Interview With Drs. Alegría and Chapa (cont’d)
That got me interested in moving more toward disparities, because I saw that if we can’t offer these women any institutional support, how can we expect them to reintegrate, to recover, to have an opportunity to thrive? We’re closing the door on them. That got me very much into trying to describe the disparities. From there, more recently, we’re interested in trying to do interventions to reduce the disparities. MFP E-News: Studies that world donor organizations have done on girls’ education show that, in countries where there is a big gap in educational attainment between boys and girls, those programs aimed at improving education for girls also improve education for boys. Have you found that policies aimed at improving the health and behavioral health of poorer people also have the effect of helping those at whom those policies are not directly aimed?
“A lot of young MFP Fellows have to change the status quo. Sometimes that seems like an overwhelming task. . . . They need to think about how to empower their patients, giving them more hope.” Dr. Alegría:
We published a paper about a policy change meant to be for poor people. This was one of the first studies I did in Puerto Rico. There was so much debate about this policy that they extended it to people who were what I call in the paper “nonpoor”—mostly middle class people who needed access too but typically had some access already. In that paper, I showed that on the average it didn’t make a difference, but it was actually making a positive effect more for the nonpoor than for the poor. Sometimes the changes make a positive effect for everyone, and as a result of that what we see is actually an expansion of the disparity. Mental health services for poor people are generally so limited that, when you open it up for everyone, it’s true that it improves for everyone—but it could make the gap bigger. MFP E-News: Because you’re helping the poor people a little and the not-so-poor people a great deal? Dr. Alegría:
Exactly. So we establish indicators in the quality of the care to make sure we’re eliminating the disparities rather than augmenting the disparities. MFP E-News: Dr. Chapa, have you found the same thing? Dr. Chapa:
At the service delivery level, absolutely. When we opened the floodgate, through the Affordable Care Act and the Mental Health Parity Act, we increased access to care, but we need to do more to increase access to providers. I feel we still need to create policies and approaches that are transformational—and continue to build culturally competent community services, et cetera. There are good people—the disruptors—out there working on these issues every day. It may take time and persistence, and we won’t give up! MFP E-News: How has your field changed since your first entered it? Dr. Chapa:
I think back at some of the services that were provided in the past, how unique and innovative they were, and today we talk about them as though, “Oh, this is very specialized.” For example, in the late ’70s and early ’80s, in San Francisco, where I worked as a nurse at Mission Mental Health [a San Francisco neighborhood] culturally based mental health services existed right there within a community. People could get to them; transportation was available and accessible. Nobody used the term social determinants of health
—and I’m thankful that we have that term now, because we can talk about what the elements are and what to do. We did, however, have diverse leadership that was multicultural and very sensitive to key mental health services issues. I have fond memories of those leaders.
Good culturally competent services still exist. Maggie, you’ve worked in that environment in Massachusetts. The environment is one where it belongs to the community. People walk in, and the receptionist is engaging and welcoming, the environment looks clean. [By contrast,] sometimes I’ve been in places where a fish tank is running with oxygen, but had no fish. I thought. “Oh, my God, get rid of that tank if you’re not going to add fish.” It was so symbolic of not having enough; of poverty.
“No matter what generation, no matter what decade, no matter what year, new ideas and transformation will always cause some pushback. . . . [W]hat is important . . . is to learn how to be resilient and strong in the face of difficulties and negativity.”
My clinical psychology predoctoral internship was with the Infant–Parent Program at San Francisco General Hospital (at the University of California at San Francisco). It was a wonderful program and psychodynamically oriented. We studied Freud and Object Relations Theory. Our clients were often the most needy, the most poor. It was heartbreaking to see an infant suffering from ‘failure to thrive’ and a mother with severe depression. Some families were homeless, sought temporary shelter with a friend, or lived in a makeshift room behind a larger residence. Many families were actually starving, and I remember a woman telling me: “You know what I need? I just need some beans! I’m hungry.” I bought her beans and also fed her. I could not turn a blind eye to reality. I would come back lamenting in clinical supervision because the program wasn’t set up to address that.
Many changes have taken place since then, and I see real movement in that direction, which is great. MFP E-News: What do you think are the most significant challenges that today’s MFP Fellows are likely to face in their careers, when trying to address and reduce behavioral health disparities? Dr. Alegría:
I think one of the challenges will be the ability to empower their patients and transform their patients’ lives. A lot of young MFP Fellows have to change the status quo. Sometimes that seems like an overwhelming task. I hear people sometimes saying: “Well, there’s so many things to change, and situations have gotten worse. There are issues of social determinants, of comorbidities, lack of resources. I can’t get them the services they need.”
They need to think about how to empower their patients, giving them more hope. They need to make sure they don’t get so burnt out that they lose that connection to their patients. MFP E-News: This must not be any different from when you were getting into the field. Dr. Alegría:
I would say it’s a lot harder now. MFP E-News: Really? Why? Dr. Alegría:
Because there are more institutional constraints in what people can do and in how they can do it. I think clinicians now have less autonomy in how they can use their time. There’s a lot of monitoring and compliance issues that have come into play. When I was practicing, I could see someone for an hour and a half. Now you’re very, very lucky if you can see them for 30 minutes. There’s a very different approach to service delivery. And then people have to do all of this productivity assessment. When I was practicing, that was not an issue. I think clinicians are having a much harder time now in executing their roles than I did. What do you think, Teresa? Dr. Chapa:
I think that piece is true, around compliance and so forth. However, I believe it’s always been that way for minority providers and for providers to minority or underserved communities. A lot falls on our shoulders, and we find ways to make things happen.
Maggie is right concerning what Fellows can do. Be creative in finding mutual support, so you can continue to learn and grow and support one another in a network—either within a clinical setting or make it part of an institutional meeting or group or review. Don’t be alone. Because of the constraints Maggie mentioned, there’s a lack of interest and investment. Time is a factor. I know the Fellows still want to make a difference in X
community. MFP E-News: What do you think will be the greatest opportunities for current Fellows in their future careers to make significant contributions to reducing behavioral health disparities? Dr. Alegría:
There are a lot of evidence-based practices that can be put to use. I think that the role of the clinician has been emphasized a lot more. What the elements of the clinician are that really make a difference have also been emphasized more—like therapeutic alliances, like communication, the importance of dealing with bias. So I think clinicians today have a lot of groundwork on which to develop good clinical practice. We know a lot about disparities. We know quite a bit about things that might reduce disparities. So I think they can take that on and tackle it. Dr. Chapa:
I agree 100 percent. Also, there’s a lot of versatility in work. You can do a lot of different things. Maggie mentioned communications. That’s been an interest of mine in recent years and a great opportunity for clinicians. I believe that people want to know more and learn about mental health. So, how do we best share information—including what services are available. Sometimes our community members are just unaware of what mental health services are. MFP E-News: Both of you are scholars on implicit bias and can likely cite chapter and verse of peer-reviewed published studies showing how implicit bias does harm to people of color and gives preferential treatment to white people up and down society. But there are millions of Americans who (perhaps not having read these studies) hear a few words about implicit bias and remark, “Oh, that’s just a bunch of ‘politically correct’ mumbo-jumbo.” How do you react when you meet pushback to your findings? Dr. Chapa:
No matter what generation, no matter what decade, no matter what year, new ideas and transformation will always cause some pushback. I think what is important for us is to learn how to be resilient and strong in the face of difficulties and negativity. That means continuing with the research, dialogs, and convening. Dr. Alegría:
I agree. In the last 5 years, there has been a big transformation in the level of—and the number of—people talking about disparities. It used to be an issue that would be for the few rather than for everyone. Now it’s on everyone’s radar screen. I think people now talk about implicit bias and explicit bias all the time in conversation. I had never seen such a push all over for diversity in the workforce—at the National Institutes of Health, at the National Academies of Medicine—you can see it now everywhere. I think there are some people who think, “This does not concern me,” and they roll their eyes, but I think it’s a lot less than it used to be. Dr. Chapa:
You’re right. At least we’re able to talk about it. You talked about implicit bias. I think we’re at a new stage of explicit bias—people saying rude things just because they can. It’s taken the past several years and a whole movement to make this part of everybody’s lexicon. And, even so, we still have very low minority representation in the field. I’d like to see some different approaches to build diversity in our graduate psychology programs, like those used in medicine or in physics or at the NIH or in psychology—a ‘bridge program’ that might provide foundational support to those without adequate level of preparation. What do you think, Maggie? Dr. Alegría:
I think people are more subtle. But I think there are other ways of showing bias—not offering funding, not providing human resources, not collecting the information you need to move things forward. I think it’s a lot more subtle than it used to be. But I think we have a real opportunity to unite forces. There are so many people interested at all levels in reducing disparities. People are starting to understand that it really improves everyone’s life, because when we leave some people behind we’re actually doing a disfavor to everyone. We’re all connected, and there’s need for bringing everyone forward. I’m very optimistic, I guess. MFP E-News: That’s encouraging to hear. One area where we’ve seen tremendous improvement in the past 35 years in the United States is acceptance of LGBT individuals. Dr. Alegría:
I completely agree. Dr. Chapa:
I also feel the LGBT has strong leadership and campaigns that forwarded their cause. I lived in San Francisco for almost 20 years and saw, firsthand, the political strength of the community and the Equal Rights Campaign—directed to families of LGBTQ. MFP E-News: The Minority Fellowship Program Coordinating Center is all about mentorship and paying tribute to those who helped us find our way. Any shout-outs to your guardian angels? Dr. Chapa:
Yes. My mother and grandmothers—who despite not fully understanding my career pathway—nurtured me through encouragement and spiritual support. Some very early educators from elementary through high school believed in me. They made me feel special and that I could do anything. But I credit two people who took me on as a California State mental health intern, when I was a nurse graduate trying to pivot into mental health: Sal Rossitto and Beth Blakeslee, both clinical social workers. They were true mentors who gave me my first chance to work in mental health, including in a psychiatric hospital. Later it was Dr. Carmen Carrillo, the first Latina director at San Francisco Mission Mental Health. She inspired me to pursue a doctorate in clinical psychology. And later, Dr. Yvette Flores, my mentor and doctoral chair, who understood and supported me on my journey to finish the Ph.D. She encouraged me always to take chances and to follow my dreams. If you did participate in the April 25 webinar, you likely decided also to tune in to the MFPCC’s June 13 webinar, also featuring Drs. Alegría and Chapa, on how to create positive change. Look for that second webinar later this month on the MFPCC website.