- So I want to just take a moment to welcome everyone
to our public lecture series for social work
and to the Brown Foundation research lecture in particular.
My name is Maria Torres and I'm a new faculty member
at the School of Social Work.
And I'll be starting--
(applause)
(feedback)
(laughter)
Sorry!
- [Voiceover] It was celebrating.
- I know, that's some celebration.
And it's my real privilege and an honor
to get to introduce Maggie Alegria to you this evening.
I have known Maggie since 2004
when we worked together on, Maggie hired me
as a project manager for the National Latino
and Asian-American study and really took
a chance on me as a clinician that really wanted
to learn about research.
Maggie herself is a clinician and a researcher by training,
and as you can see from the bio here, which I'll just
read a little bit about.
So Maggie is the director of the Center for
Multi-Cultural Mental Health Research
at the Cambridge Health Alliance
and Harvard Medical School.
As a professor of psychology in the
Department of Psychiatry at Harvard Medical School,
Dr. Alegria is the first Latina full professor at Harvard,
which I think is really important to highlight.
(applause)
Maggie is currently the PI of three national institutes
of health-funded research studies, the International
Latina Research Partnership, Effects of Social Context,
Culture, and Minority Status on Depression and Anxiety,
and Building Community Capacity for Disability Prevention
for Minority Elders.
She's also the PI of the PCORI Grant, a patient-centered
outcomes research institute project, Effectiveness
of Decide in Patient-Provider Communication,
Therapeutic Alliance and Care Coordination.
Dr. Alegria has published over 200 papers,
editorials, intervention trainings, et cetera.
I looked at her CV this morning before I came today
and it's 56 pages long, which just tells you, you know,
this is an incredibly accomplished and thoughtful woman
that has dedicated her life to research that moves forward
the agenda of individuals that have been marginalized
in any way, shape, or form.
And her research and influence has incredible depth
in terms of her work on different councils,
public service work, work with communities, et cetera.
So it is, I'll let you read the bio, you have it here,
but it is a great pleasure and a privilege
to introduce Maggie to you today.
- [Maggie] Thank you.
(applause)
I think this is one of the best pieces of,
seeing your trainees become the faculty
and eventually your boss.
So I'm hoping that the next step
will be Maria being my boss.
(laughter)
I really want to thank you, because
coming here at 7:30 is quite an achievement.
People being so nice to really share
a little of their time, especially because
I know you have 300 other things to do.
So I'm very grateful.
I want to thank Mary Ann for inviting me,
Peggy for the wonderful coffee,
Irene for the amazing food that she took me to,
Maria for the great presentation,
and Dr. Candelario for an amazing story.
If you keep me here a little bit more,
I probably won't go back to Harvard,
so be careful what you ask for.
(applause)
So, let me start by telling you a little bit
of why I started to do this work,
partly because I was doing a lot of work
describing problems in immigrant communities,
but felt eventually that nothing was happening.
I've actually been in this area for, you won't believe it,
but 30 years, and in 30 years, the change
is so minimal.
Actually if you look at disparities,
they're getting worse, not getting better,
in mental health care.
This is one of the areas there has been no traction.
No traction, you see a lot of the people
talking about behavioral health
and behavioral health, but actually
there's been no traction whatsoever
in terms of disparities.
So I got a little tired and decided, this is,
I mean, I have to, someone asked me
"what's your impact?"
And I became like, I couldn't really say anything.
I said, "Well I have some publications, but,
"beyond publications, I mean, not really a big impact."
And decided to go into this area.
I'm going to talk today about three areas very quickly.
One, why immigrants do not seem to access care
for their mental health problems, tell you a little bit
of the problems we have of why for over the past 40 years
we've been talking about this with no traction
with hopes that you are the generation
that can make a big difference.
Second thing I want to talk a little bit about is
what have we found out that works.
(feedback)
Oops.
And then finally, I'll talk about funding
because it's part of the biggest problem
we have in this arena is that the funding
is really not allying.
Oh, okay.
So even better.
So I'm going to start with children, because
I think for some reason in this country,
although the demographics are dramatically changing,
what we're seeing is, there's no attention to,
this is a new landscape.
The children in schools look like
nothing we had before.
And it seems that we are not really prepared
to deal with all these immigrant children
that are coming in.
By 2050, more than one-third of the hundred million
US children will be minorities, more than one-third.
But if you think about it, there's a huge gap
between the populations, the size of the populations
and actually the knowledge that we have
in how we can serve them.
So there's a big gap in this area.
You would think everyone's preparing.
By the way, I gave a talk about disparities
to the state legislators and things,
and the amazing thing is, we had a group
of people from the community.
And everyone was saying, you know, we talked
about this 20 years ago, and again we're talking
about the same, same issues, it was so sad.
And one of the things that we talk in that brief
is disparities, I have to say, have become
better for certain groups, but not all groups.
And we have to keep on watching it.
The other thing is that, besides not knowing
a lot about how to help these children,
these children have special needs
that we are not prepared to serve.
They have incredibly high rates of trauma,
they have, a lot of them have had
extended parental separation, they have
few resources to access care because
they come from high rates of poverty.
They also have problems of food and housing,
especially one of the areas that you should be
looking and assessing is food insecurity.
Food insecurity is tied to every single
behavioral health outcome you can imagine.
It's tied to suicide, it's tied to depression, anxiety,
you name it, food insecurity is strongly tied
to bad behavioral outcomes.
We also see in these children, especially
if they are undocumented, high rates of uninsurance.
So providers are struggling to find how can
I serve these kids that have such immense needs,
and so little access to care.
The other big problem that you'll see
is the issue of linguistic isolation.
These kids live in families with
a lot of linguistic isolation.
So why do these children do not seem
to access mental health for their problems,
and why has this not changed for over 40 years?
You would wonder, I mean, we all know about it,
why aren't we changing it?
Let me show you the rates of children
in immigrant families that are linguistically isolated.
23 percent have no one in their household
that speaks English.
So one of the biggest problems
is actually try getting services, first in English,
and then if you don't speak English,
you are completely wiped out, especially
in certain areas of Massachusetts
where you would think that we have
so many immigrant populations that people
would be ready to have these services.
So right now we're running a project that's on
mental health and substance abuse.
I was telling Maria that one of the biggest
problems we're having is incredibly
high rates of suicide ideation.
Try getting someone to help you,
the best team that has someone
that speaks Spanish.
Forget Spanish, imagine any Asian languages,
Mandarin or Cantonese.
Or try Hatian Creole, or try Portuguese.
No one.
To something so serious as suicidality.
So this is an area where we're having
terrible, terrible problems in getting services.
And if you're in substance abuse, if your child
has a substance abuse problem,
try getting some services that is non-English.
Almost nothing.
The other thing you'll see, and this is
a very, it's uninsurance, children by poverty status,
household income, age, race, and Hispanic origin.
But I want you to see non-citizens.
29 percent of non-citizens are going to
be uninsured children.
So this creates a serious problem
because you don't have that many alternatives.
Who are the providers that are willing to see
these children without insurance?
Okay, you have another big, big issue.
You can see there in terms of less income,
the children in poverty are less likely to have
any access to care.
I wanted to show you that in Massachusetts by the way,
we're actually quite lucky.
Because if you think about Massachusetts,
one of the things Massachusetts is that green,
very green light, I don't know
if you can see it here, we are in Massachusetts.
And you can see that it's one of the few places
that gives medical coverage for children
regardless of status.
However, there's questions of whether
that's going to change with the Affordable Care Act.
Because the Affordable Care Act
is making a distinction between children
that are documented and legally here,
and children that are undocumented.
So we hope that doesn't change,
but it's something to be seen, and something
that might be scary.
The other thing I wanted to show you
was quality of care.
We've been doing work looking at
quality of care and both attention deficit disorder
and depression are really very, very,
like clear-cut, you know, easy things to treat.
Very easy things to treat.
This is in a study that we publish, Nick Carson,
he's one of my colleagues, and this group,
in 2011, where we saw in a system of care
that serves a lot of immigrant families,
we compare in this study, Haitian, African American
and White kids to see if they were
receiving guideline-concordant care
for attention deficit disorder and depression.
And as you can see there, dramatic difference
within the same system of care.
As you can see there, whites receive,
are much more likely to receive
guideline-concordant care than either
black or Haitian kids.
It's amazing, this is the same provider, okay,
the same providers in the same system of care.
Some people have said, well it's partly a problem
that they go to different systems of care.
But this is not the case.
This is in the same system of care
with the same providers, they get
less quality care.
The other thing I wanted to show you,
is when do people get care?
And this is a very sad story.
So we publish a paper in psychiatric services
showing that if you look, these are people
that have White, Black and Latinos, that have
any drug or alcohol dependence or abuse.
These are people that are quite severe
in terms of alcohol, drugs, in terms of dependence or abuse.
And if you look at the rates there, you actually see
what we call a reverse disparity
if they were treated in the substance abuse treatment.
Okay, so you see what we call a reverse disparity.
That's white are less likely to be treated
in the substance abuse treatment sector
as compared to blacks or Latinos, okay?
But if you look at mental health care
treating these populations, they're
much more likely to be, whites are
much more likely to be treated
in the mental health system, for the same condition,
by the way.
These are all with the same condition.
Compared to blacks and Latinos.
So when you ask, having been treated
in any of the systems, what you see is
that then there is a disparities, with whites
being more likely to be treated.
But guess what?
What's really driving the people that are treated
in the substance abuse system?
Unfortunately, what we see is, Latinos,
no matter if they have a criminal history or not,
are less likely to be treated.
Once you adjust for the experience
of being in the Criminal Justice system,
but what you see is, once you adjust for
having a criminal history, or SCS, you then see
that actually the disparities in the substance abuse
treatment become larger for both blacks and Latinos.
In other words, most of the people that are entering,
Latinos and black, to the substance abuse system,
are being included because of criminal history
or low SCS.
But they're coming through a different sector of care,
I mean, which is very worrisome.
I think for elder immigrants, we're finding
the same, identical story.
Really sad, identical story.
We publish a paper with (unclear)
showing that if you are Latino or Asian,
only one in 10, one in 10 would receive
quality care for depression.
So that means that nine out of the 10
are not receiving any quality care.
And we're talking about depression.
Depression is like, you know, such a,
it's not like we're talking about
a complicated schizophrenia or bipolar,
or something more complicated.
This is for depression.
So the rates are very, very low.
And it's important if you think about it,
because many of our non-English elders
are really in isolation.
We see a lot of depression, a lot of
non-acceptance that they have a mental illness,
and this is partly because their support system
has really eroded by family disruption,
occupational demands, and growing disorganization
of the families in urban environments.
If you think about it, for a lot of these elders,
they came and sacrificed for their children.
Work, work, work, work, with the expectation
that someone's going to support them
and really take care of them, and suddenly
they find that that's not the norm, necessarily
in this country, and that they're actually
going to be left by themselves.
So this is why I say only 8.6 percent
of Asian Americans report having used
any mental health services, compared to
17 percent of the general population.
So very, very, very limited.
So why hasn't then this changed over
the past 40 years?
I think we have done a lot of work
finding that there are several things that happened.
First, what we're finding is that most elders
don't want to recognize that they have,
they don't really want, they don't think
the symptoms are symptoms of mental health.
So many of them really report that their symptoms
have to do with some other thing, like suffering,
like general conditions of being aged, aging,
but not necessarily that they have
a mental health problem.
There's a huge stigma, especially if
you come from a country where people
are actually secluded if they have
a mental health problem.
So recognizing that they have a mental health problem
has a different connotation.
And people say a lot, you know,
I'm not going to go into mental health care,
that's really for the very, very sick.
You know, for the ones that are locos,
or people that are completely out of their realm.
The other thing we've seen and we publish a lot,
is what other people call self-reliance.
You know, people in these communities
have a government or have a system
that doesn't respond to them, so the idea
that someone can take care of them
and help them is not in their tool box.
So they believe that actually they should
be self-reliant and try to problem solve.
The second thing is we have, there's very,
very few access to mental health services
for a non-English populations.
There's a lot of unfamiliarity
about the mandates, about who's
eligible to go, and many of these people,
by the way, are not eligible to Medicare,
so they don't really have a source of insurance
like the other elders that we have in this country.
So it makes it very hard for them.
There's also lack of access to Medicare
and employer-based coverage and usual
healthcare providers.
One of the biggest areas where they've shown
is that compared to the general population,
this population has a lot of primary care providers
but they don't have a lot of specialty care provider access.
I don't know if any of you have tried getting
a mental health for PCPs in primary care providers.
One of the worst areas actually, we underlined this,
is if you look at Medicaid, very, very few providers,
specialty providers, are willing to take Medicaid patients.
The pay is so low in behavioral health
that very few people are willing to take it.
It doesn't happen for other specialties.
So behavioral health is one of the ones
that is really the worst, where people
are actually not covering.
But the other thing we have is
fears on documentation.
You cannot imagine how many people
miss their appointments because they see
a policeman and immediately they turn around
and go back home.
Things like that, that you would not have thought
are things that happen.
And then there's a lot of poor quality
mental health services, so the communities here
that people are not getting better,
and that in itself becomes a vicious cycle.
I wanted to just clearly cover this
because I think there's a lot of confusion.
In fact, I have (unclear) which is a person
that works with me on the issue of immigrants
and the health care laws, and they are,
with all the things that are happening,
especially, what we see is that
the only people that are eligible, supposedly,
according to the Affordable Care Act,
are people that have been here
for more than five years as legal residents
or what's called legally here.
So this really is putting a lot of people
at jeopardy of losing things like CHIP or Medicaid
that were actually covered here in Massachusetts.
And it's going to be something to be looked.
So for undocumented migrants, what you hear
over and over again, is that they're eligible
for emergency services.
But that's about it.
And this is an area where people are trying
to fight and actually, the people
from Healthcare for All in Massachusetts
have been advocating for the immigrant group
to be included.
I think one of the biggest problems we have
that is now becoming very obvious to everyone,
including Deval Patrick when he was in the states
is that we have a horrendous work shortages,
work force shortages.
By the way, in the IOM I participated in this report,
it's a great report if you haven't read it.
It's the Mental Health and Substance Use
of Older Adults in Whose Hands Are We?
And it's basically that you look at
who's taking care of the elders
is people that have no preparation,
zero preparation for behavioral health.
And if you look at a place like Florida,
where they were actually looking at who comes
into behavioral and psychotropic medications
and the rates of psychotropic medication
three months after you have been
in a nursing home, are exponential.
Three months and people go into
amazing rates of psychotropic medication.
People that had never had a mental health problem
in their life, and suddenly they're coming
into nursing homes and are getting
psychotropic medications.
And maybe some needed it, but we were
so concerned that this report covers,
we need to do something rapidly.
But I mean rapidly.
And the work force is not there.
We don't have our work force trained for the elders.
No geriatric work force whatsoever.
So, anyone who's here and wants to go into
geriatric social work, believe me, you have
your career for sure.
I'm not kidding, I'm not kidding, if you look
at this report, please look at this report,
you'll be convinced immediately,
but I mean immediately.
I think we have also very serious problems in what
we have been offering people in terms of
our practice models.
I'm very concerned our practice models
are really not made for immigrant populations.
The idea that you can get someone
to come 16 times, 16 times during three months for care,
it's someone that really does not know
the life of an immigrant family.
So it's, some of the concerns that they raise
are real concerns.
The other thing is that there is
a lack of understanding of the unique stressors
that immigrants go through.
All the issues of acculturation,
all the issues that have to do with
the living circumstances of immigrants
are so unique, and I think it's an area
that we need to train more people
so they can really understand and talk
to their clients, you know, like,
we know about what you're talking about.
There's also time limitations.
Actually, we did some work on trying to see
what patients value, and it's really interesting
because one of the differences I've even presented here.
But one of the big differences we find
between white, Latinos, and African Americans,
is that minority people value time
while whites value more, how much
it's going to cost me.
But isn't it interesting that time
is the big, if you tell people you're going to
come for 16 sessions, they go like, not a chance.
So I was telling Maria that we have now
a clinical trial, which by the way, Judy,
that's here, is one of the clinicians,
so she can tell you more about it,
but one of the things we do now,
is we tell people it's 10 sessions.
And if people say no way, no way I'm going
to 10 sessions, we go, how about if you try two?
Try two, and if you don't like it, you're done.
But try two, so it's a different concept
of you have to have a commitment,
a lifetime commitment to treatment.
Because people see time as something
so serious and of the essence.
The other thing is, they have less access
to prescription medications.
And one of the things you better find out
is what are they taking, because believe me,
one of the biggest problems we're finding
in minority communities is benzodiazepines.
People are taking benzodiazepines like there's no tomorrow.
And it's a big, big problem, as a recent JAMA
article pointed out.
People are just trying benzodiazepines
as a way to cope.
The other issue we're finding, it's very hard
to convince some of this immigrant populations
that self-care is important.
That if you can't take care of yourself,
you can't take care of your children,
you can't take care of your jobs,
because they actually believe that they
are of very low priority in the things that they're housing.
They're being evicted from their homes.
They have problems with their kids at school.
They're having problems in terms of their domestic violence,
and you're asking them to take time for themselves,
and that seems like, no way.
The other thing that we have is they typically
have multiple jobs, so one of the problems
we're seeing is people cannot tell you
when they can see you.
So the idea of an appointment does not
become operant in this population.
They get called in the morning and they are told
that morning at what time they have to
be in their jobs.
So if you, if they have to choose
between your appointment or their job,
guess what's going to win?
So the idea of making an appointment
for next week, it's not operant.
So what we do is, we actually accommodate
to your time, and you call us and then
we try to set you up that day if necessary.
It's a very different approach.
And then, they typically have to pay
more out of pockets because they typically
are underinsured, if they're in employer-based insurance.
So they have to pay for more.
We also see like I said, treatments are too long,
they require a high level of health literacy,
there are actually very few treatments
that address non-language English, LEP,
linguistic, people that don't have language
English proficiency.
So we have, one of the problems is,
changing everything and being able
to provide care in the language you speak.
And let me tell you the importance of that.
The IOM did a committee of what is
the language you need to get good care.
And unless you can speak English very well,
very well, not well, very well, you should not
be having your therapy in that language.
Because there's obvious that there's problems
in diagnosis, problems in treatment adherence,
problems in misdiag--
You know, all sorts of problems
that are going to happen if you're not
able to speak the language very well.
But ask people, how well is, how,
what is the chance that they can get
the treatment in their language,
in their primary language.
And I don't know if people have
tried going to another country
and translating in your mind, but if you
translate in your mind, you sound very disorganized.
And when you translate in your mind,
something that's not your language,
what you see is people, clinicians thinking,
this person has a cognitive impairment.
And they don't have a cognitive impairment,
they're just translating in their own mind.
Or people saying, this person is so disorganized.
They have a real big problem in disorganization.
But if you have to think and translate
and repeat back, imagine how hard it is.
Imagine how hard it is.
I tell people I fight with my, when I fight
with my husband, it takes me double the time.
(laughter)
Because I have to think about what I want to say,
and then say it in English, and it's
really more complicated.
And by the time you say it, it doesn't sound the same.
I tell him, he's at an advantage.
But he says no, I'm still at an advantage fighting.
So...
I think the other thing is, we have a lot of things
that people, when they are talking in treatment,
are things that you might miss, like things about
social mobility, or remittances.
How you have to send money to your country.
Or how you're taking care of your grandmother,
the aunt, and the other, and you're only
15 years old and you're taking care
of a lot of family.
You have to talk about separation.
The issue of the narrative of separation,
we're now doing some help for the (unclear)
Cambridge School system, who had 800
unaccompanied minors in the last two years.
And the issues, teachers are, you know, dying,
because suddenly these kids come,
they're 12, 10, and they're acting as adults
and they don't want to be treated as children,
because they've lived on the trains
on their own for two years, and this person
wants to treat me like a 10-year-old?
Is she kidding me?
And so, all the problems that you have
of this separations and trauma
are not things that people can confront.
The other issue we're having is language barriers.
Language barriers really are problematic
for therapeutic alliance.
We've actually done some work, which I think
it's really interesting, coding the communication
that goes on where the diet is a different diet.
That is, if you're Latino and your provider's Latino,
versus if you're white and your provider is Latino,
versus your provider is Latino and you're white,
you know all the combinations.
And I can tell you, you won't believe it,
but language is very different in those diets.
How people spend the time, how people
use the communication, how they use
issues of warmth, affect, interpersonal dynamics
in that communication is very very different
depending on the composition of the diet.
And these are things that people don't understand,
people say, well why are people so dissatisfied
with the communication with their providers?
Why are Latinos and African Americans so dissatisfied?
But it's that the communication is different in those diets.
There's also issues about misinterpretations,
I mean, we published two articles on misinterpretations
in behavioral health care.
And I can tell you they're worth seeing.
Amy Bauer is the first author.
But it's basically showing you the problems
that there are when the providers
don't speak the same language and
it's through interpreter's services.
And we have all types of interpreters.
Great interpreters, some average interpreters,
and a lot of lousy interpreters.
And you would be amazed the missing
of information that happens when people
cannot interpret correctly.
So what are some of the key findings
that we find?
So we did a paper, and this is a shocking paper,
I think it was really interesting, where we actually,
I'm not going to go through the whole paper,
but what we find is that neighborhood clinics
in the area where people live are really critical.
For example, Latinos, if you think
in terms of disparities reduction.
Latinos utilize community health centers
700, 700 percent higher than whites.
And African Americans use it 550 more
in percentage than whites.
So community clinics are so central to the lives
of these people that having community clinics
in their areas can make a huge difference.
However, we actually did simulations
using well, what if you put a community health clinic
in the neighborhood.
And what if you gave universal health insurance to people.
And guess what, the sad, sad thing is that
still, 59 to 66 percent of people
would still not go to care.
Would still not go to care.
And what we're thinking is why would that be?
Why would that be?
And I think one of the biggest issues that we have
is the patient-provider interaction.
I think we've been doing a lousy job
with our minorities in the system of care,
and not necessarily having a good experience.
So one of the things that we, I'm going to
aggregate, I'm going to show you now
some of the work that we're doing,
is that people should leave the clinic walls.
That if we are going to be effective
in what we're doing in terms of
disparities reduction, we have to go
beyond the clinic walls.
We can't wait for people to come to us.
By the time they come to us, they are
so disempowered, and so complex
in their problems, that it's very little
what we can do.
So I think going outside the clinic walls
might be very necessary.
And I'm happy to later on discuss this.
The other thing is that the safety net pools
are being eroded so quickly, that people
I think, are going to because we are taking
some of those funds out, I'm very worried
that this, our people are not going to be
included in many of the care.
Very quickly, we know that supply of providers
can be a great source for people to access care.
The more provider availability that we have,
the more likelihood people are likely to use care.
This is what we're trying.
I'm going to go very quickly to tell you
the things we're trying.
So, we think that you need to do
multi-system interventions.
All the way from patient-provider interaction,
and I'll tell you a little bit about what
we are doing about that, improving
the patient-provider interaction.
I think you need to do interventions
in clinical care to make sure that you increase
the evidence based interactions
and clinical care that we provide.
So that there is competency in evidence-based care,
but also in helping work with providers, PCPs
so that they can actually enter people in care.
And then I think we have to do interventions
at the community.
We're doing a lot of work, doing interventions
in community agencies where we bring
the providers to the community agencies
to provide the care before people get very sick.
So it's actually training people
in the community agencies to be the people
that provide the first line of services
and refer cases that are more severe
to actually professionals as a way
to try to intervene with bringing in
community capacity and building community capacity
to make sure that people are serviced early on.
And then we have, I think we have to do more
in policy and market forces, especially
market forces, we're talking more about policy,
but I don't think we have done enough
market forces in terms of trying to work
with how can we get insurers to do a better job
of what they're doing.
So why are clinicians failing to engage
and retain diverse patients?
I think part of the problem is,
they're really unaware of the patients
cultural interpretations about what they're talking.
So when they define the problem for the patient,
there's very little overlap between
how that patient defines the problem
and how the provider defines the problem.
And I think if you don't have a good overlap
at the startup point, there's very limited chance
that you're going to make it.
Minorities who perceive that clinicians
do not understand their cultural views
are seven times at higher odds
of ending treatment prematurely.
So this is a basic, basic thing,
and it's not necessarily only cultural formulation,
it's actually making sure that when you use,
when you're defining the problem for that Asian,
that you're using the same words, that you're
explaining the problem from the same narrative,
that you're using the situational examples
that that patient says that they're having,
so there's a big overlap in that narrative
and the narrative of the patient.
Because if not, you're going to lose them.
So this is an example of one of the interventions
we have done, it's called a decida intervention,
and it's an intervention to try to make sure
that patients can tell you about
what they want in care, what they want in care,
and it's their agenda that gets serviced in care.
It's called decida, and basically it's
a patient activation and self-management intervention.
And the general idea is, you help patients
to formulate questions to their provider
as a way to make sure that they say
what's of interest to them, what they want
to cover in the session, what are their questions
that they have, so we teach them how to formulate questions,
how to focus on key decisions, and this
is a very big change.
Because people think about care
as people come and vent out, right?
But if you think about care as key decisions
in your life, in your treatment,
in your relationships, and your options,
what are your options?
What are your options that you have
in those areas, that's actually
empowering to the patient.
That really activates the patient
and gives them a source.
And then how to manage disease,
their own disease.
The more people know about their illness,
the better they can do questions
and be activated in their care.
So, we, I'm not going to cover this,
but we actually do only three trainings,
they're 45 minutes by a care manager,
someone that's trained in this,
and we teach the, the care manager
teaches the patient how to do questions
and we've actually shown that it works very well.
We've actually published saying it
works very well.
Let me tell you what happened, however.
We only got somewhat, not really strong effect,
and we went back and did focus groups
with patients trying to figure out
well, what's going on?
Well what we found is, providers
were not happy with activating their patients.
(laughter)
They really don't like people that come
with their sessions, to their sessions
with a list of questions, priorities,
and want to discuss these things.
It was really, really challenging.
So, we started getting people saying,
what are you doing with my patients?
They're asking me what diagnosis do they have,
they've been in care for 10 years,
this is the first time they've asked me
what diagnosis they have.
Why I am not in this clinical trial.
Why are you giving me this medication?
I found out that there's three other types
of medications that have less side effects
and now you're bringing me this medication.
So, the thing we had is providers
were not necessarily that happy,
and in fact some providers actually
were very unhappy.
So now we're actually doing intervention for providers.
And I can tell you, doing patients is a piece of cake.
Try doing interventions with providers.
This is a coaching that we give providers.
And what we did with providers,
is we audiotaped their sessions.
And give them feedback.
By coding their sessions and giving them
direct feedback of what they're doing.
And believe me, they are like, oh my god.
Because you send them a page and then
you call them on the phone, and you tell them
okay, look at your feedback.
And it's a life-changing experience.
You could say.
So, I think patient activation and self-management
is critical to help patients have their own voice
and get the care that they want,
not the care that you're planning to give them.
Which is a big change of alternatives.
I think we need to test good evidence-based care,
that people can receive in a low-resource setting.
I think we can't think that people are going to
go to NGH, or they're going to go, we have to think
of what can we give that's low-resource, high quality?
High quality, good care.
And that's what we're trying to do,
make sure that they get really good quality
and that clinicians have a back up,
a real good back up, so you get stuck,
you get the resources and the supervision needed.
The next thing I wanted to tell you is,
trying to make sure that our interventions
are actually interventions that are tailored,
culturally tailored to that population.
So what we're doing is, this is a depression intervention.
It's very short, it's only six sessions.
Actually, Judy again was part of our
spectacular clinician team of social workers
and psychologists that were trained
on this intervention, it is very short,
as you can imagine.
And then the other thing we tested it,
can it be given by phone?
So we randomized to having the intervention
by phone, or in person.
And the end story is that basically,
so we did, before I tell you how we actually did
the cultural adaptation, we adapted
the training in terms of language, culture and context.
So we made it very, very tailored to where they are.
We looked at issues that have meanings
and values to people.
So we use analogies that people would understand
as having meaning in their country.
We actually train master-level social workers
and psychologists a six to eight session,
and it's actually committed behavioral training.
It's actually information on depression
and motivational interviewing.
But one key issue, one key issue that we added
is care management services for other problems.
Because if you think about it, behavioral health
is only one aspect of their life.
These are people that have problems
with housing, with legal authorities,
with you name it, they have it.
So this is a care manager that would serve
for the other things.
I want to show you how we change the manual
because instead of showing people
things that were very wordy, and very like
conceptually driven, we use a lot of visual images.
To convey the messages, and make it,
like negative thoughts.
When we pilot-tested the intervention,
people were like, well I really like
your intervention, but I never got
what was negative thoughts.
And that's like critical.
If you don't understand negative thoughts,
it's the big piece of the intervention.
So we have to create images to tell people
about negative thoughts.
And then we did a lot for health literacy,
because actually, 30 percent of our sample
actually had less than sixth grade education.
Okay, so one of the things you have to think about,
and we actually had like three cases
where people didn't read at all.
So the idea of giving homework,
take this and read it in your house
and come back, was non-existent.
So clinicians had to think very carefully
what they do.
Basically, we found that people that were
in the phone were much more likely
to initiate care than people that were in person.
So given the option of having the intervention by phone
really made a big difference in initiating care.
We lost 21.5 percent of people
that never came to care compared to only 10 percent
when we used the phone.
So you make a big difference.
But we actually found not only meaningful reductions
in depression, but we actually found
meaningful reductions in anxiety symptoms, too.
So it's one of these types of interventions
that's good for depression and for anxiety.
So this is the story.
One of the things that people loved
is the idea that they could take
the intervention on their phone in the bus
going to work, they could take it,
believe it or not, in their car,
driving to work.
People could take it at lunch,
in their lunch hour, so it took away
from the demands of having an intervention.
I want to finish by the National Institute of Health,
I really, really, I'm very worried
on how we're focusing, oops.
We're focusing so much on the biological body
and so little on the social component
of people's lives and how this
is going to have terrible repercussions.
So we're focused on illness, not on wellness,
and we're really losing the point
of focusing on how can we view this?
I also think that we're still on the basic
science of the brain, but there's
very little interest for services and treatments.
And given everything I've told you,
this is just, I think, a tragic thing
of why we don't improve in our service delivery.
So I think, rather than think of
clinical services, which I think are important,
I think we also have to move to community activation
and actually trying to get the prevention dollars
to serve our costs.
I think that the biggest problem we have
is that now the institutes are not spending
any money on adaptations, very little money
on adaptations, very very little money
on immigrant provider interactions,
and very little money on diagnosis
of multi-cultural populations so that
we can serve them right.
So to me this is a huge problem.
So, I think if you're lost, you're in good company.
Because we're all trying to figure out how
is it possible that there's not sufficient information
to try to improve the care for immigrant populations
given everything I've shown you.
So it's a call for all of you to advocate for what we need,
which is more on-service delivery to improve this.
So, I don't think we're seeing that the (unclear) phase
of addressing language, I don't think they're excluding
socio-cultural factors in thinking about the illness,
and who gets invited?
I mention this because who gets invited
to say what's important priority?
If I invite 20 neuroscientists to come to me
and tell me, what do you think
is the most important topics for mental health
today, guess what, you're going to get
neuroscience topics.
So we need to have more social workers
in the picture, saying how social context
is such an important aspect, and social conditions
are such an important context in life.
So I think future generations assigned the,
are going to say, how could well-meaning
and highly-educated researches working
in their usual circumstances, studying
diverse populations of patients,
create a pattern of results that appears
to be discriminatory and not well-suited
to represent their problems and solutions
to their mental health service needs?
So thank you.
(applause)
So I'm very happy to take questions.
Yes.
(inaudible question)
I completely agree.
But in between the transition, in between
the transition, I think it's really important
to train the work force that is now
on how to do a better patient-provider interaction.
Because I think, I mean, again, I think
it's very courageous by the way
of the clinicians that are willing to be audiotaped
and given feedback, I have to tell you,
I take my hat to them, because it's not easy
to lend yourself after maybe 30 years of practice
to have someone hear your tapes and give you feedback.
But I think that is a critical aspect
of improving our work force.
There's one person on the back, you , yeah.
And then I'll come here.
(inaudible question)
Sure, thanks.
She's asking if you want to get providers
out to community agencies, what type
of community agencies are you talking about?
So for example, for the elders,
we're actually going to elder services.
Community agencies that treat the elders.
And what we're doing is, we're working
right now with six community agencies
that serve elder, all ethnic minority elders.
And we're building capacity in those agencies
to provide behavioral health care of a person
trained there that we supervise
and provide the care, and the idea is
that we'll do that for the first two years,
and then the last three years is helping
the community keep doing it on their own,
sustaining and being able to get paid for it.
That's the strategy.
There was someone here, yes.
(inaudible question)
Yeah, that's a excellent question.
How about clinicians that speak the language
of the patient very well.
So the jury is out.
So we don't have an exact answer to this.
It seems that it varies more for some populations
than for others.
And we actually don't understand why is that.
So there's some evidence that it does matter
for certain groups more like, for example,
and I'll, the data that's out there suggests
that for Latinos, it's actually good enough.
But for other populations, it's not.
Like Asians.
They're not finding the same results
in the study that they have done on Asians.
Why is that?
I mean first of all, there's not tons of studies on this
to start, but the idea is maybe it's more difficult.
Because it's not only, I want to be clear about this,
it's not only the linguistic proficiency of the provider,
but there's something about how you speak,
how you relate, how you, all the non-verbal.
That might be very important.
For some reason, don't ask me why,
it's not as important with Latinos,
at least the evidence that has come out.
And some people think it has to do with,
Latinos are one of the groups that have
higher inter-racial marriages, so it might be
that they're for some reason more open,
I don't know, we really don't know.
But it's a really good question.
Just to tell you, we did in this study
that I talked to you about communication,
look at providers that spoke Spanish
with Latino patients, their communication was different.
So although they spoke the language,
still their communication was different.
Yes.
(inaudible question)
Care.
So, I think it's going to be interesting,
it's still ongoing.
We did publish recently a paper
in Psychiatric Services actually on that.
So it's having a big impact on screening on Latinos,
but not on the other groups.
One, except Brazilians by the way.
So it's , well, including Brazilians in the Latino group.
It's not having an impact screening yet
on Asians that we're seeing, or in
African Americans.
Two, it's only on screening, so we're not seeing
the effect in quality.
So I think it's going to be really interesting
seeing whether that also translates
to quality care.
So I think we have to be, I mean
I know everyone's very excited
about integrated care, and I have to say,
I'm very skeptical.
Partly because I'm worried about
having enough time for the behavior health component.
So we'll see what happens.
Yes.
(inaudible question)
Yeah, I actually review for Katie Willging, who was
the one who was doing the evaluation.
I think you have to be careful.
I don't have an opinion yet, because the data
that I saw was actually at the very beginning.
I think there is a lot to be learned
from shamans and from people that are doing,
like, if you look at astrologers
and things like that, why do we
invest so much money in them?
I mean it's a big question.
So actually, when I've gone to several conferences
relating to that, because I was very interested.
And I mean, they go because they go
wherever the patient wants to go.
They respond to the question the patient has to go.
But whether they're going to be effective,
I don't know whether the integration of native healers
is going to be important.
I think for certain populations,
it has turned out to be very important.
So for children's asthma, there's
a very good work that Glorisa Canino did
on children's asthma, and integrating healers
in asthma care.
And it actually helped to talk,
because the person felt more open
to disclosing what they were getting
from the healers, and sometimes
there was something that was going to be
very problematic.
Or was going to be substituted
for the actual medication.
So I think there are components that are important.
But I think we have to, all of the same,
I'm a big believer in evaluating.
Yes.
(inaudible question)
That...
Can I answer your first one?
Let me just, you know, to make sure I answer it.
So, we, the reason we didn't follow them
longitudinal, is this was one of the things,
I don't know if people heard about it,
what was it called challenge grants?
So the government had some money,
and put out there, well we have,
write your thing, actually it's really interesting,
because this challenge grant was only for two years.
Actually then, we had a known-cost extension
and took it to three years.
But we couldn't follow people for enough time.
We're now doing the study with the elders
using the same type of intervention,
a little more expanded because
we're including other things.
But we'll have a chance to follow people for 12 months.
We're actually doing a study on mental health
substance abuse for people that have dual pathology
and those we'll follow for a year.
So we'll have more information.
(inaudible question)
I really am so glad you asked that question.
Because I can tell you the first thing
clinician told us is the phone won't work.
Because we won't be able to have
the same therapeutic alliance as we have in person.
We actually tested that and found
that that's not true.
I think it has, the reason we actually
describe that in the paper, is we think
so many of these immigrant populations
maintain a connection through the phone.
That they are used to having this
connection by phone, and in fact,
what we found in certain cases
where the provider, this we didn't allow
if you were in the telephone arm,
and by the way, clinicians had to be
in both arms.
So it was not an effect of clinician
being one arm and not the other,
so you have to be in both arms.
But anyhow, what we found is that
the therapeutic alliance, there was
no significant difference across the two groups.
And we measure that.
Questions, yes?
(inaudible question)
Yeah, so let me tell you, in clinical care
it's more difficult, because, I mean,
and this is where cultural humility comes in.
You might say to the person, I have no clue
what is this word that you're using.
Or trying to find out someone that can
help you with a wording.
So one of the things, just for the clinical care
what we did is, we actually have
a bilingual committee that is made of
people from many, many, like Spanish-speaking countries
when we were doing Spanish, so it was
not only like, Puerto Rican Spanish
or Salvadoran Spanish or whatever.
And what we do is we put like,
all these words, slash, slash, slash, slash.
So the person can look when they are doing,
like which of the words are they
you know, it's going to be this person
is from Argentina, well I can start
doing different words.
We also, I mean, for questionnaires,
when we do questionnaires, we actually
allow what they call throttling.
So you can go back and forth, and
the same, it will show you many, many words.
And that's how we try to compensate
for, because there's not one Spanish,
and there's not one Chinese, and there's
not one Creole.
I mean if you think about it, there are
many iterations depending from where you come.
So I think that that's where we train
our clinicians about cultural humility.
Because it's not only language.
I mean, we have everything from
sexual orientation to people, how they
dress, how they react, and so we really think
it's important for you to make a connection
and we do a lot of things to try to create
that environment.
Yes.
(inaudible question)
Sure.
Well, I mean, I think you know,
I have to say there are limits
to what data can do.
That's actually one of the reasons
my last grant, the last grant
I have submitted was more, not only
bringing the data, but actually
working with community groups,
stake holders, policy makers, to try to
help them generate the intervention
that they wanted.
Because I actually found that although
you might bring, like for example,
let me give you the example of
patient-provider communication.
I mean, everyone agrees that we do
biases, stereotypes, everyone,
I mean, there's no question.
People agree less on whether they're doing it.
That's obviously.
But I would say that you know,
they're willing to even take that on.
But it's something very different when you tell them
like the coaching, we do a 12-hour coaching.
And what we find is that the coaching helps,
because it creates awareness, and it also
will help in why we're focusing on
these components of our training.
But actually, it's not that effective.
I think what's really effective
is telling you what you are doing
that doesn't work that might be changed
and might get you along with your patient.
And that really triggers something
different in people, because it's not like,
everyone does biases, and everyone
does stereotypes, it's, you're doing this.
And this is attributional error.
And when you do an attributional error,
you distance yourself from the patient.
So this is what you could do.
You could do x and y and it's very different.
It's a very different component.
I think the same happens for policy makers.
We can give them all the data we want,
but they have to be part of the solution.
To make a change.
Other questions.
Yes.
(inaudible question)
Oh.
Sure.
You know, unfortunately, this was
a big epidemiologic study, so we know
that there are many things.
I can tell you what qualitative work,
which I think does a better job
of trying to capture why are people not coming.
I think there are many issues.
I think the biggest one is, people
really don't think they have a problem
that's so serious that they need professional care.
I think that's a huge, huge problem.
And unfortunately we know that
it takes 15 years, 15 years of disorder
for people to start going to care.
That's really the time lapse that it takes
for people to start going to care.
So to convince people earlier on
in their illness trajectory means
you have to be really convincing
about why they should do it earlier.
And I don't think we do a good job about that.
I think there is a lot that can be done
with motivational interviewing,
but I think you need other strategies
to convince people they should
go to care earlier.
So that's one big issue.
I think the second big issue is,
I don't think care is very accessible
for people that are working today.
I think people have a lot of issues
in going to care if they're working full time.
And so it's very difficult to maneuver that
unless you have a community health clinic,
you know, 15 minutes down your work.
And that's very unlikely.
And I can tell you because I hear
a lot of, when I'm doing supervision,
I hear a lot of tapes.
And you can see people saying,
I can't come that frequently, no,
you know, I can come in two months.
Well in two months you don't even
remember who's this person.
I mean, their problem is probably
a lot more severe.
So I think thinking about how we can
provide care and work in ways that
don't require people to come all the time,
I think is critical.
I think the third thing that we,
I have to say, I don't think we're
providing that great care, I think
we're doing a lot of venting out
and hearing people vent out, but not
necessarily helping people gain
greater insight.
And doing more illness management.
And part of that is because it's
very labor-intensive to do that.
But I think we need better training.
So I think those three things are drivers
of why we're not getting good care.
And people to go to care.
Thank you very much.
Really appreciate it.
(applause)