Roseberry‐McKibbin & O’Hanlon, 2005; Verdon, Blake, et al., 2016; Westby, 2007).
Though this literature review is not exhaustive, and it is not meant to be comrehensive due to space limitations, it serves to point out the fact that, as far‐ranging as the topics covered may be, there is no single manual that comprehensively tackles and addresses learning objectives, standards, and required materials for MMI instruction in SLDs, or communicative disorders in general.
2.4 Identifying an MMI Curriculum
Having a mind for diversity and, by extension, being able to provide apposite and applicable clinical service delivery requires a specification of what counts as MMI‐related know‐how and aptitude. Such specification criteria include (a) knowledge of facts and theory, (b) an understanding of how such knowledge relates to applications, and (c) a capacity for intercultural communication, that is, intercultural competence or responsiveness. To elucidate, factual information entails numerical data (statistics) on patterns of globalization, demographics, and how economics and politics affect health‐related policies, aspects of which are rudimentarily showcased in Section 2.2. Theoretical information (Section 2.5) includes a demarcation of principal themes in the following topics: culture and cultural diversity, language and linguistic diversity, learner ability, bilingualism, accent, and a transparent link that connects these to SLDs. Applications (Section 2.6) include diffusion of research advances and their implications for assessment and therapy methods, accent modification, and the function of interpreters and/or bilingual service providers. Last, intercultural competence (Section 2.7) involves learning to deal with universal or unique (to specific groups) cultural characteristics, alongside investigating SLP attitudes, and finding ways to minimize cultural barriers (Kim, 2019) and unconscious bias in SLP–client interaction. These are outlined in more detail in the following sections.
2.5 Relevant Theory
Diversity implicates both micro‐ and macro‐levels of interaction, with the individual being part of increasingly larger contexts, as emphasized in theoretical approaches (e.g., Bronfenbrenner’s ecological systems, 1986; Hofstede’s cultural dimensions, 2011) and health organization policies (e.g., WHO, 2019b). The micro‐level implicates personal factors: body functions/structures, health conditions, and an individual’s participation in exosystem groups (family, peers). The macro‐level implicates environmental factors like the role of society, history, culture, and economy in peoples’ lives. Understanding clients from diverse backgrounds relies on the relationship between an individual’s culture and language, and how these affect speech language services. Disability itself has different meanings across (sub)cultures (Battle, 2012). Whereas the capacity for learning is innate, culture and language are learned constructs, having a dynamic nature characterized by both evolution and/or dissolution in someone’s lifespan. In all cultures and across languages, individuals vary based on values, experiences, outlook, behaviors, and linguistic/cultural differences. Even among the same cultural group(s), individuals speaking the same language(s) will exhibit patterns of difference across any of the above aspects. Body language, humor, attitudes toward family, authority, religion, gender roles, and time correspondingly diverge across individuals and cultures. It is worth noting that all these entities are themselves in constant flux.
2.5.1 Culture and Cultural Diversity
Culture is “that complex whole that includes knowledge, belief, art, morale, laws, custom, and any other capabilities and habits acquired by humankind as members of society” (Tylor, 1970). Thus, cultural diversity includes race, ethnicity, national origin, age, gender (and gender identification), language, religion, presence of disability, literacy, and education, occupation, sexual orientation, geographic region, and socioeconomic status. When diverse cultures and even subcultures mingle, a number of different outcomes may emerge, as illustrated by theoretical models of acculturation and assimilation: conformity, melting pot, cultural pluralism (e.g., Battle, 2012). This, in turn, intensifies cultural and linguistic diversity in the individuals involved. Socioeconomic, historic, institutional, and linguistic barriers playing on acculturation/assimilation processes affect the level of people’s adaptation in social groups, which in practice translates into inequity in assessment and treatment, and disparity in clinical service provision. For instance, a monolingual Spanish‐speaking mother, seeking speech and language services for her bilingual Spanish–English child in a monolingual‐English clinical service provision, is unlikely to provide all the micro/macro background information necessary to assist in accurate diagnosis and intervention of the child’s speech and language delay, or other SLD, unless an interpreter or a bilingual service provider is employed.
Mahendra et al.’s (2004) metaphor, “Why is yogurt good for you,” pinpoints how live/living culture(s) sustain human wellness; however, communicating with people that are different may not necessarily be as effortless, especially given humanity’s biological setup to mistrust the strange or alien. Due to the nature of culture being itself multifaceted, cultural traits/characteristics are not absolutes but, on the contrary, controlled by assumptions, opinions, and beliefs that subsequently manifest as tendencies in people. The negative aspects of such tendencies are stereotyping, overgeneralization, and conscious or unconscious bias. These constructs have the potential to affect both speech language development in children and adults, as well as the efficacy of clinical care provision in resulting SLDs in terms of diagnosis, assessment, and therapy. Such constructs may also influence, even at the most basic level, an individual’s perception of disability (including diagnosing it as existing or not), whether that relates to one’s own disability or that of others.
Cultural dimensions have both a societal and an individual component. To provide a couple of examples, two such dimensions and their relation to clinical practice provision are:
1 The extent to which people in a society are integrated into groups (individualism/ collectivism); so a patient from an individualist society will be focused on self‐sufficiency and independence, and practitioners will need primarily to encourage a return to self‐care. On the other hand, individuals from a collectivist society will rely on ongoing support from care providers or family to return to a state of full recovery.
2 How values are distributed between the genders (masculine/feminine society); people from a masculine society, more so males than females, will be assertive and competitive, which translated into a clinical setting would mean that the father deals with procedural aspects of the child’s clinical experience and the mother addresses emotional aspects. Conversely, individuals in a feminine society would exhibit variability with regard to social and affective functions across genders; this, in turn, translates into the roles being more uniformly divided between male/female family members during their interactions with clinical service providers.
Other individual and societal cultural dimensions, not to be discussed here in more detail due to space limitations, include power distance (low vs. high), indulgence and restraint, long and short‐term orientation, uncertainty avoidance, class, status, roles (e.g., roles of the elderly), rituals and superstitions, beliefs and values, views of time and space and, lastly, communication styles and language (Biggar, Forsyth, & Forsyth, 2019; Hofstede, 2011). The purpose of this section is to highlight the fact that the systematic study of people and their cultures, ethnography, is a significant component of clinical competence where a CLD clientele is present. Making sense of behavioral variation across social contexts enhances cultural responsiveness and promotes evidence‐based service delivery. This is where the clinical service provider needs to work toward enhancing ethnographic skills, that is, to be an ethnographer.
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