Implicit Bias as a Public Health Issue CEU Course

Hey there everybody and welcome to this presentation on implicit bias as a public health issue. I'm your host Dr. Donnisee Snipes. Today we're going to start out by defining implicit bias. Explore the scope of implicit bias in behavioral health. Explore factors that may activate implicit bias and lead to misdiagnosis or inappropriate treatment. and end by exploring current recommendations for implicit bias awareness and intervention. So what is implicit bias? Implicit bias is a negative or even positive attitude, belief, or stereotype about a group based on race, ethnicity, age, ability, gender, sexual orientation, weight, or other characteristics. It operates outside conscious awareness. That's the implicit part and can influence judgment and behavior without intent or conscious valition. So let me step away from the humans for a minute and we'll talk about implicit bias when it comes to dogs. Now I know in my mind that pitbulls can be very nice. I know that there are other dogs, cocker spananiels, that can be very mean. However, I have an implicit bias based on a couple experiences I had with pitbulls that make me more fearful of pitbulls. That's my implicit bias that I have to check every time I encounter a pitbull or pitbullesque dog. Likewise, I have positive implicit biases towards most other dogs. When I see them, I assume they are going to be friendly and they're going to want love and, you know, fill in the blank. That's my implicit bias. That's my schema based on my past experiences, my past learning that help me anticipate or try to help me anticipate what's going to happen. However, it's not accurate all the time. It's not a fact in this context at this time necessarily. Now, explicit bias is an attitude a person consciously acknowledges, endorses as correct, and can report directly. Most people have certain explicit biases as well, but we're not going to talk about that today. Today we're really focusing on those subconscious biases that propel us to make certain judgments or well make certain judgments. Implicit bias is a public health issue because it is a modifiable modifiable driver of health inequalities that is nearly universal among providers as well as behavioral health organizations and impacts entire populations by influencing diagnosis, treatment, communication, and access in ways that produce measurable pattern disparities in morbidity and mortality. across entire marginalized or minority populations. And when I say minority, I mean other than the identified majority. A lot of times when we talk about implicit bias, people's first thought is race or ethnicity. And yes, that's part of it. But implicit bias goes far beyond bipok people and also encompasses people who are LGBTQIA, deaf, blind, HIV positive, old over 60 years of age, of low so socioeconomic status, live in rural areas, have particular diagnoses like borderline personality addiction or schizophrenia, or are men. There is documented evidence that there are implicit biases in the instruments we use, the treatments that are recommended for some of these groups. Now, everybody doesn't have an implicit bias toward every group. It's important to recognize that, but you need to be aware of where your implicit biases are or what they are so you can keep them in check. Most treatment programs and trainings are designed around white, middle class, and upper economic status individuals. Thinking about things like motivational interviewing, that's not necessarily culturally responsive. thinking about some of our treatment programs that don't integrate spirituality or native traditions. Obviously, we're not providing the quality of care and the type of care that certain people may need. Think about how the following may cause symptoms or behaviors that are misdiagnosed as a mental or behavioral disorder or resistance to treatment based on people's implicit biases. You're working with somebody who lives in poverty. What assumptions do you make about them? What treat how might treatment plans differ for this person? What about people with limited education or limited English proficiency? How might your diagnosis be a little bit different? And when I worked in Florida, I worked at a a community behavioral health care center, wonderful place. A lot of the people that we work with were impoverished and had limited education. But that didn't mean they were resistant. that didn't mean that they were um necessarily had any particular disorders besides obviously addiction that they were diagnosed with. It's important to look at behavior in context. If a client is falling asleep in group, if a client seems to be um resisting doing what you ask them to do or even become somewhat disruptive, we want to examine what is that behavior saying. For people with limited education, it may be saying, "I don't understand. You're going too fast. You're using a lot of jargon. This is not useful to me." And it's very frustrating. People with dyslexia often are misdiagnosed as having oppositional defiant disorder when they're children because in school they can't read uh as well as the other children or maybe they have difficulty with math and there's another word for that um that I can't remember right now. But instead of asking what is this behavior saying when this child refuses to participate in activities, when this child becomes agitated when they're told to sit at their desk and read an entire chapter in their social studies book, what is that telling us? Um, have we screened for other issues or are we jumping to the conclusion based on certain characteristics they have that they are being oppositional defiant? People who have shift or hourly work may have difficulty participating in treatment that's available during banker's hours. And if they are participating, maybe they work midnight shift, then they have to come directly to group and they start falling asleep in group. Are they being resistant? Are they unmotivated? No, they're sleepdeprived. We need to step back and say, what else could be causing this besides pathology? People with poor health care access may have difficulty with a lot of things. if their thyroid is low, if they are in pain all the time, it's really hard to concentrate and be in a good mood when these things are going on. So, they may be more irritable. Um, environmental toxins can alter cognitive abilities. Um, people may show evidence of confusion and brain fog when exposed to environmental toxins. Does that mean they have early onset dementia? No, not at all. It means that they're having a toxic reaction. Lack of access to natural spaces. The research is just overwhelming. That shows that when we're out in natural spaces, it helps regulate a lot of our um biochemical processes. It reduces cortisol. It helps reduce blood pressure. They found that children who don't have access to natural spaces, green spaces, actually show more symptoms of behavioral issues and ADHD that they don't have ADHD, their ADHD like symptoms. Um, as opposed to children who do have access to those green spaces. And that was when they compared children who are in urban environments, even ones that have access to a park, but a park with no trees, no grass, no nothing, versus environments in which there's grass and trees and that sort of thing. So that's interesting, but let's think about who lives in these really urban areas and could that be contributing the the imbalance um in the child's chemistry as a result of having a lack of access to natural spaces, food insecurity. When you're hungry, it's difficult to focus. It's difficult to have energy. It's difficult to be motivated. If you're stressed about food, there may be hoarding of food. But generally, when we talk about food insecurity, we're talking about the result of being hungry. And think about yourself and ways your behavior changes when your blood sugar is low. This isn't just be having a grumbly tumbly. This is having low blood sugar, not having enough calories to fuel your brain to help you do what you need to do. Community violence keeps people from feeling safe, keeps people from sleeping well, may keep people on edge and hypervigilant, which eventually can lead to irritability, um, resistant behaviors, acting out behaviors, people become more stressed and more defensive. They stay in that stressed place and react from that stressed place when in general they feel like their environment is unsafe. And finally, unstable, crowded or unsafe housing. If you can't get good sleep, it impacts every aspect of your being. It impacts you physically. It impacts you emotionally, cognitively. It impacts your relationships, your self-esteem, and can create a lot of other issues. People need adequate quality sleep in order to be able to function. When we are assessing somebody who is presenting with symptoms of depression or anxiety or ADHD or cognitive dysfunction of some sort, we need to back up and say what else might be going on for this individual that is contributing. As you know, a person of the middle class, I may not experience these things. So they may not be the things that first pop into my head, but it's important that we recognize the environment, the culture, the experiences from which our clients are emerging. How might the following structural issues contribute to implicit bias, the perception that a client is being resistant, or treatment dropout, lack of public transportation? Again, when I worked in Florida, we had multiple IOP programs. One of our programs was designed to meet the needs of people who worked 8:00 a.m. to 5:00 p.m. Program started at 6:00 p.m., got out at 9:00 p.m. Sounds wonderful, right? not so much. A lot of our clients didn't have transportation. The buses could get them there after work, but then they had no way to get home. And we lived in a relatively rural county. So, it wasn't as easy as walking home or riding your bike or hitching a ride with somebody. Uh and this lack of transportation made it difficult for a lot of people to continue to participate. Even the ones that were courtmandated to participate or mandated by Department of Children and Families, they may be trying their God's honest best, but if they couldn't get a ride, how are they supposed to get there? Because an Uber is not likely affordable for them. Um, thinking about the clients we were working with at at Meridian, that just wasn't even in the cards to pay an Uber to drive you to and from IOP, having clinic hours only during weekday days. There are a lot of people who work uh weekday days and they don't have PTO. They are hourly workers. And if you're asking them to take time out, even for an hour therapy appointment, by the time they drive there, get their appointment, drive back to the office, that's at least two hours. Can they afford to lose that kind of time? You have people that work night shift and if the appointments are weekday days, they may need late afternoon appointments in order to accommodate their circadian rhythms. Lack of child care is another issue and a lot of centers not all of them but a lot of centers have started offering um virtual sessions and teleaalth in order to help accommodate this but it's not a panacea. Yes, a lot of places do have internet access that most anybody can get. Still not everywhere. So that's one problem. Number two, even if you're working with a patient who has children and doing teleaalth, it doesn't mean that they're going to be able to focus or even talk freely because they may have a three-year-old or a 5-year-old pop in at any time. If they're expecting their children to be on autopilot for an hour while they're in session, a lot of times that's unreasonable. if they have older children, yes, that may be possible if they're like middle school age. But people who have younger children and don't have child care may have difficulty. A lot of facilities cannot afford to provide child care. And this is where it's important to connect with other community resources to see if that can be made available. um our IOP groups, most of the time our clients were able to come get there at 8 am. They left at noon, no problem, because the kids were already in school when they came and they got home before the kids got home. But then we had summer break and spring break and Christmas break. And a lot of times our clients didn't have the resources to pay for child care 5 days a week for three hours, five hours a day in order to accommodate. And we would tend to see less participation. We would tend to see more dropout, more relapsing. and that's not fair. Uh trying to figure out how to make treatment available and equitable to everybody is important. But we do want to recognize that sometimes people will not participate in treatment or will have difficulty staying awake or will drop out not because they are in pre-contemplation or not because they uh have some other diagnosible issue but because they have a structural barrier to participating in services. A lack of representative staff is another structural issue. Not every person is comfortable seeing a 20 or 30 something white female, which makes it really difficult. Again, thinking back to places I've worked, a lot of the larger organizations, that was the predominant uh description of most of our clinicians. And we were not representative of the people served. Treatment programs that use a one-sizefits-all approach. This one just drives me absolutely baddy. If we are assuming everybody is going to be motivated and get on board to participate in a group therapybased 12step program for addiction recovery or is motivated to participate in uh cognitive behavioral therapy, we are sorely mistaken. And I recently did a course on working with Alaskan natives. And there are certain um issues that arise for Alaskan natives. Number one, there are certain times of year where they are engaging in subsistence activities and they just can't. The subsistence activities have been shown to be extremely strong protective factors. So of course we don't want to disrupt that. Um, additionally, they're just not there because they're out in the fishing villages or whatever. Uh, programs that are tied in with criminal justice or child welfare. If you assume that people are going to trust you, that you're going to protect their information and yada yada, that's a faulty assumption. The proof is in the pudding and we need to make explicit to our clients what we can and cannot do and help them feel like they're part of the process. With my clients, I would always involve them in writing the treatment plan and the progress note and even the assessment. I would tell them, if you want to read this, you are more than welcome to. I'm not going to write anything down that I don't want you to see. I'm not going to keep secrets from you. And using instruments that are not normed on the target population. This happens so often. Using instruments that were normed on college students or white middleclass individuals. um not people of uh lower economic status, not people of lower education, not people with low English proficiency, not people of different ethnicities, or even not people of the same age. The instruments that you're using for a 30some may not be entirely valid or reliable for someone who is 60 plus or someone who is under 18. You must know who that instrument was developed for and normed on in order to adequately apply it. And even then there are cultural differences in behaviors which means that certain cut offs for problem behaviors versus non-pro behaviors may need to be loosened a little bit. Uh hard cut offs are not respectful of the individual's experience. Consider a person with a disability presenting with depressed mood, sleep disturbances, psychoot retardation, and feelings of worthlessness. Are these symptoms consequences of the disability? this person just hasn't adjusted to their disability or they, you know, they have this disability and they're going to through a ongoing grieving process or are they experiencing major depressive disorder or both? We see both types of errors. We see clinicians that assume that a lot of the symptoms are a result of the disability and disability adjustment. We also see a lot of clinicians that see the symptoms as a result of major depressive disorder when maybe it is part of the person's disability adjustment. Another example, think of a child who is restless in class, persistently irritable, actively resists participation, and rarely completes their homework. Is this oppositional defiant disorder or might they have dyslexia, a history of trauma? So, they're not feeling safe. They're feeling edgy. They're hypervigilant which can contribute to all these symptoms. Do they have generalized anxiety? or are they experiencing some sort of physiological issue like poor sleep, unstable housing or um lack of adequate nutrition. Being hungry is a big problem for a lot of students. Our brain uses a ton of energy and when students don't have that energy, their blood sugar drops. when their blood sugar drops, their behavior becomes more irritable, restless, and disruptive a lot of times. And again, that's an implicit bias right there, assuming that for everybody when their blood sugar drops, they're going to evidence those symptoms. A lot of people may, but not everybody. It's important not to blame a child's or a person's irritability and outbursts on low blood sugar without knowing a little bit more. Maybe it's not low blood sugar. Maybe there's something else. And finally, an elderly man with a hearing impairment scores a seven on the MMSE. A seven is a really low score. And I will tell you that and the question that you're trying to answer because the MMSSE screens for dementia. Is this really dementia or did the person not hear you and it's hearing loss? My grandfather went to explore certain assisted living facilities and they gave him the MMSE at one of them and he scored a seven. And ultimately, I'll jump to the end. It's because of his hearing impairment. He can't hear much of anything, but in order to please people and not cause problems because of the way he was raised, he nods and acknowledges and tries to get along even though he's not hearing and understanding because he can't hear most of what's being said. He's still sharp as attack, but he wasn't able to hear. And the person who was administering this assumed that because he was 94 years old and he wasn't answering the questions the way he was supposed to that he must have dementia. No. Absolutely not. Consider a person with an addiction that's assigned to IOP treatment that begins at 6 and ends at 9. A lot of times they drop out. Is this, as we talked about earlier, is this resistance or a lack of resources to support participation? Maybe they don't have transportation. Maybe they've got kids at home they've got to take care of. Uh maybe maybe there's a lot of things that we need to consider. Maybe they work in the evening or a rotating shift. There are a lot of places where people may work day shift a couple of days a week and evening shift a couple of days a week which means that the person can't attend a 6 to 900 p.m. IOP every single day. We want to ask instead of assuming that people in addiction treatment are inherently resistant and an Alaskan native that refuses to discuss thoughts of suicide or self harm. Does that mean they're hiding something and they are at high risk for suicide? Not necessarily. In certain cultures, discussing suicide or self harm is believed to awaken the spirits that may promote this type of behavior. Uh, approaching it from the perspective of evaluating their protective factors is the culturally responsive way to do it. But a lot of people who are working with Alaskan natives may go in and just start with a standard suicide assessment or you know crisis assessment and that is not going to go very far. There are certain problems with implicit bias training and I think it's important to bring this one up that when we treat implicit bias as an individual level problem, you the clinician are not assuming the right things. You the clinician are not taking in enough factors. You the clinician are not being objective. It decouples bias from social context and ignores the way in which communities, clinical training, yeah, our our own clinical training and healthcare organizations embed prejudice and stereotyping into daily practice. We need to explore what that means. Again, we're not just talking about race or ethnicity, sexual orientation, religion, disability. We want to pay attention to how some of these things are incorporated and alter the way we work with or treat some of the people in our on our case loads. What do we do about it? Number one recommendation, improve workforce diversity. When you have people working at your organization that are representative of the person served, they can help increase awareness of implicit biases in other therapists and improve treatment overall. Additionally, that person may be able to serve as an advocate for some of the per people served. We don't want to assume, however, that all people with disabilities understand the needs of all people with disabilities. That's not it. Even all people who are parapolgic can understand and adequately respond without implicit bias to all other people who are parapolgic. No, it doesn't work that way. And people get caught in a trap assuming that you how did they lose the functioning in their lower limbs? How long ago did they lose the functioning in their lower limbs? What does that mean in their perception of self in their ability to perceive to pursue the goals that are important in their rich and meaningful life? Those questions are different for just about everybody who has parapolgia. Therefore, we can't assume. And um oh gosh, her name escapes me right now, but it has been said that the same thing is true with people with autism, for example. Um all people with autism are not the same and we cannot assume that. The same thing is true with people with depression, with addictions. It goes on. When you make assumptions about people even based on their diagnosis, you are imposing sometimes faulty assumptions. We need to increase clinician awareness of sources of implicit bias. What things in our belief systems, in our the way our organization runs and in our the instruments we use and the treatments we use, what aspects of those may promote implicit bias. Um, ensure instruments are normed on the population served. We already covered that. foster a sense of belonging and voice for bipok and minority patients. And I was kind of lumping everything together here to include all of those people that may be the recipient of implicit bias. We need to help people have a sense of belonging. If you have a clinic clinic that is not accessible for someone in a wheelchair, does that promote a sense of belonging or is that an implicit bias that kind of says no, we don't want to deal with it? All clinicians should address social determinance of health. And I love this one. uh including housing, education, transportation, employment and racism itself in and discrimination itself as part of the patients comprehensive treatment and recovery plan. I struggle struggled for many years with the with NBCC because they said case management is not part of our job. And I argue argue with that vehemently. If our clients think about Maslo's hierarchy, if our clients do not have access to the basic things that they need for health and shelter and clothing and food, guess what? They're not going to be able to function very well in therapy. Additionally, when they have all those things going on, it's going to compound how badly they feel. When the body is under stress, the brain is under stress. When the brain is under stress, neurotransmitters, hormones, all kinds of stuff gets out of whack. How much of what you're seeing in your patient, and I've had a couple of these patients, uh, is due to an underlying physiological issue. I had one patient who was referred to me through an employee assistance program who was presenting with some suicidal ideiation, extreme depression, low motivation, lots of tearfulness, and fast forward, turns out that she was severely anemic. Um, I encouraged her to go to the doctor and get a physical just to make sure everything was going well under the hood. when she did, they actually admitted her to the hospital to stabilize her um to to help her with her anemia. Um so that's one example. I had another patient who had polycystic ovarian syndrome that had not been yet diagnosed. And we know that in the majority of patients with PCOS, not only do they have gonatal hormone imbalances, they also have thyroid hormone imbalances. She was presenting with classic symptoms of major depressive disorder. And once she was able to get her self balanced out again and start addressing the PCOS, her mood improved, her energy improved. Yeah, there was a lot of work to do on other things um that were contributing or sometimes the result of the PCOS, but there was a lot of stuff at the beginning that was helped by her addressing the underlying physical stuff um that was keeping her from being motivated, that was contributing to her brain fog, that was contributing to her um depressive symptoms because when you're foggy, unmotivated, and depressed, it's really hard to focus in therapy and benefit from it. But once she started to come out of the fog, it was just a whole different ballgame. Bipok and minority people should be better represented as part of clinical trials including as part of the team conceptualizing, conducting, analyzing and in interpreting and disseminating the clinical research. It is important to include people who have disabilities physi visible disabilities as well as invisible disabilities like POTS or chronic fatigue syndrome we must include those people when we are looking at treatments when we're looking at does cognitive behavioral therapy work does EFT work how does EMDR benefit this group. It's important to recognize that each group may respond a little bit differently. Clinicians should not apply a fixed cutoff for certain behaviors or symptoms when using assessment instruments. The DSM itself even notes that tolerance thresholds for particular symptoms or behaviors differ across cultural contexts. differ across cultural contexts. We need to be aware of that what may be appropriate or acceptable behavior in majority white culture may not be acceptable or tolerated behavior in Japanese culture or in Korean culture or in you know Hispanic culture. It's important to not overgeneralize and assume that this set of behaviors is right for everybody because it ain't. Unite is a very useful pneummonic that you can use when thinking about implicit bias. U stands for understanding stakeholder experiences through listening. And this when we talk about stakeholders, we're not just talking about clients. We're talking about clients, their families, your clinicians, um even your payors sometimes. But we want to understand stakeholder experiences. Clinicians who are representative of the people served. Let's understand their experiences. Clinicians who are representative of the majority may have a lot to contribute. about hey I don't know how to address this or help me understand a little bit more please give me training so we need to understand stakeholder experiences through listening stands for needs assessment of all stakeholders including the clinicians and persons served what a clinician's need to better address implicit bias and provide culturally responsive ive empowering care and what do the person served need? How can we modify our programs? How can we modify our scheduling or the delivery in order to better meet their needs? Teleaalth is one. Um incorporating um cultural traditions is another. It depends on what group you're working with. and offering specific groups. For example, I I was recently doing some work with some Alaskan companies and there are certain treatment programs there that have pro treatment paths, if you will, or programs that are specifically designed for Alaskan natives and based on Alaskan Native culture. Yes, there are people who live in Alaska that are not Alaskan natives. There are also people in Alaska who are Alaskan natives that are more acculturated to the majority culture. We don't want to assume, but having the options is paramount for ensuring that we are not discriminating against certain populations. I stands for improving the organizational culture and structure for equity and inclusion. You know enough said T stands for transparency, communication and accountability with internal and external stakeholders. There has to be communication not only between clinicians and clients but between clinicians and seuite and seauite and clinicians. Too often edicts come down from on high that clinicians or line staff don't understand the reasoning for and seuite may not have conceptualized the multiplicity of negative impacts that this edict will necessarily cause. which is where as line clinicians and mid-level supervisors, it's our job to advocate. It's our job to speak up and go, "Hey, wait a minute. That ain't going to work. That ain't going to work." Um, I had one instance where senior management decided it would be a good idea in order to prevent vandalism and ensure the safety of the patients who by all rights were safe. It's not like we were having fights or anything in the facility, but whatever. Um, and allegedly to monitor and prevent people from bringing drugs into the facility, they decided to put cameras in group rooms and they were like, "Oh, well, it doesn't have any sound to it. Nobody can hear anything. We can just see." Oh my gosh, how many different ways was that punitive? and showing implicit bias, assuming that people in these groups were going to bring in drugs, assuming that people in these groups would be okay having their image recorded um even though it was on a local server. No, it wasn't okay. And there was quite a row over it among not only the clients but also the staff who said, "This isn't going to work. My clients don't feel safe if they've got big brother watching them all the time. Ultimately, management acquiesced and took the cameras out of the group rooms, left them in the hallways and outdoors. Okay, that's their right. But it was a step in the right direction. Um however if we had not had that transparency and communication and if line staff had just said okay you know whatever we'll handle it um or we'll accept it then that would have been discriminatory to those people who felt violated. Um, and the fact that senior management said, "This is why we're doing it." Allowed us to finally get on the same page and say, "Okay, if you want to have the cameras outside, um, clients seem to think that that would be okay, but we're not bringing them in the group room." E stands for education about the strengths and limitations and biases in assessment and treatment methods. Helping people understand how motivational interviewing techniques [clears throat] may be in general useful but need to be modified for certain populations is really important. helping them understand um how EMDR may not be appropriate for everybody, encouraging clinicians to dive into the research and find out who exactly has this been tested on. I mean, dialectical behavior therapy started out as a treatment for borderline personality disorder and it seems to be used for everything now. How many of those subgroups that it's being used on have actually had research done to evaluate its effectiveness? Every person has implicit bias. It doesn't mean you're a bad person. It means you've had experiences that have programmed your brain to see people or see dogs or see something and assume I see dark clouds outside. My implicit bias it's fixing to rain. Doesn't necessarily mean that's true. Um, pay attention over the next couple of days. Pay attention to how many assumptions you make without knowing all of the facts. And that's where implicit biases come in. It's making decisions. You know, if I look outside, it's cloudy. I'm like, h, it's going to rain. Guess I'm not going on a run today. I'm changing my behavior based on an assumption from looking outside. could be the sun just hadn't completely come up yet or something else. Awareness of implicit biases in yourself as well as in your organization and the assessment instruments and treatments you choose is an ethical imperative. We cannot provide quality treatment equitably to people using one-sizefits-all. It just doesn't work that way because we are all individuals and it's not onesizefits all.