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Josie is a 78-year-old woman who is recovering from a stroke. She has regained most of her speech and language, but still experiences difficulty swallowing. To receive adequate nutrition, she is receiving nutrition through a gastric tube for a few more weeks before the SLP completes a follow-up swallow study. Josie’s family comes from a Brazilian background and loves to gather and cook Brazilian food together. Josie reports feeling isolated from these customs and does not want to continue with the gastric tube.

This case study centers around feeding and swallowing disorders and cultural background. What does a communication professional need to know in order to best serve Josie?

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The majority of the population in Brazil speaks Portuguese. They tend to have a more indirect communication style, but they still are very expressive and emotive in their speaking. Nonverbal cues are a large focus, and they often use physcial contact when conversing.

A wide range of food is consumed by those who are a part of the Brazilian culture. Most of their foods consist of rice, beans, eggs, cheese, and beef. Coffee is a very common drink. Food is a sign of community and family, and most celebrations consist of a large meal.

(Brazil: Explore Brazilian Culture, n.d.)

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This podcast consisted of a few medical SLPs who have done research in the area of cultural sensitivity with dysphagia. They talked about how it important to consider a persons likes and dislikes and consider their allergies when coming up a with diet for them. It is also important to think of what access they have to these materials (money and location). Identity is something that is important to people, so it should be important to the SLP as well. Asking open ended identity questions instead of multiple choice identity allows you to learn more about the person and their identities. This will help you know how they identify which can help you understand the food the normally eat, the holidays they celebrate, and what they believe in. It is important to support the client and make sure the client has support at home as well. Educating the caregivers is almost as important as educating the patient. Overall, the best thing you can do is to listen to your patient.

Although this podcast is about dysphagia and not g-tubes, it is still relevant. When one has dysphagia, there is a limit on the types of food they can consume. The patient in our case study wants to eat more of her cultures food, but is unable because of her g-tube. Many of the aspects of cultural sensitivity mentioned in the podcast apply to the treatment of our case study client, Josie.

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304 – Cultural Sensitivity in Dysphagia: Nourishing Patients Beyond Nutrition

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Cultural Considerations in Tube Feeding Decision-Making 

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Cultural Considerations in Tube Feeding Decision-Making 

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This research article focuses on tube feeding and the cultural values an SLP must acknowledge when administering them. Tube feeding encompasses more elements than simple medical care. Cultural and family care must be considered when offering a feeding tube to a patient. SLPs must communicate with their patients and understand how their values align with their decisions. Each culture and family will have their values. Because dysphagia is present in many cases of older adults, feeding tubes can often be beneficial; however, other aspects such as poor oral care and possible symptoms of aspiration can affect this decision. With cultural values playing a role, it is important to understand the challenges an SLP may endure while learning about an individual's values. SLPs play a major role in administering feeding tubes to these patients and to do so, they must recognize a patient's cultural values over their own.

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Counseling Clients With Dysphagia: A Resource for Clinicians 

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Counseling Clients With Dysphagia: A Resource for Clinicians 

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In this research article, they discussed the lack of counseling skills provided to SLP’s. SLP’s have to give a lot of life changing news to their patients. There has been research shown with therapies on other areas of speech disorders, but not many have been done on dysphagia. Cognitive Behavioral Therapy, Rational Emotive Therapy, and Acceptance and Commitment Therapy, are the three main therapies the articles dives into. These approaches have been proven to be the most effective when it comes to SLP. With CBT, the approach to the disorder is focused around addressing negative thoughts and exposure techniques. The RET technique targets specifically irrational thoughts, challenging them, and creating new positive, helpful thoughts. With ACT, the focus is to take the negative and irrational thoughts, and redirect that to focus on the positive things in their life that bring them joy. When it comes to counseling, there are three times you would need to have this training ready. The first case scenario is delivering the news, the second case scenario is navigating the diagnosis and negative thoughts the client is experiencing earlier. The last case scenario is the ability to support the care givers. The opportunity to support the caregiver is possible throughout the entire diagnosis journey. The biggest thing to know when it comes to SLP’s counseling is to know when things are outside their scope. SLP’s need to know when to refer to mental health specialists and that it is okay to not know how to assist further. In conclusion, when working with dysphagia clients and their caregivers there is a need for counseling skills. These patients are dealing with a life altering disorder that can be a lot on them and their caregiver. The best thing SLP’s can do is continuing to educate themselves and stay up to date on counseling techniques for their clients.

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For Josie, we decided that involving her family would be beneficial to her and her culture. One way to involve her family is to allow them to express concerns and the values they feel the SLP should know by conducting an ethnographic interview. They also may share aspects of their culture so the SLP can understand on a deeper level. Like in our podcast, one essential aspect is to involve the family in her journey, allowing her to receive support from her family, rather than only the SLP. Another important aspect of the interview is to ask about her food preferences and what she can eat orally now. It is important for us to know the kinds of food she feels like she is missing out on to see if there is a way to integrate it into her diet. Listening to Josie's feelings and preferences is the most important thing an SLP can do during the assessment process.

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For the intervention strategy, the SLP is responsible mostly for counseling and education. Educating the family on both general feeding/swallowing disorders and Josie's particular feelings towards hers. Involving Josie and her family in counseling and support groups may also alter her initial view of her gastric tube. Her family may have more understanding and adapt to her needs more. For Josie, hearing others relate to her situation at a support group may allow her to overcome any hardships she is facing due to her feelings of isolation and her resentment towards her feeding tube.

An SLP will need to continue with feeding and swallowing therapies to ensure that Josie will only need her g-tube for a few more weeks. It may also be beneficial for Josie to do almost a countdown until the day she will no longer need the gastric tube. This will help her stay positive and keep working towards no g-tube. All of these interventions are essential to Josie's recovery and will allow her to feel more included at family gatherings.

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Brazil: Explore Brazilian culture | learn more AFS-USA. AFS-USA. (n.d.). https://www.afsusa.org/countries/brazil/

Lawton, J. (2022). Counseling clients with dysphagia: A resource for clinicians. Perspectives of the ASHA Special Interest Groups, 7(3), 807–815. https://doi.org/10.1044/2022_persp-21-00263

Richard, T. (2023). Cultural Sensitivity in Dysphagia: Nourising Patients Beyond Nutrition. Swallow your Pride Podcast. episode. Retrieved from https://open.spotify.com/episode/25PAlzhAwW71BQX5khG2nl?si=5W9w-hrkSBq7DUUE8cKviA&nd=1&dlsi=d6f1fac4692f4c01.

Watson, N., & Bell, C. (2014). Cultural considerations in tube feeding decision-making. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations, 21(2), 63–73. https://doi.org/10.1044/cds21.2.63