"Hidden rules": a duo-ethnographical approach to explore the impact of culture on clinical practice.

Thomas, Amy ; Sham, Fiona Tsz Ying

Prologue

The growth of rigorous qualitative methods for music therapy research has opened opportunities to systematically explore clinical practice. However the dynamics of some issues remain difficult to unpack. For this article we used a duo-ethnographic strategy to explore our experiences of culture in practice. Education researchers Sawyer and Norris (2012) drew on ethnography and narrative research to develop duo-ethnography. The process of creating a dialogic narrative provides multiple understandings of a shared phenomenon. This process is also intended to be transformative for the authors, creating a transparency and articulation of perspectives, thoughts, and wonderings while purposefully creating self-reflexive reconstruction (Sawyer and Norris, 2013).

For clinicians in Australia "culture" is a broadly stated topic with multiple dimensions such as the experience of the client, the therapist or the context of care. We have a tendency to be tentative in our discussion and review of culture because each perspective may have sensibilities about which we are unsure. However as Sawyer and Norris note, the difficult conversations are needed because when fundamental questions are ignored, "such questions do not go away. Instead they become personally and socially resonant." (2013, p.1).

Process

The primary author is an Australian music therapy senior clinician, and the second author is a Chinese clinician who works with and is supervised by the primary author in a sub-acute hospital setting. During supervisory sessions, we had many discussions about the impact of cultural background on clinical practice. We agreed that this topic was important to a wider audience, rather than remaining in supervision discussions, and decided to explore a more systematic approach to reviewing how our own backgrounds and experiences impacted our clinical practice. After reading Norris and Sawyer (2008), duo-ethnography appeared to be a research method that would champion our exploration more thoroughly.

We engaged in a series of four recorded conversations about our experiences of music therapy and culture. Between the conversations, we independently reviewed each recorded conversation and reflected on themes we considered important to the dialogue, drawing on our clinical experiences and relevant knowledge from the literature. This allowed new realisations to emerge and be explored further in the next conversation. The relationship between the two authors has an obvious imbalance as senior clinician and clinician, which we acknowledged early in our conversations. The accumulated dialogue is presented as a conversation to emulate the process by which it was prepared, focussing on our own perceptions of culture, rather than what has been written more widely in the literature.

The Dialogue

Fiona In my first music therapy placement during my training, one of my challenges was the English language. My English was not very fluent and I couldn't follow conversations well. I struggled in this placement and I thought it was because of the language barrier and my music therapy skills. Over time, I realised that while I had thought these challenges were an issue of language, it was really because of different aspects of culture. The only way to overcome some of these challenges was to learn more about Australian culture. To really understand a culture I think you need to understand the society and how to relate to people from that culture. I started to understand this more when I completed my Master's thesis on the training and practice challenges for music therapists originating from Asian countries (Sham, 2011). My experience of learning and adapting to a new culture is a concept called "acculturation". Berry (1980) describes acculturation as the process of moving into a new culture, knowing the language, knowing the social norms, knowing the lifestyle and "hidden rules". I can really relate to this process. When I moved to Australia I experienced the "separation" process, maintaining my own cultural heritage and not ready to adapt to a new culture. I think I am now in the "integration stage" maintaining my own culture but learning a new culture simultaneously (Berry, 1997).

Amy Defining culture is important isn't it? I have always thought of culture as how we live and what we do, and our traditions. And this would be how I define culture, for myself and in my clinical work.

Fiona When I first moved to Australia I also thought traditions and the way people live were what defined culture, but the longer I live and work in Australia the more I find it's much more than that when understanding another culture. What helps you to understand another culture are all the things you are not aware of if you are living in your own culture.

Amy That's interesting that even our definitions of culture differ! I do have some experience of living in Sweden for 12 months, but it is very limited compared to your current experience in Australia. I attended school there but I did not work in that culture. It makes me question what is important to understand culture.

Fiona Culture is not only what people do traditionally, but it is the relationship between people. For example the way you talk, what is polite, asking the right questions and using humour. These are the things that you take for granted when you live in your own culture, but really notice and have to try and understand when you live in another culture. It is these things that are important. For example in Hong Kong I easily make friends and in a group of people and I would be a humorous person. I don't think you can tell in Australia, because I don't know how to use humour here. I told a joke to a group of people recently. My friends from Hong Kong found it funny, but my Australian friends gave me a blank look and didn't seem to understand. Humour is important in developing interpersonal relationships. These are the little things that are hard to identify and articulate when talking about another culture. These are "hidden rules". You also need to understand the systems of a culture such as health and education to be able to live in that culture.

Amy So what I'm hearing from you is that there are three parts to culture. There are the aspects of culture that you are able to learn such as traditions, the aspects of culture that you are not able to learn or "hidden rules" and the third is a systems level of culture. I have not ever considered culture in this way. Is any one of these more important than the others?

Fiona Actually I think they are equally important and interrelated. All of these aspects of culture impact on how people interact in a society, but from my perspective the "hidden rules" are more difficult to understand than the others. It is difficult because you don't know what you don't know! Clinically, I think it is the hidden rules that affect how the music therapist builds the therapeutic relationship and rapport.

Amy Okay, as I reflect on that, I realise that if I was working with someone from a different culture I think I would look at the learned aspect of culture, such as their spoken language, music, traditions and festivals. I think of these issues particularly when assessing a patient and needing to understand and respect them to be able to address their needs effectively.

Fiona I can relate to that and like you I am definitely aware of the learned aspects of culture when assessing and working with a patient, but I don't feel the need to investigate it further with them. To me the learned aspects are more obvious and I can discuss these things with the patients or look it up when needed. It is the unlearned things that impact on my clinical practice more. These things affect the therapeutic relationship.

Amy I don't think I have ever have thought of culture as being so multifaceted. My own experience of Australia is that it is a multicultural society. I went to school with students from many different countries, my sense if that Australia encompasses people from many cultures. I realise that in my clinical practice I have assumed I will always work with patients from a variety of different countries and cultures because this is where I grew up and what I know. I reflect on my own time living in Sweden for 12 months before training as a music therapist and this may have affected my perception of culture, but I am not currently living and working in a different culture. And maybe this means that in relation to culture I assume more things in my clinical practice. I understand a person has a different background and speaks a different language but at some level I think I assume they have an understanding of the Australian systems and our culture.

Fiona While for me, the more I am aware of the cultural differences the less I assume in my clinical work. I think am definitely aware of the aspects of culture more because I live and work in a country that I did not grow up in.

Amy And so the assumptions we make in our clinical practice are different because of our backgrounds and our definitions of culture. I am really interested in hearing more about how you have transferred your thoughts and perceptions of culture to your professional clinical practice.

Fiona At the beginning, I struggled in my clinical placements. The way I thought about patient needs was different. The general needs of people in Australia and Hong Kong may be similar, but Hong Kong people perceive healthcare and music therapy very differently to here in Australia. Healthcare in Hong Kong is faster paced and people need to see therapy as immediately effective with clear outcomes in a short period of time. It is more prescriptive, so if someone was receiving music therapy they would want to know how many sessions are needed to "get better". Australia sees all of a person's needs--physical and psychological. In Hong Kong it is more task-orientated.

Amy So in Hong Kong would you not receive the same referrals as we do in this setting, to address people's mood, anxiety, and depression?

Fiona People working in the health system in Hong Kong are aware of these patient needs, but not many people are willing to spend the time, effort or money to treat or address these issues. In Australia individuals are more willing to seek help, like seeing a psychologist or therapist. This difference in treatment focus and outcome orientation, also means that when working in Australia, I also feel the need to use my interpersonal skills differently, such as empathy.

Amy So culture also impacts on clinical skills like the use of empathy. I am wondering whether empathy is defined differently in Australia than in Hong Kong?

Fiona I think the definition of empathy is the same, but when I work with people from Hong Kong, I also understand the background story, so what their stressors are for each issue. We share an understanding, so it is easy to "feel" with them, because they don't need to "spell it out". But if they are from a different culture, I don't always understand the background to the stressors of the issue.

Amy So that makes me wonder why? I think about the fact that you are trained in Australia, and a part of that training is to identify client issues and the stressors they produce. Our patients don't always tell us, and our role as a clinician is to identify these issues. So if we are both using this trained skill, what is the difference?

Fiona Well firstly I'd like to emphasise that yes because of that training, generally it is fine. But I am always aware that I did not grow up in this culture and even though I've been here for five years to train and work, it's not the same. I empathise with clients through how they describe their stories and feelings. However as I grew up in another culture, which has different norms, values and beliefs, those same events might not evoke similar emotions on me. For instance, I remember that in a lecture we identified the possible needs of a cancer patient. I answered financial issues, but the lecturer told me that the medical costs are covered by the government, which is different from where I came from. Another example is that the relational needs of family might also be different due to the different perceptions in roles and responsibilities of family members.

Amy Hearing you speak of your experiences emphasises to me just how much culture impacts on our clinical skills.

Fiona Yes I agree. It might sound odd but I'd like to talk about silence and eye contact. These are subtle but key aspects of the therapeutic relationship. When I did my social work training in Hong Kong, we sometimes avoided eye contact to give the patient more space, but here in Australia we are encouraged to maintain eye contact during the silences. How much silence is appropriate? I don't have a definite answer to this, and I think it is because I am from a different culture.

Amy So for me, I actually think there is the fine line between silence and eye contact being a cultural issue, and being the therapeutic process. For me, these things are part of the therapeutic process, not a cultural issue. When you talk about not knowing how long the silences should be, you think of this as your perception of the Australian culture?

Fiona Yes, from my experience living in two cultures, using silence even in casual conversation is different. Working in my own country with people of my own culture, I know what is appropriate, but working with patients from another culture I don't know what is comfortable for them. I have had to learn it but that's not the same. These are the things about culture that are hard to explain.

Amy And I see that it is these things that have the largest impact on you as a clinician. Are you aware every single time you go into a session that the cultural differences are an issue?

Fiona Yes.

Amy So if you are aware of culture in every session, where do you draw the line between what is a cultural difference and what is part of the therapeutic process? For me, silence is still an issue, an issue of consideration in the clinical work that I do, but I wouldn't say it was cultural, I would say it was part of the therapeutic process and being in the moment. So for both of us it is a constant issue but for different reasons.

Fiona Yes. I would still consider this to be part of the therapeutic process, however I strongly identify it as cultural. I have worked with people from my own culture here in this setting, and it is very different from working with people from other cultures.

Amy That's a really useful distinction. So what is it that is different?

Fiona To be honest, I feel more comfortable working with people from my own culture. I understand the hidden rules. I know how to relate to them, and I don't have to think about culture. For example, working with the elderly in my culture, there is a hierarchy of age in which the younger gives great respect to the elder. So even though you are a therapist, you speak to them with deference, you call them by their title instead of their first name. With a person of my own culture I understand the hidden hierarchy of age between the patient and me so I can build the therapeutic relationship easily and comfortably. With patients from Australia, it is not difficult, but I am not sure of the hierarchy and I am never a hundred percent sure that the questions I ask show enough respect or show too much formality.

Amy So the purpose of a music therapy session is similar but the way you approach a patient and start a conversation would be quite different to how I may start a conversation.

Do you believe that is because the issue of culture is at the forefront of you mind? Do you consciously think--this person has a cultural background that is different and therefore I need to respect their culture differently?

Fiona I think so.

Amy That is fascinating for me, because as an Australian, I don't think that I approach the cultural differences in the same way as you do. I would respect their culture but because I am not living in that culture I don't know what those hidden rules are and therefore I cannot put culture at the forefront of my mind when assessing and working with a patient. The multi-faceted nature of culture is not at the front of my mind as I am working in Australia, so I am often working in that familiar way you described with people in Hong Kong.

Fiona That's right. Because the different aspects of culture are not at the front of your mind, you wouldn't consciously change the content of the conversation or consciously change how you address them. By living and working in your own culture you don't know what is necessary to change.

Amy So again I think, that in our workplace we know that patients who come from a different culture may have difficulty adjusting to the hospital environment, and I wonder if we expect them to just fit in? I don't know that we truly consider the culture from which the person comes and try to accommodate that to help them adjust. Even if we do, I think it is that learned aspect of culture, the traditions.

Fiona Yes but patients from other cultures know that they are from another culture, so even though clinicians may not approach them in the most comfortable way, I think the patients are the ones that accommodate the cultural gap. Australia is such a multicultural society. We are not able to understand all cultures.

Amy And in our setting we see so many patients from different cultures. So as a clinician from another culture, perhaps you have an advantage?! Can you talk a bit more about your approach to patients from different cultures and how that conversation may be different because of your awareness of culture?

Fiona I may approach patients from the culture I know well differently and I know there are cultural differences between different countries. However I do not understand, so they are all "new cultures" to me. I will explore them in the same way as working with Australian patients. I can tell the cultural difference between an Australian patient and a patient from Hong Kong or China in details, but not the cultural difference between a patient from Australia and say Italy.

Amy Culture has an impact for both of us in different ways. Do you ever think there will come a time when you feel you know enough about Australian and Australians for culture not to be an issue in your clinical work? I know that it will always be a consideration, but when it will not define you as a therapist? Do you think your awareness adds to your capacities as a clinician? I ask because it never appears to be a hindrance, but more a strength in your clinical practice.

Fiona At first I thought it was a hindrance because I was quite stressed. I tend to think and reflect and sometimes worry too much about the cultural difference. But later on it became more a strength because I can reflect on the influence of culture in a broader way as you have mentioned. And because I am aware of the cultural difference I think about the patients' considerations a little bit more. Sometimes as a clinician you need to make clinical judgments, but I think as a person I use my cultural awareness more broadly before I make that judgment.

Amy I would be interested to see how you work if you go back to Hong Kong and how your experience in Australia will impact on your clinical practice in HK.

Fiona I think it will be different from when I was working there before. How I think and reflect will be different now.

Amy And after all this I realise that because I am Australian, I don't know or understand those differences. Maybe you can only really understand those "hidden rules" of another culture when you are living it.

Fiona Yes!

Epilogue

We acknowledge that this duo-ethnographical approach to explore and reflect on culture includes only two perspectives of culture and no in depth discussion about music in relation to culture. The imbalance between the two authors is also acknowledged with the experience of Fiona being more prevalent than Amy's. The authors agreed that this is predominantly because Fiona is Chinese and living in Australia, therefore her more conscious and pronounced experiences are of more interest. The imbalance in the dialogue is also representative of the real world experience of their relationship within the workplace as Senior Clinician and clinician.

The intention of this process was not to test the topic, but to inform the dialogue in the profession. From our dialogue we have identified that we make assumptions according to our background and cultural influences when working in a familiar cultural environment. The dialogue has enabled us to acknowledge the implicit aspects of culture as they relate to music therapy practice. We have reflected on the process, and believe this exploration and reflection on the topic has had an impact on our perceptions of culture in our current clinical practice.

Amy This dialogue and process of duo-ethnography has broadened my perspective of the impact of culture in my clinical practice enormously. I am much more aware of cultural considerations when working with patients, and am prepared to stand back to look at their cultural needs with greater clarity and questioning of my own assumptions in my clinical practice. It has also strengthened my working relationship with Fiona, as I have a much greater understanding of her perceptions of her clinical work, which allows me to offer her greater support in the clinical program and in her supervision.

Fiona This dialogue has helped me reflect on the impact of my process of acculturation on my clinical practice, and I understand more how Amy, an Australian born clinician, sees culture in her clinical work in such a different way. I have realised how multi-faceted culture is, and how it may not be so easy for someone who has not lived in a different culture and experienced cultural shock to understand what it is like for me. This process has made me think more about clinicians' assumptions in clinical practice, and how sometimes "we don't know that we don't know" when building therapeutic relationships with patients from a different culture.

As clinicians, it is not always an easy or comfortable process to transfer these discussions and reflections to paper. The duo-ethnographical process has enabled us to create insights, which will serve us well. We hope that this will encourage other clinicians, students and clinical supervisors in music therapy and other allied health professions to further explore the impact of culture on their clinical practice and maintain the dialogue about assumptions in our clinical work.

Acknowledgements: We thank Helen Shoemark for encouraging us to undertake this experience and produce this article.

References

Berry, J. W. (1980). Acculturation as varieties of adaptation. In A. M. Padilla (Ed.), Acculturation: Theory, models, and some new findings (pp. 9-25). Boulder, CO: Westview Press.

Berry, J. W. (1997). Immigration, Acculturation, and Adaptation. Applied Psychology, 46(1), 5-34.

Sham, T.Y. (2010). Challenges that Registered Music Therapists originating from Asian countries face in music therapy practice or clinical training placement in the Australian Context (Unpublished master's thesis). University of Melbourne, Melbourne, Australia.

Norris, J. & Sawyer, R. (October,2008). Duoethnography. Workshop. 9th Qualitative Health Research Conference, Banff CA.

Sawyer, R. D., & Norris, J. (2013). Duoethnography. Understanding Qualitative Research. New York, NY: Oxford University Press.

Amy Thomas BMusEd, GDipMusThrpy, RMT

Monash Health, Melbourne, Australia

Fiona Tsz Ying Sham BSS (Hons), MMusThrpy, RMT

Monash Health, Melbourne, Australia

Corresponding author: Amy Thomas

Email: amy.thomas@monashhealth.org