Hernando Gonzales (pseudonym), age 63, incurred a traumatic brain injury to the left and right frontal lobes and the left temporal lobe and a broken right shoulder during a car accident on March 15 of this year. Mr. Gonzales was born and resides in Mexico and was visiting his sister, Maria, for a two month vacation when the accident occurred. This was his first visit to Buffalo, NY, though he has visited Miami, Florida and San Antonio, Texas several times in the past 20 years. Mr. Gonzales has been a widower for 6 months and has four adult children who reside in Mexico. Mr. Gonzales completed ninth grade in Mexico and worked as a security guard at an industrial site. He speaks fluent Spanish and reads and writes Spanish at about a fifth grade level. Although he has taken English emersion classes for several years and his auditory comprehension of English is good, his spoken English is limited. Reading and writing English are basic and inconsistent. He is an ardent soccer fan, enjoys Mariachi music, and attends church on a regular basis.

According to his sister, Mr. Gonzales has a history of hypertension, prostate cancer, and osteo–arthritis. He had a partial knee replacement to the right knee in 2005. He wears corrective lenses that were broken during the car accident, and during the optometric evaluation to replace his lenses, early stage bilateral cataracts were noted. Three years ago Mr. Gonzales was diagnosed with a mild bilateral sensori–neural hearing loss during an employment hearing evaluation but refused amplification.

Following the TBI, Mr. Gonzales made rapid physical recovery. He received intensive occupational and physical therapy for four weeks in a medical rehabilitation unit. Therapies focused on gaining independence in activities of daily living (ADLs). Although Mr. Gonzales made marked improvement in ADLs, he continued to need prompting and reinforcement to initiate and complete activities such as dressing, grooming, and bathing. Cognitive–communicative therapy was also implemented and stressed word retrieval strategies, sentence production related to ADLs, auditory comprehension and verbal expression, and executive skills such as planning, problem solving, and self–evaluation. All therapy stressed the use of English language. Each therapist commented that Mr. Gonzales had difficulty following simple commands given in English and preferred to communicate in Spanish even though only the speech–language pathologist was somewhat fluent in Spanish. He switched between Spanish and English during most informal conversations.

Mr. Gonzales enjoyed inpatient therapies but seemed to want to socialize with other patients and clinicians more than do therapy. Other patients did not understand his overtures spoken in Spanish. Mr. Gonzales became increasingly distracted and uncooperative when tasks involved speaking or understanding English. The female clinicians also noted that Mr. Gonzales infrequently made direct eye contact with them during therapy activities. They were also concerned about some of what they considered inappropriate comments about female patients and therapists. Continued home–care based therapies were recommended at time of discharge. Mr. Gonzales states that he would like to return to his job on a part–time basis when he returns home in several months.

Mr. Gonzales's sister, Maria Lopez (pseudonym) age 70, is also a widow and resides in an apartment with her adult daughter Rose, age 36, who works as an accountant for a national hotel chain. Rose travels frequently for her employment and relies on friends and neighbors from their church to help her mother. Mrs. Lopez speaks only limited English and prefers to communicate in Spanish. Her daughter says that her mother actually understands English relatively well but is "insecure" about her spoken English skills. Mrs. Lopez indicated through her daughter that she does not want her brother sent to a nursing home and will provide care for him on an extended basis. Mrs. Lopez visited her brother almost daily while he was in medical rehabilitation, often bringing him herbal drinks, sweets, and prayer cards. Therapists noted that Mr. Gonzales became more passive when his sister visited, and he expected her to meet his needs. Thus, Mr. Gonzales will reside with his sister for the next three to four months to receive home care therapy before returning to Mexico. His adult children will visit intermittently to help with care but will be available on an irregular basis. Only two speak English fluently.

You are the speech–language pathologist, physical therapist, or occupational therapist assigned to do home care with this patient. You do not speak Spanish fluently but know some social Spanish. Consider the following questions as you prepare to work with this client in his sister's home.

Questions to consider about this case. 1.In reviewing the background information, what cultural, physical, cognitive, communication, and environmental factors would you need to take into consideration in working with this client in a home care situation?
2.How might cultural differences be confused with or compounded by other physical, cognitive, communicative, or environmental characteristics in this case? Why is it important to differentiate cultural differences from those related to the client's other characteristics?
3.What adjustments might you make in both your assessment and intervention based on this client's cultural and linguistic background and his traumatic brain injury?
4.How would you enlist the help of this client's family, particularly his sister, to facilitate therapy? What problems might you have in working with them to enhance therapy effectiveness? References on Working with Hispanic Clients

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Goldstein, B. (2000). Cultural and linguistic diversity resource guide for speech–language pathologists. San Diego: Singular Publishing Group.

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