An episode of “Changing the Conversation” podcast
Amanda Weber and host Joey Rodriguez discuss culturally responsive care for youth experiencing early psychosis. This episode is sponsored by the New England Mental Health Technology Transfer Center Network (MHTTC).
January 1, 2024
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Joey Rodriguez, Host (00:05): Hello. Welcome to Changing the Conversation. This episode is sponsored by the New England Mental Health Technology Transfer Center, or MHTTC. I’m your host, Joey Rodriguez. I’m a clinical research assistant at Beth Israel Deaconess Medical Center and McLean Hospital.
(00:22): Our topic today is culturally responsive care relating to clinical high risk for psychosis and early intervention services. Today we have on Amanda Weber. Amanda Weber is the clinical director of CEDAR Clinic. And CEDAR Clinic is the Center for Early Detection Assessment and Risk. Amanda, it’s so great to have you on today.
Amanda Weber, Guest (00:47): Thanks, Joey. I’m really excited to be here. Thank you for having me.
Joey (00:51): Amanda. How do you understand culture?
Amanda (00:54): Culture is how we are socialized, you, I, everybody in this room. How do we think about things? How do we move through the world? What are our values? How do we interact with each other? So they have a lot to do with relationships, how we think.
(01:09): So culture is everything from the point that we were born and probably even before that too. So what indoctrinates us into the world. And I’m using indoctrination loosely, what are the things that influence us every day?
Joey (01:22): So with this enveloping conception of culture that you have, what’s it like to provide care with this sort of approach to culture?
Amanda (01:32): Complicated. [Laughter] No, I think it’s actually really, really hard. And I don’t mean that in a, oh, clinical care is really hard. What I mean is, is that it’s a lot of information to hold onto, for me as the person providing clinical care, but then also for the person sitting across from me.
(01:51): So how do you capture a person or narrate a person or understand a person when you have every second of their life that has influenced the way that they show up? And so how do you begin then to provide competent care or even responsive care? So it makes it difficult because I will never have enough time to truly understand every single part about you, your values, the way you move through the world, the way that you are in relationship with me. But that’s what’s really important. That’s what makes culturally responsive care the most powerful thing. If I can have a semblance of who you are and how you show up, then I can provide better clinical care, or I think so anyway.
Joey (02:36): Yeah. So there are clear limitations in the ability to get to know someone in care and to be truly culturally responsive because in doing so, you have to understand the entirety of someone’s history and their background and how they understand that background and perceive it, and then understanding how they interact with the world based on that understanding. Right?
Amanda (02:57): Mm-hmm.
Joey (02:57): Within your practice and early intervention services at CEDAR Clinic, what have you prioritized when getting to know someone?
Amanda (03:06): When I’m doing an evaluation, so I’m just getting to know you, trying to understand who you are, what’s going on. One of the things that I ask is, what is the thing that’s troubling you today? Now, there’s some pathology in the idea of troubling, but I’m using that question as, how do I get at what’s actually going on for you? Not what your parents sent in, not what a provider sent in, not what other people have concerns of. You, what’s troubling you?
(03:33): Because oftentimes what you’ll get is not symptoms. I’m not looking for symptoms. I’m looking for the thing that matters to you. What’s your narrative? What’s behind all of that? And if I can understand that beginning framework, then I can think about all the other things that I need to ask about.
(03:48): So maybe an example of this is somebody saying, I’m just not doing as well in school, or I’m having trouble making friends, or I notice I’m losing friends a lot. So then I can begin to understand, how is it that you have relationships? What’s your value around relationships? What are the ways in which you communicate to people? What are your beliefs about relationships? And I mean all the relationships. So platonic, parental, sibling, cousins, all of it. So all the ways in which you operate in relationship, all will help me understand what is troubling you.
Joey (04:23): What’s the tension like working with adolescents and transitional age youth in early intervention services, who have values instilled from them by their parents, and that expectation of how they should proceed culturally, and that creating a tension between what they ultimately find valuable about themselves?
(04:43): One thing that I’ve always been curious about in culturally responsive care, especially in early intervention services, what I’m really interested in, is how do you tease that value of, there is something that’s culturally accepted and regarded as important? And providing culturally responsive care means addressing that and touching that, but then also providing culturally responsive care means touching on that spot that’s truly valuable for that person in the midst of that culture. It’s a really difficult kind of topic.
Amanda (05:11): It is. And I also think that it becomes even more prevalent when you’re working with a family who maybe has migrated here and the person or the person sitting in front of me is a first generation person or a half generation person, even though it shows up outside of that as well. But I think it becomes most apparent in that case.
(05:30): But one of the things I like to get at is, okay, you have your family system or your cultural system that says X is important, and maybe that person has a different understanding of it or doesn’t find it important or whatever. That’s what you’re asking, right?
Joey (05:42): Yeah.
Amanda (05:43): So I always ask, well, how much distress is that causing you? Maybe it’s not causing you any. Maybe you’re somebody who can be, eh, I don’t really care. It’s fine. I’m happy to have a different cultural belief, value, whatever.
(05:57): So if it’s not causing you any distress, I don’t need to go down it. But if it is, how can we help you either talk to your parents about why it is that you have a different view, thought, belief, and if you do, how do we help your parents and you find a way to work together so that we lower the distress down?
(06:17): And I’m saying parents loosely. Anybody in the family system.
Joey (06:20): Caregivers.
Amanda (06:20): Yeah. Anybody in the family system. Because you could have a problem with your sibling too. You could have a sibling that has the same value as the family system you’re operating in, and that’s not causing any tension either.
Joey (06:33): Culturally responsive care can unintentionally center itself around whiteness. From your perspective of providing care with caregivers and with the individual themselves at CEDAR, could you touch on maybe you yourself have seen taking a culturally responsive care stance has accidentally centered around whiteness?
Amanda (06:54): I don’t think it’s an accident, Joey, or unintentional. I think it’s pretty intentional. Our systems of clinical, the way we learn is very white. Early psychosis is a pretty white space. So I don’t think it’s accidental. I think it’s actually quite intentional.
(07:08): I think one of the things that I have been trying to understand and think about for many years is how do I decenter my own self? Or how do I decenter whiteness within this space? And that’s just from anything, right? So the way that I ask a question about your family system. So the last eval I did, I made the assumption that the person in front of me, who was a Latinx young man, I was, oh, I have the assumption that maybe he’s more spiritual than what he actually was. And upon asking, I was asking him about spirituality and come to find out he wasn’t spiritual at all.
(07:48): And so that has a lot to do with my own whiteness, in the way that I grew up. So I grew up in a very religious household. So I make the assumption that if you’re growing up that you have a religious background. That’s the centering of my own type of White that I am, but that’s also reinforced by all the training that I got too.
Joey (08:09): That makes a lot of sense. In terms of trying to tease out the religious differences in people or the lack thereof of religiosity and trying to get to know someone and find what’s ultimately most important in them. Because that seems to be the integral part of assessment and evaluation, not necessarily the clinical high risk for psychosis symptoms, although that is an important part of it, definitely. But it’s more so trying to understand the person so you can recognize whether or not they’re at clinical high risk for psychosis or not.
Amanda (08:37): Right.
Joey (08:38): When trying to disentangle whether or not spirituality is an integral part of someone’s life, how have you provided culturally responsive care after you’ve messed up?
Amanda (08:50): If I take this instance or any instance where I’ve messed up, just say, with spirituality specific, I often will check myself. I’ll catch the way that I’m asking the question, which I think is a really individualistic focus, and I’ll be, oh, yes, that’s the check mark on, oh, whatever delusional belief or whatever psychosis thought disorder I’m thinking it is, blah, blah, blah, blah, blah.
(09:12): But then I always have to… I eventually, well hopefully, crossing my fingers, I catch that. I can then go on and be, okay, wait, tell me about how you learned to practice your religion. Tell me about what are the beliefs that are important to you? Tell me about the other ways in which your family practices. Because if I’m not doing that, then I’m just going to pathologize it. Because I’m going to make all sorts of assumptions. Again, because I’m going to have centered the way that I understand spirituality. So I’m going to center my own whiteness in that regard.
Joey (09:37): Yeah, I think we could go down a huge rabbit hole of the paradox of providing culturally responsive care, that necessitates that you exclude whiteness from the conversation, while also operating in a system that centers whiteness, because psychopathology is a White-centered ideal of what is well and what is sick, and how do we feel when we’re feeling okay. What are some strategies that you’ve used as a provider when trying to facilitate culturally responsive care in early intervention services?
Amanda (10:12): One of the first strategies I use is trying to… I was alluding to this a little bit ago, but really trying to understand the values of the system, so the family system, the cultural system, what’s important to you, and then the individual.
(10:25): So until I have a good framework or an understanding of that, then I can’t actually really provide good clinical care. So once I have that understanding, that informs how I give “psychoeducation” around what is psychosis, right?
Joey (10:39): Mm-hmm.
Amanda (10:40): Because as we know, that the content of psychosis is culturally-based, so I think there’s a statistic or something like that where it’s, in America the number one form of delusion is that somebody can put thoughts into my head, but other parts of the world that doesn’t exist, right?
Joey (10:55): Yeah.
Amanda (10:56): So providing the framework for how the parent understands this is also important. So once I understand all of that stuff, then I can frame psychosis or whatever that might mean to the parents so that they can take care of their child in whatever way that makes sense for them in their system, but also does meet us in a way that we can collaborate together.
(11:19): So there has to be something there that we can both work from, otherwise we’re just going to miss each other. So I have to be able to communicate that to that family system so that we can care for this young person too. I think sometimes what’s tricky is in the clinical high risk population is that we don’t know if this person is going to develop schizophrenia or a psycho spectrum disorder.
(11:39): So sometimes parents are, no, this is clinical high risk, or no, my kid isn’t developing that. Or, no, you think my kid is bad, or et cetera, et cetera, et cetera. And so having to take that as, oh, you’re a White provider. You’re stigmatizing me for this reason, because you see me as a person of color. You see me as somebody who migrated here. You see me as whatever. And so I also need to break those assumptions down.
(12:06): So now values, how do I provide psychoeducation is really framed in that way? How do I collaborate with you? Because I need to learn that style of relationship. And then how do I help you collaborate with me?
Joey (12:19): There has to be a lot of input, not only from the provider, but there has to be some input of breaking down the stigma and breaking down what are the cultural conceptions that may actually get in the way of understanding myself or communicating with a provider to help me better understand myself.
(12:36): It puts a lot of responsibility, I think, on the provider to make sure that they have a good understanding of the circumstances. I think I want to shift gears and ask, when a client or an individual receiving CEDAR services are in line with you. So you’ve described a lot of situations where there are clear racial, ethnic, and cultural distinctions. What about situations where they do line with you? Do you really feel the intercultural differences more? Or do you feel more equipped to help understand these folks?
Amanda (13:18): Yeah. That’s why I was saying… At one point I said that the type of White I am. So I think one of the things that I have learned a little bit more is that to your point, the intercultural differences are actually quite profound. I am a very particular type of White. I grew up in the Midwest, on a farm in a rural area. That makes me a very different type of White than what I find out here in New England. I talk about that a lot actually.
(13:45): So maybe in some ways providing care here out in New England is easy for me, because I notice a very stark communication difference, and so it makes me notice it and then lean into the curiosity about how have you been raised and what are the ways in which you do relationships? That said, I think that unless… I have to maintain my curiosity around that, otherwise I just make a lot of assumptions, honestly.
(14:12): And this shows up in some of our team meetings when we were talking about parents and the way that we operate. We will spend more time thinking about maybe a BIPOC person’s family system, in the ways in which parents might be parenting, which is an assumption we’re making too, right, than we do on a White family. Yes. And when we have our act together, we can also do the same thing about what’s showing up with this White family. How is psychosis stigma showing up too? What are the ways in which communication and trying to collaborate is really breaking down? And what do we need to do? Now, do we always frame that as culturally responsive care? No, but that’s what it is, to your point.
Joey (14:48): Yeah.
Amanda (14:49): Yeah.
Joey (14:50): What are some misconceptions that you’ve seen people hold about providing culturally responsive care?
Amanda (14:54): Yeah. The one that gets under my skin a lot is it’s about “the other.” So kind of what we’re talking about is that, as you were highlighting, there’s intercultural differences. There’s other cultural differences. I think one of the things, and I think this is how we’re trained too, is that culture is in the other. So that’s in the other person who is of some oppressed identity.
(15:18): I think that’s a significant misconception. Culture is about both of us. It’s about how we’re coming and being in relationship with it together. Culturally responsive care is anyway. I think other misconceptions are that this can only happen with individuals who have a clear ethnic identity. White people have ethnic identities too. Maybe they’re attached to them. Maybe they’ve been erased by coming here or migrating here and having generations of family here.
(15:45): But I think that’s not enough, right? I think there’s subcommunities of culture. The queer community has multiple subcommunities of culture, and that’s going to show up in different ways. So the ways in which your identities also form. I’d say those are the big three ones that I think I see most often.
Joey (16:03): Where do you see the future of culturally responsive care going?
Amanda (16:07): I feel pretty cynical about the future of it right now, but I would say where I would like it to go, is that I would like our training programs to shift a bit. I know when people do training and clinical work, one of the things is always self-reflection, but there is a really strong missing component of the self-reflection and the culture itself, and what does that mean, and having some history to it. There is years and years of history of people talking about this and ways to operate differently and do clinical practice differently, to be quite frank.
(16:44): And so I want the training to really focus on the self as a cultural being before we think about the other. I think about my multicultural class. It was, this is what African-Americans want. This is what Asians want. This is whatever. That’s not how this works. So I’d like to see more of that. But the other thing is, I’m hopeful that with some of the attention to the ways in which our training programs have been structured, and hopefully there’s a deconstruction of some of that. And so who we look at, who we value, and then who we bring in also will shift, because I think that’s important as well. So those are two hopes I have.
Joey (17:23): Yeah. I know it’s tough. In undergraduate education there isn’t a lot of priority in any clinical psychology or psychology around focusing on the self in the context of culture. And it’s always about putting immediacy on the other person’s cultural identity, and it’s difficult.
(17:45): Because as you mentioned, we understand other people through our own perception of them. And I thought it was really profound your way of articulating that, because I do hope that there are future services that are able to better capture what it means to be culturally responsive, and also understand what culture is.
(18:04): And I also really appreciated your articulation of culture being so enveloping and ever-present, because I think that interpretation really appreciates, one, how dynamic culture is, and two, that it isn’t a reductive definition of culture. It’s not saying, oh, culture is everything, let’s move on. It’s saying culture is very dynamic, an ever-present force.
Amanda (18:27): It influences our experience.
Joey (18:30): Yeah. It constantly impacts how we understand ourselves and how we understand other people. Is there something about culturally responsive care in early psychosis services that you feel people are doing well, that you feel we have a good grip on?
Amanda (18:45): I think the integration of the peer movement and people with lived experience is profoundly impactful in terms of culturally responsive care, clinical care. I think it influences all of us as mental health providers if we can tap into those two communities, because I would say they’re probably the major driving force for us to be more humanistic and empathetic and really understand the ways in which the content of the psychosis is culturally driven, and the ways that it shows up is culturally driven. And so I think when we’re at our best and we’re listening, that’s probably the place where we shine, where we’re doing the best.
Joey (19:27): Amanda Weber, thank you so much for being on the podcast today.
Amanda (19:31): Thank you, Joey, for having me here. This was lovely. Thank you.
Joey (19:34): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (19:39): Visit c4innovates.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, New England MHTTC, and was produced by EriKa Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Our hosts for this series are Joey Rodriguez and Lola Nedic. Join us next time on Changing the Conversation.
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