kathrin hartmann, ph.d. barbara a. cubic, ph.d. eastern virginia medical school

Cultural Competence Training of Senior Faculty

Paper Presentation in Supervision and Training

APPIC Friday 4/17/2009 3:00pm -4:30pmKathrin Hartmann, Ph.D.Barbara A. Cubic, Ph.D.

Eastern Virginia Medical School

K.Hartmann / B. Cubic APPIC April 17, 2009

2

Cultural Competence Training of Senior Faculty: Self-Perceptions and Supervisory Experiences

Today’s Educational Objectives1. 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.


3

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


4

The EVMS Clinical Psychology Internship

ProgramProgram 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


5

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 residentsDr. Barbara Cubic led the way in responding to the HRSA GPE program to recreate and expand this training


6

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 disordersConfounds created when mental illness coincides with chronic physical illnessTime constraints for primary care providers


7

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


8

EVMS Grant Objectives Need to prepare the workforce (psychology interns and primary care residents) for a cultural diverse populationNeed to educate the existing faculty [both psychology and primary care] in multicultural issues in order to prepare the needed workforce

K.Hartmann / B. Cubic APPIC April 17, 2009 8


9

EVMS Grant ObjectivesEnhanced patient careImmediate access to mental health consultation and treatmentOptimal patient-treatment matchingSpecial exposure to underserved populationsHigh accountability of services providedComplete integration of mental health issues into overall primary care management


10

Proposed Educational Model

Designed to teach psych interns the subtleties of working in primary care while concurrently fostering education of DFCM residentsPsych interns placed in the role of educators, consultants, and service delivery agents in primary care settings and trained side-by-side with DFCM residents


11

EVMS Grant MethodologyJoint patient care deliveryAdditional didactics added to DFCM seminar seriesJoint intensive and collaborative supervision by Dr. Cubic and DFCM faculty for both psychology interns and DFCM residentsSpecialized training for faculty in cultural competence


12

Settings for the TrainingMorning rounds in an inpatient setting Consultation in an outpatient primary care practice Specialty experiences in settings manpowered by family medicineCarefully created opportunities for exposure to geriatric populationsFocus on insuring that trainees have exposure to a cultural diverse population


13

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


14

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 ScalesTrainee Satisfaction RatingsPatient Satisfaction RatingsPre and Post Tests on Knowledge of and Attitudes about Integrated Care and the Elderly


15

Number of Patient Contacts by Setting

020

406080

100120140160

Outpatient Inpatient Nursing HomeNeurofeedback Assisted Living


16

Males36%

Females64%

Gender Distribution of Patient Population Across

all Settings


17

Caucasian51%

African American

48%

Other1%

Racial Distribution of Patient Population Across

all Settings


18

Low48%Middle

51%

High1%

SES Distribution of Patient Population Across all

Settings


19

<1916%

19-3511%

36-5016%51-65

18%

>6539%

Age Distribution of Patient Population Across all

Settings


20

Mood D/O51%

Anx4%

Sub Use4%

ADHD14%

Cog Px11%

Other16%

Main Psychosocial Issues Addressed Across all

Settings


21

Gap in Cultural Competence between Faculty and TraineesMajority 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).


22

Cultural Competence in Supervision

Significant relationship between supervisors’ multicultural competence and the number of courses or training experiences the supervisors had (Pope-Davis et al. 2003). Significant relationship between supervisees’ self-reported satisfaction with supervision and the ratings they assigned their supervisors’ competence (Pope-Davis 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).


23

Overview of EVMS Faculty Training-

SequenceFirst 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 lunchSecond 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 lunchBoth years: Obtain Pre- and Post-Workshop Surveys


24

Psychology Faculty Interests in Survey

Evidenced Based Treatment Approaches for Various Cultural Groups and Treatment for Specific Groups

LGBT, Developmentally Disabled, Forensics, Asian-Middle Eastern- African-American-Families, LEP, HIV+, SA and Alcohol Abuse for Adolescents, etc.

Culturally Competent Clinical Case ConceptualizationsCultural Differences in

Seeking and remaining in treatment; Response to psychotherapy and pharmacotherapyFamily values (e.g. in death and dying issues; intercultural marriages; religion and faith)

Fair Assessment Tools Practice Concerns and Local Referral Resources


25

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 concep-tualizations

Ingredients of cultural competent supervision Cultural

adaptations for Trainees Cultural

challenging supervisory situations for Faculty


26

Cultural Competence Training Educational Objectives: Part One 1. 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


27

Example of a Cultural Framework ADDRESSING by P.

A. Hays, 1996Age and generational influencesDevelopmental and acquired DisabilitiesReligion and spiritual orientationEthnicitySocioeconomic statusSexual orientationIndigenous heritageNational origin Gender


28

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

http://www.medschool.ucsf.edu/latino

http://www.medschool.ucsf.edu/latino


29

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)


30

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, person-centered, 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)


31

Culturally Competent Clinical Case Conceptualization

1. Identify and discuss a teaching or clinical situation that created a cultural challenge

2. Identify the cultural variables that came into play in your example

3. Identify general clinical skills you used4. Identify culturally specific adaptations you used 5. Identify potential areas of growth or need for

additional awareness/knowledge/skills that would have been helpful in your situation


32

Cultural Competence Training Educational Objectives: Part

Two1. 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.


33

Client

SuperviseeSupervisor

Clinic

Triadic Relationships in Supervision


34

Multicultural Supervision Models

(Constantine, 2003)Porter (1994) four stage model to increase multicultural

counseling competence with supervisees of colorBrown-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 SupervisionRobinson et al. (2000) recommend to integrate cultural

concepts into preexisting models of supervisionAncis and Ladany (2001) Heuristic model of non-oppressive

interpersonal development (MIF’s)


35

Working Model of Culturally Competent

SupervisionA 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


36

Supervision Vignettes1. Initial meeting with your new supervisee2. 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 supervisee5. How would you address impasses in

supervision


37

Culturally ChallengingSupervisory Situations: Our

Own1. 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)


38

Psychology Interns Self-Reported Competence

Mean 3.56 Range 0.65Standard Error 0.09 Minimum 3.3Median 3.60 Maximum 3.95Standard Deviation 0.23 Sum 24.9Sample Variance 0.05 Count 7

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

below 2 2 - 2.5 2.5 - 3 3 - 3.5 3.5 - 4 over 4Mean Response

# o

f Re

spon

dent

s


39

Highest Self-Reported Competencies for Psychology Interns

1. I interact with staff from various cultural backgrounds. X 4.4

2. I have received strong clinical training in cultural competence prior to this stage in my training. X 4.3

3. I intervene when I overhear disparaging comments from trainees or staff about cultural stereotypes. X 4.1

4. I am confident in my supervisor’s level of cultural competence. X 4.0


40

Lowest Self-Reported Competencies for Psychology Interns

1. I know how to best intervene with patients with limited English proficiency. X 2.3

2. My own values and beliefs do not enter my professional judgment when making clinical decisions. X 2.4

3. I have access to patient resources (e.g. pamphlets, brochures, and websites) that depict various cultural backgrounds. X 2.9

4. I feel prepared to treat any type of patient/client scheduled with me. X 3.0


41

Faculty Self-Reported Competence Survey Responses

0

2

4

6

8

10

12


# o

f R

espo

nden

ts Mean 3.33 Range 2.15Standard Error0.113085 Minimum 2.20Median 3.50 Maximum 4.35Standard Deviation0.542336 Sum 76.58Sample Variance0.294128 Count 23


42

Highest Self-Reported Competenciesfor Psychology Faculty

1. I intervene when I overhear disparaging comments from trainees or staff about cultural stereotypes. X 4.2

2. I employ staff from various cultural backgrounds. X 3.9

3. I know about how health disparities apply to various cultural groups (e.g. access to care, financial constraints). X 3.9

4. I am aware how racism, discrimination, stigma, and bias affect the daily lives of my patients. X 3.8


43

Lowest Self-Reported Competenciesfor Psychology Faculty

1. I know how to best intervene with patients with limited English proficiency. X 2.4

2. I display materials in the waiting-room from a variety of cultural backgrounds. X 2.9

3. I use many verbal examples in my clinical work that stem from a variety of cultural backgrounds. X 3.0

4. I am knowledgeable about various help-seeking behaviors of different cultural groups. X 3.1


44

Faculty Self-Reported Competence Before and After

0

1

2

3

4

5

6


# o

f R

espo

nden

ts

Baseline

Follow-Up

BaselineMean 3.41Standard Error 0.59Error on M 0.19

Follow-UpMean 3.68Standard Error 0.47Error on M 0.15


45

Survey Differences by Questions 1. Between Faculty and

Interns2. Faculty Baseline and Follow-Up

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 3.6Interns 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

Q#19 Q#20Q#14 Q#15 Q#16 Q#17Q#11 Q#12 Q#13 Q#18Q#7 Q#8 Q#9 Q#10Q#3 Q#4 Q#5 Q#6Totals

Q#1 Q#2

Baseline 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 3.6Follow-Up 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

TotalsQ1-20 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#20Q#16 Q#17 Q#18 Q#19


46

Typical Needs of Psychology Interns in Culturally Competent SupervisionImportant 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 skillsSupervisors 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.


47

Common Supervisory Approaches (and Pitfalls)

1. Not addressing cultural issues at all - using universal approach as supervision model

2. Feeling uncomfortable to bring up differences - waiting for the psychology intern to bring up differences about themselves and/or their clients

3. Addressing cultural issues in supervision only with psychology interns faculty perceives as different (e.g. trainees of color or other noticeable difference)

4. Tendency to focus on racial and ethnic issues as most important cultural issues to the exclusion of other background variables


48

Example of on-line Resources

Project Implicit https://implicit.harvard.edu/implicit/demo/takeatest.htmlNational 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=EnglishMental Health: A Report of the Surgeon General 1999http://mentalhealth.samhsa.gov/cmhs/surgeongeneral/surgeongeneralrpt.asphttp://mentalhealth.samhsa.gov/cre/default.aspCenter for Disease Control, Fact Sheetshttp://www.cdc.gov/omhd/AMH/factsheets/mental.htmhttp://www.cdc.gov/omhd/Partnerships/mhresources.htmThe Henry J. Kaiser Family Foundation www.kff.org/whythedifference

https://implicit.harvard.edu/implicit/demo/takeatest.html

https://implicit.harvard.edu/implicit/demo/takeatest.html

http://www11.georgetown.edu/research/gucchd/nccc/

http://www.hrsa.gov/culturalcompetence/



http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English



http://www.kff.org/whythedifference

kathrin hartmann, ph.d. barbara a. cubic, ph.d. eastern virginia medical school

Documents

cubic appic

training appic

barbara cubic

pmkathrin hartmann

interdisciplinary training

internship training

psychological training

primary care residents