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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 -4:30pm. Kathrin Hartmann, Ph.D. Barbara A. Cubic, Ph.D. Eastern Virginia Medical School.

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Kathrin Hartmann, Ph.D. Barbara A. Cubic, Ph.D. Eastern Virginia Medical School

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  1. Cultural Competence Training of Senior Faculty Paper Presentation in Supervision and TrainingAPPIC Friday 4/17/20093:00pm -4:30pm Kathrin Hartmann, Ph.D. Barbara A. Cubic, Ph.D. Eastern Virginia Medical School

  2. Cultural Competence Training of Senior Faculty: Self-Perceptions and Supervisory ExperiencesToday’s Educational Objectives • Consider areas of needed improvement for senior faculty in staying current regarding professional and ethical standards in cultural competence. • Utilize an approach to quantitatively measuring common perceptions of faculty's own awareness, knowledge, and skills in cultural competence. • Describe typical experiences of cultural dissonance for faculty based on their teaching and supervising of psychology interns. K.Hartmann / B. Cubic APPIC April 17, 2009

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

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

  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 residents Dr. Barbara Cubic led the way in responding to the HRSA GPE program to recreate and expand this training K.Hartmann / B. Cubic APPIC April 17, 2009

  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 disorders Confounds created when mental illness coincides with chronic physical illness Time constraints for primary care providers K.Hartmann / B. Cubic APPIC April 17, 2009

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

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

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

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

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

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

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

  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 Scales Trainee Satisfaction Ratings Patient Satisfaction Ratings Pre and Post Tests on Knowledge of and Attitudes about Integrated Care and the Elderly K.Hartmann / B. Cubic APPIC April 17, 2009

  15. Number of Patient Contacts by Setting K.Hartmann / B. Cubic APPIC April 17, 2009

  16. Gender Distribution of Patient Population Across all Settings K.Hartmann / B. Cubic APPIC April 17, 2009

  17. Racial Distribution of Patient Population Across all Settings K.Hartmann / B. Cubic APPIC April 17, 2009

  18. SES Distribution of Patient Population Across all Settings K.Hartmann / B. Cubic APPIC April 17, 2009

  19. Age Distribution of Patient Population Across all Settings K.Hartmann / B. Cubic APPIC April 17, 2009

  20. Main Psychosocial Issues Addressed Across all Settings K.Hartmann / B. Cubic APPIC April 17, 2009

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

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

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

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

  25. 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 Content of Cultural Competence TrainingFall 2008 Spring 2009 K.Hartmann / B. Cubic APPIC April 17, 2009

  26. Cultural Competence Training Educational Objectives: Part One • Define cultural competence as it applies to our ability to teach and train supervisees. • Define areas of improvement for our own cultural competence as faculty based on the needs assessment. • Discuss cultural competence awareness, knowledge, and skills that will enhance our ability to teach and supervise psychology interns for treating diverse patients K.Hartmann / B. Cubic APPIC April 17, 2009

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

  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 itselfWhaley & King (2007) Examples of Cultural Adaptations for Specific Groups:http://www.medschool.ucsf.edu/latino K.Hartmann / B. Cubic APPIC April 17, 2009

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

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

  31. Culturally Competent Clinical Case Conceptualization 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 K.Hartmann / B. Cubic APPIC April 17, 2009

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

  33. Triadic Relationships in Supervision Clinic K.Hartmann / B. Cubic APPIC April 17, 2009

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

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

  36. Supervision Vignettes • Initial meeting with your new supervisee • What type of supervisee do you feel most comfortable with? • How do you choose patients for your supervisee? • Issues with bias/values/discrimination of your supervisee • How would you address impasses in supervision K.Hartmann / B. Cubic APPIC April 17, 2009

  37. Culturally ChallengingSupervisory Situations: Our Own • Discuss scenarios and dilemmas of our own experiences of culturally challenging moments in supervision (in Small Groups) • Bring together solutions and adaptations based on our experiences (in Large Group) K.Hartmann / B. Cubic APPIC April 17, 2009

  38. Psychology Interns Self-Reported Competence K.Hartmann / B. Cubic APPIC April 17, 2009

  39. Highest Self-Reported Competencies for Psychology Interns • 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 K.Hartmann / B. Cubic APPIC April 17, 2009

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

  41. Faculty Self-Reported Competence Survey Responses K.Hartmann / B. Cubic APPIC April 17, 2009

  42. Highest Self-Reported Competenciesfor Psychology Faculty • 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 K.Hartmann / B. Cubic APPIC April 17, 2009

  43. Lowest Self-Reported Competenciesfor Psychology Faculty • 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 K.Hartmann / B. Cubic APPIC April 17, 2009

  44. Faculty Self-Reported Competence Before and After K.Hartmann / B. Cubic APPIC April 17, 2009

  45. Survey Differences by Questions 1. Between Faculty and Interns2. Faculty Baseline and Follow-Up K.Hartmann / B. Cubic APPIC April 17, 2009

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

  47. Common Supervisory Approaches (and Pitfalls) • 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 K.Hartmann / B. Cubic APPIC April 17, 2009

  48. Example of on-line Resources • Project Implicithttps://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=English • 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 K.Hartmann / B. Cubic APPIC April 17, 2009

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