DAVID LECHUGA
Neurobehavioral Clinic
Lake Forest, CA
Rationale
• Meetings at UCLA (Cultural Neuropsychology
Initiative:
– http://www.semel.ucla.edu/cni
• Xavier Cagigas, Paola Suarez, Lisa Moran, David
Lechuga:
– Rachel Casas and Christine Salinas
• Pipeline issues:
– Attracting those that will help meet the needs
Refinements to Houston Conference
• Evolved from public health concern:
– Changing demographics of United States
• Concerns about level and commitment:
– Cultural factors as they affect clinical and research
endeavors
– Political and legislative influences
• Need to rethink and revise guiding document
From Houston to Austin
• Dovetailed with HNS Mission:
– http://hnps.org/about/mission-statement/
• Consistent with efforts from other entities
interested in cultural competency enhancement
in neuropsychology
– Guilds
– Regulatory bodies
Today
• Presentations that provide context and
background
• Brainstorming session
– Translate into action steps
• Partnerships with other professional groups as
part of Houston Conference refinement process
Goal
• Generally, to be part of the change process
– Respond to the challenges encountered when
working with monolingual Spanish speakers,
bilingual (English, Spanish)
– Elevate the narrative
• Other demographic groups that require greater
sensitivity re: cultural factors
Bienvenidos!
• Fortunate to have representatives from
various national and international groups
• Leaders of HNS
• Students of HNS
• Members and guests of HNS
HNS Board
•
•
•
•
•
Xavier Cagigas
Roy Aranda
Veronica Bordes Edgar
Katrina Esherick Belen
Delia Silva
•
•
•
•
Gretchen Berrios-Siervo
Christina Salinas
Christina Eguizabal Love
Johanna Rengifo-Nevarez
Muchas Gracias
STANDARDS OF TRAINING: WHAT IS
CURRENTLY RECOMMENDED IN THE
GUIDELINES & WHAT IS NEEDED?
MONICA RIVERA MINDT, Ph.D., A.B.P.P.
Fordham University/
Icahn School of Medicine at Mount Sinai
Overview
• Experience with the Houston Guidelines
• Current Guideline Recommendations
• What is Needed for the Guidelines?
• So What Now?
Experience with the Houston Guidelines
In My Own Training & Training Others
Overview
• Experience with the Houston Guidelines
• Current Guideline Recommendations
• What is Needed for the Guidelines?
• So What Now?
Current Guideline Recommendations
5
Representation of ‘Cultural Competence’ Language
# of Words
4
3
2
1
0
0
Demographic Factors
Ethnic
Lingusitc
Multicultural
Culture/Cultural
Diverse/Diversity
Houston Guidelines: Total Words = 2,035; Total Culturally-Relevant Words = 11 (0.5%)
Current Guideline Recommendations
So Maybe It’s Not Quantity, But Quality?
V
V. Professional and scientific activity:
The specialist whose professional activities involve diverse cultural,
ethnic, and linguistic populations has the knowledge and skills to
perform those activities competently and ethically.
VI. Knowledge base:
1.General Psychology Core: 1G. Cultural & Indiv. Diff’s &Diversity
2. General Clinical Core: 0
3. Foundations for Study of Brain-Behavior Relationships: 0
4. Foundations for Practice of Clinical Neuropsychology: 0
Recognition of multicultural issues
Recognition of multicultural issues
0
0
0
}
Training Level
(Criteria Set By)
VIII. Doctoral (APA)
 Reviewed/Revised
Core Competencies
 Exit Criteria Includes
Cultural Competencies
IX. Internship (APA)
 Reviewed/Revised
Core Competencies
 Exit Criteria Includes
Cultural Competencies
X. Residency (NP)
☐ Reviewed/Revised
Core Competencies
☐ Exit Criteria Includes
Cultural Competencies
Overview
• Experience with the Houston Guidelines
• Current Guideline Recommendations
• What is Needed for the Guidelines?
• So What Now?
What is Needed for the Guidelines?
• Paradigm Shift in Neuropsychology
• Cultural Competence Framework for
Neuropsychology
• Lifespan Model to Cultural Competence
Source: Arial Narrow 8 pt.
Rivera Mindt et al., 2010
Paradigm Shift in Neuropsychology
• Avoid the ‘ghetto-ization’ of multicultural issues
• Develop & implement comprehensive multicultural
NP training standards
• Empirical approach to cultural competence in NP via:
• Rigorous research with URMs
• Application of evidence-based practice (EBP)
• Training that integrates:
– Best research evidence + clinical expertise + patient
values (Chelune, 2008; Sackett et al., 2000)
Source: Arial Narrow 8 pt.
Rivera Mindt et al., 2010
Cultural Competence Framework for NP
•
•
•
Assumptions/va
lues/biases @
cultural
minorities
Impact
provision of NP
services
Positive stance
towards
multiculturalism
ACQUISITION
KNOWLEDGE &
UNDERSTANDING
AWARENESS
•
Own world view
•
Clients’ culture
& world view
impacts NP
performance &
+
intervention
•
Understanding of
sociopolitical
influences
•
Specific,
culturally
appropriate
assessment,
intervention, &
communication
skills
•
Necessary to
effectively work
with cultural
minority groups
+
INDIVIDUALS &
ORGANIAZATIONS
• Development of
core cultural
competencies
• Based on new
theories,
practices,
policies
• Organizational
structures that
are more
responsive to all
groups.
D.W. Sue, 2001; Rivera Mindt et al., 2010
Lifespan Model to Cultural Competence
(Undergraduate)
Doctoral Training
Internship
Postdoctoral Fellowship
Early Career
Mid- & Late Career
•
Didactics completed with a standard for
mastery of cultural considerations in NP, based
on the growing empirical literature
•
Clinical Training in Culturally Diverse Settings
•
Proficiency Exam Qs specific to Cultural NP
•
Exit Criteria Includes Cultural Competencies
•
Cohesive multicultural training curricula for
those already in the profession (ABPP?)
•
Specific task forces charged with providing
coherent CC training for memberships
Fastenau et al., 2002; Rivera Mindt et al., 2010
The Nitty Gritty – Food for Thought
• What is the minimum type of curricula, didactics and/or training
needed for cultural competence to be achieved?
• What is the minimum level of bilingual proficiency needed?
• How would this be evaluated?
• Who would be appropriate to teach and/or supervise these
courses or students? Who would be available?
• Are broad courses on cultural diversity sufficient?
• Who would provide oversight? (Houston Guidelines have little
detail; APA has criteria for Psych but not NP)
Source: Arial Narrow 8 pt.
Overview
• Experience with the Houston Guidelines
• Current Guideline Recommendations
• What is Needed for the Guidelines?
• So What Now?
Moving Forward
Where Does this Happen?
How Does This Happen?
When Does This Happen?
Who is Responsible?
…………………………Let me give you a HINT.
Source: Arial Narrow 8 pt.
Moving Forward
• Here
• Inter-Organizational Effort
• NOW
• Together
– We Are Responsible For
Making this Happen
Muchas Gracias,
Thank you!
Fordham University
Icahn School of Medicine at Mount Sinai
NEUROPSYCHOLOGY IN
A CHANGING US
CULTURE
Christine M. Salinas, PsyD
The American Dream:
Embracing Diversity
Houston Conference-2000
Location
Location
Location
“Call to Action”-2010
Location
Location
Location
Houston to Austin:2013-2015
Location
Location
Location
Heterogeneity of Hispanics
education
ethnicity economics
language race nationality
literacy
politics
country
culture religion
acculturation
immigration insurance
Hispanic Subgroups by Region
West
0.8
7
2.7 3.7
6.9
2.4
1.7
Northeast
Midwest
13
20
1.3
7.2
16.9
8.5
38
12
80.9
76.9
0.03
Mexico
PR
Central America
South America
Other
Cuba
5.8
5.6
South
9.3
7.9
64.1
7.3
Language Use Among Hispanics
•
•
•
•
~50% of the world are bilinguals
~20% of US citizens are bilinguals
Spanish is 2nd most common language (38M) fejkj
82% of Latino adults speak Spanish*
• 38% Spanish “dominant”
• 38% bilingual
• 24% English “dominant”
• Dialect differences
• (“tutear”; grammar use; vocabulary)
• Cultural influences on L1 maintenance
Language Use Among Foreign Born
Hispanics
Changing US Culture
IMPLICATIONS FOR
NEUROPSYCHOLOGY & COMMUNITY
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Neuropsychology Trends
# of Division 40 Members
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Healthcare Disparities for Hispanics
Organization
NAN
# Spanish Speaking NPs
TX, NJ:
VA:
AZ:
CA, NY, NM, NC, NV:
FL, IL, GA, PA:
CO, WA, MA:
96
HNS
157
AACN
25
= 1:81,000
(std. NP:PX in the US)
Salinas, Bordes-Edgar, & Puente, In Press; Romero et al., 2009; Judd, 2010
Training Challenges: Hispanics
Type of Training Received to work with Hispanics
Feel Prepared
Satisfaction with Training Received to Work
with Hispanics
1.3
9.5 21.5
10.8
40.5
15.2
41.8
19.6
49.4
17.7
37.3
35.4
Yes
No
None
Graduate School
Internship/PostDoc
N/A
Dissatisfied
Somewhat Satisfied
CE
Peer Consultation
Self-Taught
Moderately Satisfied
Extremely Satisfied
Did not disclose
Echemendia et al, 1997; Renteria et al, 2010
Challenges in Practice
• ~15% of 3500 tests are in Spanish
• Only 5 meet Standards for Educational & Psychological tests
• Use and selection of appropriate interpreters
– 25% still use family members
• Verbatim translations are used greater than adaptations
– Up to 1/3 of time
• Clinicians are NOT using normative data when available
– Only 1/3 of time
• Supervision of bilingual and diverse psychometrists and trainees
• Minorities are judged as cognitively impaired more often
• Rec’s may based on myths, not evidence (e.g., English only ST)
(Renteria et al, 2010; Ojeda & Puente, 2010; Echemendia & Harris, 2004; Manly et al, 1998)
Challenges in Practice
• Assessment is more complex & time consuming
• Minorities may be vulnerable to comorbidities
• Serving the underserved: innovate or perish!
– Volume was on avg 2.5x colleagues
– department collected 10% for all charges 2011-2015
• Bilingual colleagues have seen 2.6x clinical volume than co-workers
– 51% Medicaid
– Medicaid & ethnic minority pxs were 7x higher than co-workers
Challenges in CN Research
• 1,834 abstracts reviewed
– 10 articles identified for inclusion in review (<1% over 5 yrs):
•
•
•
•
Peer reviewed
Direct examinations of culture/ethnicity on test performance
Use of at least 1 standardized or experimental neuropsychological test
No parsimonious link between ethnicity and test performance; several
complex factors at play
Byrd, Arentoft Scheiner, Westerveld & Baron, 2008
Challenges in CN Research
• >600 abstracts reviewed (PubMed):
• Epilepsy+
language/memory/cognition/behavior/QOL/NP/fMRI
• 15 articles identified for inclusion in manuscript review:
– Peer reviewed
– Use of at least one standardized or experimental neuropsychological test
– Sample size greater than 5
• Keywords: culture, Hispanic, Spanish
Challenges in CN: Latin America
Lack of academic training programs
46.9%
Lack of clinical training opportunities
45.4%
Lack of willingness to collaborate between professionals
35.9%
Lack of access to neuropsychological instruments
35.0%
Lack of professional leaders in the field
30.9%
Lack of access to literature/ libraries
11.3%
There are no barriers
8.3%
Lack of access to technology/ computers
3.7%
Lack of access to the internet
1.2%
Arango et al, 2015
Lack normative data for my country
Not adapted to my culture
Too costly/ expensive
Aimed at individuals with high levels
of education
Are often not applicable because my
patients cannot read or
Not translated to my language
Do not have good psychometric
properties
Take a long time to administer
There are no problems with the
instruments that I use
Too complicated to administer and/
or score
Other
62%
56%
49%
25%
23%
19%
15%
13%
8%
5%
3%
CNP 365:
New Mandates
Xavier E. Cagigas, Ph.D.
UCLA Cultural Neuropsychology Initiative
Cultural Neuropsychology:
The New Norm
N
Title VI
Federal Civil Right Act of 1964
• Prohibits discrimination on the basis of race,
color, or national origin
• National origin includes language and so
prohibits discrimination against persons who
are limited English proficient (LEP)
Executive Order 13166
• Requires recipients of federal financial
assistance to take reasonable steps to ensure
that LEP persons have meaningful access to
federally funded programs and services
Rehabilitation Act of 1973 - Section 508
Plain Writing Act of 2010
• Requires federal agencies to use plain writing
for all public communication, especially
public communication about benefits and
services…in any language used to
communicate with individuals with LEP.
Patient Protection and
Affordable Care Act – Section 1557
• Prohibits discrimination on the ground of race,
color, national origin, sex, age, or disability
under any health program or activity that is
administered by an Executive agency or any
entity established under Title I of the Affordable
Care Act or its amendments.
NIH LAP: Language Access Plan
• Scope:
– Programs or activities involving the general public
as part of ongoing NIH operations
– Programs or activities directly administered by
NIH for program beneficiaries and participants
• Timeline: End of Fiscal Year 2016
HHS/NIH LAP for LEP
• Recipients must consider:
– The number or proportion of LEP persons in the
eligible service area
– The frequency with which LEP persons come into
contact with programs
– The importance of services provided by the program
– Resources available
NIH LAP 10 Elements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Assessment of Needs and Capacity
Oral Language Assistance Services
Translation of Written Materials
Policies and Procedures
Notification of the Availability of Free Language Assistance
Staff Training on the Provision of Language Assistance
Assessment of the Accessibility and Quality of Services
Stakeholder Consultation
Digital Information
Grant Assurance and Compliance
NIH Cultural Framework for Health
• Provides a tool for researchers and program evaluators to use in project design.
• Identifies why culture is fundamental for understanding human behavior and the
impact of cultural ways of life on mental and physical health and well-being.
• Identifies the major scientific challenges with the current use of the concept of
culture for health behavior research.
• Presents methods and tools to discover the salient cultural processes involved
with health behaviors, and how the processes and behaviors influence health
and well-being.
• Provides a processual framework that guides researchers through six steps that
more effectively distinguish cultural processes relevant in any given study
context, and how they likely influence health outcomes.
National CLAS Standards
• Intended to advance health equity, improve
quality, and help eliminate health care
disparities by providing a blueprint for
individuals and health and health care
organizations to implement Culturally and
Linguistically Appropriate Services
Principal Standard
1. Provide effective, equitable, understandable,
and respectful quality care and services that are
responsive to diverse cultural health beliefs and
practices, preferred languages, health literacy,
and other communication needs.
Governance, Leadership & Workforce:
2.
3.
4.
Advance and sustain organizational governance and leadership
that promotes CLAS and health equity through policy, practices,
and allocated resources.
Recruit, promote, and support a culturally and linguistically
diverse governance, leadership, and workforce that are
responsive to the population in the service area.
Educate and train governance, leadership, and workforce in
culturally and linguistically appropriate policies and practices on
an ongoing basis.
Communication & Language Assistance:
5.
6.
7.
8.
Offer language assistance to individuals who have limited English
proficiency and/or other communication needs, at no cost to them, to
facilitate timely access to all health care and services.
Inform all individuals of the availability of language assistance services
clearly and in their preferred language, verbally and in writing.
Ensure the competence of individuals providing language assistance,
recognizing that the use of untrained individuals and/or minors as
interpreters should be avoided.
Provide easy-to-understand print and multimedia materials and
signage in the languages commonly used by the populations in the
service area.
Engagement, Continuous
Improvement, & Accountability:
9.
Establish culturally and linguistically appropriate goals, policies,
and management accountability, and infuse them throughout
the organization's planning and operations.
10. Conduct ongoing assessments of the organization's CLASrelated activities and integrate CLAS-related measures into
measurement and continuous quality improvement activities.
11. Collect and maintain accurate and reliable demographic data to
monitor and evaluate the impact of CLAS on health equity and
outcomes and to inform service delivery.
Continued
12. Conduct regular assessments of community health assets and needs
and use the results to plan and implement services that respond to
the cultural and linguistic diversity of populations in the service area.
13. Partner with the community to design, implement, and evaluate
policies, practices, and services to ensure cultural and linguistic
appropriateness.
14. Create conflict and grievance resolution processes that are culturally
and linguistically appropriate to identify, prevent, and resolve conflicts
or complaints.
15. Communicate the organization's progress in implementing and
sustaining CLAS to all stakeholders, constituents, and the general
public.
The so what, now what test…
• NIH EDI 365 Pledge 
CNP Houston to Austin Pledge
• Revisit Houston Guidelines in light of CLAS
• Do we need a CNP sub-specialty or are we
committed to raising the bar together as a
community of practice in neuropsychology…?
¡Gracias!
TONY PUENTE
“REAL LIFE EXAMPLES:”
SOCIALLY RESPONSIBLE
NEUROPSYCHOLOGICAL
PRACTICE
Paola Suarez, PhD
Cultural Neuropsychology Initiative,
Postdoctoral Fellow
Social Responsibility
• “Ethical framework which suggests that an
entity, be it an organization or individual, has
an obligation to act for the benefit of society
at large.”
Source: Arial Narrow 8 pt.
Socially Responsible
Neuropsychology
• Practicing socially responsible
neuropsychology (SRN) challenges our field
to engage in individual and organizational
practices that benefit all patients in an
equitable manner regardless of their race,
ethnicity, sex, language, or sexual
orientation.
Source: Arial Narrow 8 pt.
Equality vs. Equity
• Equality:
– Ad-hoc translations
– Use of interpreters
– Ask bilingual students to provide
care for patients without proper
supervision
Equity vs. Equality
• Equity:
• Norms
• Guidelines for practicing with
underrepresented groups
• Assessment tools for non-English
speakers
• Programs to serve the
underrepresented
• Some of us in this room; culture
relevant assessments
Socially Responsible
Neuropsychology
• However, as a field, we continue to fall short in
judiciously providing equitable care for all
patients, in part, due to insufficient emphasis on
the development of competencies relevant to
working with culturally and linguistically diverse
patients through the course of
neuropsychological training.
Source: Arial Narrow 8 pt.
Case Sample #1
Demographics: 63-year old right-handed married “SpanishAmerican” man with 15 years of formal schooling (education
Mexico)
Reason for referral: Pt. was referred for neuropsychological
evaluation by the epilepsy team for localization of
epileptogenic foci since an evaluation conducted outside did
not provide any significant clinical information
Source: Arial Narrow 8 pt.
Case Sample #2
Demographics: Pt was a 55-year old, bilingual
(Spanish-dominant) female of Central-American
descent with 12 years of education (completed in
Spanish)
Reason for referral: Pt. was referred for
neuropsychological evaluation by the cardiac
transplant team given a previous diagnosis of
dementia, which was questioned by the Spanishspeaking cardiologist at the time of his evaluation
Source: Arial Narrow 8 pt.
Case Sample #3
• Demographics: Pt. was a 73-year old , Spanishdominant female of Puerto Rican-descent with
12 years of education
• Reason for referral: Pt. was referred for an
assessment by a Spanish-speaking neurologist
who questioned an AD diagnosis given to the
patient 3-years prior.
Source: Arial Narrow 8 pt.
Case Sample #4
• Demographics: Pt. was a 54-year old , Spanishdominant male of Mexican-descent with some
college education
• Reason for referral: Pt. was referred for a
language evaluation by the cardiology team to
better characterize his aphasia (approximately 1
year post-stroke) in order aid in treatment
planning.
Source: Arial Narrow 8 pt.
Socially Responsible
Neuropsychology
• These real life examples were selected to
illustrate how and why we need to intervene as
a discipline in a culturally and linguistically
responsive manner, and not just delegate the
care of LEP or culturally diverse populations to
minority professionals or those with an
expressed interest in issues of diversity.
Source: Arial Narrow 8 pt.
Conclusion
Equality
• Individual
• Patients are
most vulnerable
• Trainees are
vulnerable
• No specific guidelines
• Left to individual
interpretation
• No accountability
Equity
•Competencies are
acquired at the
individual level
•Patients are served
adequately
• Burdensome for a
few
•Trainees are still
vulnerable
SRN
•Collective
•Culture at the core of
competencies
•Equitable care for ALL
patients
• Broader impact on
the Health Care
System
• Social Justice
THANK YOU
JENNIFER
MANLY
RACHEL CASAS
CNI:
A CNP Training Model
Xavier E. Cagigas, Ph.D.
UCLA Cultural Neuropsychology Initiative
A Point of Departure…
• "Of all the forms of inequality, injustice in
health is the most shocking and inhuman.”
• “Justice too long delayed is justice denied…”
– Martin Luther King, Jr.
Olvera Street, Los Angeles
(November, 2015)
Moving Beyond Bystander Status Quo
The Bed of Procrustes
The WEIRD problem
Behavioral Science Citations
70%
US
Non-US
30%
96% of behavioral clinical samples come from
countries with only 12% of the world’s population
“W E I R D” Populations
• W estern
• E ducated
• I ndustrialized
• R ich
• D emocratic
•
•
•
•
R ace
E thnicity
A nd
L anguage
The First Cultural Neuropsychologist…We
all need Heroes!
The Cultural Neuropsychology Initiative
(CNI)
• A clinical service to provide Spanish and bilingual
neurocognitive and psychodiagnostic assessments
• A training program to help develop the next
generation of culturally and linguistically competent
clinical neuropsychologists
• A new base for clinical and translational research with
an explicit multicultural focus on brain health
CNI Culture and Neurocognition
Assessment Service (CANAS)
•
•
•
•
•
•
•
Presurgical epilepsy evaluations (e.g., Wada)
Organ transplants (e.g., heart, liver, kidney, lung)
Deep Brain Stimulation (DBS) for Parkinson’s disease
Brain tumor resection (e.g., electrocorticography)
Differential Diagnosis (e.g., dementia, neurological)
First-response psychodiagnostic assessment
Bilingual educational assessments
Philosophy for leveraging the pipeline
•
•
•
•
•
Direct clinical service for patients
Multiplicative impact of students
Multi-level students learning alongside attending doctors
Feedback to structural components of health system
Community engagement within own institution and
beyond our borders
• Disruptive Innovation…
CNI as Transformative Nexus
Psychiatry
Neurology
Neurosurgery
Neuropsychology
Pediatrics
Organ Transplant
Internal
Medicine
Geriatrics
Rehabilitation
CNI Modus Operandi
• Building resilience in providers is as important as
cultural and linguistic competence
• Bilingual supervision in an open and inclusive case
conference environment
• Multidisciplinary input and convergence of ideas to
triangulate best practice
• Patient-centered clinical pathway
• Reconfiguration and/or allocation of resources
Psychiatry 463: CNS Syllabus
(10 week Quarter)
•
•
•
•
•
•
•
•
•
•
Introduction: Historical Antecedents & Sociocultural Theory
The Cultural Neuroscience Paradigm
Literacy, Quality of Education & Demographically Adjusted Norms
Ethnographic Considerations & the Influence of Technology
Bilingualism as a unique Cultural Practice
A Developmental Perspective to CNP
Acculturation, Stereotype Threat, & other Factors
Ethno-neuropsychopharmacology & Pharmacogenomics
Interpreters and Translations: Limitations in Equivalence & Equity
Ethical Considerations in CNP
Cultural “considerations” reframed…
 More than half of the world population, and by some estimates up to two thirds, is
multilingual
 Globalization is making self-identification with a single race/ethnicity more untenable
 Documented Health Disparities exist across all levels of assessment, intervention, and
outcome
 Increased utilization of services by underrepresented groups (or not…)
 Historical lack of participation and/or inclusion in research studies
 Investigators are not in the habit of reporting cultural demographic information in the
studies they do publish; poor evidence-base
 Limited instrumentation; poor diagnostic specificity (and at times sensitivity) in
assessment measures, and poorer clinical outcomes as a result
The “Ouch!” Factor & Minority Tax
Cultural Humility
Humble reflection on how “one’s knowledge is
always partial, incomplete, and inevitably biased”
(Wear, 2008)
Cultural Humility: 3 principles
• Lifelong learning and critical self-reflection
(process-oriented)
• Recognize and challenge power imbalances
and affirm contributions (Patient-focused)
• Institutional accountability & respectful
partnerships for advocacy
(CBPR)
»
Tervalon & Murray-Garcia, 1998)
(
Competence vs Humility
Cultural Competence
Goals
Values
Shortcomings
Cultural Humility
•
To build an understanding of minority cultures to better and more
appropriately provide services
•
To encourage personal reflection and growth around culture in
order to increase awareness of service providers
•
•
Knowledge
Training
•
•
Introspection
Co-learning
•
Enforces the idea that there can be 'competence' in a culture other
than one's own.
Supports the myth that cultures are monolithic.
Based upon academic knowledge rather than lived experience.
Believes professionals can be "certified" in culture.
•
Challenging for professionals to grasp the idea of learning with
and from clients.
No end result, which those in academia and medical fields can
struggle with.
•
•
•
•
•
Strengths
•
•
Allows for people to strive to obtain a goal.
Promotes skill building.
•
Encourages lifelong learning with no end goal but rather an
appreciation of the journey of growth and understanding.
Puts professionals and clients in a mutually beneficial
relationship and attempts to diminish damaging power
dynamics.
The so what, now what test…
• Use CNI Training Model to Develop:
– CNP Faculty Training Consortium
– CNP Training Fellowships
– CNP
¡Gracias!
CULTURALLY AND LINGUISTICALLY
DIVERSE TRAINING:
STUDENTS’ PERSPECTIVE
Christina E Love, MS
PsyD Candidate
Octavio A. Santos, MS
PhD Candidate
1993 Survey (Monitor, 2004)
Stats
2014 ANST Survey (n=188)
11%
13%
Hispanic/Latino
Non-Hispanic/Latino
87%
“Ethnic minorities in
particular are horrendously
underrepresented in NP”
(Monitor, 2015)
Hispanic/Latino
(n=20)
Non-Hispanic/Latino
(n=167)
89%
ANST survey
5%
Caucasians (n=166)
6%
1%
Asians (n=12)
African-Americans (n=9)
88%
American-Indian/Alaska
native (n=1)
Our Training Journey: Background & Issues
Octavio
Christina
• B.S. from Colombia: Tests normed in
Spain/U.S.
• 2nd generation immigrant to the US,
Colombia
• Bilingual psychometrician: On-site
translations & lack of norms
• B.A. Psychology
• PhD
– No Spanish-speaking faculty/NPs,
lack of appropriate tests
– Misperceived as an “expert”
– Shadowed and worked with bilingual NP
• Florida Institute of Technology
– M.S. 2013
– PsyD
Ethical dilemmas in Training
• NPs responsible for ensuring they are trained in crosscultural and/or cross-language work
• Currently no consensus on who is qualified to provide
supervision for cross-cultural NP training
Started questioning myself & others…
• Referral question?
• Anyone more appropriate to refer to?
• Language(s) of evaluation?
• Do I have the clinical skills for these
questions?
• Interpreter available?
• Cultural consultation available?
• What do I know about this culture?
• Should I take the case?
Burden or Asset?
Taking Action!
• Purchased 1st Spanish battery & supervised by English-speaking
faculty & HNS consultants
• Initiated communications between HNS members & NP
practicum supervisors
• Hosted 1st Div 40 EMA/ANST Cross-cultural NP Webinar
• Represented fellow trainees at APA/APAGS, AACN, NAN & HNS
Taking Action!
• Referral for middle-aged Mexican-American woman
– Rule outs: Memory problems vs. depression
• Provided case consultation and joint supervision in testselection, interpretation of results, and dx
– Loaned test-materials
• Practice issues, when to say “no”
• Sustainability of consultation model
Taking Action!
• Advanced NP Epilepsy Practicum
• 2+ years clinical and research
Hispanics seen at FH by Nationality
• Know your population (CF)
• Test-selection (norms)
– Translated vs. adapted
• Not just learning the tests in other language
– Cross-cultural NP literature
• Language dominance
• Mentoring
11%
Puerto Rico (n=5)
11%
Colombia (n=2)
56%
22%
Mexico (n=1)
Cuba (n=1)
Internship Applications
Octavio (2015)
Christina (2014)
Spanish-Speaking NP
Spanish-Speaking NP
19%
29%
Yes (n=4)
Yes (n=5)
No (n=17)
81%
No (n=12)
71%
Aspirational Training Goals
• Be skilled at:
– Assessing literature, researching/taking client’s cultural, language,
acculturation & migration history
– Interpreting/translating or working with an interpreter if needed
– Establishing rapport across cultures
– Understanding neuroepidemiology & public health relevant to
immigrant populations
– Communicating findings/recommendations to clients, families & other
professionals
Aspirational Training Goals
• Know/follow professional ethics, laws and guidelines concerning cross-cultural
clinical work
• Consider diversity variables in interviewing, testing & planning interventions
• Evaluate test translation/adaptation according to ITC guidelines
• Be aware of personal cultural perspectives/background & linguistic limitations
• Educate others in cultural sensitivity/competency
Modeling
Global
Perspectives
Creating a
Collaborative Learning
Imagine…
Community
Engaging students in
class/case discussions
Using hypothesis-testing
approach
Preparing trainees to work
responsively
Testing carried out in accordance with APA, ITC,
HHS, Judd et al. (2009) and related
guidelines/literature
¡Gracias Totales!
HNS BOD
&
Drs. Christine Salinas, Tedd Judd, Orlando Sanchez, Melissa Castro,
Shelley Peery, Paola Suarez, Antonio Puente, Pedro Saez, Juan Arango,
April Thames, Jakeel Quiroz, Franchesca Arias, Michelle Madore,
David Mirich & many others who have been part of our training journey
Brainstorm 101
• Ground Rules
–
–
–
–
–
–
–
–
One Conversation at a time
Go for Quantity
Headline! (1 idea per Post-it)
Build on the Ideas of Others
Encourage wild ideas
Be visual
Stay on Topic
Defer Judgment-NO Blocking
• “How might we develop a culturally
competent neuropsychologist at the entry
level?”
CNP Ethics & Ethos
Courtesy of Monica Rivera-Mindt
Ethics & Ethos
• Under the provision of APA’s Ethical Principles of
Psychologists and Code of Conduct , it is clear that
neuropsychologists, similar to all psychologists, have
an ethical mandate to provide culturally competent
neuropsychological services to ethnic minority
clients.
– APA’s Ethical Principles of Psychologists and Code of Conduct
(EPPCC; 2002)
Ethics & Ethos
• Ethical Standard 2.01 (Boundaries of Competence)
states that:
– “cultural expertise or competence at the individual level is
essential for the clinician who is working with crosscultural populations.”
• APA Ethical Standard 9.02b states:
– “Psychologists use assessment instruments whose validity
and reliability have been established for use with
members of the population tested.”
– EPPCC, 2002
Ethics & Ethos
• Charge of APA - New Ethical Subsections:
– Assessment Standards, Standard 9.0
– 9.02 - Emphasizes that psychologists:
• If validity & reliability not yet established -describe
strengths/weaknesses of results & interpretation
• Use assessment methods APPROPRIATE for a patient’s
language preference and competence (unless the use of
another language is relevant to the assessment)
Ethics & Ethos
• Standard 9.06 (Interpreting Assessment
Results) of the code states that:
– when psychologists interpret assessment results,
they should:
• “…take into account the various test factors, test-taking
abilities, and other characteristics of the person being
assessed, such as situation, personal, linguistic, and cultural
differences, that might affect psychologists’ judgments or
reduce the accuracy of their interpretations.”