ACLP DEI Guide

 Diversity, Equity and Inclusion | DEI Resources from Other Professional Organizations | ACLP DEI Guide  |
DEI at ACLP Annual Meeting 2021 

ACLP Diversity, Equity, and Inclusion Guide

Authors: Michael Maksimowski, MD; Arslaan Ari Arshed, MD MS MHA, Liliya Gershengoren MD MPH

Purpose: Consultation-Liaison (CL) psychiatrists are tasked with providing effective mental health care to diverse populations across different settings and locations. To do so effectively necessitates an understanding of systemic bias and discrimination and how such factors impact the care we provide. The ACLP DEI Task Force Report from Feb 2021 identified significant gaps in the integration of cultural humility, structural competency, and DEI in our educational materials for trainees and members. The articles and chapters included in this guide are meant to serve as supplemental material in learning about and teaching DEI within the field of CL Psychiatry. These resources were compiled by the Academy of Consultation Liaison Psychiatry (ACLP) Interdisciplinary Education Subcommittee and peer reviewed by the DEI Curriculum Task Force.

How to Use the Guide: Each topic (section) contains articles and/or book chapters that were selected based on relevance to CL Psychiatrists and when possible, accessibility (e.g., available for free). Articles and chapters that were more process-oriented (“how”) were balanced with content-oriented (“what”) to ensure the guide included both practical and theoretical resources. Links to professional organizations and websites were also included in some sections; such information could be useful to educate patients, their supports, and other healthcare providers. You will find a link under each reference that either connects you to the full article/chapter or the abstract if a free copy is not available. Note that articles from the Journal of the Academy of Consultation-Liaison Psychiatry (previously, Psychosomatics), Journal of Psychosomatic Research, or General Hospital Psychiatry can be accessed by any member of the ACLP by first logging on to the ACLP website, then selecting ‘Access Online Journals’ from the ‘For Members’ section.

Disclosures: No relevant (direct or indirect) financial relationship exists between the authors of this guide and any for-profit company which could be considered a conflict of interest.

Comments: This guide is a work in progress, and we welcome feedback! Please send correspondence to michael.maksimowski@gmail.com.

Contents:

Section 1: Individual, Interpersonal, and Structure; Factors of Mental Health

Mills, S., Xiao, A. Q., Wolitzky-Taylor, K., Lim, R., & Lu, F. G. (2017). Training on the DSM-5 Cultural Formulation Interview improves cultural competence in general psychiatry residents: a pilot study. Transcultural Psychiatry54(2), 179-191. Full article

The authors describe how 1 hour of training in the Cultural Formulation Interview (CFI) led to significant improvements in scores on the Cultural Competence Assessment Tool. This improvement was irrespective of previous experience in cultural diversity. Emphasis is made on such training being an integral part of any psychiatric training program.

 


Jarvis, G. E., Kirmayer, L. J., Gómez-Carrillo, A., Aggarwal, N. K., & Lewis-Fernández, R. (2020). Update on the cultural formulation interview. Focus18(1), 40-46. Full article

The authors discuss the Cultural Formulation Interview (CFI) included within the DSM-5 as a means for improving clinical communication with patients. They discuss the benefits of implementing the CFI within psychiatric assessments (e.g., improving cultural competency) but point out challenges and criticisms as well, including its neglect of structural competency.

 


Calhoun, A. J., Martin, A., & Calhoun, J. W. (2022). A Developmental Framework for Progression to Anti-racism in Academic Psychiatry. Academic Psychiatry, 1-6. Full article

The article discusses an anti-racist framework for academic psychiatry that begins with the intentional decision to strive towards antiracism. Anti-racism is defined as ideas and behaviors that aim to mitigate or eradicate racism and establish justice and equity across all races. A four-stage developmental framework of anti-racist progression is introduced: Dismissing, Acknowledging, Analyzing, and Enacting when witnessing racism or racist policies. The article uses language introduced by Ibram X Kendi, advocating for an anti-racist framework, which can be applied to all ethnoracial backgrounds, as well as non-Hispanic White Americans. As psychiatry and C-L programs develop DEI curricula, this article introduces foundational language and framework for evaluating and changing current structures.

Section 2: Disparities in Psychiatric Treatment

Cantu-Weinstein, A., Taljan, K., Gonsalves, L., Yao, M., & Goje, O. (2022). Racial Disparities in Psychiatric Treatment Among Patients Positive for COVID-19 During Pregnancy. Abstracts from the Annual Meeting of the Academy of Consultation-Liaison Psychiatry, November 10-12, 2021. Journal of the Academy of Consultation-Liaison Psychiatry63, S89. Abstract

A retrospective chart review was conducted from patients who received obstetric care from March to December of 2020. Patients with a COVID-19 diagnosis were match-controlled using race, age, marital status, and geographic location to those with a negative COVID-19 test prior to delivery. In the COVID positive cohort, a higher proportion of Black patients had positive postpartum depression screens and were less likely to receive psychotropic medication compared to White patients. Results were similar in the COVID negative cohort but also demonstrated a lower attendance rate for postpartum visits for Black patients compared to White patients. This data adds to research demonstrating minority women are at higher risk for undertreatment of psychiatric conditions.

 


Beayno, A., & Angelova, Y. (2022). The Health Care Experience of a Transgender Woman: The Role of the Consultation-Liaison Psychiatrist in Advocacy Against Discrimination in the Hospital Setting. Journal of the Academy of Consultation-Liaison Psychiatry. Full article

The authors discuss a consultation case for ‘agitation’ for a young transgender woman with no prior psychiatric history. The case highlights the impact of stigma and discrimination on the provider-clinician relationship and how CL psychiatrists can advocate for patients in the hospital setting. 

Section 3: Implicit Bias

Definition: Associating negative attributes to a particular individual or group without conscious awareness, leading to adverse patient-clinician interactions, clinical decisions, and patient perceptions of care.

Merino, Y., Adams, L., & Hall, W. J. (2018). Implicit bias and mental health professionals: Priorities and directions for research. Psychiatric Services, 69(6), 723-725. Full article

The article is a nice introduction to the concept of implicit bias and details the interplay of implicit bias with accessing mental health care, crisis care, short- and long-term care, and the criminal justice system. Implications and directions for future research are also discussed.

 


McDowell, M. J., Goldhammer, H., Potter, J. E., & Keuroghlian, A. S. (2020). Strategies to mitigate clinician implicit bias against sexual and gender minority patients. Psychosomatics, 61(6), 655-661. Full article

The authors use multiple case scenarios to illustrate the negative impact of implicit bias on patient-physician communication and health care quality to sexual and gender minority people. The article concludes by offering strategies to mitigate implicit bias.   

 


P Goddu, A., O’Conor, K. J., Lanzkron, S., Saheed, M. O., Saha, S., Peek, M. E., … & Beach, M. C. (2018). Do words matter? Stigmatizing language and the transmission of bias in the medical record. Journal of general internal medicine33(5), 685-691. Full article

The authors make a case for how language reflects bias and how documentation can be a means of transmitting bias from one clinician to another. Two different case vignettes (one with stigmatizing and one with neutral language) are given to physicians-in-training who are then asked to provide attitudinal responses about the patient and render decisions on pain management. Exposure to stigmatizing language was associated with more negative attitudes about the patient and less aggressive pain management. The results of the study highlight the importance of language in medical records to promote patient-centered care and reduce healthcare disparities.

Section 4: Microaggressions

Definition: Intentional or unintentional slights or comments of a verbal, behavioral, or environmental nature that communicate hostile, derogatory, or negative attitudes towards stigmatized or culturally marginalized groups. Microaggressions can repeat or affirm stereotypes as well as demean members of a minority group.

Wittkower, L. D., Bryan, J. L., & Asghar-Ali, A. A. (2021). A Scoping Review of Recommendations and Training to Respond to Patient Microaggressions. Academic Psychiatry, 1-13. Full article

This is a systematic review of multiple studies providing strategies and tools on how to respond to microaggressions. Strategies were grouped into establishing a supportive culture, addressing the microaggression, supporting the targets of microaggressions, discriminatory requests, and institutional responses. Several articles also included specific tools to address microaggressions (e.g., ERASE framework).

 


Sotsky, J., & Worthington, C. (2021). A Workshop on Interrupting Microaggressions for a Surgical Service: An Opportunity for Consultation-Liaison Psychiatry to Address Bias and Inequity. Journal of the Academy of Consultation-Liaison Psychiatry62(3), 363-367. Full article

The authors detail the creation of an invited workshop on recognizing and interrupting microaggressions in the healthcare setting. They argue that CL psychiatrists have the interpersonal skills necessary to educate ourselves and our medical colleagues on microaggressions. The discussion section includes several reflections from their experiences in creating and running the workshop and what next steps can and should be taken by CL psychiatrists in addressing microaggressions.

Section 5: Structural and Cultural Competency/Humility

Cultural competency is the ability to understand, appreciate, and interact with people that have different cultural or belief systems than one’s own. Structural competency is the ability to understand the economic and political conditions that produce health care inequalities. The term humility can be applied instead of competency to recognize that cultural and structural understanding is never mastered and to normalize not knowing.

 


Trinh, N. H., Tuchman, S., Chen, J., Chang, T., & Yeung, A. (2020). Cultural humility and the practice of consultation-liaison psychiatry. Psychosomatics61(4), 313-320. Full article

The authors challenge the use of the term ‘cultural competency’ and encourage a transition to the term ‘cultural humility’ to minimize power imbalances between patients and clinicians. A case vignette is included to highlight cultural humility in action. Suggestions are also made in how to train providers in cultural humility and how to use the DSM 5 to better understand the role of culture in diagnosis, treatment, and management.

 


Yeung, A. S., Trinh, N. H. T., Chen, J. A., Chang, T. E., & Stern, T. A. (2018). Cultural humility for consultation-liaison psychiatrists. Psychosomatics59(6), 554-560. Full article

The article reviews the concept of cultural humility and uses two cases to highlight cultural humility in action. Frequently Asked Questions about cultural humility are also discussed.

 


Hansen, H., Braslow, J., & Rohrbaugh, R. M. (2018). From cultural to structural competency—training psychiatry residents to act on social determinants of health and institutional racism. JAMA psychiatry75(2), 117-118. Full article

An opinion piece that highlights social threats to mental health, emphasizes the importance of social theory in clinical practice, and gives examples of how their programs are furthering understanding of cultural and structural competency for their psychiatry trainees.

 


Corral, I., Johnson, T. L., Shelton, P. G., & Glass, O. (2017). Psychiatry resident training in cultural competence: an educator’s toolkit. Psychiatric Quarterly88(2), 295-306. Full article

The authors review cultural competence training as recommended by the Accreditation Council for Graduate Medical Education (ACGME) and American Academy of Child and Adolescent Psychiatry (AACAP). The article also includes resources for cultural competence education in psychiatry.

 


Perdomo, J., Tolliver, D., Hsu, H., He, Y., Nash, K. A., Donatelli, S., … & Michelson, C. D. (2019). Health equity rounds: an interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees. MedEdPORTAL15, 10858. Full article

The authors present a series of lectures as part of their curricula to bring faculty and trainees together to learn about implicit bias and structural racism. A total of 7 lectures are included along with handouts and a creation guide. This article provides a practical forum through which participants can improve awareness and develop tools to better reflect on implicit biases.

 


Alvarez, K., Polanco-Roman, L., Samuel Breslow, A., & Molock, S. (2022). Structural racism and suicide prevention for ethnoracially minoritized youth: a conceptual framework and illustration across systems. American journal of psychiatry179(6), 422-433. Full article

The Structural Racism and Suicide Prevention Systems Framework includes cultural racism, institutional racism, interpersonal racism and intrapersonal racism. The authors describe how these elements impact suicide risk identification and management. Cultural racism is defined as negative attitudes and beliefs about racially and ethnically minoritized populations embedded in societal values and practices. Institutional racism is defined as laws, policies, and regulations embedded in organizations that consolidate power among White people. Interpersonal racism is defined as behavioral manifestation of racial or ethnic prejudices during interpersonal exchanges. Intrapersonal racism is defined as the internalization of negative attitudes and beliefs about oneself due to exposure to racism. Critical opportunities to measure and mitigate structural racism include provision of culturally informed behavioral health services in outpatient and schools settings as well as through community crisis response interventions. The article introduces a new suicide prevention framework based on well-defined existing thought on health disparities. However, there remain limited data around the application of this theoretical framework. C-L psychiatrists must consider the impact of racism and its manifestations in different aspects of social and health systems when evaluating suicidality in ethnoracially minoritized youth.

 


Hankerson, S. H., Moise, N., Wilson, D., Waller, B. Y., Arnold, K. T., Duarte, C., … & Shim, R. (2022). The intergenerational impact of structural racism and cumulative trauma on depression. American Journal of Psychiatry179(6), 434-440. Full article

Cumulative trauma is a concept that is used to explain syndromes that result from repeated injury or are aggravated by repetitive insults. The authors emphasize how cumulative trauma due to structural racism may contribute to the intergenerational transmission of depression. As ethnoracially minoritized individuals are exposed to the insults of structural racism, this increases their risk of depression in themselves and their offspring. The article uniquely intersects intergenerational trauma with structural racism and provides concrete examples on how to disrupt structural racism. There are limited data and experience to inform the implementation of this framework. C-L psychiatrists should consider the impact of intergenerational transmission and family history of structural racism in the evaluation of depression in medical settings.

Section 6: Evidence-Based Psychological and Pharmacological Interventions Specific for Diversity

Chaudhry, I. B., Neelam, K., Duddu, V., & Husain, N. (2008). Ethnicity and psychopharmacology. Journal of Psychopharmacology22(6), 673-680. Full article

The authors discuss intrinsic factors such as race and ethnicity as influential factors in medication responsiveness and prescription practices. Biological bases for ethnic differences in psychotropic use and response are considered. The authors concede that there remains considerable controversy regarding what the concepts of race and ethnicity measure.

 


Lee-Tauler, S. Y., Eun, J., Corbett, D., & Collins, P. Y. (2018). A systematic review of interventions to improve initiation of mental health care among racial-ethnic minority groups. Psychiatric services69(6), 628-647. Full article

The authors start by discussing the racial-ethnic disparities of initial access to mental health care. Their systematic review suggests that screening and referral, colocation of primary care and mental health services, and collaborative care interventions are highly effective in improving mental health outcomes and reducing disparities in initiation of care. The review is highly supportive of integrative care as a means of reducing racial-ethnic disparities in the initiation of mental health care.

 


Flores, G. (2005). The impact of medical interpreter services on the quality of health care: a systematic review. Medical care research and review62(3), 255-299. Full article

The article begins by highlighting the diversity of languages spoken within the United States as well as the rising number of Americans with Limited English Proficiency (LEP). A systematic review found the use of a professional interpreter optimized communication, increased patient satisfaction, improved outcomes, and decreased clinical errors. Although psychiatrists believed that LEP patients interviewed with trained interpreters had poorer outcomes (e.g., felt less understood or were helped less), the opposite was true. The author concludes that cultural disparities in health care can be mitigated for LEP patients when a professional interpreter is utilized.

 


Hu, J., Wu, T., Damodaran, S., Tabb, K. M., Bauer, A., & Huang, H. (2020). The effectiveness of collaborative care on depression outcomes for racial/ethnic minority populations in primary care: a systematic review. Psychosomatics61(6), 632-644. Full article

Studies have shown racial and ethnic minorities have reduced access to mental health services and utilize such services at a lower rate compared to White adults. The authors sought to investigate whether Collaborative Care in the United States improves depression measures for racial/ethnic minorities. A total of 10 randomized control trials and 9 observational studies (most of them with cultural/linguistic tailoring) were found that included core principles of the Collaborative Care model and comprised adults from at least one racial/ethnic minority group.

Results supported the overall effectiveness of Collaborative Care in improving depression outcomes for racial/ethnic minorities compared to physician-only care.