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Cultural Humility And Competency In Occupational Therapy: Looking Through The Lens Of Real Life Experiences

Cultural Humility And Competency In Occupational Therapy: Looking Through The Lens Of Real Life Experiences
Valeri Calhoun, MS, OTR/L, CHT
May 9, 2024

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Editor’s note: This text-based course is a transcript of the webinar, Cultural Humility And Competency In Occupational Therapy: Looking Through The Lens Of Real Life Experiences, presented by Valeri Calhoun, MS, OTR/L, CHT.

Learning Outcomes

  • After this course, participants will be able to identify 3 skills to use to determine the cultural preferences of their client.
  • After this course, participants will be able to examine one method to distinguish the effectiveness of their teaching method concerning the cultural sensitivity of their client and family.
  • After this course, participants will be able to compare and contrast two different treatment methods to allow for cultural differences when treatment planning.


I appreciate the warm welcome. Following my recent mission trip, I'm compelled to discuss the significance of cultural humility and competency. With over 40 years of experience in the field, I've had extensive exposure to diverse cultures, leading me to recognize the importance of this topic in contemporary healthcare and occupational therapy practice.

What Are Cultures?

  • All the ways of life, including arts, beliefs, and institutions of a population that are passed down from generation to generation. Culture has been called "the way of life for an entire society." As such, it includes codes of manners, dress, language, religion, rituals, and art.

Cultures encompass a society's ways of life, encompassing various aspects such as the arts, beliefs, and institutions transmitted across generations. It's often described as the collective way of life for a community or population, incorporating norms of behavior, modes of dress, language, and religious practices.

Merriam-Webster Dictionary

  • the customary beliefs, social forms, and material traits of a racial, religious, or social group
  • the set of shared attitudes, values, goals, and practices that characterize an institution or organization

Merriam-Webster. In Merriam-Webster.com dictionary. Retrieved March 24, 2024, from https://www.merriam-webster

According to the Merriam-Webster Dictionary online, culture is defined as a racial, religious, or social group's customary beliefs, social forms, and material traits. Alternatively, it can refer to shared attitudes, values, goals, and practices that characterize an institution or organization. This illustrates that culture can pertain to smaller groups beyond broad categories like race, country, or major religions.


  • Ethnic Groups: Bosnian, Hispanic, South African St. Vincentian, Indian, Etc.
  • Local Cultures: urban/suburban/rural
  • Religious Cultures: Christian, Jewish, Latter-day Saints, Agnostic, Atheist, Muslim, Amish, Mennonite, etc.
  • Political Groups
  • Others: Sexual orientation, socio-economic groups
    • Help to define who the person is

In my experience practicing in St. Louis, Missouri, I've encountered various ethnic groups, including a significant Bosnian population. Additionally, there are Hispanic, South African, St. Vincentian, Indian, and other ethnic communities that contribute to the diverse cultural landscape. Beyond ethnic groups, local cultures are shaped by urban, suburban, and rural settings. Religious cultures, encompassing a wide range of beliefs and practices, further enrich the cultural tapestry. While political groups are relevant, I'll focus on cultural considerations in treatment for now. Other subcultures, such as LGBTQ communities and various social and economic groups, influence individuals' identities and perspectives, impacting their access to and experience of healthcare services. This underscores the importance of understanding and addressing cultural factors in healthcare delivery.

Cultural Competency

  • Acquiring knowledge about a culture or group of people. 
  • Incorporating that knowledge into interactions and treatment
  • Stagnant

Cultural competency, traditionally understood as acquiring knowledge about a particular culture or group of people and applying that knowledge in interactions and treatment, has limitations. The term suggests a static state of mastery that fails to recognize the dynamic and evolving nature of culture and individual identity. In reality, achieving a deep understanding of someone else's culture is an ongoing and humbling process that we may never fully attain. This recognition has led to a newer concept called cultural humility.

Cultural humility, which gained prominence around 1998, particularly in public health and mental health contexts, before expanding to all areas of healthcare, emphasizes an attitude of openness, self-reflection, and continuous learning. Instead of claiming mastery over someone else's culture, cultural humility encourages healthcare providers to approach each encounter with curiosity, respect, and a willingness to acknowledge their biases and limitations. It's about recognizing the inherent power dynamics in healthcare relationships and striving to create partnerships based on mutual understanding and trust.

Cultural Humility

  • “Cultural humility involves an ongoing process of self-exploration and self-critique combined with a willingness to learn from others. It means entering a relationship with another person with the intention of honoring their beliefs, customs, and values. It means acknowledging differences and accepting that person for who they are.“

Foronda, C., Baptiste, D.-L., Reinholdt, M. M., & Ousman, K. (2015). Cultural humility. Journal of Transcultural Nursing, 27(3), 210-217. doi:10.1177/1043659615592677

Cultural humility is an ongoing process that begins with self-exploration and self-critique by the healthcare provider. It involves a deep willingness to learn from others and to approach every interaction with the intention of honoring the beliefs, customs, and values of the individual being served. This means not only acknowledging differences but also actively adapting treatment approaches to align with each person's unique identity and needs.

In essence, cultural humility goes beyond mere acceptance of others; it requires providing care and treatment that are genuinely responsive to who the individual is rather than imposing one's own expectations or assumptions. While it shares similarities with client-centered approaches, cultural humility emphasizes a deeper understanding and incorporation of the individual's cultural beliefs and background into the therapeutic process.

  • Cultural humility is a person's ability to identify and understand their culture and biases.
  • A focus on humble, compassionate, empathetic interactions with diverse populations
  • A process of reflection and lifelong inquiry involving self-awareness of personal and cultural biases as well as awareness and sensitivity to significant cultural issues of others
  • A fluid change and dynamic process

Cultural humility encompasses a person's capacity to recognize and comprehend their own cultural background and biases, emphasizing humble, compassionate, and empathetic interactions with individuals from diverse backgrounds. It involves continuous reflection and lifelong inquiry, fostering self-awareness of personal and cultural biases, as well as sensitivity to the cultural issues of others.

This approach significantly emphasizes the healthcare provider's role in self-examination and understanding, focusing on the patient and their beliefs and values. By integrating these perspectives, healthcare professionals can better navigate the differences in cultural backgrounds between themselves and their patients, leading to more effective and respectful care. Other related terms you may encounter in the literature include:

Cultural Awareness

  • Cultural Awareness: Understanding how people acquire their cultures and culture's important role in personal identities, life ways, and mental and physical health of individuals and communities; Being conscious of one's own culturally shaped values, beliefs, perceptions, and biases.

Cultural awareness is another term often found in discussions on cultural competency. It involves understanding how individuals acquire their cultural backgrounds and recognizing culture's significant role in shaping their identities, lifestyles, and overall well-being. This includes being mindful of one's culturally shaped values, beliefs, perceptions, and biases. Cultural awareness is the foundational step toward developing cultural humility, as it provides the necessary awareness and knowledge about different cultures to engage in humble, empathetic interactions with diverse populations.

Cultural Sensitivity

  • Cultural Sensitivity is the ability to understand the needs and emotions of your own culture and the culture of others.
  • Cultural sensitivity is an ongoing, contextual, and developmental process, not an endpoint.

Cultural sensitivity is another term often used alongside cultural competency and cultural humility. While these phrases are sometimes used interchangeably, it's important to discern the nuances between them. Cultural sensitivity refers to the ability to understand and empathize with the needs and emotions of one's own culture as well as the cultures of others. It involves a deep understanding of various cultural contexts and is an ongoing, evolving process rather than a fixed endpoint.

In occupational therapy, cultural competency or humility involves addressing cross-cultural interactions between the provider and the care recipient. Given the diversity among individuals, it's rare for therapists to share the same cultural background as their clients. Multiple cultural factors, including religion, upbringing, and heritage, influence people, creating a multicultural identity for each individual. Understanding and respecting these diverse cultural influences is essential in providing effective and inclusive care while also avoiding the development of stereotypes.

Cultural Competency in OT

  • Addressing cross-cultural interactions between provider and recipient of care
  • Cross-cultural interactions in health care in general
  • There are health inequities everywhere.  These can be culturally related. 

Cultural competency in occupational therapy extends to cross-cultural interactions in healthcare overall. These interactions occur in every encounter between healthcare providers and patients, and they play a significant role in addressing health inequities stemming from cultural differences. While health inequities are widely recognized, understanding and witnessing them in practice allows for a deeper comprehension of their impact.

Healthcare disparities exist not only in access but also in the quality and nature of care received. Factors such as geographic location, socioeconomic status, and cultural background can all influence the type of healthcare individuals receive and their overall healthcare experiences. Recognizing and addressing these cultural influences is essential for promoting equitable healthcare delivery and outcomes.

Cultural Competence in OT

  • OT and healthcare providers have both conscious and unconscious biases.
  • There are power imbalances in health care.

In occupational therapy and healthcare, providers must acknowledge and address conscious and unconscious biases. While individuals may be aware of their conscious biases through self-reflection, unconscious biases can be deeply ingrained and operate without conscious awareness. Recognizing and confronting these biases is essential for providing equitable care.

Power imbalances exist in healthcare settings, where providers often have decision-making authority over patients. This power dynamic can create a perception of authority and influence over patients' decisions and actions. However, it's crucial to recognize that patients may perceive these interactions differently, feeling pressured to comply with recommendations or decisions made by healthcare providers.

Figure 1 illustrates a scenario commonly encountered in healthcare, where providers, such as surgeons and therapists, interact with patients postoperatively or during treatment planning.

Figure 1

Figure 1. Pediatric client with the healthcare team.

In these situations, healthcare providers' authority and expertise may be perceived as imposing decisions on patients. Similarly, Figure 2 depicts a healthcare team engaging with clients and their families.

Figure 2

Figure 2. Client with family during the team interview.

While providers may view this interaction as offering treatment options, clients and their families may perceive it as a display of authority, potentially influencing their decision-making process. Cultural humility addresses these power imbalances by fostering a collaborative and respectful relationship between providers and clients. Rather than exerting authority, cultural humility encourages providers to approach interactions with humility, empathy, and a willingness to learn from their clients. This approach promotes mutual respect and shared decision-making, ultimately empowering clients to actively participate in their healthcare journey.

Why Does Culture Matter in OT?

  • It affects how clients receive, process, or react to information and instruction.
  • It affects how we interact with the client. 
    • Verbally
    • Physically/tactilely
    • Auditorily
    • Setting of practice

Culture plays a significant role in occupational therapy (OT) as it influences how clients receive, process, and react to information and instruction. Failure to address or be aware of cultural needs can lead to miscommunication and misunderstandings between clients and therapists. For example, clients may not fully comprehend instructions or information if it is not presented in a culturally sensitive manner.

Moreover, culture shapes how therapists interact with clients, both verbally and physically. Anecdotes, such as speaking louder or simpler to non-English speaking clients, highlight the impact of cultural assumptions on communication. Additionally, cultural preferences regarding physical contact and tactile interactions must be respected in OT sessions, where physical contact is often involved.

Cultural factors also influence listening to clients. Understanding how cultural backgrounds shape communication styles and preferences can enhance therapists' ability to listen effectively to their clients' needs and concerns.

Furthermore, cultural considerations extend to the setting of OT practice. Therapists must consider whether the practice environment aligns with clients' cultural expectations and preferences. For example, conducting sessions in a crowded gym or in a shared hospital room may not be conducive to some clients' comfort levels or cultural norms.

Recognizing and addressing cultural influences in OT practice is essential for promoting effective communication, respecting clients' preferences, and providing culturally competent care.

  • Affects methods of teaching:
    • Verbal
    • Written
    • Demonstration
  • Want to treat diverse groups without bias for improved outcomes of treatment
  • Should share the power with the patient

Culture also significantly influences the teaching methods used in occupational therapy. Due to cultural differences, traditional approaches to health education, such as verbal instruction, written materials, and demonstrations, may not effectively resonate with all clients.

For instance, if written handouts are provided at a high literacy level to clients with lower education levels or limited reading abilities, they may struggle to understand the information presented. Similarly, rapid demonstrations without opportunities for clients to practice and demonstrate understanding may not effectively convey concepts or skills.

Moreover, cultural humility in OT emphasizes treating diverse client groups without bias and sharing power with patients. Rather than assuming a position of authority or expertise, therapists should adopt a collaborative approach, recognizing that clients are the experts in their own experiences and preferences. By embracing cultural humility, therapists can empower clients to actively participate in their own care, leading to improved outcomes and fostering a therapeutic partnership built on mutual respect and trust.

  • Occupations are linked to the culture of the client.
  • Customs and traditions are an important part of family life.
  • Affects treatment OUTCOMES!

Occupations are deeply intertwined with the client's cultural context. Early in my career, I made the mistake of assuming everyone desired to engage in the same activities that I found important, such as dressing oneself, cooking, or gardening. However, I soon learned that cultural backgrounds influence individuals' preferred occupations. What holds significance in one culture may not align with the priorities of another.

To truly understand a client's occupational needs, learning about their cultural practices, customs, and traditions directly from them and their families is essential. These elements play a crucial role in shaping family dynamics and daily routines. Ignoring or disregarding cultural considerations can significantly impact treatment outcomes.

In healthcare, achieving positive and effective outcomes is paramount. Failure to address and respect clients' cultural context may lead to suboptimal results. It's worth noting that many outcome assessment tools are inherently culturally biased, as they are designed based on the experiences and activities typical of American, middle-income individuals, particularly those from the Midwest. Consequently, using such tools without considering cultural nuances may yield irrelevant or inaccurate results when applied to diverse populations in other cultural contexts.

Knowledge of Other Cultural Groups’ Cultural Influences

  • Communication methods
  • Values
  • Gender roles
  • Clinical presentations of distress
  • Treatment expectations/desired outcomes

Understanding the cultural influences on communication methods is crucial in providing effective care. I've encountered various cultural groups and observed that communication styles vary significantly. Some individuals prefer verbal communication, while others rely more on body language or may choose to listen rather than speak. Recognizing and respecting these differences is essential for fostering effective communication and rapport.

Similarly, gaining insight into the values cherished by different cultural groups is imperative. While education and career success may be highly valued in some cultures, others prioritize different aspects of life. By understanding and acknowledging these diverse values, I can better tailor my approach to meet each individual's unique needs and preferences.

Moreover, cultural norms influence gender roles, which can significantly impact how individuals perceive and engage with therapy. Being sensitive to these cultural nuances helps create an inclusive and supportive environment for all clients.

Furthermore, cultural factors affect how individuals express distress or pain. While some cultures may exhibit stoicism and refrain from outwardly expressing discomfort, others may display more dramatic responses. Recognizing these cultural differences in presenting distress is vital for accurately assessing and addressing clients' needs.

Lastly, cultural expectations and norms extend beyond the treatment session and can shape treatment expectations and desired outcomes. Recognizing these cultural influences helps set realistic treatment goals and foster positive therapeutic relationships.

Continued Influences

  • Behavioral norms and expectations in and outside the treatment session (e.g., touching, greetings, gift-giving, level of formality between therapist and client)

Navigating cultural differences in touching, greeting, and gift-giving is crucial in providing culturally sensitive care. In many cultures, certain taboos exist regarding physical touch, especially between individuals of opposite genders or different marital statuses. Therefore, it's essential to inquire about any preferences or restrictions regarding touching before initiating treatment to ensure comfort and respect boundaries.

Similarly, greetings vary across cultures; some prefer handshakes, nods, verbal greetings, or hugs. Understanding and respecting these cultural norms can facilitate positive client interactions and rapport-building.

Gift-giving is another aspect influenced by cultural practices. While healthcare policies may discourage accepting gifts, it's important to recognize that in some cultures, offering gifts is customary to express gratitude and appreciation. For example, in certain international communities, elaborate gifts such as jewelry are commonly given to healthcare providers as a gesture of thanks for their services.

However, accepting or refusing such gifts can present challenges, particularly when balancing cultural norms with institutional policies. Therapists may sometimes need to gracefully decline gifts while explaining the reasons behind the decision, ensuring that cultural sensitivity and professional ethics are maintained.

Ultimately, occupational therapists can foster trust, mutual understanding, and effective therapeutic relationships with clients from diverse cultural backgrounds by respecting and accommodating cultural differences in touching, greeting, and gift-giving practices.

Other Influences

  • Beliefs about family roles and routines
  • Views about child rearing and responsibilities
  • Beliefs about disability or risk conditions
    • OI example
  • Views about strategies and change

Understanding cultural influences on the level of formality between therapist and client, family roles and routines, beliefs about disability or risk conditions, and views about strategies and change is essential for providing effective occupational therapy. Cultural norms shape perceptions and behaviors in various ways, and therapists must recognize and respect these differences to tailor interventions appropriately.

For instance, cultural norms dictate formality in therapeutic relationships, with some clients preferring a more informal, friendly approach while others maintain a degree of professional distance. Therapists must be attuned to these preferences and adjust their communication and interactions to establish trust and rapport.

Similarly, cultural beliefs about family roles and responsibilities can vary widely, challenging assumptions about caregiving arrangements and household dynamics. Therapists should refrain from making assumptions about parental roles and instead inquire about family structures and caregiving arrangements to inform treatment planning effectively.

Cultural perspectives on disability or risk conditions also shape attitudes and responses to health challenges. For example, some cultures may view certain disabilities or health conditions differently, considering them part of normal life or divine will. Therapists must understand these perspectives to provide culturally sensitive support and interventions that align with the client's beliefs and values.

Furthermore, cultural attitudes toward strategies and change influence receptivity to therapeutic interventions. While some individuals may be open to adopting new strategies and making changes, others may prefer to accept their circumstances as predetermined or guided by spiritual beliefs. Therapists should engage in open dialogue with clients to understand their perspectives on change and collaboratively develop intervention plans that respect their cultural values and preferences.

Acknowledging and integrating cultural considerations into occupational therapy practice can foster meaningful engagement, promote positive outcomes, and honor their clients' diverse needs and experiences.

How to Develop/Implement Cultural Humility or Sensitivity

  • Specific things you as an OT/health care provider can do to provide best practice and not allow culture to be a barrier or affect your outcomes.
  • Your own culture and beliefs can affect how you practice.

There are some specific things that you can do to provide your best practice and not allow culture to be as much of a barrier or affect your outcomes. There will always be some barriers, but we want to make it as little as possible. Again, your culture and beliefs can affect how you practice as a therapist, and you need to be aware of that.

1. Development Activities: FIRST

  • Become aware of your own beliefs, biases, and assumptions about people.
  • Become aware of your personal cultural beliefs.
  • Self-Reflection and Identification
  • Self Awareness

Self-awareness is the cornerstone of cultural competence. It requires therapists to engage in deep introspection and reflection to uncover their own beliefs, biases, and assumptions. This process involves acknowledging the cultural influences that have shaped their worldview and examining how these beliefs may impact their interactions with clients from diverse backgrounds.

By taking the time to identify and understand their own cultural beliefs, therapists can better recognize when these beliefs might influence their clinical decision-making and treatment approach. This heightened self-awareness allows therapists to remain vigilant and proactive in addressing any biases that may arise during therapy sessions.

Furthermore, therapists must recognize the ethical imperative of setting aside personal biases to ensure equitable and effective care for all clients. If a therapist becomes aware that their cultural beliefs could compromise the quality of care provided to a client, it is their ethical responsibility to refer the client to another therapist or facility where they can receive unbiased treatment.

Self-awareness empowers therapists to approach each client with humility, openness, and willingness to learn. By continuously examining and challenging their beliefs, therapists can create a therapeutic environment that respects and honors the diversity of their clients' cultural backgrounds.

Have an Open Mind

  • Do not take your preconceived ideas about a person or group of people into the clinical setting
  • Do not assume they will not understand due to language differences
  • Do NOT assume that you know best due to having the education/knowledge

Approaching each client with an open mind fosters cultural humility and sensitivity. Therapists must resist the temptation to rely on stereotypes or preconceived notions about individuals or groups of people. Instead, they should strive to engage with each client as unique, free from assumptions or biases.

For example, encountering a client from an inner-city neighborhood should not prompt assumptions about their background or capabilities. Rather, therapists should approach each interaction with curiosity and a genuine desire to understand the client's experiences, values, and goals. This may involve building rapport and actively listening to the client's perspective without judgment.

Similarly, therapists should not presume that language differences automatically hinder communication. While interpreters may be available, some clients prefer communicating directly with their therapist despite language challenges. In such cases, therapists can work collaboratively with clients to find alternative communication strategies that accommodate their needs and preferences.

Furthermore, therapists must recognize that their expertise does not automatically equate to knowing what is best for the client. While therapists possess valuable knowledge and skills, they must approach each client with humility and a willingness to learn from their unique perspectives and experiences. This requires acknowledging the inherent power imbalance in the therapeutic relationship and actively working to mitigate it by valuing the client's autonomy and expertise in their own lived experience.

  • Unconscious Superiority
  • There is an inherent power imbalance
  • Create a sharing of power and information in both directions

Sharing knowledge in a collaborative and open manner is crucial in fostering a balanced exchange of information between therapists and clients. Therapists should approach each interaction with a mindset of mutual learning and respect, recognizing that they do not hold all the answers or perspectives.

It's not uncommon for healthcare professionals to unintentionally convey a sense of superiority due to their expertise. However, this attitude can perpetuate power imbalances in the therapeutic relationship and hinder effective communication and collaboration. By embracing cultural humility, therapists can actively work to dismantle these dynamics and create an environment where knowledge flows freely in both directions.

Self-reflection plays a central role in this process. Therapists must examine their biases and assumptions, acknowledging that everyone harbors unconscious biases to some extent. However, it's essential to recognize that these biases should not dictate treatment decisions or client interactions. Instead, therapists should strive to approach each client with an open mind, seeking to understand their unique experiences, values, and preferences.

Ultimately, cultural humility requires therapists to move beyond their own perspectives and embrace the diversity of experiences and beliefs present in their clients. Therapists can foster a more inclusive and empowering therapeutic environment by valuing clients' expertise and engaging in genuine dialogue.

2. Ask Questions Prior to Tx

  • Ask about their beliefs about the condition.
  • Do they believe it can improve?
  • Ask how they learn best.
  • Ask questions to verify what is important to them.
  • Culturally different body language at times, so ask to get clarification.

Asking probing questions is an essential strategy for therapists seeking to understand their clients' beliefs, preferences, and learning styles. These questions should delve beyond the surface and explore deeper aspects of the client's cultural background and individual perspective.

One crucial area of inquiry is the client's beliefs about their condition or situation. Cultural beliefs surrounding health and illness can vary significantly, influencing perceptions of causality, prognosis, and treatment options. By asking about these beliefs, therapists can gain valuable insights into how clients understand their circumstances and what factors may shape their attitudes toward treatment and recovery.

Similarly, understanding how clients prefer to receive information and learn new skills is vital for tailoring interventions effectively. Some clients prefer written materials, while others prefer verbal explanations or hands-on demonstrations. By asking about their preferred learning methods, therapists can ensure they deliver information that resonates with the client's preferences and cultural norms.

Additionally, asking questions to verify understanding and clarify nonverbal cues is essential for effective communication. Cultural differences in body language and communication styles can lead to misunderstandings if not addressed proactively. For example, gestures or expressions that seem to indicate understanding in one culture may have different interpretations in another. By seeking clarification and validation, therapists can ensure they accurately interpret their clients' nonverbal cues and avoid miscommunication.

Overall, asking thoughtful questions and actively listening to the responses allows therapists to better understand their client's cultural backgrounds, beliefs, and communication preferences. This information forms the foundation for culturally responsive and effective therapeutic interventions.

Questions to Ask

  • Who will be assisting with care or treatment?
    • Do they have support or assistance?
  • What setting will they be in?
  • What is important to them for outcomes?
  • What is the best method to communicate or teach all involved?
  • How can they let you know if they don’t like something?

Asking detailed questions about the client's support system, living environment, and personal priorities is essential for providing client-centered care and ensuring optimal outcomes. Understanding who will be involved in the client's care, whether they have support at home, and the setting where they will receive treatment allows therapists to tailor interventions to the client's specific needs and circumstances.

Exploring what outcomes are important to the client helps therapists align treatment goals with the client's values and priorities. For example, if a client expresses a desire to perform religious rituals that require kneeling, therapists should work collaboratively with the client to find ways to adapt activities to accommodate their religious practices rather than dismissing or discouraging them.

Moreover, identifying the most effective communication and teaching methods for all individuals involved in the client's care is crucial for promoting consistency and understanding among caregivers. In cases where multiple family members or caregivers are involved, providing written instructions or conducting group sessions may be beneficial to ensure that everyone is on the same page and can effectively support the client's goals.

Finally, empowering clients to communicate their preferences and concerns is essential for fostering a collaborative and respectful therapeutic relationship. By giving clients the tools and encouragement to express their likes, dislikes, and boundaries, therapists create a supportive environment where they feel empowered to advocate for their needs and preferences.


  • Who is attending with them?
  • How do they respond to your interaction?
    • Eye contact
    • Nodding
  • Physical communication
    • Body language
    • Turn toward or away

Observing the dynamics of the client's interactions during treatment sessions provides valuable insight into their cultural norms, communication styles, and comfort levels. Paying attention to who accompanies the client to therapy sessions can offer clues about their support network and familial involvement in their care.

Moreover, observing the client's body language and nonverbal cues can reveal important cultural nuances. For instance, in some cultures, maintaining direct eye contact may be considered respectful and attentive, while in others, avoiding eye contact may be a sign of respect or modesty. Similarly, nodding or active listening behaviors may vary across cultures, and understanding these differences can help therapists interpret the client's level of engagement and understanding.

Additionally, being attentive to changes in the client's behavior or physical condition during the session is crucial for providing safe and effective care. Whether the client appears fatigued, disengaged, or experiencing discomfort, therapists must consider cultural factors and potential medical or environmental influences to appropriately address the client's needs.

  • How do YOU respond during interactions?
    • Eye contact
    • Acknowledging
    • Return what you hear
    • Distracted?
      • Staring at your screen

Absolutely, your own responses and behaviors during interactions play a significant role in fostering effective communication and rapport with clients. Maintaining eye contact demonstrates attentiveness and respect for the client's words, allowing them to feel heard and validated. Additionally, actively acknowledging and affirming the client's concerns or priorities reinforces a sense of understanding and empathy.

Conversely, distractions such as focusing on electronic devices can detract from the quality of the interaction and convey disinterest or disregard for the client's needs. By prioritizing direct engagement and attentiveness, therapists can create a supportive and collaborative environment where clients feel valued and empowered to express their preferences and goals.

Ultimately, being mindful of your own responses and behaviors enables you to cultivate positive therapeutic relationships built on mutual respect, trust, and effective communication. This, in turn, enhances the overall quality of care and contributes to more meaningful and impactful therapeutic outcomes.

3. Research and Read

  • Find literature about the culture
  • Watch videos
  • Talk with others
  • Be aware*** Don’t create stereotypes

Conducting research and seeking to understand various cultures can greatly enhance your cultural competence as a therapist. Engaging with literature, videos, and conversations with individuals from different cultural backgrounds provides valuable insights into their customs, beliefs, and communication styles.

However, it's crucial to approach this process with an open mind and guard against forming stereotypes. Recognize that cultural practices and norms can vary widely among individuals within a cultural group, and avoid making sweeping generalizations based on limited information.

Instead, strive to cultivate a nuanced understanding of cultural diversity, acknowledging the unique experiences and perspectives of each individual you encounter. By embracing cultural humility and remaining open to learning, you can foster genuine connections with clients and provide more effective and respectful care.

4. Attend Training and Events

  • Training specific to cultural humility
  • Events that are culturally informative:
    • Community events
    • Cultural events
    • Festivals, Seminars, Celebrations

Attending trainings and events focused on cultural humility is a proactive step towards expanding your understanding and appreciation of diverse cultures. These opportunities provide platforms for self-reflection and engagement with different cultural perspectives. Training offered by universities, public health agencies, and community organizations often delves into topics such as cultural awareness, sensitivity, and communication.

Events like multicultural festivals offer immersive experiences where you can explore various aspects of different cultures, from cuisine to traditional dances and demonstrations. For example, in St. Louis, the Festival of Nations is a notable multicultural event that offers food booths, activities, demonstrations, and dancing (see Figure 3).

Figure 3

Figure 3. Examples of a parade and dancing at multicultural events.

Engaging with attendees at these events can provide valuable insights into their cultural backgrounds and perspectives.

It's essential to recognize that cultural identities can vary even among individuals from the same country or region, depending on personal experiences, upbringing, and acculturation. For instance, someone of Bosnian descent living in America may have a different perspective on their culture than someone from Bosnia or Croatia.

By actively participating in these trainings and events, you broaden your cultural knowledge and cultivate a mindset of humility and openness towards different ways of life.

OT Specific Things You Can Do

  1. Add cultural questions to your evaluation
  2. Include extended family when possible
  3. Be aware of touch and personal space
  4. Language inclusive
  5. Communicate/share with colleagues

In addition to recognizing that cultures are constantly evolving, it's crucial to incorporate cultural questions into your evaluation process. Even if electronic medical records lack predefined cultural questions, adding them to your repertoire of inquiries is essential. This proactive approach ensures a more comprehensive understanding of your patients' backgrounds and needs.

When utilizing electronic medical record systems like Epic, where questions may be pre-formatted, don't hesitate to supplement with your cultural inquiries. This might involve asking about extended family dynamics or specific cultural practices relevant to the individual.

Moreover, strive to involve extended family members whenever possible. Gathering insights from multiple sources within a patient's social network provides a richer understanding of their cultural context and values.

Maintaining awareness of touch and personal space preferences, being language-inclusive, and utilizing interpreters when needed are critical aspects of providing culturally competent care.

Furthermore, fostering open communication and knowledge-sharing among colleagues is invaluable. Learning from fellow healthcare professionals' diverse experiences and perspectives can enhance your cultural competence and enrich your practice.

By actively incorporating cultural questions into evaluations, being inclusive in language and communication, and engaging in ongoing learning and collaboration, healthcare providers can better meet the diverse needs of their patients and communities.


  • Be prepared to alter and change treatment approaches based on the client's response or family's response
  • Be cognizant of their reactions
  • Example: 
    • Feeding

Flexibility in treatment approaches is essential in providing culturally responsive care. It's important to be attentive to client and family responses and adapt interventions accordingly. For example, it's crucial to consider cultural preferences and practices when addressing feeding issues.

Using familiar utensils from the client's home environment can significantly enhance the effectiveness of feeding interventions. Rather than insisting on using standard clinic utensils, healthcare providers should encourage family members to bring in utensils that the client regularly uses at home. This approach allows for a more meaningful and culturally appropriate feeding experience.

By incorporating familiar utensils into therapy sessions, healthcare providers demonstrate respect for the client's cultural background and increase the likelihood of successful treatment outcomes. This practice reflects a commitment to tailoring interventions to meet each client's and their family's needs and preferences.

Treatment Modifications

  • Dressing skills: 
  • Privacy: 
    • Modify to over other clothing
    • Modify to a private room
    • Modify to teaching a family member

Adapting treatment approaches to respect cultural norms around privacy is crucial in promoting effective and respectful care. For instance, when working on dressing skills with a client uncomfortable with non-family members, it's essential to modify the intervention to align with their preferences.

One approach is to allow the client to dress over their clothing during therapy sessions, maintaining their comfort level and privacy. Alternatively, providing a private room where the client can work on dressing skills away from the public eye can help create a more comfortable environment.

Another option is to involve a family member in therapy and teach them how to assist the client with dressing tasks. This approach respects the client's cultural values regarding privacy while still addressing their rehabilitation needs.

Being willing and prepared to modify treatment approaches based on the client's responses and cultural considerations demonstrates sensitivity and responsiveness to their preferences and needs. This flexibility fosters trust and collaboration between the client, their family, and healthcare providers, ultimately promoting more effective outcomes in therapy.

  • Self Feeding
    • Modify if the family does not feel this is important
    • Can modify to work on the grasp of similar objects
    • Perform other speed-related activities such as games

Understanding and respecting cultural beliefs and practices around activities of daily living, such as self-feeding, is crucial in rehabilitation therapy. In cases where a family does not prioritize self-feeding for cultural reasons, it's important to adapt treatment goals and interventions accordingly.

For example, in the case of the Pakistani boy who had experienced a stroke and whose mother preferred to feed him, it was essential to respect the family's values and preferences. Instead of insisting on self-feeding as a goal, the therapist wisely adjusted the treatment plan to focus on other areas, such as grasp and speed in fine motor activities.

By collaborating with the family and understanding their perspective, the therapist could tailor the therapy sessions to meet the client's and family's needs and priorities. This approach respects cultural differences and ensures that therapy goals are meaningful and relevant to the individual's circumstances.

Being flexible and responsive to cultural preferences in therapy fosters trust and cooperation between the therapist, the client, and their family. It allows for more effective and culturally competent rehabilitation interventions that ultimately improve client outcomes.

Examples: Mission Trips

  • Talk with others who have gone
  • Research the culture prior to going
  • Follow other steps when you get there.
  • Saint Vincent and the Grenadines

I wanted to go over some examples and start with mission trips. I have done many where I'm going into their culture to provide treatment, so I need to acclimate and change the way I perceive this culture.

Saint Vincent and the Grenadines

  • Live in primitive settings
  • Small contained island
  • Open air hospital
    • Large wards
    • Outdoor environment

Preparing for mission trips or experiences outside your cultural comfort zone requires careful planning and research. Consulting with others who have participated in similar initiatives can provide valuable insights and guidance. By learning from their experiences, you can better understand the cultural nuances and expectations of the community you will be serving.

Additionally, conducting thorough research on the destination country or region is essential. Understanding the local culture, customs, and healthcare infrastructure can help you navigate the unfamiliar environment more effectively. This knowledge enables you to approach interactions with sensitivity and respect for the cultural differences you may encounter.

In the case of international mission trips, being mindful of the unique challenges and constraints of the healthcare setting is crucial. Whether it's adapting to a primitive healthcare environment or navigating cultural norms within a hospital setting, being prepared and flexible is essential for providing effective care.

Ultimately, the goal is to approach these experiences with humility, openness, and a willingness to learn from the individuals and communities you serve. By embracing cultural diversity and actively seeking to understand others' perspectives, you can contribute to meaningful and impactful healthcare interventions locally and globally.

Figure 4 shows a picture of a house in Kingston, St. Vincent.

Figure 4

Figure 4. A house in Kingston, St. Vincent.

The Kingston Hospital is shown in Figure 5.

Figure 5

Figure 5. A Kingston hospital.

The scene at the St. Vincent and the Grenadines hospital is bustling with activity and resilience amidst challenging conditions. Patients fill the open-air wards, their presence audible through the wails and commotion from within. Many arrive early in the morning, prepared to wait patiently throughout the day for the healthcare services they need.

In the community, mobility is primarily facilitated by walking or taking taxis, as private vehicles are scarce. Public transportation navigates the narrow, steep, and rocky roads, presenting a formidable challenge for travel.

The government provides basic healthcare services to all citizens. However, access to specialized care is limited, as it often requires payment that many cannot afford. The education system follows a similar pattern: government-provided education up to a certain age, after which families must cover the costs if they wish to continue their children's schooling.

Despite these hardships, the people are accepting and resilient. They endure waiting times without complaint and navigate the challenges of daily life with determination and grace.

  • Patients lining hallways
  • Walk or take taxis for mobility in the community
  • Waiting time
  • Health Care
  • Education
  • What preconceived ideas come to mind?

My experience in St. Vincent and the Grenadines taught me valuable lessons about the importance of cultural sensitivity in healthcare delivery. Witnessing the realities of life in a place where access to education and resources is limited for many families challenged my preconceived notions and encouraged me to approach patient care with greater humility and understanding.

  • Setting:
  • Resources
    • Health Care
    • Home
  • Teaching methods
    • Verbally repeat information
    • Teach back method/Return of demonstration
    • Handouts

I realized that what may seem like basic assumptions or practices in my own culture could be entirely different in another. Here are some examples of treatment areas.

Figure 6

Figure 7

Figure 8

Figures 6, 7, and 8. Examples of treatment areas.

  • Living Situation
  • Responsibilities
  • Family Support
  • Access

Another thing I learned was to adapt my teaching methods by asking families if they preferred handouts before providing them, respecting their preferences and circumstances.

Figure 9

Figure 9. Mother and daughter in therapy.

Understanding the cultural context was essential in tailoring treatment plans to meet the individual needs of patients and their families. Considering factors such as living situations, family responsibilities, and available support networks helped me develop more effective and meaningful interventions.

One crucial lesson I learned was to refrain from imposing my cultural beliefs onto others. Recognizing that different cultures perceive a satisfactory living environment or quality of life is essential in providing culturally competent care.

By embracing cultural diversity and respecting the perspectives of those I served, I established effective communication and collaboration with the community. This approach improved patient outcomes and fostered mutual understanding and appreciation across cultural boundaries.

South Africa

  • Environment
  • Therapists
  • Beliefs
  • I learned as much as they did

My journey to South Africa in 2013 (seen in Figure 10) provided invaluable insights into the intersection of healthcare and culture in a vastly different setting.

Figure 10

Figure 10. Images from South Africa.

While my primary purpose was to conduct a lecture series, I learned as much from the therapists I encountered as I did from them.

Traveling across three different cities, I immersed myself in the local environment and engaged with therapists who practiced in ways quite distinct from my own experiences. One striking aspect of their professional journey was the mandatory year of service in public hospitals for therapists after completing college. This requirement exposed them to a different level of healthcare delivery compared to private practice, where they eventually transitioned to serve a different clientele.

Exploring the public health system in South Africa illuminates its challenges and complexities. Despite its primitive nature, therapists were an integral part of the system, compelled to work there as part of their professional development. I was particularly struck by the therapists' beliefs about diseases and illnesses, which differed from mine. Their understanding that certain conditions were specific to certain population segments opened my eyes to alternative perspectives on health and well-being.

One memorable experience during my trip was sharing a dinner with a group of therapists, shown in Figure 11.

Figure 11

Figure 11. Group of therapists in South Africa.

This informal setting allowed them to exchange ideas, learn from each other's experiences, and gain deeper insights into their culture and practices. It was a humbling reminder of the importance of cultural humility and the richness of embracing diverse perspectives in healthcare.

Overall, my time in South Africa was a profound learning experience that challenged my assumptions, broadened my understanding, and reinforced the importance of cultural sensitivity in providing effective and meaningful care.

Case Example: Bosnian Family

  • Initial visit with parents and infant
  • Father
  • Mother
  • Child

This is an example of a Bosnian family that I saw. They had an infant born with an orthopedic condition. I talked to the mother about how she best received information.


Video 1

Q: Was it easiest for you to receive the information by hearing it, seeing it written, or having it demonstrated?

A: I think demonstration, like the pictures (before and after), was a great tool that helped us visualize what the outcome would be from the surgeries and therapies.

Video 2

Q: In your native country of Bosnia, do you think it's the same approach towards kids?

A: I would say yes. We're such a close-knit community of kids living with their parents and then marrying and bringing their spouses. I also think everybody takes care of everybody.

In Bosnian culture, I know there are a lot of things like Down syndrome, but I don't see a lot of physical differences. It's very uncommon.

Case Example: Hispanic Family

I had a Hispanic infant with an orthopedic condition of her arm. Both of her parents came in initially. Her mother was the one who did not want to use an interpreter. She said, "The interpreter keeps changing my words. I understand, and if you can take time and listen, I can communicate with you."


Video 3

Q: Are you treated differently by other therapists?

A: The therapist, after you left, made me not feel included in the treatment and not heard of at all. She would do whatever she wanted to do. She used one treatment for everyone, which was not individualized. We were not happy about it, and my daughter didn't want to go to therapy anymore.

She would say things like, "You're hurting me when they were doing exercises." The therapist would not listen and call her a crybaby.

Video 4

Q: How did you feel others treated language barriers?

A: You always tried to listen to me to see what my concerns were. You changed things for us.

Example: Rural vs. Urban

  • Environments
  • Beliefs
  • Roles and customs

The distinction between urban and rural environments often carries a range of perceptions and stereotypes that can deeply impact individuals' experiences and interactions. During my discussions in South Africa, I encountered firsthand the sentiment expressed by rural individuals who felt marginalized or looked down upon by their urban counterparts.

Coming from a rural background but having lived in urban areas for much of my adult life, I understand the complexities surrounding these perceptions. I've personally witnessed instances where urban individuals have disparaged remarks about the education or quality of life in rural areas, unaware that many rural residents are highly educated, including a significant number of farmers with college degrees.

This discrepancy between perception and reality underscores the importance of challenging stereotypes and assumptions based on geographical location. Education and quality of life are not inherently tied to urban or rural settings, and it's crucial to recognize the diversity and strengths present in all communities.

Example: Religions

  • Beliefs and customs
  • Questions to ask
  • Roles and responsibilities


  • Determined roles and responsibilities by interview
  • Education provided
  • Clothing differences

The Amish community presents a unique cultural perspective on child labor and occupational risk, which contrasts with more urban or contemporary views. One significant aspect of Amish culture is the expectation that children contribute to family and community life through work from a young age. This often involves engaging in tasks that many urban dwellers consider too hazardous for children.

For instance, Amish children may be involved in activities such as using hatchets, axes, and saws, which might seem perilous by modern safety standards. However, within their community's traditions and values, these activities are essential for developing practical skills and fulfilling familial and communal responsibilities.

As a healthcare provider working with the Amish community, it's crucial to approach these cultural practices with respect and understanding. Rather than imposing external judgments or norms, the focus should be on ensuring the safety and well-being of the children while acknowledging and honoring their cultural traditions.


  • Don’t let yourself be a barrier to best outcomes
  • Keep your mind open
  • Make adjustments as needed
  • Enjoy learning about other cultures

Reflecting on my experiences, I've understood the profound significance of cultural humility in healthcare. Whether I'm entering someone's home or community or they're visiting my clinic, culture permeates every interaction and profoundly influences the outcomes of my interventions. As healthcare providers, our ultimate goal is to achieve the best possible outcomes for our patients. Therefore, we must not allow ourselves to become barriers to those outcomes.

Throughout my career, one of the greatest gifts I've given myself is the opportunity to learn about other cultures and people. Embracing cultural diversity doesn't always mean agreeing with or fully embracing every practice; rather, it's about continuous learning and providing the best treatment possible. It's about keeping an open mind, making adjustments as needed, and finding joy in understanding and appreciating other cultures.

By approaching each interaction with cultural humility, I've been able to forge deeper connections with patients and provide more respectful, compassionate, and effective care. It's a journey of empathy, respect, and growth—one that enriches both my professional practice and my personal understanding of the world around me.

Now let's go to the exam poll.

Exam Poll

1) What is the difference between cultural competence and cultural humility?

The answer is D, as it involves all of these. 

2) What is the first step in developing cultural humility and sensitivity?

The correct answer is B, development activities.

3) During observation, it is essential to do ALL EXCEPT?

The key is you want to do all of these except that one. You do not want to stare at your device screen and document while trying to discover this person's cultural preferences.

4) What strategy can an occupational therapy practitioner use to promote cultural humility during treatment?

The correct answer is D, all of the above.

5) Which is NOT a dressing modification for privacy?

This last one is B. You would not want them to work on dressing in the therapy gym unless over clothing.

Thanks for your time today. I have listed my bibliography and references for the talk.


Agner, J. (2020). Moving from cultural competence to cultural humility in occupational therapy: A paradigm shift. The American Journal of Occupational Therapy, 74(4), 7404347010p1–7404347010p7. https://doi.org/10.5014/ajot.2020.038067

Wray, E. L., & Mortenson, P. A. (2011). Cultural competence in occupational therapists working in early intervention therapy programs. Canadian Journal of Occupational Therapy, 78(3), 180-186. https://doi.org/10.2182/cjot.2011.78.3.6

Singh, H., Sangrar, R., Wijekoon, S., Nekolaichuk, E., Kokorelias, K. M., Nelson, M. L. A., Mirzazada, S., Nguyen, T., Assaf, H., & Colquhoun, H. (2020). Applying ‘cultural humility’ to occupational therapy practice: A scoping review protocol. International Journal of Therapy and Rehabilitation, 29(10). [DOI not provided]


American Occupational Therapy Association. (2010). Occupational therapy code of ethics and ethics standards. American Journal of Occupational Therapy, 64(Suppl.), S17–S26. https://doi.org/10.5014/ajot.2010.64S17

American Occupational Therapy Association. (2020). Educator’s guide for addressing cultural awareness, humility, and dexterity in occupational therapy curricula. The American Journal of Occupational Therapy, 74(Supplement_3), 7413420003p1–7413420003p19. https://doi.org/10.5014/ajot.2020.74S3005

American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625–683. https://doi.org/10.5014/ajot.62.6.625

Anderson, S. H. (2022). Cultivating cultural humility in occupational therapy through experiential strategies and modeling. The Open Journal of Occupational Therapy, 10(4), Article 15. https://doi.org/10.15453/2168-6408.1747

Foronda, C., Baptiste, D.-L., Reinholdt, M. M., & Ousman, K. (2015). Cultural humility. Journal of Transcultural Nursing, 27(3), 210–217. https://doi.org/10.1177/1043659615592677

Grenier, M.-L. (2020). Cultural competency and the reproduction of White supremacy in occupational therapy education. Occupational Therapy in Health Care, 79(6). https://doi.org/10.1177/0017896920902

Lekas, H.-M., Pahl, K., & Lewis, C. F. (2020). Rethinking cultural competence: Shifting to cultural humility. Health Services Insights, 13, 1–4. https://doi.org/10.1177/1043659615592677

Merriam-Webster. In Merriam-Webster.com dictionary. Retrieved March 24, 2024 from https://www.merriam-webster.com/dictionary

U.S. Department of Health and Human Services, Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report (Contract No. 282-99-0039). Retrieved from http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf

Wells, S. A., & Black, R. M. (2000). Cultural competency for health professionals. Bethesda, MD: American Occupational Therapy Association.


Calhoun, V. (2024). Cultural humility and competency in occupational therapy: Looking through the lens of real life experiences. OccupationalTherapy.com, Article 5705. Retrieved from https://OccupationalTherapy.com

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valeri calhoun

Valeri Calhoun, MS, OTR/L, CHT

Valeri Calhoun is an Occupational Therapist with over 40 years of experience in various settings. Valeri obtained her BS in OT from Indiana University and an MS in Community Health from the University of Kansas Medical Center. She obtained her CHT in 1994 and has spent 16 years in pediatric hand therapy settings. She maintains current with the adult population by providing PRN Occupational Therapy services. Valeri has taught and lectured nationally and internationally on various topics and was the internationally invited Guest lecturer for the South African Society of Hand Therapists in 2013. She has taught graduate OT courses at multiple universities. Valeri recently returned from her third medical mission trip to the Eastern Caribbean through the World Pediatric Project and Touching Hands organization through the ASSH. 


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