Hispanic Treatment Program Aims to Reduce Disparities in Mental Health

Roberto Lewis-Fernández, MD, is professor of clinical psychiatry at VP&S; research area leader for anxiety, mood, eating and related disorders; and director of the Center of Excellence for Cultural Competence at the New York State Psychiatric Institute.

His research focuses on reducing disparities in the care of underserved cultural groups and improving treatment engagement among persons with anxiety and depressive disorders, schizophrenia, and other serious mental illnesses. He also studies the way culture affects individuals’ experience of mental disorder and their expectations in seeking help.

The following interview has been edited for length and clarity.

You went to divinity school after college. Did you want to be a pastor?

I was pre-med in college, but then I decided medicine didn’t seem like the right fit. I have an interest in culture as the way a person makes sense of the world, given their background, and that if you don't understand a person’s culture—its values, differences, or conflicts with other cultures—it can be very hard to understand each other.

I grew up in Puerto Rico in a mixed family. My father was American and my mother was Puerto Rican; they met in graduate school and moved to Puerto Rico, where my mother’s family lived.  They eventually became comparative literature professors at the University of Puerto Rico. My mother was also active in theater and politics as an independentist; I’m very proud that she led the antiwar movement on the Island during the Vietnam War. The whole uncertainty about our status as a country with regard to the United States makes the issue of culture very important in Puerto Rico.

My parents were also of different religions: Jewish and Catholic. I thought that if I focused on religion, I would understand how culture makes such a difference in how people can see the world so differently. I wasn't a religious person; I wasn't going to be a pastor or a rabbi. I took a page from my parents’ book and decided I was going to be a comparative religion professor.

What drew you back to medicine?

I wanted to do something that had more of a direct impact on people’s lives. Mistakenly, I think now, I figured that intellectual work on religion may not make as much of a difference. Also, I wanted to return to Puerto Rico after school and I thought it would be easier to find a job there as a physician.  

What brought things together for me was when I discovered the field of cultural psychiatry while I was in divinity school. The field gives me the opportunity to focus on culture while also being a clinician.

Cultural psychiatry, ultimately, is about understanding the person in their context, not in some alien context where they look strange. I think psychiatry is becoming more and more aware that it is crucial to have this contextualized understanding of the person to provide quality care and conduct valid research.

We are trained as clinicians to look inside the person for mechanisms and causes of disease. But it is just as important to look at social factors, systems and institutions, and cultural frameworks as potential determinants of illness. Racism, for example, is ultimately a toxic cultural ideology that creates and sustains a societal structure that is incredibly harmful to people’s health.  

I think we should push this point further so we have a clear, systematic way of addressing these issues when we work with individual patients. And that we also then work with communities as a result, because to solve the individual pathologies we need to, in many ways, address the larger social pathologies.

What aspect of your career are you most proud of?

Several years ago, I became the chair of the cross-cultural issues subgroup—one of the groups revising the Diagnostic and Statistical Manual of Mental Disorders—and we decided to develop a consensus interview for cultural assessment of individual patients. These are a set of questions that mental health providers can use to incorporate a cultural assessment into routine care.

Psychiatrists typically don’t ask patients questions that focus on cultural views like, “What do you think caused your condition?” or “What kind of help do your family and friends think you need now?”

But these questions help us understand what the person and their family think is important. That's one way we can think of culture in person-centered care—as the meaning-making processes the person and their family engage in because of their identification with various social groups, such as their race or ethnicity, religion, or even age or occupation. Veterans or firefighters, for example, may look at things from a certain perspective. Culture is also collective, of course, and even structural—in the way institutions and policies reflect cultural values, for example—but it is also highly personal.

With this approach, the psychiatrist doesn't assume, based on any characteristic of the person, what aspects of the patient’s background are most important to them. 

It’s a way for the provider to get the person's and family’s perspective about what they consider to be the problem that brought them to care and what kind of help they prefer. And includes gathering information on the person’s position in society, which determines what resources they have access to and what constrains their ability to get better. We expect that this will reduce existing disparities in care across people from diverse cultural backgrounds. It should help understand potential pitfalls ahead of time so that the provider doesn't completely miss the boat and misunderstand how the patient sees the situation, what has precipitated the problem, what they expect from care, and what options they have access to or can use our help to obtain.

I think it's a thread in my work that is the most developed and the one I feel that's been the most impactful.

What recommendations do you have for institutions like CUIMC that are working to strengthen their diversity?

There's a lot of different ways the medical center and university could engage and retain faculty from underrepresented groups. There's been various efforts over time and some have been more successful than others, but we need to coordinate more systematically and commit real time, money, and effort to them. For example, by critically examining the representation by gender, ethnoracial background, sexual orientation, and other forms of diversity among faculty and staff. And by developing systematic procedures to make sure we can recruit and retain a very diverse workforce. The last few months have seen an increase of attention to this area. Unfortunately after so many years of these terrible tragedies, finally they have triggered a massive response. I hope the attention will be sustained and we can achieve some lasting changes.

When you have time to relax, what do you do?

I love reading. Over the last two or three years, I’ve returned to my interest in comparative religion. It’s not like reading a novel—it takes a little bit of energy—but on the weekends I will read, for example, about the development of the early Christian movement and its interaction with Judaism. It’s like having a conversation with my Jewish and Catholic parents.  

If I want to take it easy, I'll watch a movie.