[00:00:00] Dr. Sharp: Hello, everyone. Welcome to the Testing Psychologist podcast. The podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
All right, y’all. Here we are back with a clinical interview today. I am excited about this episode, y’all. Dr. Bridget Rivera is talking all about clinician identity, cultural, ethnic, socioeconomic, and so forth, and how clinician identity comes into play throughout the assessment process. We’re going to walk through the assessment process from the beginning, talking about a number of ways that identity comes into play and how we might tweak our work accordingly.
Let me tell you a little bit about Bridget. She is a licensed psychologist and a Florida-qualified supervisor. She holds the Master Addiction Counselor credential. She conducts psychological [00:01:00] assessments and provides consultation and coaching in the area of cultural humility.
Bridget began conducting diversity training about 15 years ago at a college counseling center in Maryland. University faculty, staff, and administrators started to request her consultation and training in the area of cultural competence and cultural humility, which led to the development of her consultation practice known as Authentic Diversity Training. She has since trained and consulted for both small and large organizations in the public and private sectors, including the VA, NSA, college campuses, and private organizations.
Bridget has multiple peer-reviewed publications and presentations in the area of psychological assessment, eating disorders, and cultural competence. She was awarded the Martin Mayman Award from the Society for Personality Assessment in 2010 for her distinguished contribution to the literature. I am so fortunate to have her here, and I think you’re going to take a lot away from this episode.
Before we get [00:02:00] to our conversation, I want to quickly mention my webinar, which is coming up in just two weeks. I’m going to be working with Build Great Teams and the Psychologists Association of Alberta to co-present alongside Ryan Matulis in a webinar titled Psychological Assessment of Children During COVID-19: The Nuts & Bolts. You can register using the link in the show notes. I know some of you may have heard me present on this over the course of the summer. I’ve done a number of these presentations, but I’m excited to hear Ryan’s component, which will focus heavily on working specifically with challenging and developmentally delayed kids. You don’t want to miss this one. Again, go check it out. Link in the show notes, and we hope to see you there.
All right. On to my conversation with Dr. Bridget Rivera.
[00:03:13] Hey y’all. Welcome back to the Testing Psychologist podcast. I’m glad to have you here today, and I’m really glad to have my guest, Dr. Bridget Rivera here to talk with me about what we bring to the room and just being aware of our own identities, the identities of our clients and how those may intersect throughout the assessment process.
Bridget, welcome to the podcast.
Dr. Rivera: Thank you for having me. I’m so excited to be here.
Dr. Sharp: Yes. Thank you. You reached out to me, at the time, it was right amidst everything going on after George Floyd’s murder and the protests and everyone is talking about [00:04:00] racism and anti-racism. As part of that discussion, you graciously reached out and volunteered to come chat with me. So, I’m grateful for your time. Welcome.
Dr. Rivera: Thank you. This is important work and it’s hard to engage in. So I’m really happy to be here to talk to you about this.
Dr. Sharp: Sure. That tees it up nicely, I think for the first common intro question, which is why is this important to you?
Dr. Rivera: This is important to me personally because people are often surprised to hear that I am an immigrant to this country. I was born and raised in the UK. I immigrated to the United States when I was 16 and very much remember the process of going through immigration, carrying a green card, and the struggles my parents went through, even though we were white and spoke English.
[00:05:00] I remember those difficulties. My father was deported when I was younger, prior to 16, prior to immigration. I remember what that looked like; people, just like in the movies, showing up at the house in their very nice suits and carding him off.
Cultural competence, then relations around multiculturalism in this country is important to me. I grew up, became a psychologist, and married somebody who is Hispanic. So these are conversations that we have a lot at home and just our journey through being married to somebody who is not white and what that has meant for us and what [00:06:00] it means for our kids and how we engage in this work.
Dr. Sharp: Sure. I feel like I have to ask, that seems like a powerful experience to see your dad deported. Was it?
Dr. Rivera: Yeah. I was 10 at the time. We were told to go upstairs; my sister and I were told to go upstairs and then we came back down and he was gone. I do remember the immigration officers being in the living room and that prompted the immigration process. Our green cards had expired. That’s what happened. That prompted the journey to become permanent residents. It wasn’t until I was actually in grad school [00:07:00] that I became a citizen. And those were for other reasons that I needed to do that for myself. So I carried a green card for many years in this country. I have no idea what it’s like for somebody who does not speak English, somebody who’s not white, but I can certainly speak to my own experience, but that’s personally why it’s important to me.
Dr. Sharp: Of course.
Dr. Rivera: Yeah.
Dr. Sharp: I appreciate you sharing that.
Dr. Rivera: Sure.
Dr. Sharp: And it’s coming up right away. I like that you acknowledge that you are phenotypically white, and to know that that’s just a good overlay for our whole conversation, I think, because there are things you may not know about people just from looking at them.
Dr. Rivera: That’s right. That’s exactly it. People often make assumptions based on when we see each other, when we hear each other, how we speak. [00:08:00] I think we have to be incredibly intentional to ask those questions because we don’t know what’s lying beyond those quick assumptions we’re making based on what we see.
Dr. Sharp: Right. I think that’s a great segue to jump into our topic here. We were talking about framing this conversation in terms of clinician identity and what we bring to the assessment process. My hope is that we’ll walk through the assessment process and talk through each of those components and how these things may show up. Could you maybe lay a little groundwork? Even when I say what we bring to the assessment process, what does that even mean?
Dr. Rivera: I think earlier on in training, depending upon when we were trained or early on in the field of [00:09:00] psychology, we were taught that multicultural counseling or multicultural assessment meant that when we are working with somebody who doesn’t look like us, or when we’re working with somebody who is a minority, we need to meet a set of standards to somehow illustrate that we’re competent.
Two things have happened over the last decade. We know now that everybody’s multicultural, going back to regardless of what we look like. And that is because all people are multicultural including white people. White people are often incredibly surprised to hear, Hey, I have a culture. There’s something meaningful to being white. Absolutely.
We now know that in addition, or perhaps in some cases as an alternative to being culturally competent, we need to [00:10:00] have some humility and this concept of cultural humility has emerged in the literature. So now the goal is to understand what am I bringing to the room and how my identity or my identities inform my assessment practice and what I’m bringing into the room when I’m doing testing. That includes those nuances, things that are maybe unique to what we’re bringing, to what the client’s bringing to the room. So we can think about how am I informing this process, even before we meet the client. So we want to take into account the fluid nature of culture and the challenges that we face to address maybe some inequalities that our clients may be struggling with. So we’re thinking about cultural humility as a way [00:11:00] to understand that I may not know either. I may not know what the client’s going through and ask them to be the expert for us.
First and foremost, even recognizing who am I as a psychologist and what identities am I bringing to the room so I can engage in this process of cultural humility,
Dr. Sharp: Right. You said two things there I wanted to pull out. One is, you said even white people have culture. What do you mean?
Dr. Rivera: I think about identity dimensions as being multi-faceted and how they overlap. So a couple of things there. Think about ourselves and our clients as holding race, ethnicity, sexual identity, religion, spirituality, socioeconomic [00:12:00] status, class, gender identity, disability or ability, and age.
Race-One thing we know it’s socially constructed, right? The science is very clear that there are no biological differences in race. Race is socially constructed. However, it’s still really super meaningful. So we do want clients to be able to talk about that, including perhaps our white clients. There’s no biological basis for race. We know that there’s no gene or cluster. There are no genes common to any particular race. This is a human-invented classification system as a way to define those physical differences, but we know that it’s not biologically real.
[00:13:00] People grapple with that, that this is a socially constructed phenomenon. People say, and they’ve said to me, that I can see race. I can see that you’re white. I can see that she’s Asian. I can see that he’s black. So it’s difficult, right? This is something difficult for people to realize, but we know that there’s no biological basis.
Marriage is socially constructed. However, marriage has very serious legal, cultural, and interpersonal implications. The same is true for race. I encourage my white counterparts to explore what it means for them to be white. What does this mean to you? And I think that’s really hard work for white people to engage in because then we begin to feel guilty that we’re white, right? That means that we’re carrying some [00:14:00] power, some privilege. There’s been a lot written about that.
Peggy McIntosh wrote The Invisible Knapsack. What I’m carrying around as a white person, I now have this Bag or backpack of passports that have been handed to me simply because I’m white. So let’s talk about that with our colleagues. Let’s engage in that conversation.
And then ethnicity, which oftentimes white people, and I think especially at least Americans that I’ve spoken to have a hard time even defining what is my ethnicity. I hear sometimes people say I’m Heinz 57. I’m everything. My grandparents are 50% this, 40% this, and 10% this and we’re not sure. There’s a story behind that. Where did that come from? How did your grandparents get to America? What did they have to [00:15:00] give up to get here? And what does that mean for your family? What does that mean in terms of traditions or lost traditions or how we relate to one another, how we celebrate, how we cook? All of that is incredibly informative.
The other piece is how these identity dimensions we’ve only talked about two, race and ethnicity, how do they intersect or not intersect. Which ones are most powerful in terms of how I view the world? Does my sexual identity interact with my racial identity or my ethnic identity? Does my religion and spirituality interact with any of these? So these identity dimensions do not carry equal weight. They do not carry equal power. It’s not like we can [00:16:00] compartmentalize them like pieces of pie that hopefully we cut out equally when we serve pie. One may be much larger. One may be much smaller. So typically, this isn’t always the case, but typically, those identity dimensions where we’re not holding power and privilege tend to hold more weight in how we see the world.
A black client may say, my race is holding 75% of my identity. That piece of my identity is incredibly informative, maybe not so much as my sexual identity. So where we’re holding power and privilege, they tend to feel smaller and less informative in how we view the world, because that’s where we are metaphorically invisible.
[00:17:00] I like to talk to mental health professionals about visualizing what those identity dimensions look like. If we were to draw them, what would the picture say? Which identity dimensions would overlap? Which ones might be off the page? Which ones might hold a lot of space on the page? Let’s think about what that means then for your work with your client.
Dr. Sharp: Yeah. I like the way that you phrase that. As a visual person, I think the pie makes a lot of sense. I think that’s a process that all of us need to go through explicitly at many points in our lives because they shift over time.
Dr. Rivera: Absolutely.
Dr. Sharp: That piece of how it comes into play with our clients is really important. That’s a big theme of what we’re talking about. [00:18:00] I wonder if we might start from the top of our assessment process and have some discussion around how these identities influence each component of the assessment process. Starting from the very beginning with our intakes, what are some things that we may need to be aware of as we are conducting those?
Dr. Rivera: I think being very intentional about first asking clients these questions, even though they make us uncomfortable. We tend to stray from things that make us uncomfortable. So it’s learning how to tolerate these uncomfortable questions. First and foremost, thinking about what questions am I asking now pre this discussion and what might I need to add to those interview questions. Is there something that’s making me [00:19:00] a little more uncomfortable than others?
So how we greet clients, how clients greet us, how we advertise or don’t, how we format our reports, how we’re understanding testing. All of that is informed not only by our training but also who we are and our worldview. So those identity dimensions are going to inform our worldview. Thinking about what am I doing now, what do I need to do a little bit of rub, and probably where we’re feeling that rub? Probably where we’re feeling that rub or that friction is probably where some shift might be needed. And it’s usually about engaging clients in these conversations at intake. So the cultural background of the psychologist or the supervisor or the student is going to be [00:20:00] a pretty pervasive influence for a really strong argument to continue to examine our own cultural and racial identity. This should be part and parcel of the professional psychology preparation. I don’t think it always is.
Dr. Sharp: Oh yeah, I can guarantee. It’s not always part of that preparation. You said some of these questions we might need to be aware of things that we would ask about. I know you do a lot of supervising and training, right? So what are some things that you see are some of those common avoidance points or questions that we don’t ask that we probably should be asking during intake?
Dr. Rivera: There’s some written work on this by Richard Dana. He’s done a lot of work on this. The other piece that I think, and I would guarantee everybody takes a look at if you haven’t is the cultural formulation interview. [00:21:00] It’s in the appendix in the DSM. Everybody should have access to that, hopefully. There are 16 questions there which address four domains. So we want to think about the cultural definition of the problem and the cultural perception of cause, context of the problem, how the client is getting support, and any cultural factors, again, even if your client’s white, that might be affecting coping skills or past help-seeking, think about acculturation, again, even if your client is white. Don’t make the assumptions that people may think, Bridget is American. It’s not until somebody asks or I share, oh, wow, oh, I didn’t know that, and so how does that inform how I’m walking around In the world? So think about [00:22:00] acculturation.
The other important pieces to consider are around asking clients very intentionally about those identity dimensions. So asking about religion and spirituality, asking about faith. So ask clients, do you subscribe to any religious beliefs? And what does that look like for them? Because that might have huge implications for the recommendations in a report or huge implications for symptoms.
I just tested a guy who identified as white. Some things came up a little problematic in some testing and it wasn’t until post-testing that we were digging a little deeper into his ethnic background he shared that both parents are Muslim and this was part of the reason why he was [00:23:00] engaging in some behaviors that were a little problematic. We had a really meaningful conversation about his religious beliefs, his ethnic background, and it was just, again, another headline for me of how important it is not to make assumptions based on what people look like. So ask.
Gender identity, I think we often assume that somebody might be heterosexual based on they look like the average person walking around. So always ask that question about gender identity.
Race. We can engage in those conversations. We can talk to clients about how do you identify and what does that mean to you? I usually preface those questions with, this may not seem [00:24:00] connected to why you’re here on the surface, but it’s really helpful for me to have a full understanding of who you are.
Sexual identity and practices; to be incorporating those into our intake interview, asking about a disability and ability, which may not, again, seem super obvious, clients may not share unless we ask, because they may not think it’s important.
And then to be thinking about how to power and privilege inform these identity dimensions. So where are we and clients holding both power and privilege or not? And how does that inform not only the testing data but also recommendations in terms of what we could do for that very important section of the report?
Dr. Sharp: That’s such a good [00:25:00] point. Two questions with all of that, just very practically, are you asking about all of these dimensions of identity on your demographic form or just in the spoken intake conversation or both or what?
Dr. Rivera: Both. Some of it is on my demographic form and then I use that when I’m meeting with people face to face. Some of it may not come out in that order. I may have to go back to it, or I may have to seek some clarification. And again, some of this comes down to, I think we’re trained and probably the message is, as testing psychologists, we need to be incredibly objective and be a “blank slate”. And I would argue against that. Rather than trying to be super objective, which I think it’s [00:26:00] impossible, as human beings, we are not objective at all. So recognizing what am I bringing to the room and how am I asking these questions and sometimes even making that piece of the conversation intentional and transparent with the clients.
This guy that I was just talking about, I did say to him, what’s it like having this conversation with me a woman, because he was struggling with some sexual behavior things that probably felt very shameful and guilty to him. So I needed to ask, especially given his upbringing, what it was like for him to have that conversation with me.
Dr. Sharp: Right. So just making it explicit that even talking about it could be uncomfortable.
Dr. Rivera: Right. And that adds [00:27:00] to the data. That’s very different than somebody who says, I have no problem talking about this and they’re taking maybe some pride in making us uncomfortable.
Dr. Sharp: That’s a good point. I was also curious about the elements of power and privilege and whether you ask about those explicitly or that’s something you’re intuiting somehow. How does that get brought into it?
Dr. Rivera: There’s a lot of literature on targets and agents and these are bi-directional. There’s no continuum for targets and agents where we are holding agent status. In those identity dimensions, we hold some power. Where there are identity [00:28:00] dimensions, where we’re classified as targets, that’s where there’s going to be much less power, and especially white clinicians have a hard time admitting and owning, you know what, I’m holding a lot of identity dimensions where I’m considered the agent and what that means. That means I’m holding a lot of power, a lot of privilege, very different than a person of color.
I don’t typically ask on an intake about power and privilege. That is something that I’m gathering based on how somebody has described those identity dimensions to me. For example, as a white woman, I’m holding a fair amount of power and privilege with the exception of gender. We know that women are [00:29:00] typically going to hold and do in most cases, hold less power than their male counterparts. So that’s only one identity dimension where I’m falling into that target category. But race it’s typically, and is white, is agent, lots of power there, speaking in the United States, religion, anything that’s considered Christian or somewhere in that faith, again, lot of power because that’s ‘the norm’. Sexual identity, heterosexual, again, lots of power there, that’s the agent category. Gender identity, that’s where males are going to fall into that agent’s category, a lot of power.
Socioeconomic status. This is something that promotes tons and tons of conversation and disagreements. [00:30:00] But typically because people, I think the statistic is around 80% of people in the United States will classify themselves as middle class. We all know that there’s a pretty wide middle class, but everybody wants and will identify as middle class. And that’s the identity dimension where we’re going to see agents and power there as opposed to somebody who’s going to be considered working class or lower class.
To get back to your question, I don’t ask about power and privilege unless it’s going to come up, but based on those identity dimensions, I can usually get a sense of how we’re functioning in the United States and what that means.
Dr. Sharp: I see. That makes sense to me. Knowing that there, I’m sure there are some cases where others, there are some differences in how people perceive themselves and their power and so forth, but [00:31:00] those are a number quality dimensions to be thinking along.
Dr. Rivera: Right. When we engage in this workaround cultural humility and cultural competence, that’s the work. Thinking about where am I holding power and privilege, what does this mean for me, and what does this mean for my work with clients, and being able to get down in the dirt and explore what this means. That’s the work. And that’s where people… That’s the discomfort.
Dr. Sharp: Absolutely. I think as humans, not to spend too far out into the philosophy of all this, but as humans, we like to have things make sense, classify things and people, and have rules and heuristics. With something like this, it’s hard to do that. All these intersecting identities are a very [00:32:00] complex calculus to try and figure out how it manifests for each person.
Dr. Rivera: Yeah. It’s not easy.
Dr. Sharp: Right, but that’s why we’re having these conversations bringing it to mind and breaking those those shortcuts in our brain that we’d like to make.
Before we move to the testing process and how identity might show up there, I am curious if you had thoughts on… You mentioned greeting the client or how our space is set up for clients. Are there any pieces you wanted to highlight there in terms of what we bring or what we need to be aware of?
Dr. Rivera: Yeah, I think again, what are we doing currently and what does that say about us? Questions to ask. Are we being inclusive to everybody? What magazines do we have in our waiting room or lobby or therapy [00:33:00] room? What messages does that send to clients? How I greet a client. So that has incredible cultural implications, right?
I was just speaking with somebody yesterday, a colleague, and she said somebody kept calling her ma’am. It was making her uncomfortable. And then it wasn’t until she realized, oh, that’s because of his military background and military family. That’s how he was raised. Some people are going, do they call a doctor or not? Do we require that, ask that, or recommend that? Are we okay with the first name? So there’s going to be cultural implications around that and assumptions we might make about that. What does our space visually look like? All of those sorts of things to wonder about.
Dr. Sharp: Absolutely.
Dr. Rivera: There’s no [00:34:00] magic formula. Your waiting room should not look a certain way. There’s no magic things that we need to put in or not put in, but let’s just at least reflect on this. And then based on who we’re working with, who we want to work with, or what our community represents, what can we do to be inclusive and welcoming and what might we need to tweak a little bit?
Dr. Sharp: Right. That example that you brought up of the magazines, I think, is a very simple, but very poignant one. And that if you look through the, just look through the magazines that are hanging out in your waiting area, and that was a real wake-up call for us probably 2 or 3 years ago when we did that. And then from there made the decision to include much more diverse magazine content and it’s made a huge difference.
Dr. Rivera: Yeah. Those are very small things that [00:35:00] clients talk about that make a very big difference that we may not realize.
Dr. Sharp: Sure. I will say this, there was a big, a lot of us get that magazine Psychology Today for registered psychologists. There was a big discussion a year or two ago about what percentage of their cover models were white versus people of color.
Dr. Rivera: I remember that.
Dr. Sharp: Anyway, that’s all I’ll say about that, but Magazines are important.
Dr. Rivera: Right.
Dr. Sharp: Let’s talk about the testing process. This is a big area. Just to give us some boundaries here, I suppose, I’m curious more about the process of testing versus the tests themselves, if that makes sense. Maybe we stick with the process and how these identities may show up as we’re testing.
[00:36:00] Dr. Rivera: Definitely, we want to think about that referral question, right? The referral question is going to tell us what tests we need to give. And so we’re not going to touch that. We need to think beyond that, how are we going to interpret the data based on the uniqueness of the person that we’re working with?
Being culturally competent when we’re doing testing requires that solid foundation in the traditional assessment theory methods. And that’s why we’re not going to touch that. That’s a whole other conversation. So we need to specify and then test when we’re looking at the data, what about the social and cultural world matters and what about that matters to this client to avoid making inferences based on [00:37:00] any group labels associated, most commonly it’s going to be with ethnicity or race. So we need to hold and maintain and be able to tolerate that healthy tension between behavior that’s culture-specific and culture-general as we’re looking at the data.
Students often have conversations, well, it must be all cultural. That’s how we need to understand all of this. Or no, it’s just, and I say just with air quotes there, “This is normative behavior.” We need to be able to balance both of those. So rather than go to a chapter in a textbook on what it means to understand any specific culture, let’s maintain that tension between viewing behavior as culture-specific and culture-general, and then [00:38:00] interpret the test data in that account, not just as one identity dimension. That should be the overlay, if you will, when we’re looking at the data and interpreting it in that context, based on the referral question and the test that we chose to use.
From there, we can observe the behavior during the test administration; what does this mean for this client and who they are? What might that mean for them and all of those different identity dimensions? And then we can gather cultural information from our client or we could use that cultural formulation interview that’s available in our DSM and ask some of those questions to [00:39:00] help understand the person and his or her unique context, […] the overlay, if you will, or the groundwork for embarking in this process.
Dr. Sharp: I like that. I wonder if we could bring it to life with an example of some sort. Do you have any top of mind that you could talk through and what it means to interpret the data in this way?
Dr. Rivera: Yeah. I think I shared this with you when we talked previously. The case that is always in my mind is when I was on internship many years ago, without dating myself too much, in a state hospital and a young woman came in exhibiting pretty strong symptoms of psychosis. She was hallucinating [00:40:00] and talking about voices that she was hearing. She was in her early 20s and was diagnosed at the time with a psychotic disorder. They started her on medication.
It wasn’t until somebody said, I think we need to do testing on her. Something is not quite right. The data came back pretty psychotic, pretty symptomatic of everything in line with schizophrenia, and it wasn’t until we were giving her feedback and her family feedback, it was a family member who said, and this was a Hispanic woman, it wasn’t until they said, “Her uncle just died and we’ve been practicing these religious beliefs and [00:41:00] practices around chanting and saying goodbye to this uncle. They’d been engaging in this for many days that her symptoms were likely representative of this religious practice. And she was seeing her dead uncle.
When the hospital weaned her off this medication, she came back to reality pretty shortly thereafter and we were able to dig much deeper into this religious practice that the family was engaging in, what this meant for her, and how she was incredibly bereaved missing this uncle that was very close to her. And so when we looked back at the data in that context, it made much more [00:42:00] sense and helped us understand what was going on for her. But I think about what could have happened had we not had that conversation. This diagnosis would have followed her and she was on anti-psychotic medication. So I encourage people to think about what this might look like for somebody based on what’s happening in their life at the current time.
Dr. Sharp: Of course. That is such a great example. I’m glad you went over that. It’s something that we can totally overlook if we don’t think to ask those specific questions.
Dr. Rivera: Yeah. I think about the guy that I just met with whose parents are Muslim, again, looking at the data, there were some things that were pretty problematic in terms of his interpersonal relations, and it wasn’t until [00:43:00] he was able to share with me what was happening for him in his life and that made much more sense once I had all of those details, which I would never have been able to gather unless we’d dug in and engaged in this incredibly intentional conversation. And that comes from adding those additional questions; tell me about your religious beliefs, what does that look like every day, how does that inform your relationships, what does that mean for your romantic relationships, and what does that mean for coming here and talking with me, so on and so forth? It’s like peeling the different layers of an onion and getting to the heart of the matter.
Dr. Sharp: Absolutely. I can see this very easily translating to [00:44:00] assessment of personality or behavior. Can you think of any examples of more cognitive assessment that this would apply to?
Dr. Rivera: Yeah. So where that comes alive for me is when I’m working with kids and then having to give recommendations or put in the context of behavior to parents because our worldview is everything when it comes to parenting, right? Why do we discipline the way we discipline? Usually, that’s coming from our parents, right? I think the running joke is often, Oh my gosh, I’m becoming my mother, even though we may try not to do that. So we typically discipline and talk to our kids based on worldview, which gets sometimes informed by parents and the generations [00:45:00] that came before us.
Think about somebody’s worldview and the parents of the kids that you’re working with- their worldview, and what that’s going to mean for how you set up a report, what recommendations you’re going to give, and how you’re going to understand the presenting problem in terms of what does this family look like. That’s everything. That’s everything with worldview. Again, religious practices, socioeconomic status, all of that is housed.
We may think it’s a learning disability report, I don’t have to consider these questions, but sure you do when it comes down to those recommendations because some parents are going to look at you and say, there’s no way I’m doing that.
Dr. Sharp: That’s a great point. I think there’s a lot to be said for the report [00:46:00] and recommendations. Before we transition there, are there ways, this is a tricky question or maybe a tricky topic to wade into, but without talking about test construction, validity, and so forth, are there other ways that you may encourage us to consider identity and culture in interpreting neuropsychological data, for example, or the actual scores, and maybe that’s not possible, but I’m trying…
Dr. Rivera: It gets down to our norms and ensuring that we’re using the right test for the client. Using test data, we want to make sure that cultural information is considered in terms of normative issues and how we interpret [00:47:00] as well as psychopathology. So can we adequately understand the client and his or her culture based on the test that we’re using and the test data? Are we describing any confounds or interactions? Can we include those in the report? What is informed by culture in terms of behavior, which I think is described by neuropsychology when we’re looking at a WISC or a memory test or social class might be informed based on education? I don’t know if that’s getting down into the weeds there a little bit, but are we thinking about all of those pieces? Does that make sense?
Dr. Sharp: Sure, it does. And like I said, that’s hard, I think maybe I’m looking for something that’s [00:48:00] not there that we can’t answer that question without really getting into those pieces of test construction, normative data, and so forth, which is totally fine.
Let’s talk about the report then and recommendations a little bit more explicitly. Right off the bat, thoughts on how these elements come into how we write our report.
Dr. Rivera: Richard Dana has lots of literature on this. He’s defined what he calls six psychological report ingredients. Before we get to the report, I would recommend using the cultural formulation interview, which is available in the DSM, and then using that to underscore the six [00:49:00] report ingredients.
The first is looking at the relationship between the client and the examiner and taking that into consideration, maybe in our behavioral observations section. That requires a culture-specific, hopefully, delivery style, again, thinking back to what am I bringing to my relationship with my client and am I engaging in that, and then commenting on that. That can determine adequacy, sufficiency, consistency, hopefully, reliability in terms of the client data, and then describing identity so moving down the report thinking about that demographic section, or did we ask those questions, those really important questions, which may take a little more time, and are we [00:50:00] noting those in the report, and so that includes cultural and racial identity. Again, I want to underscore, even if the client looks like us, and even if the client fits what might be considered mainstream here in the United States. So we have to state Caucasian or Asian or again, however, the client is identifying, including all of those identity dimensions, which will then eventually… Go ahead. Sorry.
Dr. Sharp: I was just going to ask where you are putting that information in the report. I know people do it in different ways. I’m curious how you do it.
Dr. Rivera: Sure. I put it in one of those first paragraphs when I’m describing the client. Jane Doe, a white, female, identifies as XYZ.
Dr. Sharp: Got you.
Dr. Rivera: And then I may come [00:51:00] back to that depending upon what I’m writing about.
Dr. Sharp: Okay.
Dr. Rivera: And I include religious affiliation, and I may come back to that.
Dr. Sharp: Okay, I like that. Right at the front.
Dr. Rivera: Yeah, where we’re describing the clients. I know people set up their reports in different ways and call that paragraph something different, but right there early on because that’s going to inform everything else. I don’t want it to get lost. I want to be very clear that this is going to inform how I’m understanding the person I’m working with.
Dr. Sharp: Okay. Thanks.
Dr. Rivera: We should then obviously inform the tests that we use if they’re culture-relevant and or not, hopefully valid.
Dr. Sharp: Yes. Good points.
Dr. Rivera: And then in terms of the test data, I think I’d also be [00:52:00] including some discussion of what that means. So, if there are some issues there with maybe an instrument not being incredibly valid, or what does this mean for the client’s culture? I have been very intentional in addressing that and how I’m using the data.
Dr. Sharp: I see. I would imagine that that discussion might go in the part of the report where you’re reporting each test result.
Dr. Rivera: And the validity as well.
Dr. Sharp: Yeah. I know a lot of people are moving toward a model of not reporting test results in the text of the report. I wonder then, maybe we could list or we could discuss it just under the validity section.
Dr. Rivera: Absolutely.
Dr. Sharp: Yeah, that makes sense. All right.
[00:53:00] Dr. Rivera: And that’s one of Richard Dana’s what he calls ingredients that we’ve recognized and described any confounds or interactions that might be informing the data. So we have to use our clinical judgment hat to make those decisions based on those questions that we’ve been very intentional about and dialogue that we’ve had in a robust manner with the client.
Dr. Sharp: Are there other things in the report that we need to be aware of aside from recommendations, we’ll talk about that.
Dr. Rivera: Yeah, I think the other big piece is what the report looks like at the very end, the final product, if you will. When we’re thinking about it, is it meeting standards? How long is it? If it’s going back to a [00:54:00] client, can they understand it? Is it user-friendly? Is it personal or informal? Are we using behavioral language that somebody can understand? The literature is geared now to avoiding jargon, using short descriptive sentences that somebody can understand. Are we using vocabulary that makes sense? Those kinds of things in terms of the final product.
Dr. Sharp: Yeah. I’ll give a shout-out to Stephanie Nelson, who’s been on this podcast. She has some user-friendly articles on how to make your reports more readable and readability level and things like that.
Dr. Rivera: Yes. It’s imperative.
Dr. Sharp: Yes. It’s something that we overlook.
Dr. Rivera: It is, and it’s something, hopefully, that I tell students all the time. Is this something you’re going to want your [00:55:00] clients to read? The answer should always be yes. If it’s not something you don’t want them to read, then we’ve got to make a lot of edits. So it’s got to be user-friendly.
Dr. Sharp: Absolutely. I’ve gotten on the soapbox before on the podcast, so I’ll keep this brief, but I think there’s a lot of evidence out there that we are riding way above the heads of the vast majority of our readers. So to me, this isn’t even a cultural or identity issue. It cuts across. It’s across the board with, of course, so many affected.
Dr. Rivera: I would argue it’s a cultural issue in terms of how psychologists have been socialized.
Dr. Sharp: Sure. I can get on board with that.
Dr. Rivera: That’s something that we are bringing to the room. So that is very much about how [00:56:00] we’ve been trained to be “scientific, empirical, super smart” because that traditionally represents, again, white invisible, “normal” middle to upper class, highly educated individuals. We’ve just demonstrated that. Again, let’s take a look at how long are our reports. What’s the language we’re using? Does this make sense? What work do I need to do now to change that?
Dr. Sharp: Such good points. How about the recommendations then?
Dr. Rivera: Yeah, let’s think about that. When we’re writing those recommendations, first of all, are they realistic for the client?
Dr. Sharp: Always a good question.
Dr. Rivera: Is this something [00:57:00] that a family, if you’re working with kids, can get on board with? Is this realistic economically? Is this a resource our client has access to? What recommendations do we need to make to, hopefully, ensure they’re going to connect to those recommendations? Is this a parenting practice that a client can get on board with? So again, going back to all of that conversation we had at intake and everything we’ve learned about the client and putting those recommendations in the unique context of the client.
I’ve talked to a lot of families who say, I’m not doing medication. I’m not going to meet with a psychiatrist because I don’t believe in medication. So we need to consider that. Are they going to go back and share this with the school? Oftentimes, people don’t want to because [00:58:00] of shame. So let’s think about that. What does that mean then for my client?
So rather than a cookbook or boilerplate template of recommendations, let’s specify recommendations that are unique and particular to our client.
Dr. Sharp: Yeah, I think that’s so important. I am curious for you, Bridget, how you balance the conflicts that might arise there if “Science” or research goes against the client’s cultural identity. I’ll just give an example to illustrate. For me, this comes up a lot around spanking, let’s say. I grew up in an environment where that was totally normal. [00:59:00] I get it and I think the science is pretty clear that we shouldn’t spank our kids but a lot of families might want to do that. That’s just one example, but there are many others.
Dr. Rivera: Yes. That’s a great example. I will hold on one hand that that’s culturally acceptable in many cultures. I have to hold that. That’s uncomfortable. I don’t like it. I have to hold that. That’s something that in some cultures is acceptable and the proper way to discipline your children. I have to balance that with now what’s my role here. Do I need to have a conversation with mom and dad or parents about this and share perhaps some science that spanking is ineffective and possibly damaging? [01:00:00] How am I going to still hold very clearly that this is culturally acceptable and imagine for myself what that conversation is going to look like and what’s my job as a psychologist?
Again, this gets back to those early conversations around reflecting on my own identity and reflecting on what am I bringing to the room and how can I perhaps engage in a conversation; not just necessarily give Mom and Dad a handout on spanking, but let’s talk about this. I may ask Mom and Dad, what’s it like to have this conversation with me? This is what we’re seeing, these are some behaviors, and this is perhaps what I’m recommending [00:01:00] instead. They may come back and say, “You crazy white woman. That’s not what we’re going to do.”
Dr. Sharp: Sure. And then, what do you say to that?
Dr. Rivera: I may laugh and say perhaps you’re right. You’re here paying for a service. I’m going to try to give you the best recommendation I possibly can. These are some alternatives. What might that look like for you if you do something different? What might your social support system say? I’ve certainly had people say to me, no way I’m going to try something different because my whole family will shame me. So let’s engage in that conversation. So it is holding both pieces together and not necessarily disregarding something completely, because it’s a [01:02:00] culture “specific behavior.”
Dr. Sharp: I like how you phrase that. A theme through this conversation, I think, is holding many dimensions and ideas at once. That’s work for a lot of us.
Dr. Rivera: It’s hard work. Yes. I think the subtext here is we know and the literature has shown us and there have been studies on this, that the ability of mental health professionals, psychologists, students, supervisees, and supervisors to engage in some self-introspection and some reflection about this is incredibly effective and helpful.
There was a study done a few years back now on microaggression. [01:03:00] It demonstrated that psychologists who were able to be culturally have some humility and demonstrate cultural humility exhibited less microaggressions, which of course are unintentional than their counterparts who are not engaging in this work. But nobody ever said it was easy.
Dr. Sharp: Yeah. I’m tempted to just ask about resources for that. Is there anything else you would like to say about the report or recommendations though, before we make that transition?
Dr. Rivera: I think consulting, talking about this stuff. That’s the number one thing, talking about it, consulting about it. It’s not something we can do alone. This is not work that we can do in isolation. This [01:04:00] is not work that we can do in our own office by ourselves. So get a group of people together who are willing to have these conversations.
So we’ve now moved from this philosophy of it needs to be a ‘safe space.’ We’ve moved from that to this needs to be a brave space. Can we be brave enough to have these conversations? So no longer safe because guess what? This doesn’t feel safe. This is hard and we have to be brave and courageous. So first and foremost, being willing to have the conversations to talk about it, to engage in that ability, to reflect, and then there’s lots and lots of really wonderful literature.
I think first and foremost, I would recommend anything by Richard Dana, who’s done a ton of work on this and outlines what we need to do as a clinician. He really [01:05:00] talks about this ability to become self-aware, to identify our own biases, to think about perhaps what blind spots we have. It’s impossible to know our blind spots because they’re blind spots. And so that requires doing some hard work. So doing that. And then thinking about what we need to shift in terms of the assessment process. He talks about those six ingredients to the report to ensure that we’re being as competent as possible.
Janet Helms has done a lot of work on racial identity, and specifically for my white colleagues’ white racial identity. She wrote a fantastic book called A Race Is a Nice Thing to Have: A Guide to Being a White Person or Understanding the White Persons in Your Life. [01:06:00] So racial identity. Just continuing to learn about this. And first and foremost, talking about it with colleagues.
Dr. Sharp: Yeah. I love that. I think that’s part of the deal here over the last several weeks. I’m not sure when this is going to air. So forgive me if this is dated a little bit, but at least when we’re recording, that’s a huge theme around our country right now and in our field is having these conversations and doing your work and engaging in this process as much as possible.
Dr. Rivera: And for those of us working with students, being transparent and supervision about this stuff. The supervision dyad has massive [00:07:00] implications for the work with clients. I asked students, how do you know those identity dimensions? What data are those assumptions based on? I asked myself, what assumptions have I made about my supervisee because of his or her identity dimensions?
I may ask a supervisee, how do you identify? And then I need to think about, they’ve told me about their identity dimension, but what does this mean for them and their work? So engaging in that conversation and asking students, at what point did you notice your client’s identity dimension? What assumptions have you made about those identity dimensions? I asked the supervisees, what assumptions are you making about me? Of course, I’m not going to ask these questions in the very first supervision session. This happens over time slowly as [01:08:00] trust is formed to be essentially thinking about what impact our worldview has on those final conceptualizations or diagnoses.
Dr. Sharp: There’s a lot to process here and a lot to consider. My hope is that this information is really landed with people and that folks will walk away thinking hard about identity in these different dimensions and how it comes into play in this assessment process, but for ourselves and our clients. I hope so.
I just want to say, thank you for talking through all of this, being so candid, and giving great examples. I know that you’ve put together a pretty stellar document. To call it a handout seems we’re undercutting [01:09:00] how awesome it is. But we’ll have a document, let’s say in the show notes that has a ton of resources and information that overlaps with what we talked about.
Dr. Rivera: Thank you. Thanks for having me.
Dr. Sharp: Anytime Bridget, anytime. Yeah. Thank you.
Dr. Rivera: Okay.
Dr. Sharp: Okay. Y’all. Thanks so much for tuning into my episode with Bridget. I hope that you took a lot away from that and enjoyed the episode. I know that I did. She is fantastic and super knowledgeable.
One more mention for my webinar coming up in two weeks with the Psychologists Association of Alberta and Build Great Teams. You can sign up for that in the show notes.
If you are an advanced practice owner who’s looking to get some support and some group coaching to take your practice to the next level, either by hiring or hiring again, streamlining your systems, or [00:10:00] building additional streams of income, then I would invite you to check out my Advanced Practice Mastermind, a group that I facilitate with no more than 6 of your peers. And that’s going to be starting in September. So you can go to thetestingpsychologist.com/advanced and sign up for a group screen.
Okay, y’all. Take care.
The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional psychological, psychiatric, or medical advice. diagnosis [00:11:00] or treatment.
Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.
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