culture emergent in ocupation

The American Journal of Occupational Therapy 159

Culture Emergent in Occupation

Bette R. Bonder, Laura Martin, Andrew W. Miracle

KEY WORDS cultural competence culture and health diversity

Bette R. Bonder, PhD, OTR/L, FAOTA, is Professor,Department of Health Sciences, Cleveland State University,2121 Euclid Avenue, Cleveland, Ohio 44115;[email protected]

Laura Martin, PhD, is Professor, Departments of ModernLanguages, Anthropology, and Health Sciences, ClevelandState University, Cleveland, Ohio.

Andrew W. Miracle, PhD, is Associate Dean and Professor,College of Health and Urban Affairs, Florida InternationalUniversity, Miami, Florida.

This article was accepted for publication under the editorship of Betty Hasselkus.

Culture influences occupation as well as perceptions of health, illness, and disability. Therapists are aware ofthe need to address culture in interventions. However, definitions of culture can be unclear, providing littleguidance to therapists about how to recognize its effects in therapeutic encounters. A pragmatic definition ofculture as emergent in everyday interactions of individuals encourages reconsideration of the main elementsof culture, that it is learned, shared, patterned, evaluative, and persistent but changeable. Understanding of cul-ture as emergent in interaction, including therapeutic intervention, suggests three important characteristics thattherapists can cultivate to enhance clinical encounters: careful attention, active curiosity, and self-reflection andevaluation.

Bonder, B. R., Martin, L., & Miracle, A. W. (2004). Culture emergent in occupation. American Journal of OccupationalTherapy, 58, 159168.

Introduction

Occupational therapists have long acknowledged that culture is an importantaspect of occupation, and of perceptions of health, disability, and illness. Thefounders of the profession emphasized that therapeutic activities should be pre-scribed based on the individuals personal and cultural values (Dunton, 1918).This recognition has led to many calls for cultural competence in the clinic(Barney, 1991; Dillard et al., 1992; Mirkopoulos & Evert, 1994; Wittman &Velde, 2002), a call now incorporated into standards for education of new thera-pists (American Occupational Therapy Association [AOTA], 1999). It is fair to saythat few occupational therapists are unaware of the importance of consideringculture in the provision of occupational therapy services (Fitzgerald, Mullavey-OByrne, & Clemson, 1997, p. 1).

Before cultural factors can be addressed in care, therapists must have a clearunderstanding of what culture is. Anthropologists, who have a primary focus ondefining and describing culture, have throughout their history debated the defini-tion of the term and still have not reached consensus (Kuper, 1999). It is thereforenot surprising that therapists likewise are somewhat unclear about exactly what theconstruct means. Too often, race and ethnicity are used as representations of cul-ture. For example, in their book on cultural competency, Wells and Black (2000)discuss what it is that White American health practitioners (p. 138) must beaware of in their practice, suggesting that White Americans constitute a single cul-tural group and that race is a central characteristic of cultural group identity. Theequation of race or ethnicity with culture leaves therapists to puzzle about whetherculture is something that applies only to those who look different from themselvesor speak a different language (Pope-Davis, Prieto, Whitaker, & Pope-Davis, 1993).

Since effective therapeutic interventions address culturalfactors as a way to enhance quality of life and optimal per-formance (Barney, 1991; Dyck & Forwell, 1997), this con-fusion about what constitutes culture has a potentially dam-aging impact on client care.

Defining CultureIn the occupational therapy literature, an array of defini-tions of culture can be found. One definition is a state ofmanners, taste, and intellectual development at a time orplace. It is the ideas, customs, arts, etc. of a given people ata given time (Baptiste, 1988, p. 180). At approximately thesame time, Levine (1987) described culture as a blueprintfor human behavior, influencing individual thoughts,actions and collectively influencing a particular society (p.7). Krefting and Krefting (1991) called it a filter or veilthrough which people perceive lifes experiences (p. 108).Christiansen and Baum (1997) define culture as referring tothe values, beliefs, customs and behaviors that are passedon from one generation to the next (p. 61). Still anotherdefinition labels culture an abstract concept that refers tolearned and shared patterns of perceiving and adapting tothe world (Fitzgerald et al., 1997, p. 1).

Anthropologists have also developed multiple defini-tions for culture. Since it was first created by Edward B.Tylor (1871) and other late 19th century scholars, use ofthe term has evolved. Not surprisingly, changes in usagehave reflected the changed understandings of what it meansto be human that have been in vogue at various times.

By the mid-20th century, the burgeoning influence ofindividual psychology began to affect scholarly approachesto culture. Sapir (1924/1949) and Wallace (1961) notedthat the foundations for cultural traits resided in the mindsof specific individuals; that is, while patterns of thinkingand behavior might be widely shared across a society, thelocus of culture is within individuals. Wallaces theory ofmazeway as the mechanism for cultural change was explic-it in this regard. For Wallace, culture change begins when asingle individual incorporates a new element (e.g., throughinvention or borrowing) or when someone synthesizes tra-ditional elements in a new configuration. If such innovationis perceived as useful, then additional individuals in the cul-tural group may adopt it and thus widespread change maybe underway.

Geertz (1973) describes culture as webs of meaningin which people live. Kuper (1999) indicates that in itsmost general sense, culture is simply a way of talking aboutcollective identities (p. 3). Holland, Lachicotte, Skinner,and Cain (1998) suggest that culture can be conceived inseveral different ways: as defining and determining individ-

ual human needs; as a superficial labeling of deep-seatedneeds; or as a formation of motivation during development.There has been considerable debate in anthropological cir-cles about whether culture refers to behavior, or to the artis-tic expression of emotion, that is, culture in the sense of thearts and literature (Kuper, 1999).

Today, anthropologists (e.g., Reyna, 2002) work toexplain the relationship between the biological and the cul-tural. Noting the work of anthropologists such asDAndrade (1999) and Dressler and Bindon (2000),Handwerker (2002) concludes that a theory of culture ascognitive elements and structure now dominates ethno-graphic research (p. 119). Moreover, there is a growingrecognition by psychologists (e.g., Hermans & Kempen,1998; Pepitone, 2000) that the discipline can no longerassume an acultural or unicultural stance (Segall, Lonner,& Berry, 1998, p. 1101). And, sociologists (e.g., Cerulo,2001) have begun to consider culture and cognition, espe-cially in the context of race and ethnicity.

All of these conceptualizations carry some commonthemes related to individuals actions, and their attributionsof meaning and value to those actions. Two main strategieshave typically been employed to create the necessary speci-ficity in defining culture.

A Descriptive Approach

One strategy for elaborating on definitions of culture hasbeen an approach characterized by detailed description ofparticular groups through the set of characteristics that anobserver might record in studying the collective life of ahuman group (Kuper, 1999, p. 24). This descriptiveapproach is exemplified in the thorough accounts by earlyethnographers of New World indigenous groups, or by suchworks as Eliots (1948) list of English cultural traits. Suchdescriptions involve a systematic identification of the par-ticular characteristics and material goods of a given society.A full description of all the technological, economic, polit-ical, kinship, and religious characteristics of a people,together with the details of their socialization practices, rit-uals, and value systems, has been assumed to provide adescription of the culture of that people. Providing a list ofthe major traits, patterns of behavior, and material objectsthe people produce or use is believed to offer a goodapproximation of a particular cultural group at a givenmoment in time. Examples of this kind of description arenow widely available at Web sites focused on diversity, or onculture and health (for an example, see Cross-CulturalHealth Care Program, www.xculture.org/resource/library/index/cfm).

Producing these descriptions is a demanding task. It isimpossible to describe every relevant cultural fact about a

160 March/April 2004, Volume 58, Number 2

given people. Even if the task itself were manageable, sucha list can tell us nothing of the choices a single member ofthe group has made within the range of possibilities eachculture provides. This approach assumes that by describingwhat seem (to the describer) to be the significant traits of aculture, outsiders can gain an appreciation of what life islike, at least superficially, for the people involved. Most ofthe time, though, descriptive approach products simplysummarize cultures with just a few key values or character-istics. The ethnographies that abound in anthropology areexcellent examples of the descriptive approach (cf.,Hendrickson, 1995), but require constant updating as cul-tural circumstances change (Hendrickson, 1996).

Such summaries can be useful. They provide snapshotsof particular groups at particular points in time, and a gen-eral sense of the important values and behaviors of thegroup. They provide for the observer, or the therapist, astarting point from which further exploration of the valuesof the specific individual within the culture can begin. Butthey are inevitably superficial. The potential exists to createstereotypes, or to replace one stereotype with another, ratherthan to reach a genuine understanding of the culture as rep-resented by its individuals. This strategy also inevitablyresults in a limitation of scope. As an example, Hendrickson(1995) focused her attention specifically on weaving, pro-viding much less information about other aspects of life inthe Guatemala highlands, the lives of men, for instance, orthe activities of women in villages where weaving was nottypical.

A Rules Approach

Another strategy for enhancing cultural understandingfocuses on the rules for belief and behavior. Thisapproach assumes culture serves as a cognitive model ofreality for each of the groups members. For example,Skinner (1989) provides a list of rules for the behavior ofyoung girls in Naudada, a Hindu community in centralNepal. The list indicates what good daughters and goodwives do. On the list is a rule indicating that good wivesdie before their husbands. Knowing this rule, that it isunseemly to outlive ones husband, helps the outsiderunderstand why the term Radi (widow) is a pejorativeterm in that culture. Thus, understanding a culturemeans knowing how the people living in that cultureview reality, how they make distinctions among cate-gories of things, and how they generally make decisionsabout right courses of action (Schneider, 1976). Ofcourse, in taking this approach it is necessary to know(and to describe for others) most of the things that existin the world of those people. In this sense, the rulesapproach subsumes the descriptive one, but adds a list of

the rules by which the culture determines meaning,molds behavior, and incorporates new information.

Taking the approach of listing rules can be quite help-ful in providing a starting place for interaction. Manyguides to cultural competence for health care providersemphasize this strategy, indicating, for example, what therules are for interaction between genders, how to addresssomeone from a particular cultural group, or whether or notto make direct eye contact (Galanti, 1997; Wells & Black,2000). Knowing the rules can provide the therapist with astarting point for asking appropriate questions about thepreferences of the individual.

However, like descriptive accounts, rules studies arealways incomplete since not everything can be included. Norcan it ever be known with certainty that the model providedby such an approach really describes reality as understood byall the people in a society or even by most of them. Byimposing a static model of culture, this method also fails toaccommodate the ranges of variability or the combinationsof cultural influences experienced by most individuals, espe-cially those living in culturally heterogenous communities.

In spite of the consistent association between actionand meaning and the many examples of rules-based anddescription-based accounts, definitions of culture remainrelatively vague from the occupational therapists point ofview. They fail to provide guidance regarding precisely howculture relates to occupation, and, therefore, how therapistsmight address culture in assessing clients and designingmeaningful and relevant interventions. We believe that toooften therapists fail to recognize that everyone in anencounter has culture (in fact, identifies with more thanone culture, as will be discussed below), and that the cul-tural experiences of every participant in an encounter affectthe nature of the interaction (cf., Bonder, Martin, &Miracle, 2002). It is equally easy to dismiss as not reallycultures the regional differences (e.g., Appalachian) andother factors (e.g., sexual orientation, bicultural identities)that individual clients may self-describe as components oftheir cultural identities. For purposes of creating interven-tions, therapists need a pragmatic definition that can guidethe kinds of questions they ask, their interpretation ofresponses, and their design of treatment.

The Model of Culture EmergentA third approach to culture, the one we adopt here, is basedon a pragmatic definition of culture as emergent in theeveryday interactions of individuals (Bonder et al., 2002). It has been developed to elaborate on and reconceptualizefactors found in traditional definitions of culture. This definition emphasizes both group patterns and individual


variation to explain the multiple influences experienced bypeople who live and work in culturally diverse settings, andto allow for the interactive effects of noncultural influencesfrom biological and psychological aspects of the person.Rather than attempt to define and delineate specific cultur-al groups, this approach suggests that the way any individ-ual behaves is based on the array of influences, both thosegeneral to the group and those unique to her or his devel-opment. This idea is based on a conceptualization of cultureas a symbolic system that emerges through the interaction ofindividuals.

Culture emergent suggests that the symbolic aspects ofculture and cultural identity emerge in interaction and aredisplayed primarily through talk and through action. Bothlanguage and action are symbols (Holland et al., 1998;Kuper, 1999; Tedlock, & Mannheim, 1995) that resultfrom cultural learning and convey the values of the group.Talk and action are processed through the filter of inter-pretation. Actions are artifacts, signs that are intended toconvey meaning (Kuper, p. 105). This symbolic languageis public, thus, by extension the values of the culture arepublic (Kuper), and talk and action are conditioned bytransient circumstances as well as by traditional patterns ofbehavior (Sherzer, 1987; Urban, 1991). Krefting (1991)notes that although culture is a shared phenomenon, shar-ing is seen in the context of transmission and socialization.Moreover, individuals learn culture from a number of dif-ferent people and places, so each persons contact with andinterpretation of the culture is unique (p. 5).

Not only is culture uniquely expressed by the individ-ual; its expression also changes constantly, based on newexperiences and the influence of those experiences on per-ceptions. In these ways, Culture is contested, temporal,and emergent (Clifford, 1986, p. 19). Tedlock andMannheim (1995) suggest that cultures emerge and arerevised continuously in the interaction among individualswithin the group through both dialog and action.

The theoretical framework of culture emergent takesinto account the interactions of individuals and culturaldevelopment as well as the process of change in culture overtime (Tedlock & Mannheim, 1995). Thus, the focus isaway from cultural groupcultural mind-set and towardindividuals making choices within culturally-supportedboundaries. The idea of culture emergent assumes that cul-tural patterns are dynamic and collectively negotiated byindividuals through multiple interactions. The cultureemergent approach views culture itself as having evolvedfrom application of the social, problem-solving, task orien-tation of human beings. We assume that some culturalbelief structures and behavior patterns are laid down inearly childhood through learning and experience within the

family and community, but we also assume that those struc-tures and patterns are continually reevaluated. One only hasto reflect on the differences between the values and behav-iors demonstrated by his or her parents, perhaps on theissue of cultural diversity itself, and those represented by hisor her peers and profession to see that even patterns learnedvery early in life are susceptible to modification over timeand experience.

This approach also conceptualizes culture as a cognitivemodel of reality, a model that is based on the cumulativelearning experiences of the individual. However, this modelis not a unitary one shared by everyone in society, but a dif-ferentiated one located in individuals. And, since all indi-viduals have had different experiences in life, personal mod-els always vary at least slightly, even among individuals wholive in similar environments and have shared many similarexperiences. Inevitably, some elements of culture may beshared with one set of individuals, while other elementsmay be shared with other sets. Moreover, since individualscontinue to have new experiences throughout life, themodel reflects the fact that culture adapts and changes,sometimes dramatically though often slowly, through theactions of individuals. Culture emergent presupposes theindividualnot the groupas the key cultural actor, andencourages careful examination of both the group and theindividual. Within this framework, we highlight fiveimportant characteristics of culture, emphasizing the waysin which the concept of culture emergent affects tradition-al conceptualizations of culture.

Culture Is Learned

Most definitions suggest that culture is learned. It is trans-mitted from one generation to another through the processof enculturation, the acquisition of cultural knowledge thatallows one to function as a member of a particular group.The learned aspect of culture sets it apart from the biologi-cal (Kuper, 1999). It is not inherited, but must be trans-mitted from individual to individual. Observation and dis-course are the primary means of cultural transmission. Onelearns culture through interaction with others, listening,observing, and assessing those interactions.

Enculturation, the acquisition of culture, occurs boththrough purposeful instruction and through modeling andobservation. One learns the culture of a profession likeoccupational therapy in part through direct teaching in thecourse of the professional education experience. Facultyteach not only the facts required to plan and provide inter-vention, but also the value system of the profession,through, for example, explication of the professional codeof ethics, the mind-set that supports client-based care, orthe importance of evidence-based practice. This initial


learning may require organization around specific rulestaught by others (Holland et al., 1998).

In addition to this purposefully taught information,specific individuals such as occupational therapy studentsacquire information from experience, interaction, and theevaluative responses of others. This kind of learning enablesthe learner to form a gestalt that directs action in new situ-ations (Holland et al., 1998). Observing and modelingmore experienced therapists during fieldwork and the earlyyears of practice is a mechanism for learning about andpracticing particular kinds of professional behavior. Boththe intentional teaching and the less formal modeling serveto enculturate students to the professional culture.

Culture emergent suggests that since culture is learned,it must be presumed that the learning process is ongoing,and that new behaviors, beliefs, and values emerge as indi-viduals acquire new information and experience. Further,since culture is learned, it also is shared with those fromwhom it is learned and those to whom it is taught. Eachinteraction with another individual provides an opportuni-ty for learning culture and for reinforcing elements alreadyacquired. This interactive sharing and mutual reinforce-ment has the effect of binding the individual to others andto the group. It is the mechanism by which group identitiesare formed.

Culture Is Localized

Culture is created and expressed through discrete interac-tions with specific individuals in particular locations. It isfrom such interactions that one draws meaningful elementsthat will be shared with some but not all individuals withinsociety. Thus, culture is situated in personally meaningfullocales. It is from such interactions, in the immediate sur-roundings, that individuals learn meaningful elements thatwill be shared with some, even most, of the other personswithin the group. Rosaldo (1999) suggests that all knowl-edge is local (p. 31). Even in an era of mass electronic com-munication around the world, information is processedbased on local values, mores, and norms (Abu-Lughod,1999; Kuper, 1999).

Professional settings offer a kind of well-defined envi-ronment for the emergence of localized knowledge. Forexample, knowing how the occupational therapy clinic isset up, or how the supplies are classified, or how patient vis-its are prioritized is largely learned from experience orobservation in a particular setting. The specifics of suchknowledge need not be shared with others in different partsof the organization or with therapists in other clinics,although in general every occupational therapy practitionerwill need to have similar information, regardless of worksetting.

However, interactions in multiple social settings alsoprovide multiple contexts for learning culture. Thus, theconcept of culture emergent suggests that every individualembodies multiple cultural components, some based onethnicity, race, or country of origin, and others based on lifeexperience in other contexts such as professional, geograph-ic, religious, social, or family settings. Everyone is a bundleof cultural threads, and social context influences individualchoices about displaying one or another of them. In everyinteraction, only part of an individuals identity is beingexhibited, making all understanding about that identityincomplete (cf., Holland et al., 1998).

This localization of culture is part of what makes itmeaningful. Meaning is assigned to any particular culturalfactor based in part on the perspective of the individual.Perspectives can be communicated and shared with others,and can be broadened through experience and training.Nevertheless, at any given moment, each individual isresponding to a particular view of an interaction, a viewthat our model terms vantage. Like the position adopted byBakhtin (1981) and drawing directly from Hill andMacLaurey (1995), this notion suggests that at anothermoment, a similar interaction may carry different interpre-tations because of a change of vantage. Vantage effects areclearly evident, for example, in the differing interpretationsof a clients behavior from the perspective of a physician anda therapist. Similarly, asking someone how are you in aclinical setting carries a very different connotation than ask-ing the same question in a social situation.

Culture Is Patterned

Patterning is essential for social behavior and for the devel-opment and maintenance of societies (Fitzgerald et al.,1997). It is essential that individuals develop patterns forbehavior, since patterns help minimize ambiguity andrelieve us from having to renegotiate each interaction fromscratch (cf., Holland et al., 1998). Patterns emerge from therepetition of specific samples of behavior and talk. Repeatedpatterns establish the normal and customary expectationsthat structure interactions.

Culture is patterned in two senses. First, it is patternedin that the components of culture are integrated, reflectinggeneralizable patterns within which individual actions havemeaning. Culture emergent theory suggests a second formof patterning, that is, culture is patterned in the repetitivebehaviors of individuals, which become so ingrained thatthey seem like empirical reality. Through ritual, daily rou-tine, and habitual behaviors, individuals express their cul-tural identities and affiliations, as well as their individualpreferences and characteristics (cf., Holland et al., 1998).For example, a woman dressing in India will have a differ-


ent routine for donning her sari than a woman donning herpantsuit in the United States. Such routinized behaviorsserve not only to structure daily life, but also to help shapean evaluative system for assessing ones own and othersbehaviors. Both women must also make somewhat less rou-tinized decisions while dressing, including determinationsabout the level of formality in dress that is required by a par-ticular situation and personal preferences about style andcolor. These decisions reflect a degree of individual self-expression, even though the ranges in both cases are boundby culturally governed matters of availability, convention,and values. In general, we assume that the process of repe-tition leads to ritualization (i.e., assignment of symbolicmeaning). Ritualized and routinized behavior leads to ashaping of the individuals reality. From there it is only ashort step to being the right thing.

Culture Is Evaluative

Values are embedded in culture and are reflected in indi-vidual behavioral decisions and choices (Kuper, 1999).Values reflect the underlying organization of shared struc-tures that facilitate social interaction. Society would not bepossible without a significant level of shared values.Socialization within families and communities is one meansof acquiring values. Ideally, there is considerable consensusabout values within a society or a group, since commonali-ty of evaluative perception is one of the factors that helpshold individuals together in social institutions. It is doubt-ful, though, that there is ever total agreement on values,even in small groups. Different cultures, different groupswithin a society, or different individuals within a group mayagree or disagree on how to evaluate items or ideas.

Perhaps the most salient example of this difference inevaluation is one that is mentioned repeatedly in the occu-pational therapy literature. Occupational therapy is basedon a set of values that holds independence to be an essentialgoal for individual well-being (Kinebanian & Stomph,1992). However, in a number of cultures, independence ismuch less highly valued, with interdependence, or, in situ-ations of illness or disability, dependence, being bothexpected and accepted (cf., Jang, 1995). Kinebanian andStomph (1992) give the example of a Hindu man withhemiplegia who, although able to accomplish many tasksfor himself, declined to do so, indicating that he was wait-ing for God to improve his physical status.

The idea of culture emergent emphasizes that individ-uals are shaped by their culture. However, it also emphasizesthat socialization is not the same for all members of a givengroup. Individuals are continuously evaluating the applica-bility and relative weight of values in terms of personal rel-evance. Sometimes, contradictory values may exist, and

decisions about which one to acknowledge are contingenton context. Spencer, Krefting, and Mattingly (1993) reportthat when one of the researchers was introduced as an occu-pational therapist, patients with traumatic brain injuryidentified their problems as double vision, instability inwalking, and difficulty swallowing. When the sameresearcher was introduced as an anthropologist, patientsidentified their problems as loneliness, financial difficulties,and unhappiness about being labeled as retarded. In thiscase, patients expectations about the culture of theresearcher, either in terms of what they thought was expect-ed of them or in terms of what they thought the researchercould help them with, imposed a screen in terms of whatthey identified as problematic. Gender, age, innate skills,and social position are among the variables affecting anindividuals socialization experiences (Holland et al., 1998).These factors in turn affect the acquisition of values.

Ones values, the concepts of what is desirable or abhor-rent, change over the life course. Children, adolescents,young adults, middle-aged individuals, and elderly individ-uals may have differing value orientations as a result notonly of differing needs and personal experience, but alsobecause of what their interaction with the cultures aroundthem has taught them. This variation is reflected in, andreflects, another important characteristic of culture emer-gent. While elements of culture are persistent, culture is alsoconstantly evolving.

Culture Has Continuity With Change

Generally, culture is more or less stable through time. Thisconsistency is an important characteristic of culture, essen-tial if it is indeed to provide the values and beliefs that guideor pattern behavior. However, cultures are far from static(Sewell, 1999). They are constantly evolving (Sahlins &Service, 1960), and would, in fact, disappear if they did not.This is not to suggest that cultural difference is disappear-ing. Even in the face of global communication, differencespersist, perhaps even sharpening (Clifford, 1986). This abil-ity of cultures to incorporate new ideas, to borrow fromother cultures, to assimilate new information, is a strengththat enables cultures to persist.

One source of cultural change is the introduction ofnew technologies. As part of our research on the meaningof occupation for weavers in the highlands of Guatemala(Bonder & Martin, 2001), we found that weavers in smallvillages in the Guatemala highlands have begun to use theInternet to market their textiles as a way to maintain a tra-ditional art that might otherwise disappear. By openingnew markets selling on the Internet, they increased the rev-enue generated by this age-old activity, thereby sustainingthemselves as well as the tradition.


Similarly, the cultural knowledge of an individualchanges over the life course as new objects, situations, andinteractions are encountered (Tedlock & Mannheim,1995). The theory of culture emergent is particularlyfocused on this element of culture. Individual experiencesserve to shape a unique person. However, across a society,many individuals may experience forces for change almostsimultaneously and respond in similar ways. The progress ofdigital technology in the United States and elsewhere offersus many examples of such forces for change and their rela-tionships not only to life activities (e.g., job tasks) but toidentity (e.g., technophobes versus technophiles) and values(e.g., role of Internet in discussions of plagiarism and reeval-uations of intellectual property rights). Within larger cul-tural groups, smaller groups change at their own pace, oftenin response to trends elsewhere in the system. So, for exam-ple, demographic changes at a societal level produce orga-nization change at an institutional level (cf., Martin &Bonder, 2003). The concept of emergence helps explainwhy this is so and helps manage it.

Usually, cultural groups are continuous over time.Except in cases of wholesale extermination through contact-induced disease or forcible conquest, cultural change sel-dom means replacement, especially for individuals. Thoughnew cultural components are added to an individualsknowledge base, preexisting components are not excised.For example, old ideas about technology may be supplant-ed. They cease to exist only when they are no longer learnedby a new generation. Occupational therapists rarely workwith their clients on shoeing horses or making soap or usingtypewriters. However, these used to be common culturalskills, and are still viable among some groups.

Culture changes in two ways. First, at the societal level,the collective patterns may change when many individualsalter their behavior over a short period of time, as a result ofchanges in the external context. For example, when envi-ronmental circumstances change, or when one group comesin contact with another on a widespread basis, culturalchange is nearly inevitable and often invisible (Kuper,1999). Second, the cultural knowledge of an individualcontinues to change over the life course as the personencounters new elements in the personal environment andincorporates them into life and interactions.

Implications for PracticeThe idea of culture emergent has consequences for thera-peutic intervention in occupational therapy as well as in other health care encounters. It suggests a particularview of culture that has the potential to guide therapistsinteractions.

Culture and OccupationCulture is an important influence on occupational patterns,and occupational choices reflect cultural beliefs. A clientschoice of activity level, engagement in particular occupa-tions, and perceptions about the value of particular occupa-tional outcomes are all influenced by his or her culturalbeliefs. Kluckhohn and Strodtbeck (1961) suggest thatevery culture has a conception of human activity that con-veys values that may be expressed through orientations onbeing, being-in-becoming, or doing. In Western cul-ture, the being orientation is somewhat devalued (Rowles,1991), while other cultures value that orientation morehighly than the Western orientation toward doing (Jang,1995). Some Far Eastern cultures emphasize harmony withnature, acceptance of fate, and personal reflection as beingmore central than active doing of occupations. If the thera-pist values the Western doing culture, there may be a con-flict with a client who values a being perspective morehighly.

Examples of cultural influences on occupation areubiquitous. For instance, gender roles in some cultures arerigidly defined, such that women and men may have rela-tively restricted choice of productive (work) roles. In ourobservations in Maya communities in the highlands ofGuatemala, women typically look after the home, weaveusing backstrap looms, and provide child care. Men work inthe fields or take jobs in town. Women rarely run for pub-lic office or hold leadership positions in the church.However, individual personality and personal experiencedefinitely influence these roles. Some women become influ-ential in village politics through activities with womensweaving cooperatives, or through church activities linked totheir husbands roles in the church (Bonder, 2001). As edu-cational opportunities, political activism, and social supportfor expanded womens roles increase, individual women willexercise new choices, and, over time, may alter the descrip-tion of typical Maya womens work (Bonder & Martin,2001).

Cultural constructions of occupation also influence theexperience of disability. When disability interferes withaccomplishment of occupations strongly linked to culturalvalues, life-satisfaction can be compromised. We spoke witha Maya woman who could no longer weave because ofarthritis and who felt a great sense of personal loss.However, for her, modifying the activity was not acceptablebecause of the rigidity of her definition of its structure inher culture. The idea of sitting on the a chair instead of thefloor was not consistent with her view of how weavingoccurred, even though in other villages nearby, weavers hadall begun to sit on low stools. Alternatively, another Mayawoman whose disability interfered with her weaving was


able to substitute other activities that promoted a sense ofself-worth for her (Bonder, 2001).

In clinical encounters, therapists must carefully explorethe cultural construction of specific occupations and occu-pational patterns. Without such exploration, a process thatcharacterizes the critical thinking that is vital to effectivepractice (Wittman & Velde, 2002), important aspects ofoccupation will be overlooked. In exploring culture, how-ever, it is vital to recognize the emergent nature of culturein the individual. Knowledge of cultural facts is useful onlyas a means of generating preliminary hypotheses that mustbe tested for the specific client. It is also essential to recallthat the therapist, too, has culture. The values and beliefsthat accompany that culture also influence the interaction,and must be given careful attention. It is not possible for thetherapist to be an entirely objective observer of a situation(Bakhtin, cited in Willeman, 1994).

Framing Encounters

Sue (2000) suggests that effective intercultural clinicalinteraction has three primary characteristics. The first ofthese is scientific-mindedness. Sue refers here to the recogni-tion that clinical encounters are based on forming hypothe-ses based on prior knowledge, with the expectation thatthese hypotheses must be tested in the specific encounter.Experience with individuals from a particular culture maywell lead to a set of assumptions about all individuals fromthat culture. However, as Mattingly (1998) notes, therapistswho carry those assumptions into intervention withoutexamining their applicability to the specific client may wellfail in their efforts. One must also cultivate what Sue haslabeled dynamic sizing skills. The clinician must recognizewhen cultural generalizations apply to a particular situationand when individual factors predominate. In order to do soeffectively, the clinician needs at least some culture-specificexpertise, knowledge about the general characteristics of cul-tural groups.

Thus, therapeutic encounters become something of adance between the individual and the cultural. The therapistmust recognize the limitations of cultural generalities, but, atthe same time, possess a fund of knowledge from which tobegin. As an example, a therapist planning treatment for aMaya immigrant woman who has had a stroke will find ithelpful to know that in Maya culture women do the cook-ing, and that typical meals include vegetables, beans, andtortillas. Tortillas are the staff of life for Mayans, carryingmuch ritual, mythological, and symbolic content. It is alsohelpful to know that the tortillas are made through a processinvolving soaking of the corn, grinding it into meal, mixingthe dough, shaping it by clapping the dough between thehands, and cooking on a stone over a flame. However, if the

Maya woman is a second- or third-generation resident of theUnited States, she may make her tortillas using purchasedcornmeal, on a griddle over an electric burner, and may evenshape the tortillas using a tortilla press. In fact, she mightprefer to serve peanut butter and jelly sandwiches made withpurchased white bread. Different movements and proce-dures are required for the different kinds of cooking, andtreatment must be molded accordingly.

Intervention Strategies

Understanding of culture as emergent in intervention sug-gests three important characteristics that therapists can cul-tivate to enhance clinical encounters. The first of these isattending carefully to the interactional moment (Tedlock &Mannheim, 1995). Because culture emerges in interaction,each interaction is a new situation. Previous informationabout specific cultures, about the diagnosis of the client,and about other relevant factors must be understood in thecontext of the immediate situation. Therefore, attention toword choice, facial expression, body posture, voice tone,gestures, and other clues to the feelings and attitudes of theindividual can be identified only through careful attention.The symbols that convey information about a culture arepublic and observable (Sewell, 1999), assuming one isattending carefully.

Active curiosity about the meaning of these clues is thesecond characteristic that therapists can bring to clinicalencounters. It is impossible to know all there is to knowabout every labeled cultural group, Hispanics, for example,or Blacks. And as we have established, even knowing thosefacts would not provide adequate information in a particu-lar encounter. Asking questions to help interpret observa-tions can provide vital information to assist in understand-ing of the individual and framing of intervention.

Finally, therapists can engage in self-reflection and eval-uation of interactions in order to improve subsequentencounters (Rosaldo, 1999). It is impossible always tonotice the important clues, to ask the right questions, andto draw the right inferences. Nor are therapists neutralobservers (Kuper, 1999). Reflection about choices made inone encounter can assist therapists to improve the nextinteraction. Their own culture, like that of their clients, isunavoidable (Greenfield, 2000), emergent in their clinicalencounters, and, thus, subject to change. Self-reflection andevaluation can ensure that the change enhances future ther-apeutic interactions.

ConclusionsIt is well-established that culture affects occupation, andthat occupational therapists must acknowledge its impact


on daily life and on intervention strategies. Failure to do socan prevent establishment of rapport, decrease trust, andlead to communication difficulties, all of which can reduceeffectiveness of intervention (Krefting, 1991). However,culture is difficult to define, and even more difficult toquantify. Efforts to group people on the basis of a set of cul-tural facts, as is done in much diversity training practice, areunlikely to be effective because these efforts fail to recognizethe subtle but profound interplay of personal, experiential,and cultural factors in individual lives. Further, thisapproach fails to take into account the constant change thatis part of individual lives.

The task of cultural understanding involves observingwhat occurs between people in the intersubjective realm.These exchanges take place in the clear light of public inter-actions, they do not entail the mysteries of empathy orrequire extraordinary capacities for going inside peoplesheads or, worse, their souls (Rosaldo, 1999, p. 30). Rather,the therapist, like a good ethnographer, constructs data ina dialogue with informants, who are themselves inter-preters (Kuper, 1999, p. 214). Incorporation of the con-cept of culture emergent, that is, a definition of culture as apart of identity that emerges in individual interactionalmoments in specific locales, has the potential to enable clin-icians to enhance clinical care by acknowledging the pro-found impact of culture, the unique nature of each individ-ual, and the strategies that can lead to enhancedunderstanding and therapeutic collaboration.

ReferencesAbu-Lughod, L. (1999). The interpretation of culture(s) after

television. In S. B. Ortner (Ed.), The fate of culture: Geertzand beyond (pp. 110135). Berkeley, CA: University ofCalifornia Press.

American Occupational Therapy Association. (1999). Standardsfor accreditation of an occupational therapy education program.Rockville, MD: Author.

Bakhtin, M. M. (1981). The dialogic imagination: Four essays byM. M. Bakhtin. In M. E. Holquist (Ed.). (C. Emerson & M.Holquist, Trans.). Austin, TX: University of Texas Press.

Baptiste, S. (1988). Murial Driver Memorial Lecture: Chronicpain, activity, and culture. Canadian Journal of OccupationalTherapy, 55, 179184.

Barney, K. F. (1991). From Ellis Island to assisted living: Meetingthe needs of older adults from diverse cultures. AmericanJournal of Occupational Therapy, 45, 586593.

Bonder, B. R. (2001). Culture and occupation: A comparison ofweaving in two traditions. Canadian Journal of OccupationalTherapy, 68, 310319.

Bonder, B. R., & Martin, L. (2001, November). The meaning ofweaving for Maya women in the Guatemala Highlands. Paperpresented at the Midwest Association for Latin AmericanStudies, Cleveland, OH.

Bonder, B. R., Martin, L., & Miracle, A. W. (2002). Culture inclinical care. Thorofare, NJ: Slack.

Cerulo, K. A. (Ed.). (2001). Culture in mind: Toward a sociologyof culture. New York: Routledge.

Christiansen, C., & Baum, C. (1997). Personenvironmentoccupational performance: A conceptual model for practice.In C. Christiansen & C. Baum (Eds.), Occupational therapy:Enabling function and well-being (2nd ed., pp. 4770).Thorofare, NJ: Slack.

Clifford, J. (1986). Introduction. In J. Clifford & G. E. Marcus(Eds.), Writing culture: The poetics and politics of ethnography(pp. 121). Berkeley, CA: University of California Press.

Cross-Cultural Health Care Program. (1996). CCHCP Library.Retrieved June 5, 2002, from http://www.xculture.org/resources/library/index.cfm

DAndrade, R. (1999). Comment. Current Anthropology,40(Suppl.), S16S17.

Dillard, M., Andonian, L., Flores, O., Lai, L., MacRae, A., &Shakir, M. (1992). Culturally competent occupational ther-apy in a diversely populated mental health setting. AmericanJournal of Occupational Therapy, 46, 721726.

Dressler, W. W., & Bindon, J. R. (2000). The health conse-quences of cultural consonance. American Anthropologist,102, 244260.

Dunton, W. R. (1918). Occupational therapy: A manual for nurs-es. Philadelphia: Saunders.

Dyck, I., & Forwell, S. (1997). Occupational therapy studentsfirst year fieldwork experience: Discovering the complexity ofculture. Canadian Journal of Occupational Therapy, 64,185196.

Eliot, T. S. (1948). Notes toward the definition of culture. London:Faber & Faber.

Fitzgerald, M. H., Mullavey-OByrne, C., & Clemson, L. (1997).Cultural issues from practice. Australian OccupationalTherapy Journal, 44, 121.

Galanti, G. (1997). Caring for patients from different cultures (2nded.). Philadelphia: University of Pennsylvania Press.

Geertz, C. (1973). The interpretation of cultures. New York: BasicBooks.

Greenfield, P. M. (2000). What psychology can do for anthropol-ogy, or why anthropology took postmodernism on the chin.American Anthropologist, 102, 564576.

Handwerker, W. P. (2002). The construct validity of cultures:Cultural diversity, culture theory, and a method for ethnog-raphy. American Anthropologist, 104, 106122.

Hendrickson, C. (1995). Weaving identities: Construction of dressand self in a Highland Guatemala town. Austin, TX:University of Texas Press.

Hendrickson, C. (1996). Women, weaving and education inMaya revitalization. In E. F. Fischer & R. M. Brown (Eds.),Maya cultural activism in Guatemala (pp. 156164). Austin,TX: University of Texas Press.

Hermans, H. J. M., & Kempen, H. J. G. (1998). Moving cul-tures: The perilous problems of cultural dichotomies in aglobalizing society. American Psychologist, 53, 11111120.

Hill, J. H., & MacLaurey, R. E. (1995). The terror ofMontezuma: Aztec history, vantage theory, and the categoryof person. In J. R. Taylor & R. MacLaurey (Eds.),Language and the cognitive construal of the world. Trends in


linguistics, studies and monographs, 82 (pp. 277329). Berlin,Germany: Mouton de Gruyter.

Holland, D., Lachicotte, W., Skinner, D., & Cain, C. (1998).Identity and agency in cultural worlds. Cambridge, MA:Harvard University Press.

Jang, Y. (1995). Chinese culture and occupational therapy. BritishJournal of Occupational Therapy, 58, 103106.

Kinebanian, A., & Stomph, M. (1992). Cross-cultural occupa-tional therapy: A critical reflection. American Journal ofOccupational Therapy, 46, 751757.

Kluckhohn, F. R., & Strodtbeck, F. L. (1961). Variations in valueorientations. Evanston, IL: Row, Peterson, & Co.

Krefting, L. H. (1991). The culture concept in the everyday prac-tice of occupational and physical therapy. Occupational andPhysical Therapy in Pediatrics, 11(4), 116.

Krefting, L. H., & Krefting, D. V. (1991). Cultural influences onperformance. In C. Christiansen & C. Baum (Eds.),Occupational therapy: Overcoming human performance deficits(pp. 102122). Thorofare, NJ: Slack.

Kuper, A. (1999). Culture: The anthropologists account.Cambridge, MA: Harvard University Press.

Levine, R. E. (1987). Culture: A factor influencing the outcomesof occupational therapy. Occupational Therapy in HealthCare, 4, 315.

Martin, L., & Bonder, B. (2003). Achieving organizationalchange within the context of cultural competence. Journal ofSocial Work in Long-Term Care, 2(1/2), 8194.

Mattingly, C. (1998). Healing dramas and clinical plots: The nar-rative structure of experience. Cambridge, MA: CambridgeUniversity Press.

Mirkopoulos, C., & Evert, M. M. (1994). Nationally speaking:Cultural connections: A challenge unmet. American Journalof Occupational Therapy, 48, 583585.

Pepitone, A. (2000). A social psychology perspective on the studyof culture: An eye on the road to interdisciplinarianism.Cross-Cultural Research, 34, 233249.

Pope-Davis, D. B., Prieto, L. R., Whitaker, C. M., & Pope-Davis,S. A. (1993). Exploring multicultural competencies of occu-pational therapists: Implications for education and training.American Journal of Occupational Therapy, 47, 838844.

Reyna, S. (2002). Connections: Mind, brain and culture in socialanthropology. New York: Routledge.

Rosaldo, R. I. (1999). A note on the cultural essayist. In S. B.Ortner (Ed.), The fate of culture: Geertz and beyond (pp.3034). Berkeley, CA: University of California Press.

Rowles, G. D. (1991). Beyond performance: Being in place as acomponent of occupational therapy. American Journal ofOccupational Therapy, 45, 265271.

Sapir, E. (1924/1949). Culture, genuine and spurious. In D.

Mandelbaum (Ed.), Selected writings of Edward Sapir.Berkeley, CA: University of California Press.

Sahlins, M., & Service, E. R. (Eds.). (1960). Evolution and cul-ture. Ann Arbor, MI: University of Michigan Press.

Schneider, D. M. (1976). Notes toward a theory of culture. In K.Basso & H. Selby (Eds.), Meaning in anthropology.Albuquerque, NM: University of New Mexico Press.

Segall, M. H., Lonner, W. J., & Berry, J. W. (1998). Cross-cul-tural psychology as a scholarly discipline: On the floweringof culture in behavioral research. American Psychologist, 53,11011110.

Sewell, W. H. (1999). Geertz, cultural systems, and history: Fromsynchrony to transformation. In S. B. Ortner (Ed.), The fateof culture: Geertz and beyond (pp. 3555). Berkeley, CA:University of California Press.

Sherzer, J. A. (1987). Discourse-centered approach to languageand culture. American Anthropologist, 89, 295309.

Skinner, D. (1989). The socialization of gender identity:Observations from Nepal. In J. Valsiner (Ed.), Child devel-opment in cultural context (pp. 181192). Toronto, Ontario,Canada: Hogrefe & Huber.

Spencer, J., Krefting, L., & Mattingly, C. (1993). Incorporationof ethnographic methods in occupational therapy assess-ment. American Journal of Occupational Therapy, 47,303309.

Sue, S. (2000, June). The provision of effective mental healthtreatment by service providers. National Institutes of HealthConference Toward Higher Levels of Analysis: Progress andPromise in Research on Social and Cultural Dimensions ofHealth. Bethesda, MD.

Tedlock, D., & Mannheim, B. (1995). Introduction. In D.Tedlock & B. Mannheim (Eds.), The dialogic emergence ofculture (pp. 132). Urbana, IL: University of Illinois Press.

Tylor, E. B. (1871). Primitive society. London: J. Murray.Urban, G. A. (1991). Discourse-centered approach to culture:

Native South American myths and rituals. Austin, TX:University of Texas Press.

Wallace, A. F. C. (1961). Culture and personality. New York:Random House.

Wells, S. A., & Black, R. M. (2000). Cultural competency forhealth professionals. Bethesda, MD: American OccupationalTherapy Association.

Willeman, P. (1994). Looks and frictions: Essays in cultural studiesand film theory. Bloomington, IN: University of IndianaPress.

Wittman, P., & Velde, B. P. (2002). The issue is: Attaining cul-tural competence, critical thinking, and intellectual develop-ment: A challenge for occupational therapists. AmericanJournal of Occupational Therapy, 56, 454456.


culture emergent in ocupation

Documents