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  • Journal of Psychotherapy Integration Association Between Patient-Provider Racial and Ethnic Concordance and Patient-Centered Communication in Outpatient Mental Health Clinics Christin Mujica, Kiara Alvarez, Shalini Tendulkar, Mario Cruz-Gonzalez, and Margarita Alegría Online First Publication, January 16, 2020.

    CITATION Mujica, C., Alvarez, K., Tendulkar, S., Cruz-Gonzalez, M., & Alegría, M. (2020, January 16). Association Between Patient-Provider Racial and Ethnic Concordance and Patient-Centered Communication in Outpatient Mental Health Clinics. Journal of Psychotherapy Integration. Advance online publication.


    Association Between Patient-Provider Racial and Ethnic Concordance and Patient-Centered Communication in Outpatient

    Mental Health Clinics

    Christin Mujica Tufts University and University of Arkansas

    Kiara Alvarez Massachusetts General Hospital, Boston,

    Massachusetts, and Harvard Medical School

    Shalini Tendulkar Tufts University

    Mario Cruz-Gonzalez and Margarita Alegría

    Massachusetts General Hospital, Boston, Massachusetts, and Harvard Medical School

    Patient-centered communication (PCC) has been identified in the literature as central to providing quality care to patients. Some evidence suggests that racial/ethnic patient- provider concordance may be associated with increased PCC because of perceived simi- larity between the patient-provider match. This study examines whether there are differ- ences in emotion focused PCC between racial/ethnic concordant (n � 55) and discordant (n � 36) dyads in a sample of behavioral health providers (n � 34) and their patients (n � 91) recruited from community mental health care settings as part of a larger study. PCC was measured using three items from a novel third-party coding system on whether providers “identified feelings,” “accepted feelings,” and “encouraged emotional expression” of the patient. Three separate mixed linear regression analyses were conducted to assess relation- ships between racially/ethnically concordant or discordant dyads and each of the commu- nication items: (a) � � .20, p � .12; (b) � � 0.12, p � .39; and (c) � � �0.05, p � .75. No significant differences were found between groups in the three items, suggesting that racial/ethnic concordance may not be linked to PCC measures related to emotion. It is possible that racially/ethnically discordant providers may compensate for cultural barriers to communication through additional emotion-focused communication strategies, or that other aspects of patient-provider similarity are more salient to PCC. Continuing to identify the characteristics and circumstances that lead to improved PCC may be a way to bridge the gaps in the quality of behavioral health care received by underserved communities, particularly communities of color.

    Keywords: patient-centered communication, race, ethnicity, psychotherapy, concordance

    Editor’s Note. This was an invited article, stemming from a poster presentation at the Diversifying Clinical Psychology event held in conjunction with the Midwinter Meeting of the Council of University Directors of Clinical Psychology. The invitation was issued with the intent to feature the work of an emerging scholar in our field. However, reviewers were un- aware of that invitation and the entire blind review process was engaged, per usual, prior to acceptance of the paper for publication in this journal.—JLC

    X Christin Mujica, Department of Community Health, Tufts University, and Department of Psychology, Univer-

    sity of Arkansas; X Kiara Alvarez, Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, and Department of Med- icine, Harvard Medical School; X Shalini Tendulkar, De- partment of Community Health, Tufts University; Mario Cruz-Gonzalez and X Margarita Alegría, Disparities Re- search Unit, Department of Medicine, Massachusetts Gen- eral Hospital, and Departments of Medicine and Psychia- try, Harvard Medical School.

    Correspondence concerning this article should be ad- dressed to Christin Mujica, Department of Psychology, University of Arkansas, 316 East Memorial Hall, Fay- etteville, AR 72701. E-mail: christin.mujica@gmail .com

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    Journal of Psychotherapy Integration © 2020 American Psychological Association 2020, Vol. 1, No. 999, 000 ISSN: 1053-0479


  • Research has documented extensive evidence of mental health inequities across racial and ethnic groups in the United States (Centers for Disease Control and Prevention, 2014; National Alliance on Mental Illness, 2017). For example, multiple studies show that African American and Latinos receive less quality care for mental disorders than their White counterparts (Alegría et al., 2008; Dinwiddie, Gaskin, Chan, Nor- rington, & McCleary, 2013; Hirschfeld et al., 1997). While there are several reasons for the inadequate quality of mental health care re- ceived by people of color, some attribute it to the scarcity of clinicians, especially clinicians of color, available to adequately treat mental health issues. Others add that a lack of effective communication impedes the quality of care pro- vided to patients of color (Alegría et al., 2008; Dinwiddie et al., 2013; Hirschfeld et al., 1997). Communication plays a central role in intercul- tural and interracial therapeutic relationships (Qureshi & Collazos, 2011). For example, Qureshi and Collazos (2011) describe how cul- tural differences in communication style regard- ing aspects of health and healing lead to diffi- culties for providers in connecting with patients in patients feeling comfortable disclosing their feelings.

    Patient-Centered Communication (PCC)

    The Agency for Health care Research and Quality (2011) suggested that to improve access to quality health care, people should be able to find a provider with whom they can communi- cate clearly, trust, and receive quality care. The Institute of Medicine (2001) indicated that a way to improve communication and trust is through the use of PCC. PCC has been opera- tionally defined by Epstein et al. (2005) and includes understanding the patient’s perspective which includes their feelings, concerns, and needs, among other characteristics. Other as- pects which are not focused on in the present study include: understanding the patient within their own psychosocial context, working to- gether to understand the patient’s problems and what treatment would work best according to the patient’s values, and sharing power and re- sponsibility with the patient (Epstein et al., 2005).

    Multiple studies have been conducted to exam- ine the relationship between PCC, patient trust,

    and health outcomes (Beck, Daughtridge, & Sloane, 2002; Hall, Roter, & Rand, 1981; Stewart, 1995; Street, Makoul, Arora, & Epstein, 2009; Swenson et al., 2004). The consensus in the liter- ature seems to be that better-quality PCC results in greater trust, augmented patient empowerment, increased patient knowledge, and adherence to treatment—all of which are intermediary out- comes that lead to better health and general well-being (Street, O’Malley, Cooper, & Haidet, 2008). Other studies have found more direct relationships between PCC and health outcomes (Beck et al., 2002; Stewart, 1995). Stewart (1995) reviewed 21 studies and found that 16 studies reported positive health out- comes related to greater PCC (i.e., less head- aches, lower pain levels, and improved hemo- globin status), while Jiang (2017) more recently found that there was a positive rela- tionship between patient emotional well- being and PCC. Given the benefits of PCC on patient satisfaction and health outcomes, one way to improve health care quality may be to maximize PCC among mental health care pro- viders.

    Racial/Ethnic Concordance (REC) and Therapy Outcomes

    According to Street et al. (2008), patients who perceive ethnic/racial similarity also per- ceive personal similarity in beliefs and values with their providers. Theoretically, health in- equities can be improved via REC because it provides a foundation for mutual respect, trust, communication, and satisfaction, there- fore strengthening the therapeutic alliance which is necessary for treatment to be bene- ficial (Cabral & Smith, 2011; Meghani et al., 2009). As such, REC could facilitate easier understanding of emotions and feelings than an intercultural therapeutic relationship as seen by improved communication of the pa- tient-provider dyad.

    The literature surrounding REC, while abun- dant, remains inconclusive. Various studies have found positive relationships between REC and psychotherapy outc