Intercultural communication in
the medical care sector
W. Shadid

Published in: W. Shadid and P.J.M. Nas (red.):
Culture, development and communication,
CNWS, Leiden,1993, pp. 70-91.
© No part of this article may be reproduced or copied without
acknowledgement of the authors and source

It is a well-known fact that communication between individuals from different cultural backgrounds, intercultural communication, may be influenced by factors which can be traced back to their respective cultures. Even though the concepts of culture and communication have a long history in the social and behavioural sciences, it is mainly the complexity of both concepts that has hampered a deeper understanding of the scope of this influence, as well as of the manner in which it occurs.
In the first half of this century, the interest in the subject of intercultural communication was often directed towards the description of other cultures, primarily from a Western point of view. The scientific attention paid to this field, and especially to its theoretical and methodological foundation, has gradually resulted in a fundamental reconceptualisation of the basic concepts and in a reconsideration of the legitimacy of the Western ethnocentric views on culture. As a result of several factors such as migration, improvements in the means of communication and an intensification of the world trade, the past few decades have shown a considerable increase in the importance of intercultural communication in society at large. More than in the past, many realise and experience daily the fact that a cultural distance between people, may form a fundamental barrier in their mutual communication. The relevancy of such a cultural distance is not limited to informal social contacts only, but also applies to professional services and industrial organisations.
The presence of various ethnic minority groups with their own cultural traditions has made it clear that the Dutch service facilities, social, cultural and economical ones, are not sufficiently equipped to offer adequate assistance to members of these ethnic groups. Although many scholars, practitioners and health officers have devoted much attention to analysing and operationalising the communication process across cultures, it is obvious that many problems in the field of theory building as well as in optimalising the assistance offered to members of ethnic minorities still need to be resolved.
This article discusses the current state of affairs in the field of intercultural communication. In the first place, a short reflection on the dynamics of culture and communication is presented and an attempt is made to elaborate on the current state of theory building in this field. Furthermore, attention is paid to several factors hampering the process of communication between practitioners and migrants of an Islamic cultural background, especially in the medical care sector in the Netherlands.

Culture and Communication
It cannot escape notice that several handbooks and review articles have been published on the components and dynamics of culture and communication. Even though scientific debates on the process of intercultural communication have resulted in various theories and classificatory systems, the picture of the field of application is not yet clear. As has been mentioned before, one of the most important bottlenecks in this regard is the complexity of both concepts and their relation to social reality. The main proposition here is that culture is not only a mirror of reality but, at the same time, the creator of that same reality. Furthermore, communication is not only structured and managed by culture but, at the same time, it also contributes continuously to the very creation of culture.
Some argue that culture is a coherent system of meanings, cq. knowledge. Culture does not merely provide an orientation towards reality, but also forms a framework for living. As a matter of speaking, culture provides the individual with a 'program for action', through which he can deduce the things that are worthwhile pursuing and the paths that can be followed to make the best of a particular situation.... Culture does not only inform the individual about the reality he lives in, but also structures the manner in which that information is applied with respect to human behaviour (see Tennekes 1985: 24). In other words, culture is not only an information supplying mechanism, but also an information processing one. As a result of these characteristics, one may argue that culture is even a self-generating mechanism. Culture is learned day by day, applied, changed and produced by interaction and communication between human beings. The way in which this takes place will be discussed below from the perspective known in the social sciences as that of symbolic interactionism. First of all, however, it is imperative to pay some attention to communication in general and to the communication process in particular.
Communication implies a process as complex as that of culture. Adler (1986: 51) argues that communication is "the exchange of meaning: it is my attempt to let you know what I mean. Communication includes any behaviour that another human being perceives and interprets: it is your understanding of what I mean. Communication includes sending both verbal massages (words) and non-verbal massages (tone of voice, facial expressions, behaviour, and physical setting). It includes consciously sent messages as well as messages that the sender is totally unaware of sending. Whatever I say and do, I cannot not communicate. Communication, therefore, involves a complex, multilayered, dynamic process through which we exchange meaning". In other words, the process of communications consists of a sender, a receiver, a message, and processes of intentions, exchange of meanings and reactions.
Communication has to be conceptualised as episodic. Each act is localised in time and space, and therefore unique and not to be repeated. Furthermore, the dyad is the basic unit of interpersonal communication, no matter how many people are participating in an event. We can only understand what happens in the interaction "by collecting data that show moment by moment interaction of the speaker and each member of his audience from the time defined as the beginning to the time chosen as the end of the episode". Furthermore, because communication is a social act, what occurs in participants is not as significant as what they produce together (see Howell 1979: 26-28) .
In the course of the communication process, individuals exchange meanings by means of communication codes. Cooley and Asuncion-Lande (1983: 48) consider these codes as "a culturally defined, rule-governed system of shared arbitrary symbols used to transmit meaning. Included within the concept of code are language, paralinguistic phenomena, non-verbal phenomena, silence, language choice, multilingual behaviour, interruptions, turn-taking and organisation of talk".
From the ethnomethodological approach we learn that in communicating people call on each other to complete, by means of unspoken codes, the incompleteness of what they say and do in a particular context. If an individual knows the norms and values of a certain culture, but is not aware of the unspoken codes and symbols that are relevant to the situation, he remains an outsider, a stranger. The observed behaviour will be incomprehensible which, in case of communication, may lead to conflicts. This means that intercultural miss-communication cannot merely be avoided by eliminating such barriers such as the lack of knowledge of the language, norms and values of the other culture.
Furthermore, getting an insight into what happens in intercultural communication processes may be hampered, especially in a migrational situation, by the intensified dynamics occurring in the original culture of the migrant due to his confrontation with a different one. As has been mentioned before, communication, on the one hand, is structured and managed by culture, but at the same time also contributes continuously to culture. This process of interrelation is adequately described and elaborated upon from the perspective of symbolic interactionism. According to this perspective, social reality is considered to be a meaningful reality manifesting itself through interaction and communication. In an interactional situation the individual is continuously involved in a process of interpretation with respect to his own behaviour as well as that of the other. By means of this interpretation process meanings are attached to codes which consequently are transformed and concretised into verbal and non-verbal behaviour. In interpreting his own behaviour an individual places himself in the position of his interaction partner. He asks himself, 'what am I allowed to do and what is not permitted?' and takes a decision about his own behaviour accordingly. This interpretation process is based on: (1) what one has learned from socialisation, this being the objective part of reality, (2) one's own experiences in similar situations, by means of which the subjective part of reality is introduced. In other words, human beings are not passive, merely behaving according to existing norms and values, but are the active creators of their own culture and reality.
In a situation of migration the experiences of the individual are more intensive and diverse. Mainly due to these new experiences, migrants do not necessarily always behave according to their original culture. After a period of time they adopt norms and values of those with whom they have an intensive social interaction. The pace at which this may take place largely depends on various factors such as the length of stay in the host society, the educational level and most important of all on the relation of these norms and values to the core aspects of the original culture. This process is identified as (instrumental) adaptation or adjustment, and may induce the emergence of one or more new subcultures, the so-called migrants' culture(s).
As a result of the above-mentioned views on reality and culture, one may argue that the behaviour of migrants in a cross-cultural setting may be understood more properly when it is looked upon as sub-cultural rather than as a variation of the original culture of the migrants. According to Tennekes, subcultures refer to variations in models of reality within a more coherent cultural context. In general, these differences largely depend on social differences, i.e. differences in the concrete living conditions of the various social categories (social classes, urbans and rurals, gender, etc.). It is worth mentioning that, even though the distinction between social and cultural differences is theoretically and for research purposes extremely important, its contribution to understanding the practice of intercultural communication and the circumstances under which miss-communication may take place is minimal. People from different cultural backgrounds mainly communicate with each other on the basis of the existing mutual cultural and ethnic stereotypes. Every miss-communication, or behaviour deviating from the norm, is often attributed to the background of the other.
The above-mentioned complexity and dynamics of both culture and communication did get a great deal of attention from scholars in this field, and still do. Vermeulen (1992: 15 ff.) presents a clear and critical analysis of the applications of the concept of culture in studies on ethnic groups. He considers culture to be the common world of experiences, values and knowledge that are characteristic of a particular social unit. He moreover argues that some authors regard cultures as units with clear-cut boundaries, while others prefer to see cultures as the subcultures of a global culture only be understood in their relation to this world wide culture. He pleads in favour of the latter view and stresses the internal heterogeneity of cultures. He furthermore states that it is possible for cultural differences between two subgroups of an ethnic minority to exceed those existing between them and their Dutch surroundings.
The previous discussion makes clear that one has to be cautious in labelling behavioural differences between groups automatically as cultural differences or to hold only culture responsible for every instance of miss-communication that emerges between individuals from different cultural backgrounds. Especially in a situation of migration, the danger exists that researchers and practitioners culturalise miss-communication more than necessary. The danger of this culturalised approach is that cultural ideas and values are often used as indicators for what we cannot understand, as an 'explanation that does not explain' but merely indicates that a certain type of behaviour is specific to the groups concerned. In contrast to 'our'behaviour, which is considered to be a natural and logical reaction to a particular situation, their behaviour is seen as structured by culture. This way, 'our' behaviour seems to be rational and 'theirs' irrational and based on tradition (see Vermeulen 1992: 16).

Intercultural Communication
The scientific attention paid to the relevancy of cultural differences has primarily been introduced by anthropologists like Boas, Bendict and Malinowski. At the beginning of this century, the culture and personality school was developed, with cultural relativism as its main interest. In the sixties, the cross-cultural and intercultural studies emerged, with special attention to studying societies by means of intercultural comparisons. Even though intercultural communication as a scientific discipline is of recent date, the attention paid to this topic over the past thirty years has been enormous. During the sixties not one university in the United States had a course in intercultural communication. Today, almost every major university in the country offers such a course (see Asante, Newmark and Blake 1979). The explanation of similarities and dissimilarities which impede or enhance communication across cultures is the first aim of this field. They state, furthermore, that it is a multidisciplinary field which has emerged from a combination of psychology, anthropology and communication sciences as "a response to the continuing drama of Western orientations in social sciences. Intercultural communication attempts to shed the trappings of ethnocentrism and explain the communicative act in its own terms". The intercultural comparison in itself did also contribute to the individual disciplines in the social sciences themselves. It became evident that above all theories from psychology, which were looked upon as universal, were not applicable outside their own cultural boundaries.
At the beginning, the theoretical foundation of this discipline was lacking. Even in 1979, Asante, Newmark and Blake (12 ff.), prominent specialists in this field, could not explain specific theories on intercultural communication. With respect to the meaning and value of intercultural communication they distinguished between the cultural-dialogue group and the cultural-criticism group. Proponents of the former, primarily anthropologists and communicationists, are in favour or internationalism and humanism and of developing theories to promote world wide understanding. The cultural-criticism group, on the other hand, seeks to find the points of conflict in each culture in order to isolate them as researchable issues in trans-cultural interaction. To them, seeking similarities and universals in cultures are of no importance until a classificatory system adequately describing those cultures is developed.
Classifications which are consequently used in studies on intercultural communication are those which differentiate cultures according to the position of the individual in society (the we-cultures versus the I-cultures), or according to the types of communication codes, or according to a combination of both. In this respect, the best known classification is that of Hall (high context versus low context) communication, which is more or less similar to that of Bernstein, who divides communication codes in implicit versus explicit. The former implies that the information given is minimal, and therefore to be understood by insiders only. The information given by explicit codes, on the other hand, is optimal and can be understood by almost everyone. In the Netherlands and in relation to intercultural assistance, the above-mentioned typologies of culture (the we-culture versus the I-culture) and communication (implicit versus explicit) have only been used once to construct an explanatory model for intercultural communication (see Eppink: 1981). This model consists of four quadrants, each comprising different types of individuals. It has been criticised as being vague, offering nothing but a rough classification of culture types of which the basic variables are not clear enough (see Tennekes 1985: 20-22). The concepts culture and communication are furthermore only used as variables and not as theoretical constructs. It is obvious that such an approach does not fit in with the above-mentioned perspective where both concepts are viewed as theoretical and dynamic.
Asante et al. (1979: 12) draw the following conclusion in relation to the general state of affairs of this topic up to the end of the seventies: Intercultural communication "is a field of inquiry without a clear tradition rooted in the social or behavioural sciences. What one finds are the tangential forays of anthropologists, communicationists and psychologists who, while on their various journeys into their cultural field, happen to pass by".
It was but a decennium after the publication of the above-mentioned handbook by Asante et al. that a rich variety of theories on intercultural communication were being used or developed. It is indeed in the course of the past decade that a number of specific theories could be designated. Gudykunst and Nishida (1989: 41 ff.) make up the balance and state that in the eighties the development of theories on intercultural communication was enormous. Based on empirical data Hofstede (1983; 1991), for example, developed an expanded classificatory system of cultures, the so-called system of cultural variability. In this approach cultures are classified according to four dimensions.
(a) Individualism - collectivism: The former emphasises the individual's goals, whereas collectivistic cultures stress the group's goals and put more emphasis on common interests, traditions and the avoidance of loss of face.
(b) Large and small power-distance: This implies the degree to which societies accept inequality as being natural and existential, which is the case in cultures with a larger power-distance.
(c) Much and little uncertainty-avoidance: Cultures with a larger extent of uncertainty avoidance posses many formal rules (behavioural codes) and stress the importance of cultural values. Such societies are aggressive, emotional and intolerant.
(d) The role of gender: masculine cultures have a clear division of roles between the sexes, while feminine cultures stress the equality of sex roles. In the former, men are expected to be assertive, ambitious and competitive.
According to Gudykunst and Nishida (1989: 37 ff.), the theories that were developed or that were frequently used in research on intercultural communication in the eighties mostly originated from other disciplines and were based on various perspectives, methodologies and research traditions. The combination of a perspective (objective versus subjective or ethic versus emic) and the origins of a theory (derived from communication, from other disciplines, or newly developed) yields a taxonomy of six approaches to developing theories on intercultural communication. Gudykunst and Nishida, however, stress the fact that the distinction between objective and subjective perspectives is artificial, and that they should not be used as opposing paradigms. See for a selection of the theories applied in this field most often (Gudykunst and Nashida 1989).

As an illustration, it is worth discussing briefly one of the newly-developed theories from each perspective.
There is, first of all, Ting-Toomey's Theory of culture and face-negotiation, which has been classified as being developed from an objective perspective and which links one dimension of Hofstede's cultural variability (individualistic-collectivistic) to the face-negotiation process. This theory stresses the 'face'(identity), which is considered to be "the projected image of one's self in a relational situation and which is conjointly defined by the participants in a setting". It differentiates between self-face and other-face; positive-face (inclusion need) and negative-face (autonomy need); and direct and indirect face-negotiation strategies. The theory is summarised in twelve propositions dealing with the difference between individualistic and collectivistic cultures in relation to the differentiated faces and negotiation strategies. In a conflict situation members of individualistic cultures tend to express: 'a greater degree of self-face maintenance, use in managing conflict more autonomy preserving strategies, use more self-concern positive- and self-concern negative-face supra-strategies, use a greater degree of direct negotiation strategies, use to manage conflict more dominating strategies, and a greater degree of solution-oriented conflict style. Members of collectivistic cultures, on the other hand, tend to express in conflict situations 'a greater degree of mutual-face or other-face maintenance, use in managing conflict more approval-seeking strategies, use more other-concern positive- and negative-face supra-strategies, use a greater degree of indirect face-negotiation strategies, use to manage conflict more smoothing strategies, and a greater degree of avoidance-oriented conflict style. (A summary of the twelve hypotheses of the theory of culture and free negotiation as discussed by Gudykunst and Nishida 1989: 31).'
An example of a theory developed in concurrence with the subjective approach is the Rules theory of cultural identity of Collier and Thomas. This theory focuses on the analysis of the symbolic text which emerges in an interactional situation, and stresses the importance of the so-called cultural identities. Collier (1989: 295) defines culture as a "historically transmitted system of symbols, meanings, and norms. The emphasis in this conceptualisation is upon identities, inter-subjectively defined by similarities in symbols and norms, which are posited to potentially change during the course of a conversation [...] In some encounters, nationality may be a key construct, but in others, gender, the relationship, or one's professional position may be key constructs in the understanding and accounting for outcomes. Therefore, I believe that identity adopted, managed, and negotiated during an encounter can be an important focus. Culture can be measured thus as background and heritage, and as emergent patterned conduct around a particular thematic identity". In other words, culture is the emergent identity. The two basic assumptions in this theory are: "persons negotiate multiple identities in discourse and communication is rendered intercultural by the discursive ascription and avowal of differing cultural identities. Cultural identities are identifications with and perceived acceptance into a group which has shared systems of symbols and meanings as well as norms/rules for conduct". These identities can vary according to three central, interdependent dimensions: scope (the number of persons sharing the same identity), salience (its relative importance in a particular situation in relation to other identities), and intensity (the strength with which this identity is communicated). Collier (1989: 296) moreover states that, ontologically, members of a culture group are expected to know the meaning of their symbolic forms, how to use them and how to behave appropriately. Epistemologically, it is however possible to describe cultural identity and cultural competence by analysing the text or by considering them both to be impressions of the respondents immediately following a conversation.
A number of objections can be raised against the theories discussed above. The theory first mentioned presents nothing but idealised types of behaviour. As has been mentioned before, Hofstede's cultural variability consists of four dimensions, with some of them being even negatively correlated. When only one dimension is used in research, the outcome is merely a variation of the well-known classification of cultures into modern versus traditional, which inevitably leads to unacceptable generalisations. Besides, also collective cultures posses a considerable heterogeneity, even in relation to central values. Even though politeness, for instance, is a core value in collectivistic, as well as in individualistic cultures, its operationalisation may differ within each culture of the same type. It is even possible that within the same category of cultures polite behaviour in the one may be considered as impolite in the other. Both of the theories discussed also do not take the inequality in power relations in interactional settings into account. The influence of differences in status on communication is of great importance, especially in situations of assistance and in solving conflicts. In addition to this, both theories consist of hypotheses which are hardly interrelated, which reduces their usefulness in an assistance setting.
However, the above-mentioned theories posses a heuristic value and can be used to guide research in this field. The state of affairs in the field of intercultural communication is not sufficiently developed so as to generate formal theories on the subject. It is, therefore, more appropriate to aim at developing substantive and middle-range theories for dealing with intercultural communication.
These theories, furthermore, have not been applied to the cross-cultural assistance sector. Looking at the literature concerned, one is struck by the paucity of theoretical studies dealing with assistance in intercultural setting. As a result of the lack in theory regarding this field, on the one hand, and its multidisciplinary character, on the other, as well the limited attention paid to it in the professional training for the various relevant occupations, a number of bottlenecks can be pointed out in the cross-cultural medical care sector in the Netherlands.

Bottlenecks in the Field of Intercultural Assistance
Not until recently did policy-makers show an awareness of the importance of the cultural dimensions of intercultural assistance. Thus, in a report of the Ministry of Welfare, Health and Culture, it was stated, for instance, that "the majority of assistance questions of migrants are non-specific. For this reason the dispatchment and the solution of these questions require no specific expertise or knowledge of the cultural backgrounds of these migrants" (Ministerie van WVC 1986: 11,17). This incorrect statement can be best interpreted against the background of the current policy at the time which emphasised the abolition of the so-called categorical social assistance.
Gradually a keen interest has developed, however, in the cultural dimensions of assistance and management. The awareness has been growing that the assistant or health officer who is working with immigrants should not only possess the general qualities necessary for each interaction situation such as, for instance, the right attitude, being willing and capable of listening well and of showing respect (Ministerie van WVC 1986: 11,17). but should in addition also have substantial knowledge of the culture of the migrant concerned in order to offer optimal assistance.
In spite of the growing interest in this subject, intercultural assistance as a field of study and work in the Netherlands, especially in the field of health care, shows some shortcomings, as is evident from the numerous publications in this field.

The Statical Approach to Culture
With respect to the problem of intercultural communication, in general, and of assistance, in particular, consensus exists about the dynamic character of culture. Except for some minor remarks, a practical elaboration of this dynamic is, however, still absent in the relevant publications by scientists and assistants. In practice, the concept of culture is still used in an a-theoretical and statical way. At best, a few authors such as Van Dijk and Schoenmakers (1983: 23) mention the emergence of a so-called migrants' culture, it being the result of migrants finding more or less new solutions to new conflict situations in Dutch society. In other words, based on their experiences in the host society, people develop patterns of expectation and frames of reference that may deviate from those current in their countries of origin. Thus, many concepts such as illness, illness behaviour, health, doctor-patient or employer-employee relationships acquire a different meaning.
As a warning against the statical approach of culture, the concept of a migrants' culture is valuable. Besides the proposition that comparable experiences could lead to comparable perceptions, frames of references and solutions are plausible, especially in the long run. In practice, the concept of a migrants' culture has not been investigated yet and its outlines and contents have likewise not been given concrete form. Nearly all of the studies in this field fail to succeed in pointing out the concrete cultural changes meant here.
It also remains questionable whether the above-mentioned experiences and reactions of migrants can be defined in a meaningful way, in practice thus leading to a deeper understanding of the matter. In the literature, therefore, one remains stuck with theoretical notions about the backgrounds against which these cultural changes may occur. It is moreover, doubtful whether comparable experiences of migrants of different cultural backgrounds will automatically lead to common perceptions and reactions. One may wonder whether this will even apply to those originating from the same ethnic group. Depending on many factors such as, for instance, his own specific circumstances, his cultural background and the cultural item at stake, an individual will react to certain experiences in a very personal way. The objections are not repudiated by Van Dijk and Schoenmakers either. They state that differences in the reaction patterns of individuals may be caused by differences in, for instance, age, educational level and region of origin and also by the extent to which one wants to preserve traditional norms and values. They conclude that "this diversity turns the migrants' culture into a incoherent and inconsistent entity" (Van Dijk and Schoenmaker 1983: 23). They do not conclude, however, that also this concept is of little value to practical situations. On the contrary, they come to the conclusion that "after its development, the migrants' culture, being part of the social existence of the migrants, acquired a specific, historical role and dynamics". As to the research in the field of intercultural communication this conclusion is important, however, because it is precisely its lack of coherence and inconsistency that turns the concept of a migrants' culture into an artificial construct and not useful in practical situations.

Insufficient Knowledge of the Cultures of Minorities
As has been stated before, knowledge of the original cultures of minority groups and of the above-mentioned migrants' culture based on experience are of the utmost importance if optimal assistance is to be offered. Research has shown that the knowledge of the workers in this field is often insufficient. Even though the importance of extending the know-how has been generally acknowledged, workers formulate several obstacles impeding the acquisition of knowledge that is considered to be essential (Shadid and Van Koningsveld 1983). Matters such as the lack of specific literature on the subject, the tight work-schedule of the workers, and the cultural heterogeneity of the migrants are here in order. A general practitioner put it this way: 'One may assume that each of these groups has a different outlook on life, each moreover differing substantially from that of the workers. Especially in case of a superficial study the danger exists that these various outlooks will get mixed up, so that one no longer knows which belongs to which.' Finally practitioners mentioned the disproportionate investment in time as a barrier: the small percentage of their clients belonging to minority groups does not justify the investment in time needed to obtain useful knowledge about their cultural backgrounds.
One may conclude from the above that in all of the schooling programs of the different professions extensive attention should be paid to the cultural dimension of intercultural assistance if the latter is to be taken seriously. Research has pointed out that in two-thirds of the 416 educational centres for health care in the Netherlands attention is indeed being paid to minority groups. However, in each curriculum an average of only 11 hours has been set aside for his subject (see Gijtenbeek and Riemersma 1986: 12-13).
Moreover, in these curricula, the emphasis is primarily on the description of the original cultures of these groups without taking their position and new experiences in the receiving society into account, which, as has been stated before, have become an indispensable part of their culture. This means that in dealing with culture, no link is established with the social circumstances under which it is being produced and reproduced (see Vermeulen 1992: 26). If a curriculum for intercultural assistance is to pay attention to the cultural dimension, it is imperative that above all the following aspects should, in any case, be taken into account. First of all, attention should be paid to the general outlines of the original cultures of one or more of the minority groups. The norms and values relating to social, economical and political issues, family relations and religion are primarily at stake here. Knowledge of these cultural elements is essential to the understanding of both the former and the current situation of the cultures concerned.
The second topic is related to aspects of the original culture that have a bearing on the assistance-situation concerned. To Muslims certain aspects in the field of health care may be primary of importance; for instance, the meaning of illness and cure, traditional healing, the relationship between the sexes and the position of the sick in society and in religion.
Thirdly, attention should be paid to the social, economic and cultural heterogeneity within the minority groups. Generally speaking, the issues of ethnical and regional origins of educational levels and training, and of the degree of secularisation are at stake here.
Finally, a discussion on the socio-economic, political and juridical position of migrants in the host society in general is indispensable. This mainly concerns, on the one hand, their position on the labour-market, the housing-market, in education, in politics, in legislation and, on the other hand, their acceptation in society at large, including the existing prejudices and stereotypes.
The information on migrants presented in such training programs should also be tested as to its accuracy. The information on people with an Islamic background given at the moment in certain educational programs, however, leaves much to be desired. Thus, it is mentioned in the literature that, for instance, certain foods such as honey, olive oil, milk and dates are allegedly recommended by the Quran. In the same way hospitality is presumed to be an obligation to them, which moreover has to be observed according to strict rules. A classical example of the wrong approach is the provision of a list with information and so-called practical hints (see M.J. Lutjenhuis: Migranten als patiŽnt. Praktische tips. In: Syllabus week huisartsengeneeskunde, Universiteit Leiden, 1992). On such a list given to medical students one finds, for instance, the statement that migrants "attach greater importance to family matters and unexpected visitors at home than to an appointment with the health care officers". One of the pieces of advice on the list is: "one should greet the husband first, then the sons and afterwards the wife". The author even warns against generalisations and stresses the fact that the typically minority patient is just as non-existent as the typically Dutch patient.
In a report on the mental health care of migrants, health officers are furthermore advised not to put the question 'do you hit your wife and children?' too hastily. They are "not accustomed to discussing their problems. They do not like to wash their dirty linen in public" (see Mevissen 1989: 24). This advice and its explanation, though in themselves correct, do, however, not only apply to migrants, but also to the Dutch themselves. Not washing one's dirty linen in public (which, by the way, is a Dutch saying), is of universal application and should therefore be used in a gradual sense only.

The Assistance to Minority Groups is Strongly Culturalized
Another bottleneck in the existing intercultural assistance in the medical sector is the rather exaggerated emphasis on the role the culture of minority groups plays as an explanation of the various possibilities of miss-communication. Because of this emphasis, other non-cultural obstacles are neglected. Poortinga and Hofstede (1986: 154) are justified in observing that the interest in culture and its influence on assistance may also have its drawbacks. They consequently stress the real danger of culture possibly becoming the explanation for everything, it thus being reduced to a meaningless label. Every difference observed can be attributed to culture. Indeed, such a danger is not only imaginary but can really be observed in practice. In the literature on this subject, the culture of the Moroccans, for example, is frequently considered responsible for the lack of co-operation in the course of medical examinations. This can be illustrated by the following statement: "They distrust a Dutch physician from the start. They are of the opinion that the practitioner does not belong to the family and should therefore have no access to private matters" (Van Neerbos 1981: 381).
However, the client's lack of co-operation does not need to be caused by the physician being distrusted as a member of the outgroup. In this respect, other factors such as a lack of clarity of the questions, or their relevance may be more important. For instance, some clients do not see the relationship between the general questions asked and their somatic complaints perceived, or they have no knowledge whatsoever of the history of the family diseases.
Communication between the migrant and the health officer may furthermore be disturbed by other factors, such as mutual interests and power relations not directly related to his original culture or to the above-mentioned factors (see Shadid and Van Koningsveld 1983; Tennekes: 1985: 24). In the first place, a disturbance in the normal mutual human expectations may be responsible for a good deal of miss-communication. Clients expect the health officer to pay sufficient attention to their complaints, to treat them in a friendly and respectful way, and to provide them with sufficient information about what is going to happen during the physical examination. These expectations are not in any way different from those of non-migrants. The practitioner in his turn also expects the client to co-operate, to supply correct information and to observe his prescriptions. When one of these respective expectations is not met, a charged atmosphere will inevitably ensue. It is self-evident that these expectations may be culturally defined. However, human expectations may even be thwarted within the same cultural settings.
In this regard mutual preconceived ideas may also be of importance. When the client or the practitioner, for one reason or another, is convinced of the other party's negative attitude towards him, communication between the two will be disturbed. A migrant's feelings of not being accepted by the social environment, for example, may also be ascribed to the practitioner as part of that environment. This is also valid when the latter has prejudiced and stereotyped ideas against the migrants as simulating and somatising their complaints.
Because practitioners and researchers in the medical care sector do not take the effects fully into account of the above-mentioned non-cultural factors regarding communication in an intercultural setting, Van Dijk (1989: 131) speaks of culture as an excuse for a failing assistance. The structural shortcomings in medical care itself, as well as the insufficient appearance of the practitioner are then left out of consideration.

A Vicious Circle of Case Histories and Generalisations
Another bottleneck in the field of intercultural assistance is caused by the case history approach. In this approach, behaviour of, for example, Moroccans is explained mainly by referring to some aspects of their original culture, such as ingroup - outgroup distinction, fatalism, and the hierarchical relations between men and women. This type of approach implies that practitioners are applying rather antiquated models of explanation to the analysis of the behaviour of the client in a particular case history. Besides, these models are no more than hypothetical constructs, formulated by the assistant himself and projected onto the principal person in a case history, who can hardly recognise himself in the analysis. Sometimes, members of minority groups, especially Muslims, are allotted caricatured characteristics. In the literature on medical care one can find statements such as: "Moroccans have a rather ambivalent attitude towards western medicine. They consider the medical ritual as magical forces to manipulate with." "Only out of necessity do they trust a western doctor, who is an atheist. Besides, the negative attitude of the Moroccan client is also directed towards nurses, who are considered to be threatening and impure because they handle human blood and waste matters." "Some of these clients do not even accept the authority of the nurse, just because she is a woman." (see Van Mol 1979: 16; Geurts 1980: 34-35; see also the research results of Van der Zwaard 1992: 5) Practitioners do not try to estimate the frequency of appearance of such behaviour from a sample of the ethnic group concerned. Furthermore, the case histories end prematurely. The reader does not learn whether knowledge about the culture of the patient discussed in the case history had any effect on the therapy.
To take such histories to be examples of the interaction and communication in an intercultural setting is misleading and may even have a preposterous effect. The danger of such an approach lies in the fact that other assistants may consider the specifically individual behaviour described in a case history to be the normal behaviour of the ethnic group as a whole and may even generalise across the boundaries of the ethnic groups. It is inevitable that the result should be a mechanical action model, because the cultural component, introduced to optimise assistance, is used here as the primary axle of the diagnosis. A possible effect of this approach may be the doctor who thinks to know he is dealing with a venereal disease when the client pronounces the word Amsterdam (see Brueker and De Vries 1979: 80).
If such a group-oriented and generalising approach continues to exist, optimal intercultural assistance will probably be impossible. Even though exotic ideas on minorities no longer occur quite as frequently, general recommendations for the assistance in an intercultural setting are still to be found in the literature. Such recommendations are: less verbal, explicit, direct and confronting communication and less individually oriented assistance. On the other hand, more non-verbal, implicit communication and assistance aimed at the group as a system of clients (see Eppink 1985: 56-57).

In this article I have paid attention to the dynamics of culture in general and in relation to theory building in the field of intercultural communication and assistance. The state of affairs in this field is not sufficiently developed to allow for formal theories to be formed. In my opinion it is more adequate to try to develop substantive and middle-range theories on sub-aspects of intercultural communication. An additional merit of this approach is that we will be able to understand the nature of miss-communication and the ways to deal with it better. I have moreover stressed the need in intercultural assistance for a knowledge of the specific cultures of the minority groups and of their experiences in the host society. This knowledge should nevertheless be applied flexibly and must be used from the right perspective. This means that the assistant is urged to investigate whether and to what extent a client tends to stick to his original culture, on the one hand, and in what way these cultural aspects may impede the adequacy of the assistance offered. If these questions are not taken seriously, members of minority groups will be reduced to caricatures of their original cultures. However, the lack of a theory in this field which deals with the dynamics of culture as well as of communication, and the lack of the assistant's knowledge of the various minority cultures are important obstacles to putting the above-mentioned approach into practice.
Furthermore, the rationale of the aforementioned is that the assistant, especially in an intercultural setting, should approach his client as the creator of culture and as a person with his own experience and personality. This means that it is not adequate to assume beforehand that a client with an Islamic background experiences sickness in a different way or that he has views on time or space which are different. This reduces such a client to a robot who is driven by his original culture. Such generalisations not only cause obstacles to communication, but are counterproductive as well. In other words, the assistant's knowledge of the cultures of minorities should only be used as a background to the understanding of specific cases, because the influence of the migrant's culture on his behaviour is only probabilistic and not deterministic in nature.
Finally, one may deduce from this article that the assistant in an intercultural setting has to be all-round. He or she not only needs to posses knowledge of the cultures of the various minorities but must also be an expert, a psychologist, an anthropologist and a specialist in the socio-economic and juridical position of minorities in the host society. It is doubtful whether such characteristics are to be found in one and the same person. In any case, a specific type of education, open-mindedness and an unprejudiced attitude are the necessary conditions for adequate intercultural assistance.
N.B. For recente discussions on the multicultural society in the Netherlands, see (Shadid: 2008).

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