Don't Follow That Gut Instinct - Debiasing for Equitable Care in Child Life

ACLP Bulletin | Spring 2021 | VOL. 39 NO. 2

Katy Tenhulzen, MS, CCLS
Central Washington University, Ellensburg, WA

By now, we all should be aware of the ongoing fight for social justice and the dire need for systemic change. Accordingly, the ACLP has encouraged us all to engage in this work within our child life teams, academic programs, and hospitals. Each of us has a responsibility to actively engage in self-reflection about our role in combating — as well as our role in inadvertently contributing to — inequity and injustice. Most people who provide support to children and families of diverse backgrounds would be unlikely to view themselves as overtly racist, sexist, or intolerant of certain groups of people. However, each of us has developed biases which impact our view of the world and the people in it. Some people may be aware of negative beliefs and perceptions they have about a group of people based on certain characteristics. Many of our biases, however, are implicit, meaning we have internalized and unconscious beliefs, attitudes, and perceptions that impact the way we behave around others. It is only with intention that we can identify and shift implicit biases (Amodio & Swencionis, 2018). In this paper, we will examine how biases develop, how these biases can impact patient care, and what strategies can be implemented to overcome implicit bias.

Schemas and Bias
Think back to Piaget’s concept of schemas: the way we organize information to understand the world around us. Schemas can be understood as metaphorical file folders in which we store and add bits of information as we encounter things in our environment. Much of the information we store is implicit — understood without necessarily being linked to conscious thought. The contents of these folders include facts (gathered through direct and indirect methods and which may or may not be objectively accurate), sensory information, and emotions (experienced personally or observed in others). Implicit memory works by linking our sensory and emotional experiences. For example, as an adult, the smell of warm chocolate chip cookies may stimulate feelings of comfort and joy because baking cookies with a loved one was a positive experience of connection as a child. Alternately, hearing a dog barking may elicit a fear response if one was bitten by a dog as a child. As our schemas become more complex, they help us filter through the vast sensory input we experience throughout a given day. This helps our brain to quickly decide:

what to pay attention to
how to respond to things or people we encounter, and
whether we should approach or avoid them based on unconscious threat assessment (Soon, 2019).

Automatic positive or negative feelings, assumptions, and responses to someone based on these unconscious assessments and schemas are called biases (Perception Institute, n.d.). According to Eberhardt (2019), “implicit bias is not a new way of calling someone a racist…implicit bias is a kind of distorting lens that’s a product of both the architecture of the brain and the disparities in our society” (p. 6). Since childhood, we have been developing schemas and perceptions of people based on many social categories, such as race, ethnicity, ability, body size, age, gender, sexuality, and political affiliation. Over time and with repeated exposure, the brain will link positive or negative emotional responses and intrinsic beliefs about people with certain characteristics. This happens through direct experience, such as seeing or hearing the way parents or teachers talk about, or to, people who look a certain way. This also happens through indirect experience, such as media exposure (Payne & Dal Cin, 2015). Consider the typical appearance of the hero, the love interest, the incarcerated, the ideal parent, the abusive parent, or the drug dealer. The biases we develop from recurring media exposure are particularly powerful when it comes to groups we don’t have much interaction with in real life.

Schemas are refined over time, but once they have been developed it takes a lot of new and different information to alter them. The human brain resists the discomfort of disequilibrium, so we easily accept new information if it integrates with what we already believe to be true. In contrast, if we encounter something that contradicts an existing schema, we tend to consider it an anomaly rather than evidence that we might be wrong. Accommodation generally requires multiple experiences that contradict a schema. The human brain also has a negativity bias, which means we tend to notice, focus on, and retain memories of negative stimuli over positive stimuli (Vaish, Grossmann, & Woodward, 2008). This is an adaptive function of the human brain because it increases the likelihood of survival, but it can lead to harmful consequences for us emotionally and socially. Even without our conscious awareness, negative biases can trigger emotional responses such as fear or anger. Our attitude, body language, behavior, desire, and ability to engage and connect with others can be altered by even a slightly elevated stress response. This, in turn, can alter their perceptions, behavior, desire, and ability to engage and connect with us.

Impact on Patient Care
In-Group/Out-Group Bias
In less than one second, our brain processes an initial impression of someone using existing schemas and biases (Pichon, Rieger, & Vuilleumier, 2012). Existing schemas increase our efficiency in determining an appropriate response, including whether this is someone we should avoid or approach. If that person is deemed “safe” we receive an unconscious “green light” to approach and engage with them. This sense of safety and comfort may be influenced by how similar they are to us, how similar they are to other people we have engaged with who have made us feel at ease (or not), and/or how the media we consume generally portrays people who look like them. “In-group biases” refer to the underlying preferences humans tend to have for people who are like us (Tropp & Molina, 2012). Several factors influence whether someone fits into a person’s in-group or out-group including race, ethnicity, ability, body size, age, gender, religion, socioeconomic factors, etc. When we feel safe and comfortable approaching someone, they are more likely to feel at ease with us. This feeling of mutual safety and comfort increases the likelihood the interaction will be positive. This feels rewarding and can perpetuate a cycle where we tend to spend more of our time and energy with people from our in-group(s).

We may prioritize seeing or spend more time with patients and families who are in our in-group. Patients and families who do not provoke an underlying feeling of comfort and ease for us will likely feel the same way with us. Studies suggest that interactions with people from out-groups tend to increase anxiety. Provider bias and anxiety often leads to inequitable care, shorter visits, less eye contact, less time spent building rapport, and less collaborative decision-making (Powell, Tropp, Goff, & Godsill, 2014). In-group/out-group bias can also significantly impact students who desire to enter this field. We must consider how bias and other systemic barriers have thwarted us from creating teams that represent the populations we serve.

"Reflect on your own in- and out-groups. How might they impact your interactions with patients and families? How might they influence who you choose to hire and which students you tend to select to mentor?"

Bias and Nonverbal Communication
Implicit bias impacts non-verbal communication in both directions. Our perception of whether someone is approachable, or not, is influenced by facial expressions, eye contact, and the amount of physical distance (current COVID precautions excluded) we put between us. This is a bidirectional process, with the provider and patient/family assessing the safety and approachability of the other. The nonverbal cues we present to patients and family members, and the perceptions we have about their nonverbal cues, impact our ability to build rapport and develop therapeutic relationships. We may not even be aware of the subtle nonverbal cues we are giving to families, and our biases influence our interpretation of their cues. For example, White people who have stronger implicit racial bias are more likely to interpret neutral expressions as angry if the person is Black (Hugenberg & Bodenhausen, 2003). These kinds of misperceptions may lead a child life specialist to wrongly assume the family is not interested in child life support or to misinterpret the needs of a child or family during assessment. Further, having even a subtle defensive reaction to a patient or family may lead them to feel a sense of unease or, worse, may confirm existing negative schemas they have developed based on previous experiences with racism in health care.

Bias and Empathy
Researchers such as Forgiarini, Gallucci, and Maravita (2011) highlight MRI studies that suggest people tend to have more empathy for others who are in their in-group. This is significant for child life specialists since our ability to empathize is critical to our ability to provide psychosocial support. White providers are more likely to have a stronger emotional reaction when observing a White patient in pain than when observing a Black patient experiencing pain — even when the patients are subject to the exact same procedure. Many people, including health care providers, believe that Black people have a higher pain tolerance or fewer nerve receptors (Hoffman et al., 2016). Zestcott, Blair and Stone (2016) describe health care discrimination as a significant problem, and patients of marginalized groups feel this impact on many levels: from experiencing microaggressions, mistrust in their health care team, and even higher mortality rates in various contexts. Healthcare workers may be more likely to perceive a patient of color as being uncooperative, defiant, or as displaying more behavior problems. This may reduce the patience extended to certain patients, lead to harsher verbal interactions, and increase the probability of using physical restraint.

Bias Interventions
Clearly, bias impacts the experience of patients and their families in health care settings. The good news is that we can shift our biases and behavior, which can have immediate positive consequences in our provision of care.

Identifying biases is the first step. Take the Harvard Implicit Bias tests: https://implicit.harvard.edu/implicit/takeatest.html

Learn more about implicit bias: UCLA Equity, Diversity and Inclusion

Take action to debias:

"How might biases impact relationships and communication with pediatric patients and families who fall into one’s out-groups?"

"How might a child life specialist’s ability to provide equitable procedural and pain management support to certain patients be impacted by reduced empathy, an underlying expectation of “toughness,” and/or perceptions of defiance?"

Acknowledge without shame. People who are drawn to child life are kind and empathic, and it can be difficult to acknowledge we have biases that impact the care we provide. Shame is not motivating and is more likely to make us shut down or become trapped in denial. If we allow ourselves to believe that our inherent kindness means we are immune to bias, we will continue to cause harm while missing out on opportunities to learn, grow, and provide more equitable care.
Focus on equity. If a person’s desire to “not appear biased” is top of mind when interacting with a person from a marginalized group, this heightens anxiety and leads to hypervigilant monitoring of what we are communicating and how it is being received (Powell, Tropp, Goff, & Godsill, 2014). Focus your motivation on being an equitable provider rather than on avoiding external judgments. Act with purpose and intention rather than reacting or avoiding situations out of fear, by using the following recommendations.
Replace stereotypes. Notice your negative reactions to others. Does this reaction stem from a stereotype you have integrated into a schema? Replace the stereotype with self-talk and by intentionally noting what makes the individual unique rather than making assumptions based on one dimension of who they are.
Conscious consumption. What stereotypes are being perpetuated in your social circles and in your media consumption? Whose faces and voices are represented? How are they represented? Be intentional in avoiding media that reinforces negative stereotypes and seek out sources that elevate people who are typically marginalized. Diversify your social media feed, read books written by authors of color, and listen to podcasts from people who have different lived experiences as you. Adjusting negative biases requires repeated exposure to things that don’t line up with your existing schemas.
Empathy and perspective-taking. Connect with people who are different from you. Put yourself in the shoes of people who experience marginalization and bias and consider the toll it would take on you. Sit in discomfort as you acknowledge the privilege you have had to not have to think about these things until now.
Override your “gut instinct.” Our biases inform our gut responses which drive us to behave and communicate in certain ways. Pay attention to what happens internally when you interact with certain people from your out-groups. Is there tension somewhere in your body? Does your heart rate change? Do you find yourself tempted to wrap-up an intervention more quickly? What can you do in these moments to regulate and feel a sense of neurological safety so you can be fully present with this patient and family?
Integrate mindfulness. In addition to myriad other benefits of mindfulness practices, experts suggest this can also reduce anxiety related to implicit bias and increase positive interactions with clients from a practitioner’s out-groups (Kanter, 2020). Specific recommendations include 10 minutes of mindfulness/meditation per day and engaging in a brief practice (even just 30 seconds) of mindfulness before entering a patient’s room. Pair this with mindful breathing: our nervous system calms when the count of our out-breaths are longer than the count of our in-breaths (e.g., breathe in for 3 seconds, out for 5 seconds.)
Collect and analyze data. Collect demographic data within your department to track the distribution of time, services, and resources. This can be a great way to track whether patients and families are receiving equitable care and a chance to evaluate why this may not be happening. Is the diversity of your patient population reflected in your team and the students you select to work with? If it’s not, why is that? What systemic barriers and biases need to be addressed?
Continued education. How can your department continue to learn and grow together? Be intentional in integrating diversity, equity, and inclusion into you work through book clubs, trainings, and setting specific goals and objectives for improvement.

“Neither our evolutionary path nor our present culture dooms us to be held hostage by bias. Change requires a kind of open-minded attention that is well within our reach” (Eberhardt, 2019, p. 7). Please join me and many other leaders in the field in committing to this work with open minds and hearts so we can demand change and equity in the child life profession and within our respective institutions.

REFERENCES:

Amodio, D. M., & Swencionis, J. K. (2018). Proactive control of implicit bias: A theoretical model and implications for behavior change. Journal of Personality and Social Psychology, 115(2), 255–275.

Eberhardt, J. L. (2019). Biased : Uncovering the hidden prejudice that shapes what we see, think, and do. Penguin Books.

Forgiarini, M., Gallucci, M., & Maravita, A. (2011). Racism and the empathy for pain on our skin. Frontiers in Psychology, 2, 108.

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America, 113(16), 4296-301.

Hugenberg, K., & Bodenhausen, G.V. (2003). Facing prejudice: Implicit prejudice and the perception of facial threat. Psychological Science, 14, 640-643.

Kanter, J.W. (2020). From ally to antiracist: Using psychological science and mindfulness to cultivate growth and action. The Center for Child and Family Well-Being.

Payne, B. K., & Dal Cin, S. (2015). Implicit attitudes in media psychology. Media Psychology, 18(3), 292–311.

Perception Institute. (n.d.). Implicit bias. https://perception.org/research/ implicit-bias/

Pichon, S., Rieger, S. W., Vuilleumier, P. (2012). Persistent affective biases in human amygdala response following implicit priming with negative emotion concepts. Neuroimage, 62(3), 1610-1621.

Powell, J. A., Tropp, L. R., Goff, P. A., & Godsil, R. D. (2013). The science of equality volume 1: Addressing implicit bias, racial anxiety, and stereotype threat in education and health care. UC Berkeley: Othering & Belonging Institute. https://escholarship.org/uc/item/2t95b844

Soon, V. (2019). Implicit bias and social schema: A transactive memory approach. Philosophical Studies, 177, 1857–1877.

Sukhera, J., Milne, A., Teunissen, P. W., Lingard, L., & Watling, C. (2018). The actual versus idealized self: Exploring responses to feedback about implicit bias in health professionals. Academic Medicine, 93, 623–629.

Tropp, L. R., & Molina, L. (2012). Intergroup processes: From prejudice to positive relations between groups. In K.Deaux & M. Snyder (Eds.), Oxford handbook of personality and social psychology (pp. 545-570). Oxford University Press.

Vaish, A., Grossmann, T., & Woodward, A. (2008). Not all emotions are created equal: The negativity bias in social-emotional development. Psychological Bulletin, 134(3), 383–403.

Zestcott, C. A., Blair, I. V., & Stone, J. (2016). Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations, 19(4), 528–542.

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