Cultural Humility as Listening: The Power of Not Knowing

When I was first starting out as a pediatrician, I worked at a clinic serving a large population of Cambodian refugees. I had yet to be exposed to the vast research and knowledge of the field of infant-parent mental health which at the time was just beginning and largely siloed from pediatrics training. Perhaps my ignorance was a blessing as I listening to story after story with no particular idea of what was “normal.” The clinic had on staff a number of interpreters who served as so much more than language translators. They helped us to support parents who struggled to bridge the two drastically different cultures. The intimate relationship I and my fellow clinicians shared with these Cambodian women-who became not only our colleagues but our friends-was among the most influential experiences of my professional life. They helped us address wrenching issues in a population who had survived terrible trauma in their home country. They invited us to joyous family events in their homes. We attended the engagement party of the arranged marriage of one of their sons, where they generously invited us to join in food, dance, and song. As the experience occurred so early in my development as a clinician, it embedded a natural sense of openness and curiosity.

Fast forward thirty years to my current position as faculty of the University of Massachusetts Boston Infant-Parent Mental Health Program. At the conclusion of the two-year program. in a 4 day long colloquium, I have the exhilarating experience of learning from fellows from a wide variety of disciplines and different stages of their careers from all over the world. Each graduate has 20 minutes to present a project that bring together different aspects of the learning from leading researchers in the field. Inevitably a rich and lively discussion follows. One powerful presentation sticks in my mind. A fellow from a country in South America tearfully shared exposure to attachment theory when she first began studying child development in the United States. The idea that a child has one or even two primary attachment relationships, a concept rooted in the work of John Bowlby, the British psychologist who is considered the father of attachment theory, felt foreign to her. In her culture, a broad range of relationships with a wide variety of community members of different generations was the norm. The frame of “secure” vs “insecure” attachment with a primary caregiver felt deeply shaming to her as she struggled to connect the concepts with her own upbringing. She wept as she shared with the group the relief and joy she experienced when fellowship exposed her to new ways to think about parent-infant relationships.

I thought about her when I worked with a mother from Africa who had been taken from her village as a child and raised in a refugee camp. Now US citizen, she struggled with separation when her 12-year-old daughter went to camp, calling the director every day overwhelmed with anxiety. She explained to me that in her culture children were raised by the whole village. The trauma of her separation from her home translated into behavior that could be called “helicopter parenting” but for her had a very different meaning. Meanwhile, her daughter embraced the separation with joy as she made new friends with whom she shared new adventures. Rather than try to understand this intergenerational experience from the perspective of attachment theory, I saw the more universal experiences of loss and love. This mother’s loss of everything familiar to her as a young child led her to fear the experience of “camp.” She struggled to connect with her American daughter’s relishing of the freedom of growing up.

As a physician in training, I learned the concept “cultural competence.” The term suggested that by acquiring knowledge and information we could become experts in people different from ourselves. The current term “cultural humility” reflects a kind of humbleness of not knowing; a necessary time when we feel awkward and uneasy.

Babies offer a fundamental lesson in the power of not knowing. They enter the world with a unique self, capable of complex communication. Listening to their baby from a stance of flexibility and curiosity, not always “getting” what the baby is communicating but taking the time to figure things out when they are off the mark, caregivers pave the way for social adaptation and the tolerant uncertainty inherent in all social interaction. The ability to find our way into another person’s experience begins to develop when caregivers naturally respond to an infant’s wordless communication. This early experience of being seen and heard builds a primary feeling of connection and belonging. Throughout our lives getting to know each other, especially people different from ourselves, inevitably involves many interactions over time where we miss the mark. Letting ourselves experience the space of uncomfortable uncertainty opens opportunity for meaningful connection.

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