Vol. 11, No. 3
Welcome to the June edition of Tips and Topics, especially all the new international readers. This edition is influenced by my recent overseas trip.
David Mee-Lee M.D.
SAVVY and SKILLS
Dr. David Powell is President of the International Center for Health Concerns, Inc., and the Clinical Supervision Institute, and has trained for the past 36 years on clinical supervision and other topics in 50 states and87 countries. He is also Assistant Clinical Professor of Psychiatry, Yale University School of Medicine and Senior Advisor, Yale Behavioral Health Program, Department of Psychiatry. In 2012, he assisted the governmentsof Malaysia, Singapore and Vietnam to develop and train clinical supervisors for the respective ministries of health. He oversees a 60-bed adolescent substance abuse treatment center in southern Turkey, on the Syrian and Iraq border,
“Since 1976, I have trained clinical supervisors worldwide, visiting over eighty countries and all fifty U.S. states. As I near the end of this career, there are lessons I have learned about working with the culturally different.
How does one provide clinical supervision with staff who is culturally different, or how do you establish a system of supervision in a different cultural context? This seems like a straightforward question. It is not, as I found out.”
Common Mistakes and What to Do
- Americans lecturing or consulting overseas far too often think the people they train will be like us, just using a different language. For example: at international forums, I have shared platforms with numerous presenters who use American colloquialisms, slogans and terminology, leaving the translators uncertain how to interpret what was said.
- What we miss is they are acting under different cultural rules than we.Unconsciously, we bring our own cultural frame of interpretation when we step on foreign soil. For example: at a conference on addictions at Beijing Medical University in 2002, a prominent U.S. expert (who will remain anonymous) began his talk by speaking of General Douglas McArthur’s parting wordswhen he left Chinese soil after World War II. This was not an image of which the Chinese were particularly fond.
What to Do:
- The core of intercultural awareness is learning to separate our observations from our interpretations, postponing interpretation until we know enough about another culture.
- Language is much more than learning new vocabulary. It includes knowing what to say, and when,how, where, and why.
- Nonverbal communication is critical in working with other cultures: gestures, posture, and other areas that show what we are thinking and feeling.
- Stereotypes area major communication barrier.
- We tend to evaluate behaviors of the other culture as good and bad, making judgments based on our own cultural bias.
What to Do:
- We must remember that all foreigners will not one day become like us. This is difficult when one walks into the new airport in Beijing and is immediately confronted by Starbucks and McDonalds. We assume they have become Americanized, untilwe realize while the sign outside might be the same, many things aren’t.
- We need to distinguish between modernized and westernized. Culture is communicated not through names but through symbols, some as ordinary as the napkins used. (DML: When traveling in Myanmar, on planes and in restaurants, moist, scented individually-wrapped towelettes were often used as napkins.)
- Even ordinary symbols can have a powerful influence on relationships and the ultimate success or failure of the effort.
This article can briefly address key issues a supervisor might consider when implementing supervision for culturally-different personnel. If you supervise staff with different backgrounds, or if you have an opportunity to establish supervision systems in other countries, here are a few tips. The article will highlight principles of cultural variations primarily in four countries where I have recently trained on supervision: Vietnam, China, Singapore and Turkey.
Remember the powerful role of culture in shaping management/supervision styles.
Cultural values are derived from many sources, among them, the relationship to authority, conception of self (the individual vs. the collective), ways of dealing with conflict, certainty and ambiguity and long-term vs. short-term orientation.
- Norms are standards for behavior that exist within a group or category of people.
- We cannot change the way people in a country think, feel or act by simply importing our way of management.
- Globalization meets fierce local resistance because systems are not culture-free.
- Unawareness of national limits causes supervision ideas to be exported without regard for the values context in which they were developed.
- Psychology is predominantly a U.S., individualistic discipline. Sociology is predominantly European.
–> This is essential for those who train overseas, thinking far too often that we will simply teach other countries how we do things in the U.S. Then we wonder why they don’t embrace our way of working.
Example from Vietnam:
With Vietnamese managers, the American way would be to give and receive personal feedback. When tried with Vietnamese managers, this was virtually impossible and resulted in ritualized behavior: the receiver of feedback felt that he must have insulted the sender in some way.
Solution: Understand that Vietnamese participants concentrate on tasks, rather than interpersonal process issues.
Recognize how power differences between management and employees affects conflict resolution and decision making.
Power distance indexesaddress how employees respond to disagreements with management, subordinates’ perception of their boss’s actual decision-making styles, and subordinates’ preference for the boss to make the decision.
- Power distance can be defined as “the extent to which the less powerful members of an organization within a country expect and accept that power is distributed unequally.” (Hofstede, p. 46).
- America ranks low (59 of 61) in power distance, meaning U.S. employees generally want to be part of the decision-making process, whereas in China (ranked 12th), employees prefer bosses to make decisions for them.
Example from work in Turkey
I began overseeing an adolescent treatment program in Turkey (ranked 32nd on the powerdifferential scale). I brought to Turkey a U.S. mentality, which gave preference to the employees to be part of the decision-making process. I’d ask staff for their opinions on what to do. Staff sat there with no response. They are used to being told what to do, not to voice their opinions untilthey know what the boss thinks.
Example from work in China
In China, employees donot want to lose face by saying something the boss might not agree with. Employees are given a choice so they do not lose face by having to say “yes” or “no” and exploring together what they think the boss thinks.
- Young psychiatrists in China would express their clinical concerns to me in supervision but, when encouraged to address these issues with their supervisors, said, “No, I cannot do that. It is not my place to do so.”
- In China, teachers/supervisors are treated with great respect (the older the teacher, the more respect and awe).
- Classrooms are teacher-centered with strict order, and the teacher initiates communication. People in class speak only when invited to by the teacher.
- Teachers should never be publically contradicted or disagreed with.Inequalities among people are expected and desired.
Example from work in Vietnam
In Vietnam, it is important not to mistake supervisee shyness for apathy or to assume rudeness inthe form of classroom conversations between students.
–> In sum, when an American trains in China, Vietnam or Turkey, they must realize how the power differential issue affects their training and their clinical supervision.
- High power distance between manager and employee or supervisor and supervisee applies to most Asian countries (such as Malaysia, China) and somewhat less for Turkey,France, etc.
- Low value power distance countries would be the U.S., the U.K., New Zealand, Australia, etc. which value “participative management” where employees are encouraged to take the initiative to have input.
- Such countries value entrepreneurship and intra-preneurship (encouraging ideas to emerge from within organizations).
- These principles are unlikely to apply in countries high on the power differential scale where the typical response might be “He is the boss. Why doesn’t he tell me what to do?” In Asia, there is less dialogue and power is based on tradition and charisma.
Identify how self-esteem and self-care are affected by Individualistic vs. collectivistic cultures.
In individualistic cultures, the individual is expected to look after him/herself vs. collectivistic cultures where the individual is integrated into a strong, cohesive group. Throughout one’s lifetime they continue to protect the group and collective.
- Collectivistic cultures stress filial piety and patriotism.
- Individualistic cultures are built around guilt.
- Shame is social in nature, guilt isindividualistic.
- Individualistic cultures tend to use the pronoun “I” when referring to themselves.
- Collectivistic cultures tendto drop the pronoun and rarely capitalize “I”.
- Individualistic cultures encourage an independent self.
- Collectivistic cultures stress interdependent self.
- Not surprisingly, the U.S. is #1 on the individualistic index. We value our independence. Turkey ranks 41, China and Vietnam rank 56-61 respectively.
Example from work in China
In China, a shame-based culture, loss of face, saying/doing the wrong thing, is feared. One loseswhen they fail to meet essential requirements placed on them. They “give face” in these cultures by honoring prestige.
Supervisors working with Chinese cultures need to understand these factors and never put either themselves or a supervisee in a place where they will lose face or be shamedby the group.
Here is an example of this issue. Dr. Hope Lee, a Chinese psychiatrist friend, wrote about an incident in her mental hospital. Another psychiatrist colleague was hit on the head from behind by a patient (not the psychiatrist’s patient). Dr. Lee asked me how to process the incident with staff. I recommended the usual form of critical incident debriefing as we would do in America. When the psychiatrist was asked to engage in a debriefing, she said no because she would lose face in front of her peers. I asked, “Why would you lose face, since this was not your patient?” to which the psychiatrist said she did not want to “stand out from the group, to be different.” Collectivism means being inthe in-group, not standing out.
Collectivist-oriented Chinese supervisees tend to perform best when operating with a group goal and in anonymity. Management in individualistic-oriented America is management of individuals vs. management of groups.
Example from work in Vietnam
In a collectivist society like Vietnam, discussing a person’s performance openly with him is likely to clash head-on with the society’s norm of harmony. The subordinatewill lose face.
Feedback in these cultures is more indirect, either by being withdrawn or verbalized through an intermediary. In the collectivist society, the priority is the personal relationship more than the task to be done and the personal relationship should be established first. In individualistic societies, the task at hand is more a priority than the personal relationship.
When students or employees feel threatened by uncertainty and ambiguity, they can expect teachers and managers to make the decisions.
“Uncertainty avoidance” is the extent to which members of a culture feel threatened by ambiguity or unknown situations. Turkey ranks 23rd in the world, meaning that people in Turkey are in the top 25 countries where people feel threatened by uncertainty and ambiguity. The U.S. is 62, China and Vietnam are 68-69 respectively and Singapore is last at 74th. Singaporeans are more comfortable with uncertainty and ambiguity.
- Anxious cultures tend to be expressive cultures: people talk with their hands, where it issocially acceptable to raise one’s voice, to show one’s emotions.
- People with high uncertainty avoidance want to reduce ambiguity, and stay away from unclear, ambiguous situations.
- In these cultures, personnel give positive answers to any question, regardless of its content. Students expect their teachers (or supervisors) to be the experts who have allthe answers.
- Students fromcountries where there is less fear of uncertainty and more comfort with ambiguity accept a teacher who says, “I don’t know.”
Example from work in Turkey
I taught addiction counseling in 2008 in Turkey. However I came in with a Chinese mentality, offering the students a range of choices for them to consider, never putting them in a place where they would lose face. In China, ambiguity is tolerated, perhaps even encouraged. In Turkey, employees awaited direction before they would act. “Subtle” didn’t work! Counselors wanted to be told what to do and how to do it. This was a difficult and foreign concept for me.
Whether a culture takes a short-term or long-term view affects what is valued in personal effort, accomplishments, relationships and counseling.
In long-term orientation (LTO) countries (China, Vietnam), virtues are fostered toward future rewards, in particular, perseverance and thrift. (DML: This is the virtue of delayed gratification versus the need for positive feelings and results straight away). In short-term orientation (STO) countries (U.S., U.K., Canada), virtues are related to present and past, in particular, respect fortradition, and fulfilling social obligations.
- LTO applies to a society in which wide differences in economic and social conditions are considered undesirable.
- STO applies to meritocracy, differentiation according to abilities – meaning that how you are rewarded and recognized depends on differences in your abilities. (DML: If you are a top athlete or actor, few people in STO cultures resent the celebrities multimillion salary for a game or movie)
- The Chinese give priority to common sense over rationality, which is seen as abstract, analytical, and idealistic, whereas common sense is seen as more human and in closer contact with reality.
When Chinese Premier Chou En-Lai was asked fifty years ago what he thought of the French Revolution he said, “Too early to tell.” China has a very long-term orientation. America measures success by quarterly earnings.
- Western psychology assumes people seek cognitive consistency, hence the popularity of cognitive approaches to counseling.
- This is not the case in East and Southeast Asian countries. The Chinese, in comparison with Americans, view disagreement as less harmful to personal relationships than injury or disappointment.
- The western way of practicing psychology that emphasizes rationality, liberalism, and individualistic ideals does not fit in East Asia where human relations can be characterized as being virtue-based rather than rights-based.
This has been a cursory overview of how different it is to work in different cultures and countries. We can apply these same concepts to working with colleagues, born and raised in other countries, who are now working in addiction treatment centers in the USA. Although we might think of the USA as a melting-pot of cultures, we are (and will be) more like a tossed salad, each culture offering its own unique flavors and approaches.
When working overseas or with people from other cultures in the USA, we must explore our culturaldifferences, be sensitive to these variables, and not try to export American systems of treatment, training and management without some adaptation tocultural norms.
For further information, contact David J. Powell, Ph.D., at the International Center for Health Concerns, Inc., firstname.lastname@example.org
In the May edition, I asked for feedback on what’s on your Top 10 list of waysto improve patient safety and behavioral health care NOW!? – especially ifyou have any supporting evidence or data. Thanks to readers for their suggestions that I will share next month. I will add yours too if you send them to me. Tell me if and how you would like to be identified whenI include your feedback.
Obviously I have been impressed with my trip to Myanmar – why else would I have two SOUL sectionsabout this back to back?! It was fascinating to see what a country is really like before we Americans dot the country with McDonalds, Subway, Kentucky Fried Chicken, Starbucks and 7-Elevens.
It reminded me a lot of what it was like going into China in the late 1970s soon after that country opened up to tourists. Now China feels like New York, Tokyo or London.
So I thought it would be fun to share about “Things you don’t need in Myanmar“. We thoughtof maybe 30, but here’s the top 10 list:
No. 1: 401 K Retirement accounts
Our English-speaking guide made less than $2,000 US dollars a year.
No.2: Dog groomers
Skinny dogs abound roaming the streets scrounging for food, but no one is worrying about making them look like cute dolls.
No. 3: Weight LossClinics
There are lots of places to eat, but no fast food restaurants. Portion sizes are adequate and appropriate, so no obesity.
No.4: Parenting classes
“It takes a village” to raise the children and that’s what they have: lots of relatives and extended family/villagers to help.
No. 5: Fancy toys for children, Toys R Us mega stores
Children know how to play with simple toys – a stone, a rock, a stick or whatever. They don’t need iPads and ‘Angry birds.’
No. 6: Televangelists
It seems that there isa pagoda or temple on every corner. No need to tune into TV to practice your spirituality.
No. 7: Yoga classes
Children and adults seem like they can squat for hours at a time with great flexibility and natural stretching. No Downward Dog moves needed.
No.8: Health club memberships
Between walking, biking and carrying heavy loads on your head, every muscle gets exercised every day.
No. 9: Shoeshinersand shoe racks in your closet
Flip flops are sufficient and easy to slip off, especially when needing to be bare-footed in temples and pagodas.
Everything you need for day-to-day living is on the street near you already: food markets, gasoline in small bottles if you are wealthy enough to own a motorbike or scooter(that carries you, your wife, your toddler and your packages).
Until next time
Thanks for reading. See you in late July.