Effective and Ineffective Communication in The Spirit Catches You and You Fall Down
Understanding the medical justifications given for procedures and treatments is difficult enough without the existence of cultural differences and language barriers. The Hmong refugees from Southeast Asia encountered these difficulties first hand when they sought asylum in Merced, California. The Spirit Catches You and You Fall Down by Anne Fadiman explores the Lee family's experiences with medical institutions in the United States with their daughter, Lia. There are many valuable lessons that can be learned about intercultural communication from their story.
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The Lee family was thrown into a world vastly different than their own when they became refugees. This world, one of a western culture, was full of very few effective intercultural communicators, thus leading to ineffective and miscommunicated treatment for their epileptic daughter, Lia. Despite the majority of professionals who came in contact with Lia being bad cross cultural communicators, Jeanine Hilt was an effective communicator. Jeanine, a social worker that worked for Child Protective Services (CPS), was put on Lia Lee’s case well into the development of her condition. Fadiman mentions that Jeanine is one of the only Americans who did not describe the Hmong negatively (Fadiman 112). Jeanine was able to suspend her prejudices and preconceived biases about the Hmong people, unlike many other characters in the story, when working with the Lee’s. She was also persistent in educating the Lee’s on Lia’s medication, even with the setbacks and frustration of cultural differences (Fadiman 90). What makes Jeanine a more effective cross-cultural communicator than many of the other professionals that had came into contact with the Lee family was her ability to see the situation with realistic cultural empathy. Jeanine was one of the few people that Fadiman spoke to who had asked the Lee’s what they believed was happening to Lia, “...she had these spirits in her and might grow up to be a shaman…” (Fadiman 22). Because Jeanine asked the Lee’s, she understood that from their perspective, this wasn’t always a medical problem. Her ability to view the situation from the Hmong perspective and the western medical perspective permitted her to effectively create an environment of mutual understanding that previously had not been able to exist.
Neil Ernst, a doctor at Merced County Medical Center (MCMC), spent a lot of time, energy, and resources treating Lia. Despite his best medical efforts, Neil is a bad cross-cultural communicator. Unlike Jeanine, an effective intercultural communicator who is associated positively in Lia’s life despite her relations to CPS, Neil is associated with many negative events in Lia’s storyline. Neil was the one who decided to report the Lee’s to CPS for child endangerment. From the frame that he was seeing the situation through, this was the appropriate thing to do. In his, and many other medical professionals minds, this situation of parental noncompliance on behalf of the Lee’s could have been contributing to why Lia continued to have seizures. Under United States law this is classified as child endangerment regardless of the culture the family is from. Along with that, he could have gotten into legal trouble himself if he had not reported the situation. However, Neil never considered that the Lee’s were being noncompliant not because they simply did not want Lia to take the medicine she was prescribed, but because they had a different idea of what was happening to Lia. They also were never taught or shown how to administer the medicine, and the gravity of the situation from a western perspective was never communicated to them. Neil experiences cognitive dissonance about his decision. He uses the argument that he would have been in legal trouble himself and that he attempted to hold off calling CPS for as long as possible. When Fadiman speaks with Neil about his choice of reporting the Lee’s to CPS, she says that whether or not he would have compromised Lia’s health by being so uncompromising still bothers him (Fadiman 78).
Moving forward, medical professionals should become more effective intercultural communicators to ensure that their patients, no matter what culture they are from, get the same level of treatment. In The Spirit Catches You and You Fall Down, the professionals lacked cultural understanding and let their generalizations create biases. When Fadiman looks at medical records from Lia’s admissions, she sees that some of them say things like “H’mond” “Mong” and “Mongoloid.” In one of the notes sections she even saw that one nurse concisely explained the situation by just saying “Hmong” (Fadiman 38). Clearly the staff of MCMC was fed up with the Hmong refugees, and therefore did not make many attempts to clear up the language and cultural barriers and issues that arose when Hmong patients came in.
It is important for medical professionals to understand that different cultures have different perspectives on medical care, which may explain why patients and their families are reluctant to follow through or allow treatments. In the case of the Lee’s, Nao Kao and Foua were noncompliant with Lia’s medicine because to them, this was not going to help what they thought was going on. From their perspective, they believed that Lia’s soul had left her body and a dab had come, which is just a different way for them to explain what western medical professionals call epilepsy. However, these two explanations would have different types of treatments in each culture. By having realistic cultural empathy towards patients from another culture and asking the family what their perspective on the situation is, doctors may be able to explain what they believe is happening from their own perspective. Doctors should thoroughly explain why they believe their treatment will help because it will create a situation that is more efficient than if they simply assumed everyone was on the same page about the condition and treatment. Similarly, doctors may be able to use treatments which treat the illness from the other cultures perspective in addition to what they believe will work, thus increasing the chances of compliance to western treatments.
In their many encounters with the Hmong, MCMC staff complained that the process was slow because the Hmong needed to ask those with cultural authority over them for permission to accept certain medical care, “Decisions-especially about procedures, such as surgery, that violated Hmong taboos-often took hours. Wives had to ask their husbands, husbands had to ask their elder brothers, elder brothers had to ask their clan leaders…” (Fadiman 71). Understanding power distance and hierarchies within different cultures is a large part of seeing the situation from your patient's perspective. It may be frustrating to have to wait for a yes or no answer to the treatment you know will save their life, but this is their culture and their ways need to be respected, not treated like they are inferior. The Hmong culture is collectivist while US culture which is individualist, which explains why, along with the power distance that exists, medical treatment approval was a group decision. A medical professional should be cognizant of these types of culture differences when working with patients from other cultures.
Medical practices and institutions, when dealing with an influx of patients from other cultures, should be wary of the differences between translators and interpreters. A translator simply translates the words you are saying into the other language. While on the other hand, an interpreter will take cultural meaning of the dialogue into account when communicating. A translator may be fine for administrative work, but an interpreter should be used for mutual understanding of what is wrong, how it will be treated, and how to follow through with the treatment at home or at the medical facility. An interpreter was used occasionally in Lia’s story, for instance when nurses went to the Lee’s home they brought an interpreter with them (Fadiman 49). Despite the use of interpreters in these settings, they were rarely used when the Lee’s came into MCMC. Another example for why an interpreter should be used in medical settings is because, as Dan Murphy points out, the Hmong did not have words for certain organs and concepts so there was no way to effectively translate the situation to them (Fadiman 69). This may be the case across many different cultures, and if a translator is used rather than an interpreter the value of the message will be lost. Similarly, nonverbal communication should be taken into account when interacting and conversing with patients from different cultures. Medical professionals should be conscious of their kinesics, as to not make any offensive gestures or overly confusing facial expressions. Doctors should also be conscious of their oculesics, and whether or not it is considered rude to make eye contact in the other culture. These actions may result in patients losing respect for the authority of the medical professional. In the case of the Hmong, they did not appreciate when the medical staff of MCMC treated them like they knew nothing simply because they came from a different culture. Overall, medical professionals should be conscious of their behavior and how they are using their authority.
The Spirit Catches You and You Fall Down exhibits a situation that occurred from interactions of few effective intercultural communicators with many ineffective communicators. From Lia Lee’s story, medical professionals should learn the importance of understanding cultural differences between patients, especially when it affects medical views and care. Had the staff of MCMC asked the Lee’s why they were noncompliant, and what they believed was going on, as they knew full well they were from a different culture, Lia may have had less severe and less frequent seizures. Medical professionals should also consider whether or not they should use a translator or an interpreter to communicate messages to patients. In addition, the lessons of cultural empathy and understanding revealed throughout this book are relevant in the world today. From the refugee crisis and our increasingly globalized society, the value of intercultural communication skills are more important now than ever before.