True or false: When entering into a clinical interaction,
most providers and clients are able to check their various biases—cultural,
racial and otherwise—at the door.
Before answering the question, consider these words of
bumper-sticker fame: "Don't believe everything you think." That phrase,
expanded a bit to say, "You don't know what you don't think you think,"
captures the premise of "implicit bias," our inability to consciously recognize
many attitudes shaping our every interaction with others.
And lest you dismiss this concept as Freudian pop
psychology, consider the fact that decades of empirical research by
experimental psychologists indicates that we all hold implicit biases. Among
these researchers are Harvard University psychologist Mahzarin R. Banaji and
University of Washington psychologist Anthony G. Greenwald, authors of the
recently released book "Spot the Blind Spot". Together
with colleague Brian Nosek, they developed the Implicit Association Test to
unmask what we don't know we think.
Available on the Web for anyone to take, the test has revealed to 14 million-plus takers
just how deep their implicit biases run. For many, the results are sobering,
even disturbing. In fact, the site warns that test-takers may find the
interpretations "objectionable" and advises them not to take the tests if
unprepared for that outcome. You can try out tests that uncover your own
implicit biases in such areas as weight, race, religion and gender.
The effects of such biases in the health care arena can be
very real, albeit insidious, suggests Margaret Rogers, ASHA's chief staff
officer for science and research. She points to research indicating that bias fuels
disparities in people's access to treatment and the quality of services they
receive (see reports from the Institute of Medicine, for example). This bias can be based on a variety of
factors, including age, gender, culture, race, appearance, ethnicity and
And implicit bias shows its strongest effects when it comes
to what health care providers don't do for some patients, says implicit bias
researcher Greenwald."They may not
order or fast-track a referral for some patients, and the question is whether
clinical need is the primary factor driving these decisions. Most people are
not fully aware of how their implicit biases affect their decisions. They just
feel they're doing some patients a favor."
In comparison, those who hold explicit biases are well aware
of their prejudiced attitudes, and may act or speak in ways that demonstrate
their bias. But they may keep obvious expression of their explicit bias in
check, so as not to violate social norms. To gauge effects of both explicit and
implicit bias in the communication sciences and disorders arena—as well as bias
flowing in both directions, client-to-provider and provider-to-client—we asked
CSD professionals to share their related experiences. Here, with their names
withheld to protect their privacy, is what people said.
—Bridget Murray Law
"We are waiting for ..."
One of my cultural and communication experiences occurred
while living in Michigan and working in home health care. I made the
appointment with one of the daughters of a gentleman who had a stroke. Over the
phone, the daughter was delighted that her father was going to receive services
and indicated that they all would be waiting for my arrival at the appointed
At the appointed time, I rang the doorbell and when the door
opened, the eyes of the person who greeted me became as big as saucers. I
introduced myself and told her that I had spoken to someone on the phone on the
previous day regarding a speech-language pathology appointment with their
father. She continued to look at me in amazement and said we are waiting for
[name withheld]. I introduced myself again. I am [name withheld], the
speech-language pathologist you spoke with on the phone. All of the siblings
said, "Oh." I asked where their father was and they indicated that he was in
the kitchen at the table. I excused myself and went into the kitchen to
introduce myself to the father and his wife.
Meanwhile, I heard a lot of talking going on in the living
room. I kindly excused myself and went back into the living room. One of the
siblings said, "You speak Italian?" I said, "No, but I know what you are
saying." They said, "Oh, no. Everything is all right." They all got up and left
the house. I was then left alone with their parents. This is just one of my
cultural communication experiences that I have encountered over my 30-plus
years as an SLP.
Judged by the way I look and talk
I would say my experience was not very implicit. It happened
several years ago, when I was asked to screen a private school student who
lived within my school district's boundaries. I spoke to the mother by phone to
schedule an appointment. I also talked to her about the screening process and
what to expect. When I asked her if she had any questions, she told me that she
was concerned because she detected an accent. I shared my background, that I
was born and raised in the Philippines, moved here in the United States to
pursue my master's and have been practicing for about five years.
When I met with her face-to-face to talk to her about the
results of my screening, she was apologetic and probably realized that she was
out of line. She explained that she was afraid that her son might imitate my
accent! She further explained that her father spoke in what she described as "a
very thick Irish brogue." Seeing this as an opportunity to educate, I told her
that her own experience should allay her own fears. If accents do "rub off" on
other people, then how come she does not sound like her father? I could see she
was taken aback. She apologized again and said she was going to eat crow. I
must admit that I was quite upset after our initial conversation, but I accept
my reality that sometimes my competence as an SLP will be judged by the way I
look and the way I talk.
-Round Lake Beach, Ill.
Not the "speech aide"
Unfortunately, in 26 years of practice, I have had several
incidents regarding this issue. One day, during a home health visit, I knocked
on the door, and the patient's wife answered the door. I identified myself,
showed my badge and let her know I was there to evaluate and treat her husband.
She told me, "We don't allow Negroes in our house! Now get on out of here and
send a white lady!"
Another time, I had been corresponding via e-mail and phone
with a very well-known contract company. The position was mine. I just needed
to go into the office to sign the contract. I arrived 15 minutes prior to my
appointment. I said who I was there to see. After sitting for 20 minutes, I
asked the receptionist if she knew when I would be seen. She went into the
office to inquire when I could be seen. Turns out, the person I was to meet
with had come out, "looked" for me, did not see the person she thought would be
there, and went back into her office.
In the school setting, I often get asked if I am the speech
aide. These issues and others get very old after a while. Thank you for
acknowledging this issue and being willing to discuss it.
Had to be perfect because of my culture
I have been treated differently and unfairly in a
professional setting. I had to be perfect, speak perfectly and present myself
in the best light possible because of my Latino culture. As an
eighth-generation Texan, I was congratulated on "how well I spoke English" and
told that "you don't look Mexican." You see, I have been in this wonderful
field for 38 years as a bilingual speech-language pathologist. We are still few
and far between in this field, my friends. I am now a professor at a university
and I love what I do and really love my students and patients. I constantly
stress, through example and my teaching, how important empathy is in our field.
I teach that we need to follow the Golden Rule, and I stress acceptance of
differences in our culture and society. I will retire soon but have a few years
left to mentor and support my students in this highly rewarding field. I am so
glad you are doing this article on culture and communication. I find it ironic
that SLPs can sometimes be the worst communicators.
As an overweight woman working in an outpatient rehab
facility, I had definitely felt the bias of my size from patients and sometimes
fellow staff. After gastric bypass last year and loss of 123 pounds (so far!).
I have seen a significant difference in how people respond to me. Then again,
it may also be that I carry myself differently, have more confidence, etc.,
that people react to differently, rather than my change in a number on a scale.
Many of my fellow staffers and patients have been very supportive, and it's
been an amazing experience!