Laura Howe-Martin, PhD (UT Southwestern Medical Center, Dallas, TX)Laura.Howe-Martin@utsouthwestern.edu

Deanna Denman, PhD (Brooke Army Medical Center, San Antonio, TX)Ddenman@mail.smu.edu

§ No financial conflicts of interest

§ Biases & Theoretical Orientations:§ Psychologists in Health Settings (DD, LHM)§ Third-Wave Feminism (LHM)§ Contextual Psychology (LHM)§ Minority provider (DD)

Identify at least three ways in which discriminatory statements can impact the therapeutic relationship.

Tie at least two ethical principles to the issue of discrimination in the therapy setting.

Recognize at least 2 common problems related to addressing diversity in supervision, and ways to address the most common problems.

Identify the impact of choices regarding discriminatory comments (as a psychologist and/or supervisor) in the broader contexts of society and on the profession.

Self-assessment

Small group

discussion

DidacticEthical

“crowd-sourcing”

§Current APA Ethics Code handout§Current APA Multicultural Guidelines handout (recently revised) §Case Study #1 & #2§Your Brain, Your Heart, & Your Colleagues

Identify at least three ways in which discriminatory statements can impact the therapeutic relationship.

Tie at least two ethical principles to the issue of discrimination in the therapy setting.

Recognize at least 2 common problems related to addressing diversity in supervision, and ways to address the most common problems.

Identify the impact of choices regarding discriminatory comments (as a psychologist and/or supervisor) in the broader contexts of society and on the profession.

1. What do you know about various ways to handle discrimination and/or hate in therapy?

2. What guidance or supervision have you received on how to handle discrimination and/or hate in therapy?

§“You’re one of the good ones.”§“Why do all these women have children just to put them in daycare?”

§“Why can’t they just send me a doctor who speaks English? I bet he didn’t even graduate from a real medical school.”

§“I’m not a racist or anything, but I just don’t want my daughter dating black men.”

1. Resentment/tension on the part of the therapist2. Lack of “nonjudgmental acceptance” of the client3. Impression of collusion with negative statements4. Reinforcement of avoidance around uncomfortable

discussions5. Racist/Prejudicial remarks can be diagnostic of patients’

presenting concerns6. Therapist could miss opportunity for interpretation and

intervention

Bartoli & Pyati, 2009; MacLeod, 2013

Identify at least three ways in which discriminatory statements can impact the therapeutic relationship.

Tie at least two ethical principles to the issue of discrimination in the therapy setting.

Recognize at least 2 common problems related to addressing diversity in supervision, and ways to address the most common problems.

Identify the impact of choices regarding discriminatory comments (as a psychologist and/or supervisor) in the broader contexts of society and on the profession.

This case involves a racial minority supervisee who was asked by the supervisor to directly address racist comments made by a client

§ Principle A (Beneficence and Nonmaleficence)§ Trying not to harm the patient§ Trying to keep the patient engaged (not defensive)

§ Principle B (Fidelity & Responsibility)§ Do I teach them not to be racist? When have I overstepped my boundaries?§ Could turn into argument§ Do we have a responsibility to teach them how to deal with differences?

§ Principle C (Integrity)§ Staying within the therapeutic context

§ Principle E (Respect for People’s Rights and Dignity)§ Emphasis on Patient Autonomy§ Can I honor your autonomy AND the responsibility that comes with it?§ How do they vs. others define the problem?

Guideline #1 (Intersectionality): Psychologists seek to recognize and understand that identity and self-definition are fluid and complex and that the interaction between the two is dynamic. To this end, psychologists appreciate that intersectionality is shaped by the multiplicity of the individual’s social contexts.

Guideline #2 (Self-Awareness): Psychologists aspire to recognize and understand that as cultural beings, they hold attitudes and beliefs that can influence their perceptions of and interactions with others as well as their clinical and empirical conceptualizations. As such, psychologists strive to move beyond conceptualizations rooted in categorical assumptions, biases, and/or formulations based on limited knowledge about individuals and communities.

Guideline #3 (Importance of Language): Psychologists strive to recognize and understand the role of language and communication through engagement that is sensitive to the lived experience of the individual, couple, family, group, community, and/or organizations with whom they interact. Psychologists also seek to understand how they bring their own language and communication to these interactions.

Guideline #4 (Social/Physical Environment): Psychologists endeavor to be aware of the role of the social and physical environment in the lives of clients, students, research participants, and/or consultees.

Guideline #5 (Righting Wrongs): Psychologists aspire to recognize and understand historical and contemporary experiences with power, privilege, and oppression. As such, they seek to address institutional barriers and related inequities, disproportionalities, and disparities of law enforcement, administration of criminal justice, educational, mental health, and other systems as they seek to promote justice, human rights, and access to quality and equitable mental and behavioral health services.

Guideline #6 (Adaptive Interventions): Psychologists seek to promote culturally adaptive interventions and advocacy within and across systems, including prevention, early intervention, and recovery.

Guideline #7 (International Role): Psychologists endeavor to examine the profession’s assumptions and practices within an international context, whether domestically or internationally based, and consider how this globalization has an impact on the psychologist’s self-definition, purpose, role, and function.

Guideline #8 (Lifespan Impact): Psychologists seek awareness and understanding of how developmental stages and life transitions intersect with the larger biosociocultural context, how identity evolves as a function of such intersections, and how these different socialization and maturation experiences influence worldview and identity.

Guideline #9 (Culturally-informed): Psychologists strive to conduct culturally appropriate and informed research, teaching, supervision, consultation, assessment, interpretation, diagnosis, dissemination, and evaluation of efficacy as they address the first four levels of the Layered Ecological Model of the Multicultural Guidelines.

Guideline #10 (Strength-Based/Resilience): Psychologists actively strive to take a strength-based approach when working with individuals, families, groups, communities, and organizations that seeks to build resilience and decrease trauma within the sociocultural context.

Identify at least three ways in which discriminatory statements can impact the therapeutic relationship.

Tie at least two ethical principles to the issue of discrimination in the therapy setting.

Recognize at least 2 common problems related to addressing diversity in supervision, and ways to address the most common problems.

Identify the impact of choices regarding discriminatory comments (as a psychologist and/or supervisor) in the broader contexts of society and on the profession.

Emotional Competence Technical Skills

Knowledge of Cultural Issues

Socialization into

Professional Roles

Competence

Knapp & VandeCreek (2012)

• Supervisors often leave an “internalized influence”

•Responsibility of engendering Principle A: Beneficence & Nonmaleficence in the form of general beneficence (i.e., fulfilling obligations to society in general & future patients)

•Appreciation of diversity directly relates to upholding Principle E: Respect for People’s Rights and Dignity

Knapp & VandeCreek (2012)Ronnestad & Skovholt (2001)

§Cultural Humility – “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client [or supervisee]”

Initiate Invite Instill

qWhen is the last time you took a cultural diversity course?

q Have you ever completed a culturagram for yourself?q Do you routinely incorporate diversity issues into your progress notes or case conceptualizations?

qWhat does your office space look like?q Are you an omniscient expert or a cultural learner?q Are you modeling advocacy & action?

1. Trainee discomfort- Fear of judgment for lack of knowledge or being politically

incorrect/racist

2. Lack of initiation by supervisor & supervisor discomfort

- Supervisees often bring up issues, not the supervisor

3. Lack of responsiveness or affirmation- If receptive à “Progressive” relationship (Supported to explore cultural issues)- If unreceptive à “Regressive” relationship (Ignored, discounted, not affirmed)

•Evaluate events as they unfold• Pro: Integrated / Smooth process•Con: Scattershot method

à Research reflects minority supervisees OFTEN bring up issues of diversity (not the supervisor!)

Inman & Kreider (2013)Burkard et al (2006)Burkard et al (2009)

Goals

Required Tasks

Roles of Supervisor & Supervisee

Self-Assessment & Feedback with

a focus on

CLIENT OUTCOMES

&

SUPERVISEE DEVELOPMENT- Explicitly orient importance of personal cultural factors

- Model & Initiate exploration of personal cultural factors/strengths

Identify at least three ways in which discriminatory statements can impact the therapeutic relationship.

Tie at least two ethical principles to the issue of discrimination in the therapy setting.

Recognize at least 2 common problems related to addressing diversity in supervision, and ways to address the most common problems.

Identify the impact of choices regarding discriminatory comments (as a psychologist and/or supervisor) in the broader contexts of society and on the profession.

The second case involves a white psychologist whose client made several discriminatory remarks during therapy.

§ It is important that health professionals not judge patients, but we have an obligation to ensure that others/our colleagues are not subject to discrimination

§Nurse: Directly address and remind them this is a multicultural society; document

§ Ethicist: Follow best medical practice; make care of the patient the first concern

§ Lawyer: Explain the inappropriateness of remarks; elevate issue to supervisor; refer to policy

§HRmanager: Employers have a duty to protect their staff-Directly address; refer elsewhere - for the protection of the staff member

Baraitser, 2006

§ Per Title VII of the 1964 Civil Rights Act: Employees of health care institutions have the right to a workplace free from discrimination based on race, color, religion, sex, and national origin

§ Patient racial preferences can be “painful and degrading indignities, which cumulatively contribute to moral distress and burnout.”

§ “We believe that institutions should not accommodate patients in stable condition who persist with reassignment requests based on bigotry.”

Paul-Emile, et al (2016) – NEJM

§ Solid rapport -> more tolerance

§ She asked for opinion

§ How does this align with your values?§ Cognitive dissonance

§ Don’t want to silently collude§ Position of power

LAURA.HOWE-MARTIN@UTSOUTHWESTERN.EDU

DDENMAN@MAIL.SMU.EDU