Constructions of ‘Culture' Versus ‘Clinical' Talk In Cross-Racial Clinical Encounters

Purpose and Study Objectives: In this paper we explore how socio-cultural power dynamics are constructed and re-produced in clinical encounters. Current approaches to cultural competence indicates a split between: a) culturally responsible and sensitive practice that has a tendency to focus on clinical issues and b) critical race theory (Delgado & Stefancic, 2001) and anti-oppressive practice (Strier & Binyamin, 2010) theories that highlight the structural processes of intersecting oppressions. The former has been criticized as blurring together multiple oppressions while dismissing critical race issues (e.g., institutional racism) and their impacts on systematic structural levels, whereas the latter has been critiqued for not clearly assessing how intersecting oppressions impact individual and interpersonal interactions in clinical settings. In this paper, we explore both institutional and interpersonal dynamics of oppression that manifest when social workers respond to and communicate with their clients in clinical practice.

Methods and Study Design: We conducted conversational analysis (CA) (Drew & Heritage, 1992: Peräkylä, 2004) of clinical sessions involving self-identified white female clinicians and clients who identified as racialized immigrants in Canada. CA methodology aims at observing, classifying, and describing the structures and general sequences and patterns of utterances between a speaker and hearer. These include turn-taking, closing conversations, introducing and/or changing topics, asking questions, making requests, and other related features of talk (Forrester & Reason, 2006). Our use of CA draws upon theories of language as a social action. Conversation provides a means in which "separate minds are able to influence and be influenced by each other, managing to some extent, but always imperfectly, to bridge the gap that inevitably exists between separate selves” (Chafe, 1997, p. 52).

A total of 17 clinical sessions, totaling 800 minutes, were recorded and fully transcribed for analysis. Based on a review of relevant literature, we defined cultural content as verbal reference(s) to culture, race, ethnicity, religion, nationality, majority/minority status, cultural differences, cultural conflicts, racial-cultural identity, and geographical or social conditions arising from any of the above factors (Constantine & Ladany, 2000; Keenan, 2001; Worthington et al., 2000). A total of 19 episodes were identified as ‘cultural dialogues', accounting for about 16 percent (about 130 minutes) of the total data pool.

Findings: Our findings illustrate how whiteness, power, and racism manifest in clinical sessions as seen in the clinician's interruptions and efforts to shift topics away from ‘cultural dialogues' to more so-called ‘clinical' discussions; topics which often are based on Eurocentric constructions of what kinds of talk are useful for clinical interventions. We focus our discussion on the following: 1) the construction of ‘cultural versus ‘clinical' talk in clinical encounters, 2) how clinicians dismiss ‘cultural dialogues' to regain control of the clinical dialogue, and 3) how clients attempt to elicit clinicians' responses to cultural material and/or reluctantly modify their verbal and non-verbal dialogues to demonstrate compliance with whiteness (i.e. by showing loyalty to the dominant culture). We conclude with a discussion of strategies to better train clinicians to address both interpersonal and socio-cultural dynamics when working with people from marginalized populations.