Crossing Borders, Culture Blindness, and Understanding the Client

As with most journeys like this one, I set out with a specific trajectory in mind, however I arrived at a very different destination than what I would have expected. My goal in the beginning of this project was to understand how Occupational Therapy was being provided to Guatemalans and Nicaraguans based in their own culture and from native therapists in hopes of informing and developing the approach therapists take when working with these specific populations. My question was originally, "How does occupational therapy change and adapt to the cultural differences of Guatemalans, indigenous and ladino, and Nicaraguans?" When looking deeper into the current situation of these countries, along with the current status of Occupational Therapy in them, I realized this question was not so simply answered.

We believe that Occupational Therapy is a client-based profession, one in which therapists must understand their patients' goals and meaningful activities to truly provide effective therapy. However, naturally we, as therapists, employ our own cultural framework to expedite this process. We function from assumptions about our patients that are inherent to our own culture, using  presumed and simply understood cultural paradigms to approach therapeutic intervention. When crossing cultures and even sub-cultures this becomes an obstacle to effective therapy delivery. To provide effective therapy to individuals from diverse socioeconomic and cultural backgrounds, therapists must step outside of what occupational therapy scholars have called "culture blindness", being immersed in one's own culture so comprehensively that the therapist does not recognize their own cultural influences in the therapeutic relationship.

From my experiences in Guatemala and Nicaragua, I have come to realize that for culture blindness to subside and culturally competent occupational therapy to be delivered, therapists must take a step back from their traditional and assumed interventions and approaches and begin to look first at the theoretical foundations of occupational therapy. Therapists must first shave off the culturally biased flavors in which occupational therapy has developed and discover the raw underlying philosophy of the profession. From there we can allow this raw philosophical seed to grow in the natural culture of our patients, bearing the appropriate interventions and approaches rooted in the patients' own cultures and experiences.

This process requires a variety of factors to be in place. The first and foremost is rich soil into which the occupational perspective can be placed. Resources, time, and support are all necessary for the occupational perspective to be cultivated within a population in a way that connects theory to the patient in an authentic and effective manner. Unfortunately, just as Guatemalan campesinos have little land to cultivate their own crops, Guatemala and Nicaragua have little room to develop the occupational perspective. In Guatemala, the healthcare system is overburdened, disjointed, plagued with ethnic tension, overrun with NGOs, and has little room for prioritizing occupational therapy. In Nicaragua, what little occupational therapy is present is restricted by economic and political limitations, having neither the time nor the resources to effective emerge through the Nicaraguan culture.

Secondly, for the occupational perspective to take root and emerge through a new culture it must be interpreted effectively. Because of the huge presence of NGOs, service organizations, and foreign aid in Guatemala, much of the therapy is provided by non-Guatemalans who, although with good intentions, may not be providing the most effective or appropriate interventions for Guatemalan people. On many occasions, therapists provide interventions and techniques that come directly from their experiences in their respective countries instead of providing the reasoning and underlying philosophy behind those interventions to native therapists or caregivers. This creates a situation where patients, family members, or caregivers are performing interventions that may not make sense, are not effective, and maybe even create more of a burden rather than alleviating a problem.

As caregivers or therapists begin to realize that these transplanted interventions are not effective with their population, for example in Nicaragua, they resort to simplified non-occupation based techniques that do not resemble true occupational therapy. The occupational perspective, which was cultivated in Western/Developed cultures, has not been effectively interpreted for cultural differences outside that paradigm. Occupational therapy, because it is such a client based approach, must be acculturated before it can be sustainably effective. For this to occur, occupational therapists must step outside their own cultural paradigms and begin to understand the many structural and contextual factors that influence the efficacy of the therapy.

Understanding that in Nicaragua, the idea of independence may not be the most meaningful concept for a 75 year old woman because culturally she expects her children to care for her. Understanding that the routine of an indigenous woman in Guatemala may not have the flexibility to provide extra exercises to her child with special needs. Understanding that the standard approaches and solutions for assistive equipment, adaptive solutions, or even safety procedures may not be accessible, affordable, available, or of high quality. Understanding that therapists are viewed with less authority and less respect in some cultures. Understanding that sickness, disability, poverty, and independence are all viewed very differently within these cultural contexts.

For therapists crossing borders, it is integral to first understand these factors that affect their clients' in order to be creative, innovative, and revolutionary practitioners and effectively facilitate rehabilitation and/or change. Therapists crossing borders, whether that be across national borders or stepping into a homeless camp, work with tools that both hinder and facilitate potential success in their practice, having to take the time and effort to understand the full context of their patients while also bringing a new and diverse perspective on ways to resolve obstacles for their clients. It is the responsibility of therapists to find a balance between these two, uncovering a manner in which they foster occupational justice while preventing the imposition of their own culture.

Translation: "I want to be happy: To study and to play"

As a global community and a global profession, we must learn to share ideas across cultures effectively and dialogue between therapists, professions, and nations. As occupational therapists, the adaptive thinkers that we are, we approach obstacles from a new and exciting way, thinking of new and sustainable ways to overcome occupational injustice using innovative minds and passionate communities. When we hone the ability to apply the theory, values, and principles of our profession across cultures, socioeconomic statuses, gender, sexual orientation, religion, and countless other diverse contexts, we will make a new step in becoming a globalized profession seeking to support occupational justice for all people both locally and on an international scale.

Nicaraguan Occupational Therapy: Seeing the Whole Picture

Craft Materials

As I began my observation and participation in occupational therapy in Nicaragua, I was planning on providing a reflection on each of my days at the hospital where I am working. It quickly became apparent that this was not going to be an effective manner of conveying my experience because to truly
display and understand the complexities of what is happening in Nicaragua with OT would take much more time to understand or even reflect on. Therefore I altered my approach and attempted to dive deeper into what I was seeing in the therapy room, what I was hearing from the therapists, and connect that to what I already knew about Nicaragua.

Block Pusher

This week has been an interesting and fulfilling experience to say the least. I have been fully immersed in one of two or three locations (still uncertain) that officially provide occupational therapy in Nicaragua, a rehabilitation hospital called Aldo Chavarria (Aldo for short). However, the occupational therapist who I am observing noted that she was unsure that the other places still gave OT. When it comes to receiving OT, Aldo is the place to go in Nicaragua.

Aldo has many departments including physical and occupational therapy, prostheses, aqua-therapy, and others I am sure I have not seen. I have focused all my time in the Occupational Therapy room working with a Nicaraguan occupational therapist and a physical therapist who has taken some courses in occupational therapy. I arrive at 7:30am every morning and begin observation from 7:30am to 10:00am. I have performed two different types of observations: 1) Patient observations - noting every exercise or action the patient performs during their time in therapy and 2) OT observation - noting every interaction, activity given, and other activities performed by the OT. These hours are the most populated by patients. After these hours I begin lending my time as a student by treating patients and actively observing treatment of other patients.

Rheumatism Gym - Excercises for neck

From my observations I have come up with a typical session within this OT room: 1) Patient enters and greets therapist 2) Therapist takes appointment card and sends patient to an exercise for a specific amount of time (usually between 5-15 minutes) 3) Patient performs exercise while therapist is giving activities to other patients (sometimes up to 10 patients), doing paperwork, or standing watching the room 4) Patient alerts therapist when time has been completed or therapist stops patient 5) Therapist directs patient toward a different exercise 6)This continues until end of 30 minute session. The OT occasionally will provide further explanation or instruction to the patient and observe them perform the activity for a few seconds, however the majority of the time she does not have one-to-one interaction with the patients for more than the time it takes to set them up with a new exercise. On some occasions, the OT will stand back and watch the room of patients without interacting with anyone. On a few occasions, I have seen the OT have increased interaction with more severely involved patients with stroke or spinal cord injury. Some patients come with a family member or helper who provides one on one interactions with the patient during their session, sometimes even taking the patient through a set of routine exercises they have

Large Peg Board

learned, without consulting the therapist. In many ways, these helpers and family members are actually providing therapy to the patients, however they may not always be providing the most effective or most beneficial techniques.

Some of the typical activities used are: large peg board (placing pegs in and out of holes), small pegs or blocks, standing while sliding objects across wires, wiping a slide board, removing and placing small velcroed squares or large tic tac toe pieces on a board, lifting rings from one pole to another, general shoulder exercises, wrist machines, squeezing hand strengtheners, screwing nuts on and off bolts, weaving shoe laces through small holes, finger ladder, and making circles and arcs on the table with an ace bandage. (See pictures of some of these activities throughout post). In the fact that I am able to even attempt to list most all the activities I have seen in one week, one can seen their repetitive and unvarying nature.

Sensory integration, autism, adapted technology, occupation based interventions, therapeutic use of self, mental health approaches, and environmental approaches, all of which are huge focuses today in OT, are rarely if at all present in the occupational therapy I am seeing in this Nicaraguan rehab hospital. Physical rehabilitation exercises and the bio-medical model prevail over any specifically occupation based theories or approaches. The PT told me that in the 80s, occupational therapy was provided to the psychiatric hospital near the rehabilitation hospital, but it no longer offers that to their patients. In my

Ring Poles

observations in the past week, I noted 4 patients in the OT room of probably around 100 who received ADL training (wheelchair to bed transfer and functional mobility). The physical therapist performs many of the ADLs in the inpatient rooms. She travels throughout the hospital working with referred patients, maybe 5-7 per day. Otherwise patients, especially out-patients are performing usually one of the repetition based exercises above for sometimes up to 20 minutes. Entering the room, and after a little searching, one can find many materials that could be used to do crafts, games, or creative activities. When speaking to the OT, she recognizes that they have these materials, but she does not use them.

As I sat on my first few days, observing and noting all that I saw, I felt a pinch of condescension and authority believing that I already could see ways therapy at this hospital could be improved. As a student accustomed to the fast paced, function based, productivity oriented, and necessary one-to-one therapy of the United States, my first few days of observation left me frustrated, irritated, and asking

Finger Ladder

the question, "Why won't they do more?" From an outside and foreign perspective, especially one educated in the contemporary OT theory emerging in the US, Europe, and other "developed" countries, I was tempted to harshly judge this OT's methodology for being non-occupation based, simply medically oriented, and far from holistic. Sometimes we are even be tempted to patronize the therapists we seek to serve when we travel abroad and volunteer our time because, "they just don't understand or know". We may believe they don't have a good answer to the question, "Why won't they do more?'

After a few days of internal self-touting, the OT actually asked me directly, "What are you seeing? What do you think about me?" with the attitude that she already knew what my answers would be, and she did. I provided my observations just as I did above. She then proceeded to explain to me her reasons why she had to provide therapy the way she did, recognizing very blatantly that she knew about occupation and occupational therapy and that she knew what she was doing wasn't the best therapy possible. As she continued, each of her reasons sharply poked holes in every view and recommendation I had. I slowly began to realize I had been roped into superficially looking at a situation, allowing myself to forget what this whole project has been about. By the end of the conversation, I realized instead of asking the question "Why won't they do more?" I should have been asking "Why can't they do more?". I needed to step back, understand the context, and see the whole picture.

In the next few paragraphs I will attempt to present my thoughts as to what the answer to this question might be, based in and informed by my observations, quite frank conversations with both therapists, and my current knowledge of Nicaragua and its structures.

When OT is Emphasized

Exercises for the elbow and wrist

According to the PT, in the 80s occupational therapy was focused on in Nicaragua. This was a time directly after the victory of the Sandinista Revolution and during the Counterrevolutionary war which I assume would require from occupational therapy a much more medically focused approach to meet the needs of the physically injured soldiers. However, as stated in this paper by West (1984) published in the American Journal of Occupational Therapy, seated crafts were still considered the standard for OT intervention and only just then were beginning to be critiqued. Imagine a Nicaraguan soldier returning from guerrilla war in the jungle after losing a leg and being asked to make a basket or sew a design in cloth. OT's craft focus at this time may not have helped its proliferation within the Nicaraguan culture especially since many of the crafts, ideas, theories, and methods were based in other cultures not experiencing the social and economic obstacles Nicaragua faced then and still faces today. This may have left OT to be misunderstood and not respected within the rehabilitation world.

Materials in the Closet

How OT is Viewed
As OT has grown its authority, prestige, scope of practice and scientific base as well as broadened its interventions through a deeper understanding of its philosophy and purpose, Nicaraguan occupational therapy has been left behind in a resource scarce context. As therapists become more respected in the developed world, the OT here notes that she feels least respected of all the therapists and that no one thinks OT is important. In the developed world, therapist have the ability to evaluate their patients and plan their treatments, here in Nicaragua the doctors decide the amount of time a patient will be in therapy, how often they will go, and sometimes even what specific activities they will be doing. She stated that patients often refuse to do what she asks and treat her poorly. Unfortunately, she also notes that her job is at risk if patients complain about things like her being too hard on them. For this reason she feels she cannot have more in depth and challenging relationships with the patients and therefore stands back and keeps her distance during therapy. With the patients who she can tell want to work and be challenged, she says she does build rapport and works with more closely. She does not enjoy the job security and support of an administration like many therapists do in the States when it comes to therapist respect, patient interaction, and complaints.

How OT Comes

Tactile Materials

Most commonly occupational therapy arrives in Nicaragua through the hands of foreigners. US citizens, Japanese, Canadians, and others who come to Nicaragua and provide activities they have learned in their own cultures.  In essence, occupational therapy has not bee translated for Nicaragua, it has been transplanted from other cultures. The local university, Universidad Nacional Autónoma de Nicaragua (UNAN), had an OT program that apparently chronically lacked resources and has since been closed. I cannot find any information about this program, how long it was open, how many students graduated from it, or who the professors were. However, the OT at Aldo is one of those graduates. She stated that she had classes for three years on activities, medical conditions, and some psychology to receive her degree. It is clear however, that this program neither had the time nor the resources to truly begin teaching what I might call "Nicaraguan" occupational therapy.

Craft Materials

From my observations and conversations with the OT it seems the activities that Nicaraguan OTs were taught to use are not meaningful or desirable for the Nicaraguans. She says she has tried to use crafts and the patients think they are silly and prefer to come in and do repetitive exercises and leave. The patients do not enjoy nor understand how making a craft like origami, which has no cultural significance, will benefit their progress after a stroke even if the therapist attempts to explain it to them. According to the OT, these crafts do not speak to Nicaraguan patients. The occupations the OT was taught to use do not find meaning in the hearts of Nicaraguans so she stopped attempting to use them.

How OT has Adapted
It hasn't. Occupational therapy has not had the opportunity, resources, or personnel necessary in Nicaragua to flavor the profession to the needs of the Nicaraguan people. The occupational therapist has outdated and, due to the culture, ineffective techniques for providing therapy.  She therefore resorts to non-function based repetitive exercises that lack the attributes that characterize occupational therapy. She understands the value of the diversion activities for mental health and the physical benefits of specific movements during those activities. However, I do not think the underlying philosophy of using meaningful occupations of the patient as a means and ends (which has more recently been more deeply developed in the profession) was emphasized greatly in her education due to context and time in which she received it. The other therapist who is by profession a physical therapist, commented that she had received one class from a professor from Philadelphia that did focus on this perspective. The professor supported the idea of using occupations relevant to Nicaraguan culture and the Nicaraguan people (e.g. planting a garden for the those patients who come from the countryside). The therapist said this could not continue after the professor left because the hospital did not have the resources to provide it. The lack of emphasis on this philosophy as well as the many other structural factors facing occupational therapists have hindered at least this Nicaraguan OT (one of the only ones giving occupational therapy) from applying it to her own culture and social systems, preventing her from developing applicable activities and occupations for her patients to perform. This leads to a stagnant and irrelevant existence for occupational therapy in Nicaragua as nothing more than physical exercise for the upper body.

Continued Conditions of OT
The word that I can use to best describe the OT I work with is burnt out. She is sometimes required to

Small Pegs

treat all the 30-60 patients that come through her door each day. On Tuesdays, Wednesdays, and Fridays she is virtually alone due to the responsibilities of her partner who is the department head. When her partner is there she is not alone, but she is still treating 20-40 patients. Most of these patients come in the morning because they refuse to come later in the day. According to her, if she tries to schedule them later, they tell her no and to schedule them earlier or they just won't come. She cannot use activities that require too much one-on-one attention due to the patient caseload or non-reusable materials due too lack of physical resources that she cannot replenish.  She cannot prescribe adaptive technology because there is no way for the patient to get it. I am also not sure how much education she has had with assistive or adaptive equipment in general, let alone classes or workshops on using local resources to create the equipment. Wheelchairs are often donated and therefore she does teach patients wheelchair mobility and transfers. In my first few days, I was constantly wanting to use a slide board for spinal cord injury patients, a walker for stroke patients, and gait belts for everything else because that is the safety measures I have been taught. However, it would be impractical and actually not function-based to offer a slide board or a 

Wrist Machines

walker to a patient who will not be able to acquire one outside the hospital. With all of these obstacles and demands placed on the OT, I can see why the OT is not the happy fluttering butterfly full of energy and new ideas that we often envision ourselves needing to be as occupational therapists. Therefore she is demotivated and overworked with little resources, leading to therapy that does the job, but is the bare minimum.

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I began my week in the mind set of an occupational therapy student from the United States. As my week comes to an end, I find myself adapting and changing to the needs of the patients here, learning and understanding how to function within this setting. In my short time here, I won't be able to truly understand the complex situation that occupational therapy is existing within in Nicaragua, but I can at least gain a taste of the structural factors and circumstantial obstacles that face the occupational therapists working here. In the upcoming week, I hope to reflect more on how my own treatment, approaches, and presence changed as I begin working with more patients.