When faced with the opportunity to establish a coaching relationship with a new patient, many factors may enter the coach’s mind as they prepare to engage and support the individual patient. What is known about the patient beyond the chronic disease or condition(s) that brought him/her to the coaching environment? How has the patient attempted to self-manage the condition? Is the patient generally compliant with suggestions made by the healthcare team? Another question increasingly being considered is how might characteristics such as race or ethnicity, gender, cultural background or socioeconomic status impact the patient’s ability to self-manage their condition? And how might knowing about these other, social characteristics change how the coach approaches the session or views the patient?
Continuing the series on integrating behavioral health and primary care, careful consideration needs to be given to our own feelings toward coaching our patients, including those with behavioral health needs or diagnoses; and how, whether we are aware of it or not, our own biases may affect our ability to effectively engage and support the patient.
This article provides merely a brief introduction to the topic of implicit bias; there is a vast and rapidly expanding field of evidence in this area. It is important to begin by offering some definitions.
Conscious (or explicit) bias:
A particular tendency, trend, inclination, feeling or opinion, especially one that is preconceived or unreasonable. Anurag Gupta, MPhil, JD, founder and CEO of Be More America. Racism, xenophobia, classism, and misogyny are some examples of explicit bias.
Unconscious (or implicit) bias:
Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control. Residing deep in the subconscious, these biases are different from known biases that individuals may choose to conceal for the purposes of social and/or political correctness. Kirwan Institute for the Study of Face and Ethnicity, Ohio State University
A mark of shame or discredit. Merriam Webster Dictionary
Tackling bias is an enormous undertaking given that our biases are based on systemic, cultural issues that are bigger than all of us. And, in the case of implicit bias, it is not something one is usually even aware of. And yet, in light of recent events in the US and elsewhere, it is incumbent upon health care professionals to begin to think about how these issues impact the work we do and the people we serve.
The formation of bias stems from the process of categorization, which forms early in life – as early as age 3-5 years. Categorization is the thought process of ‘grouping’ that gives order to life and allows one to make sense of and interact in their environment. If exposure to diverse experiences is limited, then stereotyping and bias can form. In recognition of this, in their Bright Futures Guidelines, the American Academy of Pediatrics now recommends that pediatricians address discrimination, prejudice and lack of cultural opportunities with parents and caregivers at various points throughout childhood https://brightfutures.aap.org/Pages/default.aspx.
It is certain that bias is present in healthcare. In an article in The Permanente Journal, of the US National Library of Medicine within the National Institutes of Health, published in 2011, the authors summarize the research documenting bias in healthcare and its impact on healthcare decisions and interpersonal communication. Further, the authors suggest the research indicates that bias in the healthcare setting may lead or contribute to health disparities https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347358/.
What can a Clinical Health Coach do to address this issue?
Thinking about this issue may seem a bit daunting, but there are a variety of suggestions in the literature. The Joint Commission, in a Quick Safety Advisory on Implicit Bias in Health Care, offers some skills that, along with organizational support, training and cognitive resources and motivated individuals, can help lower racial bias, including:
- Perspective-taking: The cognitive component of empathy, perspective-taking can reduce bias and inhibit unconscious stereotypes and prejudices. Physician empathy positively affects patient satisfaction, self-efficacy perceptions of control, emotional distress, adherence, and health outcomes. Perspective-taking refers to the act of viewing a situation from another person’s perspective, or “putting yourself in their shoes”. Perspective-taking in a coaching environment might involve taking stock of the factors that might be impacting a patient’s capacity to self-manage their diabetes, as an example, when the patient is also suffering from depression, anxiety, and is in an unstable housing situation. Managing their diabetes might be the furthest thing from the patient’s mind, in this situation. Understanding this, by thinking about how the coach might feel if faced with a similar situation, may change how the coaching session is approached.
- Emotional regulation skills: Clinicians who have good emotional regulation skills and who experience positive emotion during clinical encounters may be less likely to view patients in terms of their individual attributes, and to use more inclusive social categories. It’s easier to empathize with others when people view themselves as being part of a larger group. Emotional regulation involves taking a step back when one is in a situation and faced with an emotional response, considering why the response is occurring, and deploying a strategy to temper the response. This is a coping strategy we all use in situations throughout the day in response to stimulation that evokes an emotional reaction. There are healthy and unhealthy ways in which we regulate our emotions. In the coaching environment, the coach may hear things from the patient in which they strongly disapprove, but does the coach show that disapproval? Of course not – that would betray the coaching relationship. In this type of situation, the coach is deploying emotional regulation, by tempering response to a situation (patient talking or behaving in a way that evokes a strong emotional response in the coach) in order to maintain the spirit of the coach/patient relationship.
- Partnership-building skills: Clinicians who create partnerships with patients are more likely to develop a sense that their partner is on the same “team,” working toward a common goal. There is no need to elaborate on this skill – the Clinical Health Coach is already adept at establishing a partnership with the patient! https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf
Recognizing and being aware of how bias might impact our perceptions and reactions is an important step toward addressing our own biases. With training and organizational support, the Clinical Health Coach can work to recognize and address implicit bias, regardless of the population served, and move forward utilizing the skills in communication and engagement that elicit behavior change within the patient.
For those interested in exploring your own implicit bias, the Implicit Association Test (IAT) – a computerized, timed dual-categorization task measures implicit preferences in a variety of areas. There is even a Project Implicit Mental Health, designed to find out your implicit associations about self-esteem, anxiety, alcohol, and other behavioral health topics. Developed by Project Implicit, you can learn more and register to take the IAT at https://implicit.harvard.edu/implicit/.