stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
It is important to start obtaining generalized knowledge during these unusual
experiences where we are not typically using carefully designed randomized trials.
What that is going to require is institutional partnerships with advanced directives.
Otherwise, we are going to be doing passive studies and making the same mistakes
each time. I think there is a good opportunity to design randomized trials in disaster
settings. I understand with suicide that a standard control group is next to impossible
to do; thus, the rollout design is a useful design. The last point I want to make is
that these broad-based interventions have differential impact as a function of social
networking. If we do not take that into account when designing and measuring
interventions, we probably will not be successful.
DR. CROSS: I am going to focus on this pragmatic topic of train ing and the
transfer of training. I hope it has some relevance for what you are all thinking about
tonight and tomorrow. Why should we focus on training This was brought up
earlier today. The issue of stigma and disparities in care is a workforce education
and development issue. It is an issue in a couple of ways. One is to develop competencies
among the providers. Another, which a couple of us were talking about
earlier today, is the issue of stigma within our own behavioral network, even in our
own workforce.
But what I will focus on today is the first issue, the well documented gap between
programs that are shown to be efficacious and how they function in usual care.
People are talking a great deal today about evidence-based practices. Those practices,
those programs, those procedures, big or small, were developed in one setting and
proven to be effective in that setting. Then, when we take them to communities we
find them to be not as effective. One of the reasons for that gap is due in part to
failures in training practices.
My main point today is that a program cannot be more effective than the person
delivering it. Once you choose your program, you need to plan the implementation.
The implementation can be measured on at least two levels. One is at the macro
program/intervention level and the other is at the implementer/provider level. This
is the level that I am most interested in talking about today. It is as if there is a black
box. The black box exists between the intervention that you are going to roll out,
and the outcomes that you are expecting. There are a number of efforts and activities
going on between the choice of the intervention and the outcomes, including training
interventionists. They occur in this “black box” of implementation.
Once you have chosen your intervention, you are going to “let your training
begin.” Here is a cartoon that shows someone who has just come back from training.
He says, “I have this really big binder. The training has already been forgotten, but
the binder will last forever. It is a living monument to temporary knowledge.” Not
exactly what we want to hear, right Now, this person who attended the training
was probably very satisfied with the training. One thing we know, however, is that
satisfaction is not related to learning outcomes. Satisfaction is the one variable that
everybody measures though. Whether you are in business or education or mental
health, we want to know if people liked the training. Their responses will likely
inform our training design. But, satisfaction does not tell us if participants learned
from the training or if they will carry that new learning into practice.
I am going to build a model of training and transfer of training that occurs in the
black box previously mentioned. One way to think about the model is in terms of
phases starting with pre-training characteristics or variables, the training event itself