Marrying Cultural and Clinical Practices: Adapting Clinical Practices to be Inclusive of Cultural Beliefs

Mrs. Ibrahim, a 33-year-old Muslim woman, came to clinic accompanied by her husband and two children, ages 14 and 8, seeking voice therapy services. The family arrived 45 minutes past the appointment time and were surprised when the receptionist explained they would have to reschedule the evaluation because of a strict policy about arriving on time. Mr. Ibrahim explained they were not used to such strict rules about punctuality and would wait in the lobby until there was an opening.  The administrative staff told them this was not possible.

As the family was ready to leave, the staff received a phone call, and because of a last-minute cancellation, Mrs. Ibrahim was able to be seen that afternoon. Mrs. Ibrahim’s husband completed all administrative forms and was the primary interviewee during the intake. He explained that her primary complaint was a complete loss of her voice. When offered an interpreter, Mr. Ibrahim stated that he spoke English fluently and said that his wife knew “enough English to get by.” They shared that the family speaks Punjabi at home.

Mr. Ibrahim explained that their family had relocated to the United States in the last year from Pakistan when he was accepted as a graduate student at a local university. Mr. Ibrahim was concerned because his wife was very healthy until 3 months ago when she developed severe hoarseness and general fatigue. A visit to a physician a few weeks after the onset of her symptoms documented Mrs. Ibrahim’s use of whispered speech, prompting a referral to a speech-language pathologist for a full voice evaluation. Mr. Ibrahim expressed concerns about his wife’s loss of voice affecting her ability to work as an Arabic tutor for university students and her ability to socialize with other Pakistani women in their community. Throughout the interview, when questions were addressed to Mrs. Ibrahim, she gazed toward her husband who would respond for her, and she would nod while looking down. After the initial interview with all family members present, Ms. Carter, the speech-language pathologist, and her male student clinician, Mark, invited Mrs. Ibrahim to accompany them on her own to an examination room.

While in the exam room, a full voice evaluation was completed:

Noninstrumental observations of breathing, posture, and muscle tension were gathered while Mrs. Ibrahim attempted production of sustained vowels at comfortable pitch and loudness, at soft and loud levels, and at low and high pitches. To assess more functional speech, the clinician asked Mrs. Ibrahim to read standard sentences and the Rainbow Passage as well as speak about her voice problem. Mrs. Ibrahim fully cooperated with all requests using a whispered voice.

For the final task of the evaluation, under the supervision of Ms. Carter, Mark politely requested that Mrs. Ibrahim remove her hijab for a manual examination of her neck area. She declined the exam. At that point, Mark explained that the procedure would help the clinicians clarify whether displacement, pressure, and massage of the muscles in the neck area could release any muscle tension that may be contributing to her voice loss. After Mark explained the rationale, Mrs. Ibrahim accepted the explanation and completely removed her hijab.

During the manual examination and trial therapy, Mrs. Ibrahim was able to produce brief, but clear, speech elicited after sustained laryngeal massage. The massage appeared to be effective in reducing some of the extrinsic laryngeal muscle tension that was previously identified and contributed to her aphonia. After the trial, Mr. Ibrahim was asked to join his wife along with Ms. Carter and Mark in the exam room. The results of the evaluation were explained. 

The clinicians reported that Mrs. Ibrahim presented with muscle tension dysphonia as originally diagnosed and that manual circumlaryngeal techniques, including laryngeal massage used in trial therapy, were successful in helping Mrs. Ibrahim produce some voicing. Mrs. Ibrahim was invited to demonstrate her progress in phonating to her husband. Mrs. Ibrahim removed her hijab and demonstrated speech production during the laryngeal massage. Mr. Ibrahim asked the clinicians several questions regarding the treatment. 

Mr. and Mrs. Ibrahim thanked the team, and they scheduled their next appointment before leaving the clinic. The following week, Mrs. Ibrahim missed her clinic appointment. The clinic conducted a follow-up phone call and were notified by Mr. Ibrahim that his wife would not be returning for treatment. Mr. Ibrahim did not share any reasons for this decision.