Everyone can actively work to develop greater intercultural competence. The Intercultural Development Continuum™ provides a roadmap for individuals, teams and organizations who wish to improve on their ability to understand and adapt to the diversity around them and become more fully inclusive. Sidney Van Dyke, the director of health equity and language access at Regions Hospital, discusses the five mindsets along the Intercultural Development Continuum™ and shares practical examples to bring it to life.
Everyone can actively work to develop greater intercultural competence. The Intercultural Development Continuum™ provides a roadmap for individuals, teams and organizations who wish to improve on their ability to understand and adapt to the diversity around them and become more fully inclusive.
Sidney Van Dyke, the director of health equity and language access at Regions Hospital, discusses the five mindsets along the Intercultural Development Continuum™ and shares practical examples to bring it to life.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guest: Sidney Van Dyke
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is Off the Charts.
Steven Jackson:
Today we have a very special guest. We have Sidney Van Dyke. She serves as the director of health equity as well as language access at Regions Hospital. Wow, I'm already scared.
Kari Haley:
I already don't know what half of that means.
Steven Jackson:
Sidney, welcome to our show.
Sidney Van Dyke:
Thank you. I am really thrilled that you invited me to lend my voice to the really incredible conversation that you guys have begun.
Steven Jackson:
Well, we've had some good opportunities, not only just with the podcast, but just meeting some great people who know what the heck they're talking about, and those are the people I like to be around and learn from. And today for our listening audience we want to continue on our journey to development. We talk about only as a HealthPartners organization, but beyond, as we attack the powers that be such as racism and bias and the like. We want to continue to learn about how we can develop more, how we can develop as people, as a society, as an organization, as a world. So, Sidney's going to fix all our problems. So, get a pen and paper.
Sidney Van Dyke:
So, let's get going.
Kari Haley:
Yes, let's hear more about this intercultural development.
Sidney Van Dyke:
So, I want to share with you guys a model that has been really meaningful for me in my work, it's called the Intercultural Development Continuum™, and it was adapted from the Developmental Model of Intercultural Sensitivity that was developed by somebody by the name of Milton Bennett back in 1986. And there are two things that I really love about this model. One is that it was developed using culture general frameworks versus culture specific frameworks. So, what does that mean? What that means is rather than being developed comparing two distinct cultural groups with each other. The Chinese versus the Americans versus the Germans. It was developed looking at cultural variation. So, things like how cultures relate to time, how they relate to power, how they relate to relationship building. So, these much more general frameworks, because really what they understood from the get go is that there is great variation between cultures, but there's also great variation within cultures.
Sidney Van Dyke:
And so by using that culture-general framework, it makes this model one that is much more broadly applicable across different differences, right? So, not just between two cultures, but as I am engaging with people who have a different sexual orientation than I do, that have a different racial background than I do, that are a different gender than I do. It's a model that is still really incredibly useful for me. The other thing I love about it is that it says it in the title, it is a developmental model. So, it's really all about how can we move forward if we want to become more interculturally competent? What do I mean by intercultural competence? So, I like to define it both at the individual level, as well as the organizational level. So, at the individual level, it's really the capability to shift cultural perspective and adapt or bridge behavior to cultural commonality and difference.
Steven Jackson:
Do I need to be a subject-matter expert in different cultures with this model?
Sidney Van Dyke:
You do not. And I'll talk about the importance of developing greater awareness of otherness, but I'll talk more about developing greater self-awareness.
Steven Jackson:
OK. OK.
Kari Haley:
I want to hear more about that. And you're already sparking things in my mind about how this could relate to concepts such as code switching and just knowing that knowing yourself and how you relate to other people and how you are relating to the environment that you're in.
Sidney Van Dyke:
Absolutely.
Steven Jackson:
Yeah.
Sidney Van Dyke:
So, at the organizational level, I really define cultural competence is the capability to adapt policies and practices to cultural commonality and difference resulting in more equitable outcomes. So, the focus really becomes outcomes. And in order to become more culturally competent, either as an individual or as an organization requires really deep self-awareness at the individual level, deep cultural self-awareness at the organizational level, deep understanding of the cultural underpinnings of the organization of its policies and its practices. But it also requires other awareness. So, a deep understanding of the experiences of people from different cultural communities in perceptions and values and beliefs and behaviors and practices. And finally it requires skill building. You have to develop the skill to move from theory, the cognitive understanding, to actually being able to bridge difference in your behavior, in the policies and practices of your organization.
Steven Jackson:
Yeah. See, what I like about that is that it's not just conceptual, but it's something that has teeth. It's something that has arms and legs and it has to leave the classroom. There are a lot of theories out there and we talk about race and we talk about bias. We talk about cultural competence and it stays in the theory mode, but this sounds like something that we can apply every day to our own lives and in our practice as well. So, we'll love to hear about it.
Sidney Van Dyke:
And that's become, I would say so in the last several years, when there's really been a racial awakening in this country and people are approaching me more often than ever before to say, what can I do? How can I be better? How can I contribute towards our efforts to work towards health equity? And this model really gives you something to grasp onto. It gives you a starting point and it gives you some forward direction to becoming more interculturally competent. An intercultural competency has gotten a little bit of a bad rap. Just because cultural humility has entered the conversation as well. And I think people have a misunderstanding thinking that cultural humility trumps cultural competency. And I would say that intercultural competence is actually foundational to cultural humility. That when intercultural competence is practiced with cultural humility, that's when you really get transformation to happen.
Steven Jackson:
Yeah. That's an awesome point you bring up, because I've often heard, even if it was implied that the concept of cultural competence is inferior to cultural humility, it's almost like cultural humility in some circles has replaced cultural competence. And there are many reasons for that. I know for me, sometimes I get intimidated when I think about another culture that I know nothing about, and I'm charged with maybe a list of facts that I need to be familiar with so that I can not offend or have an optimal practice setting for all patients and families. But it sounds like what you're saying, if we would simply humble ourselves and kind of go into the situation ready to learn that we're already ahead of the game.
Kari Haley:
And what I really like to, it sounds like with the is model, it's not the thought of cultural competency is very different than what I was taught. Like, you need to know so much about being this specific culture or this specific culture and more about how do you develop the skills to just be open to hearing about those differences, learning about those differences and then putting in the humility of being humble enough to say, I know I don't know everything, but using the skills to learn it.
Sidney Van Dyke:
Exactly. Exactly. So, the continuum itself really plots folks along five different orientations or mindsets along a continuum. So, the first mindset is called denial and simply put, people in denial really miss difference. They tend to live and work in homogenous environments. They don't have a lot of interest in talking about racial diversity or racism or cultural diversity. They're just sort of fine living in the environments that they live in. The next mindset is polarization and polarization is dualistic thinking where there is an over-emphasis on things like racial identity, coupled with strong, strong evaluation or judgment. And it can happen in one of two ways. It can be us them thinking. Why do all of the X, fill in the blank with whatever cultural or racial group you want, do this? But it can also be the reverse of that, where you are basically under critical of the other.
Sidney Van Dyke:
Why aren't we more like that group? And over critical of your own group. So, it's dualistic. So, the first is called defense. My group is better than your group. The second is called reverse. Your group is better than mine, but in both cases it's dualistic thinking. The developmental work of somebody who wants to move from denial into polarization is to just have more access and engagement with difference. But the work of someone in polarization is to equalize criticism. To really think about equalizing criticism and finding common humanity. So, finding more about what we have in common.
Steven Jackson:
Yeah. And it's funny because, I mean, you just said that intercultural competence is the foundation of cultural humility. I think that's what you said. And in order for me to sort of level the playing field, meaning make the judgment equal or make the criticism equal, that requires humility.
Sidney Van Dyke:
It does.
Steven Jackson:
If I'm a person who feels that I come from, say, a dominant and or superior culture, I'm sure there are mindsets out there like that. It's going to take humility to come off of that and say, "Yeah, I need to look at this thing different."
Sidney Van Dyke:
Yep, exactly.
Kari Haley:
And I like that part about the equalizing, too, because I think that with the polarization, people do often go to one extreme to the other when they see one thing. It's black and white. It's like, they're good or they're bad or I'm bad or they're good. But then it's that equalization of saying we're people, we're human. That humanistic piece again that actions are bad, no matter what.
Steven Jackson:
Yeah. Common humanity. I love it.
Sidney Van Dyke:
The third mindset is by far the most common mindset, about 65% of people who take the intercultural development inventory, which is the assessment that helps people understand their starting point on this continuum, as well as how to move forward. About 65% fall within minimization. Simply put, people in minimization really de emphasize difference. They tend to advocate for things like color blind and race, neutral policies. You'll hear them say things like, I don't see color.
Kari Haley:
I was just going to ask you, where does that person lie on the spectrum? Answer.
Sidney Van Dyke:
Firmly within minimization. And I'll talk a lot more about minimization, because I also think that minimization of all of the mindsets is sort of the most deceptive. It's the one in which people feel the most confident that they're doing well and are blind to the ways in which they aren't really intercultural competent more so than in others. And the work in minimization is actually to first and foremost, gain deeper cultural self-awareness before you then also deepen your understanding of culture general and culture specific frameworks. It's the idea of turning a mirror on yourself when you encounter difference.
Sidney Van Dyke:
So, many people when they encounter difference, they say, "Wow. That Hmong colleague of mine has really different beliefs about X, Y or Z about childbirth," for example. "I'm really curious to learn more about why that's so different." What they fail to do is turn the mirror on themselves and say, "What about my cultural background is important when I think about childbirth? What underlies what I value in pregnancy and childbirth?" And so the work in minimization is really to be constantly turning that mirror back on yourself, as well as sort of leaning in with humility and curiosity, to learn more about the other and understand how the lenses you are wearing is affecting the way that you are seeing that difference.
Steven Jackson:
It almost seems like we're trying to define or redefine what's quote unquote "normal" because I know born and raised in America. And that has its own implications, but there are certain things in certain ways, I'm sure that I think based upon the culture that I live in, and if I meet or come across a person from a different culture, I'm challenged to not look at it as their culture is different from mine. There should be, as you said, sort of a collective, should I say, judgment or collective assessment of my culture, as well as the culture that I'm not familiar with, as opposed to me simply looking at things from my own point of view. And I think that might be one of the challenges that maybe we all face and it requires humility.
Kari Haley:
And it is hard to look in the mirror.
Sidney Van Dyke:
It is.
Kari Haley:
I like your analogy of that, because I think it really is so difficult to give yourself a true unbiased assessment of yourself and where you are at. So, yeah, that stuff sounds like a really difficult stuff to actually move past.
Steven Jackson:
Thanks, Sidney. Thanks.
Sidney Van Dyke:
Well, I mean, even when you hear somebody say, "Oh, we have five diverse candidates for this position." Who are they talking about? By saying they are diverse and these other candidates aren't, and they're talking about BIPOC (Black, Indigenous, and other people of color) individuals, they are centering whiteness and attaching difference only to the BIPOC individual, completely unaware that the BIPOC individuals are looking at the whiteness and saying they're different from me. We all have difference. So, that's really the work in minimization is to understand that and spend a lot of time in self-reflection. And then there's another really interesting characteristic. Minimization in non-dominant groups sometimes shows up as a coping or survival mechanism. So, if you are in order to be accepted to gain credibility at work, you are de-emphasizing your accent, de-emphasizing your race.
Kari Haley:
Code switch.
Sidney Van Dyke:
De-emphasizing your gender. Go along to get along. That is minimization and it shows up quite frequently in non-dominant groups.
Steven Jackson:
Wow.
Kari Haley:
That's something to really sit and reflect on, because yeah, I never would've thought of it that opposite way.
Sidney Van Dyke:
So, then we move on down the continuum to acceptance.
Steven Jackson:
I'm speechless here, Sidney. Go ahead.
Sidney Van Dyke:
I'm ready to move on. Steve is still ruminating. So, we're going to move on to acceptance. People in acceptance really deeply comprehend difference. But they haven't necessarily developed the skills to be able to act upon it. They find racial difference interesting yet challenging. They're the ally in word, not the ally in action. So, they're the ones, I think Toweya Brown-Ochs in an earlier podcast that you did shared a story about someone seeing something in a meeting and coming up to her afterwards and saying, "Wow, that must have been really hard for you." Like aware. I get it. The impact on you of that was different maybe than the impact on anyone else in the room, but they didn't speak up in the meeting. They didn't disrupt.
Steven Jackson:
Didn't change behavior.
Sidney Van Dyke:
Exactly. And that often happens because people sort of are dealing with this moral dilemma I don't want to hurt anyone else in the room, it's important to be respectful, yet I see this happening. And so rather than do anything, they are sort of paralyzed. That's a very common theme in acceptance is that people are a little bit paralyzed, aware, unable to act. And then adaptation is really about having developed that skillset to bridge difference. What adaptation isn't, people make this mistake all the time is becoming someone that you aren't. It's about becoming a better version of yourself.
Kari Haley:
I like that.
Steven Jackson:
That's right.
Sidney Van Dyke:
So, it is not about acting in ways that are completely inconsistent with how you normally act when you encounter difference. So, I encounter someone with an accent. It's not about me all of a sudden taking on an accent I don't have. That's called mockery. That's not called adaptation. It's also not about throwing away your values. And this is really, really important. For example, if I'm a physician and I learn that there's a cultural pattern where Somali women are particularly sensitive to being touched on any part of their body by a male. May not be the case with every Somali woman.
Sidney Van Dyke:
Again, great variation with any cultural group, but it's a cultural pattern. I, as a physician, am not truly adapting if I simply decide, I guess I won't touch any more of my patients who are Somali females. You're leaning in with assumptions first and foremost. But second of all, you're throwing your values of caring, the foundation of who you are as a doctor away. And that is not adaptation. Adaptation is about bridging, understanding what can I try that's going to simultaneously hold to myself and respect the values of this patient in front of me?
Steven Jackson:
That's awesome.
Kari Haley:
That is awesome. And I can see how that can be very difficult, because that probably requires a conversation in one that you are both have humility, otherwise things could go astray.
Sidney Van Dyke:
Exactly. It helps me always to kind of play this out with an example. And so I'll use the example of a team from a neonatal intensive care unit (NICU) that's coming together to look at their visitor policy. Now, if this team is primarily made up of folks in denial, they're not talking about difference at all, how people respond to the visitor policy different. They may not even work in a birth center where they have a very diverse population. That's not even on their radar.
Steven Jackson:
There is no difference.
Sidney Van Dyke:
Yes. If the group is primarily in polarization, you're going to hear things in the meetings like, well, they don't respect our policy. They always show up with like 20 family members expecting to get into this NICU when we have to keep the baby safe. That us, them polarized thinking. Moving into minimization, this group would say, we understand that there's difference in the way that people perceive this policy, but we apply it the same way to everyone. And so it is fair and therefore it is fine, but maybe because we see difference in minimization, we might want to translate the visitor policy into a couple of our top languages. Now this group starts to think differently. They're moving towards acceptance.
Sidney Van Dyke:
They start to really understand that the policy may impact some, despite their intent, differently than it impacts others. So, they may see that certain cultural groups for whom introducing the baby to the elders right away is just absolutely so important to them are disproportionately impacted by only being able to have one or two visitors in a NICU, because of safety concerns, but they don't know what to do about that. What do we do? We can't just throw a policy away.
Steven Jackson:
So, that paralysis, I guess.
Sidney Van Dyke:
That paralysis. People in adaptation start to say, how can we hold that idea that value of safety central, but also be more accommodating to this cultural difference that we're seeing? And in the case of the neonatal intensive care team here at Regions Hospital, went out and purchased some great technology that allows me as a mother to give a link to any family members I want so that when I'm in bathing this baby, I can introduce the baby on a video conferencing link, not the greatest thing in the world, but hey, adaptive. And still keeping the baby safe. So, that's just an example that I think how helps illustrate what this continuum looks like at different stages along it.
Steven Jackson:
Sidney, it's no wonder you're the director of health equity.
Sidney Van Dyke:
Yes.
Steven Jackson:
Because you are spitting the knowledge today. And we talk a lot about trust on our podcast and we talk a lot about equity and making sure that, and I'm thinking about the different images and how equity is displayed, whether you have the three folks trying to see the baseball game and each person has just enough boxes to stand on so they all can see. And then you have the others and I won't go into them right now, but it seems like the point is how can we be ... and being true to ourselves, but still be accommodative to all of those that we serve so that everybody can have a great experience. They can have the best possible medical outcomes and walk away, feeling like that they were taken care of. And they were seen, heard, supported, protected, and known. That's equity in a nutshell. And that's ...
Sidney Van Dyke:
And the day that happens, I'm out of a job. And it will be the best day of my life.
Kari Haley:
And I do like how, when you kind of started all of this too, that this model is really applicable to the individual, to the group, to the larger organization, to the world. And each person can be somewhere within that continuum, but also as a group moving forward, no matter, even if the one individual may be somewhere else on the continuum.
Sidney Van Dyke:
Yeah. And research has shown that moving forward isn't just about, OK, I'm aware now. It actually takes intentional hard regular work to move forward. But by using sort of those developmental prompts. Like when I'm in acceptance, it's about practicing, trying different things to develop that skill. And a lot of people think, oh, at adaptation, end of the road, I don't have any developmental opportunities. The real work of people in adaptation is to manage the stress of adaptation. Always having this challenging work of adaptation at the forefront and having other people who are not as far along and the frustration. So, really the work of someone in adaptation is managing that stress personally so that they don't burn out, but also meeting people where they're at, giving them grace but not a path. Helping them develop forward. But it does take intentional work. It's not just about, I know the model, now I'm good.
Kari Haley:
Sit back, clasp the hands, feet up.
Sidney Van Dyke:
Exactly. And so I said earlier that minimization is by far the most common mindset and also the one that I think is most deceptive. One of the reasons it's deceptive is because people in minimization really believe in fairness. We treat everyone the same. They tend to be very tolerant. They do see difference. They're very accepting and they're very well intentioned. But again, that intention does not always equal impact. And I think an example I can give of this, of not turning the mirror on yourself is if you have a team and you recognize that you want to have more diverse voices at the table. And so you go out and you find one of your BIPOC employees and say, "I'm going to have you join this team. We really want to hear your voice."
Sidney Van Dyke:
And you have your first meeting and that person doesn't contribute at all. And I think to myself, hmm, why aren't they contributing? Are they disengaged? I'm going to call them into my office and reemphasize how important it is that they are representing their community. And we want to hear their voice. We need them to speak up in the meeting. Next meeting comes along, person is silent. And so I immediately interpret that with disengagement and I immediately evaluate the situation and replace that person. That's somebody in minimization saying I saw the difference, but through my own lens. I have this little game I play and it's not really a game. It's a tactic that I use frequently where I always ask myself, is there another interpretation of what's happening here?
Sidney Van Dyke:
Could this person have maybe had a really different communication style that I wasn't attentive to? So, maybe they need to process what they're hearing, go back and talk with their more collectivist cultural group to come to consensus and then come back and participate and really represent the larger cultural group. Is this an issue of tokenism? That this person feels like are only on the group as a token and they've shut down because of that. And I look for alternative interpretations not to find alternative truth, but to find doubt, because the minute I find doubt, I have to lean in with greater curiosity and move away from evaluation and judgment, which I think we all tend to run too quickly towards. And I have to learn more about myself and how I've contributed to that poor outcome as well as others.
Steven Jackson:
And you say at the sort of the medicine for those that are in minimalization is self-awareness. So, intentionally and purposefully turning the mirror on themselves or ourselves, wherever we stand on that continuum and work on that self-awareness piece so that we're not just seeing things from our own lens, which is limiting as you know.
Sidney Van Dyke:
Exactly. And it's hard to do. It's hard to ... we don't learn about our own culture in school. We don't learn that Americans tend to be individualistic, direct communicators. Like what? And that there's a whole 'nother way of being out there. And so it takes some work. And one of the tactics you can use is to find someone who is different and to say... I love my team of interpreters, because they come from all over the world and I can say to them, tell me how you experience this in American culture. And they teach me because they've got that sort of objective space that they're in, where they can see American culture in a way that I can't. And that's really helpful.
Steven Jackson:
Wow.
Kari Haley:
I have no words. I mean that's a lot to sit back and absorb, but I really appreciate that leap that you're talking about with minimalism or minimization and then that flipping the mirror. Because like I kind of said earlier, maybe like, I think it's really hard. I think it's a really hard thing to do. And as a parent, you try to teach your children to do those things. Just like, how did you contribute to this? This scuffle on the playground or whatever, but it's so hard to do for ourselves. And especially in the space of this cultural competency where we just are not well versed on it. It's we know how to fight on the playground. We know that there's things that happen. We don't know how to do this. We don't know how to do this cultural competency thing. So, it's really foreign and really hard.
Sidney Van Dyke:
Yeah. One final question that I get a lot about this continuum is, "Well, isn't it just contextual? Doesn't it depend on if I take this assessment at one point, I'm going to be here and at another point I'm going to be here if I'm thinking about this?" And the answer is no and kind of yes. And I like to use a bike riding analogy. When you learn to ride a bike, you don't ever dis-learn that skill. But if you are put in a very different context, so you learned to ride the bike on pavement and now somebody hands you a bike and makes you ride it on the beach, you're going to struggle. You're going to kind of all of a sudden have to re-find your bearings, but you can apply some of the same skills that you used on pavement.
Sidney Van Dyke:
OK. I need to pedal, but I probably need to pedal a little harder in order to learn how to adapt to that particular context, that new context. I had my first child in Indonesia, I'm married to this amazing Indonesian man. And I had spent years in Indonesia learning the culture, working, going to school. I had this culture down. And then I got pregnant and had my first child in Indonesia. And the rules around pregnancy and childbirth culturally are so embedded. Like in every culture they're so strong. And I found myself acting in really sort of polarized mode. Why are they telling me I can't hold my baby on its stomach. This us, them thinking.
Sidney Van Dyke:
And it took a while for me to sort of process the emotion of that new context, having to re-learn that culture, to be able to get back to a place where I was able to adapt to my behavior, but not lose my values. So, when I've got guests over, I'm going to have my baby swaddled and on his back and the minute they leave I'm going to un-swaddle the baby and put him on his stomach so he can gain those muscles. So, again, it's how do you really hold true to yourself while learning how to better interact with difference and commonality?
Steven Jackson:
What would you tell our listeners as we start to close? What's the one or two takeaways that anybody, regardless of where they are on the continuum, what do they need to hear? What do they need to know?
Sidney Van Dyke:
Give yourself and others grace and not a path. Do the work. And know that where you think you are on the continuum is probably further along than you actually are. And so always, if you look at that continuum and say, I think I'm here, look one mindset back and start there.
Kari Haley:
That's really good advice.
Steven Jackson:
That's awesome. Awesome. Well, we just want to say thank you for educating us. My brain is pulsating. I need to ruminate, as you said and process this, but you've given us a lot to think about. I know our listeners appreciate you and all the work that you've doing for the organization and just for our world in general. I think you're making it a little bit better, Sidney. So, we appreciate what you're doing.
Kari Haley:
Thank you so much for being on our podcast and sharing all of this breadth and wealth of information. Something I've never heard before. And hopefully our listeners will be able to take away some of those key points and be able to look in the mirror at themselves and see where they lie and what their next steps are.
Sidney Van Dyke:
Thank you for having me.
Steven Jackson:
Come back anytime.
Sidney Van Dyke:
Really great to have such amazing partners in our collective development.
Steven Jackson:
Yeah. Thanks so much.
Steven Jackson:
Off the Charts is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.