11. Cross-Cultural Communication in Refugee Health

How can health professionals deal with communication barriers in a resource-oriented and productive way? This chapter looks at a process that concerns not just individual health professionals and persons with refugee experience, but also policymakers and organizations responsible for setting up structures and services in the health system, including refugee organisations.

Communication is the process of exchanging information, ideas, thoughts, and feelings between individuals or groups through various mediums and channels, generating meanings within and across contexts and cultures. It is a fundamental aspect of human interaction and vital to achieve understanding and convey meaning in personal relationships, organizations, and society as a whole. Communication can take various forms (including verbal, nonverbal, written, and visual). Healthcare professionals must get to know their patients by understanding their cultural and linguistic backgrounds to ensure that they provide appropriate care. Effective communication is an essential basis for fostering good interpersonal relationships and significantly enhances the efficacy of service delivery in healthcare, thereby leading to better results and improved goal attainment.

1. The concept of inclusive communication represents a process in which different strategies are applied to allow people with communication vulnerabilities to feel acknowledged and respected in the communication and to become actively involved in society. Consequently, inclusive communication is adapted to the individual communication strengths and needs of the persons seeking information and requires accessible, individualized resources together with appropriate communication partners that have the necessary skills, knowledge, experience, and attitude (Money et al. 2016).
2. The concept of inclusive multilingualism values the interactive strategies or communicative modes applied by participants in multilingual interactions who use different means to achieve mutual understanding (Backus et al. 2013). This recognizes the importance of linguistic diversity and acknowledges that all communication partners contribute to efficient communication. In the context of refugee health this could mean affirming and valuing the patients’ cultural backgrounds, prior experiences and linguistic resources as a contribution to patient agency.

1. Do you know these factors from your own work?
2. Do additional factors need to be taken into account in the area of refugee health?
3. Which strategies could help to address:
   • the ability of persons with refugee experience to access health information and services?
   • the ability of persons with refugee experience to develop a therapeutic alliance with healthcare providers?
   • challenges associated with engaging language interpreters?
   • existing gaps in healthcare provision and improve health outcomes?

The fact that there are different perspectives on counselling underscores this individuality. One such perspective is offered by systems theory, which, generally speaking, assumes that all parts of a system are in contact with each other and work towards a common goal (Forrester 1972: 9). Systems theory aids in abstracting the specifics of a counselling situation while simultaneously allowing for flexible consideration of the characteristics of the client and the counsellor. Hence, systems theory provides an analytical framework for retrospectively analysing counselling scenarios and prospectively preparing for future counselling sessions.

The following overview aims to show how the systems theory approach provides a structured understanding of counselling situations involving people with refugee experience. First, the basic principles of counselling processes are presented (see Figure 11.1 below): the structural coupling of the participants in the counselling process, viability, connectivity, and the experience of difference regarding counselling content. Then, the concepts of perturbation tolerance and contingency are introduced as analytical tools to explore possible resistance and obstacles.

A systemic perspective rarely produces entirely new or unknown insights. Rather, it helps to recognize known but possibly misunderstood mechanisms and patterns of action and communication. This is important because only patterns that are consciously perceived can be reflected upon. Reflection, in turn, forms the basis for learning. Ultimately, a systemic perspective offers professionals the opportunity to further develop their counselling skills.

Basic Aspects of Counselling

Counselling situations vary considerably not only in terms of content but also in person-oriented approaches. Therefore, the counsellor needs explicit skills to address the individuality of each counselling situation. This includes the ability to determine the appropriate amount of technical content to provide and the level of support needed to enable clients to develop self-learning skills.

In general, in any counselling situation, those who seek counselling and those who provide counselling are of particular importance. In addition, the specific context of the counselling situation needs to be taken into account.

The differences among those seeking counselling, i.e., the clients, are apparent. Each individual has a unique biography, which also encompasses their own counselling biography, including personal experiences with situations in which they have initiated or attended counselling. Additionally, the client’s biographical knowledge includes insights into the subject of the counselling, as well as their own interests and inclinations. The same is true for those who provide counselling, i.e., the counsellors. They also have experience and knowledge, such as an understanding of which approaches have proven beneficial or obstructive in various situations for different clients.

Counsellors must continually reflect on whether they are being approached in their formal, professional capacity or whether they are dealing with a more informal request. In both cases, they should clearly identify their respective role and clarify it with the client. However, it should be borne in mind that individuals seeking counselling in a professional context will often assume that the counsellor is acting in a professional capacity, even in informal settings, despite the counsellor making it clear that they are speaking outside their professional remit or expressing their personal opinion. For the benefit of those seeking advice, professionals should err on the side of caution and refrain from making statements outside their professional scope in such situations.

With respect to the specific context of the counselling situation, the various media that can be employed will be briefly addressed. For example, it is important to distinguish whether the information in the counselling session is presented orally or in writing. If written information is used, it is essential to ascertain whether the available documents are tailored individually for the client or whether a general information brochure is used. In the case of verbal counselling, for example, distinctions must be made between face-to-face meetings, telephone calls, or video calls. Additionally, the necessity for interpreting services for language mediation is a relevant consideration. Each of these setups brings its own relevant aspect to the counselling process. For example, if a general information brochure is used, it is important to assess whether their content adds value for the specific client in the given counselling context, or whether it might actually be more of a hindrance. Counselling based on the maxim ‘more is better’ is only beneficial in the rarest of cases. In the scenario of consultations conducted via video calls, the skills and technical equipment of all participants need to be taken into account. Depending on the tools and telephone network used, the quality of communication may be unreliable. Each of these factors can lead to significant disruptions, particularly at the onset of the consultation, when the counsellor and client are becoming acquainted with each other.

This brief overview of the relevant aspects of explicit and implicit counselling, whether by professionals or laypersons, the biographical backgrounds of counsellor and client, and the different media used, illustrates the complex nature of counselling. The perspectives on and descriptions of counselling situations are as varied as counselling itself. A systemic perspective is adopted here to analyse counselling scenarios in general, and specifically with persons with refugee experience. The systemic approach allows for the identification of underlying patterns, while at the same time allowing for a detailed examination of specific situations. This analytical framework facilitates both retrospective analysis of past counselling scenarios and prospective preparation for future sessions.

In the following, we will frequently refer to the client, i.e., the person seeking counselling, and the counsellor, i.e., the person providing it, in order to succinctly identify the two main roles in a counselling session: the one seeking an answer and the one assisting in finding that answer. In the following sections, we will explain why counsellors should be cautious about ‘giving advice’, and instead see themselves as companions on the client’s journey of seeking advice.

In a systemic approach, individuals are regarded as self-contained systems that are initially closed to all external influences, including interactions with other people. This approach is based on self-reference, which is characteristic of all closed systems (Luhmann 1985: 403). In humans, statements such as “I’m fine the way I am” or “Why should I learn anything new? I’m fine the way I am” exemplify this concept. Similarly, people seeking advice may express sentiments such as “What can this person tell me that I don’t already know?” or “What qualifies this person to be an expert in my situation (or in my life)?”. Individuals initiating a counselling situation or seeking answers often adopt these or similar attitudes. Conversely, counsellors can use this self-reference to adopt perspectives such as “The way I counsel is the right way to counsel” or “Why won’t the client understand what I’m explaining?”. When such positions dominate the counsellor’s actions, they clearly get in the way of focusing on the client’s needs.

Another consequence of the closed nature of such systems in relation to external influences is that they can only be observed from the outside. Luhmann (1985: 405) describes this phenomenon as a “black box”, explaining that this lack of transparency is often compensated for by assuming that the processes and decision-making patterns in other systems are comparable to one’s own. Applied to counselling situations, this means that counsellors perceive the actions or words of the clients without recognizing the actual intentions behind them. The counsellor will automatically seek explanations for what has been said that are consistent with their own perspective. To counteract this automatic tendency—especially when understanding the reasons behind the statements is crucial—the counsellor should rely less on their own biased perceptions and instead inquire directly from the client. However, even explanatory words are open to interpretation, so the counsellor can only judge whether the explanations seem coherent. A clear assessment of the inner decision-making patterns is therefore not possible.

From a systems theory perspective, this isolation from external influences can be broken through structural coupling with another system (another person) (Maturana & Varela 1984: 85). The basis of such a coupling is primarily the common interests and common goals of those involved (Siebert 2009: 95).

Basic common goals in counselling may include the desire to solve a problem, clarify a situation, or obtain an answer to a question. Conversely, unsolicited or unintentional counselling initiated by the counsellor is likely to lack these basic elements. It is possible that the other person, not yet in the role of the client, may develop an interest in the proposed topic through the counsellor’s initiative, but this requires at least some common interests. Without common interests and goals, it is highly likely that the systems will remain metaphorically side-by-side without structurally binding. In such cases, the counsellor’s content may, metaphorically speaking, ‘bounce off’ the (non-)client and miss its target, while the counsellor might assume that the information has been received. Common interests may relate to the content of the counselling or to aspects independent of it, provided they are comparable for the people involved. The interests of the counsellor and the client must be aligned. This phenomenon explains why individuals with questions about their health situation or healthcare often trust the advice of someone they know more than that of medical specialists or therapists who, despite their professional competence, are initially unknown to them. This trust can only develop once a sustainable structural coupling, based on common goals and interests, has been established. It is important to note that longer-established structural couplings are likely to be more intense and resilient. In conflict situations or when faced with contradictory information, this may mean that clients are more likely to trust those with whom they have long-standing structural couplings, regardless of their professional qualifications.

The existence of a common language is highly relevant to the establishment of structural coupling. Without a common set of signs, it is far more difficult to find common goals or interests. One way to mitigate this is to involve interpreters. The interpreter must be structurally coupled with all parties in the counselling system. In practice, there is often an acquaintance gap; either the client or the counsellor already knows the interpreter. Both lack of acquaintance and well-established connections can have a negative impact on the transfer of information. If the structural coupling is weak, the interpreter may not be trusted; if the structural coupling is strong, the interpreter may be reluctant to convey the real content and instead present what they personally believe to be valid. Regardless, bias remains inevitable, for example due to time lags between non-verbal and verbal aspects of communication or potential mistranslations due to misinterpretation of the content of the consultation.

In general, if there are common goals and interests, possibly supported by additional commonalities such as a common language, structural coupling can be successfully initiated, laying the foundation for counselling. In this case, the participants form a new system or counselling system that is distinct from the environment. It is crucial that both the counsellor and the client remain unchanged and independent within this new system; they are only connected through the structural coupling that has been formed (Becker & Reinhardt-Becker 2001: 65).

Despite these challenges, changes can either weaken or, in extreme cases, break the initially strong structural coupling, ending the counselling system. Counsellors must therefore continuously monitor the current coupling during the counselling process and recognize or inquire about changes in the client’s goals and interests.

Making Counselling Content ‘Palatable’ for the Client: Viability, Connectivity and Experience of Difference

Establishing a sustainable structural coupling based on common interests and goals is the basis for, but not a guarantee of, successful counselling. Another element to consider is the viability of the counselling content. In systems theory, viability is defined as content that appears relevant, meaningful, or feasible to the client (Glasersfeld 2012: 30). This can be quite challenging for the counsellor. This is especially the case when the counsellor has not only the necessary skills for person-centred counselling but also professional skills in the respective counselling context. It is easy to explain what is relevant and important from the perspective of a knowledgeable person. However, this content may be of little or no relevance to the client. Information that is not relevant for the client is ignored and, to use another metaphor, bounces off the outer shell of the client’s closed systems.

The counsellor should filter out aspects that are likely to be relevant. It may be helpful to ask questions first, for example, about the reason for seeking the advice and the exact interest in knowledge, before answering questions quickly. In addition to a clarifying viability, the client’s goals can also be specified, and if the counsellor agrees with the goals, the structural coupling can be further strengthened.

If counselling content is connectable, it is more likely to be integrated into the client’s knowledge network (Arnold 2007: 69). However, connectivity can also result in content from counselling sessions being connected to content other than that intended by the counsellor. It is up to the counsellor to check as best as possible whether the information given has actually been ‘received’. This can be done, for example, by asking follow-up questions or by reviewing the action steps resulting from the counselling. However, there is no definitive certainty. The client alone decides whether and where counselling content is linked to existing knowledge.

One aspect that determines whether counselling content is connected, is the answer to the question “Do I already know this?”. If the information is already known to the client, i.e., if it does not represent sufficiently an experience of difference from the client’s own knowledge, it will also bounce off the outer shell—to stay with the metaphor. What is labelled as “I already know!” is also decided exclusively by the client. In the case of counselling systems that extend over several sessions, the challenge in relation to the experience of difference is for the counsellor to make sure of the client’s current status at the beginning of each session. This is not only useful to ensure the appropriate difference in the counselling content, but also helps to review the objective and thus the viable counselling content.

During counselling, counsellors walk a tightrope between content that is compatible, i.e., as close as possible to the client’s existing knowledge, and a lack of experience of difference on the part of the client, i.e., when the content is ‘too close’ or in line with what the client already knows. At the same time, it is always important to look back at the goals that have been set, i.e., to ascertain whether the current path can lead to the agreed goal. This is the only way to ensure the relevance, i.e., the viability, of the current counselling content.

One conclusion to be drawn from the tension described above is that counsellors should give as little advice as possible, but instead support clients in finding the information they need themselves or deriving it from the known and the unknown. When clients are actively involved in achieving the goal and help shape the process and content, it can be assumed that aspects that lack viability or connectivity will often be directly excluded. Information that offers clients too little experience of difference is also unlikely to be included. This type of accompanying advice requires a high degree of flexibility from the counsellor and, if possible, a willingness to accompany people along paths to solutions that the counsellors themselves would not have chosen on the basis of their own experience. Ultimately, it’s about finding content that is connectable and offers an experience of difference. A practical tip could be ‘listen and ask questions’. On the other hand, this does not mean that the counsellor should sit back and ‘let the client do everything’, which would most likely also have a negative impact on the structural coupling. The responsibility for the process and the design counselling remains with the counsellor.

New Information as a Disturbance of the Known: Perturbation Tolerance of the Clients

Section 2 on structural coupling has already described how external stimuli to closed systems are initially perceived as disturbances—systemically: perturbations—and, metaphorically speaking, bounce off the outer shell of the system. Information, such as that perceived during counselling sessions, is also a stimulus and initially has a perturbing effect. However, as Section 3 has shown, counselling content can be integrated into the client’s knowledge network, provided that it is viable for them, designed to be connectable, and offers an experience of difference. The basic prerequisite for this is the structural coupling of all relevant participants.

Even if the perturbing effect can be minimized in individual cases through high-quality structural coupling as well as viable and connectable content, the counselling content still remains disruptive to the client’s system. In addition to the counselling content itself, all other stimuli in daily life also have a perturbing effect. This means that counselling can also lead to double perturbation.

Firstly, the individual counselling content perturbs the client’s system. If the new content is connected and changes behaviour, further perturbations may arise due to reactions from the client’s environment. Unfortunately, it is not possible to make a general statement as to whether an early indication in the context of counselling, in the sense of ‘Be prepared for the fact that your environment might react if you change your behaviour’, has a mitigating effect on the expected perturbations. On the one hand, clients are prepared for reactions that are new and perturbing for them; on the other hand, this may lead to the new elements not being integrated at all or being integrated differently into their behavioural patterns, which may lead to different feedback or reactions from the environment.

The reference to the family illustrates another aspect of perturbation tolerance, which has already been described in connection with structural coupling: people from the client’s environment, such as family members, may also be relevant to the counselling process although they are not directly involved in it. This is partly due to the structural coupling that the client has with these people. In addition, their perturbation tolerance may directly or indirectly influence the client’s potential for change. For example, clients may be ready for the changes initiated by the counselling, partly due to a high tolerance of perturbation, while their (family) environment may react negatively, possibly due to a low tolerance of perturbation. For instance, the client may want to undergo a specialist (preventive) medical examination as a result of the counselling they have received, but refrain from doing so because of negative reactions from their personal (family) environment. The more strongly the connection between the client and their environment is anchored in the client’s biography, the more likely it is that the client will take into account the needs of others and postpone their own changes. Through such connections, people from the client’s wider environment, who may be unknown to the counsellor, can also be highly relevant to the design of the counselling, highlighting the importance of attentive inquiry and questioning of the context.

In the case of counselling sessions that involve several individual meetings, counsellors should be prepared for such situations and should also question possible patterns of client response that may result from these causes.

In conclusion, it should be noted that the level of perturbation of each individual piece of information, i.e., each stimulus, is just as variable as the amount of perturbations a person can ‘tolerate’ before their own perturbation tolerance is exceeded and they tend to reject new content across the board, regardless of connectivity or viability. In addition, perturbation is highly dependent on topic and situation. Finally, counsellors must always bear in mind that the counselling situations are only a part of the perturbations to which clients are exposed on a daily basis.

A Person’s Scope of Action Determines the Integration of the New: The Contingency of the Clients Seeking Advice

In the context of connectivity, one aspect has already been mentioned in a previous section and will be discussed in more detail in this section: clients connect new content to their own knowledge network in a way that seems reasonable or viable from their point of view. These alternative courses of action are also called contingencies (Willke 2006: 249). In other words, one’s own contingency determines whether, how, and where new content is integrated into one’s own knowledge network and, moreover, what effect this information has and whether, and if so, how it changes one’s own actions. The contingencies of the participants in a counselling system differ, and actions or reactions may seem surprising or irritating to the other participants, even though they seem perfectly logical and consistent to the person involved.

In a counselling system, this effect is particularly noticeable when clients, due to their contingency, connect information in unexpected ways, resulting in seemingly illogical actions. From a systemic point of view, however, these actions are not wrong but rather logical, at least for the actors, i.e., the clients. Counsellors need to adapt to this unpredictability of reactions and evaluate them individually.

One evaluation criterion is whether the client’s reaction counteracts the agreed goal or represents a potential solution. This requires a high degree of flexibility, as it is not about the path the counsellors themselves would take, but about a path that the clients consider relevant for them. Depending on the outcome of this assessment, a (corrective) response may be necessary or a change in the counsellor’s own solution may be required.

Another assessment criterion is the client’s perturbation tolerance, as described in the previous section. If, in the counsellor’s opinion, this tolerance is exhausted, the counsellor’s own reaction should be assessed with particular sensitivity to possible disturbance of the structural coupling.

Given the above arguments, it seems logical that the ability to assess the contingency of the clients as accurately as possible is particularly relevant for counsellors. On the one hand, it helps if the counsellor has experience of counselling on comparable issues or people in comparable contexts. On the other hand, the duration of the counselling is important. If it takes place over several sessions, experience from previous sessions can be transferred to the current session. However, counsellors should always be prepared for the unexpected. Contingencies may change over the course of a series of counselling sessions, or even within a single session. Ultimately, there should even be changes within the contingency, as the implicit goal of counselling is often to change the client’s scope of action, i.e., the contingency.

Each counselling situation and each client must be considered individually. No matter how much experience the counsellor has, the client’s contingency remains a black box.

What Is the Benefit of a Systemic-Constructivist Approach to Counselling in Refugee Health

Overall, counsellors should be seen more as facilitators in the counselling process. Once the goal has been set and the establishment of structural coupling has begun, it is beneficial for the clients themselves to discover the viable aspects and identify the appropriate content. This approach helps to mitigate the risk of a lack of exposure to experience of difference, as the clients can directly reject non-viable information and move on to more appropriate content. Counsellors should act as companions in this process, respecting the autonomy of the clients and supporting them on their individual paths to the agreed goal, possibly providing guidance or helping to structure complex contexts.

This more reserved role can be particularly difficult for counsellors, especially if they believe, perhaps from years of experience, that the path chosen by the client may not lead to the desired goal. It requires a great deal of flexibility and courage to suggest possible paths and then to accept if the client chooses a different one.

As a consequence, asking questions is more important than ‘giving advice’. It is never about asking ‘why?’ with an implicit demand for justification, but about understanding the client’s current situation and biography. This understanding is one of the keys to person-centred counselling: on the one hand, the biographical context provides the basis for the client’s scope of action and starting points for new information. On the other hand, the current situation provides clues to other relevant people who should also be involved in the counselling process through structural couplings.

When asking questions, the aspect of observation, already mentioned in connection with structural coupling, must be considered. Closed systems can only be observed from the outside. Applied to the counselling system, this means that counsellors can never be sure that clients’ responses are not primarily tailored to what they believe is appropriate for the situation. When counsellors are on an official, regulatory mission, clients, especially those with refugee experience, may draw on patterns of interaction with officials in their home countries. This can lead to disruptions in structural coupling or in the connectivity of counselling content.

The quality of the counselling can be assessed by counsellors on the basis of correctness, for example in terms of regulatory or scientific evidence. However, this is of much less importance in systemic counselling. The quality assessment is more likely to be done by the clients. Criteria here could include aspects such as suitability for everyday life and a focus on participation. These are far more subjective than technical, content-related criteria. For example, a counsellor may have ‘done everything right’, but the counselling was not found helpful by the client. In evaluating their own performance, counsellors should rely on the clients’ feedback and accept their ‘judgment’. This requires the ability, energy, and willingness to continuously question, reflect on, and adapt one’s own counselling skills. In essence, it is not just about content or professional skills, but also about person orientation. Person orientation involves creating and maintaining resilient counselling systems through sustainable structural linkages and developing skills to accompany clients in their search for solutions, for example through topic structuring and follow-up questioning techniques.

Setting Up Culturally Responsive Structures and Services

If patient care is to take into account the cultural backgrounds of patients from the perspective of self-determination and equity, appropriate structural conditions must be created. Without suitable structures and space to implement measures, even culturally responsive staff cannot act effectively. Uniform, universally applicable structures must be created at all organisational levels in which culturally responsive patient care is standard (Peters et al. 2014). Measures should include improving workforce diversity, conducting structural analysis, and ensuring competence in planning, policy formulation, and practice (Spitzer et al. 2019). The scoping review by Grandpierre et al. (2018) found that patients and caregivers expressed an appreciation for services that incorporated cultural awareness into practice protocols. This involved services that used culturally appropriate materials and tailored care to meet their needs. Another recommendation was extending the appointment times for patients who do not speak the service language.

The main policy and practice considerations based on the findings of this review in the WHO European Region are to:

These recommendations underscore that effective cross-cultural communication in healthcare can only be guaranteed if the necessary measures and strategies are implemented at the macro, meso, and micro levels. However, the HEN report also shows that knowledge of a wide range of successful interventions at these three levels already exists. These interventions have been tested and evaluated in practice, and can be utilized by others to minimize the negative effects of communication barriers experienced by persons with refugee experience.

Effective and Respectful Communication in Patient Care across Language Barriers

In addition, according to the review by Grandpierre et al. (2018), patients and caregivers emphasize the significance of their relationships with healthcare practitioners and the need for collaborative partnerships within those relationships. They value practitioners who share information about their lives, including social, cultural, and historical aspects. Patients and caregivers also express the importance of having a consistent therapist to facilitate long-term relationships. It is often beneficial when the practitioner shares a similar cultural background or gender, as they may be perceived as more familiar with cultural taboos. However, it is worth noting that some patients also express concerns about maintaining confidentiality within their communities when such facilitators are present (Grandpierre et al. 2018).

In situations where refugees and staff are under pressure, maintaining a friendly, patient, and attentive demeanour may prove challenging. Various factors, such as anger, insecurity, fatigue, and pre-existing prejudices, can impede refugees’ ability to express themselves, while also hindering staff members’ active listening and respectful actions. Additionally, the power imbalance between refugees and staff can limit open communication, create unrealistic expectations, and heighten tensions (UNHCR n.d.).

Whereas interpreters are typically only responsible for verbally translating spoken information from one language to another, cultural mediators facilitate mutual understanding by also providing advice on cultural understandings of healthcare issues. According to McGarry et al. (2018) cultural mediation has three main components: language interpretation, a responsibility to mediate cultural differences or facilitate intercultural communication, and knowledge about a specific healthcare topic or health service.

As the European review by McGarry et al. (2018) highlighted, strategies were often put into action by teaming up people from different areas, like healthcare providers, community organizations, and academic institutions. These worked together to come up with plans that could be implemented in one place or spread across a whole region. Evaluation of these strategies showed in most cases that refugees and migrants gained better knowledge about health, improved their health habits, and got easier access to healthcare services. This shows how crucial it is for different sectors to collaborate and for regional and local authorities to create and carry out official plans that tackle communication issues faced by refugees and migrants in healthcare settings throughout the area.

Exercise: Interprofessional Collaboration to Prepare Information Material

Working in small interprofessional teams, participants will be asked to create posters that address different aspects of cross-cultural communication in refugee health. These posters should encapsulate the perspectives of the different professions represented in each team, using strong visual elements (such as pictograms) and minimal text. The posters will then be presented during the plenary session, where participants will explain their design choices.

Key topics for consideration include:

Altorfer, Andreas, Käsermann, Marie-Louise (2021). ‘Die Bedeutung des Nonverbalen in der Kommunikation,‘ [The Importance of the Non-verbal in Communication] in Transkulturelle und transkategoriale Kompetenz: Lehrbuch zum Umfang mit Vielfalt, Verschiedenheit und Diversity für Pflege-, Gesundheits- und Sozialberufe [Transcultural and transcategorical competence: Textbook on the scope of diversity for nursing, health and social professions], ed. by Dagmar Domenig. 3rd, completely revised and expanded edition (Bern: Hogrefe).

Arnold, Rolf. 2007. Ich lerne, also bin ich, Eine systemisch-konstruktivistische Didaktik [I Learn, Therefore I Am: A Systemic-constructivist Didactics] (Heidelberg: Carl Auer, 2007).