic interaction are self, objects, society, and the act. Symbolic interactionists believe that meaning is co-constructed between individuals. In other words, meanings are given to one another's actions while interacting with each other. According to Blumer (1969, pp. 4,5), human beings act towards things such as objects, other persons, and themselves based on the meanings that these things have for them. Hence, in order to understand an individual's behavior, one has to understand meanings from that individual's perspective as he/she interacts with others (Steele, 1999). The symbolic interactionist perspective guided my framing of the research questions as well as my development and exploration of specific questions throughout the investigation. During data collection and analysis, symbolic interactionism provided a sensitizing framework for identifying experiences of participants related to the clinical interaction process. Symbolic interactionism also facilitated my identification of the meanings participants gave to different situations and concepts based on their own perspectives and interactions with other individuals and objects. It sensitized me theoretically to actions participants undertook in a clinical context, and how they understood and attributed meaning to these actions. By examining the process of collective-collaborative activity between participants during clinical interactions, symbolic 71 interaction helped me frame the analysis in dynamic terms that interrelated and explained past, present, and future social activities (Hall, 1987). 4.2.2 Symbolic interactionism and grounded theory I chose to combine the theoretical perspective of symbolic interactionism and grounded theory because together they would serve to help me answer my research questions and to guide me in constructing a theoretical explanation for the complex interactions between participants who do not share a common language and/or culture. Symbolic interactionism and grounded theory allowed me to identify factors that influence participants during clinical interactions (e.g., linguistic and cultural factors), and to develop a substantive theory, when theory is not extant for the particular phenomenon under investigation (Creswell, 1994; Denzin & Lincoln, 1994). Grounded theory fits well with symbolic interactionism because it was developed based on a symbolic interactionist perspective (Glaser, 1967). Grounded theory also meets the methodological requirements of symbolic interactionism in that it employs interactive open-ended semi-structured interviews and participant observation for the purpose of discovering meanings and generating a theory of how participants manage their problems in the social world (Benoliel, 1996; Charmaz, 2002). The active, dynamic lens of symbolic interactionism and the exploratory nature of grounded theory guide in exploring the complex social network of interactions and relationships that exist between participants in diverse speech and language clinical interactions. 4.2.3 Grounded theory Grounded theory, developed by Glaser and Strauss, involves developing theory from systematically analyzed data (Glaser, 1967; 1978, 1992; Strauss & Corbin, 1998). Grounded theory is an interpretive qualitative method that enabled me to utilize an inductive approach to 72 analyzing data from interviews with participants and observations of the participants in their natural settings (Charmaz, 2002; Strauss & Corbin, 1998). A substantive theory was developed from the current investigation by an iterative analysis of the data known as "constant comparative analysis" (Glaser & Strauss, 1967). To develop a substantive theory, I undertook sample recruitment, data collection, and analysis simultaneously (Glaser, 2002b). Concurrent data collection and analysis involved analyzing collected data as soon as it was gathered, followed by further data collection and analysis. This iterative process in conjunction with the constant comparative procedures helped identify key issues for participants such as linguistic and cultural barriers and strategies used to overcome them. My use of constant comparative analysis involved a) constantly comparing and analyzing the transcribed interview data, field notes, and the reflexive journal to develop codes and categories; b) writing memos that documented each step of the analysis; and c) conducting theoretical sampling (Glaser & Strauss, 1967). Each of these procedures will be explained in detail in the section on data analyses below. I attended to the requirements of grounded theory by utilizing a variety of data sources including participants' perspectives obtained through interviews, and field notes of observations of participants during the interviews (each of these data collection methods will be explained in detail in the section on data collection). I used the different data sources to generate a theory based on a detailed, contextually-based description of the experiences of participants in linguistically and culturally diverse (LCD) clinical interactions. I chose grounded theory, because I wanted to understand and explain the "underlining processes of what is going help manage participants' main concerns" (Glaser 1998, p.5). Grounded theory procedures helped me organize, interpret, and understand participants' experiences and how they managed the process of interacting in LCD clinical interactions. 73 Substantive theory is intended to be a middle range theory that provides knowledge about a particular context (Glaser & Strauss, 1967). The grounded theory approach assisted me to effectively develop a substantive theory to explain how participants from different linguistic and cultural backgrounds managed their clinical encounters. 4.3 Inclusion and Exclusion Criteria I developed inclusion and exclusion criteria for participation by clinicians, clients, family members, and interpreters. Inclusion criteria: 1. Speech-language pathologists (SLPs) were required to: a) be native speakers of English with a Euro-Canadian background; b) have a minimum of two years of professional experience in clinical practice; c) if bilingual, have a dominant language of English and a second language that was not the same as that of the LCD client's native language 2. Clients were required to: a) be an Indo-Canadian adult diagnosed with aphasia by a SLP; b) have a severity of aphasia ranging from mild to moderate; c) have either Anomic aphasia or Broca's aphasia; d) be greater than two weeks and less than six years post-onset of stroke; e) be a native speaker of an Indian language with second language skills in English ranging from minimal ability to bilingual proficiency 3. Family members were required to be adult family members who were: a) either a spouse, adult child/grandchild or a parent of the client with aphasia; b) actively involved in the rehabilitation process of the client; c) native speakers of an Indian language with second language skills in English ranging from minimal ability to bilingual proficiency 74 4. Interpreters were required to: a) be actively involved in interpreting in both directions (i.e., for the speech-language pathologist and for the client and/or family) during clinical interactions; b) have bilingual proficiency in an Indian language and English; c) have a minimum of three years professional experience interpreting for speech-language pathologists Exclusion criteria: 1. Speech-language pathologists (SLPs) who were from the Indo-Canadian cultural background; or who were fluent in an Indian language 2. Clients who were unable to communicate due to memory deficits, or due to severe non-fluent or fluent aphasia 3. Family members who were children less than 18 years of age, or adults with cognitive deficits (e.g., dementia, traumatic brain injury) 4. Interpreters with no recent experience interpreting for speech-language pathologists I based participant selection on purposeful sampling and theoretical sampling (I explain theoretical sampling in detail in the data analyses section below). I began with purposeful sampling because it was not possible to undertake theoretical selection before some of the theoretical underpinnings were developed. Purposeful sampling involves a "calculated decision to sample a specific location or a type of interviewee according to a preconceived but reasonable initial set of dimensions (such as time, space, identity) that are worked out in advance of a study" (Strauss, 1987). Participant selection was also dependent upon participants' ability to communicate and willingness to participate (Morse & Field, 1995). Following concurrent data collection and analysis and the development of preliminary categories, I undertook theoretical sampling of incidents and participants until theoretical saturation was achieved. Theoretical sampling is a procedure which involves collecting data that 75 saturation was achieved. Theoretical sampling is a procedure which involves collecting data that will serve to theoretically develop categories, their properties, and relationships by looking for incidents or events in further interviews, which in turn will help build the theory (Glaser & Strauss, 1967). Theoretical saturation, on the other hand, involves arriving at a point where the data collected does not provide further information to develop the categories and properties that have been constructed for the development of the theory (further description of these terms and given below) (Glaser, 1998). In this study, I achieved theoretical saturation with 27 participants. Because of logistic difficulties, I was not able to interview and observe clusters of clients, clinicians, and interpreters who were all working together. I relied on reports from these groups functioning in their respective contexts. 4.4 Ethical considerations Prior to data collection, ethics approval was obtained from the Behavioral Research Ethics Board, University of British Columbia (Appendix A). Following this approval, ethics approval was obtained from the Vancouver Coastal Health and Fraser Health authorities to conduct the study (Appendices B & C). Written informed consent was obtained from all participants prior to conducting the interviews (Appendices D through G). Time was provided for the participants to read the consent form and ask questions prior to giving consent. A brief verbal description of the study was provided to all participants before beginning the interview. An interpreter was used for all interviews involving participants who had limited English skills. The interpreter verbally translated a brief description of the study as well as the information in the consent form into the client's native language. The interpreter and I informed participants that they were free to withdraw from the study or interview session at any time. If participants were uncomfortable 76 with any part of the recorded interview, they were free to request that I delete that information. They were also informed that their participation in this study was entirely voluntary. All participants were assured about confidentiality. Participants were informed that the study findings would be discussed as aggregate findings and would not be specifically attributed to any identifiable participant. All completed interview data were identified by an assigned number only. Pseudonyms were used in transcripts. Any information which could be used to identify the participants was altered. The data transcripts and tapes were stored in a locked filing cabinet. The computer used to store the transcripts was accessible only to me through the use of a password. The nature of the study posed a potential risk of participants becoming emotionally distressed when talking about their unpleasant experiences with speech and language deficits. My personal experience as a clinician assisted me in dealing with situations where I found it necessary to stop the interview and provide support to the participant. Participants were informed that they could discontinue the interview if they did not wish to share information that was emotionally disturbing to them. 4.5 Recruitment Procedures Speech-language pathologists, Indo-Canadian adult aphasic bilingual/ESL clients, family members, and interpreters were recruited with the help of coordinators of the Vancouver Coastal Health and Fraser Health speech-language pathology departments. In addition, coordinators of stroke clubs (a place where individuals and their family members with stroke can socialize and obtain rehabilitation services) and Indo-Canadian organizations assisted me with recruiting clients and family members. 77 In both the cases of the health authorities and client organizations, initial letters of contact with a brief description of the study were sent to coordinators (Appendix H through K). Separate meetings were held with coordinators to describe the purpose of the study and help identify potential participants. Coordinators made decisions to identify potential participants and to provide them with the initial letters of contact. Interested participants contacted me by telephone or by e-mail to set up a time for an interview. 4.6 Settings I collected data at sites that participants indicated were convenient. Twelve participants were interviewed at their homes and fifteen were interviewed at a hospital or a rehabilitation centre located in the Greater Vancouver Regional District. When using the grounded theory method, the investigation seeks variability in collected and analyzed data to allow for maximal scope of the substantive theory developed (Glaser & Strauss, 1967) and to approximate the reality of the investigated process. The participants I recruited were heterogeneous in that they spoke different languages, came from predominantly two different cultures, and included clinicians, clients, family members, and interpreters, all of which allowed me to capture diverse perspectives on the phenomenon being investigated. 4.7 Data collection tools The primary method of data collection was interactive in-depth individual interviews. Observations of clinical sessions and field notes served as secondary data sources that assisted in informing and contextualizing the analysis of the interview data. I also used a reflexive journal and a post-interview summary form. The different data sources enabled me to capture the complexity of the dynamic processes that participants experienced during clinical interactions. 78 4.7.1 In-depth individual interviews I conducted a total of 27 in-depth interviews with participants: 11 interviews with speech-language pathologists, 5 interviews with clients, 6 interviews with family members, and 5 interviews with interpreters. Despite the disparate nature of these participant groups, the data gathered were combined and analyzed together to develop a substantive theory that explains perspectives of different participants in managing clinical interactions. No second interviews were conducted with any of the participants as data saturation was achieved with the 27 participants. All interviews were audio-taped. Twenty-four interviews were conducted in English with the speech-language pathologist, the aphasic client, the family member, and the interpreter. Three interviews (i.e., one aphasic client and two family members) were conducted in Punjabi with the help of an interpreter who was fluent in English and Punjabi. Interpreted interviews took longer to conduct because of the need for clarification between the interpreter and the researcher regarding words or questions. All interviews were transcribed verbatim by the researcher for further analysis. Interview duration ranged from a minimum of forty-five minutes to a maximum of two hours. Each interview began with an open-ended question. Symbolic interactionism sensitized me in developing the questions so that the interviews would elicit meanings participants assigned to their clinical, experiences. I used a semi-structured guide during the interview process (Appendix L). Initial interview questions were used to access how each participant perceived and interpreted the LCD clinical interaction process (Spradley, 1979). For example, a speech pathologist was asked, "Can you share some of your experiences with me about your clinical interactions with your Indo-Canadian aphasic clients?" The initial question guide was modified based on the categories that were identified during constant comparative analysis. For example, 79 the development of the category 'family involvement' led to asking questions such as "Could you describe to me how family members are involved in the clinical interactions?" The interview questions were also modified in response to participants' foci and experiences related to the clinical interactions. This process enabled me to ask more specific questions on issues that my participants indicated to be relevant. For example, earlier interviews indicated that clinicians talked about how the linguistic competencies of their clients affected the assessment and treatment process. Later interviews included questions such as "Do you think the client's linguistic competencies affected the interaction? If so, how?" 4.7.2 Observations Observations were conducted on three clinical interactions with individuals and two group therapy sessions. Symbolic interactionism assisted me in looking at a variety of ways participants undertook complex actions during individual clinical sessions and group sessions. Individual clinical interactions involved therapy sessions between an SLP and an Indo-Canadian client. Group sessions involved therapy sessions between 1 or 2 SLPs and aphasic clients from diverse linguistic and cultural backgrounds. Group sessions involved approximately 8-12 clients. I undertook a total of 10 hours of observation of clinical interactions. Before, during, and after the clinical interactions, I took notes that described the communication between clinician(s) and client(s). These notes included my observations about clinicians' and clients' eye contact, position and seating, greetings, and the process of initiating and terminating the sessions (Emerson, Fretz & Shaw, 1995). The symbolic interactionist approach likely influenced my notes on observations due to my interpretation of the observed behaviour or event based on my past and current experiences with it. 80 4.7.3 Field notes Field notes were written during and after each interview to capture the nuances of the interactions that cannot be readily captured on audio-taped recordings (Agar, 1996). For example, nonverbal communication such as gestures, facial expressions, tone of voice, and mood were described. Field notes allowed for a detailed description of the interview scene such as the physical layout, the seating of participants, and the placement of the tape-recorder and microphone (Emerson, Fretz & Shaw, 1995). Field notes also provided information on other factors that may have enhanced or interfered with the interview, and this information helped me to recall the context of the interview more vividly. 4.7.4 Reflexive journal I used a reflexive journal to account for my thoughts, ideas, emotional experiences, and interpretation of the field work. The symbolic interactionist framework helped me in identifying my interpretations and responses to actions of participants and reporting them in the reflexive journal. The reflexive journal emphasized my reactions to situations during field work and analysis. This reflexive journal was in part linked to the field notes that were taken down'during and after conducting the interviews, wherein I provided my impressions of the collected data. For example, information in the reflexive journal elaborated on the field notes by integrating my impressions and ideas of a topic being discussed, observation of a participant's behaviour, or influence of my presence on the data collection and analysis. Guided by symbolic interactionism and my appreciation of the construction of the data, the reflexive journal helped me to maintain an account of my influences on participants and participants' influences on me. The reflexive journal helped me account for the inter-subjectivity that influenced interpretation of participants' experiences. A brief example pf what I wrote in the reflexive journal was: On observation of a 81 group session, two SLPs and their clients from different cultural backgrounds are discussing various topics such as World War n, Chinese New Year, and arranged marriages. One of the SLPs' turns toward a younger Indo-Canadian client and asks if she could use his example and discuss with the group about arranged marriage. Client nods his head and says "Yes." Then she begins by saying "So your dad set you up with this girl, right?" The client says "No:" The SLP frowns, looks confused, and says: "But, I thought that was what your fiancee said." Client nods head and says "No, no." He struggles to try and put some words together and says "My...girl...father...(long pause)." The SLP looks at the client and says, "Yes, the girl was set up by your dad and you are fine with it." Client says "Yes.. .no, no." He sits up and stiffens in his chair, closes his eyes and tries to think as if trying to find the correct words to communicate. The struggle goes on for a few minutes between the SLP and the client. AlthoughT was there as a researcher, it was a challenge to keep myself out of the clinical interaction. I could not resist in taking part in this conversation. With the permission of the SLP, I asked the client: "Did your dad show you this girl...who is now your fiancee?" He said "yes, yes." smiled and leaned back in his chair and relaxed. Then he continued: "Father show, yes." This example demonstrated to me how the cultural interpretation of arranged marriage led to miscommunication based on the clinician's word choice (set up instead of show). Had I not intervened, this culturally-based challenge in a diverse clinical interaction might have been missed. My notes from this situation not only made me aware of my presence influencing the data collection and the analysis process, but they also provided evidence that observations of struggles due to linguistic differences during clinical interactions corroborated the data obtained from interviews with participants. 82 4.7.5 Post-interview summary form Following each interview, I completed a form to summarize key information such as issues, themes, challenges, successes, and suggestions to consider for future interviews. The post-interview summary form summarized each participants' responses to my interview questions and only captured my initial impressions of the data gathered from each interview. It served to help me condense the information in transcripts. I used it prior to the coding process. Information from this summary assisted me in managing the data, and modifying the initial question guide. For example, I extracted the following information from participant 14 and classified it under speech and language issues in the post-interview summary form: 'despite good fluency skills in English do not treat them as native English speakers because may be operating in native language at home, and may miss out things in vocabulary.' 4.8 Data analysis The present study used data analysis procedures described by Glaser and Strauss (1967) and Glaser (1978). According to Glaser's approach, data analysis is carried out by using the constant comparative analysis techniques of open coding, selective coding* and theoretical coding. Theoretical sampling and memoing also helped in developing a substantive theory (Glaser, 1998). Below, I first provide an overview of constant comparative analysis, followed by more detailed descriptions of a) coding b) memoing and c) theoretical sampling. 4.8.1 Constant comparative analyses I used constant comparative analytic procedures (Glaser and Strauss, 1967; Glaser, 1978; Strauss & Corbin, 1994), which involve concurrent data collection, data analysis, coding, sorting, and memoing. I used these procedures in an iterative process, which allowed me not only to manage the voluminous data efficiently by constantly comparing and contrasting similarities and 83 differences across collected data, but also to systematically structure and organize the data (Charmaz & Mitchell, 2001). The constant comparative method was particularly important because of the complexity involved in analyzing the multiple perspectives of different groups of participants (e.g., clinicians, clients) from different cultural backgrounds. Constant comparison of data within and between interviews and field notes helped me to manage this complexity as I used codes to develop categories and properties of categories. According to Glaser (1978), comparing incidents eventually leads to the emergence of categories, and comparing categories to incidents helps to develop in-depth properties of categories. Symbolic interaction sensitized me to organize codes and categories from the data according to the meanings participants gave to different actions. Comparison between categories helped integrate the categories to fully conceptualize the investigated process in order to develop the emerging theory. 4.8.2 Coding I began the theory-building process by coding the data. Developing codes or the coding process involves labeling chunks of data to capture what is going on (Stern, 1985). I labeled the codes using names I developed or directly by using the language of the participants. For example, one clinician's statement: "well for linguistic things I dunno whether the morphology is right, the syntax is right, the semantics is right" (participant 19) was coded as 'Lacking competency to assess linguistic skills.' After coding was undertaken, I compared and contrasted the codes, identified similarities and differences across codes, and grouped codes into categories. That process assisted me with identifying the properties for codes and categories. For example, codes such as 'belief in supernatural powers,' 'belief that medical treatment can cure communication difficulties,' and 'keeping the client's diagnosis a secret due to perceptions that the disability or diagnosis is a barrier to socializing and communicating,' were grouped together and classified under the category 'Perceptions of disability, recovery, and care.' Coding and memoing also allowed me to conceptualize categories, develop theoretical connections, and integrate the theory (Glaser, 1992; 1998). Coding undertaken for the present study involved three levels: open coding, selective coding, and theoretical coding. Open coding. Data collected through in-depth interviews and field notes were transcribed and open coded. When I used open coding, or in vivo coding as it is also called, I read the transcripts line-by-line and labelled sections of the data. Either a sentence, a few sentences or a paragraph were given a label to conceptualize the information (Creswell, 1994). For example, 'limited services offered due to lack of resources' was an open code developed from a family member's transcript. The family member was describing her challenges in finding a speech-language therapist in the community that could offer services once a week for her spouse with aphasia. This was the first stage of coding. As interview and field note data were collected, transcribed, and coded, I developed new codes and compared them to codes within the same interview and the previous interviews and field notes. Codes developed during open and selective coding (described in the next section) were called substantive codes (Glaser, 1978), which reflect the substance directly from the data. I took substantive codes that were conceptually similar, repetitive, and occurred under similar incidents and clustered them and condensed them into categories. For example, the substantive codes 'knowledge of speech language pathology,' 'food preferences' and 'assertiveness in clinical settings' were clustered into a category called 'cross-cultural differences between clinicians and clients.' I compared and contrasted codes and categories, sorted them, and resorted them throughout the data analysis process. 85 During the process of open coding, I wrote down memos. Memos involved writing up ideas about substantive codes and their theoretically coded relationships as they emerged during data collection, coding, and analysis, and during memoing itself (Glaser 1998) (further description of memos is given below). The following is an example of coding, sorting, and re-sorting using memos. 'Increased time and effort' was initially grouped under 'language barriers.' Memos written in relation to increased time and effort indicated that the lack of English proficiency skills and the severity of the client's condition complicated matters wherein greater time and effort was required for clinicians to make an accurate diagnosis. However, during the analysis process, another memo related to time and effort indicated that increased time and effort was not only required to obtain an understanding of the client's condition, but also to manage the logistics of the situation when an interpreter and/or family member is involved. After comparing and contrasting the codes, and analyzing the memos written on 'time and effort,' I moved this code under the category 'involvement of family member and/or interpreter.' Such re-sorting of the category was undertaken as 'time and effort' was influenced to a greater extent by the involvement of a third party compared to clinicians trying to get an understanding of the client's condition. Selective coding. Selective coding was carried out by going through memos, field notes, and the already coded data. I started selective coding when I had identified an initial core category and stopped open coding. I identified the core category as the one commonly recurring and dominant category that interwove existing categories and explained relationships among many of the categories I had developed (Glaser, 1998). During selective coding, I purposefully and selectively coded categories that related to the core category. Examples of codes and categories from the present study are provided in this 86 chapter to illustrate the process undertaken to develop the substantive theory. The core category I identified was 'coordinating communicative goals.' It explained how participants managed or resolved the problem of engaging in LCD clinical interactions. The core category emerged when I identified no new codes and properties of codes. Once I identified the core category, codes and categories were modified to relate to the core category. For example, 'resources' was originally developed as a separate category. When I identified the core category, it became clear that 'resources' should be divided into two broader categories, one related to linguistic resources and the other related to cultural resources. For example, the category called 'problem with use of and access to resources' fit better with another category called 'linguistic competency of clinicians and clients.' This was because the language barrier between the clinicians and clients resulted in challenges with the access to and use of assessment tools. Thus, resources as a linguistic barrier negatively affected the process of coordinating communicative goals in clinical interactions. I regarded the core variable 'coordinating communicative goals' as representing the highest abstract level of coding during my analysis. As Strauss and Corbin (1990) stated, the goal is to develop a single storyline around which everything else is connected. Using 'coordinating communicative goals' as the core variable enabled me to develop the story line for this study. As indicated by Glaser (1978), the core category represents a basic social process that helped to describe and explain the variation and the interrelationships between categories by identifying the conditions, contexts, actions, and consequences that led to the development of a theory. The theory developed will thus explain the core variable that captures the processes and conditions derived from the data. Theoretical coding. I engaged in theoretical coding after I identified the core category. It involved reviewing, sorting and re-sorting of memos, categories and their properties as they 87 related to the core variable (Glaser, 1978). Theoretical coding is the highest level of coding and conceptualizes and integrates data to a higher conceptual level for theory development (Glaser, 1998). When I was coding theoretically, I developed hypotheses to identify relationships between the categories by comparing their similarities and differences. Theoretical coding "weave[s] the fractured data back [together] again" (Glaser, 1978, p. 116). According to Glaser (1978; 2004), it involves looking at how the codes developed during substantive coding fit into categories and relate to each other, and how categories can be integrated for the generation of theory. I made use of the eighteen theoretical coding families proposed by Glaser (1978) to assist in the process of theoretical coding (Appendix M). These coding families, as Glaser described, help not only in the general coding process but also in conceptualizing the data to develop the theory. An example of theoretical coding from my study follows. Based on my hypothesis that barriers in clinical interactions lead individuals to use strategies to overcome those barriers, theoretical coding (along with memoing) directed me to develop more abstract theoretical categories, such as "encountering challenges in clinical interactions" and "using strategies to overcome challenges." Each of these theoretical categories explained the relationships between other categories in order to capture the process of how participants managed the problem of interacting in LCD interactions. For example, "linguistic barriers," and "cultural barriers" were two of the conditions identified that led to encountering challenges in clinical interactions. In this way, the hypotheses I developed during theoretical coding assisted me to make connections between categories and develop a theory that explained the investigated phenomena. The formulation of the final theory included the suggestions from the supervisory committee 88 members. The members engaged in one-upping which assisted me to refine and extend the categories and their relationships (Glaser, 1978). 4.8.3 Theoretical sampling Theoretical sampling is a procedure which involves looking for incidents or events during data collection that help to theoretically develop categories, their properties, and relationships (Glaser, 1978). As Glaser and Strauss (1967, p. 45) described, "the researcher decides what data to collect next and where to find them, in order to develop theoretically relevant categories that will help build the theory." I used theoretical sampling during data collection to identify where to locate specific incidents in order to explore relationships and further develop and integrate categories for the purpose of developing the theory. For example, early interviews (and open-Coding) indicated that Indo-Canadian participants (clients, family members, and interpreters) preferred clinicians of the same gender. Based on such a finding, the category 'gender preferences' was developed. Further interviews with participants involved exploring incidents that assisted me in explaining how gender preferences affected the quality of interactions and working towards collaboration. Theoretical sampling also assisted me in determining when to terminate data collection. Data saturation occurred when information obtained from the data collected did not further add to the variability of the categories and their properties (Glaser, 1998). For example, the category 'strategies to overcome linguistic barriers' involved strategies participants used to overcome the challenges with the linguistic competencies of clinicians and clients. Once repetitive and recurrent information on strategies such as using simple language, going slower, and providing clear explanations were obtained from consecutive participants, with none of the subsequent interviews extending my understanding of strategies used to overcome linguistic barriers, I 89 terminated exploration of specific incidents. At this point, data saturation was achieved for this category. The process of theoretical sampling which terminated with data saturation helped to extract themes and, as indicated by Glaser (1998), to develop an understanding of the causal conditions, context, actions/interactions, and consequences of the investigated phenomenon. I undertook theoretical sampling to enable the substantive theory to have greater scope and parsimony by making the categories dense with many properties. Theoretical sampling allowed me to explore a full range of possibilities in developing categories and their properties as these were theoretically relevant to the study. 4.8.4 Memoing I wrote memos throughout the analytic process. Memoing has been described as "writing up of ideas of codes and their relationships as they strike the analyst" (Glaser, 1978, p. 83). Symbolic interaction helped me in developing a theory that was dense by enabling me to explore ideas and concepts, identify relationships between categories, and link categories, all by capturing the actions and processes that participants undertook during clinical interactions. I created memos for this study by writing ideas down by hand, typing notes, and creating diagrams. I maintained detailed written memos and diagrams which illustrated the step-by-step processes involved in developing basic codes and relationships between codes, in sorting of codes for the development of categories, in integrating categories, and in relating these to the core category for the development of a theory. Since I wrote memos throughout the investigation process, my memos were classified as early and late memos. I Wrote early memos to investigate the meaning of a code, to identify its relationship with other developing codes, and to identify if codes could be clustered into specific 90 categories. For example, an early memo that I had written on 'focus on exercise more than speech,' involved asking questions such as "Why is exercise more important than speech?", "Are codes on limited English skills and lack of knowledge on speech-language therapy services related to the code 'focus on exercise more than speech'?" My early memos also involved developing relationships with other codes, for example, "greater knowledge in traditional methods such as massage that helped improve physical health could possibly be a reason for more interest in physical rehabilitation." Glaser (2004, p. 63) notes that "The basic goal of memoing was to develop ideas on categories with complete freedom into a memo fund that is highly sort-able." Writing and comparing memos helped me to elaborate, ask questions and provide answers on why participants said what they said. Memos reflected my thought processes while coding and analyzing the data. Memos also guided me to make decisions and take certain directions during the analysis process by linking categories and exploring relationships among them. Memos written later in the analytical process, and during the formulation of the core category, reflected the complex process of further sorting of codes into categories to develop saturation and to identify the core category. My later memos were more abstract and theoretical in that they related to identifying underlying conditions, mechanisms, processes, and strategies and elaborating the relationships between them. An example of a late memo that I had written on 'Factors that negatively influence clinical interactions' follows: Many factors have been identified that negatively influence clinical interactions. How do participants perceive these factors and how can I classify them? Based on a symbolic interactionist perspective, factors can be classified as internal, external and interpersonal. Internal factors include the meaning individuals give to specific concepts, situations, and 91 experiences in the clinical interaction (e.g., language and cultural differences). External factors include conditions such as involvement of family members that were barriers to interactions. Interpersonal factors are barriers encountered due to the many individuals interacting with each other. Based on this memo I developed a hypothesis that "Linguistic competency of clinicians and clients," "Involvement of family members," and "Building rapport" were different conditions that affected coordinating communicative goals. "Linguistic competency of clinicians and clients" addressed lack of knowledge in the client's language for the clinician and lack of English proficiency skills for the client. "Involvement of family members" included the beliefs and practices as well as the interference of family members in clinical sessions that caused challenges to the interaction. "Challenges in building rapport" included the interpersonal conditions/factors such as trust and collaboration that created challenges in multi-party clinical interactions. All the three categories negatively affected the process of coordinating goals in clinical interactions. Making connections between different memos helped me to develop theoretical codes and generate the theory. Memos provided my written account of how a theory was formulated based on the abstract thinking process of the researcher (Strauss & Corbin, 1990). 4.9 Rigor Qualitative research must be examined in terms of its rigor. To make a qualitative study rigorous, the researcher is obligated to report perspectives of his/her participants as truthfully as possible and make clear the manner in which the study was conducted. In this section, I briefly discuss data triangulation and the specific criteria for rigor for a grounded theory study. 92 4.9.1 Data triangulation Data triangulation was used to support the validity of my qualitative investigation. The different forms of data gathered, specifically the interviews, observations, and field notes, supplemented and/or complemented each other so that they provided a faithful representation of the investigated phenomena (Agar, 1996; Hammersley & Atkinson, 1983; Morse & Field, 1995). An example of converging evidence for a particular perspective comes from an interview and an observation. In an individual interview, a clinician indicated that topics used with clients in group therapy sessions were often not of interest to all clients. Upon observing in a group session, it was evident that a topic such as World-War U was indeed not of interest to the Indo-Canadian clients. Although data were collected from different groups of participants, they were all combined together and analyzed. The resulting variability in the data (from different groups) allowed for maximal scope of the substantive theory developed (as mentioned earlier). On the other hand, between-group variability is accounted for at the conclusion of the findings chapter. 4.9.2 Criteria for rigor in grounded theory Glaser (1978) proposed fit, work, relevance, modifiability, parsimony, and scope for evaluating the rigor of grounded theory research. Hall and Callery (2001) additionally proposed reflexivity and relationality as another form of rigor that should be incorporated in grounded theory studies guided by symbolic interactionism. These criteria account for the data being constructed inter-subjectively and based on the relationship between the researcher and participants. In the following section, I describe each criterion. 93 Fit Glaser (1978) described 'fit' as the ability of the core variable to fit the problem being investigated. I undertook the process of constant comparative analysis of the data and reviewing and sorting categories and memos in relation to the core category to ensure that the core category fit with the problem that the participants were trying to manage. Glaser (1978, 1992) also stated that if the core category can account for maximum variation in the data, then it fits the data. I developed concepts, categories, and their properties from various groups of participants. Using my theoretical sensitivity and theoretical sampling, as well as memos, I accounted for the multiple perspectives and variation in the data. By comparing different incidents, perceptions of participants, and relationships between categories, and by identifying inconsistencies and contradictions of participants'perspectives, I was able to develop the core category, "coordinating communicative goals." The core category thus fit the data because it accounted for the variation of experiences in terms of how participants worked toward collaborative communicative goals. Work Glaser (1978) states that when a core category is able to integrate and explain all other categories and their properties, then it 'works.' The basic social process "coordinating communicative goals" worked as it was able to integrate sub-categories such as "strategies for building rapport," "strategies for managing the impact of involving family members" and "strategies for integrating interpreters" to explain the processes that participants identified. The core category linked those categories in order to explain the process of managing clinical interactions when there is not a common language and culture. 94 Relevance According to Glaser (1978), a core category should be able to connect and relate to many concepts and their properties for it to be relevant. Relevance can be distinguished from fit, which signifies the link between the core category to the participants' management of the problem. Reading of the transcripts, writing field notes, and memos helped in the process of determining relevance and developing the core category from the data. Relevance was also obtained by manually coding all the data, while being careful not to force data into preconceived categories. The core category was relevant to the many actions, processes, and consequences that were identified during the analysis of participants' experiences interacting in linguistically and/or culturally diverse clinical sessions. Modifiability Glaser (1978) stated that the grounded theory being developed must be readily modifiable to accommodate any new variations that emerge from future data. Modifiability can be achieved if the core category fits with the data, and the other categories work together with the core category. For example, in the present study the core category "coordinating communicative goals" fit with the data and worked in linking together other categories such as "challenges in building rapport" and "involving family members" and "involving interpreters." The basic social process "coordinating communicative goals" identified in the present study was developed from the data, and linked together categories that explained the processes that participant used to manage LCD clinical interactions. The theory generated can be modified if any changes occur in the future to the existing encounters of SLPs and their LCD clients . The incidents and categories that develop from further studies would serve to modify the theory (Glaser, 1998). 95 Parsimony and scope Apart from fit, relevance, work, and modifiability, Glaser (1978) stated that by accounting for the most variation in the data with the fewest manageable categories, parsimony and scope can be maximized. Developing few high level abstract categories that can account for the variation in the data adds weight to the claim that the emergent categories are relevant, fit, work, and modifiable. In addition to parsimony, the scope of the variation accounted for will influence the extent to which the emerging theory demonstrates density of categories, saturation, and practical applicability to the issue being researched. For example, in the present study I identified six categories that captured many different actions, properties and consequences that were linked to the core category. Using these six categories, I was able to develop a theory that was grounded in the data. Theoretical saturation (discussed earlier) made it possible for my theory to achieve parsimony and scope. When no new properties of categories were identified and no new relationships between the theoretical concepts from data emerged, the fewest categories that could capture the processes and conditions of managing clinical interactions were identified. Reflexivity and relationality In addition to Glaser's (1978) criteria for rigor, my study incorporated Hall and Callery's (2001) criteria of reflexivity and relationality to enhance the rigor of grounded theory studies. According to Hall and Callery (2001), 'reflexivity' involves examining and providing accounts of one's role, biases, and influences on the participants, and 'relationality' addresses the power and trust relationships between the researcher and participants. Incorporating reflexivity and relationality in my study allowed me to account for the co-creation process involved in data collection and theory development. 96 Reflexivity and relationality allowed me to make my data collection more transparent and provided strategies to account for intersubjectivity (Hall & Callery, 2001). In order to document the views of my participants as clearly as possible, I wrote notes about our interactions. I maintained a reflexive journal to account for my biases, my impressions, and my feelings during the study. For example, an initial note in my reflexive journal states: Due my previous clinical experience working closely with linguistically and culturally diverse clients, I bring certain biases to the proposed study. My perspective is that diverse clinical interactions are often challenging for the clinician. Frequently the clinical encounters are a trial and error method, 'a walking on egg shells approach,' as the clinician is unsure of how to go about with the clinical management of a client when there is no common language and/or culture. The clinical process is one that involves great effort, frustrations, surprises, and strategies in the course of overcoming the challenges encountered during the clinical interaction process. Because of this perspective, the way I view the clinical interactions, understand the perspectives of participants, collect, analyze, and interpret the data may be influenced by my biases. All information in the reflexive journal was linked to my field notes, which described my observations of the participants' behaviour. In addition, my memos captured my comments and interpretations made during data analyses, and therefore, they helped me to reflect about how my biases could potentially shape data collection and analysis and to take steps to minimize their effects. With respect to relationality, I made efforts to address and treat all my participants with respect in the present study. This was particularly relevant to the Indo-Canadian participants who were older than me, in which case I addressed them in specific ways to respect their age. In 9 7 addition, being aware of gender roles within the Indo-Canadian context, I made attempts as a woman to be neutral in my views and not to sensitize participants about gender issues. However, there were circumstances where female participants did talk about their roles and responsibilities and this could have been due to the effect of my gender on the study. I presented myself as a learner and a student, which made participants feel comfortable and relaxed, and appeared to decrease any power imbalances between me as the researcher and my participants. I acknowledged to participants between interviews the importance of their assistance in furthering our understanding of how to improve services for Indo-Canadian clients. I reassured them that the information that they shared with me would remain confidential. 4.10 Chapter summary In this chapter, I discussed the research design and rationale for using the grounded theory method in the present study. I provided information on ethical considerations, inclusion and exclusion criteria for participants, and the recruitment procedures undertaken. I explained the data collection procedures involving in-depth interviews, observations, and field notes. I also explained how I made use of a reflexive journal and a post-interview summary form to assist with the analysis. I then discussed the grounded theory procedure for coding, namely, constant comparative analysis. I discussed each stage of coding and provided examples of how I developed the codes and categories, and sorted and resorted them as part of the process of theory development. I explained theoretical sampling and memoing, which served to develop the theory from the collected data. Finally, I discussed several criteria for maintaining rigor in my study. In the next chapter I discuss the findings from my study. I provide a detailed explanation of the classification of codes and categories, and how these led to the development of the theory. 98 CHAPTER FIVE: FINDINGS 5.1 Introduction The purpose of the study was to develop a theory that explains how speech-language pathologists, Indo-Canadian clients, family members, and interpreters interact and respond to each other in linguistically and/or culturally diverse (LCD) clinical interactions. The grounded theory method was used to collect and analyze interviews, observations, and field notes from 11 speech-language pathologists, 5 clients, 6 family members, and 5 interpreters. Codes were developed from the interview data and then compared with field notes and a reflexive journal and integrated to develop categories, sub-categories, and their properties. Memos were used to document code and category development. Analyses resulted in a core category that explained most parsimoniously how participants managed LCD clinical interactions. In this chapter, I begin by describing the sample characteristics followed by an overview of the substantive theory 'coordinating communicative goals,' its stages, and the conditions that influenced it. Then I describe each stage in detail, encountering challenges in clinical interactions and using strategies employed to overcome these challenges, along with the three conditions that factor into each stage (linguistic barriers, cultural barriers, and involvement of family members and/or interpreters). Sample characteristics Over a period of 12 months from March 2005 until March 2006, a total of 27 participants was interviewed once. These included the following: a) Speech-language pathologists (SLP) (n=l 1): SLPs held a master's degree in speech-language pathology, and their work experience ranged from a minimum of one year to a maximum of 22 years working with LCD Indo-Canadian clients. All SLPs were female. One 99 worked in private practice, two worked in acute care hospitals, three worked in a sub-acute care hospitals, and five worked in rehabilitation settings. All clinicians were from a native English-speaking Euro-Canadian background/Four of the SLPs had second language skills that ranged from minimal skills to bilingual proficiency in either French, Spanish, Cantonese. Clinicians ranged in age between 25 to 55 years (See Table 5.1). Table: 5.1 Demographic information: Speech-Language Pathologists Participant number Age Gender Second language skills Years of SLP experience Clinical setting 3 50-60 Female Fluent in French >22 Private practice 4 30-40 Female >10 Sub-acute care hospital 5 40-50 Female Fluent in Spanish >10 Rehabilitation centre 6 20-30 Female Fluent in Cantonese >1 Acute-care hospital 7 45-55 Female - >20 Rehabilitation centre 9 30-40 Female - 3 Acute-care hospital 10 45-55 Female - >20 Rehabilitation centre 11 25-35 Female Fluent in Spanish >5 Sub-acute care hospital 14 35-45 Female - >10 Rehabilitation centre 19 20-30 Female - >2 Sub-acute care hospital 21 45-55 Female - >15 Rehabilitation centre b) Indo-Canadian adult aphasic clients (n = 5): All clients had experienced a stroke within the last six years. Time elapsed since the stroke ranged from five months to six years. The severity of clients' aphasia ranged from mild to moderate. Clients varied in their expressive difficulties; three had difficulty with word finding, and two had a preponderance of content words but limited functional words in their speech production. Two clients were fluent in English, one had English as a Second Language (ESL), and two had limited English language skills. All clients were male 100 and were within the age range of 55-70 years. All clients except one were born in India. All the clients from India except one were from the state of Punjab and spoke Punjabi as their first language. The other one was from Kerala and spoke Malayalam. All clients had lived in Canada for more than 15 years. Clients' education ranged from high school to a master's degree (See Table 5.2). Table: 5.2 Demographic information: Indo-Canadian aphasic clients Participant number Age Gender Native language Second language skills Type of Aphasia Education Number of years in Canada 1 63 Male Punjabi ESL Brocas Bachelors >15 2 58 Male Punjabi Fluent in English Anomia High school >50 20 61 Male Malayalam Fluent in English Anomia Bachelors >15 24 53 Male Punjabi Limited English skills Brocas Masters >25 26 70 Male Punjabi Limited English skills Anomia N/A >15 c) Family members (n = 6): Family members were spouses or adult children. There were five females and one male. Only one family member, a spouse of one client, was from a Euro-Canadian background. All others were from the Indo-Canadian cultural background. Two family members were fluent in English, two were ESL, one had limited English skills, and one did not understand or speak English. Family members ranged in age from 25-65 years. All family members had lived in Canada more than 15 years (See Table 5.3). 101 Table: 5.3 Demographic information: Family members Participant number Age Gender Native language Second language skills Education Number of years in Canada 8 25 Female Punjabi Fluent in English N/A >25 16 40-50 Female Punjabi Fluent in English Bachelors >15. 22 40-50 Female Punjabi ESL N/A >18 23 40-50 Male Punjabi ESL Bachelors >17 25 63 Female Punjabi - N/A >15 27 65 Female Punjabi Limited English N/A >16 d) Interpreters (n=5): Interpreters included two males and three females. All interpreters were certified to interpret for medical and court settings. They were fluent in English and spoke at least two Indian languages (Hindi and Punjabi). Interpreters' experience ranged from 6 years to 13 years. All interpreters were from an Indo-Canadian cultural background. Interpreters ranged in age from 35 to 60 years. All interpreters had lived in Canada for more than 15 years (See Table 5.4). Table: 5.4 Demographic information: Interpreters Participant number Age Gender Education Years of interpreter experience 12 42 Female Masters 13 13 36 Female Bachelors 7 15 60 Male Bachelors 6 17 40-50 Female Bachelors 8 18 45-55 Male Bachelors 8 5.2. Overview of the substantive theory The core category, 'coordinating communicative goals,' represented the basic social psychological process of how participants interacted and worked toward their respective goals in LCD clinical contexts. The stages subsumed by the core category were 1) encountering 102 challenges in clinical interactions and 2) using strategies to overcome challenges. These interrelated stages were elements of the process of 'coordinating communicative goals,' and they were influenced in turn by three conditions/categories: a) linguistic barriers, b) cultural barriers, and c) involvement of family members and/or interpreters. The core category is a dynamic, social, and interpersonal process that was affected by the three conditions during LCD clinical interactions. The core category explained how these conditions led to challenges and how strategies were used to overcome the challenges (See Figure 5.1). It explained how participants managed competing tensions in attempting to achieve their goals leading to successful interactions. Successful interactions were characterized as interactions in which all individuals worked collaboratively to achieve their respective goals. Clinicians' goals included conducting complete assessments to obtain an accurate diagnosis and achieving improvement for clients during treatment. The clients' goals were to improve their speech and language communication abilities. The family members' goals were to achieve improvement for the client. The interpreters' goals were to satisfy all parties' communication needs during the interaction. All of the interactive processes were in the context of structural features, such as assessment and treatment settings, and health care organizations. These have been described under the headings of linguistic barriers, cultural barriers and involvement of family members and/or interpreters and their access and use of resources. 103 Figure 5.1 Basic social processjCoordinating communicative goals 104 A comment from one clinician captures the basic social process of coordinating communicative goals: "I think it's much harder to get a picture of what your successes are. You know I guess when there is commonality as we're all attempting to help this person with their difficulty" (Participant 5). Challenges were encountered throughout the clinical process, from conducting assessments, to decision making about treatment and discharge of the client. The three conditions that gave rise to the challenges are summarized below. The first condition, linguistic barriers, accounted for challenges associated with 1) the linguistic competencies of clinicians and clients and 2) problems with access and use of resources by clinicians, clients, and family members. The second condition, cultural barriers, captured the difficulties due to 1) availability of culturally appropriate resources and 2) cross-cultural differences between clinicians and clients. The linguistic and cultural barriers hindered the process of conducting assessments and providing treatment for LCD clients and thereby created difficulties in coordinating participants' communicative goals. The involvement of family members and/or interpreters in the clinical interaction was the third condition that created tensions in coordinating participants' communicative goals. This third condition involved three sub-categories: 1) expenditure of time and effort 2) difficulties in building rapport and 3) impact on assessment and treatment. Because the involvement of family members and interpreters was in response to the linguistic barriers encountered by clinicians and clients, the issues surrounding family members and interpreters are discussed as part of the third condition rather than within each of conditions one and two. When LCD clinical interactions were characterized by the foregoing challenges, participants used strategies during clinical interactions to overcome the linguistic and cultural 105 barriers, and the challenges of involving family members and/or interpreters. The employment of these strategies contributed to clinicians and clients communicating more effectively, which in turn led to greater success in achieving goals in interactions. In the following sections, I describe in detail the findings pertaining to the stages and conditions, their strong interconnections, and how they comprise the process of coordinating participants'communicative goals. 5.3 Encountering challenges in clinical interactions The first stage of 'coordinating communicative goals' involved participants encountering various challenges in clinical interactions. These challenges arose when clinicians and clients did not share a common language and/or culture, and when clinical interactions drew in family members and/or interpreters. In this section, I present evidence supporting how the three conditions and their sub-categories and properties captured challenges that participants were confronted with in LCD interactions and how these challenges impeded the participants' coordination of their communicative goals. 5.3.1 Linguistic barriers All participants faced linguistic barriers in clinical interactions. Linguistic barriers were encountered due to the lack of a common language between the clinician and the client, the lack of adequate speech and language resources, and the lack of information for clients to access services in their native language. I describe these specific problems encountered by participants in the section below. Linguistic competency of clinicians and clients One of the main challenges that affected efforts to engage in clinical interactions was the lack of a shared language between clinicians and their clients. The mismatch in language 106 contributed to a lack of competency on the part of the clinician to interact with, assess, and provide treatment to Indo-Canadian clients. Similarly, clients' lack of proficiency in English made it difficult for them to communicate with the clinician during clinical interactions. The more limited their English language skills, the greater were the communicative challenges they encountered. As a result of their limited knowledge of the client pre- and post-stroke linguistic abilities, clinicians were often unable to get an accurate understanding of the client's current speech and language abilities. As one clinician reported, "It is definitely more challenging than working with English speakers. I have no idea regarding the East-Indian languages in terms of my own.. .you know capacity. Figuring out where one word ends and where the other begins.. .it is definitely a challenge" (Participant 11). Although clinicians obtained a language history from families, this information did not necessarily represent the client's actual or current language abilities. All clients and family members perceived that the client's stroke impacted all language modalities of the client (i.e., understanding, speaking, reading and writing), and most clients and family members said that both or all languages of the client were equally impaired following the stroke, although recovery was often better in their native language. One client who was bilingual described better recovery in English than Punjabi. This was attributed to the greater use of English pre- and post-stroke, despite Punjabi being his native language. Although this anecdotal information from family members and clients was useful in contextualizing the clients' language histories, clinicians nevertheless needed to conduct language assessments in order to know what specific aspects of language were affected post-stroke in order to determine appropriate treatment goals for clients. 107 Many clinicians were uncertain about how to initiate and proceed with assessment and treatment process because of the tentative picture of clients' pre- and post-stroke language abilities. Clinicians were faced with a dilemma about whether the client should be assessed in English (vs. their native language). For example, one clinician said: Well for linguistic things I dunno whether the morphology is right, the syntax is right, the semantics is right. Like things like you can pick up on in any language. You know if somebody is mixing word or word order or whatever.. .So I'm not sure (Participant 19). Lack of information about pre-stroke language skills affected assessment and treatment processes and outcomes for clients. When clinicians proceeded to conduct assessments in English, they were often unable to determine whether the linguistic deficits identified were due to the impact of aphasia or due to the client's limited pre-stroke English proficiency. As a result, clinicians were unsure about which component of language (e.g., vocabulary, syntax or semantics) needed attention in therapy. As one clinician described, "Word finding that I could see. I haven't picked up the other linguistic issues and differences because I don't have the same kinda' linguistic training" (Participant 2). Furthermore, some clinicians reported that their jobs were to provide speech therapy and not teach English (assuming that some client's deficits were attributable to pre-stroke lack of proficiency in English). In addition to the impact of the clinicians' lack of knowledge of the client's language(s) on assessment and treatment procedures, the clients' English language skills influenced the extent of difficulty they had interacting with the clinician. Clients' language skills ranged from no English skills, limited English skills, English as a second language, to native-like proficiency in English. Clinicians described clients with limited English skills as ones who could understand some English, but with limited verbal expressive skills in English. Clients who were considered 108 ESL had acquired English formally through education, could understand and speak English, but often with a noticeable accent. Clients who had no English skills or limited English skills were often identified by some clinicians and interpreters as older or recent immigrants to Canada. Although these clients were treated as illiterate by some clinicians, they often had formal education and/or skills in reading, writing, and speaking their native language. Some interpreters and a few clinicians reported that most ESL clients felt inferior, ashamed or embarrassed to admit that they lacked verbal fluency skills in English. Fluency skill in English was often associated with academic education in India. Due to the association of language skills and academic education, many clients did not acknowledge their limited English language skills in clinical interactions. As one interpreter reported: You know the habit of our Indian people, they don't give up easily.. .they pretend that they know English. They don't want feel like inferior. Like they say T know English, I'm BA from India or I'm MA from India.' They speak English, but the pronunciation, the accent and all that kind of stuff is from back home. But that's fine. Professionals here they do not understand...and when the professional asks them question and they have an accent, they, they will turn their face towards me (Participant 18). Those clients did not seek clarification during clinical interactions, but behaved as though they understood the instructions and information provided. This often led to miscommunication during interactions. Clients who were ESL had often acquired English formally in school and used it in environments other than home on a regular basis. However, even clients with verbal fluency in English reported they preferred to interact in their native language, for example Punjabi or Hindi, because they felt more comfortable and found it easier to share information. As 109 a result, some clinicians assumed that clients were ESL when they spoke minimal English in their clinical interactions. This assumption, however, was inaccurate when the client in fact had good fluency skills in English but chose not use to them with the clinician. For example, one interpreter reported: I can give you other example.. .where an English speaking person started talking in Punjabi because he was not able to express in English whatever he wanted to say to the professional. Mind you...the guy is professional., he knows English well. But the person is talking in Punjabi.. .he's not talking in English anymore. Because his childhood, his old memories everything was in Punjabi. And his play mates and his sports and whatever he has being doing.; .had been doing in Punjabi language and he was comfortable expressing in Punjabi. And these people (professionals) they look at me.. .they think he has a language problem (Participant 18). ESL clients were described by all participants as facing fewer challenges in clinical interactions than those who had no or limited English skills because they understood some English and were capable of carrying on a conversation in English. Nevertheless, some clinicians described ESL individuals' speech and language as being truncated and accented. As one clinician reported, "When they do speak the English language, it has an ESL component to it. So sometimes the grammar is a little more telegrammatic when they describe things... it's a little more non-specific. I have noticed their rate... it's quite quick actually (Participant 5). Two ESL clients also code-switched or borrowed words from the first language, and this made it difficult for clinicians to understand their linguistic deficits in each language, especially when clinicians did not speak the client's languages(s). 'Code-switching,' a rule-governed process employed by many normal individuals who speak more than one language, makes it difficult for clinicians to 110 assess grammatical competence because the substituted words and phrases are not English words and the resulting word order may be different from English. According to one family member (participant 16), code-switching tended to occur when the client was upset, tired and had difficulty expressing himself in his first language. On one occasion, code-switching occurred when I was conducting an interview with the client (participant 1), wherein he code-switched when he had difficulty finding a word in the second language (English). The code-switching process facilitated the interaction as I was able to understand what the client said and the conversation continued. Since code-switching was reported in only two instances, further research is needed to understand other contexts that lead clients to code-switch into their first language, and importantly, how code-switching serves to facilitate or interfere with participants managing their communication goals in diverse clinical contexts. In summary, the lack of linguistic competencies of clinicians and clients often led to a lack of understanding of the client's language abilities and to inadequate information upon which to assess and develop treatment goals for the clients. The resulting uncertainties and dilemmas led to difficulty for clinicians and clients in coordinating their respective goals in clinical interactions. Problems with access and use of resources The language barrier between the clinicians and clients also contributed to challenges with the access and use of assessment tools, and these challenges made coordinating participants' communication goals difficult. SLPs employed assessment tools to understand clients' severity of impairment, current levels of functioning, and deficits across different modalities of language. Without appropriate speech and language assessment materials in the client's native language, 111 SLPs often relied on alternate modes of obtaining information such as modified or informal assessment procedures. As one clinician said: To be honest I rarely use standardized materials in assessing clients with various culturally different backgrounds. I find it easier to use some informal measures that I have developed and sort of hand picking bits and pieces from talking to family and understanding what's different to patients. I have attempted to use modified standardized materials.. .translated, bits and pieces of the past. By and large I use lot of informal stuff (Participant 4). Some clinicians used initial screening instruments that were compiled from different language assessments. These screening tools involved a short tape-recording of clients' receptive and expressive language abilities, as well as obtaining information from family members about the client's speech and language abilities. The screening tools that were commonly available to SLPs were used with all clients and were not developed specifically for Indo-Canadian clients. This often led to challenges in LCD interactions because the materials used with Euro-Canadian native English-speaking clients were not necessarily linguistically and/or culturally appropriate for LCD clients. As one clinician said: Certainly screening and formal assessment tools and I think that's where you see some of the language and cultural barriers, because our formal standardized assessment tools reflect Western tradition. So it doesn't necessarily relate to culturally meaningful things to the client (Participant 4). When clinicians identified specific areas of concern during the initial screening, some proceeded to conduct full-standardized assessments. However, many clinicians, family members, and interpreters reported difficulty with formal and standardized test materials because some 112 tasks were inappropriate for Indo-Canadian clients. For example, family members and interpreters stated that use of unfamiliar words and tasks (e.g., sentence completion, certain narrative tasks) were challenging and/or confusing to the client, and were described as having too much content or presenting too complex a task for the client to process. It is likely that their perceptions arose in part from the client's limited English proficiency. A few clinicians also reported that assessment tools were very limited in providing diagnostic information on aphasia or cognitive impairment for LCD clients. Others clinicians discussed the need for assessment protocols in both languages of the client. A few clinicians, family members, and interpreters reported that, although there has been awareness of the lack of appropriate assessment procedures, there has been no major changes made to the assessment or intervention process with Indo-Canadian clients. Two clinicians reported that the greater the severity of the client's impairment, the more limited were the utility of assessments in order to identify and interpret the language modalities affected. Although many of the clinicians reported using standardized tests with Indo-Canadian clients, other clinicians avoided them. The latter clinicians reported using modified assessment procedures or informal assessment procedures with clients. The use of these modified procedures can be considered a strategy clinicians used to address the challenges of using standardized tests (see Section 5.4.1); however, because these modified approaches to assessment also created challenges in clinical interactions, they are described below. Since the information obtained from these modified or informal procedures is essential to make informed decisions regarding treatment for the client, challenges with them detracted from the timely development of treatment goals for clients. 113 One means of modifying assessment tools involved translating standardized tests into clients' native languages. Some clinicians used tests translated into Punjabi or Hindi (with the help of interpreters), such as parts of the Western Aphasic Battery (WAB) or the Boston Diagnostic Aphasia Examination (BDAE). Clinicians used these translated tests, although they were not standardized on Indo-Canadian clients. This posed challenges for clinicians and interpreters. Interpreters discussed difficulty in translating certain English phrases into Punjabi or Hindi (e.g., no, ifs, ands, or buts) in some of these test materials, because such phrases did not exist in the first language of the client. Naming, repetition, reading, and writing were reported to be challenging tasks as they lost their relevancy and purpose when translated. For example, a clinician stated; Naming is also fraught with difficulty because.. .for example the Boston Naming Test some of the things that are considered to be on the simple end can be uncommon words or objects or items for people who haven't lived in Canada for a long time. Let's face it even people in Canada don't know what an 'acorn' is half the time. It's an Eastern thing (Participant 14). In addition, some clinicians were unsure of what kind of materials to use for different modes of communication such as visuals and gestures. Translating assessment materials also made it difficult for clinicians to analyze the accuracy of clients' responses. As mentioned earlier, clinicians were unable to identify morphology, semantics, syntax, and word order differences in the client's native language, and therefore, some of this information was lost in translation. Some of the clinicians reported difficulty analyzing pragmatics (the contextually appropriate use of language) without actually knowing the client's culture. Due to the challenges associated with conducting objective 114 evaluations of clients, all clinicians described resorting to conducting subjective evaluations. That is, clinicians provided their own perspective of the client's current abilities based on information gathered from previous clinical reports and family members. As one clinician mentioned: Standardized testing in any case is not going to be.. .1 couldn't stand by the results and say... 'definitely this is what's going on.' I wanna find out how they're communicating rather than purely thinking purely linguistically what is this person doing. And so to get an idea of how communication is happening.. .we are looking at their history and conversation in the family and...that's the priority (Participant 10). The language barrier also contributed to clients having limited access to information and resources about health care services in Canada. The majority of clients and family members had been unaware of speech-language therapy services. Even if they had been aware, they did not know where to access SLP services because the information and pamphlets provided to them were in English, and they had limited skills in English (Participants did not comment on how they eventually were able to access SLP services, but it was likely through another health care professional's referral). For example, one family member said, "Like I said if it's in English it's hard. If they had information in Punjabi it makes it easier for us to read and understand" (Participant 26). Lack of information provided to clients and family members at the time of discharge also contributed difficulty seeking follow-up SLP services. These language-related barriers to knowing about and/or obtaining SLP services indirectly affected clinical interactions in that clients and/or family members were unsure of what SLPs could do for them, and/or they did not have the language skills to navigate the health care system. 115 The lack of clinicians' knowledge of clients? languages and the range of clients' English proficiency combined with the lack of linguistically appropriate resources made it challenging for clinicians and clients to communicate their respective needs and goals to each other. On the one hand, clients had difficulty accessing and participating in clinical activities due to their limited English. On the other hand, clinicians found it challenging to know how to assess the clients' language abilities and create appropriate treatment goals when there was so much uncertainty about the source and degree of their language problems. These linguistic barriers negatively affected the process of clinicians and clients managing their communicative goals. 5.3.2 Cultural barriers Clinicians' lack of knowledge and education about Indo-Canadian culture, and clients' lack of familiarity with the North American assessment and treatment process introduced additional challenges in clinical interactions. For example, clinicians felt that identifying and understanding Indo-Canadian cultural nuances was difficult and attempts to do so often led to misinterpretation and breakdowns in communication. In this section, I describe difficulties clinicians encountered with assessment resources, and the cross-cultural differences reported by clinicians and clients, both of which affected the process of coordinating communicative goals. Difficulties with assessment resources Like the challenges associated with lack of appropriate linguistic resources discussed in the previous section, the limitation of cultural resources also caused problems for clinicians in coordinating communicative goals in the LCD context. Many clinicians reported that limited information and education provided to them during or following their graduate schooling created knowledge deficits around providing care for Indo-Canadian clients. This knowledge operated as one of the challenges in the assessment process. 116 When administering certain assessment tasks with LCD clients, some clinicians made assumptions that North American themes and stories from standardized English assessment tools would be appropriate for Indo-Canadian clients. As one clinician reported: It's also good to get their [interpreters] feedback on the cultural significance of some of those tasks. For example in the Cookie theft or the.. .Boston naming test is a word 'trellis' a word that doesn't even exists in Punjabi, may be not. I've only learnt through professional interpreters those materials is that there are.. .cultural differences which make those standardized materials.. .not necessarily appropriate by and large (Participant 4). Tasks that were complex, unfamiliar, confusing, and culturally inappropriate contributed to clients being disinterested and/or unable to perform the task. Clinicians, interpreters, and family members indicated that the use of culturally inappropriate test materials also led to clients' responses being scored as incorrect. As one family member reported: They were like cartoon type pictures. My mom she is not used to for that.. .so she did not do correctly. Other stuff they gave in English. Like... Romeo and... she has to complete the sentence. It's very tough. (Participant 22). Several family members and interpreters from the Indo-Canadian culture identified some culturally inappropriate pictures and said that, since they were not familiar with such pictures and words in their first language, clinicians should not expect the client to know them. For example, one interpreter reported: They have three or four pictures about the shaving. A person is shaving. So they ask 'what comes after what?' Now the person is Punjabi person.. .with turban and beard. 117 They have no idea about the shaving and which picture comes after and before (Participant 17). By recognizing the cultural differences and their impact on clinical interactions, all clinicians, clients, family members, and interpreters indicated that linguistically and culturally appropriate standardized tests were needed for Indo-Canadian clients. In the words of one clinician: Certainly, the formal assessment tools that we're using...there are cultural barriers, because our formal standardized tool reflects Western tradition. So it's just not simple translating these tests... I think as a speech pathologist... it certainly is a barrier to evaluating the language. So somebody not speaking English... it's very difficult for me (Participant 4). While many clinicians, family members, and interpreters discussed difficulties associated with using North American normed assessment materials, only a few reported challenges with the materials employed in treatment. This may be because family members and interpreters assisted in developing culturally appropriate treatment materials (see section 5.4 below). Cultural differences between clinicians and clients Cultural differences between clinicians and Indo-Canadian clients had a significant influence on how they were able to coordinate their communicative goals. The cultural differences that were identified by participants included their perceptions and views of: disability, recovery and treatment; the importance of speech-language therapy; client caregiving practices; assertiveness in health care settings; food, gender and age preferences; arid decision making practices. Each of these dimensions of cultural influence on the clinical interaction is presented below. 118 Perceptions of disability, treatment, and caregiving Clinicians, clients, interpreters, and family members had differing views of disability, recovery, and treatment. Many clinicians, clients, and interpreters indicated that the family often kept the disability or diagnosis a secret from the client because they believed it would worsen the client's suffering and hasten his/her death. For example, as one interpreter said, "He didn't want his dad to suffer. He thought if he tells him, it will hasten his death. If he's gonna live six months, it may be reduced to a month. It may be true, not true.. .1 dunno" (Participant 15). Some clinicians and interpreters reported that clients and family members who were aware of the disability and diagnosis often did not discuss them with others because they perceived that the disability must be kept as a private issue. As one clinician reported: I'm seeing something that looks like a pretty severe deficit and family is insistently telling me that there is absolutely nothing wrong. That mom's just a quiet person and everything is fine. It's something that I have seen more than once. So I'm not sure if that is a privacy issue or a cultural issues or a cultural way in dealing with disability (Participant 4). Keeping disability and the client's diagnosis a secret also resulted in some cases in isolating the client and reducing their interaction with others. In the course of data collection there were only two instances where clients were kept isolated (one client was in this study, the other was referred to by a clinician). As one client said, "nobody talk... [to me at] home. Wife no talk. Son.. .daughter no talk. Me slow talk. Me go home, watch.. .TV" (Participant 24). Similarly, one clinician said: I remember feeling very badly for this one East-Indian fellow.. .it was upsetting for me because he was really doing his part and wanted to get better. But there were many things. 119 He had dysphagia so there were some serious risks.. .And he had this big family he went home to.. .just sort of living in the basement, in one room. And he wasn't able to get up the stairs where everyone else had their meal. And his meal was brought down to him and he had to eat alone. And it just seemed like a prison. He has some significant swallowing difficulties. He was able to eat orally only with a modified diet. Nobody did his oral care and things like that. I wouldn't be surprised if he died from respiratory complications a few years later (Participant 14). Participants' comments illustrate clients' absence from social activities, and the effects of concealing clients' diagnoses/illnesses, which may have contributed to inadequate care of the client. Clients and family members had their own perceptions of how best to provide care. The majority of the clients and family members preferred to receive care at home and did not want to stay in hospital. For example, one family member said, "He was surrounded by sick people.. .a lot of sick people. He didn't want to go back there. I brought him home, bathed him twice a day and kept him at home" (Participant 25). They perceived the hospital and extended care facilities as being for sick people who did not recover from their ailments and illnesses. Some clients reported that they became more ill when they were in hospital. Many of the clients and family members reported that the client's health improved when at home and when receiving rehabilitation services at home. They saw their homes as safer and more comfortable environments. The majority of clinicians were unaware of clients' preference for rehabilitation services at home. They were unsure why clients were irregular in coming to clinical appointments or why they discontinued services after only a few visits. Clients' and family members' preferences for providing care at home could to explain their behaviours. Conflicting 120 cultural views regarding taking care of clients contributed to misinterpretations in clinical management by many clinicians (e.g., due to incomplete client history, gaps in assessments), lack of service seeking by clients, and premature discharge of LCD clients. In other words, they interfered with efforts at coordinating communicative goals. Some family members and clients were unrealistic about clients' prognoses for recovery. They believed that medical treatment could cure communication difficulties. For example, one client reported an injection given by a doctor that caused him to regain his speech and language abilities. Other clients and family members reported religious and spiritual beliefs about recovery, despite poor prognoses given by health care professionals. They believed in miracles and the supernatural power of God, which would enable clients to regain their speech. As one family member reported: She was there for sometime and after the hospital release she was home for another 2-4 weeks. Well I think things are going ok. This is you know.. .we're thankful to the God... he helped us.. .that everything went.. .ok.. .God gave her speech back (Participant 23). Many clients and family members also discussed the use pf traditional or alternative treatments for speech and language difficulties. These included gargling, vocalizing, massage, acupuncture, hydrotherapy, and oxygen therapy. Some clients believed in different effects of hot and cold liquids on the human body. Cold liquids were perceived to have negative energy, while hot liquids had positive energy. As a result, clients treated for dysphagia preferred hot liquids to cold liquids for their management. One clinician reported: The patient was having difficulty with glass Pf water. Unable to swallow. He was trying to drink water and he coughed.. .and then he said it's not just water.. .it's water, juice or pop. If it's cold its got negative energy and therefore goes intp his lungs and he cpughs 121 and chokes on it. Whereas if it's warm again doesn't matter what it is.. .it's got good energy and he'll able to swallow it (Participant 19). In summary, clinicians' lack of knowledge about clients' and family members' views on disability, recovery, and treatment led to treatment decisions and making recommendations that were often poorly received by some clients and family members due to their own beliefs and practices regarding how to deal with medical problems. Clinicians expected clients and family members to accept and follow North American medical practices and treatment options even though many of these were new and unfamiliar to Indo-Canadian participants. Some clients resisted or were disinterested in trying new unfamiliar practices. This led to challenges in adequately coordinating the communicative goals of both clinicians and clients during clinical interactions. Knowledge of speech language pathology Because they possessed limited knowledge and awareness about speech-language pathology, clients and family members did not seek such services. Many participants were unaware that speech-language therapy services had helped clients improve their communication abilities. A few participants perceived the SLP to be a teacher who taught the client to speak. Participants perceived SLP sessions to be questioning sessions and educational tasks for the client. For example, one family member described her experience with a speech therapist as follows: The lady would bring in some paper and keep asking him 'what did you do yesterday, what did you do today?' and keep on asking him questions. I don't know much about what it was. It seemed more of an education task (Participant 25). 122 Conducting assessments and/or therapy activities when clients were not adequately informed or ready to participate was intimidating to a few clients, which contributed to their lack of motivation to engage in speech-language services. For some clients and family members, this contributed to their reduced interest in attending further sessions. As one family member (son) described: My mom didn't find it pleasant you know. First of all.. .the way they were saying things in English she didn't understand.. .then it has to come through me, I was right there. It was her first experience with speech therapy here and she wasn't comfortable to make sounds you know. She was not cooperative.. .and she just wasn't happy.. .that was the end of speech therapy (Participant 23). Some clinicians, family members, and interpreters indicated that family members preferred to respect client's wishes to not seek further speech therapy. Another challenge, which reduced family members' and clients' seeking of SLP services, was lack of self-advocacy skills and assertiveness in obtaining information and seeking services. Younger family members tended to be more westernized, proactive, and interested in clients' rehabilitation than older family members. A few clinicians and interpreters attributed family members' involvement in advocacy to generational differences. The majority of clients and family members set physical therapy as a higher priority than speech-language rehabilitation. One client reported that once he recovered his physical ability to walk and move his limbs, he realized that communication and socializing was still a challenge. It was at that point that he decided to pursue speech therapy, as noted in his following comments: I decided that I'm actually ok. After a couple of weeks I quit. But afterwards I found that not fully you see.. .Because I could travel to Calgary and so many places.. .everything 123 was ok. But my talking had problems. I was less... meeting people. Then my wife said 'Go and try.'Then I went 3, 4, 5 weeks. Then I decided to continue speech again (Participant 20). Lack of knowledge about speech-language services, and the differing views about the importance of speech-language pathology, affected family members' and clients' motivation in seeking and continuing SLP services. Assertiveness in health care settings The majority of the clients and family members reported they did not question the professional judgments of health care professionals. As one family member commented, "It was so new to me that I didn't ask anything. I was just watching and learning what they do. To pick up thing I can do to help him remember or help him with his speech" (Participant 8). Although some family members stated their preferences, they relied on clinicians to make judgments and decisions regarding the client's recovery and rehabilitation. Such behaviour on the part of the clients and family members was described by most clinicians as non-assertiveness or passivity, and it often led them to wonder whether the clients and/or family members had understood what was said to them. As one clinician reported: I find culturally difficult is may be some of the.. .it's just the passiveness. Just the willingness to like you know just pursue a lot of questions, a lot of information, lots of phone calls. You know a lot of my other clients I get questions. I feel more frustration because I'm not satisfied that we've really connected or that I've done every thing I wanted to do, about how I feel it's somehow hot been under my control, and I dunno how to fix it, I dunno how to make it better (Participant 7). 124 This clinician qualified the comment by indicating that although clients and/or family members may not address their concerns overtly and directly, they did indicate whether they liked or disliked what was happening of being said through their non-verbal actions and gestures. Most clinicians perceived Indo-Canadian clients' and family members' reticent behaviour as a lack of enquiring, a lack of feedback, decreased desire for interaction with the clinician, and minimal or no advocating for the client. Clinicians wondered whether the passivity in clients and family members was due to English language proficiency, a cultural difference, or just a lack of interest on the part of the family to participate in clinical interactions. The resulting tension in clinical interactions created challenges for coordinating the communicative goals of clinicians. Food preferences Many participants discussed food as a source of love, hospitality and socializing for Indo-Canadian clients and family members. Food was offered to clinicians on their home visits and brought to clients in the hospital by friends and family members. Because food was culturally significant, there were conflicts about clients' food preferences when they violated medical restrictions for stroke clients. For example, certain consistencies of liquids and foods were not allowed for clients with dysphagia. Most clients preferred home-prepared food as they found hospital food to be too bland and believed that home food was cleaner, healthier, and purer than the hospital food. Clinicians and clients differed in their views about food for dysphagia management. All clients had beliefs that some types of foods were curative, healing, and restorative. For example, tea was often believed to restore the body to healthy balance after illness. Clinicians found it challenging when clients had specific food preferences, because their preferences were not suitable for dysphagia management. As one clinician reported: 125 It's hard when someone's on a very controlled diet to make sure that no food is brought in from home. Because it seems to be very important.. .it's hard to impress upon them, this not very just have to be very explicit in saying...this is a safety issue. I know you want to bring food in, feed your loved one, but we need to make sure it's appropriate, make sure it doesn't have the potential to aspirate or make them sick (Participant 9). Participants' differing views on food and medical safety negatively affected what ideally would have been a process of coordinating clients' food preferences without compromising SLP practice standards. Gender issues Many participants identified gender issues that influenced the participants' approaches to clinical interactions. Some clinicians (who were all female in the present study) identified challenges in working with male clients or family members because they believed they lacked respect for female clinicians. One clinician responded to the question "Did you experience any issues regarding gender differences?" as follows: They were calling for a snow storm and we cancelled with quite short notice. And he was very upset. He's a trucker and I guess he had cancelled a job to be at home with his mom to be at the appointment. So he was very distraught that we had cancelled the appointment and instead of finding a more productive way to express himself, he sort of yelling at me and swearing at me and wanting to talk to my supervisor (Participant 11). One can infer based on this response to the question that the clinician was attributing the outburst of this family member to differences in their genders. A few clinicians also said that men were at times flirtatious or uncomfortable with female clinicians. For example, one clinician said, "In 126 fact he's a bit flirtatious. That's something you have to use your discretion about. The other speech-language pathologist, you could ask her obviously too. Something that she had too.. ;to deal with" (Participant 3). Clinicians also indicated that Indo-Canadian men were often not overtly receptive to information provided by women. For example, one clinician said, "I don't find it's overly receptive. But I wonder if there would be more interaction if I was a man I dunno if it would have been different" (Participant 11). Many clinicians and interpreters indicated that women were passive when men were present in clinical sessions. They often spoke very little in front of the men in the family. For example, one clinician stated, "I saw daughters and daughters-in-law asking a lot more questions and providing greater input, especially when the men folk were not around. They usually tend to talk less when the men were around" (Participant 10). Some family members reported that Indo-Canadian men talked more than women. Many clinicians and family members reported that male family members communicated more often with professionals and were often the decision makers for the client. Some clinicians and interpreters reported that women lacked eye contact with men or persons of authority (e.g., head of the family, health care professionals). One interpreter explained that an Indo-Canadian woman's lack of eye contact signifies her respect, rather than hiding something or being shy and scared. It was a stroke patient and it was a lady. She is trying to answer the question, but not looking at you or the professional and not having eye-contact. And professional thinks that the patient is tired or is not interested to talk or may be scared. When the interview was over, I put into the knowledge of the professional that since the lady is Hindu lady from India, and religiously and culturally ladies are not expected to look into the eyes of 127 other people especially men, because I am interpreting as a male person there. So in this culture eye-contact means different things. Back home in India, it is considered disrespect (Participant 18). Interpreters indicated that lack of eye-contact by clients or family members caused clinicians to perceive that the client and/or family members were not interested in the activity or had other challenges (e.g., traumatic brain injury). Four of the five interpreters reported clients' embarrassment about sharing personal and sensitive issues with interpreters who were from the same culture but of opposing gender. Clients' preference for interpreters varied in this study based on the clients'/family members' education and urban or rural background. Some clinicians and interpreters reported that clients and family members who were educated and from urban backgrounds had no specific preferences for interpreters, but a few clients and family members from rural backgrounds who were uneducated preferred older interpreters from the same gender. When clients could not obtain a gender-specific clinician and/or interpreter, they were either uncomfortable in the interaction or they discontinued the clinical process. Both of these outcomes negatively affected coordination of communicative goals. Age Some clinicians indicated that older family members were less outspoken than younger family members. Thus, the previous finding of perceived passivity by clinicians may be particularly in relation to older clients. For example, one clinician said, "I do notice that when there are elderly around they're usually not active...but silent. They're not one of the ones that's outspoken" (Participant 11). 128 Many of the interpreters reported that the date of birth was not recorded for some older clients, which is common practice in rural India. Older clients often did not know their correct age, or were 5-10 years off when reporting their age. Clinicians were often unaware of such cultural differences and made the assumption that the client had problems recollecting their birth date due to aphasia or memory problems. For example, one interpreter reported: Some of the questions they ask are very simple.. .the date of birth. In our culture my grandfather, grandmother they don't know their date of birth. Maybe a younger generation, say my mom would know her date of birth, but not my grandparents. And when speech pathologists ask 'what is your date of birth and I translate into Punjabi, and they say T dunno.' I know that they dunno because they never knew that when they were ok...when they didn't have any medical condition.. .as it was never recorded and they do not remember (Participant 17). Age was a cross-cultural factor that affected the evaluation of clients by clinicians. When older adults did not voice their needs, or clinicians misinterpreted clients' performances on specific questions, the process of conducting and interpreting assessment data and formulating treatment goals was negatively affected. Decision-making Multiple family members were often part of making decisions for/with the client. One clinician defined it as "an extended decision making process due to so many family members involved" (Participant 14). Some clients were more comfortable when sessions were conducted in the presence of a family member. They often requested that a family member be present to answer questions and make decisions for them. These requests were due to the cultural practice that a joint decision was always better as the client was a part of a larger family, and his/her 129 issues always affected the whole family. Clinicians and interpreters found the extended decision making process challenging as it took a lot of time, which was generally in short supply. As one clinician reported: I've had situations where I've made decisions with the whole family. It's been an extended sort of decision-making process. And that has affected the way that I've done therapy and the way I've approached things compared to a Western client for example— it's more just me and the client. It's much more challenging. Half hour or an hour session is much more draining and half as much is accomplished (Participant 5). In certain circumstances, clinical sessions had to be postponed if a particular family member was not around during a clinician's visit. For example, one clinician reported, "I have to wait another week for a family member to come back in again to find out whether the home work has been done. Whether they're doing it correctly, hard to tell. So family isn't very consistent at coming in very frequently" (Participant 16). The involvement of many family members for decision-making created challenges due to the longer time and greater effort required by clinicians. In this section, I presented findings on several cultural barriers that directly impacted the quality of clinical interactions. Significant problems were mentioned in accessing and using assessment resources with clients. Cross-cultural differences were described between clinicians and clients about how clinical issues should be handled. These challenges contributed to incomplete assessments and unsatisfying interaction outcomes, which in turn made it difficult for participants to work together in coordinating their communicative goals. 130 5.3.3 Involvement of family members and/or interpreters The third condition that accounted for challenges in interactions was the differing perspectives of family members and interpreters. Due to the language and cultural differences, clinical interactions had to involve a third person—a family member and/or an interpreter. The involvement of more than two individuals with differing perspectives created many challenges that negatively affected the process of 'coordinating communicative goals/ These challenges were captured in three subcategories: 1) the increased time and effort required to harmonize the perspectives, 2) challenges in building rapport between the clinician, client, family member and/or interpreter, and 3) the effects of differing perspectives on assessment and treatment. Increased time and effort Many clinicians identified the higher levels of time and effort required to harmonize the perspectives of many individuals involved in LCD clinical interactions as a major challenge. Longer time was needed for clients and family members to process and understand the information provided to them in English, or through an interpreter in their native language. Many clinicians, family members and interpreters regarded the organization and logistics of sessions as more challenging because more people were in same room at the same time. As one clinician reported, "if there is an interpreter present generally it's a little more lengthy. It's just more time consuming because there are three people involved in the interaction" (Participant 9). When family members and interpreters were involved, extra time was needed for translating, for modifying assessments, for decision-making, and for providing information and explanation to clients and family members before, during, and after sessions. Family members and interpreters recommended that clinicians use culturally appropriate picture stimuli or tools when assessing LCD clients. However, clinicians said that they generally 131 did not have time to find such materials, and as a result, culturally appropriate assessments/interventions were often not implemented. Many clinicians indicated that in some clinical contexts they did not have time to utilize interpreter services. For instance, their overwhelming caseloads in acute and sub-acute settings did not allow them to involve interpreters in treatment sessions as it required too much time. As one clinician explained, "I guess the nature of acute we don't have much time for treatment as much would be desirable" (Participant 11). Thus, the already limited time frames were exacerbated by trying to harmonize the perspectives of family members and interpreters. Some clinicians indicated that involving family members and interpreters allowed them less flexibility because time was constrained. A few clinicians felt that very little of what they planned to do in a treatment session was accomplished when using family members and/or interpreters. Due to the lack of time, family members were often given home training activities to do with the client. Family members, on the other hand, indicated that the time taken to care for the client's other needs resulted in them spending less time on home training activities provided by the clinician. The lack of time on the part of the clinician and family members contributed to challenges as appropriate assessments were not always carried out to reach an accurate diagnosis and little consistency in treatment sessions was maintained for the client. The complexity of clinical interactions was increased due to third person involvement and modification of existing methods of assessment and treatment. These factors demanded more time and effort on the part of the clinicians as well as other participants in the clinical interactions. However, time was often not available in many clinical interactions and contexts, and therefore, compromises had to be made in trying to harmonize participants' perspectives to J coordinate communication goals. 132 Challenges in building rapport Rapport building was described as the extent of connectedness and collaboration among participants to coordinate their communication goals in clinical interactions. Rapport building influenced all of the clinical interaction process from initial screening to discharge of the client. Rapport-building with three or more participants was more complex than in a two-person interaction. Most clinicians indicated that they needed more time to build rapport when there were three or more individuals involved in the interaction (including family and interpreters). All clinicians described challenges with rapport building as difficulty in connecting and establishing trust with the clients and family members due to the language and/or cultural differences. As one clinician reported: "Whenever there is a language barrier, I think it takes longer to connect with the patient/Because you're always going through someone else, it's difficult to develop that rapport directly with the patient. They might develop that rapport with the interpreter" (Participant 4). Time limitations restricted clinicians' and interpreters' opportunities to build rapport and collaborate effectively. As one interpreter described: Everything is rush, rush, rush. Like you know they just grabbed us.. .it's been like that with interpreters. Nobody ever cares and has said 'this is so and so..., this is what we're doing' and we can get going.. .but there is no time.. .they (clinicians) don't have time...they don't make time (Participant 12). The lack of time available for clinicians and interpreters to harmonize their perspectives resulted in minimal rapport and collaboration, which resulted in ineffective and inefficient use of interpreters. 133 Building rapport affected the assessment and the treatment process of clinical interactions because, without establishing good interpersonal relationships with all participants, it was challenging for clinicians to assess and treat clients. For example, one clinician reported: Yeah, I always find that if you have somebody who doesn't trust you, who's too shy.. .then you don't get a full picture of their communication. I find it very difficult because I cannot interact with them directly.. .1 dunno what is appropriate and what is not appropriate (Participant 19). Building rapport was difficult when language and/ or cultural differences required family members and/or interpreters to be involved in the assessment and treatment process. Involving a third person led to indirect communication between clinicians and clients/Clinicians regarded this as a big barrier to communication because conversations were altered due to many repetitions, rewording, and the need for clarifications. Including a different perspective from a third person contributed to confusion and making the client nervous and uncomfortable because clients were already having difficulty in communicating with one individual. As one family member reported: My mom felt it is a little crowded and confused. She found it difficult that person is telling another person, the other person then translates it.'Cause even in regard to her health she is so sick, has had brain haemorrhage and a big crowd she does not like it. It is difficult for us to make her understand (Participant 22). In summary, reliance on a third person in clinical interactions created difficulty for clinicians and clients in getting to know each other's feelings and building trust. As a result, in some cases it was difficult for participants to express and discuss their needs and goals in interactions. 134 Impact on quality of assessment and treatment Involving family members and/or interpreters affected the assessment and treatment process from initial stages of obtaining information and assessment, to decision making, treatment, and discharge planning. Participants described changes in the dynamic process of SLP services provided to Indo-Canadian clients. In this section, I first describe the challenges that arose due to the involvement of both family members and interpreters. Then I describe the challenges participants reported to be specific to each group. Several clinicians reported that some family members and interpreters underestimated clients' difficulties or they did not appreciate the purpose of the tasks used for assessments. Their perspectives were not in harmony with those of the clinician or in some cases the client. Often family members and interpreters compensated for the clients' losses in order for clients to do better on tasks. They made the client look less impaired by providing extra cues and information during assessments. As one clinician reported of an interpreter: I could tell he was repeating things and providing extra cues.. .he wouldn't tell me he had repeated, which is of course very important in a communication assessment. How many times you have to tell the client this instruction before he actually understands it. So, that was one difficulty I had to encounter having worked with an interpreter (Participant 19). Some interpreters took sides with clients and supported them in their communication, to the point that they helped clients out during assessments, assuming the tasks were too complex for Indo-Canadian clients. For example, one clinician reported, One Punjabi interpreter.. .it was almost like having a family member and wanting to give the extra cues and you know trying to just help the client. He'd repeat things a few time.. .you can hear the same thing being repeated. So I'd say 'you know how many 135 times did you say that?' And then he'll tell you that he wants the client to pass and to do well. I also found that he underestimated the difficulties the client is having. He'd say 'Oh yeah, he did fine, I just needed to repeat the things a few times.' Like looking at the answers he's giving you're kinda going... T don't think so, I think it's a little bit more than just needing a repetition (Participant 19). When family members or interpreters harmonized their perspectives with making the client 'look good', they provided extra information to clients, which either confused clients or made them look better than their actual performance. That decrease in objectivity defeated the purpose of the evaluation. Similarly, clinicians were faced with a dilemma when there was lots of dialogue between the client and the family member or interpreter and it left the clinician wondering what the conversation was about. As one clinician said, "I'd say a short sentence and the interpreter would say this long sentence. And you know it was hard to say whether he's interpreting exactly the same thing or whether he was adding things in" (Participant 19). Interpreters and clinicians also reported difficulty in concentrating and carrying out activities with the client without the interference of family members. As one clinician reported: As a clinician I find it challenging...six or seven members in the same room as me. When I'm doing an assessment with the client, it's more challenging for the client because you know if they have aphasia., they're not able to cope with the tasks that we do. So for me that's challenging (Participant 7). Having so far described the challenges common to involving family members and interpreters, I now present some problems unique to involving family members in the clinical assessment and treatment process. Clinicians and family members reported that because there 136 was limited funding in certain clinical settings, such as rehabilitation centers, to access interpreters on an on-going basis, family members were often involved in the treatment process. Many clinicians reported that involvement of a number of family members, with different members caring for the client at different times, made it challenging to know if there was carry over and practice of home training activities and whether information was being conveyed to other family members. Finding one individual family member who could act as a mediator, not only to support the client but also to provide information to the rest of the family, was challenging. Some clinicians stated that family members said they would interact with the client and conduct home training activities, but many did not carry out the training. Involving family members in assessment was also difficult when they were used as interpreters even though they had limited English skills themselves. As one clinician reported, "the brother who was doing the translating for me was ESL himself. And it's as hard to get a handle on whether the deficit I was seeing in the client" (Participant 6). Family members' grammar and pronunciation acted as barriers to obtaining reliable assessment information about the client. Likewise, many clinicians described a range of quality of interpretation. One clinician described her experience with interpreters as follows: Some of them are great because they work with SLPs a lot. And they have better sort of intuitiveness. But.. .some of them are hopeless. It's just no matter how many times you...1 will stop the interpreter and say 'No, we need to back up we need to start this again. This is what I need you to do. Okay? So as he (the client) says each sentence, I need you to repeat back to me (Participant 14). Poor interpreter skills and interference by family members and interpreters affected conducting assessments with the client. One clinician described this as follows: 137 The challenges of having family do the interpretation unquestionably is that they're emotionally involved, so when they're repeating, gesturing and demonstrating the command when I just want to see if the client is able to complete the task without any cues is challenging. They want their family member to do as best as they can. It's impossible to get an objective evaluation of communication with family (Participant 4). There also were some unique challenges to involving interpreters in clinical interactions. These challenges involved dialect differences between interpreters and clients, interpreters' abilities to recognize speech or language difficulties in the client, and lack of understanding or respect by clinician and interpreter for each other's responsibilities. Identifying the dialect of the client and matching it with a particular interpreter was challenging for some clinicians because clients' dialects were identified by interpreters only at the time of the sessions. While most clinicians were often unaware of the importance of dialect differences, some family members were often upset when they identified dialect differences between interpreters and clients. As one family member said: Like...she can understand me well. Sometimes there is Punjabi's kind of not the same.. .Punjabi the same way.. .my mom is from a village. I dunno, whether she understood the interpreter. With me what I speak she is able to understand me well (Participant 22). Many clinicians indicated it was difficult to find ah interpreter who spoke the dialect of the client, so that getting someone who did not was the only option. Family members argued that using interpreters with dialect differences led to misinterpretation of the client's level of functioning. Many clinicians and interpreters described lack of harmony about their respective roles and responsibilities. All interpreters felt that their roles were not clearly understood by clinicians, 138 clients, and family members. An interpreter's role was defined by one interpreter as 'helping communication between two individuals to convert the source language into the target language and vice versa' (Participant 18). Another described her role as 'just a voice for verbal interpretation and helping two individuals who do not speak the same language to communicate with each other without providing opinions and getting emotionally involved' (Participant 13). One challenge that many interpreters mentioned was the difficulty for them in determining the extent of language skills present in the client. Although they recognized the need to work together with the clinician to determine the language abilities of the client, communication problems such as slurred speech by the client made it difficult for interpreters to understand the client's speech and translate it. As one interpreter said: Sometimes speech is not clear, tryin' to understand what the person is saying, I'm not getting any sense... I'm unable to make any sense what has been said. So I just say that I am unable to understand. Sounds like it... that's it., that's what I report sometimes (Participant 12). Some interpreters indicated that it was not their responsibility to identify slurring of speech, word substitutions, or sound substitutions as expected by some clinicians since they were not trained to identify such errors. Most clinicians, on the other hand, were unsure about the quality of translation as English words were used during translation in addition to the client's first language (for example, /apne book padliya/ = "did you read the book" in Hindi makes use of the work 'book' in English. The specific word in Hindi is /kithab/). As a result of this, clinicians questioned the fluency skills of the interpreter in the client's first language. Many interpreters reported that they did not like being given the initial paperwork to be completed with the client, while the clinician left the room. They felt that it was not their 139 responsibility to do the initial paperwork with just the clients. For example, one interpreter said, "Sometimes they leave in between. They give us the papers and ask us to do paperwork with the patient and they leave from there. They can't leave us with the papers. But now.. .that still happens" (Participant 12). Part of the initial paperwork involved clinicians inquiring with interpreters about cultural information on the client. One interpreter explained that she could only provide general cultural information in the paperwork due to the many sub-cultural differences in the Indian culture: I provide general cultural information if the message is being misinterpreted. Otherwise I let it go. It works best that the professional ask the patient. So instead of the Speech-Language Pathologist asking the interpreter, 'So what is the cultural norm?' It is good to ask the patient...thru'the interpreter as patient can then clarify better according to their own culture or cultures or where ever they came from. Because you know the interpreter has language skills, but not cultural information from all over India.. .where ever people speak Punjabi. People are from many different parts. So there are different cultures (Participant 12). These comments highlight how misunderstandings arise when the role of interpreter and clinicians' expectations regarding their knowledge of client's background are not made clear. The resulting disharmony between participants detracts from coordinating their communicative goals. Many interpreters reported that clinicians were unaware of what is expected of the interpreters while communicating with the client during translation. Some interpreters mentioned that clinicians and clients spoke 10-15 sentences at one time and this was challenging. It resulted in them providing summaries of translations, which led to misunderstanding or erroneous 140 messages being translated. One interpreter reported, "Like professionals says 10-15 sentences and if I summarize that to the client or the patient, that would be risky. Patient might misunderstand the message. So that is a challenge" (Participant 18). In addition to challenges associated with dialect differences and role misunderstandings, interpreters reported that some clients preferred interpreters who were the same gender. For example, one interpreter reported: last week.. I had this elderly lady with her daughter. I was gonna go in and the daughter asked. 'Well they don't have female interpreters?' I said 'Yes, they do.' She says 'Well, I think my mother would like a female interpreter.' I said T i l make a call for you and see if we can find one at this time (Participant 15). These family and client gender preferences were not always accommodated due to lack of availability of interpreters for specific sessions. In such instances, some clients and family members reported that they did not want an interpreter despite their limited language skills. Those who did not want to use an interpreter were left with the option of using a family member who spoke English, or discontinuing services. In summary, the involvement of a family member or an interpreter to overcome the linguistic and cultural challenges posed its own problems. The third person involvement not only involved greater time and effort, but also created challenges in building rapport between the many individuals. In addition, the interference by family member and interpreter in providing extra cues or support to the client resulted in a compromised assessment and treatment process. The many challenges with family members and interpreters made it difficult for participants to harmonize their perspectives and work together toward meeting their communicative goals. 141 5.3.4 Summary of encountering challenges in clinical interactions In this section, I presented findings on the first stage of the process 'encountering challenges in clinical interactions.' Under the first stage, I described the three conditions 'Linguistic barriers,' 'Cultural barriers,' and 'Involvement of family members and/or interpreters,' their sub-categories, and properties, all of which contributed to challenges in clinical interactions. Participants' conflicting understandings of the clinical process and differing views on how to best meet the client's needs and goals made it difficult to develop successful communicative outcomes for the client. In the following section, I present findings that demonstrate how participants implemented strategies in an attempt to overcome some of the challenges with each of these conditions. 5.4 Using Strategies to Overcome Challenges 'Using strategies to overcome challenges' was the second stage of the process that participants experienced in clinical interactions. In this section, I present various strategies that were implemented by participants to overcome some of the challenges associated with each of the three conditions (presented in section 5.3). It is important to note that the strategies participants mentioned did not always lead to successful outcomes (e.g., resolving challenges), and there were some challenges for which no strategies were mentioned. I begin by addressing the strategies participants used to overcome the problems associated with language differences between the clinician and the client as these affected the assessment and treatment process. Then I discuss strategies participants used to counteract the tensions associated with cultural differences between clinicians, clients, and family members in clinical interactions. Finally, I talk about strategies participants employed to facilitate positive collaboration when there was involvement of family members and/or interpreters in the clinical interaction. Using various 142 strategies, participants were able to overcome some of the problems in communication and to achieve successful interactions or outcomes characterized by all individuals working together to reach their respective goals. 5.4.1 Strategies to overcome linguistic barriers Strategies to overcome linguistic barriers counteracted the lack of linguistic competencies of clinicians, clients and family members and problems with access and use of resources. Many clinicians and interpreters reported that simplifying their language, going slower, and providing clear explanations to clients about what they were doing and why, and making sure clients understood the information and instructions prior to the beginning of a session helped overcome barriers associated with lack of linguistic proficiency. Providing information to clients on the nature of their problem, the significance of the assessment or treatment activities, and explaining medical terminology also helped clinicians better manage the communicative goals of the client. As one interpreter explained, "Professionals use the medical terminology and the patient does not understand what has been asked. Then interpreter has to explain and say it in simple English and the communication becomes smooth" (Participant 18). Although medical jargon is problematic even for a native English lay person, it becomes even more critical to modify language with clients who have limited English proficiency. As discussed earlier, some clients who were fluent in English or were ESL were reluctant to communicate in English fearing that they would be perceived as lacking competency in English. Some clinicians who motivated these ESL clients and made them feel comfortable before they participated in sessions had greater success in the interaction. A few clinicians and interpreters used strategies such as limiting questions at the initial stages and giving the clients time to listen and process information and talk about their concerns to facilitate interactions. 143 Some clinicians identified clients' strengths and weaknesses in each language if they were bilingual or ESL, focused on their abilities, and worked on what they intended to accomplish post-stroke. Strategies to make treatment more effective centered on practical, personal, and meaningful activities for the client such as working on everyday conversation or writing skills, and working in their native language with the help of interpreters or family members. Other strategies, such as providing cues and prompting clients to respond by adding information, assisted in helping therapy sessions go more smoothly. Using activities related to the client's day-to-day life, topics and themes that were interesting and familiar to them, linking conversations to the client's past history, and using humor in interactions all contributed to successfully coordinating communicative goals. As one clinician reported, I tend to do a lot of activities in treatment that are very personally meaningful. I have family bringing in pictures of the grandchildren and a holiday that they went on last summer. We sit down and look at those pictures and we name people items and places in those pictures find that in treatment activities that with someone who speaks another language or comes form another culture, you really have to make it meaningful to them, so that they don't tune out. I try to make it about things that they enjoy. I find doing canned therapies much more difficult with clients from different cultures (Participant 4). Clinicians described using visuals and pictures that were more concrete as strategies that helped clients understand instructions and better process the information. A few clinicians, family members, and interpreters reported that providing basic situational examples in simple picture format with simple language (in the client's native language) below the pictures helped clients to understand the information. As one interpreter reported, "An example of a pointing task before the actual assessment is conducted will help the client understand the tasks better" 144 (Participant 17). Similarly one family member said, "I talked to try real pictures...then they got in some real pictures. Now she recognize those really great" (Participant 22). Using materials that were more familiar to clients and culturally appropriate resulted in putting clients at ease so that they could concentrate on performing the tasks. In so doing, clinicians were able to get a better understanding of their communicative abilities. Although the above strategies improved coordination of communication goals with Indo-Canadian clients, many were also relevant to native English clients. Clinicians had described some challenges when using interpreters or family members for translating assessment materials; however, during treatment activities, they used interpreters or family members to translate materials to help clients overcome the linguistic challenges in interactions. All participants reported that developing and using written translated materials by interpreters and/or family members and observing the client's challenges on specific tasks helped clinicians arrive at a better understanding of the client's abilities in their native language. Written instructions in the client's native language also facilitated clients' understanding of information. For example, one clinician said: So even just written materials in their language, for me that would make me look like as I'm helpful... to say'Here's something you can read and take home. Something simple and basic. These are things that help make it easier. All the little tips, just the every day things that would be band-aid solutions. And it certainly be a huge help (Participant 21). Clinicians used written materials developed in the client's language to increase clients' and family members' interest and motivation, because writing was a more stable medium. A few clinicians mentioned that using strategies such as a multi-modality approach (e.g., gestures or paper and pens) Or any alternate means of communication such as AAC (Alternative 145 Augmentative Communication) helped clients communicate more effectively in clinical interactions. For example, one clinician reported: I think its, it's just looking at whatever is important to them in their lives that they accomplish first and foremost in order to get back. And if isn't talking.. .then access to augmentative communication in a big way. So if it means that they've to use a pad and paper to write notes and pictures and things like that.. .which are really helpful (Participant 21). Clinicians indicated that communication boards with pictures and words below in the client's language facilitated communication. Use of speech and language modifications and supplementary materials in the client's language helped clinicians understand the client's current level of functioning and provided more useful information upon which treatment goals for the client could be developed. These strategies or communication accommodations also promoted greater participation by the client and enhanced their satisfaction with the clinical interaction process. Apart from strategies used to overcome challenges with the linguistic differences of the clients, many clinicians, clients, family members, and interpreters described strategies that might help overcome the linguistic barriers of the clinicians. These strategies included identifying and recruiting Indo-Canadian clinicians who were bilingual and/or multilingual to provide services to Indo-Canadian clients, and increasing awareness and knowledge of linguistic differences in LCD clients through providing more cross-linguistic education and training for SLPs. The need for Indo-Canadian clinicians who speak the clients' languages (bilingual or multilingual clinicians) was identified by all participants as the most important strategy that could facilitate coordination of communication goals in clinical interactions. For example, in 146 response to the interview question 'How can we improve services for Indo-Canadian clients?, one client responded, "Having Punjabi and English...both...clinician...(is) really wise" (Participant 2). Similarly, one clinician stated, "I think more speech-pathologists who are multilingual would be definitely helpful. That is a real, real issue for clients." (Participant 14). Many clinicians, clients, family members, and interpreters reported that it would allow direct interactions between clinicians and clients without the presence of an interpreter or a family member. Some clinicians and interpreters reported that despite inevitable dialect differences, clinicians who spoke the client's native language would be in a better position to make sure the client has understood instructions and information during assessment and treatment services. It would also provide a better understanding of the client's LI (native language) and L2 (second language) abilities. Many clinicians, and a few family members and interpreters discussed ways to overcome the linguistic barriers associated with assessment materials. They discussed the increasing need for standardized speech and language instruments that have linguistically and culturally appropriate test items. For example, one clinician said "I think developing some assessment instruments that are sensitive to the linguistic and cultural vocabulary would be important" (Participant 14). They indicated that the availability of standardized tests in the client's native language could increase the likelihood of their use by interpreters, which should lead to obtaining greater objectivity during testing, compared to direct translation of English tools, or the informal testing procedures they were using. Because of the lack of assessment tools available in the native languages of many LCD clients, some clinicians attempted to overcome the linguistic challenges with assessment and treatment by using modified and informal assessment procedures. Clinicians discussed 147 modifying English standardized assessment materials to get some understanding of the clients' level of communicative functioning. As one clinician said: I really more often do non-standardized types of testing. I modify the WAB use pictures, action cards whenever possible.. .or use visual materials. And...I'll ask them (clients) you know how they used to sort of go shopping and identify prices of.. .find pictures ahead of that time (Participant 10). Some clinicians used English tests (such as parts of the WAB or the BDAE) translated into Punjabi or Hindi with the help of interpreters, even though these modified tests were not standardized. Word fluency, open-ended conversation, and picture description tasks were described by some clinicians and interpreters as easier tasks to conduct, and provided better understanding of the responses of clients. Other clinicians supplemented test materials with pictures from other sources. The use of modified assessment procedures resulted in more complete responses from clients and assisted clinicians in achieving their goals during clinical interactions. However, as mentioned earlier, the use of modified materials had drawbacks (see Section Because the use of modified materials enabled clinicians to assess client's abilities and get some understanding of how to manage their communicative goals, the benefits seemed to outweigh the disadvantages. Many clinicians described using informal assessment procedures with Indo-Canadian clients. Informal assessment procedures involved gathering information from family members on the client's pre- and post-morbid language skills, obtaining information from family members on the functional communication impairments of the client, and conducting informal assessment of the client's functioning in different language modalities. Informal assessment procedures incorporated linguistic and/or culturally appropriate tasks and pictures. For this reason, they also 148 motivated clients and family members to interact and respond in sessions, thereby contributing to greater coordination of communication goals. As one clinician reported: I always check with family members...'is this word part of.. .do you have such a word in your vocabulary? Would this be familiar in your culture?' I also ask family to bring in things that are familiar to the client... there's some religious books the client usually reads that is familiar, then we can use that as assessment materials. I ask them to tell me something specific about their culture or where they come from, or that is important to them... instead of showing them the cookie theft picture (Participant 5). A few other clinicians and interpreters reported making dynamic changes (i.e., while assessments were being conducted) to the assessment process with the help of family members or interpreters. As described by one interpreter, "Some will go on what is written there... some speech pathologists will ask us and make the simpler form of that question. After 5-6 questions, then they get the idea of the person's ability, they start simplifying the questions" (Participant 17). When clients did not follow or understand a task, changes were made on the spot to the testing procedure. Throughout the assessment session, family members or interpreters helped identify tasks that were linguistically and/or culturally inappropriate. The problems associated with minimal time for assessments and lack of time for treatment resulted in some clinicians providing treatment in between the assessment sessions. Clinicians indicated that the lack of time for assessment and treatment was partly due to greater time needed to conduct those activities when a third person was involved to overcome the language barrier. This involved conducting parts of ah assessment with the help of an interpreter, and then providing treatment based on the information obtained from part of the assessment, and finally conducting the rest of the assessment to identify further goals for treatment. Although this 149 led to the assessment sessions being conducted in two or more parts, it contributed to greater satisfaction for the clients and family members. Clients were more satisfied with such an approach because they perceived assessment tasks to be more of an ordeal than a process to identify a client's level of functioning. Having treatment sessions between assessment sessions provided greater confidence for clients as it gave them an opportunity to begin working on tasks that they found challenging in their native language, and thereby increased their successes in clinical interactions. Some clinicians and family members also described strategies that could be implemented to overcome the language problems associated with accessing services. Many family members and clients said that information on health care services, stroke, and tips on home training activities in the clients' and family members' native language would promote greater access to and understanding of health care service information. They also reported that community health care services in terms of home visits would increase the ease of access and provide greater convenience for clients and family members. For example, one family member said, "I would like it if someone comes home, just by coming I feel such a burden is lifted off my shoulders" (Participant 25). In this section, I described the various strategies that participants identified to overcome linguistic barriers. Some of these were strategies targeting the linguistic competencies of clinicians and clients, while others addressed limitations of current assessment tools and health care services. These strategies accounted for ways participants handled (or would handle) linguistic barriers to improve their management of communication during LCD clinical interactions. 150 5.4.2 Strategies to overcome cultural barriers A number of strategies were suggested and/or implemented by participants to overcome cultural barriers associated with limited resources and cross-cultural differences in the beliefs and practices of clinicians and clients. Many clinicians and interpreters mentioned the importance of using culturally appropriate pictures that took into consideration the age and gender of the client. For example, one interpreter reported the negative effects of pictures that were not gender appropriate and how he intervened to explain the client's behaviour to the professional: She is showing pictures where a girl is taking shower, sitting in the tub and swimming pool and that kind of stuff. She is asking to differentiate what the girl is doing. Now the guy doesn't want to look at the page. And the professional doesn't understand what is going on. Now the professional asks me 'what is this?' When professional is asking me what is this, then I have to put into her knowledge that culturally we been trained not to look at girls, when girls are not wearing clothes (Participant 18). Some clinicians and interpreters reported that recognizing clinicians' own biases and avoiding assumptions based on experience with one individual helped in coordinating the communicative goals of clients during clinical interactions. Respecting clients and family members by inquiring with them about their beliefs, values, and practices improved the quality of interactions. For example, one interpreter said, "It works best that the professional ask the patient about beliefs...the cultural information. They can then clarify better according to their culture or cultures or where ever they come from" (Participant 13). Clinicians indicated that attempting to accommodate clients' belief systems about managing aphasia was an important strategy. For example, one clinician reported that if clients 151 and family members thought gargling would improve their speech and language she did not discourage it. However, she did encourage using speech-language activities for the client to practice at home in conjunction with gargling. By not denying or refuting the client and family member's practices, the clinician contributed to a collaborative process of meeting both the clinicians'and clients'goals for SLP therapy. Another strategy involved clinicians taking into account the client's preferences regarding the gender and age of the clinician and the interpreter, and their food preferences. One interpreter reported: Sometimes the female patient in the presence of male.. .sometimes the other way. They're shy and reserved. If they are from the same sex.. .oh, they are way more open...they'll tell the problems they are having. Also...age is a factor as well. Patients younger than me.. .or the same age.. .they will not be that embarrassed. Senior person than me... they'll be more embarrassed (by me). Same age level is fine. But the senior...will be embarrassed (Participant 12). This interpreter alludes to the cultural construction of age as it influences preferences around interpersonal communication partners. A few clinicians reported that it was beneficial to discuss with clients and/or family members their culturally-based diet preferences before conducting swallowing assessments and making modifications of type of food and consistency. This collaboration is illustrated in the following description from one clinician: When their diet is certainly different, we generally work with what they eat and not what we eat. When we go to somebody's home...we ask him or her to have a sample of 152 whatever he is having trouble with. Usually people bring up /dhal/ [cooked lentils] and we work around with the consistency together with family input (Participant 11). Clinicians who incorporated the client's food preferences during swallowing assessment coordinated the client's and clinician's goals during clinical interactions. A few clinicians and interpreters also reported obtaining information on the specific roles of each family member within the family, and identifying the family member who was responsible for decision-making. Clinicians and interpreters suggested this as a strategy to help understand the relationship between the different family members and the client, and to make sure that the decision making process respected the family's wishes. For example, older women and men were often seen (by younger Indo-Canadians) as decision makers, or male members were considered to be the head of family. These individuals needed to be consulted for decision-making regarding the client. By obtaining such information, the clinician would know how important it was to a family member in clinical interactions. As an alternative, some clinicians and interpreters suggested asking clients about the appropriateness of involving family members in clinical interactions to show respect for the client's autonomy. This also provided them with the option of honouring family and cultural preferences. Some clinicians and interpreters reported that discussing issues regarding the client only with the family member, without informing the client, disrupted interactions. Also in some cases, family members used discussions for their benefit, without taking into consideration the needs of the client. They viewed identifying the family members' relationship with the client, as well as the client's wishes, as an important strategy which influenced the extent to which the clients and family members could exercise their respective roles in coordinating communicative goals. 153 Some clinicians gained a better understanding of clients' ESL needs and cultural values, beliefs, and practices by engaging in practical, personal, and/or clinical experiences with the Indo-Canadian culture. For example, one clinician said, "Well I'm fairly familiar with the culture, so it's a combination of twenty years of working overlapping with personal experience with life with friends with people in my life" (Participant 14). Personal experiences as former ESL teachers helped a few clinicians make necessary linguistic modifications that facilitated clients' participation in clinical interactions. Exposure to cultures other than their own helped some clinicians to better appreciate cross-cultural similarities and differences and make accommodations to clients and family members during interactions. One clinician said: I generally don't find it difficult to build rapport or have had trouble communicating with or.. .no, not really. I make sure I clarify things with the interpreter or family and try to accommodate their likes and dislikes. May be it's because I've grown up in this area so long. Like I've come from Victoria, where there are very many different cultures.. .and here too.. .and so I have been exposed to a lot of different cultures (Participant 9). The use of an interpreter in clinical sessions to assist in conducting assessments was another strategy reported by many clinicians to address cultural barriers. Some clinicians integrated and used interpreters not only for translating but also for modifying the assessments by suggesting cultural appropriate tasks and materials. As described by one clinician, "We rely on interpreters to tell us if there are certain words or expressions that are not linguistically or culturally sensitive or don't translate well. Usually they'll tell us that kind of thing" (Participant 11). The use of bilingual/multilingual Indo-Canadian clinicians was also suggested by many clinicians, clients, family members, and interpreters as a strategy to overcome cultural challenges 154 between clinicians and clients. For example, one family member reported, "I think it would have been helpful if there was an Indian person as a speech therapist.. .you know from same culture...that would have made a big difference" (Participant 23). Such comments are likely based on the assumption that bilingual/multilingual Indo-Canadian clinicians shared similar cultural patterns of Indo-Canadian clients and/or family members. This might have led then to think that Indo-Canadian clinicians were in a better position than Euro-Canadian native English-speaking clinicians to understand their values, beliefs, and practices as they impacted clinical interactions. Some clinicians and interpreters reported that having clinicians from the same cultural background would reduce the chances of uncertainties regarding cultural practices, and provide a better understanding of the client's abilities during clinical interactions. Many clinicians and interpreters suggested that if there were no Indo-Canadians clinicians available, actions should be taken to train clinicians to work with Indo-Canadian clients. The majority of the clinicians and interpreters recommended conducting continuing education programs such as workshops and seminars for SLPs regarding the cultural values, beliefs, and practices of different faiths and religious backgrounds; food, dress, gender and age preferences; and eye-contact with Indo-Canadian clients. It was mentioned that university programs should not only educate student clinicians regarding Indo-Canadian culture but also enable them to obtain practical experience working with Indo-Canadian clients. Many clinicians and interpreters reported the need for the provision of on-going information and education on cultural differences. For example, one clinician said: I think in the health care system there's efforts being placed to educate staff about cultural differences. It's important to have on an on-going basis. It's great to have a little in-service on Indo-Canadian families and cultural issues that arise and how to manage 155 those. It's an important issue and I think that education piece for staff is really important (Participant 4). The various strategies discussed in this section were identified by participants to overcome cultural barriers in clinical interactions. These involved using culturally appropriate assessment tools, identifying cross-cultural differences, and attempting to work with the client, family, and interpreter on how these differences can be successfully managed to uphold the needs and goals of both clinicians and clients. In addition, participants described the need for more Indo-Canadian clinicians, and to provide education to clinicians about working with Indo-Canadian clients. The many strategies identified by participants provided insight into some of the ways participants handled (or would handle) cultural barriers to achieve success in clinical interactions. 5.4.3 Integrating family members and/or interpreters Integrating family members and/or interpreters involved the strategies taken by participants to overcome challenges with third person involvement in clinical interactions, in particular, challenges with time constraints, building rapport, and managing the impact of a third person on the clinical processes of assessment and treatment. In this section, I discuss the strategies employed by participants as they worked togetherto achieve their respective communicative goals in clinical interactions. Strategies to overcome challenges with time and effort Many clinicians, family members, and interpreters reported that making additional time enabled them to better discuss and implement linguistically and/or culturally appropriate materials during assessment and treatments and educate family members on issues related to stroke, rehabilitation services, and home training activities. As one clinician said, "With more 156 time I can educate family members and the patients.. .before they leave what services are available so that they know how to access them. Provide them with information so that they can call us" (Participant 11). Clinicians made it clear that by making extra time for one client, the available time to spend with other clients was diminished. Thus, the strategy of making time was not without consequences. All participants indicated that taking time in clinical interactions helped to establish better relationships between them. Many clinicians, family members, and all interpreters reported that being able to take more time enabled clients and family members to process the information and understand the purpose of each clinical activity. Making time before and after sessions provided clinicians and interpreters with opportunities to discuss the session and how to go about interpretation. It enabled them to coordinate communication goals more effectively and thereby improve the quality of clinical interactions. As one clinician reported: I explain to the interpreter what I'm looking for beforehand. Why I'm doing these little things... 'you have to look for the articulations, the apraxias, those sort of little things that I can't pick up on.' It takes time, but I try and get them to listen for those things. I not only tell them before the assessment, but ask them the specific questions after...'did you notice any of this. Or if you get a response quite not what you expect you know get the interpreter to do a little bit of probing, give them multi choice questions whatever it is you need to do to try and figure out what is going on there (Participant 16). Some clinicians and family members described ways that conversational group sessions helped to address the problem with huge caseloads and long waiting periods for clients to access services. These groups or sessions involved two or three participants from the same language and/or culture, and they facilitated clients getting the SLP services they needed when they 157 needed them. For example, one family member reported, "It's only two or three persons' group. Speech activity they call it. Speech Pathologist too run that group. So he goes in that group now. And that's really good. It's three times a week" (Participant 16). The strategy used to manage the challenges associated with the extra time and effort required in finding interpreters and scheduling them in the clinical session was to incorporate family members as interpreters in treatment sessions. For example, one clinician said: No, I don't use interpreters for long-term therapy. Therapy is effective riot for 45 minutes twice a week, but the information and the education that goes back to home is really important. It's been more helpful if there's a family member there.. .who can go and relay the information to everybody else (Participant 7). Since treatment sessions were perceived by many clinicians, clients, and family members as less challenging than the assessment process, they indicated that using family for treatment, and interpreters for assessments contributed to more accurate and efficient assessment and more consistent following through with treatment at home. Managing time constraints in clinical contexts involves trade offs and creative use of alternative therapy activities and partners. With this knowledge, some clinicians appeared to successfully anticipate and plan assessment and treatment sessions in a way that freed up the time required for accommodating to LCD clients needs. Strategies for building rapport Thirteen clinicians and clients (of the twenty-seven participants) reported no major challenges to rapport building during clinical interactions. Interaction experiences for these participants were described as warm and positive between clinicians and clients. Many clients and family members reported that clinicians did their best to understand the client and his/her 158 communication challenges, despite the linguistic and cultural differences. Many clinicians reported that rapport building was easier with clients and family members who had some English skills and had assimilated into the mainstream North American culture. For the fourteen other participants, strategies for building rapport were implemented to increase rapport among participants. When rapport was developed, participants were better positioned to coordinate communicative goals. Building trust was a strategy identified by many clinicians, family members, and interpreters as the mostimportant factor in facilitating good rapport. It involved increasing the comfort level of participants, slowing down, and sharing one's own experiences. As one clinician reported: I don't have expectations, so I've adjusted my expectations of what's going to happen...I speak more slowly, and possibly give about twenty minutes to find out about that person...because that pays back so much. If I gain their trust, then they are on my side and understand what I'm trying to say.. .it gives me back so much (Participant 14). Once trust was established between the clinician and the client, family members, and interpreter, it facilitated more open and honest communication. Another strategy for building rapport was ensuring that clinicians and clients had direct interaction, even in the presence of an interpreter and/or family member. Direct interaction involved the clinician having direct eye-contact with the client taking the time and effort to understand the client's concerns and needs, making the client feel accepted despite his/her challenges, not setting prior expectations of the client's performance, and answering questions that the client may have. One clinician reported: Building a direct rapport.. .what I do is I look at the client when I speak.. .when I ask my questions. Learn more about the culture and understand things. And with somebody who 159 doesn't speak my language, my first session is taking the time in getting to know them and who they are and getting their trust in me (Participant 14). (It is worth noting that these clinicians did not comment on the possibility that such eye contact might make their clients uncomfortable given their cultural background). Other strategies of direct interaction between clinician-client were for the clinician to speak in the first person directly to the client (i.e., not just to the family member or interpreter), to ask the interpreter or family member to stand beside the client, and to request the client to directly interact with the clinician. Some clinicians reported obtaining information about the likes, interests, and dislikes of the client from the family member, which served to build rapport with the client. Some interpreters reported that clinicians who attempted to use simple greetings and phrases in the client's native language facilitated building rapport, which contributed to coordination of communication goals. As one interpreter reported: And some of them (clinicians) purposely have learnt some Punjabi words or Hindi words. /namste/ [a greeting like hello], /kya hal hai/ [how are you], /roti/ [bread], /dhal/ [lentils].. .they know. Patients just like that Indian word... they just feel so connected to them. They feel closer (Participant 15). Understanding the relationship between the client and the family member was also important. Some clinicians, family members, and interpreters reported that inquiring with the client through an interpreter regarding the presence and use of a family member and/or interpreter during sessions was useful as a few clients did not want a family member around during interactions. In the few cases where clinicians and interpreters indicated that clients did 160 not have good relationships with family members who were present, there was discomfort and fewer responses from the client. When clinicians took time before and after sessions with family members and interpreters, it assisted in building rapport and coordinating communicative goals. In addition, more successful collaboration occurred when clinicians provided brief information to interpreters about how the session would unfold and showed interest in communicating with the client (e.g., addressing the client directly even when an interpreter is present). Strategies for managing the impact of involving family members Many clinicians and interpreters described strategies that facilitated working with family members during clinical sessions. Since any decision made for clients would also affect family members, involving family members was important as it facilitated the assessment and treatment process. This section addresses some of the strategies participants used to effectively integrate family members in clinical interactions while minimizing the potential negative effects. Participants referred to strategies to address challenges in incorporating family members in the clinical interaction including: dealing with the client's limited language skills, accommodating to differences in cultural beliefs and practices, and incorporating family members in treatment. Despite the challenges associated with involving family members, their presence was viewed by some clinicians to be critical to the management of clients' clinical goals. As one clinician explained, "I think that largely the success or satisfaction in working with this particular population comes from the support person who comes along with the client" (Participant 7). Family members were encouraged to contribute in a variety of ways related to the client's limited language skills. This included providing information on the client's history and pre-161 morbid language skills, and in interpreting during assessment and treatment sessions. Many clinicians reported that information on pre-morbid skills from family members assisted in conducting assessments done in the second language (English), and helped clinicians to understand the families' current expectations for clients. Discussions were conducted with family members to obtain information on the client's abilities in different languages (LI, L2), modalities (understanding, speaking, reading and writing) and levels of language (vocabulary, syntax, and semantics), which provided clinicians with a better understanding of the client's deficits and abilities and facilitated coordination of communicative goals. Family members were also assisted in monitoring the progress of the client's language recovery during SLP therapy. Family members were integrated by clinicians who used them as interpreters when clients had limited English skills or when interpreters could not be accessed. Daughters, sons or grandchildren served as interpreters. Despite some inaccuracies in using family members for assessments, some clinicians still preferred using them over interpreters since they were accustomed to the client's communication and provided more specific information than interpreters on the client's abilities. In addition to the strategies targeting the language needs of the client, participants described strategies involving family members to overcome challenges associated with cultural differences. Clinicians integrated family members by seeking their assistance to modify tests to make them more linguistically and/or culturally appropriate for the client. Taking advice and suggestions from family members and implementing their suggestions in clinical sessions showed respect for both the client's and family members' cultural background and helped them work collaboratively during sessions. As one clinician said: 162 I gather information from family members.. .1 might ask them is there is a specific word in Punjabi, is this relevant.. .so I always try to understanding from them to make judgments as to where I think this person is (Participant 5). Although these comments do not make specific mention of cultural inappropriateness, they were made in response to an interview question about challenges associated with cultural issues. As mentioned earlier, involving several family members in the client's therapy created challenges in the continuity of therapy (see Section However, many clinicians, interpreters, and family members reported that extended family support encouraged the entire family to participate in rehabilitation at home on a daily basis. In part, this was due to there being responsibilities and tasks undertaken by all family members. Some family members said that they took turns in keeping all family members involved in the client's life. For example, one family member reported: Like we all spend 15-20 minutes with him... doing just the therapy. I have my kids... they have to spend... like two of my daughters... they have to spend 20 minutes with him. So it's like we're all talking turns... they know they have to.'Cause it's working... they know, they see when it's working (Participant 16). Such family teamwork contributed to greater involvement of the client in therapy, thereby enhancing coordination of communicative goals. Some clinicians also used strategies to minimize the impact of family members who interfered in the clinical interactions. For example, when one clinician was asked "What do you do when family members interfere in your interactions?", she responded as follows: 163 I think the keys are building trust, communication and listening and by doing those things, I've had fairly good success in coming to a happy discharge plan, treatment plan with families. You just have to be open and leave things open as well (Participant 4). A few clinicians and interpreters reported that removing family members who interfere during clinical interactions and integrating them in other activities, such as participation with the client at home and other social activities, decreased the negative effects on the assessment and treatment process and made it easier for clinicians to successfully manage the communication needs of their clients. For example one interpreter said: There was this stroke patient he was about 75 years old. So...the speech pathologist starts asking the questions and the granddaughter...she's a nurse in some hospital starts answering the questions. She said'I'm here to check your grandfather.'She [granddaughter] says,'Well, he doesn't understand your questions.' 'Ok, if he doesn't understand the questions, we have the interpreter here.' She says 'Well, I'm a nurse for the last 20 years and what do you think of yourself. Let me stay here, and I would like to...'so many things...'my grandfather can't tell you what he's going through.' Professional says 'That is not important, I'm just here to see how the person talks. What answers he is giving. He could give wrong answers... doesn't make any difference. I just want to check his pronunciation, his words and just what he is talking." Then the professional had to stop the interview and tell them [client's granddaughter and daughter] and request them that 'maybe you please leave the room or if you want to sit you please stay quiet' and then things settled down and went smoothly (Participant 18). Other strategies mentioned by some clinicians to integrate family members included providing them with hope, encouragement, and motivation when they were already overwhelmed 164 with the responsibilities of taking care of the client. When clinicians did this, it helped family members to continue working with the client on their communication needs. For example, one family member reported: She (speech pathologist) asked us to be involved. She said 'it's not enough when I'm doing it.. .I'm doing it 45 minute with him. You guys have to do it at home too.' She told me yesterday too...'give me something that he used to do' like he was in the construction. She said 'give me that we can ask him about his work...what he used to do... what he likes to do.' And we understand that... and we have to... and we do homework at home too. It's not like he can go there once and that whole week doesn't do anything. That won't work either (Participant 16). Family members were able to be successfully integrated into clinical interactions when clinicians obtained information about the client's language abilities and cultural preferences, educated and spent time with them, and encouraged teamwork among family members. These strategies helped minimize the negative impact of family member involvement on the assessment and treatment process during clinical interactions. By decreasing their negative impact, clinicians were able to achieve greater success through working together with them and the client in coordinating communicative goals. Strategies for integrating interpreters Many of the clinicians said using professionally trained medical interpreters who were knowledgeable, non-biased, and consistent during interpretation helped overcome the language barrier between the clinician and the client and/or family member. These advantages were despite the challenges associated with involving interpreters mentioned earlier (e.g., underestimation of the client's difficulties and compensation for the client's losses). 165 Due to the challenges of a language mismatch between the clinician and client, integrating skilled interpreters for assessment purposes helped in obtaining more accurate diagnoses and understanding of clients' abilities. Some clinicians requested a skilled interpreter based on their previous experience with that interpreter. As one clinician said: I try to have regular skilled interpreters. So over the years I got to know a handful of people who are used to knowing about the kind of assessment that I do and when I can I get those people and by virtue of working in the past we're kinda been able to request and use them more consistently (Participant 4). As mentioned earlier, some clinicians spent time to provide the interpreter with a brief history of the client and to clarify information before and after the session. Some interpreters also assisted in obtaining information on pre- and post-morbid skills and the cultural beliefs and practices of the client when no family member was present. This yielded the same benefits described earlier when clinicians obtained such information from family members. Although eliciting this information required greater time and effort on the part of the clinician, it facilitated coordinating communicative goals in clinical interactions. Obtaining some information from clinicians on the client's language background was also found to be useful in helping interpreters during translation. In particular, some interpreters reported that knowing whether formal or informal language registers should be used with clients would impact the client's understanding of the language. For example, clients educated formally in their native language of Punjabi would have better understanding of formal Punjabi. Clients who were uneducated would understand better if language was modified to a more colloquial dialect. For instance, one interpreter said: 166 Professionals should change the register.. .so we can use the same Punjabi word. Person is not speaking English or educated in English, but their Punjabi language level is so high that when I'm translating into English... formal English into formal Punj abi, they are answering beautifully because they are answering in that language. They should recognize this that they need to check with the interpreter.. .is this person's Punjabi formal Punjabi or is it just a colloquial, lay you know... coming across. So that way both parties can work together and produce a good result (Participant 12). One of the challenges mentioned earlier in incorporating interpreters in clinical interactions was that their dialects may differ from clients' dialects. Although interpreters did not raise this issue when discussing strategies, many did mention clinicians' need to be educated on differences in dialects of clients' languages. They said that colloquial Punjabi and Hindi languages use some borrowed words from English that are commonly used in everyday conversations, and knowing that some clients with ESL picked up what is said, despite the use of an interpreter, was important as it could affect the assessment process. For example, some ESL clients responded on tasks even before the interpreter had translated. Interpreters also described how subtle differences in English (LI) may not be found in Punjabi (L2) (e.g., boat, canoe), and clinicians need to aware of it because a lack of understanding of such differences could result in the client's responses being perceived as incorrect. Some clinicians said that there was greater reliability of the assessment results when discussing these with interpreters, compared to using family members for translation/Although use of interpreters was limited for treatment purposes, when interpreters were used, they helped to explain to the client and/or family the carry over activities (i.e., communicative tasks that need to be generalized outside the clinical settings) and home training activities. A few clinicians also 167 integrated interpreters by using them for educating the client and/or family member about the illness, and for providing training activities for speech-language therapy in the client's native language. This resulted in better understanding and knowledge by the clients and family members and helped them coordinate communicative goals. Some clinicians preferred using interpreters over family members because they were more objective and had better English fluency skills than most family members who claimed they were fluent in English. Integrating interpreters even if family members/clients did speak some English was useful since some clients/family members were more comfortable communicating in their native language. Using interpreters with clients who were ESL helped maintain clarity of information as illustrated by one interpreter's comments: Even academically, if they have studied English as a subject, but as a language they might have not practiced it. They'll say 'Oh yeah, I know English.' But when they start talking to each other, question is being asked...answer is coming something else. When this thing is happening then what's wrong with the patient... 'Is it a mental problem or a language problem?' Then the interpreter intervenes. You'll be amazed how smoothly the session goes. Proper communication happens between the two people (Participant 18). When clinicians included interpreters in a collaborative process, it often led to sessions being educational for interpreters as they learned the purpose of the assessments and what was expected of them. They, in turn, guided clinicians and provided suggestions on culturally appropriate activities and materials that could be used during interactions with Indo-Canadian clients. As one interpreter reported: They'll say 'Do you think this is appropriate?' And then some of them...will just judgments 'oh, no this is not appropriate. Oh no she can't write don't worry.' And then 168 I'll say 'May be she could write in Punjabi.' May be we can ask if she's educated. And then we'll ask and then she'll be able to write. So you know.. .there's clarifications needed at every step. At every step really the interpreter's role is also working together with SLPs (Participant 13). When clinicians used strategies to integrate interpreters in positive ways, and clinicians and interpreters worked collaboratively, it reduced the challenges associated with participants' differing perspectives on the roles and responsibilities of clinicians and interpreters. As a result, the process of coordinating communicative goals in clinical interactions was enhanced. In this section, I presented the strategies participants reported using to overcome the challenges with involving interpreters. Interpreters were successfully integrated into clinical interactions when clinicians spent longer time with them before and after sessions, educated them about the assessment and treatment process, and obtained language differences and cultural information on the client. These strategies facilitated successfully coordinating communicative goals in clinical interactions. 5.4.4 Summary of using strategies to overcome challenges Using strategies to overcome challenges was the second stage of the process that participants described in LCD clinical interactions. Strategies were implemented by participants to overcome challenges with linguistic barriers, cultural barriers, and involvement of family members and/or interpreters. The use of these strategies contributed to participants working together in developing assessment goals and in achieving progress in treatment. Successful interactions led to participants having greater satisfaction with the outcomes of clinical interactions. 169 5.4.5 Chapter summary In this chapter, I described the three conditions and the two stages that explained the process of coordinating communicative goals in clinical interactions. Linguistic barriers seemed to emerge as the main concern of all participants. Despite this, linguistic and cultural barriers were closely interconnected in that the linguistic barriers mediated the cultural challenges encountered in clinical interactions. For example, if clinicians were not able to communicate with a client they were not in a position to ask and clarify cultural information with the client or the family member. In order to overcome the linguistic barrier, a third person was involved, usually a family member or interpreter. However, their involvement posed its own challenges related to their own linguistic proficiency and/or attempting to compensate for the client's deficits. Third person involvement also created additional cultural barriers, for example, when family members' beliefs and practices interfered with clinical interactions. Hence, all three conditions were interrelated and created challenges to coordinating communicative goals. While information from all participant groups contributed to the development of the various categories, there were some challenges and strategies that were developed based on information from particular groups of participants. In relation to the first condition, linguistic barriers, clinicians and interpreters predominantly reported challenges regarding the linguistic competency of clinicians and clients. All participants, however, identified problems with use and access of resources. With regard to the second condition, cultural barriers, all participants except the client group, described difficulty with the cultural inappropriateness of some assessment resources. All participant groups mentioned perceptions and/or challenges due to cross-cultural differences 170 between clinicians and clients. Family members and interpreters described their general perceptions of disability, recovery, care, and treatment without referring to them as challenges. Clinicians, on the other hand, who were unaware of the latter groups' perceptions, referred to these issues as challenges. Clients and family members provided comments on their lack of knowledge of speech language therapy. Clinicians identified lack of assertiyeness in clinical interactions, and family members'comments confirmed this. All participant groups, except interpreters, described culturally-based food preferences and the challenges associated with these. While gender and age preferences were identified as a challenge primarily by clinicians and interpreters, family members too identified age as a factor that plays a role in managing clinical interactions. Clinicians and interpreters primarily described the challenges associated with the decision making process in LCD interactions. All participants except the client group identified the final condition, involvement of family members and/or interpreters, as a challenge. While clinicians and interpreters predominantly described time and effort and building rapport as challenges, the impact of a third person on the assessment and treatment process was described as a challenge by all participant groups, except clients. Turning to comparisons of strategy use across participant groups, it is first important to mention that participants described employing strategies in an attempt to overcome some, but not all, of the challenges they identified in clinical interactions. All participant groups described linguistic strategies to overcome the challenges with use and access of resources. Whereas family members provided strategies to overcome the problems with cultural inappropriateness of resources, clinicians and interpreters predominantly described strategies to overcome the challenges with some of the cross-cultural differences between participants. 171 To overcome challenges with the third person involvement, all participant groups provided suggestions and/or strategies to overcome challenges with time and effort and rapport building. Clinicians and interpreters provided strategies to integrate family members and/or interpreters in clinical interactions. Coordinating the communicative goals of participants in clinical interactions involved an iterative process of attempting to implement strategies when challenges were encountered, monitoring the success of those strategies, and in some cases, implementing new strategies to overcome the challenges. This trial and error approach served all participants in their efforts to manage their communicative goals. 172 CHAPTER SIX: DISCUSSION 6.1 Introduction Qualitative research findings on perspectives of participants' efforts to manage clinical interactions around speech and language deficits have rarely been reported in the literature. The present study addressed this gap by using a grounded theory method together with a symbolic interactionist framework to understand the experiences of speech-language pathologists (SLPs), Indo-Canadian adult aphasic clients, family members, and interpreters in linguistically and culturally diverse (LCD) clinical interactions. Analyses resulted in a substantive theory that explained the basic social process of participants "coordinating communicative goals" when they did not share a common language and/or culture. The process of coordinating communicative goals in clinical interactions involved two stages, "encountering challenges in clinical interactions" and "using strategies to overcome challenges." The substantive theory explicated how the participants' use of strategies helped to overcome the challenges, thereby meeting the goals of participants in clinical interactions. In this chapter, I begin by discussing the key findings from the current study in relation to previous literature and the theoretical.framework of symbolic interactionism. Following this, I discuss the implications of the study for clinical practice, education, research, and policy. Then I discuss some of the limitations of the present study, followed by a summary of the present chapter. Finally, I provide a conclusion to the dissertation. 6.2 Overview of the key findings The key findings that emerged from the present study were two stages and three conditions that influenced the clinical process. As mentioned, the two stages were 1) encountering challenges in clinical interactions and 2) using strategies to overcome challenges 173 for successful clinical interactions. The three major conditions that influenced the stages of the clinical process were 1) linguistic barriers, 2) cultural barriers, and 3) involvement of family members and/or interpreters. The three stages and conditions provided answers to the following research questions: 1. What are the linguistic issues and cultural elements that facilitate or impede successful communication in LCD clinician-client interactions? 2. What actions and processes are involved in LCD clinical interactions? (e.g., How is rapport built and what is the process of conducting an assessment?) 3. What are the consequences of the actions and processes? (e.g., Does lack of the same language and culture obstruct the clinical interaction process i.e., assessment and treatment?) In the following section, I discuss each condition and its influence on the two stages, indicating in particular how the symbolic interactionist framework assisted in guiding and interpreting the findings. 6.2.1 Linguistic issues Findings from my study indicated that participants encountered linguistic barriers in clinical interactions and used strategies to overcome them to achieve their respective goals in interactions. Symbolic interactionism provided direction in terms of looking at how language was used by individuals to negotiate meanings (Blumer, 1969). The lack of a shared language between clinicians and clients was identified by all participants as one of the main concerns in clinical interactions. The linguistic barriers in clinical interactions were primarily due to the language competency limitations of clinicians and the varying degrees of English proficiency skills in clients. 174 My findings identified some specific challenges encountered by clinicians due to their lack of knowledge and competency in the Indo-Canadian clients' native language, and in particular, across the different components of language. Clinicians indicated that they had limited understanding of how to proceed with assessment and treatment in such cases and how to differentiate between a language disorder (aphasia) and a language difference (ESL). The lack of competency of clinicians to provide services to LCD clients was also likely one contributing factor to LCD clients' limited seeking of SLP services. These findings corroborate the published recommendations of ASHA (2004) and CASLPA (2002) position papers, which identified particular areas of knowledge and skills necessary for speech-language pathologists and audiologists to provide culturally and linguistically appropriate services. My findings also support the results from two survey studies (one American, one Canadian) which indicated that few clinicians have the necessary competencies to provide services to LCD clients (Kritikos, 2003; Simmons & Small, in preparation). The results from my study extend these position papers and research findings by providing details about the skills and knowledge lacking for SLPs in the context of managing LCD clients. In response to the many challenges encountered by clinicians in this study, participants mentioned the need to recruit more bilingual/multilingual clinicians, educate practicing clinicians (e.g., informing them how to modify the clinical process), and use interpreters. The need for Indo-Canadian clinicians who speak the clients' languages was identified as one of most important factors that could improve interactions. It would allow direct interactions between clinicians and clients without the presence of a professional interpreter or a family member interpreter. Bilingual clinicians who speak the clients' languages would also be in a better position to ensure clients understand instructions and information during assessment and 175 treatment. Several researchers suggest recruiting SLPs who speak the client's language in order to overcome the linguistic barrier (Goldstein, 2000; Huer & Saenz, 2003; Roseberry-McKibbin, 2002; Roberts, 2001; Wallace, 1997). Comments from the participants in the present study provide empirical support for these suggestions. My study participants also indicated the importance of educating clinicians on cross-linguistic and cross-cultural differences and providing them opportunities to work with Indo-Canadian clients. The ASHA (2004) and the CASLPA (2002) position papers describe how clinicians can improve their linguistic and cultural competencies related to LCD clients. These papers offer several strategies, including recognizing one's own biases, obtaining knowledge and skills in the client's language or dialect, and working collaboratively with interpreters to obtain such information. According to these position papers, having adequate linguistic and cultural skills is not only a quality of care issue but must be a basic competency that SLPs need to develop in training or as part of continuing education. In order to ensure LCD clients receive effective services, the literature suggests that clinicians be involved in a continuous process of gaining knowledge and skills on specific LCD client populations (ASHA Ethics, 2003; Roseberry-McKibbin, 2002; Wallace, 1997). My findings support the need to increase the knowledge and skills of clinicians through education, practicum experience, and continuing education, but also extend the literature by providing examples of strategies practicing clinicians use to bridge linguistic and cultural differences. My findings indicate that clients better understood tasks and activities when clinicians spoke slowly, provided concrete examples, used topics of relevance and interest, and asked few questions at one time. In addition, the use of more visuals and the written media in the clients' languages enabled the clients to better respond to and participate in sessions. My study provides 176 empirical evidence for recommendations made by Goldstein (2000), Roseberry-McKibbin (2002), and Saenz and Huer (1996), who suggested using simplified instructions and nonverbal cues to enhance adolescent LCD clients' understanding of instructions. My findings also indicate the need for clinicians and interpreters to be aware of the language and dialect differences in clients because such differences can lead to lack of understanding of words and phrases that the client uses, which in turn may cause misinterpretation of assessment results. Wallace (1997) discussed the need for clinicians to be aware of such differences so that they could prepare ahead of time for a session. However, she also says "the mismatch in the use of standard English and dialect between clinician and patient will not affect the patient's or the clinician's ability to understand each other" (p. 60). Although Wallace makes this claim, she states the need for further research to identify whether language and dialect differences can have a negative effect on the client's assessment results. Holland (1983), on the other hand, suggested that those differences could negatively impact the client's performance. My findings provide support for Holland's (1983), because clients in the present study were confused or not able to complete tasks when there were dialect differences between the client and the interpreter. My findings indicated that the lack of competency of clinicians in the clients' native language created many challenges in arriving at a diagnosis and planning treatment goals. As described above, some of the strategies suggested or implemented by participants to overcome the challenges included clinicians changing the way they talked with LCD clients, educating clinicians on language and dialect differences, and recruiting more bilingual/multilingual clinicians. 177 Findings from my study indicated that like clinicians challenges due to their limited competency in the native language of the clinician. Clients often did not acknowledge their limited English language skills to clinicians for fear that they would be perceived as illiterate. Hence, many did not ask for clarifications even if they did not understand what was said by the clinician. These actions contributed to misunderstandings between clinicians and clients during clinical interactions. It also created challenges in differentiating language impairments from language differences. Several studies have reported misattribution and classification of client's ESL language abilities to a language disorder (Paradis, 2005; Windsor & Kohnert, 2004). Similarly, Molrine and Pierce (2002) identified differences in African-American normal individuals on assessment subtests such as the BDAE and the WAB. She concluded that such differences were due to African-American English differences rather than any expressive language disorder. One similar study on interactions between doctors and their African-American patients indicated that doctors perceived these patients as less likely to perform accurately on cognitive and affective dimensions (Ryn & Burke, 2000). Perceptions that in turn contributed to patients' lack of interest and motivation to participate in clinical activities. My findings are similar in that perceptions by SLPs were described by participants as having a negative impact on clients and their motivation to participate in sessions. In addition to creating challenges in interactions between clinician and client, the lack of language match between clinician and client had adverse effects on clients' willingness to seek and/or continue SLP services. My findings indicated that when Indo-Canadian clients did not speak the language of their clinicians, they were uncomfortable and refused to seek further SLP services because they preferred interacting with a clinician who spoke their language. Deng 178 (2003) similarly reported that the linguistic (and the cultural) match between clinicians and clients determines the extent to which Asians utilize health care services. These results are similar to Ponce, Hays and Cunningham (2006) findings indicating that older adults with limited English proficiency were worse than older adults who were proficient in English in both their health care status and in accessing health care services. They concluded that language competency is an important factor in determining the health status of older adults in a foreign country. My findings expand on this research because many participants from my study indicated that in addition to lack of a common language between clinicians and clients, the lack of access to language specific information (e.g., information on stroke, home training activities), and the lack of familiarity with the health care system led to them not continuing speech language services. A lack of understanding of the different types of rehabilitation services available could have been another reason for low participation rates in SLP services by clients in the present study. On the other hand, clients and family members mentioned strategies which could help increase their knowledge of and access to speech-language therapy services (e.g., providing them with translated written materials in their native language). Apart from language being a barrier to clients' abilities to access services, when services were available and accessed, language often hindered the process of conducting assessment with Indo-Canadian clients. My findings indicate the need for alternative and/or nonbiased assessment procedures for LCD adult clients. Many researchers have also identified problems with assessment resources not being appropriate for LCD clients (Battle, 2002; Goldstein, 2000; Roseberry-McKibbin, 1994, 2002; Wallace, 1997; Wyatt, 2002). Two survey studies documented the challenges that clinicians encountered when using standardized procedures including difficulty in administering, interpreting, and scoring the client's responses (Kritikos, 179 2003; Kennedy, Glaze, Kan, & Carney, 2003). Findings from my study support those results by providing evidence of challenges encountered when standardized assessment procedures were used with adult aphasic Indo-Canadian clients. My findings also extended the existing literature by indicating that, even when modified standardized assessment were used with LCD adult Indo-Canadian clients, problems persisted and assessment results were often unreliable because these procedures lacked objectivity. Reliance on an interpreter to assist in modifying standardized assessments did not overcome problems of assessment stimuli and material being inherently biased towards native English-speaking Euro-Canadian clients. The foregoing challenges made it difficult for clinicians to judge the current language abilities of the client and to arrive at a correct diagnosis. Ideally, developing standardized tests in the client's native language would lead to obtaining greater objectivity during testing, compared to direct translation of English tools, or the informal testing procedures that are currently being used. This in turn would result in a more accurate diagnosis of the client's language abilities, a better understanding of the effect of the stroke on different language modalities, and more effective planning of treatment goals for the client. However, recognizing that the development of such tests in many languages will not be realized in the immediate future, the literature oh SLP practice with LCD clients has indicated the need to use alternative assessment procedures (i.e., not standardized instruments), which despite their general lack of objectivity, enable clinicians to get an understanding of the client's communicative abilities (Damico, 1991; Gutierrez-Clellen & Penna, 2001; Roseberry-McKibbin, 2002). In the present study, attempts by clinicians were made to overcome some of the challenges with assessing LCD clients through the use of more informed assessments (e.g., language samples of conversation or picture descriptions) and dynamic assessment procedures 180 with clients. These informal procedures contributed to more effective assessment by not relying , on the standardized measurement of isolated components of language but rather measured how these components are put to use by the client in functional communication activities. My findings provide empirical evidence for the utility of such alternative procedures. Although dynamic assessment procedures have been used with LCD children (Gutierrez-Clellen & Penna, 2001), my findings document the advantages of using them with adults, wherein it not only reduces the challenges with standardized assessments, but also enables the clinician to provide treatment to the client as an accompaniment to assessment in the initial stages. One can conclude that, in my study, the use of such informal testing procedures and being flexible during clinical interactions contributed to a greater and more accurate understanding of the client's level of communicative functioning, and consequently, to more successful interactions between clinicians and clients. In summary, language barriers hindered the process of communication by making it difficult or impossible for the clinician to obtain information from, and assess and treat, the client. These barriers also prevented the client from expressing their concerns, needs and goals throughout the clinical process. Strategies that served to overcome these challenges were directed at increasing clinicians' competency in the languages of clients, and clients' gaining competency in English, as well as making accommodations to meet the limited language skills of each party. 6.2.2 Cultural issues The second major condition that was identified in the present study involved cultural barriers. A symbolic interactionist perspective can enable one to understand participants and their relation to a larger society or cultural group through providing information on the context 181 within which meanings are created, influenced, and interpreted in interpersonal interactions (Hall, 1990). Using symbolic interactionism as an analytic lens yielded an understanding of the influence of cultural norms, beliefs, and practices on individuals and interactions through comparing the perspectives of individuals from the same cultural group (clients and family members) with those of individuals from different cultural groups (clients/family and clinicians). In chapter two, and the section above, I construed and described culture as norms, values, beliefs, and practices that make up individual characteristics and bind together individuals to set them apart from another group. Before the data collection and analyses, I perceived that the two groups (i.e., Indo-Canadian and Euro-Canadian) likely had their own sets of beliefs and practices, and that my investigation would identify cultural differences that influence clinical interactions. However, through the inter-subjective process that contributed to the analysis and interpretation of the data, my understanding of what culture means expanded. First, it became clear that all individuals despite their cultural backgrounds share general characteristics with each other. For example, many participants in the present study were dealing with aphasia and change in family dynamics in one way or another. Second, there was evidence that individuals in a culture are on a continuum wherein they vary to a greater or lesser degree on how closely they conform to the norms, beliefs and practices that constitute a particular society. For example, many of the Indo-Canadian participants preferred mainly Indian food, whereas a few others had no food preferences. Third, the reflective process of investigating cultural differences enabled me to shift the focus from individual cultural differences to the larger unit of the organizational culture in clinical practice. Clinicians had set methods of assessment and treatment procedures that formed a part of the culture of clinical practice. It was evident from my findings that any change to the culture of clinical practice that was considered routine created tensions between participants. For 182 example, encounters with clients who were non-native English speakers often created tensions for clinicians as most standardized assessments are in English. Further exploration and understanding of the culture of clinical practice will provide a better understanding of the functioning of individual components of assessment and treatment in clinical practice and methods to improve services for LCD clients. The cross-cultural differences between the clinicians, clients, and family members contributed to culture-related challenges in clinical interactions. Whereas clinicians perceived cultural differences as barriers to communication, clients and family members rarely mentioned culture as a challenge to communicative interaction. The primary cross-cultural differences identified in this study were participants' views on disability, recovery and treatment, and assertiveness in clinical settings. Secondary cross-cultural differences were clients' and family members' preferences regarding the gender and age of clinicians. A discussion of these differences, how they resulted in challenges, and what strategies participants employed to overcome them is presented below. Perceptions on disability, recovery, and treatment My findings indicated that views on disability among Indo-Canadian participants often differed from the native English-speaking Euro-Canadian clinicians. These differences posed challenges to SLPs who recommended and employed practices based on mainstream North American views of communication disorders and rehabilitation. Some clients and family members in my study preferred to not talk about the client's disability with each other or in public. Not discussing the disability may have arisen from the perceived social stigma of the disability, fear that informing the client about his illness may hasten his illness or worsen his/her condition, and/or lack of acceptance of the disability. Shankar, 183 Saravanan and Jacob (2006) reported that Indian clients and family members in their study often found it difficult to accept clients' conditions, they kept the illness/disability a secret, or they explained disability in terms of karma (destiny). Stanhope (2002) in her review of family involvement in psychological rehabilitation in India and the United States, stated that individuals within the Indian culture often protect a person with the disability by not overtly expressing their emotions to the patient. This would suggest that some clients and family members in my study may have preferred to keep disability a private issue because of the strong emotional dimension of disclosing and/or discussing disabilities. Similar to these findings, clients and family members in my study denied the actual extent of the severity of the clients' condition and perceived everything was alright. In addition, some participants attributed disability to spiritual forces (e.g., a gift from God, or due to evil spirits). Keeping the disability a secret had negative consequences for participants, because clients' needs were not always recognized by clinicians, and clients had decreased social interaction with others. Participants did not mention any strategies to manage their differing views on disability and illness. An approach to overcoming challenges would be to explore the current beliefs and expectations of clients or family members (rather than dismissing or challenging them) and to suggest alternative forms of management that incorporate some of their ideas into the clinical process as illustrated below. My findings show that some SLPs found it challenging to provide interventions because of the conflict between intervention procedures developed in North America and the traditional methods of intervention that were more familiar to Indo-Canadian clients and family members. Treatments such as massage, hydrotherapy, dietary modification, and acupuncture were thought by clients and family members to be effective in curing their disabilities. The challenges associated with such cross-cultural differences were primarily related to communication 184 breakdowns that occurred when client's preferences conflicted with SLP recommendations. It is likely that clinicians did not consider such alternative treatment practices as relevant, and this could have caused clients to be disillusioned with clinicians'responses, leading to communication breakdown. Herselman's (1996) ethnographic investigation of South African patients describes the impact of socio-cultural differences on seeking health care. Her findings demonstrated that doctors were unaware of traditional medical practices and patients were unaware of Western medicine and treatment options, which led to discrepancies between clinicians' and clients' treatment preferences. Extending Herselman's findings, my study provided data on what clinicians did in such cases of conflicting perspectives. Some SLPs attempted to incorporate traditional methods in their intervention plans, and as a result, reported more successful outcomes in clinical interactions. For example, when clients wanted to use gargling as a treatment, clinicians allowed them to do this (with caution) in conjunction with SLP treatment. It is important to note that while alternative methods of treatment should be respected, and may be able to be integrated with the SLP's treatment, clinicians need to also be aware of how these alternative procedures may interfere with treatment or otherwise negatively affect the client's current health condition. Assertiveness in clinical settings In my study, clinicians perceived a lack of assertiveness in some clients and family members. This passivity was attributed to the clients' lack of skills in the English language, clients' and family members' limited understanding of the clinical process, and/or their demonstration of respect to clinicians as persons of authority. Clinicians reported that passivity in Indo-Canadian participants negatively influenced the clinical interactions because clients and family members appeared to be not interested in the clinical activities or sessions. Such 185 perceptions may have been particularly applicable to Indo-Canadian women, some of whom may not have taken opportunities to express their perspectives as readily as men. Passivity also affected interactions when family members did not confidently advocate or make decisions for the client, Similar findings are reported by Herselman (1996) and Assanand et al. (2005) in their investigations of South African patients and Indo-Canadian clients, respectively. Assanand et al. reported that passivity in Indo-Canadian clients is due to the great trust placed by clients in their clinicians, who are perceived to have the best understanding and knowledge of the client's health condition. Herselman reported that patients' discomfort in clinical interactions led them to be reticent, emotionless, and likely to withhold information from the doctors during interactions. Together, the findings from these studies and the present study suggest that clients' reserved communicative behaviour in clinical interactions can be misinterpreted by clinicians and can lead to misunderstandings during clinical interactions. It is necessary to point out that passivity is not only a culturally-based phenomenon but is also subject to intergenerational differences. For example, whereas native English-speaking Euro-Canadian adults born in the early to mid 20th century are more likely to be passive in interactions with health care professionals, recent generations may take more initiative in disclosing their problems and negotiating treatment options (Green, Adelman, Charon & Hoffman, 1986). Since many of the clients and family members in the present study were older adults, it is not possible to disentangle the relative influence of culture and age on their lack of assertiveness. Given the challenges that passive behaviour created in clinical interactions, my participants described strategies to enable greater participation of clients and family members. Clinicians suggested that probing, asking more questions, and sharing similar experiences of 186 other families from the same cultural background would help clients see that the clinicians had a sincere desire to hear what they had to say. Other possible strategies to encourage participation on the part of clients and family members would be for the clinician to mention their strengths and give them positive feedback about their efforts in managing the client's disability. Gender and age preferences The present study found that adult male family members were the primary decision makers and communicated with professionals on issues regarding the client's health. This finding is similar to Grewal, Bottorff, and Hilton's (2005) work. In their qualitative ethnographic study on South Asian women's health and health-seeking behavior, they reported that men were the primary decision makers consulted on a variety of health issues. These authors also reported that men had difficulty in accepting women's changing role of working outside the home because they expected them to fulfill traditional roles of being homemakers. The latter finding may explain in part why some male clients/family members in the present study lacked respect for female SLPs or did not take their recommendation for the clients seriously. Thus, gender preferences by clients and/or family members appeared to compromise the quality of interactions and in some cases undermine the management of participants' goals. It is important to mention that gender preference is not only a cross-cultural issue but could also be due to the tendency for greater communication and comfort level between individuals of the same gender within a culture (Tannen, 1994). Participants in my study did not identify strategies to overcome problems with gender preferences. One possible strategy could be for clinicians to discuss with the client/family member the role they perceive the clinician to have. If that role does not undermine the clinician's professional credentials (e.g., if the client is perceiving you as a daughter, rather than as someone who is incompetent), then accepting that role, reciprocating 187 with respect, and working on clinical goals within clear professional boundaries may be a viable option. If that doesn't help, it may be best to refer the client to a male SLP. Family members and interpreters in my study indicated that older clients were shown respect and cared for by younger individuals within the Indo-Canadian culture, thereby corroborating Grewal et al's (2005) findings that Indo-Canadian elders were respected for their age and guidance on health and valued for their wisdom and experience. On the other hand, challenges emerged due to older adults' perceptions of younger (female) clinicians as lacking in knowledge, skills, and experience. Because of the latter perception, clients became uncomfortable when interacting with professionals who were younger than them. In order to avert communication problems associated with clients' age preferences, clinicians could inquire with clients/family members about their preferences and, if these cannot be accommodated, can share with them how other older adult clients from the same cultural background have worked successfully with younger clinicians. To summarize, differences in beliefs and practices between clinicians and their clients and family members regarding disability and treatment, perceived passivity, as well as gender and age differences, caused breakdowns in communication and division between the two groups regarding management of the client. Nevertheless, through negotiation and showing mutual respect for each other's cultural preferences, participants in my study worked collaboratively toward meeting their clinical goals. Having discussed the role of culture (this section) and language (previous section), I now turn to a discussion of the ways in which culture and language functioned together in their influence on the clinical interaction process and how my findings relate to the theoretical literature on language and culture. 188 6.2.3 Language and Culture As discussed earlier (see section 2.3.1.), language and culture are inherently interconnected. Sapir (1966) and Whorf (1956) argued that differences in language were due to the influences of underlying cultural experiences, and without understanding these cultural experiences, it is challenging to interpret what one actually means. An example provided in the next section refers to clinicians' use of humor, analogies, and metaphors, the meaning of which was often lost in translation due to the cultural meanings attached to certain strings of words and phrases. Because language is molded by cultural processes, trying to address linguistic differences in LCD interactions independently of cultural differences will likely result in an incomplete understanding of individuals' concerns and lead to inadequate coordination of their communicative goals. From a symbolic interactionist perspective, the relationship of language and culture can be viewed as the use of language between individuals during interactions to create group-specific meanings (influenced by cultural beliefs and values) for the purpose of socialization (Charon, 1989). Although Sapir-Whorf hypothesized that language determines thought, this conceptualization of the relationship appears to be static and noninteractional. My findings indicated that despite the linguistic (and cultural) discrepancies between clinicians, clients, and family members, successful communication and interaction did occur in many cases. One could explain this finding by taking a symbolic interactionist viewpoint wherein individuals having different symbols for communication (language systems) and different thought processes modify their existing meanings to accommodate the meanings of other individuals during interactions (Blumer, 1969; Charon, 1985, 1989). It would follow then that an understanding of language and culture necessarily be situated within particular socio-cultural contexts. 189 Kleinman (1980) argued that any cross-cultural study that focuses on clinicians, clients, and illness without taking into account the health care system as a cultural context, distorts reality. He provides an analogy by saying that "just as language can be thought of as a cultural system linking thought and action, health care systems can be considered cultural systems linking illness and treatment" (pp. 43-44). He further described both language and health care systems as cultural systems with forms of symbolic reality, both anchored in cultural beliefs, relationships, and individual behaviour. In my study, the health care system was represented as the clinical context in which clinicians interacted with LCD clients. An integral part of these interactions was the third person involvement (discussed further below), which was necessary for participants to overcome language barriers; however, at the same time, third person involvement was driven by the cultural practices of Indo-Canadian participants wherein family process superseded individual preferences. Thus, the findings in the present study not only support Kleinman's ideas around the intersections of language, culture, and health care practice, they also extend them by explaining how despite these different drivers, interactions were often successful. 6.2.4 Involvement of family members and/or interpreters Another key finding from my study was the costs and benefits of involving multiple individuals in clinical interactions. Including family members and interpreters in interactions increased the complexity of the interpersonal dynamics and affected the processes of building rapport, assessment, and treatment. Drawing on a symbolic interactionist perspective, my study described individuals' interactions (the self) with other individuals (social objects) and presented the interpretation and meanings perceived/created between individuals that led to miscommunication, lack of collaboration, and/or to the participants' modification of these 190 meanings as they attempted to coordinate their respective goals in the clinical interaction (Blumer, 1969; Lai, 1995). In this section, I discuss the challenges and strategies associated with building rapport, the involvement of family members, and the involvement of interpreters. The organization of this section differs slightly from that followed in the findings chapter. In the latter chapter, one subsection addressed the impact of involving other persons on assessment and treatment, whereas in this chapter it made more sense for assessment and treatment (as well as other issues) to be discussed under two subsections, one addressing family involvement and the other interpreters' involvement. Similarly, whereas time and effort were treated as a separate section in the findings chapter, in this chapter it was more suitable to integrate these factors in each of the following subsections. Building rapport My participants indicated that building rapport was the foundation for clinicians to work collaboratively with clients, family members, and interpreters. The more complex dynamics of multi-party interactions required that clinicians build and sustain rapport with each individual involved in the interaction. My findings indicate that although clinicians found this challenging they developed strategies to navigate and build relationships with other participants in the clinical interactions. Some of the strategies they mentioned addressed the following challenges— the language and cultural barriers (including understanding non-verbal cues), the involvement of another person with varying perspectives, and the lack of time. These challenges and strategies are discussed below as they relate to and extend findings from previous research. My findings indicate that clinicians found it difficult to use humor or certain verbal analogies to build rapport with LCD clients and family members. Although humor may be perceived by clinicians as a normal way to establish rapport, using it with different cultural 191 groups created challenges due to the cultural basis for understanding humor (e.g., irony and metaphoric language). In addition, the assumption that injecting humor was appropriate when building rapport in a clinical context did not seem to be shared by LCD clients and family members. Similar to my findings, Vereen, Butler, Kent, Franklyn, Darg and Downing (2006) identified how use of humor could be used as a clinical tool to connect with African-American students during counseling. Their findings indicated that humor had to be incorporated with caution, especially when students came from different cultural backgrounds. When humor was not perceived the way it was intended, the outcome was miscommunication rather than rapport. My results support and extend Vereen et al.'s findings, because, although clinicians indicated there could be difficulties with using humor, they identified several alternative means to build rapport when the use of humor did not work. For instance, clinicians learned simple phrases and gestures in the client's language and used them with clients. Such attempts to accommodate to clients' communication backgrounds appeared to put clients at ease and to assist clinicians in feeling more comfortable communicating with clients. My findings also indicate that some clinicians were not aware of the influence that certain non-verbal cues can have on building rapport. For example, some clinicians lacked awareness about how differences in eye-contact behaviour across cultures could lead to misunderstanding of clients' behaviour and interfere with building rapport. Oetzel, Duran and Lucero (2006) similarly reported that Western practitioners found it challenging to understand their culturally diverse patients' gestures and non-verbal cues. These researchers concluded that patients' problems should be interpreted and understood in the context of their cultural background and history, which was often difficult for Western practitioners who lacked such information. My findings extend Oetzel et al.'s results, because, although participants were generally aware that 192 non-verbal cues varied across cultures, they were not sure about specific cross-cultural differences and what these meant in clinical interactions. Participants in my study did not mention any strategies to overcome challenges with lack of an understanding of nonverbal cues. -One possible way for overcoming such a challenge is for participants to inquire with each other after the session about specific non-verbal cues such as what a hand gesture or lack of eye-contact meant during the clinical interaction. Such information could be obtained from the family member or interpreter involved in the interaction. My findings indicate that building rapport was affected by other people being involved in the interactions (a family member, an interpreter or both). The involvement of others (discussed more fully in the next section) contributed to indirect interactions between the clinician and client, which in turn, made it challenging for clinicians to build rapport with the client. Similarly, Higgins, Dey-Ghatak and Davey (2007) identified the challenges of mental health nurses in involving another person (mainly a family member) in the rehabilitation process for clients with schizophrenia in China and India. According to them, the involvement of family members determined whether there would be a positive or negative effect on the clinical interactions. When family members interfered by determining what was best for patients, it contributed to greater challenges in coordinative communicative goals. In my study, when a third or fourth person was involved in the interaction, interpreters and clinicians suggested that having direct interaction with the client would help build rapport with the client. Direct interaction involved clinicians facing and looking at the client (being aware that female clients may not reciprocate), addressing the client in the first person, and/or having the interpreter or family member stand beside the client. Such direct interaction made the client feel as though they were the primary person of importance, which facilitated voicing their 193 concerns to the clinician. The preceding findings complement research by Henbest and Fehren (1992) on doctor-patient communication. They found that patient-centered communication in which the doctors directed their questions to the patient and allowed the client to freely voice their concerns led to the patient feeling understood, to greater patient-doctor agreement, and to resolution of symptoms and concerns. My findings, like Henbest and Fehren's study, suggest direct interaction between client and clinician was preferred, but they extend their findings by describing additional ways of interacting directly with clients. My findings indicated that the lack of time and effort due to the many individuals involved in the interaction led to challenges in building rapport. In those cases, clinicians who took the extra time to listen to clients' concerns and made efforts to accept family members and/or interpreters in clinical interactions were more effective at building and maintaining rapport with their clients, family members, and interpreters. Wallace (1997) in her text book suggested that additional time was needed with LCD clients in order to gather background information, develop linguistically and culturally appropriate materials, locate interpreters, and assess clients. My findings extend her non-empirical report in that extra time and effort taken by clinicians was perceived to contribute to more satisfied clients and better quality interactions. Building rapport with LCD clients was a complex phenomenon whereby a relationship had to be nurtured in the absence of a common language and culture. The complexity was increased further when it involved family members or interpreters. Findings from my study extend the existing literature by identifying challenges and strategies addressing language and/or culture barriers, lack of time, and involvement of a another person in the clinical interaction. 194 Involving family members in clinical interactions Family members of Indo-Canadian clients were involved at every stage of the clinical process. The close interrelationships between clients and family members affected clinical interactions both positively and negatively. In this section, I discuss the challenges faced by clinicians and interpreters and the strategies they used to include family members. I begin by discussing the positive role that family members can have, and then proceed to talk about challenges and strategies addressing family member's interference in assessment, treatment and the decision making process. Findings from my study indicate that family involvement during clinical interactions most often resulted in positive outcomes for the client. When clinicians incorporated family members, they gained information about the client's history, including their language abilities and cultural preferences/Clinicians integrated family members in clinical sessions by obtaining their help in developing culturally appropriate materials and by educating them on stroke and home training activities. These steps led to better responses from the client and increased motivation in family members to participate in the client's rehabilitation. Positive outcomes due to family involvement were also reported by Leung, Chen, Lue & Hsu (2007), who conducted a survey study investigating the social support and family involvement of older Chinese patients with psychological symptoms. According to Leung and colleagues, family involvement included taking care of the client, reducing daily life stresses, and controlling emotions in front of client. Their results indicated that family involvement positively correlated with older Chinese patients' abilities to cope better with chronic diseases and their better prognoses. Despite the many advantages to using family members reported in the present study, there were also some challenges associated with their involvement in the clinical interaction. 195 During assessment, family members compensated for clients' losses by overstating their capabilities, and otherwise sometimes interfered with the clinicians' assessment and treatment \ activities. These findings are similar to those of Leung et al. (2007), who reported the negative effects of including family members in clinical interactions. Namely, family members brought their own stresses to the interaction, which affected the patient's behaviour and consequently interfered with the clinician-client interaction process. My findings identified strategies participants used to overcome the challenges associated with family members interfering in the clinical process. When clinicians educated family members on the purpose of assessment, involved family members more in treatment than in assessment, and explained to them how their interference could affect the diagnosis of the client, family members' involvement became more constructive. For example, to involve family in treatment activities, communication books were a useful resource used by clinicians to collect information about the client and communicate with family members who were not present at a session. In a sense, these strategies facilitated building rapport, thereby helping participants coordinate their communicative goals. My findings indicate that family members were involved in making decisions for the client, and this often prolonged the time needed for developing treatment goals and activities for the client. In addition, clinicians often had to wait or reschedule sessions when the decision-maker in the family was not available when clinicians made their visits. In a similar study, Kleinman (1980) reported that there was enormous involvement of family members in clients' treatment processes. He indicated family members interpreted the severity of the client's condition and provided treatment for the client, if they thought the client's condition was not sufficiently severe. They also made decisions about whether the client should seek treatment 196 from Chinese or Western medical practitioners. In another ethnographic study, Nunley (1988) investigated clients in two psychiatric hospitals in India and found that families were actively involved in the clinical care process. According to him, someone in the patient's family made decisions about whether patients got treatment and determined what kind of treatment they received. This family member often provided information about the patient, advocated for the client, and provided for continuity of care. Because Nunley's study involved patients with psychiatric disabilities, the degree of family member's involvement, and the patient's capacity for decision-making, were likely issues that differ from a typical client with aphasia. The findings, however, do raise the issue of how much control family members should take in the decision-making process for a client. In the case of a client with aphasia, in which decision-making capacity may be only somewhat affected, making decisions for the client could have a negative impact on the clinical interaction when clients' (and clinicians') goals differ from those of family members. In the present study, it appears that, although family members were involved in making decisions, in contrast to Nunley's participants, they were more passive and did not strongly advocate for the client. My findings did not include any particular strategies for successfully involving family members in the clinical decision making process. Although involving the persons of authority and decision makers within the family in clinical sessions entails taking more time, this extra time can be offset by the more efficient handling of discussing and setting goals and activities for the client. One strategy that might serve to expedite the multi-party decision-making process would be to assign one family member to act as a mediator between the clinician and the family members to convey recommendations of the clinician and obtain decisions of the family. In 197 addition, clinicians could also provide alternative options, so that a joint decision of choosing from one of the options can be made. In summary, due to the interdependence of family members in the Indo-Canadian culture, it is useful for clinicians to involve family members at every stage of the clinical process and to develop clear channels of communication between family members and clinicians. My study findings corroborate some of the literature discussed above in that the advantages from using family members outweigh the disadvantages of involving them. My findings extend the existing literature by providing specific strategies such as using family members for obtaining background information and to assist in modifying assessment and treatment materials. Educating family members about how they can contribute to the clinical process should help promote positive coordination of participants' communicative goals. Involving interpreters in clinical interactions The findings from my study provided the perspectives of clients, family members, SLPs, and interpreters regarding the integration of interpreters in speech-language service settings. In this section, the challenges involved in using interpreters and some of the strategies clinicians use to facilitate their collaborative involvement. I begin by discussing the lack of knowledge of interpreter services by clients and family members. Then I talk about the role conflicts between interpreters and clinicians. This is followed by a discussion of the specific challenges encountered in assessment protocols due to language and culture variations, and a lack of training of interpreters and clinicians. I discuss the strategies used or suggested under each section. There appears to be no existing literature that discusses challenges or strategies associated with clients' and family members' use and access of interpreters in health care 198 contexts. Rather, the existing literature about how to use interpreters is tailored to a professional audience. Thus, my study fills a gap in the literature by identifying clients' and family members' knowledge regarding access to interpreter services for clinical interactions. Interpreters in my study mentioned that although clients and family may have been aware of interpreter services, they were not aware that they could use them. The latter may have been caused by interpreters' lack of visibility to clients and family members. For example, some interpreter services are advertised in newspapers or the internet which could be a challenge for clients and family members who have limited English skills and/or are illiterate. Even if clients and family members were aware of how to access interpreter services, using an interpreter may be too expensive for many clients and family members. Participants from my study indicated that educating the Indo-Canadian community about interpreter services for health care should assist in decreasing the linguistic and cultural barriers to accessing speech-language pathology services. Other possible strategies would be to educate clients and family members during their visits to hospitals on the access and use of interpreter services. Reception areas could also provide verbal/written information in their language on interpreter services. In the event of cost being a factor for the client/family member, some interpreters may be willing to offer volunteer services, or individuals within the client's community could be trained as volunteer interpreters. Although the latter alternative would likely compromise the quality of interpreter service, it would be preferable to not addressing the problem at all. Findings from my study indicated that interpreters primarily perceived their role to be providing direct translation in collaboration with the clinician. They expected clinicians to always be present in the sessions, even when translation involved completing paperwork on the client's history. Interpreters felt disrespected when they were left to do the paperwork with the 199 client as they felt it violated their roles and responsibilities. They were also frustrated as they could not clarify things for the patient without the presence of the clinician. Interpreters suggested that it would be important to educate clinicians on the roles and responsibilities of interpreters. Likewise, clinicians mentioned that providing interpreters who have specific training for working in SLP contexts would help decrease misunderstandings involving expectations and facilitate working together. A review by Wallin (2006) indicates that the role of the interpreter in cross-cultural health care settings has received little attention in research. Her review identified only 13 papers that discussed the role of the interpreter, and minimal description was obtained regarding their role and impact on the clinical sessions. Langdon and Cheng (2002) reported on interpreter responsibilities and SLP responsibilities during interpretation. However, they did not provide information about conflicts that could arise between these two professionals. My findings contribute to an emerging literature that identifies conflicts in the roles and responsibilities of clinicians and interpreters. Findings from my study point to several challenges associated with interpreting for SLPs and clients during clinical assessment. For example, clinicians expected interpreters to identify speech errors such as slurring and sound substitutions in the client's speech. Since interpreters lacked knowledge about specific speech disorders, it posed a challenge for them when translating for the clinician. Avery (2001) and Langdon and Cheng (2002) presented general pre-assessment guidelines for interpreters and the challenges for interpreters from the SLP's perspective. According to them, interpreters should be knowledgeable to identify the type of errors in the client's language described above. My findings, on the other hand, indicate that interpreters found it challenging to identify errors, because they did not have prior training on specific 200 speech-language disorders. Langdon and Cheng (2002) suggest strategies to overcome the challenges interpreters encounter in clinical interactions. They suggest that clinicians brief interpreters before the session, and then debrief them after the session to set up appropriate expectations and consider how to improve interpreting between clients and clinicians. My study supports Lang and Cheng's suggestion in terms of interpreters commenting that more time taken before and after the session enabled them to better prepare and assist participants during clinical interactions. The use of interpreters also created some difficulties around translating certain linguistic content. For example, interpreters found it difficult to translate some words, phrases, and humor from English into Punjabi since equivalents did not exist in Punjabi. Similarly, Langdon and Cheng (2002) identified linguistic challenges in translating idiomatic expressions, emotional connotation of words, and humor from English to Spanish. Interpreters from my study mentioned that they routinely request information from clinicians on whether they need to use formal or colloquial vocabulary because formal and colloquial vocabulary have differences in word meanings, which could possibly lead to misinterpretation if the interpreter uses the wrong vocabulary. Interpreters reported that one strategy to overcome the problem of differences in formal and colloquial vocabulary was for clinicians to obtain such information from family members based on the educational and urban/rural background of the client and convey that information to the interpreter. Such information can facilitate decisions on using formal or colloquial vocabulary with the client and avert lack of understanding and misinterpretations in clinical interactions. So far, I have discussed the challenges perceived by interpreters. In what follows, I discuss the challenges encountered by clinicians in clinical assessment. My findings indicated 201 that according to clinicians interpretation quality varied according to interpreters' experience and language skills. Avery (2001), Bot (2005) and Langdon and Cheng (2002) also identified lack of training of interpreters for health care settings as one of the challenges in using interpreters. My study extends their findings because both clinicians and interpreters suggested that specialized training for interpreters in speech-language pathology would bridge the gap between SLPs and interpreters and facilitate their working together effectively. Clinicians also identified challenges associated with interpreters compensating for clients' losses. That is, clinicians perceived interpreters to add information and provide explanations so that clients could better understand what was said by the clinician. When interpreters made the client look better, clinicians indicated it was challenging for them to obtain objective assessment data. Merlini and Favaron (2005) studied SLP interactions involving interpreters, first generation Italian immigrants clients, and their English speaking Australian SLPs. Their results indicated that interpreters had a great influence on clinical interactions. They shared control of turn taking and topic development with the SLP when interacting with the client and slowed down for the benefit of the patient. Interpreters also provided explanations to clients that were not originally provided by the SLPs. As a result, clients in their study identified with interpreters and responded better when interpreters encouraged them. Bolton (2002) in his ethnographic investigation of using interpreters also identified interpreter statements as not being precisely what the doctor said and unclear messages being transmitted to the client. The findings from the present study support these two studies by demonstrating the potentially negative impact that interpreters can have on the clinical interaction process. Such intervening behaviours can cause clients to appear less impaired than they really are and, therefore, the diagnostic process may be compromised. Some of the strategies identified in my study for helping to 202 prevent interpreters from compensating for clients' losses include: clinicians clearly explaining to them the nature and purpose of the assessment prior to the session, providing specific instructions on how many times the interpreter can repeat, and cautioning them on the use of non-verbal cues or gesturing when it may interfere in clinical interactions. These findings address a gap in the literature on strategies clinicians could use to more successfully coordinate with interpreters. My findings indicated that interpreters were not only used for language translation during clinical sessions but also for cultural interpretation. Although clinicians preferred getting cultural information from interpreters, interpreters provided cultural knowledge only when they identified or anticipated the potential for misunderstanding or misinterpretation between SLPs and clients. My findings regarding the perspective of clinicians are in agreement with Hwa-Froelich and Westby (2003), Bot (2005), and Langdon and Cheng (2002). They reported that interpreters were expected to provide cultural knowledge as part of their roles during interactions. My findings also concur with Bolton's (2002) statement that although interpreters were strictly there for translation, they were often invited to be cultural brokers and they did provide cultural information at their discretion. Interpreters in my study reported that familiarity with Indo-Canadian sub-cultures was almost impossible due to the many sub-cultural differences within the Indian culture. Sub-cultural differences are more diverse than the sub-cultural differences in North America, and interpreters reported that they cannot be expected to be familiar with the cultural backgrounds of all Indian clients. My study extends previous work by providing an explanation for why interpreters preferred not to provide cultural knowledge and a strategy clinicians could use to obtain cultural information. Namely, interpreters suggested that cultural 203 information should be obtained by the clinician by asking the client and/or family member (through the interpreter's translation). Findings from my study also speak to clients' and family members' perspectives about using interpreters. Most of these participants reported that they did not want an interpreter despite their limited language skills. Although the literature does not speak to this issue, one possible explanation for such a perspective could be due to the fear that an interpreter who spoke the same language and was from the same culture would gossip about the client's condition. As discussed earlier, since disability is often kept a secret in Indo-Canadian culture, participants preferred using family members instead of professional interpreters. Family members identified dissatisfaction with interpreter services when challenges were encountered due to the different dialects between client and the interpreters. However, as discussed earlier, passivity and acceptance of the clinicians' decision led family members to not voice their concern during the clinical interactions. Using interpreters in SLP settings has costs and benefits. While interpreters can serve to overcome the linguistic barrier between clinician and client and act as cultural brokers, their impact on the clinical interactions must be carefully considered. For interpreter services to be effective, interpreters and clinicians must be educated on the expectations and goals of each other as well as the clients. Coordinating and working together can avoid conflicts, improve relationships and facilitate good communication. 6.2.5 Contributions to theory To conclude this section on the three conditions identified in this study, I refer to a theory that seems to capture both the interdependence of language and culture and the dynamic processes involved in multi-party interpersonal health care interactions—'communication 204 accommodation theory' (Giles, Coupland & Coupland, 1991; Small, 2006). In particular, communication accommodation theory provides additional perspective on how participants in this study accommodated to each other in an effort to coordinate their communication goals. This theory addresses how communicators modify their language and nonverbal behaviours in interpersonal interactions according to their perceptions, stereotypes, and beliefs about the other person(s) in the interaction. For example, when perceptions or beliefs lead one to view another communicator as lacking in competence, it can lead to over-accommodating behaviours. In the present study, this occurred when clinicians perceived and assumed that an Indo-Canadian client did not speak English (when he actually did), and consequently, spoke through an interpreter to the client. On the other hand, communicators may under-accommodate another person if they perceive or assume (mistakenly) that the individual has certain abilities. An example of this from my study is when clinicians expected interpreters to be capable of recognizing certain speech characteristics in clients (when interpreters indicated they could not). Since either over- or under-accommodating behaviours often lead to communication breakdown (Small, 2006), communicators who seek to have positive interactions with others need to make individualized accommodations by coming to an understanding of each person's needs, goals, and communication styles; The findings from my study contribute to the literature on communication accommodation theory by indicating that over-accommodating and under-accommodating behaviours can create challenges during LCD clinical interactions. When participants did not accommodate to each other in ways that supported the other's needs, goals, or beliefs, this created barriers to effective interaction. On the other hand, participants mentioned using 205 strategies to overcome these barriers, and oftentimes these strategies involved modifying their communicative behaviours to accommodate to the beliefs and goals of others in the interaction. My study also extends the relevance of communication accommodation theory in different contexts by showing the importance and complexity of taking into consideration the varying perspectives and beliefs of multiple individuals during LCD interactions. For example, clinicians may slow down, use simpler vocabulary, or exaggerated intonation based on perceptions they have of a client's limited language abilities. Although such accommodations may address clients' linguistic competencies, they may not be welcomed by the clients and/or family members, and may rather be seen as patronizing. In a situation where a client may not mind such accommodations, but a family member does, it would be important for the clinician, before making accommodations, to talk with the family member about their knowledge of the client's functional abilities as well as their perceptions about how to effectively and respectfully accommodate to the client's needs. My findings indicate that accommodating only one individual's needs may have detrimental effects in working with another in multi-party interactions. Hence, in multi-party interactions, each communicator is faced with trying to accommodate to more than one person at a time. If this were not challenge enough, when differences in participants' language and culture are entered into the mix, the challenge of accommodating to the linguistic and cultural systems of each party becomes daunting. Yet, the findings from my study indicate that through coordinated effort by all involved, the multiple goals of participants in LCD clinical interactions can be successfully reached. 6.3 Implications My study is unique in providing a theory about how participants in LCD clinical interactions coordinate the process of achieving their respective goals. The findings support 206 some previous reports in the literature based on anecdotal evidence, but they substantiate anecdotal information by providing an empirically based theory that incorporates the challenges encountered and strategies used by individuals in LCD interactions. My findings have implications for clinical practice in speech-language pathology and other health care domains, education, future research, and policy. This section discusses these implications as well as some of the limitations of the present study. 6.3.1 Clinical practice The perspectives of participants provided insights about how SLPs might effectively manage the challenges and coordinate the strategies used in assessing and treating LCD clients. The issues raised in the present study not only represent clinicians' perspectives but also those of other participants in the interaction, specifically, clients, family members, and interpreters. By documenting participants' shared and differing views on challenges and strategies, more specific and relevant courses of action can be implemented in clinical practice. Up to this point in the chapter, some references to practice issues have already been mentioned in relation to specific findings from this study and related research literature. In this section, some more general implications for clinical practice are presented. The findings indicated that clients' proficiency in English can make diagnosis a challenge for SLPs in English-speaking contexts. Since language differences may be misperceived as language disorders, clinicians need to be cautious when assessing ESL or limited English speaking clients. In addition, the findings suggested that SLPs need to aware that humor, analogies, and metaphors cannot be easily used with LCD clients due to lack of a language and cultural match between the two languages. The language differences also have an impact of the assessments used for clients. SLPs need to be aware of the challenges with standardized 207 assessment procedures and be prepared to implement suitable alternative procedures such as informal or dynamic procedures to obtain more useful information from the client. In addition to language issues, the findings indicate that SLPs need to be aware of their own beliefs and values in comparison with those of their clients to appreciate similarities and/or differences. This study provides evidence that when there are differences SLPs can avoid communication breakdowns by acknowledging those differences and adapting accordingly. One issue that SLPs need to keep in mind is that decision making for the Indo-Canadian client within the family is dependent on multiple individuals. The resulting complexity of interpersonal dynamics means that a strategy that works for decision-making in one family may not be the same for others. For example, although a mother-in-law could be a decision maker in two Indo-Canadian families, the client in one family may be pleased with her decisions whereas in the other he/she may show opposition. In such circumstances, it is best to consult with the client regarding the involvement of such a family member, before involving them in the decision making process for the client. Apart from the language and cultural issues of clients/family members, the findings indicate that SLPs would gain from knowing interpreters' roles and conflicts that can arise due to differing perception of each other's roles. From the perspective of interpreters, more collaborative partnerships between SLPs and interpreters could be developed by making sure the expectations, roles, and responsibilities of each participant in the clinical interaction is clarified before, during, and after each clinical interaction. SLPs can attempt to spend more time during clinical sessions to build rapport with all parties involved in the clinical interaction, to elicit the preferences of clients and family members, to modify the clinical process accordingly, and to 208 work with them in developing therapy goals. Increasing time spent for these purposes is likely to pay substantial dividends when it comes to helping clients achieve their goals. My findings also contribute to the social approaches to the management of aphasia such as the Life Participation Approach to Aphasia (LPAA, 2000). The LPAA combines many different social approaches from around the world for managing aphasia. The basic assumption is that life with aphasia affects and is affected by those around a person with aphasia, which can in turn result in an enabling or disabling environment (Simmons-Mackie, 2000). In LPAA, other individuals (e.g., family members) are trained to support and facilitate communication with the individual with aphasia in an effort to increase the aphasic client's participation, social connections, and overall well being (e.g., Kagan & Gailey, 1993; Lyon et al 1997). My study identified some of the factors that enabled participation of others (strategies) and factors that disabled or hindered their participation (challenges). My findings indicated that communication and language modifications on the part of the clinician, the interpreter and/or family member by slowing down, using simpler sentences, and repetitions resulted in better communication between the client and the other individual. Some of the social strategies incorporated by clinicians were encouraging clients to communicate despite their struggles, and educating family members on aphasia and how to support the client's communication. These findings indicate the need to train SLPs as well as other communication partners on modifications that can facilitate communication by and with an individual with aphasia. My findings of how others can support communication also compliment the communication accommodation theory (discussed above) that suggests that partners accommodate to each other's communication needs and goals in an effort to improve communication. 209 6.3.2 Education The findings suggest that education is needed to inform graduate students and practicing SLPs about the challenges encountered in increasingly diverse SLP clinical contexts. While many of the findings are relevant to working with any LCD client population, some results are specific to Indo-Canadian clients. For example, students could be educated in their course work about the specific linguistic and cultural issues encountered with the Indo-Canadian client populations and the strategies to effectively deal with them. Students could also be given practical experience in clinical sessions that involve Indo-Canadian clients. Similarly, continuing education program developed for practicing clinicians could help them develop skills and knowledge in interacting with LCD clients. My findings on using third parties in LCD clinical interactions could be used to educate students, clinicians, family members, and interpreters about how to effectively work together in complex multi-party clinical interactions. This would entail providing information on the impact of family members and/or interpreters' contributions to assessments and treatment, the roles and responsibilities of interpreters, and the influence of the language and cultural background of each party on the interaction process. Workshops for interpreters could provide information and training on translating in speech-language pathology settings and the purpose of different assessments. Educational sessions directed at clients and family members could focus on issues related to stroke, services that are available for communication disorders, and how to access these services. Providing education and training to each stakeholder in the interaction provides opportunities for them to be more sensitive to the linguistic and cultural differences that shape communication in LCD interactions. 210 6.3.3 Future research Although this study supports and expands on work addressing services for linguistically and culturally diverse clients, my findings point to several areas in need of further research. First, we know very little about how differences across the languages/dialects and cultural practices of Indo-Canadian clients in Canada (e.g., Punjabi and Hindi) influence the quality of SLP interactions. Research on this topic will elucidate the role of specific linguistic components and culturally determined behaviors in LCD clinical interactions. Second, there is a need for research on the influences of a client's English proficiency and cultural background on the assessment of communication disorders so that clinicians can know how to better differentiate language and cultural differences from language disorders. Although the present study included client participants who had varying degrees of premorbid English proficiency, there were insufficient numbers of clients from differing levels of proficiency to explore whether the challenges and the strategies they each use in clinical interactions varied substantially. One could surmise, for example, that at a certain level of English proficiency, clients become more likely to seek SLP services and continue with therapy. One might predict that the degree of clients' acculturation to mainstream North American culture would factor into this equation, such that the more acculturated one is, the fewer barriers he/she would encounter. Research exploring the experiences of bilingual/bicultural Indo-Canadian SLPs when interacting with Indo-Canadian clients would also contribute to our understanding of the challenges they face and the strategies they employ to manage such clients. Such research has the potential to identify the similarities and differences between monolingual native English-speaking SLPs and Indo-Canadian SLPs and thereby help monolingual English speaking clinicians better manage interactions with Indo-Canadian clients. 211 Future research should also include observational data which captures different combinations of dyads—clinician and client, clinician and interpreter, and clinician and family member—in order to identify specific discourse patterns and points at which challenges, misinterpretations, and breakdowns occur in dyads' communicative interactions. Findings from this research could assist clinicians in identifying conversational behaviours that either assist or detract from successfully coordinating the roles and expectations of those involved in the interaction process. Finally, the results from my study indicate the importance of developing and providing appropriate resources for assessing Indo-Canadian aphasic clients. One resource that is lacking is standardized test materials and language specific assessments in the client's language. Further research is needed to evaluate the reliability and utility of alternatives to standardized procedures when clinicians cannot administer standardized tests. Another resource that is often needed in LCD clinical interactions is interpreter services. Family members and interpreters are increasingly being involved in clinical interactions with LCD client population yet research is needed to explore the relative use and effectiveness of family versus professional interpreters in SLP clinical interactions. 6.3.4 Policy While the needs of Indo-Canadian adult clients in some ways are similar to the general adult client population, there are specific needs of this population that would benefit from the attention of policy makers (keeping in mind that my findings are not applicable to all Indo-Canadian clients). Some of these needs revolve around the personal and socio-cultural expectations of this client population. For example, there is no stroke or aphasia program in British Columbia that contributes specifically to the rehabilitation services of adult Indo-212 Canadian clients. My findings indicated that Indo-Canadian participants preferred to have services in their native language. They also indicated that they preferred to be seen in their homes. Although accommodating to the language and location preferences of clients seems like a reasonable request, the resources required to train and recruit sufficient bilingual/multilingual clinicians and/or provide in-home SLP services would likely be prohibitive in the face of current health care funding constraints. A more cost-effective alternative to these measures might be to augment ESL education programs for those adult Indo-Canadians with limited or no English proficiency. Gaining some facility in English would not only be a benefit to them in the clinical realm but would likely increase their participation in and contributions to Canadian society at large. It seems clear that increased funding from various sources would facilitate programs and investigations to increase the provision of appropriate SLP services to LCD populations. Health care systems could liaise with educators (community or university), Indo-Canadian heritage and community organizations to increase clients' access to information and services. It is only through partnerships among different stakeholders that policy makers may consider altering the current system in a way that honors the needs of LCD clients, and ultimately, creates a system that is accessible and affordable to all adult clients. 6.4 Limitations of the present study Although the findings of this study further our understanding of how participants coordinate the communicative process in LCD clinical interactions, there are some limitations that should be mentioned. First, the limited number of participants in each participant group and relatively small overall sample size limit the extent to which the findings can be applied to other LCD contexts and situations. In addition, the challenges with recruiting adult Indo-Canadian 2 1 3 aphasic clients, and their communication difficulties, led to a limited amount of data being obtained from the client group. Nevertheless, the grounded theory method used in this study accounted for the diversity of participants' perspectives and led to a theory that explained how participants coordinated their goals for successful interactions. The theory captures an interactive process "coordinating communicative goals," and conditions that may be applicable to other cultural groups who are encountering similar challenges around reaching mutually satisfying communicative goals. For example, groups such as Francophones or Hispanics accessing services in English could benefit from considering the stages and conditions described in the theory. Another limitation of the present study was that analysis of participants' perspectives on each issue was not systematically carried out within the same group (e.g., client group) and compared to that of the other groups. This was not done as it was beyond the scope of the present study. Nevertheless, as mentioned in chapter five, some general description was provided of intergroup variability on the major issues. This analysis indicated that all participants perceived language to be a barrier to communication and interaction and all participants employed strategies to overcome language barriers. All participants except clients perceived challenges arising from third person involvement in clinical interactions. Although all participants provided strategies to overcome challenges to a third person involvement, clinicians and interpreters predominantly provided strategies to overcome the challenges with third person involvement. Cultural barriers were predominantly perceived by clinicians, but were also reported by some family members and interpreters. Further secondary analysis could explore more detailed across-group differences on the occurrence of particular challenges and strategies. 214 Apart from sample size limitations, almost all of the Indo-Canadian participants were from one state in India, namely Punjab. This homogeneity was useful in the present study since these participants had a common language and cultural background, and given that there are a large number of Punjabi immigrants in Vancouver, B.C. On the other hand, Punjab represents only one of many states in North India, and therefore, future research could explore how participants from different states across India may approach clinical interactions from different perspectives. In the present investigation, I shared characteristics with the participants because I am an SLP who immigrated from India. While this was an advantage in understanding some of their cultural practices, it also had the potential risk of participants providing me with less information because of assumed shared background or for fear that I may disclose information to the SLP currently working with them. They also might have been biased in providing information they thought I wanted to hear. On the other hand, monolingual English speaking SLPs may have been skeptical to share information with me due to perceptions that I shared the same cultural background of the Indo-Canadian clients and/or because as an Indo-Canadian SLP I was perceived as being in a better position to interact with Indo-Canadian clients. To reduce the effects of these potential influences, I offered confidentiality of all information disclosed by participants. I also kept a reflective journal to consider ways that my perceptions might be influencing my data collection and analysis. It is also possible that Indo-Canadian participants shared more information with me because we had a common cultural background. The perspectives of some participants represented recollection of past clinical interaction experiences. Because time had lapsed between their clinical experiences and their interviews, their accounts may have been subject to lapses in memory and intentional or unintentional 215 reconstructions of their experiences. Some of these participants might have presented different perspectives if they had been interviewed in closer proximity to their actual clinical experiences. Another limitation of the present study was the difficulty in implementing theoretical sampling throughout the study due to the challenges in accessing and obtaining participants for follow-up interviews. Although multiple sources of data were used for analyses, the findings were developed from one interview with each participant. Different and/or additional findings might have emerged had multiple interviews from each participant been conducted over time. In addition, although categories were developed from participants' perspectives, and a reflexive journal was maintained through out the study, there could have been instances where I modified or altered meanings during the final development of the theory. Despite these challenges, the rigorous analysis carried out in the present study allowed me to identify the processes that participants used in coordinating their goals in diverse clinical interactions. Lastly, the development of the substantive theory was based exclusively on my interpretation of participants' experiences. Participants did not participate in the analyses in the present study. The findings could have been strengthened by providing participants with the opportunity to comment on the researcher's interpretation and their fit with how they understood their experiences in clinical interactions. 6.5 Chapter summary In this chapter I discussed the findings of the present investigation, their contribution to the existing literature, and implications of the findings for practice, education, policy, and conducting further research in this area. Current research has provided a relatively limited understanding of language and cultural differences in adult Indo-Canadian SLP clients. Moreover, we have had a poor understanding of the effects of involving a third person (either a 2 1 6 family member or an interpreter) in clinical interactions. Using a symbolic interactionist framework and a grounded theory method, the present study explained multiple participants' perspectives as these related to coordinating their communicative goals for successful interactions. 6.6 Conclusions and final reflections This unique qualitative study has resulted in a theory of how SLPs manage clinical interactions with Indo-Canadian adult aphasic clients. It has increased our understanding of the experiences of participants in clinical interactions when they do not share a common language and culture. The symbolic interactionist framework added richness to our understanding of the experiences of participants in diverse clinical interactions. The use of grounded theory in the current investigation allowed me to construct a theory developed from data that led to understanding participants' efforts to coordinate communication during clinical interactions. The key finding from the present study was that participants encountered challenges and implemented strategies in order to achieve their respective goals in clinical interactions. Three major conclusions that can be drawn from the present study are: 1. Several factors contribute to the challenges encountered in LCD clinical interactions; a) the competencies of SLPs and clients, and their culturally determined management styles, b) limited clinical resources and time, and c) involvement of many individuals in the clinical interactions. These factors seldom operate in isolation, but rather are interconnected. 2. Challenges are encountered by multiple parties in the clinical interaction (i.e., clinicians, clients, family members and interpreters). Understanding the challenges affecting each group of individuals is vital to developing methods and strategies to overcome the challenges encountered by all participants in clinical interactions. 217 3. Participants use a variety of strategies in an effort to overcome challenges. The use of strategies involves an on-going process of working collaboratively towards achieving participants' goals. Participants' perspectives and experiences are of great importance to SLPs who are increasingly faced with everyday encounters with clients from different linguistic and/or cultural background than their own. Perspectives of participants from the present investigation provide insights on the various linguistic and cultural issues of Indo-Canadian clients that need to be considered by health care professionals. Knowledge of participants' experience has the potential to make clinical interactions less challenging and more enjoyable, and ultimately, to enable those involved to successfully meet their goals regarding SLP services. Final reflections I would like to offer a few final reflections on my experience using symbolic interactionism and grounded theory as these helped me in exploring the individual meanings participants gave for different actions, activities, and situations during LCD clinical interactions. The concept of an "act" in symbolic interactionism enabled me to look at the individuals' perspectives on challenges and strategies during face-to-face interactions. For example, the concept of 'self sensitized me to identify individual perceptions such as language competencies, perceptions of roles and responsibilities, and how individuals perceived disability and treatment and had different preferences. These differences were then compared to the larger society which was comprised of individuals from the same socio-cultural group (Indo-Canadian) or a different socio-cultural group (Euro-Canadian clinicians). Symbolic interactionism also enabled me to understand how individuals interacted with objects such as assessment tools and other individuals such as family members and interpreters. It provided a basis for understanding how 218 individuals used language as a means of communicating meaning and the modifications they made to meanings based on their interactions. It also enabled me to understand that when challenges were encountered, individuals changed their course of action and meaning to accommodate the lines of actions of others. When these lines of action and meaning were not accommodated, there were breakdowns in communication. Grounded theory seemed the most applicable method for the purpose of this study as it complemented symbolic interactionism by enabling me to identify the perspectives of multiple participants regarding communication in face-to-face clinical interactions. Although it did not allow the in-depth exploration of a single clinical context in understanding verbal and non-verbal behaviors of participants (which ethnography would have provided), it enabled me to identify the meanings of actions (linguistic, cultural, and third person involvement) and processes (challenges that led to the employment of strategies) that different participants provided in different clinical settings. The constant comparison method of analysis in grounded theory enabled a line-by-line analysis of the interview transcripts that could be subsequently compared with other transcripts in order to allow for a cross-comparison of multiple perspectives. Such a process in grounded theory allowed for the management of the data during the development of codes and categories. The conceptual categories, conditions and properties of challenges and strategies reflected the basic social process of coordinating communicative goals in LCD clinical interactions. The qualitative design used in the present study provided a holistic in-depth understanding and explanation of adult LCD clinical interactions. My study contributes to the emerging body of qualitative research that investigates cross-cultural interpersonal interactions in the discipline of communication sciences and disorders. My study also compliments and further 219 expands on the limited existing quantitative investigations on adult LCD interactions. Despite the contributions of the facts provided by quantitative investigations, many such studies lack in providing contextualjy specific interpretations of those facts. For example, Kritikos (2003) survey study reports that SLPs encounter challenges when assessing, scoring, and interpreting test results with LCD clients. My study goes beyond this by providing a more in-depth understanding of the underlying causes for those challenges and how some of those challenges were managed by participants. Such knowledge from qualitative investigations can help clinicians to gain a contextual interpretation of quantitative findings, thereby contributing to their evidence-based practice for LCD clients. In conclusion, my findings demonstrate that diverse clinical interactions involving multiple individuals need to take into consideration the influence of language and culture on each individual involved in the interaction. In addition, such multi-party clinical interactions are situated within the larger organizational unit of the health care system and incorporate the many structural features (e.g., time and settings) that influence the interactions. Continued research will further our understanding of how these individual and contextual factors operate together, with the goal that SLPs will be better informed as they seek to provide culturally attuned services for LCD clients. 220 References Agar, M. (1994). Language shock: understanding the culture of conversation (1st ed.). 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