An episode of “Changing the Conversation” podcast
Vera Muñiz-Saurré and host Joey Rodriguez discuss experiences with culturally responsive care in early psychosis and strategies for providers. This episode is sponsored by the New England Mental Health Technology Transfer Center Network (MHTTC).
November 20, 2023
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Joey Rodriguez, Host (00:05): Hello, welcome to Changing the Conversation. I’m your host, Joey Rodriguez. I’m a clinical research student at Beth Israel Deaconess Medical Center and McLean Hospital. This episode is sponsored by the New England Mental Health Technology Transfer Center, and our topic today is culturally responsive care in early psychosis. I am very excited to have an amazing podcast guest, Vera Muñiz-Saurré. Vera is a Peruvian, queer, non-binary public health professional, serving as a clinical research program coordinator and peer counselor at different medical institutions across Boston. Vera received a master’s in public health at Boston University and has a lived experience of psychosis. Vera, it’s a pleasure to have you on.
Vera Muñiz-Saurré, Guest (00:53): It’s a pleasure to be here.
Joey (00:55): What are a few things that people should know about culturally responsive care?
Vera (00:59): I think unlearning what we have been taught in our professional spaces, and honestly professional spaces outside of academia, outside of hospital settings. In the public health realm, there’s been a lot of movement to shift to the language of cultural humility, understanding that you don’t know everything about a person’s culture, to not make assumptions about the motivations or the beliefs that underlie a person’s behavior. And I think that there is that element that needs to be brought into culturally responsive care, but there’s also the element of being proactive, looking up information about the cultural and historical context that your clients are coming from in both the clinical and research settings. If you’re working regularly with a client, I think it’s really important to know, where do they come from? What is their story? What is the story of their ancestors? What is the land that they come from? What is happening in the land that they come from? What is happening to their family in the places where they’re from? And using that to inform your approach to learning more about a client.
Joey (02:08): Yeah. And learning more about a client and having that understanding of patient-centered care is essential in providing culturally responsive services. From your lived experience, what was receiving care like, and was it culturally responsive?
Vera (02:25): A lot of the care that I received was not very culturally responsive. I would say the majority of the care that I receive has not been very culturally responsive. It’s no secret that the mental health industry as a whole has a racism problem and a demographics problem, an admission problem in academia. And then there’s sort of this model that has some criticism because it frames as being passive of being a leaky pipeline. At different stages, at different junctures of the pipeline, people are being lost, especially if they have marginalized backgrounds. And the further along you get in academia, the fewer people of color you end up seeing. And so my experience has been that most of my providers have been white people of middling or high socioeconomic status. There have been some exceptions. And they’ve been great. I feel like the only time with a provider of color that it hasn’t worked out has been when it’s just not a good match. There just hasn’t been a good fit.
(03:23): But with white providers, something that I’ve had to navigate has been underlying assumptions for my behavior, as well as a general attitude towards what I’m able to accomplish. I do think that a lot of the providers of color that I interacted with had a tendency to be very uplifting to wanting to help me achieve the goals that I wanted to achieve, even if they seemed kind of farfetched or lofty. And a lot of my earlier providers questioned my experience a lot. They questioned my own knowledge of my own experience and the language that I was using to describe it, and they just weren’t redirecting me towards resources that I was asking for. And it was super frustrating, honestly.
(04:09): And nowadays, I seek care now at a First Episode Program here in the Boston area, and my providers are pretty great. I am really thankful for them. The first Andean medical provider that I’ve ever had in my entire life was among them. And that’s the first time I’ve had somebody of not even my own background, but a similar background to me, giving me care. It’s wonderful too, because even the white providers that I’ve had have done the extra work of doing the research of my family’s history. Talking to them very vaguely about being Peruvian and about my family moving to the United States in the 80s gave them a reference point for them to be able to just do their own research and find out why my family might’ve left. And obviously, still doing that work in session with the client and provider one-on-one can be super helpful. And also, I think it’s super important to make sure that your client isn’t the one teaching you about everything to do with their lives because there is a…
(05:05): Particularly when it comes to immigrant clients, I find who are, particularly from families who are fleeing an unstable political situation, I think that there is sort of a lot of homework that needs to be done on the part of the provider when you’re working with a client with that background. You need to know what it was that they were experiencing, who their family was affiliated with, in what way that affiliation had any sort of effect on your current client’s wellbeing or mental health. And that can be very different from group to group, because particularly from a Latin American context, there’s this tendency for the United States to lump all of Latin American cultures into a monolith, and that can be very limiting because it makes it seem that we across Latin America have very similar experiences, which in some ways is true based on our history of colonization. But the ways that the colonization took form in different countries, in different areas, in different countries was very different.
Joey (06:04): Vera, you mentioned this disconnect between the provider and the person receiving care in a way that kind of shows this separation of experience. You suggest that providers need to do their homework because the person who’s receiving care isn’t going to explain their entire cultural background when they’re trying to receive care for something, right? But at the same time, a clinician and a provider should do their best to provide care that is culturally responsive, and they do so in doing their homework a lot. From your experience of receiving care, have you ever been in a circumstance where there is still that sort of limitation where a provider can only do their homework so much, and they don’t have that lived experience of being in a Latin family, for example, or being in a household of an immigrant family? Do you think that that’s a natural limitation?
Vera (06:57): Yeah, I think that there is some level of limitation, particularly when it comes to the topic of privilege. And we do have that sort of diversity issue in the industry. So there are a disproportionate amount of people who make it to get a PhD level education, who have those certifications, who come from usually high socioeconomic status backgrounds or who may come from many levels of intersection of privilege, who may just not think about in general these considerations as being something that might be necessary for a person to receive care. If you grow up mostly in white middle America and that’s all you know, it can be very hard to understand the hardships and the necessary precautions that people with marginalized identities need to take in order to even be ready to ask for care, in order to be ready to seek support in any way, and in what ways they interact with community, or the different health structures or government and social structures that they have to interact with on a day-to-day basis that they rely on for survival.
(08:01): And I do think that that can be lost a lot of the time. I feel like particularly when we’re talking about peer positions and trying to incorporate people with lived experience into the industry. The pay isn’t there. And also, I think that there is a larger issue of the benefits that are being offered to hospital employees, not covering all care and still requiring copays. And so things like the socialized model that we have in Massachusetts become a lot more appealing in terms of being the insurance that we use. So in a way makes it so getting out of poverty in any meaningful capacity removes your ability to access structures that you’re relying on for your survival to support your functioning.
Joey (08:43): Yeah. Right. So there’s this element of barriers receiving culturally responsive care from a financial and a systematic standpoint that’s facilitated by people enacting the status quo, which is oppression to people that mitigate their ability to navigate the mental healthcare system, but then there’s also, when you get in the environment where you’re actually receiving care, there is still culturally responsive barriers. And you were speaking a little bit on this topic of culturally responsive care being a bit of a, I want to say —
Vera (09:16): Rhetorical buzzword?
Joey (09:17): Yeah. It’s a rhetorical buzzword. The idea where to provide culturally responsive care, there is a responsibility of recognizing maybe someone is Latin. But that, while important, doesn’t recognize, in totality, someone’s background and someone’s experiences.
Vera (09:35): Their personhood.
Joey (09:36): Yeah.
Vera (09:37): Yeah. I think individual personhood is something that gets kind of ignored in some ways because of the system of racism and white supremacy that we live in and operate under the United States, that very often people do get lumped into these larger racial ethnic categories that are meant to be descriptive. And even you see that in the literature where we have generalizations of Latinos, Latin Americans, White Americans, Black Americans. And it really is in service of colonization to use those larger racial terms and not describing the population that you’re actually referring to.
(10:13): Because even if we’re talking about European identities, there’s different health outcomes from different European countries. And the same thing can be said to Asian countries, east Asian countries versus Southeast Asian countries versus South Asian countries, which even those are very large broad categories. And in the United States, what I have noticed is that there’s a tendency to group all of Latin America under the label of being Latino or Latin American, or in some way Hispanic. And those, I find, are not necessarily very meaningful demographic categories for looking at health outcomes, because in Latin America, a lot of the health disparities and the different ways that people are affected by larger political conflict fall along the lines of race, class, like the same things here in the United States.
(10:56): The conceptualization of how those social structures and social identities are treated is slightly different, but using the idea of larger cultural monolithic generalized trends sometimes goes too broad. And I think providers kind of sometimes fall into that too, where they think all Latinos are the same, or all Latin American people are the same or will have very similar presentations, issues and cultural conflicts. But I do think that that can be even a gross generalization. I do think an individual’s experience is more important.
Joey (11:27): When you’re receiving care, can you tell that a provider has these sorts of preconceptions when you’re receiving their services?
Vera (11:35): Not immediately, but over time, the things start to add up. I have had a tendency of trying to overlook blatant racism when it’s happening, as long as someone’s being polite about it, because I don’t want to be seen as rude or causing conflict by calling it out in the moment moment. I don’t even think about that being the potential motivation or cause of someone’s behavior until later. But there are times where I have had previous providers question whether I want to get better, question whether I’m actually trying in my treatment plan, questioning whether I have any motivation to be alive at all.
(12:15): And that has been something that I have particularly noticed is more common with white providers that I’ve had in the past. And it’s extremely frustrating because for me to be seeking care at all, that is me making an effort, and it does not make it any easier for me to continue making that effort if my motivations for that effort are continuously being called into question. I do think that often, providers aren’t doing it on purpose. There is this tendency for white people in the United States to be socialized to this idea that if a Brown person has a bad attitude or is responding negatively to something, that it’s “them problem”. It’s not something that’s a result or response to stressors in their environment.
Joey (12:59): Yeah, or stressors of having not adequately responsive care.
Vera (13:04): Absolutely. Yeah. Were the care that I was receiving early on, a lot more responsive culturally even, I would’ve felt a lot more supported. Honestly, early on, the care that I received was from a mental health clinic in my community, and it was okay until I actually started expressing things that were different from very commonly addressed depression or anxiety or talking about my own family trauma. My first therapist was this White lesbian lady, and she was really nice, but whenever I first started talking about psychosis, she asked me, “Are you sure that’s what you’re experiencing? Are you sure you’re not making yourself see those things by focusing so much on them that they’re visually presenting themselves?” I’m like, that doesn’t even make sense to me as an individual.
Joey (13:55): Yeah. And was this happening during the assessment, or was this during you were fully integrated into their —
Vera (14:00): This was a few sessions in. After that, I was just like —
Joey (14:03): That’s unbelievable.
Vera (14:04): Yeah, we’d already talked for a while. We’d established rapport. I was talking about my own trauma. She was very responsive to things like conversion therapy and talking about my own homophobic family, but she was not really, I guess, comfortable giving me agency and labeling my own experience, which was weird. It was only where points of common understanding were what she was willing to, I guess, address as being valid. But the things that I understood that she didn’t, she was not really willing to do the work to understand.
Joey (14:34): Yeah. So the idea of providing a space for you to understand your own experiences and for you to label them on your own accord is essential in culturally responsive care. Are there any misconceptions or myths of culturally responsive care that you can speak about on the receiving end and in general?
Vera (14:54): Yes. Oh my God. One of the myths is that diversity is going to… First of all, diversity is super important. There needs to be diversity in the workforce and the people who are administrators in all aspects of the mental health workforce, but thinking that just having new clinical interns or adding people in places that don’t have any leverage or decision-making power is going to fix the problem is very frequently relied upon in academia in general, in order to show that an effort is being made, as opposed to making tangible steps to make sure that change and sustainability is built into those structures. I think that a lot of people think that if they just hire new people lower on the professional hierarchy, that the diversity will fix the issue.
(15:41): But if the people who are in charge are ultimately still old White people with PhDs and of high socioeconomic status, mostly straight people, then that’s going to reflect in the quality of the care and the policies that are made, and even the measurement tools that are allowed to be created as standard, and even the practices that are allowed to be created as standard in the industry.
Joey (16:02): And from receiving care, have you ever been in a situation where the provider is trying to provide culturally responsive care, but it’s clear that they’ve not done their homework, but they have some sort of sense of obligation, a moral obligation to at least save their own face and try to provide culturally responsive care?
Vera (16:23): The performativity is palpable sometimes. The provider’s own feelings about themselves and their own confidence that they’re doing best practices, I think can come above a person feeling heard or a person actually having their perspective considered. It can often come down to, particularly with White providers of providers who don’t also have lived experience of experiencing psychosis, which also is not really very represented in the industry, I do think that there is sort of a bit of reliance that happens on the validation of your client in that case. And I do think that there needs to be some level of check-in, so that way you make sure you’re providing good care, but sometimes it can feel as if you are asking your client to teach you everything that they need to know about being culturally responsive. The burden should not be on the client.
(17:15): I don’t think that those instances of people failing to recognize the performativity of their actions is coming from a bad place. And also, when someone feels like they are just being asked very general questions about their experiences with racism, I think it can be very invalidating to not focus on the person’s internal experience of that, or even focusing at all on the ways that the structures that they’re operating under in your care system are affecting them. There is that tendency to make it external, making it an external issue, something that’s not an issue within the clinic. It’s an issue of the society.
Joey (17:55): Yeah. So if I’m understanding you correctly, there’s this sort of necessary but not sufficient quality for a provider to have the intention to recognize your personhood. It’s necessary to provide culturally responsive care, but it’s not sufficient. And in just doing that, that’s where the performative actions start to come. With that being said, do you have any other sorts of ideas for the future of culturally responsive care and what that might look like?
Vera (18:23): When we’re thinking about culturally responsive care going forward, something I think could be applied across different fields in our clinical and research language is this idea of acknowledging positionality for clinical interactions, like acknowledging the positionality of the provider, acknowledging where you come from, what your perspective is, what you know and do not know, and being very clear about that at the beginning of your sessions.
(18:46): And if someone is looking for more involved care with someone who has more experience with their own cultural background, helping them find those resources, but also not leaving them without care, making sure that you’re able to provide as culturally responsive care to the best of your ability as you can, but also recognizing that there’s limitations to your experience. If you are a white middle class person from the United States who’s never traveled outside the United States, who isn’t particularly well versed in the political situations of other countries, maybe you’re not the best provider for this and Andean person coming from political instability. And also, you’re the person that they have right now, so you have to make sure that you’re learning about them as much as possible and giving them the resources that they’re asking for and need.
(19:32): I think that is essential, is recognizing that you have limitations from your perspective, regardless if you have a PhD or an MD or whatever, that you don’t know everything and that you are not the expert in the individual’s experience, and that the client that you’re working with is going to be a lot more knowledgeable on things dealing with their own life about dealing with their own experience, and making sure to meet the needs that they are voicing, but also creating the space explicitly for them to voice those needs and being like, “Is there anything that I can do to help you find resources? Are there any communities that you would help finding? Are there any considerations that you think I should take when we’re having our sessions together?”
Joey (20:12): Yeah.
Vera (20:12): Or even just like, “How do you feel about the power dynamic?” And doing check-ins, like I was saying, throughout sessions and your time together, asking, “How do you feel things are going? Do you think that you’re getting benefit from these sessions? Is there anything that I can do better to better meet your needs?” And being very open to that criticism.
Joey (20:32): Thank you so much for speaking about all of this, Vera. Do you have any other thoughts?
Vera (20:38): Yeah. I personally think that it’s really important for providers to understand, particularly that from a client perspective, there’s often this sense that no one is going to advocate for you unless you advocate for yourself. I think that is the case. And also, having the support of your community helps you advocate for yourself a whole lot more. I don’t think that a lot of clients really feel comfortable asking for what they need, so making sure that your client feels empowered to advocate for themselves, and also making sure that they don’t feel alone in that.
Joey (21:20): Vera Muñiz-Saurré, thank you so much for being on the podcast.
Vera (21:24): Thank you for having me. Oh my gosh. I’m glad to be here.
Joey (21:27): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (21:31): Visit c4nnovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode is sponsored by New England Mental Health Technology Transfer Center and was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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