Transcript of Talking Heads with Dr. Noosha Niv – Episode 7
Bridging Culture and Care: Dr. Steve Lopez on Transforming Mental Health in Latinx Communities
Announcer: This is Talking Heads. Explore the latest in research and policy about serious mental health disorders with Dr. Naan.
Dr. Niv: Hi, I’m Dr. Niv and today’s guest is Dr. Steven Lopez. Dr. Lopez is professor emeritus at the USC department of psychology. His research has focused on culture, serious mental illness, families, and intervention. He has studied the relationship between family factors and the course of schizophrenia, particularly among Mexican-American families. The primary focus of his most recent work was to reduce the duration of untreated psychosis among Latinos with the first episode of a psychotic disorder. I’m grateful to call him a mentor as he was also my dissertation chair back in the day at UCLA. All right, welcome Dr. Steven Lopez. Thank you so much for joining me.
Dr. Lopez: Well, thank you for the invitation, Dr. N.
Dr. Niv: Thanks for being here. Um, so let’s start with what led you to the field of psychology and then more specifically the focus on psychosis.
Dr. Lopez: So I went to Claremont Men’s College which is now Claremont McKenna College. I was an econ major when I began in 1971. Didn’t do so well in econ uh but did well in my psychology courses and my junior year I had changed majors to psychology. It just seemed to fit uh my interest. I it was fun and I thought about those issues in psychology and in terms of psychosis kind of backed into it. Um my My main interest in psychology has been culture and ethnicity and how that relates to intervention, psychopathology, etc. But I I was asked to be a consultant on a study uh that was led by Marv Carnau and Janice Jenkins and Ian Foon actually was involved in it. Uh and it was to look at expressed emotion among families and as it relates to course of illness. And so I was the diagnostician, spoke Spanish, speak Spanish, and I was a diagnostician. It was a a study focusing on Mexican-Americans. And so I would had keys to three or four of the main hospital, psychiatric hospitals here in Los Angeles. This was in the early 1980s. And from that, I began looking at issues of family factors in conjunction with a a student at the time, Amy Weisman. Uh, and so that’s really how I backed into it. I still have an interest in culture and still continued that but it really started with psychosis and I never thought I would actually study psychosis. I saw that is on the severe end of mental illness and and less opportunities for improvement. That was my perspective in the 70s as a graduate student. Uh but now we know so much more and people can lead very full lives and psychosis been is been an interesting area of research and it it it allows for the study of culture as well. So that’s how I got interested in psychology and study of serious mental illness.
Dr. Niv: Okay. And and your current research is related to first episode um psychosis and what’s the goal of this line of research?
Dr. Lopez: Right. So close colleague of mine friend Dr. Alex Capelloitz. He’s here at UCLA and I started doing some research in in Mexico Meico. And one day I called him up and I said, “You know, there’s a lot of documentation of the needs, mental health service needs for the Latinx community, but why don’t we do something about it? Why why instead of documenting the needs, why don’t we try and improve the mental health status and prevent at least secondarily kind of burden upon on individuals?” And so that led to us carrying out this research which was to improve what we refer to as psychosis literacy. So the knowledge of psychosis, uh how to manage it, taking medications, psychosocial interventions and the like, but how to improve psychos literacy primarily so that people early on can identify in their loved ones. Usually people don’t self-reerve for psychotic illnesses and so their loved ones can recognize the illness and then get prompt care. And so we started started off in Mexico in teaching people how to identify uh the signs of serious mental illness and it expanded here to the United States with largely Spanish speaking community. But the main goal is to help people get the kind of care early on so that the burden isn’t as great to them as well as their loved ones.
Dr. Niv: Can you expand on that and discuss the importance of getting people into treatment earlier?
Dr. Lopez: Sure. One of the goals of the relatively recent campaign was to as I said earlier reduce the delay in getting the services but to do that we have to establish a conversation uh and so we carried out a campaign which we tried to initiate conversations in communities in groups in churches in schools with people with mental illness and people without mental illness and the idea is that if we can enhance conversations we can get people into care early on. In fact, I recently had a a family a situation where one of our loved ones uh developed serious mental illness and I was told that that’s not something that they wanted to share with others and and I respected that. The downside of that is that a person doesn’t get the kind of support from the loved ones, doesn’t uh help them think about avenues and options for care. And so really what we want to do is expand the conversation so people can get the support and they can get the care. And often times if you wait too long then the individual with the mental disorder is actually less likely to seek care and less likely to continue to seek care once they’re getting care. The other thing is that it ends up in an acute situation. Hospitalization is needed often times an emergency. Sometimes the police get involved and it can be an ugly kind of situation and it ends up serving as a barrier for people to continue the care. And so enhancing communication, you can get the support that you need. You can explore options early on in in the illness course so that the person can participate in that decision-m and you can avoid really acute episodes that require hospitalizations. It ends up being a very negative experience and doesn’t promote continued care. So those are reasons why it’s important to get early care.
Dr. Niv: There’s been so much research in the last 10 to 15 years particularly and the outcomes are pretty remarkable. The earlier people start the better off they are overall.
Dr. Lopez: Yes. Not only does the duration of untreated psychosis, so the time from the onset of the illness to when they’re be treated, that evidence is pretty clear that the shorter time period in which they’re not being treated the better outcomes both clinical symptoms and also functioning but in addition I think it’s really important to indicate that that time period can be reduced at least two studies to my knowledge one is the tip study in Norway and then the uh mend study in the Yale with Dr. Denodeari have demonstrated that you can reduce that duration of time with campaigns with getting out the word and so that over time people can get the word and get into care so that they can prevent some of the negative consequences. So yes, that time period is really important to keep it as short as possible.
Dr. Niv: I I want to talk about the campaign in just a moment, but before we do that, you know, we know the Latinx population takes longer to engage in treatment. Do you see that as just a literacy issue? Like why do you think that’s happening?
Dr. Lopez: Yeah, it’s a great point, Dr. Nev. It’s our intervention. Our campaign is to enhance literacy, but that’s one avenue in which you can hopefully reduce the duration of untreated psychosis. But I really see it as a structural issue primarily a structural issue in terms of availability of Spanish-speaking mental health professionals, the the knowledge of primary care physicians and their ability to refer folks into mental health care as needed, the schools as well. So, If I had a lot of money, I would invest in ways to enhance the structure of care in the different ways in which people actually reach services. So yes, literacy is an important point and the campaigns have often argued that we want to enhance literacy and we want to reduce stigma so that people can get the kind of care that they need. And I think that’s important. But if you don’t have the structural elements in place, people don’t have insurance. People don’t know about the mental health services because they’re not well known. You don’t have Spanish-speaking individuals that have the thrust of of the Latinx community. And no matter how much literacy you may have in knowledge of the illness, it’s less likely that you’re going to get the care that you need. So, I think it’s not just a factor of literacy, although that’s one way of intervening and we focused on that. It’s it’s a lot about the structure of care in my opinion. the services and how they’re provided.
Dr. Niv: Yes.
Dr. Niv: Um you you mentioned stigma. Can you talk a little bit about the role of stigma in um surrounding mental health in Latinx populations?
Dr. Lopez: Sure. There’s I think most of us believe that stigma is really an important barrier in the Latinx community. And I think many of us believe that it’s greater in the Latinx community. A student uh she’s now a doctor made the point that in particularly the Mexican community what what are people going to say is a common expression. My dad used to say his mother used to always say my dad said who’s who who’s going to say something but this idea that people are going to comment and and so that you should suffer from a mental illness or that you should have a loved one with a mental illness you know what are others going to say about that that is a factor that may play a role in people not getting the care and may be greater among this community than others. I don’t have any evidence that that’s the case, but I’ve heard so often from people within the Latinx community, particularly the Mexican origin community, talk about the stigma being greater.
Dr. Niv: Did you find that about 50% of people who recognize symptoms suggest seeking care from a mental health professional? Am I remembering that correctly?
Dr. Lopez: 50%. Say that figure again.
Dr. Niv: Among people who are noticing symptoms in family, only 50% suggested seeking help from a mental health professional.
Dr. Lopez: You’re referring to a particular study that we did.
Dr. Niv: I may not remember correctly, but yeah, I feel like I read that in an interview you gave or does that sound familiar?
Dr. Lopez: 50% seems high to me.
Dr. Niv: Okay.
Dr. Lopez: Yeah.
Dr. Niv: But I think the point being that family members, even if they recognize something’s wrong, they are not referring people. They’re not suggesting, hey, my son, brother, or whoever go to a mental health professional, where are they going for help?
Dr. Lopez: Good question. Um, there’s a large literature talking about seeking services from folk healers or seeking services from family physicians and the like. I’m not so sure that people are seeking the services from those individuals. I I don’t recall recent data in in that regard. Here’s a wonderful case that we had in our study and I think it it makes an important point about words of a conversation. We were in the community. This one gentleman said that his he had somebody who he knows who suffered from these symptoms that we call lav which are symptoms of psychosis. He says I know somebody and and so our community outreach person said well contact the number which was the number to the outpatient clinic didn’t contact he did not And then this outreach person goes to a pharmacy and and reaches out to the community, sees the same gentleman and he says, you know, it’s actually it’s my son and she says, “Contact uh this phone number.” Doesn’t contact the phone number. He he texts her a number of times. So he knows he has the knowledge that these symptoms are a reflection of mental illness, but he’s not calling. Finally, the son gets aggressive and he calls the police
Dr. Lopez: and he tells the police, “Take him for drug rehabilitation. He’s doing drugs.” Police say we, you know, take to drug rehabilitation. We can either take him to a psychiatric hospital or we can take him to jail. He says, “No, take him to the drug rehabilitation center.” No, we can’t do that. And then the police officer said, “Because we were involved with the police and did some training with them, the police said, “Well, if you go to the psychiatric hospital, they have the Laclave program.” And he knew about Lac from our campaign outreach person. And so he said, “Oh, take him to Lak Lab. So, it’s about multiple people having a conversation so that you can feel confident and you can trust that seeking mental health services is the right thing to do. Also, we’ve been in the community and uh some people will say, “We can’t go to that clinic because we don’t have insurance.” Well, that’s a public mental health system and you don’t need insurance. Or, we can’t go to that mental health clinic because they don’t speak Spanish. Well, in that mental health clinic have a number of providers speaking Spanish.
Dr. Lopez: So the perception that the community has often times is not congruent with the resources out there. But the more we have people talking police, family members, school teachers, counselors, and people are going to start feeling comfortable to talk about mental health. This idea of being crazy is really problematic. And so having a conversation. I think it’s about trust really. So they’re they’re just not getting the service. Not that they’re getting it in some other place. I think they’re just not getting it because they don’t trust the system. They don’t want people talking about them.
Dr. Lopez: Another situation that I’ll never forget, one of our families had a son or daughter who needed acute care. The ambulance came out. They took their loved one away. The next morning, somebody had spray painted painted on their garage and this house is a family of crazy people.
Dr. Lopez: This house is a unos locos.
Dr. Niv: It’s devastating.
Dr. Lopez: So again, that idea stigma, that idea of what are people going to say, that idea of letting out.
Dr. Niv: So they really have to hear the same message repeatedly from different sources to trust.
Dr. Lopez: Yeah. So structure and trust.
Dr. Niv: Can can you talk a little more about the um the communication campaign. What does it consist of? What is what is it teaching people?
Dr. Lopez: I was interested in coming up with common everyday ways of describing serious mental illness as opposed to in clinical or technical terms. Some campaigns talk about schizophrenia or psychosis. I didn’t think that that was a way to go. Instead, I wanted to come up with ways in which people can talk about it easily. And so, I went to my wife uh who’s born in Pueblo, Mexico, and she was a Spanish language instructor and I said, “Latisia, look at I want to teach people about hallucinations, illusions, and thought disorder. Disorganized speech is a way of capturing thought disorder, but say it in a way in English and in Spanish, in a way that can be commonly used.” So, she came up with, which means delusion, false belief, disorganized speech. What kind of so the first letter of each of those words you come up with the word clave and clave means guide. Clav means index. Clav means key. So clav use the key. Graves, use the key to identify serious mental illness. And so we go into the community and teach people about Laave. When we first developed this idea, we would use popular cultural icons to illustrate each of the symptoms. So we used a snippet from a song by Mana called Slas. And Samlas, which is the peer of samblas. It’s a real port in Mexico. And in samblas, a woman believes that her lover is going to return and everybody knows that he’s not and she ends up living in the pier of Sunglass and she’s decompensated terms of her dress and and other ways. So that’s an example that everybody knows that song. They don’t necessarily listen to the lyrics and really think about it, but that resonates and then they walk Organis we used a clip from Canlas who was a very famous Mexican comedian who would go from one idea to the other without any clear connection and he did it for comedy and everybody knows Kantas in Alusion. There’s a song by a Puerto Rican group song by for named Sophia and Okasio. She uh lost her mind when she started seeing her lover and hearing him and seeing him. So we would use these popular cultural icons to get people’s attention. in an entertaining kind of way so that they could recognize it. But our main emphasis of the campaign was that we developed a narrative film, a 15-minute brief film. This was all funded by the National Institute of Mental Health and we hired a Hollywood director, Patrice Carloso. She’s Colombian did the movie Grilled Women Have Curves. You may have seen that movie. And we have a 15minute film that you can see if you go to our website. laclave.com or use laclav.com and it communicates this whole process of of family members uh who have a an an adult daughter who starts developing delusions, false beliefs and they think she’s just stressed out because of the divorce
Dr. Lopez: and they don’t consider seeking care until a neighbor who has a son with serious mental illness says, you know, I think it’s something more than that. No, not not the stigma, you know, that’s not my daughter. No. And then that she finally gets the care that she needs and as a result of the input from the mother. And that’s the core of our film. So, we would go into the community, as I mentioned, schools, churches, health clinics. Uh the the swap meet was one of our best places. Uh we would just hang out there and hand out brochures.
Dr. Niv: Interesting.
Dr. Lopez: So, we we got the word out about Lac and in an effort and in an effort to get them coming into the clinic and we measured then the treatment delay of people with first episodes over a 2-year period after we did the campaign.
Dr. Niv: That’s amazing. And were there particular aspects of public health messaging that really resonated with the population you were approaching? You know, you talked about popular icons. Did you find anything else that really worked? I
Dr. Lopez: I think this narrative film was really helpful. To give you an example, we went to church, maybe the 30 people there. And when we administered the film, we’d first do a little introduction. And we asked the questions, “What’s mental health? What’s mental illness?” And people would raise their hand and they would describe. And this one woman says, “I know what mental illness is, but I’m not going to share it with you.” Okay. Left it at that. Watch the movie. After the movie, people really chimed in and that kind of opened the door to to having these conversations. And uh this one woman disclosed that it was a family member who suffered from a mental illness and she began to talk about it openly. So I think seeing this movie opening up people’s eyes that this can happen uh this is real and other people willing to talk about it can open up the conversation. Now I don’t think a movie this 15-minute movie is something specific for the Latinx community. Uh, but I think it just captures really nicely some of the key barriers to getting care and then the fact that there’s hope. That’s that’s one of the main messages of this of this movie is that by getting care early,
Dr. Lopez: you can have your loved ones leading full lives. Uh, hope I think is really important. Uh, but I think this translates across communities. But the fact that it was in Spanish, it used idioms that made sense to people and there’s no question that the movie enhanced psychosis literacy. We did a number of studies. We did it online compared to a TED talk. Uh we did it with health promoters, promotas administering this. We did it when we administered it. We did pre and post. We did experimental controls. It’s no question that the movie and and our different ways of teaching about psychosis really enhanced psychosis literacy.
Dr. Niv: That’s really interesting that compared to like a real life presentation, there’d be a significant difference.
Dr. Lopez: Yeah. Can we switch gears completely for a moment? And sure.
Dr. Niv: I I had Shirley Glenn on the podcast a few weeks ago and we talked at length about the negative impact of family factors or family criticism and hostility on outcomes. And your work has also looked at the relationship between family factors and outcomes in schizophrenia, particularly among Mexican-Americans. But you’ve really looked at it from a very different angle. You you spent years studying what families are doing, right? What are they doing? Well, that’s protective. What What have you learned?
Dr. Lopez: That was some time ago. Uh I I really enjoyed that line of work. A couple things that that we learned. One is that with one of our samples and Mexican-American samples that uh warmth predicted the outcome or relapse rates. So that those persons with schizophrenia who are living with families that were high in warmth were less likely to relapse 9 months later. And there were Only two other studies and there were over nearly 30 studies at that time and only two other studies even considered a positive aspect warmth in particular. One was that out of the old Yugoslavia and another one was in Italy. So one thing that they shared was the Catholic faith. We didn’t look to see whether or not that played a role. But for me I think it’s really important to look at what families are doing in a positive way as well. as well as what families might be doing in a in a quote negative way that plays a role in in the outcome. So the implication of our finding about warmth is that therapists should not just be focusing on decreasing negativity. We characterize it as hostility or criticism or emotional over involvement, but that you also think about how to build on the strengths of the family and their caring and their connections. And I I think you know some of the early research in family interventions did point out the importance of positive communication for example but I think overall the emphasis has been about the negativity of family so that’s that’s one thing that we learn
Dr. Niv: what what is warmth
Dr. Lopez: yeah it’s a good question thank you the way it was defined and keep in mind how these constructs were measured what I really liked about the study of warmth and criticism and emotional involvement etc. is that it was based on families talking about their loved ones with schizophrenia and it’s expanded to other other disorders as well. So they’re talking about them and so warmth is tonal on a measure of 0 to five to what extent does a person show interest in their loved one do they uh speak in in uh it’s more on the affect domain uh than it is quote positive remarks. There’s another index that’s referred to as positive remarks. You can say positive things about the love but that’s not related to outcome at least in our studies and in general positive remarks isn’t but warmth this kind of tonal interest and warm tone as well the way they’re talking about it. So if they say Joe relapsed last week or Joe didn’t take his medication or Joe you know he’s really trying hard and and you know just having a hard time. So the tone in which the person is expressing their challenges uh can play an important role. So it’s it’s more on the affective domain than and the interest that they have in in the individual. You know I remember this one mother saying Joe and I watch TV every night and just really enjoy watching TV with Joe every night showing an interest versus Joe’s, you know, very clean or Joe is a hard worker. those positive remarks aren’t as related as as that affective tone.
Dr. Niv: There’s a connection and empathy.
Dr. Lopez: Yeah, that that’s certainly that’s certainly part of it. Uh so the other thing that that we learned is that the the difference between the perception of the ill relative versus the perception of the caregiver. And so we measured not only warmth or criticism But we also measured the perception that the ill relative had of their caregiver and it’s not always congruent.
Dr. Lopez: Yeah. Some some people can see the negativity in a positive way of caring or they can see their warmth and involvement is being critical. And so that disconnect can play an important role and it opens the door for family interventions and clarifying how people communicate. and how people receive that message. Those those are two key messages that that we learned in in that line of research. It’s been a while since I thought about that. Thank you for bringing it up.
Dr. Niv: Well, that’s what brought me to you. So, years and years ago, so I appreciate it. Um, I want to jump to some questions I got in the Facebook group.
Dr. Lopez: Okay.
Dr. Niv: Uh, the first one is, I keep hearing about culturally competent care. What does that mean?
Dr. Lopez: Yeah, a lot of people have written about culturally competent care. The current view is cultural humility. But my view is it’s about shifting lenses. Culturally in in the past people criticize existing interventions, existing models as being not considering culture. And so people have gone the other extreme and say we need a psychotherapy that’s tied to a particular group or embedded with particular cultural concepts. And and I believe that we need that kind kind of information. But but I think it’s more about shifting between the client, the consumer, and the family’s perceptions of things and accessing them and then using them as you intervene and assess with your knowledge, your norms, your models. And so it’s about h I guess I’m using the word conversation again. It’s one accessing the client and family’s views and present your views and then negotiating what’s really an understanding what’s the best way of understanding this. So for example an area that’s of great interest people with serious mental illness medication. So family member says I don’t want to take the medication and the and the mental health practitioner says well I think it’s really best to do so. Those are two cultural notions if you will about how you address mental illness and coming up with a shared understanding and a shared narrative as opposed to just drawing on the client’s view or imposing your view. How can we come up with a shared narrative including okay you don’t want to take medication but let’s monitor this every week and if we see any signs that are concerning let’s intervene at that time. How does that sound? In my view that’s culturally competent care that you’re accessing the client’s view. You’re presenting clearly your view. And then you’re coming up with a shared understanding.
Dr. Niv: You’re negotiating that if needed
Dr. Lopez: and negotiating it. And sometimes you’re not going to be able to negotiate because the client is adamant they’re not going to take the medication.
Dr. Niv: That’s such a great segue to the second question, which is, “My family is Catholic. My husband is prescribed an antiscychotic, but our pastor told him not to take it, that God will heal him. I’m not sure what to do.”
Dr. Lopez: So again, what’s their conception and conr What are the advantages and disadvantages of the of accepting the pastor’s view
Dr. Lopez: and then what are the advantages and disadvantages of accepting the mental health point of view that antipsychotic medication is useful and then coming up with a a shared understanding. Of course I as a clinician would say my experience has been that people benefit from those antipsychotic medication. Is there a way that we can draw on your religious beliefs to help you and your family member with this illness? prayer attending church services involvement in the community but at the same time using the medication. So the acknowledge and and and support their religious views maybe even having a conversation with the pastor and saying tell me more God can be very present and God can help it but God also helped us come up with these medications as well.
Dr. Niv: Okay, couple more. I’m just getting started with a therapist. How can I determine if the therapist will understand my experience as a first generation immigrant. Are there specific questions you think I should ask? That’s a to
Dr. Lopez: Yes. Ask him how well are you familiar with first generation immigrants? That’s not going to get you very far.
Dr. Niv: Yeah.
Dr. Lopez: Uh I I think it’s your job as a client, as a consumer of services to talk about things and see how well they’re received and you can start addressing some touchy issues and get a sense of how they respond to that. So for example, what does it mean to you to be a first generation immigrant? Are you concerned that they may have some stereotypical notions about that? And you can share those concerns with your therapist and see how they respond. But I think the best way is to start addressing issues and seeing how they’re responding to those issues.
Dr. Niv: What do you think for someone who’s reached out to several therapists seeing who they connect with. What do you think of the appropriateness of just asking what is your experience with first generation immigrants?
Dr. Lopez: I think that’s very appropriate and maybe a clinician may not have any experience with working with somebody of that background, but uh they may be showing that they’re interested and they’re learning and they’re asking questions and they’re willing to look at the life experience from their perspective. So even though they don’t have the background in working with that population they may be very open to learning about that. Now you as a consumer you don’t want to have to teach people about your experience where you so that it takes away from the point of receiving the services but you know how open is this person to learn from others and you can get a good sense of the therapist vibe indirect kinds of ways and so I I would encourage this person to really think about it that way
Dr. Niv: and last one is should I look for Mexican or Spanish-speaking therapist? Does it matter? And then I went back and the poster clarified that they’re Spanish speaking Mexican,
Dr. Lopez: right? If it matters to them, then they should. There’s a literature out there in terms of to what extent do people of Mexican origin prefer people in the same ethnic background and there’s different points of views. I think if it matters to them, they should try and seek services from somebody who speaks Spanish if that’s important. Uh, obviously if you speak Spanish, you can get somebody speak Spanish, but if they’re bilingual and they prefer somebody’s knowledgeable about Spanish, they should do everything they can to seek services from them, that’s important to them.
Dr. Niv: There data about matching.
Dr. Lopez: Yeah, there are data. There are some data that show that matches lead to more positive outcome.
Dr. Niv: Okay. And the last question is, what are you most excited about in the field of psychosis? What are you seeing as really having the potential to improve lives and functioning in a positive way right now?
Dr. Lopez: Two things. I’ll say one is that psychosis really is an opportunity to understand what really matters to people. So when your loved one develops psychosis, what is it about it that is really concerning to you as a mom or dad or sibling or partner and it may be that they’re not going to get married or they’re going to lose their mind. It really gives you a sense of what matters and what really matters. What culture can play a really important role in the study of psychosis, something that I wondered about early on, but it’s a very rich way of understanding what matters to people. And the second thing is I’m just thrilled that we’re seeing that people can lead full lives. And I I must admit I’m I’m one of those people who learned this uh that they can lead full lives and that there’s a great deal of hope for individuals with psychotic disorders. Uh they can marry, they can have careers, they can be parents parents, but the important thing is that they get the care and they get it early. And so those are the two things. One, it’s a wonderful area of study to find out what matters to people in the role of culture. And secondly, that there’s great hope for people with serious mental illness, something that we didn’t think as much about in the past.
Dr. Niv: Well, thank you so much for joining me. I really, really appreciate it and love hearing your thoughts on culture and I love hearing about this campaign that you’re doing.
Dr. Lopez: Okay,
Announcer: this is talking heads.