Final Report Summary - INTUITION AND BIAS (Intuitive decision making and bias: Examination of their role in the initial mental-health intake with ethnically and racially diverse populations)
The proposed project investigated the complexity of provider intuitive decision-making process during the initial mental-health interview with ethnically and racially diverse populations. The project focused on examining intuitive decisions and exploring the effect of explicit and implicit bias on decisions related to patient care, including, diagnosis, treatment recommendations, and assessment of rapport. In order to address aim I which included the investigation of the effect of explicit and implicit bias on intuitive decision making through a quantitative experimental design with clinically na?ve sample, we carried out a series of experiments with none clinical samples (see midterm report). Consistent with our predictions, results from the studies revealed that psychology students of Ashkenazi decent expected a Misrahi patient to be significantly less cooperative in treatment as well as reported having significantly more negative attitudes to toward a Misrahi patient than toward an Ashkenazi patient. Implicit bias significantly predicted the effect of ethnic identity on clinical intuitive decisions, such that Ashkenazi participants who where more implicitly biased against Misrahim rated the alleged Misrahi patient less favorably. Explicit bias was not significantly related to this effect. These results replicated among mental health providers producing an even larger effect size (see Nakash et al., 2012 Israeli Journal of Psychiatry).
In order to address goals of Aim II looking at the effect of explicit and implicit bias on intuitive decision making through a mixed methods design with mental health clinicians providing services to diverse population, we conducted an extensive field study to examine to role and characteristics of intuitive clinical decisions providers make during the mental health intake. One hundred and twenty-nine in-depth semi-structured interviews were conducted with forty seven providers following intakes they conducted with patients presenting for mental health care. We qualitatively analyzed the interviews to identify themes related to intuitive decision making (see Nakash & Alegria, in press, Qualitative Health Research). Our findings suggest that intuition guided many decisions providers made during the intake. Providers referred to intuition as a cognitive process which relies on knowledge acquired through past clinical experiences and is primarily based on non-verbal cues as well as affective communication. Mental health providers used intuitive processes in making decisions about multiple topics, including whether to trust a patient, how to facilitate rapport, which information to collect and how to decide on a diagnosis.
In order to address aim III which included the assessment of clinician reactions to the recommended improvements to the decision-making process developed in Aims 1 and 2, We carried out a series of consensus groups with clinicians at the clinics we data were collected as well as in two additional clinics. Their feedback was integrated in order to distill a feasible set of recommendations to improve clinical practice and guide future research that is underway now attempting to develop interventions to reduce implicit and explicit bias in clinical practice (We are currently developing an intervention program among patients and providers aimed at reducing bias in improving patient-provider interaction in collaboration with Porf. Alegria, Harvard Medical School).
Based on the findings of the current project and drawing on social psychological research we developed a model to assist in identifying mechanisms related to patient-provider interaction that underlie mental health disparities. The model includes processes rooted in social categorisation (outgroup bias) and in social power (impaired perspective taking, making automatic attributions) and suggests that the contrasting social identities of clinicians and patients can partially account for why discordant, compared to concordant ethnic identities in clinical encounters may produce worse outcomes, measured by the quality of the working alliance and the accuracy of diagnostic decisions (Naklash et al., 2012, Israeli Journal of Psychiatry). We are currently conducting experiments with non-clinical samples as well as a large scale field study in four outpatient mental health clinics to test the viability of the model. In addition, based on project findings, we expanded our investigation of mental health disparities to study ethnic mental health disparities among persons with cancer (see Nakash et al., 2012, Supportive Care in Cancer; Nakash et al., 2012 European Journal of Public Health; Nakash et al., in press, Suicide and Life Threatening Behavior). Finally, we expanded our investigation of the complex relationship between ethnic and socio-economic disparities with findings showing that a wide array of modifiable social factors shaped by income, education, and neighborhood socioeconomic conditions can explain ethnic health differences and highlight the importance of using multivariable models of SES (see, Nakash et al., 2012, Medical Care).
During the tenure of this project Dr. Nakash developed the infrastructure for current and future community participatory research (see website http://cccr. idc. ac. il/DefaultEng. aspx for different undergoing projects) by developing strong relationships with researchers in Israel and abroad, and with the medical directors and clinicians in outpatient clinics across Israel including the Jerusalem Mental Health Center, Abarbanel Mental health Hospital and Shalvata Hospital. During this time, Dr. Nakash has taught several classes (Clinical Skills, Research and theoretical seminars on Cultural Psychology, Qualitative Research Methods, Personality Theories) and supervised 10 undergraduate students on their research and two Master Theses.
Dr. Nakash has also shown her strong ability to communicate her research aims and to work collaboratively in research teams by publishing 19 papers/book chapters and presenting papers in international and national conferences. The findings from the project were published in several high impact journal (see dissemination section), and presented and conferences in Israel, Europe and the US.
As a testament to impact of the project and its findings Dr. Nakash was appointment to be a guest editor for a special issue on culture and psychiatry in the Israeli Journal of Psychiatry together with Prof. Levav (published in October 2012) as well as was awarded several grants from the Israel National Institute for Health Policy Research and Health Service Research for a project aiming to look at mechanisms contributing to mental health disparities linked to patient-provider interaction; and from the United States-Israel Bi-National Science Foundation looking at the Reliability, validity, and clinical utility of prototype diagnosis.
In addition, Dr. Nakash was able to deepen my collaborations with researchers in the European Union and was appointed to be a Representative of Israel for the European Union, ISCH COST Action IS1103 aimed at adapting European health systems to diversity (ADAPT), as well as be a co-investigator on a European Commission TEPMUS aimed to develop an international model for curricular reform in multicultural education and cultural diversity training. These collaborations show strong integration into the European research community.
In order to address goals of Aim II looking at the effect of explicit and implicit bias on intuitive decision making through a mixed methods design with mental health clinicians providing services to diverse population, we conducted an extensive field study to examine to role and characteristics of intuitive clinical decisions providers make during the mental health intake. One hundred and twenty-nine in-depth semi-structured interviews were conducted with forty seven providers following intakes they conducted with patients presenting for mental health care. We qualitatively analyzed the interviews to identify themes related to intuitive decision making (see Nakash & Alegria, in press, Qualitative Health Research). Our findings suggest that intuition guided many decisions providers made during the intake. Providers referred to intuition as a cognitive process which relies on knowledge acquired through past clinical experiences and is primarily based on non-verbal cues as well as affective communication. Mental health providers used intuitive processes in making decisions about multiple topics, including whether to trust a patient, how to facilitate rapport, which information to collect and how to decide on a diagnosis.
In order to address aim III which included the assessment of clinician reactions to the recommended improvements to the decision-making process developed in Aims 1 and 2, We carried out a series of consensus groups with clinicians at the clinics we data were collected as well as in two additional clinics. Their feedback was integrated in order to distill a feasible set of recommendations to improve clinical practice and guide future research that is underway now attempting to develop interventions to reduce implicit and explicit bias in clinical practice (We are currently developing an intervention program among patients and providers aimed at reducing bias in improving patient-provider interaction in collaboration with Porf. Alegria, Harvard Medical School).
Based on the findings of the current project and drawing on social psychological research we developed a model to assist in identifying mechanisms related to patient-provider interaction that underlie mental health disparities. The model includes processes rooted in social categorisation (outgroup bias) and in social power (impaired perspective taking, making automatic attributions) and suggests that the contrasting social identities of clinicians and patients can partially account for why discordant, compared to concordant ethnic identities in clinical encounters may produce worse outcomes, measured by the quality of the working alliance and the accuracy of diagnostic decisions (Naklash et al., 2012, Israeli Journal of Psychiatry). We are currently conducting experiments with non-clinical samples as well as a large scale field study in four outpatient mental health clinics to test the viability of the model. In addition, based on project findings, we expanded our investigation of mental health disparities to study ethnic mental health disparities among persons with cancer (see Nakash et al., 2012, Supportive Care in Cancer; Nakash et al., 2012 European Journal of Public Health; Nakash et al., in press, Suicide and Life Threatening Behavior). Finally, we expanded our investigation of the complex relationship between ethnic and socio-economic disparities with findings showing that a wide array of modifiable social factors shaped by income, education, and neighborhood socioeconomic conditions can explain ethnic health differences and highlight the importance of using multivariable models of SES (see, Nakash et al., 2012, Medical Care).
During the tenure of this project Dr. Nakash developed the infrastructure for current and future community participatory research (see website http://cccr. idc. ac. il/DefaultEng. aspx for different undergoing projects) by developing strong relationships with researchers in Israel and abroad, and with the medical directors and clinicians in outpatient clinics across Israel including the Jerusalem Mental Health Center, Abarbanel Mental health Hospital and Shalvata Hospital. During this time, Dr. Nakash has taught several classes (Clinical Skills, Research and theoretical seminars on Cultural Psychology, Qualitative Research Methods, Personality Theories) and supervised 10 undergraduate students on their research and two Master Theses.
Dr. Nakash has also shown her strong ability to communicate her research aims and to work collaboratively in research teams by publishing 19 papers/book chapters and presenting papers in international and national conferences. The findings from the project were published in several high impact journal (see dissemination section), and presented and conferences in Israel, Europe and the US.
As a testament to impact of the project and its findings Dr. Nakash was appointment to be a guest editor for a special issue on culture and psychiatry in the Israeli Journal of Psychiatry together with Prof. Levav (published in October 2012) as well as was awarded several grants from the Israel National Institute for Health Policy Research and Health Service Research for a project aiming to look at mechanisms contributing to mental health disparities linked to patient-provider interaction; and from the United States-Israel Bi-National Science Foundation looking at the Reliability, validity, and clinical utility of prototype diagnosis.
In addition, Dr. Nakash was able to deepen my collaborations with researchers in the European Union and was appointed to be a Representative of Israel for the European Union, ISCH COST Action IS1103 aimed at adapting European health systems to diversity (ADAPT), as well as be a co-investigator on a European Commission TEPMUS aimed to develop an international model for curricular reform in multicultural education and cultural diversity training. These collaborations show strong integration into the European research community.