Elizabeth Carpenter-Song

Ethno-Cultural Variations in the Experience and Meaning of Mental Illness and Treatment: Implications for Access and Utilization

We conducted a study to investigate how understandings of mental illness and responses to mental health services vary along ethno-racial lines. Participants were 25 African American, Latino, and Euro-American inner-city residents in Hartford Connecticut diagnosed with severe mental illness and currently enrolled in a larger study of a community mental health center. Data were collected through 18 months of ethnographic work in the community. Overall, Euro-Americans participants were most aligned with professional disease-oriented perspectives on severe mental illness and sought the advice and counsel of mental health professionals. African-American and Latino participants emphasized non-biomedical interpretations of behavioral, emotional, and cognitive problems and were critical of mental health services. Participants across the sample expressed expectations and experiences of psychiatric stigma. Although Euro-Americans were aware of the risk of social rejection because of mental illness, psychiatric stigma did not form a core focus of their narrative accounts. By contrast, stigma was a prominent theme in the narrative accounts of African Americans, for whom severe mental illness was considered to constitute private “family business.” For Latino participants, the cultural category of nervios appeared to hold little stigma, whereas psychiatric clinical labels were potentially very socially damaging. Our findings provide further empirical support for differences in symptom interpretation and definitions of illness among persons from diverse ethno-racial backgrounds. First-person perspectives on contemporary mental health discourses and practices hold implications for differential acceptability of mental health care that may inform variations in access and utilization of services in diverse populations.

Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in VA Specialty Clinics

OBJECTIVE The U.S. Department of Veterans Affairs (VA) has engaged in substantial efforts to promote the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD). The authors evaluated the effectiveness of these efforts. METHODS This study used a cross-sectional, mixed-methods evaluation of treatment provided by the VA at specialty PTSD clinics in New England during the first six months of fiscal year 2010. Natural language processing algorithms were applied to clinical notes to determine utilization of evidence-based psychotherapy (prolonged exposure therapy and cognitive-processing therapy) among patients who were newly diagnosed as having PTSD. Data regarding efforts to implement evidence-based psychotherapy and other clinic characteristics were obtained through qualitative interviews with clinical and administrative staff (N=30), and the Promoting Action on Research Implementation in Health Services framework was used to identify clinic factors associated with use of evidence-based psychotherapy. RESULTS Six percent of patients (N=1,924) received any sessions of an evidence-based psychotherapy for PTSD (median=five sessions). Several clinic factors were associated with an increased rate of implementation, including prior experience with use of the treatments, customization of training, and prolonged contact with the implementation and training team. Facilitation with broad training goals and clinics with highly organized systems of care were negatively associated with implementation. CONCLUSIONS Few patients with PTSD received evidence-based psychotherapy for PTSD during their first six months of treatment at a VA specialty PTSD clinic. The implementation framework poorly predicted factors associated with uptake of evidence-based psychotherapy. These results suggest that additional research is needed to understand implementation of evidence-based therapy in mental health settings.

Reducing disparities in mental health care: Suggestions from the Dartmouth-Howard collaboration

This article presents recent collaborative efforts between the Dartmouth Psychiatric Research Center and Howard University to understand (and ultimately reduce) disparities in mental health care among African Americans. Researchers from Dartmouth and Howard recently formalized a longstanding collaboration through the support of a grant aimed at understanding recovery and rehabilitation for African Americans with severe mental illness. Grant-sponsored efforts have included two seminars between multi-disciplinary mental health researchers and clinicians to inform the implementation of a collaborative research and training program. This article outlines the prominent themes arising from these seminars on the issue of health disparities agreed upon by our multi-disciplinary research team. These are (1) situating disparity research in the context of social justice; (2) understanding trends in disparities; (3) promoting a sophisticated understanding of ‘culture’ and its role in disparities; (4) critically assessing strategies that attempt to mitigate disparities; (5) developing a reflexive research agenda.

Meanings of Recovery From the Perspective of People With Dual Diagnosis

Objective: “Creating Communities” is a research project that examines processes of recovery within small housing communities of people living with co-occurring mental illness and substance use disorders. The authors label these configurations recovery communities. All recovery communities are owned and managed by one community mental health agency. This article reports preliminary findings on perspectives of the meaning of recovery for people living in these communities. Methods: Focus groups have been conducted at 4-month intervals with residents at recovery communities since 2005. The present analysis draws on data collected in 2009 and 2010, when the authors began systematically inquiring into meanings of recovery. Focus group transcripts were reviewed to identify prominent themes. First-person perspectives were used to provide a description of the meanings of recovery among residents in recovery communities. Results: Recovery is a multifaceted concept for individuals living with co-occurring disorders. Our preliminary analysis yielded three key dimensions of the meaning of recovery: (a) acknowledgment, (b) present orientation, and (c) transformation and growth. Conclusions: Our preliminary analysis systematically articulates core dimensions of the concept of recovery from the perspectives of consumers with dual diagnosis. It is our hope that this article will contribute to the development of an integrated vision of recovery-oriented services.

Evidence-Based Medicine: Opportunities and Challenges in a Diverse Society

In this article we explore the discourse and practice of evidence-based medicine (EBM) in the context of social and cultural diversity. The article consists of 2 parts. First, we begin by defining EBM, describing its historical development and current ascendance in medical practice. We then note its importance in contemporary psychiatry, comparing dynamics between the United States and Canada. Secondly, we offer a constructive critique of the application of EBM and evidence-based practices in the context of ethnocultural diversity, as one consistent reflection on the EBM literature is that it is does not adequately address issues of diversity. In doing so, we use the situation here in Canada as an extended case study, though our observations will likely be applicable in other diverse nations, such as the United States, the United Kingdom, and Australia. We critically examine the following 6 issues related to the practice of EBM in a diverse society: generalizability and transferability of evidence-based interventions; diversifying standards of evidence in EBM; strategies to address diversity in EBM research; cultural adaptations of evidence-based interventions; integrating idiographic knowledge; and, training and health service delivery. Concurrent with our critique, we offer research and practice suggestions that may address outstanding challenges vis-à-vis the practice of EBM in a diverse society. These include a need for more effectiveness research, more openness to diverse sources of knowledge, better integration of idiographic and nomothetic knowledge, and a critical approach to extrapolation and transfer of knowledge.

Cultural competence in action: "lifting the hood" on four case studies in medical education.

In recent decades, clinicians and clinical educators have increasingly turned to the ‘‘cultural competence’’ paradigm and its correlates (e.g., ‘‘cultural sensitivity,’’ ‘‘cultural humility,’’ ‘‘cultural safety,’’ etc.) in an effort to engage clinicians in the monumental task of redressing health disparities between privileged and disadvantaged populations. Such efforts hinge on several key assumptions: first, that ‘‘culture’’ and disadvantage are related in significant and predictable ways, and second, that certain identifiable dimensions of clinical encounters are both (a) associated with meaningful differences in health outcomes and (b) amenable to change. A great deal has been written about the wide and disparate array of efforts that have developed under the ‘‘cultural competence’’ umbrella. At the same time, it has also become increasingly common to wield (sometimes devastating) critiques of such interventions, especially in an anthropological vein.

Clinicians’ Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?

Despite a training program to help veterans administration (VA) clinicians implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), uptake has been limited. To understand clinicians’ implementation challenges, we performed thematic analysis of semi-structured telephone interviews guided by the Promoting Action on Research Implementation in Health Services framework. Our sample included 22 psychotherapists in VA PTSD clinics in one region. We identified a theme not captured by our implementation framework: clinicians’ perceptions about their patients’ readiness for treatment. Clinician perception of patient readiness may be important to the uptake of EBPs and should be considered in mental health implementation work.

Evidence-based supported employment for people with severe mental illness: Past, current, and future research

BACKGROUND: Individual Placement and Support (IPS) is an evidence-based vocational rehabilitation intervention for people with severe mental illness. IPS emphasizes client choice, rapid job finding, competitive employment, team-oriented approaches, benefits counseling, and ongoing supports. OBJECTIVE: This paper summarizes 20 years of research on IPS, describes studies in the field now, and proposes priorities for future research. METHODS: To identify published and unpublished IPS research studies, we conducted an electronic search of qualitative and quantitative IPS studies, findings from recent reviews, and sought expert recommendation. RESULTS: Past research indicates that IPS supported employment is the most effective and cost-effective approach for helping people with psychiatric disabilities find and maintain competitive employment. Employment improves clinical, social, and economic outcomes. Current studies on IPS address several research gaps: IPS modification, generalizability, program settings, international dissemination, cultural awareness, and supportive technology. Looking forward, the field needs studies that report long-term outcomes, financing mechanisms, cost offsets, and standardized supported education models. CONCLUSIONS: While IPS is one of the most extensively studied of all vocational models, significant literature gaps remain.

Patrolling Your Blind Spots: Introspection and Public Catharsis in a Medical School Faculty Development Course to Reduce Unconscious Bias in Medicine

Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that “they” are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social–psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a “safe-space” where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We “lift the hood” and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.

A Qualitative Study of Social Facilitators and Barriers to Health Behavior Change Among Persons with Serious Mental Illness

This qualitative focus group study was conducted to explore social facilitators and barriers to health behavior change in persons with serious mental illness engaged in a healthy lifestyle intervention. Six focus group interviews were conducted with a total of 30 clients stratified by “high” and “low” achievers in the program based on clinically significant weight loss or significant increase in fitness. Thematic analysis of focus group discussions revealed that emotional, practical, and mutual support from family members and significant others were social facilitators to health behavior change, while unhealthy social environments was a barrier. Participants in the “high” achiever group reported more mutual support for health behavior change than participants in the “low” achiever group. Results highlight the need for researchers and clinicians to consider the potential role of family and significant others as health supporters for persons with mental illness who could encourage healthy behavior in the social environment.