Transcript Document

Cultural Competence Training
of Senior Faculty
Paper Presentation in Supervision and Training
APPIC Friday 4/17/2009 3:00pm -4:30pm
Kathrin Hartmann, Ph.D.
Barbara A. Cubic, Ph.D.
Eastern Virginia Medical School
Cultural Competence Training of Senior Faculty:
Self-Perceptions and Supervisory Experiences
Today’s Educational Objectives
1. Consider areas of needed improvement for senior
faculty in staying current regarding professional
and ethical standards in cultural competence.
2. Utilize an approach to quantitatively measuring
common perceptions of faculty's own awareness,
knowledge, and skills in cultural competence.
3. Describe typical experiences of cultural
dissonance for faculty based on their teaching
and supervising of psychology interns.
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Eastern Virginia Medical
School
EVMS is a community based medical
school founded in 1976 in Norfolk, VA
Norfolk is part of the Tidewater area of
southeastern VA, consisting of 7 cities
with a population exceeding 1.5 million
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The EVMS Clinical Psychology
Internship Program
Program is in the Department of Psychiatry
which has a strong psychology division with 8
full time psychologists on faculty
Internship has existed since1976-77 and has
been APA accredited for 30 years
Accepts 6-8 interns from approximately 120
to 160 applications each year
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Interdisciplinary Integrated
Care Focus
Grant supports internship training focused on
integrated care between the Dept. of Psychiatry
and Behavioral Sciences and the Dept. of Family
and Community Medicine (DFCM)
History of training has been highly successful for
both the interns and DFCM residents
Dr. Barbara Cubic led the way in responding to the
HRSA GPE program to recreate and expand this
training
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Purpose/Rationale of Our
Proposal
Proposal rested on reasons why mental health
disorders are under diagnosed and under treated in
primary care:
The stigma of mental illness
Primary care providers’ limited knowledge of
psychiatric disorders
Confounds created when mental illness coincides
with chronic physical illness
Time constraints for primary care providers
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Purpose/Rationale of Our Proposal
(continued)
The proposal then discussed the rationale for
interdisciplinary training:
Historic separation of medical and psychological
training leading to limited understanding of the
different backgrounds, values, professional models,
and ideologies
Often resulting in redundancy of effort, turf battles,
and mixed, confusing, or negative messages to
patients
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EVMS Grant Objectives
Need to prepare the workforce (psychology
interns and primary care residents) for a
cultural diverse population
Need to educate the existing faculty [both
psychology and primary care] in
multicultural issues in order to prepare the
needed workforce
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EVMS Grant Objectives
Enhanced patient care
Immediate access to mental health
consultation and treatment
Optimal patient-treatment matching
Special exposure to underserved populations
High accountability of services provided
Complete integration of mental health issues
into overall primary care management
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Proposed Educational Model
Designed to teach psych interns the
subtleties of working in primary care while
concurrently fostering education of DFCM
residents
Psych interns placed in the role of
educators, consultants, and service delivery
agents in primary care settings and trained
side-by-side with DFCM residents
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EVMS Grant Methodology
Joint patient care delivery
Additional didactics added to DFCM
seminar series
Joint intensive and collaborative
supervision by Dr. Cubic and DFCM
faculty for both psychology interns and
DFCM residents
Specialized training for faculty in cultural
competence
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Settings for the Training
Morning rounds in an inpatient setting
Consultation in an outpatient primary care
practice
Specialty experiences in settings manpowered by
family medicine
Carefully created opportunities for exposure to
geriatric populations
Focus on insuring that trainees have exposure to a
cultural diverse population
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Patient Population for the
Training
Heterogeneous in respect to age,
ethnicity, and socioeconomic status with
special emphasis on the treatment of
African Americans, elderly, and children
with attention deficit disorders
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EVMS Evaluation Methods
Patient Contact Reports
# of patients seen, # of patients identified with
mental health issue, other relevant tracking data
Pre and Post Physician’s Belief Scales
Trainee Satisfaction Ratings
Patient Satisfaction Ratings
Pre and Post Tests on Knowledge of and
Attitudes about Integrated Care and the
Elderly
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Number of Patient Contacts by Setting
160
140
120
100
80
60
40
20
0
Outpatient
Inpatient
Neurofeedback K.Hartmann
Assisted
Living
/ B. Cubic
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Nursing Home
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Gender Distribution of Patient
Population Across all Settings
Males
36%
Females
64%
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Racial Distribution of Patient
Population Across all Settings
Other
1%
African
American
48%
Caucasian
51%
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SES Distribution of Patient
Population Across all Settings
High
1%
Middle
51%
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Low
48%
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Age Distribution of Patient
Population Across all Settings
>65
39%
<19
16%
19-35
11%
36-50
51-65 16%
18%
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Main Psychosocial Issues
Addressed Across all Settings
Other
16%
Cog Px
11%
Mood D/O
51%
ADHD
14%
Sub Use
4%
Anx
4%
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Gap in Cultural Competence
between Faculty and Trainees
Majority of predoctoral interns (70%) have completed
a formal multicultural course while majority of faculty
(70%) have not. (Constantine, 1997)
Supervisors felt more than their supervisees that they
addressed multicultural issues in supervision (e.g.
related to the supervisory relationship, efforts to
understand their supervisees’ cultural background).
(Duan & Roehlke, 2001).
Supervisees of color may be particularly sensitive to
supervisors’ failures to acknowledge and raise
multicultural issues. (Norton & Coleman, 2003).
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Cultural Competence in Supervision
Significant relationship between supervisors’
multicultural competence and the number of courses
or training experiences the supervisors had (PopeDavis et al. 2003).
Significant relationship between supervisees’ selfreported satisfaction with supervision and the ratings
they assigned their supervisors’ competence (PopeDavis et al. 2000)
Supervisees’ own multicultural competence was a
significant predictor for their ratings of their
supervisors’ competence and their satisfaction with
supervision (Pope-Davis et al. 2003).
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Overview of EVMS
Faculty Training-Sequence
First year: Training of the Psychology
Faculty involved in the Internship Training at
EVMS; Spring and Fall, 3 hrs. workshops with
3 diverse faculty leaders with following lunch
Second year: Training of the Family
Medicine Faculty involved in the Internship
Training; Spring and Fall, 3 hrs. workshops
with 3 diverse faculty leaders with following
lunch
Both years: Obtain Pre- and Post-Workshop
Surveys
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Psychology Faculty
Interests in Survey
Evidenced Based Treatment Approaches for Various Cultural Groups
and Treatment for Specific Groups
LGBT, Developmentally Disabled, Forensics, Asian-Middle EasternAfrican-American-Families, LEP, HIV+, SA and Alcohol Abuse for
Adolescents, etc.
Culturally Competent Clinical Case Conceptualizations
Cultural Differences in
Seeking and remaining in treatment;
Response to psychotherapy and pharmacotherapy
Family values (e.g. in death and dying issues; intercultural
marriages; religion and faith)
Fair Assessment Tools
Practice Concerns and Local Referral Resources
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Content of Cultural Competence Training
Fall 2008
Spring 2009
Psychology Faculty’s own
cultural backgrounds
Mental health disparities
in the US.
Cultural competence and
evidence-based practice
Culturally competent
clinical case conceptualizations
Ingredients of
cultural competent
supervision
Cultural adaptations
for Trainees
Cultural challenging
supervisory situations
for Faculty
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Cultural Competence Training
Educational Objectives: Part One
Define cultural competence as it applies to
our ability to teach and train supervisees.
2. Define areas of improvement for our own
cultural competence as faculty based on the
needs assessment.
3. Discuss cultural competence awareness,
knowledge, and skills that will enhance our
ability to teach and supervise psychology
interns for treating diverse patients
1.
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Example of a Cultural Framework
ADDRESSING by P. A. Hays, 1996
Age and generational influences
Developmental and acquired Disabilities
Religion and spiritual orientation
Ethnicity
Socioeconomic status
Sexual orientation
Indigenous heritage
National origin
Gender
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Evidence-Based Practice and
Cultural Adaptations
Cultural Adaptation: Any modification to an
evidence based treatment to accommodate the
cultural beliefs, attitudes, and behaviors of the
target population that involves changes in
the approach to service delivery or
the nature of the therapeutic relationship or
in components of the treatment itself
Whaley & King (2007)
Examples of Cultural Adaptations for Specific Groups:
http://www.medschool.ucsf.edu/latino
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Evidence-Based Practice and
Cultural Competence
Evidence-Based Treatment: Clearly specified
psychological interventions shown to be
efficacious in controlled research with a delineated
population.
Cultural Competence: Use of the knowledge
acquired about an individual’s heritage and
adaptational challenges to maximize the
effectiveness of assessment, diagnosis, and
treatment.
From: Whaley & King (2007)
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Summary: Should WE use Cultural Adaptations in
our Evidence-Based Practices?
 Both, traditional empirically supported treatments and adapted
interventions are effective with ethnic/racial minority populations
 Treatment variables may be important as well as therapist and
client variables
 Impact of culture may occur in the process of the therapy rather
than the outcome
 Further adaptations will need to be made between each individual
therapist and patient.
Mandate: Multiculturally sensitive and effective therapists are
encouraged to examine traditional psychotherapy practice
interventions for their cultural appropriateness, for example, personcentered, cognitive-behavioral, psychodynamic forms of therapy. They
are urged to expand these interventions to include multicultural
awareness and culture-specific strategies. American Psychological Association (2003)
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Culturally Competent
Clinical Case Conceptualization
1.
2.
3.
4.
5.
Identify and discuss a teaching or clinical
situation that created a cultural challenge
Identify the cultural variables that came into
play in your example
Identify general clinical skills you used
Identify culturally specific adaptations you used
Identify potential areas of growth or need for
additional awareness/knowledge/skills that
would have been helpful in your situation
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Cultural Competence Training
Educational Objectives: Part Two
1. Define culturally competent supervision.
2. Identify common questions and needs of
trainees in culturally competent supervision.
3. Identify a range of common supervisory
approaches to address the trainees' needs.
4. Discuss scenarios and dilemmas from
workshop participants' own experiences of
culturally challenging moments in supervision.
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Triadic Relationships
in Supervision
Client
Supervisor
Supervisee
Clinic
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Multicultural Supervision Models
(Constantine, 2003)
Porter (1994) four stage model to increase multicultural
counseling competence with supervisees of color
Brown-Landrum (1995) Worldview Congruence Model
addresses the supervisor, supervisee, and client triad.
Constantine (1997) Multicultural supervision competence
framework to aid supervisors and supervisees to actively
discuss salient cultural issues in their relationships
Holloway (1997) Systems Approach to Supervision
Robinson et al. (2000) recommend to integrate cultural
concepts into preexisting models of supervision
Ancis and Ladany (2001) Heuristic model of non-oppressive
interpersonal development (MIF’s)
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Working Model of
Culturally Competent Supervision
A Supervisory Situation
that actively creates opportunities
for the supervisor and supervisee to
examine culturally relevant issues
and
that steers the supervisee toward
successful clinical interventions and
solutions with their clients
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Supervision Vignettes
Initial meeting with your new supervisee
What type of supervisee do you feel most
comfortable with?
3. How do you choose patients for your
supervisee?
4. Issues with bias/values/discrimination of
your supervisee
5. How would you address impasses in
supervision
1.
2.
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Culturally Challenging
Supervisory Situations: Our Own
1. Discuss scenarios and dilemmas of our
own experiences of culturally
challenging moments in supervision
(in Small Groups)
2. Bring together solutions and
adaptations based on our experiences
(in Large Group)
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Psychology Interns
Self-Reported Competence
4.5
# of Respondents
4
3.5
3
2.5
2
1.5
1
0.5
0
below 2
2 - 2.5
2.5 - 3
3 - 3.5
3.5 - 4
over 4
Mean Response
Mean
Standard Error
Median
Standard Deviation
Sample Variance
3.56
0.09
3.60
0.23
0.05
Range
Minimum
Maximum
Sum
Count
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0.65
3.3
3.95
24.9
7
38
Highest Self-Reported Competencies
for Psychology Interns
1.
2.
3.
4.
I interact with staff from various cultural
backgrounds. X 4.4
I have received strong clinical training in cultural
competence prior to this stage in my training. X 4.3
I intervene when I overhear disparaging comments
from trainees or staff about cultural stereotypes. X
4.1
I am confident in my supervisor’s level of cultural
competence. X 4.0
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1.
2.
3.
4.
Lowest Self-Reported Competencies
for Psychology Interns
I know how to best intervene with patients
with limited English proficiency. X 2.3
My own values and beliefs do not enter my
professional judgment when making clinical
decisions. X 2.4
I have access to patient resources (e.g.
pamphlets, brochures, and websites) that
depict various cultural backgrounds. X 2.9
I feel prepared to treat any type of
patient/client scheduled with me. X 3.0
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Faculty Self-Reported Competence
Survey Responses
12
# of Respondents
10
8
Mean
3.33
Standard Error
0.113085
Median
3.50
Standard Dev0.542336
iation
Sam ple Variance
0.294128
6
4
Range
Minimum
Maximum
Sum
Count
2.15
2.20
4.35
76.58
23
2
0
below 2
2 - 2 .5
2 .5 - 3
3 - 3 .5
3 .5 - 4
over 4
Mean Response
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Highest Self-Reported Competencies
for Psychology Faculty
1.
2.
3.
4.
I intervene when I overhear disparaging comments
from trainees or staff about cultural stereotypes. X
4.2
I employ staff from various cultural backgrounds. X
3.9
I know about how health disparities apply to various
cultural groups (e.g. access to care, financial
constraints). X 3.9
I am aware how racism, discrimination, stigma, and
bias affect the daily lives of my patients. X 3.8
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Lowest Self-Reported Competencies
for Psychology Faculty
1.
2.
3.
4.
I know how to best intervene with patients with
limited English proficiency. X 2.4
I display materials in the waiting-room from a
variety of cultural backgrounds. X 2.9
I use many verbal examples in my clinical work that
stem from a variety of cultural backgrounds. X 3.0
I am knowledgeable about various help-seeking
behaviors of different cultural groups. X 3.1
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Faculty Self-Reported Competence
Before and After
6
Bas eline
Bas eline
5
Mean
Standard Error
Error on M
# of Respondents
Follow- U p
4
3.41
0.59
0.19
Follow-Up
3
Mean
Standard Error
Error on M
2
3.68
0.47
0.15
1
0
be lo w 2
2 - 2 .5
2.5 - 3
3 - 3 .5
3.5 - 4
o ve r 4
Mean Response
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Survey Differences by Questions
1. Between Faculty and Interns
2. Faculty Baseline and Follow-Up
Total
Q#1 Q#2 Q#3 Q#4 Q#5 Q#6 Q#7 Q#8 Q#9 Q#10 Q#11 Q#12 Q#13 Q#14 Q#15 Q#16 Q#17 Q#18 Q#19 Q#20
s
Faculty 67.9 3.1 3.4 3.4 3.1 3.0 3.9 2.9 3.1 3.5 3.7 3.3 3.4 4.2 3.7 3.7 3.1 2.4 3.8 3.9 3.6
Interns 71.7 3.0 4.0 4.3 2.4 3.1 4.4 3.1 2.9 3.4 4.0 3.6 4.0 4.1 4.3 4.0 3.7 2.3 3.6 3.7 3.7
Totals
Q1-20
Baseline
Follow-Up
Q#1 Q#2 Q#3 Q#4 Q#5 Q#6 Q#7 Q#8 Q#9 Q#10 Q#11 Q#12 Q#13 Q#14 Q#15 Q#16 Q#17 Q#18 Q#19 Q#20
69.6 3.3 3.8 3.3 2.9 2.9 4.0 3.2 3.1 3.6 3.7 3.4 3.7 4.5 3.7 3.6 3.1 2.4 3.8 3.9 3.6
76.5 3.6 4.2 3.5 3.0 3.5 4.0 3.4 3.4 4.1 4.1 4.1 3.9 4.6 4.1 3.9 3.9 2.7 4.3 4.2 4.0
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Typical Needs of Psychology Interns
in Culturally Competent Supervision
Important for supervisors to initiate discussions of
cultural issues due to power differential
Supervisors do not need to have solutions but must
strive to explore their own personal values, cultural
experiences, and cultural biases, and keep expanding
their cultural knowledge and skills
Supervisors should remain mindful not to minimize or
overly magnify cultural differences in supervision to
avoid stereotyping and to be individually effective
with each of their psychology intern supervisees.
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Common Supervisory Approaches
(and Pitfalls)
1.
2.
3.
4.
Not addressing cultural issues at all - using
universal approach as supervision model
Feeling uncomfortable to bring up differences waiting for the psychology intern to bring up
differences about themselves and/or their clients
Addressing cultural issues in supervision only with
psychology interns faculty perceives as different
(e.g. trainees of color or other noticeable
difference)
Tendency to focus on racial and ethnic issues as
most important cultural issues to the exclusion of
other background variables
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Example of on-line Resources
Project Implicit https://implicit.harvard.edu/implicit/demo/takeatest.html
National Center for Cultural Competence
http://www11.georgetown.edu/research/gucchd/nccc/
U.S. Department of Health and Human Services Health Resources and Services
Administration (HRSA) http://www.hrsa.gov/culturalcompetence/
The Provider’s Guide to Quality and Culture
http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=En
glish
Mental Health: A Report of the Surgeon General 1999
http://mentalhealth.samhsa.gov/cmhs/surgeongeneral/surgeongeneralrpt.asp
http://mentalhealth.samhsa.gov/cre/default.asp
Center for Disease Control, Fact Sheets
http://www.cdc.gov/omhd/AMH/factsheets/mental.htm
http://www.cdc.gov/omhd/Partnerships/mhresources.htm
The Henry J. Kaiser Family Foundation www.kff.org/whythedifference
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