Implicit Bias in Clinical Practice
Chelsea Privette, M.Ed., CCC-SLP, for ArSHA'S Cultural and Linguistic Diversity committee
Everyone has biases – both positive and negative. Implicit bias affects our clinical practice in ways that are subtle to us, but in not-so-subtle ways to the clients we serve. The good news is that we have the ability to identify our biases through self-reflection and self-awareness, and we can shift harmful biases by taking the position of cultural humility.
What is bias?
Bias. That’s a scary word for a lot of people because it comes with a lot of negative connotations. But, the truth is that we all have biases – both positive and negative. We will always have biases. They do not go away; but they can change. When we recognize the negative biases we have and how they can hurt people, we are able to shift those biases with intentional and focused effort.
Merriam-Webster defines bias as “an inclination of temperament or outlook; prejudice; bent; tendency.” This is the more common use of the word. But bias also means “systematic error introduced into sampling or testing by selecting or encouraging one outcome or answer over others.” This particular definition goes beyond sampling or testing in a controlled environment. All of us are socialized to internalize certain biases about different people, places, and things, thus creating systematic error across systems – the justice system, employment, education, and health care included. Bias results in the policies and practices that differentially affect marginalized groups based on language, race, religion, sex, gender expression, sexual orientation, ability, age, and class. These discriminatory practices – intentional or not – produce health, educational, and economic disparities.
We hear the term implicit bias a lot without reference to explicit bias. But it is helpful to note the difference. Explicit bias can be stated. They are attitudes that we openly share with others, even if we do not share them with everyone. Implicit bias, on the other hand, are those attitudes that we do not consciously consider. Still, they contribute to our behavior. Payne and Cameron (2014) state that socially interesting behaviors are a combination of intentional (controlled) and unintentional (automatic) processes. In fact, implicit attitudes predict behavior in ways that explicit attitudes do not (Cone & Ferguson, 2014). This means that one can act in a way that is inconsistent with one’s explicit beliefs, in which case, one’s explicit beliefs are not consistent with one’s implicit beliefs. The most common example of this, particularly as it relates to race, is the statement, “I am not a racist.” No one wants to be called a racist. It is no longer widely accepted to identify as a racist. However, a person who makes that statement can be – and often is – the same person who is afraid to enter an elevator with a black man, who is repulsed by the sound of families speaking a language other than English in public, who tells their children not to bring home a significant other who does not belong to the same race as them.
Before we can attempt to change our biases (or attitudes), we must understand what they are and how they function. An attitude is an evaluative perception (positive or negative) of an object (person, concept, or thing; Oskamp & Schultz, 2005). Each of your attitudes vary in degree of favorability. The psychology literature calls this the valence – or intensity – of an attitude (see figure 1). Each of your attitudes also has three components of complexity: cognitive (information), affective (familiarity and associations), and behavioral (actions and intentions).
Due to social pressures, encounters with new information, and the power of personal experience, explicit attitudes are relatively easy to change. Implicit attitudes, however, are highly resistant to change – especially when that attitude is negative. Negative attitudes are considered to be highly diagnostic (Cone & Ferguson, 2014). This means that we take negative impressions more seriously than positive ones. Think of the old saying, “First impressions are lasting impressions.” Most of us encounter new people every day, even if we do not meet them personally. But the people you remember most are those who gave you a bad impression.
How does bias develop?
We like to think we are the sole determiners of our attitudes and biases, but we are not. In a documentary entitled “The Problem with Apu,” comedian Hari Kondabolu examines the East Indian cartoon character Apu on the long-running TV series “The Simpsons.” He says, the problem with Apu is that instead of being an east indian character, Apu is the east indian character on the show. For many people who watch the show, Apu is the only representation of East Indian culture that they have. So, this character perpetuates stereotypes about East Indian people. This is the influence that media – TV, music, the news – has on all of us.
The media influences how we understand people and things that are outside of our personal experience; and this affects how we behave towards those people and things when we encounter them in real life. The media we consume, the language we hear, the people who raised us, the social groups we identify with – these are all contributors to the formation of our attitudes. They tell us about what systems and concepts are good or bad, what symbols mean, even what is and is not supposed to be important to us. These are the biases we carry into every interaction we have, even those in the clinic.
In our own field, we use a lot of “othering” language. I don’t think the explicit intention is to “other,” but that is what it does. We talk about “diverse individuals,” “dialect speakers,” and “people with an accent,” when, in fact, everyone speaks a dialect, and everyone has an accent. Language surrounding diversity and multiculturalism is inherently comparative. This is fine when all groups or individuals involved are given equal space. However, in our current conceptualization of “culturally and linguistically diverse (CLD) populations,” white, monolingual mainstream American English speaking are excluded from being “diverse”, thus implying that they represent a superior, or “normal,” standard and that everyone else is “other.”
We learn about cultural and linguistic “others” in special classes or units that describe people from “different” cultures. The presentation of these “other” cultures are usually not designed by people from those cultures. Thus, many clinicians enter the field with what Tervalon and Murray-Garcia (1998) call a “false sense of security” in their knowledge regarding cultural competence. The knowledge they have allows them to make assumptions about the people they encounter in the clinic. Tervalon and Murray-Garcia (1998) give several examples of studies that show how this approach to cultural competence negatively impacts the quality of care that minority patients receive: Latinx patients are half as likely to receive pain medications for long-bone fractures independent of language and insurance status; African Americans are twice as likely to go blind from progressive eye diseases and half as likely to receive sight-saving procedures; poor and minority patients receive less information about their conditions and less talk overall from their doctors. These examples seem to be overtly racist, but only when they are pointed out. The doctors who were the subjects of these studies likely did not have explicit biases against the groups that experience discrimination as a result of their behavior. Still, the results are damaging.
How do we change?
Rather than viewing cultural competence as knowledge acquisition that is discretely measured and has an endpoint, Tervalon and Murray-Garcia (1998) suggest a different approach: cultural humility. Cultural humility centers the client and the families we serve as experts on themselves. Cultural humility minimizes the power imbalance inherent in all clinical interactions by making yourself – the clinician – the listener, ready to learn from your clients. Cultural humility creates partnerships with communities that respect the wisdom that our clients and families bring to the table by making institutional changes that serve the community’s needs.
ASHA tells us that Evidence-Based Practice (EBP) consists of external scientific evidence, clinical experience, and client perspectives. These three components are represented by a triangle to remind us that no one piece of the triangle is more important than the others. If you are not incorporating your client’s preferences and family input, if you are not centering your client’s culture, you are not practicing EBP.
The first step towards cultural humility and shifting one’s own harmful biases is self-reflection. We must understand our own cultural positioning that produces our biases before we can appreciate someone else’s. Activities such as the social identity wheel can help us situate our own cultural lens so that we can better imagine that of someone else.
It is also beneficial to develop a philosophy on providing culturally and linguistically responsive services (Privette et al., 2017). Regardless of your background, write a statement describing your understanding of cultural and linguistic diversity and include practical applications to incorporate into your clinical practice. Then, situate yourself on the cultural proficiency continuum described by Cross et al. (1989). Assess your position on the continuum and plan concrete steps on how you can move forward towards cultural proficiency such as taking continuing education credits and spending time with people from backgrounds that are different from your own.
Remember that there is no end to cultural humility. There is no point at which one has arrived at full cultural proficiency. Providing culturally and linguistically responsive services is an approach – a way of thinking and being with other people. Regardless of how much you know about a specific culture, if you take the position of cultural humility, you will be able to serve all of your clients and families well.
Cone, J. & Ferguson, M. J. (2015). He did what? The role of diagnosticity in revising implicit evaluations. Journal of Personality and Social Psychology, 108(1), 37-57. doi: 10.1037/pspa0000014. Epub 2014 Nov 3.
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Melamedoff, M. & Cargill, M. J. (Producers), Kondabolu, H. (Director). (2017) The Problem with Apu [Motion Picture]. United States: truTV.
Oskamp, S., & Schultz, P. W. (2005). Structure and function of attitudes and beliefs. In Attitudes and Opinions (3rd ed., Chpt 5, pp. 88-111). Mahwah, NJ: Erlbaum.
Payne, B. K. & Cameron, C. D. (2014). Dual-Process Theory from a Process Dissociation Perspective. In Dual-Process Theories of the Social Mind. Sherman, J. W., Gawronski, B., & Trope, Y. (Eds.). New York, NY: Guilford Publications.
Privette, C., Bridges-Bond, S., Gillespie, R., & Osler, J. (2017). Self-assessment of Cultural Responsiveness in speech-language pathology. Journal of the National Black Association of Speech, Language and Hearing.
Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.