An episode of “Changing the Conversation” podcast
Raúl Condemarín shares culturally responsive strategies that he uses as a psychiatrist with host Lola Nedic. This episode is sponsored by the New England Mental Health Technology Transfer Center Network (MHTTC).
January 29, 2024
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Lola Nedic, Host (00:05): Hello and welcome to Changing the Conversation. I’m your host, Lola Nedic. I’m a Clinical Research Coordinator at the Psychosis Research Program at Beth Israel Deaconess Medical Center, and I’m also the Harvard Site Coordinator at the New England Mental Health Technology Transfer Center. This episode is sponsored by the New England Mental Health Technology Transfer Center. Our topic for today is Culturally Responsive care in Early Psychosis, and our guest is Dr. Raúl Condemarin. Dr. Condemarin is a psychiatrist who has been practicing in the Boston area for over 20 years. He specializes in psychosomatic medicine and patients with severe mental illness. Raúl, thank you so much for joining us today.
Raúl Condemarín, Guest (00:48): Thank you, Lola, for having me today. It’s a pleasure to be here in Changing the Conversation.
Lola (00:54): All right, so I want to talk a little bit about what cultural responsiveness actually means to you and what that looks like in your practice because it’s a word that… It’s a phrase that’s used a lot, but we don’t necessarily talk about what that looks like in practice. So, what does cultural responsiveness mean to you?
Raúl (01:13): It’s a very simple question Lola, but also very complex, with the years become more complex. Just in personal experience, I have a severe disease two months ago it took me a little time to go back. With something, I hit my brain so I need to be home. I was told to do not watch TV, don’t use my phone, everything, no? And I was thinking my expectation to go to see the neurologist, to see the primary care, no? And I become like any other patient with expectations. What is going to happen? What do you want to say? I have the same, moreso experience when my wife got cancer six years ago and any meetings at the cancer center, a lot of expectations.
(02:12): So I think it’s more than the cultural approach, it’s something like the expectation that people have about the meeting with the providers. And one of the aspects of this whole expectation because we provided a service, like a singer, they want to do the best the night of the presentation and you are expecting I think it’s your song or something that’s very special. The culture is one of the aspect of this expectation. I think is the culture could be one, maybe one of the most important too to start the relationship with your clients.
Lola (02:53): It can definitely be difficult as a provider when you’re working a 9 to 5 every Monday through Friday to kind of make your clients feel like they’re being listened to and this is important to you. As you said, your appointment with the doctor is something that you look forward to and you have a lot of expectations for. And to them it’s just kind of part of their workday. So how do you balance that and make your clients really feel heard and attended to in sessions?
Raúl (03:20): This is a very good observation because for us it’s a routine. We open the door and so many times people know the name of the person, could be the first time or the client or so many times you just open the door and take your computer and start with the client. But this could be one of the problems. Sometimes we know the patient for a while and we don’t assume they have something special to tell us today, no?
(03:52): When my wife got sick for instance. And later after she passed, and now another call I got after two months ago get sick, is that my first priority, and it’s something I tell to the residents, cannot be done every 20 minute, every 30 minute with the client. But it’s my goal to tell a fair thing is your job is to enjoy it, this meeting with your client, so you want to learn and you want to provide something and make sure the other person got whatever he wants today. No? Because sometimes they asking for tremors or so I said no, this is nothing. But they’re not expecting that, they want something more. We can say the same thing, nothing but explain it why it’s not big deal, why it’s not big deal this tremor. Because sometimes we need to have people shaken to pay attention, but for them it’s something minimal but we need to be aware. But it’s difficult as you said.
Lola (05:00): So how do you make sure that as a provider you’re meeting and even exceeding your client’s expectations?
Raúl (05:07): Sometimes you notice, you notice when somebody is paying attention, when somebody… There is different ways to deliver the services. Sometimes you could be busy, sometimes I am behind but I want to see you this and that. And they understand rather than said, what do you want? Or I told you that. Saying like this, especially with people with mental illness. We treat like minors, like people that don’t understand many times, no? And even when you, in terms of early psychosis to understand it like you meet a group who is the patient many times doesn’t know exactly what is going on or because it’s too early, the family who doesn’t want to accept the diagnosis or understand what is going on or have the expectation with some visit to the doctor and the clinician is going to be fine.
Lola (06:10): How do you manage to create both a therapeutic relationship with the client and with their family members or friends or whoever else they’ve brought to treatment with them?
Raúl (06:21): It’s not easy. With experience you do better and better, but sometimes the student or when you starting, we do a very good job because we have a lot of passion to do it and it’s probably the best time we do it. Always is saying the medical student got the most information because they go over and they feel not judged by the doctors or anyone, or really the medical student pay attention and stay two, three hours there asking and they go early 6:00 AM in the hospital to see how is they doing and you see somebody, it’s hard but this is the job of the doctor, no? I don’t think we can do it all the time. But always I say and I try to practice to say to the student, the resident in practical ways, the job is to use the client’s shoes for a minute and understand what is going on. We cannot be because our — and all the … everybody not stay for so long, but just to have a taste what is going on?
Lola (07:35): Even after practicing psychiatry for about 30 years now, how do you make sure that you’re still meeting those expectations for your clients?
Raúl (07:43): One more time. Sorry for being repetitive but it’s not easy. But I will lie if I said I am so eager to get for every client, not necessarily, but I try to do it. We are human beings and sometimes we have our own problems but as I said to the students or sometimes we need to act. Do this, and we have power, they give us power and sometimes they give us more power than we have, but we need to be receptive there and use it in the right way. And especially in psychiatry and when we need to try to engage them because in primary care and other things people know exactly we talk.
(08:33): In psychiatry, we talk about the whole person. When you go to the gastroenterology, you talk about your pancreas, you talk about the liver. So it’s something and somebody can touch the liver, they can touch the liver, they can see an MRI and can see the pancreas, the tumor or something. We don’t have. So I need to touch you with my words and this is important to know what to do and experience has given you some way to do it.
Lola (09:03): I imagine as a psychiatrist that you often might feel burnt out or just overwhelmed with the amount of clients that you have. How do you try to not let that bleed into your sessions that you have with your clients?
Raúl (09:18): That is true. Myself, like many of the doctors, we feel sometimes burnt out. Sometimes we have so many patients in a few hours and one of the clients is decompensated. Some patient with some borderline personality can drain you in the session and the most important is to acknowledge this. And so many times I share with my clients. I think years ago was like we couldn’t say anything to more personal, but I share with my clients, sorry, I have a difficult time with some clients. And usually their answer is like don’t worry, take your time. Some question like do you like a couple minutes? You need to go out? And was nice. They understood and this is when you invest in it too. It’s a kind of relationship and you treat like it. In primary care you see sometimes your clients say, okay, I see you next year, December 27th, 2024. But here is I see you next week. It’s different relationship. No?
Lola (10:31): What are some things that you feel like you’ve improved at in your time being a psychiatrist?
Raúl (10:37): I think I try to, not always possible, but try to be on top of what is the research in psychiatry, what can be improved? Always thinking how to deliver the services in better way. For instance, I used to have a Spanish medication group almost 15 years ago. And then when I noticed the group was mostly Dominicans and Puerto Ricans. No? A different background of instruction and so on. But I realized for Latinos everything is related to food. To what do you eat, this stuff like that. And also another denominator because was a male group grasped baseball. They are good, they are big in baseball and they know. So I decided to do some slides, PowerPoint presentation, but basically in terms of baseball. So I put the field and see how to go to the first base to the second base and say please don’t stall the bases means don’t stop to taking the medication, take it wherever you are.
(11:56): And that kind of worked. This language was easy for them to understand. I use it to the same picture. There were questions about, will this medication made me pee or something. What do you need to eat? And said your plate need to be like the baseball field. When you go to a baseball game, so you enter and you see so colorful people have different colors, sometimes green, sometimes brown. This the plate need to be this, need to be green for the vegetable, need to be some beans because the Caribbean love beans and this, but this cannot be just rice and beans need to be some more colorful. But this kind of example was better than talking about carbohydrate, proteins, counting calories or Mediterranean diet. For me, that was my experience.
Lola (12:54): Wow, okay. That’s a really interesting strategy. So how do you sort of establish a plan for working with people with cultural backgrounds that are very different from yours and how much time are you putting in outside of sessions to do that work?
Raúl (13:10): Now with my experience, some 30 years, it’s a little easier for me but probably we talk. Sometimes a little homework where they coming from sometimes could be from one place but they grew up in here and it’s different, so I need to have in consideration this. Family background, anything they like any past experience. So I put this together. For instance, sometimes you started the session and we need to break the ice. It’s a little tense. We go with just yes and no questions or we need to get a little more. So this is the time like you by looking at the patient or looking the situation, it’s the one. Sometimes with the youngest one I talk about for instance about video games. I know minimum information from my son about the Mario, the other games and I talk with them. The other ones I assume sometimes people have a couple of patients with like a six four, some of them.
(14:22): And you like basketball? Yeah, so we go through basketball, Celtics, LeBron James, stuff like this and we break the ice and open. But it’s a little like a homework so you need to know more. So I have another client who are, one is a chemist from MIT. He like to talk about scientific. So I go to Google, get something and I printed for him and for me and we say I want to discuss this because he’s taking the second medication for 20 years and he doesn’t want to change it. So I believe I need to give it a good time checking he’s taking the medication and do something for him because he always said I feel lonely, nobody talk to me. Things like this. And his providers in the past everybody left. So I am the only one who is in the last 25 years with him. So I tend to do my little homework is five minutes doesn’t hurt, it’s possible. And at the end, everybody happy. I think it both, we got whatever they want. He take the medication, he feel understood, he feel listened.
Lola (15:33): So what are some strategies that you use for medication management when you’re working with clients of various backgrounds?
Raúl (15:41): Thank you for the question because this is something I do. For instance, it’s very clearly for American population, White people is different for Black a little bit and it’s different for the Latino population. The American patients ask you for the medication and tell you in front I don’t want this medication or I don’t like the side effects, clearly. The Latino populations tell okay doctor it’s fine. Yeah, perfect, good. And they don’t want to take it but you notice they’re trying to tell you something like are you happy? But it’s not true. So something, sometimes if I want cultural things, we have the diminutive ito, poquito, chiquito in Spanish and if I want some medication it started with 10 milligrams to start I offer 20 milligrams and recommend it to take just a half, please do not, and with food, because supposedly there are chemicals that are bad, but with food it’s the protection and the nurture environment. With food is good.
(16:52): Like grandma said you are getting antistaminic, but they call antibiotics are very sealed. Take your milk because you are taking antibiotics and it’s from more cultural things, we grew up with this and become a kind of comfort food. The food with the mother is the best always, always is the best. Whatever the mom said is good. Something like this. So I applied for these groups like this.
(17:25): I try to make participate the patients. There’s some people who need some help so I give it this option. How about these two or three medications you like, rather than what do you think about? And I prefer number one but I’m okay with two and three too. If they said I want number three, it’s fine, he participate, and it’s possible that he takes the medication. We need to be clear that the non-compliance with medication is very high in psychiatry. Everybody have the model, more medical oriented that you take medication for 3, 4, 5 days and even ask could be like the doctor said seven days, we know after five days we’re fine and people stop. Other people doing seven, but everybody says I’m fine. I keep it for the next time a little bit. But taking medication every day and when somebody ask you for how long you say for life, for 20 years old, 18 years old. So it’s difficult. So this way to deliver things I think in a trusting relationship.
Lola (18:43): It sounds like you do a lot to establish a trusting relationship between yourself and your clients. And I understand that you speak both English and Spanish and you sometimes practice in Spanish as well. So what does that sort of look like in practice and when do you decide which language to speak?
Raúl (19:01): Yeah, sometimes it’s very clear. Some people who are just Spanish-speaking so I need to speak in Spanish. There is some people who are bilingual but sometimes they feel more comfortable speaking in Spanish for some reason or other. Happened to me, 25 years in New York when I have 18-years-old who wanted to speak with me in Spanish. He was speaking with me all the time in English and he wanted to make sure because my feature at the time, I was looking more Middle Eastern than Latino and he always said “Do you really speak Spanish?”
(19:41): So we started the session and he just spoke a few words in Spanish and then he continued in English. I always talk to him in Spanish but he didn’t realize he was answering me in English. And sometimes he said things like, “Oh my grandma said that” or he was kind of laughing. I said, “What is going on?”, “I like this word, my grandma.” So I realized he was living, grew up with the grandma rather than with the parents or the parents were not too present. There’s some stuff like you can assume too for this, but he wanted to. So I continued this and after so many sessions I let him know why he wanted to speak me in Spanish and he answered in English and first of all he said he didn’t realize he was speaking in English.
(20:37): I think it was the fourth generation Puerto Rican family living in New York. I think his father just speak mostly English, the grandfather both. He grew up in there but was important like he do not heard it and see and understand why he wanted to do this. And that is the same with probably someone who feel comfortable to having a translator or something. But it’s so important and the reason, sorry that I mentioned initially when I hit my head and it was so slow. So I realized when I trying to do two things at a time I feel so dizzy, I was doing something more, I couldn’t do it. And now I realized we do so many things at the same time. We can be doing the computer, having our phone, thinking about something, putting a microwave. It’s a lot of things. We do it and we don’t realize the same thing need to be done in the interview.
(21:50): We need to start looking, thinking, asking questions to myself like I am doing fine with him. He’s happy or not because people express it. People express when they’re bored like “I want to go, I don’t want you to ask me questions” so we need to know. So it’s very interactive and I think it’s the same for psychiatrists and any other specialty. But the difference is if I don’t respond some question to the primary care source, sometimes they can find it through x-rays, MRIs, CT scans and we don’t. But if we look at them and understand something could be helpful in the future. This is from my experience.
Lola (22:39): It sounds like you have to balance a lot being a psychiatrist, especially practicing bilingually as well. What are some things that you personally want to improve upon in the next few years?
Raúl (22:52): There is the different things. For instance, the most important thing is I ask myself to not get tired about this, who don’t believe I know everything that I felt at some point I knew it enough. I exposed myself working during my last year in Emergency Room in New York. So I was exposed too much. So I tell to myself after that I am ready, nothing more. Then came September 11, like a new situation, and it’s always something. I think that we need to be a kind of feeling prepared but open to learn more. And now in the last year because of personal things, I has very present that my job is give it my best to the client. Doesn’t need to be the whole hour, just in some moment feel understood, feel listening. It’s difficult because everybody need to do the note or so on. People sometimes go and give you your back and I’m listening and we need to improve.
(24:03): Knowing this at least I can say, sorry I heard you’re back, but I heard this, right? And there are people who are so good in this. I think the majority do it, but sometimes it is true. If we realize sometimes we can burn out and overwhelm will be important for us.
Lola (24:23): Wow. Is there anything else you would like to say?
Raúl (24:27): The doctor need to deliver a technical services. Most of us, almost all of them are good, very good in their specialty. But something we need to learn is to, we are human beings and the best interaction and if it’s an older than me, thinking as my father or my mom or my son helps, helps. And this little call and be honest. I could be tired today or I don’t get what you’re saying and especially for psychiatrists, this is a marathon and we need to go slowly because we need to see this client so many times and be clear like a non-compliant as a problem. The treatment we give it to them are not, are a little far from being perfect and we need to keep improving.
Lola (25:21): Dr. Raúl Condemarin, thank you so, so much for being here with us today.
Raúl (25:26): Thank you Lola.
Lola (25:27): And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (25:32): 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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