By Fátima Reynolds, M.P.H.

This quarter’s Mental Health Equity Champion is Dr. Lisa Fortuna, professor and chair of the Department of Psychiatry and Neurosciences at the University of California Riverside, School of Medicine. Dr. Fortuna is a child and adolescent psychiatrist, psychiatry department leader and health services researcher with expertise in implementation and health services research focused on improving access to mental health services for underserved communities. Her area of clinical focus for the past 20+ years has been the delivery of care for culturally diverse populations, including providing immigrant and refugee specialty care for children, adolescents, and adults. Her research includes innovative models for addressing mental health care, PTSD and substance use disorder services disparities, digital and prevention interventions for youth and immigrant families, and community-partnered research. In 2022, she was the recipient of the Irving Philips Award for Prevention, given by the American Academy of Child and Adolescent Psychiatry, recognizing her as a child and adolescent psychiatrist who through seminal work has made significant lifetime contributions to the prevention of child mental illness. She also received the APA Agnes Purcell McGavin Award for Prevention, which recognizes a child and adolescent psychiatrist who has made significant contributions to the prevention of mental disorders in children and adolescents and has influenced the general well-being of young people.

What brought me down the road to child and adolescent psychiatry was that I always wanted to be a doctor, but I was interested in being a doctor who really got to know their patients and understood the stories of their life, as well as helping people through stressful times. I was also interested in culture. I am of Puerto Rican heritage and grew up in a community that was not always privileged or highly resourced, but I was always part of a culturally rich environment where community members tried to support one another. I always kept this idea of, there's not only the medical treatment parts of what we could do, but there is also how do we leverage community assets like the ones I grew up with? Understanding how we should provide mental health services became even clearer to me when I was in college. It was very stressful for me to go from Newark, New Jersey, where I grew up, to being a student at Yale.

I had a tough cultural shock that I think emotionally really challenged me. When I went to the counseling center at the university, they just didn‘t get that I was experiencing cultural shock, microaggressions and macroaggressions around being a Latina and that I didn’t have a community yet to support me. They had a more individualistic kind of approach. There was no conversation about how I am displaced from my community and what things I could reach out to here to help me transition culturally and developmentally. There wasn‘t any contextualization of my identity and who I was and what my preferences were, and all those things stayed with me in terms of the mismatch both structurally and in the content of what we actually provide. I moved from thinking it’s not just communities of color not being interested in mental health. People are worried about their psychological well-being; how do we deliver services that match their preferences and their needs? That has been the trajectory of my career.

So that‘s a big question: How do we get a workforce that has the cultural capacity and responsiveness and reflects the community? Only between 6% and 8% of physicians in place are Latino.

We‘ve been looking more at models of workforce pathways to increase the number of high school students interested in medicine. And I think that was important for me because I had other Latino professionals who were saying, “You can do this. You‘re capable.” Which is not the message that you get out in the world. I got all kinds of other contrary messages. Even with excellent grades, some people were like, “Oh, don‘t. That‘s reaching too far.” With the organization ASPIRA, we were working on providing these students with more resources around programs in the sciences and technical assistance around what medical schools are looking for and which summer programs would be helpful.

The other thing is that there is a role for ally professions. We’ve been doing projects with family navigators and community health workers and community leaders—research interventions where we combine an intervention in which we might do some task-sharing like cognitive behavioral therapy by psychiatrists and then reinforcements around behavior activation and supporting the families around reaching their other social needs from the navigators.

Related to interventions that are digital, you can use telehealth to have consultations with more culturally matched providers who can partner with their patient’s primary care clinic. We’ve also done mobile technology interventions that we co-created with adults and youth to share evidence-based practices for emotional regulation and other topical areas. We have to reach regions that don’t have enough psychiatrists, let alone Latino psychiatrists.

When you really ask people whether they worry about their mental health, they may call it different things. They may call it their spiritual wellness or their community connections or their roles in their life that are not functioning. It may be spoken in a different language. What are the social determinants and structural determinants of mental health in communities? And how do we do better in providing the kind of care that meets those needs and those preferences? And that‘s really the definition of addressing health disparities. You know that you‘re actually providing the care that is the preference of that community. And meets the need.

We’ve played with all these types of models, telehealth and mobile health and, really, this is what my career has been like: “Hey, you know, what if we think about this strategy and incorporate it into pilot clinical services?”

Innovations are not only science and technology but also innovation within a community. We have done a lot of research on what is correlated with people not accessing services, what are the barriers, what are the stressors and the impact of racism and discrimination on our health. We know these things. Now what we need is innovation on how to address those needs.

I was talking about needs and preferences of the patient, but also of the community. Address the things that I think are most important in my life and that I want to improve. We have found in our research a preference for psychotherapy over psychopharmacology and talk therapy, as well as helping with problems like housing and related distress.

And so, we‘ve integrated more of that preference. There is a lot of innovation that we can gain if we understand how to harness community assets and cultural practices that we can integrate into therapeutic interventions.

I‘ve done interventions where it‘s become very clear that something was missing from our therapy—and that was an awareness of and conversation about the importance of spirituality, or of faith in our well-being. Our patients or our study participants would frequently bring that up. I have a background in pastoral theology, but when I was hearing this, I said, “I‘m gonna integrate this.”

For example—in cognitive behavioral therapy with immigrant youth, how their spirituality reflects on how they perceive or experience what‘s happening to them, including trauma. How does that experience affect their thinking about the greater fatalism of the world or God‘s will for them or—how does their faith help them have hope or lose hope? It reflected on how they saw the world and how they can frame the world. And so when we‘re trying to do some reframing that better serves the patient, then we need to bring what assets and what cultural aspects they find important in defining how they‘re seeing the world and working with the faith-based cultural resources in the community and incorporating faith-based organizations in support of interventions and access.

I set off to do this work on mindfulness in an interesting way. I started off with a cognitive behavioral therapy model with my career development K Award (NIH K23 Mentored Patient Centered Career Award) a 5-year grant. I set out to study the effectiveness of integrated cognitive behavioral intervention for adolescents with post-traumatic stress disorder and co-occurring substance use problems. In my clinical experience with youth with PTSD who also were having problems with substances, it was such an intertwined issue. Youth were self-medicating their PTSD symptoms or had an increased risk for further trauma given that they were using substances in very risky situations. I ended up having a lot of Latino youth in my sample; some of it was serendipity because, you know, I was offering it in Spanish as well and with an organization that was working with immigrant refugee unaccompanied minor adolescents who had a high rate of PTSD and substance use issues. Now the way mindfulness came in is, with those youth whom I was talking about, reframing our thinking that you have in the classic cognitive behavioral therapy, youth would tell me, “You keep telling me to think and rethink, but when I‘m activated by trauma triggers or I‘m angry, or someone‘s confronting me or I feel threatened, I‘m not thinking. But you‘re asking me to think in that moment where I can‘t think.” They are absolutely right. We have neuroscience that shows that when we‘re in a trauma response, even the parts of our brain that are focused on language processing shut down. We‘re just like fight/run/get out of here. You‘re not thinking. You‘re not processing your thinking. So I knew I had to add something that helps around emotional regulation, slowing down that process and giving youth the regulation to have the opportunity to make decisions. That‘s when I started to integrate mindfulness, and I worked with a colleague, Zeyda Vallejo, the co-author of my book, to integrate mindfulness practice. She is a practitioner and Latina as well, so we could do it in English and Spanish. We found that youth were able to really practice that and we could measure that they were using more mindfulness and attentiveness techniques. Over time, they were able to reframe some of their cognitions around trauma. The mindfulness allowed them to have that meta reflection on their thinking and their experiences to even make a change or difference in it. So it actually helped the PTSD directly, like hyperreactivity and those kinds of things. I used to tell young people, “Mindfulness is not relaxation only. It might be relaxing, but it‘s more so improving your attention. It’s an opportunity to have choice; it helps in your world. There are dangers that you need to know about, and there are things that maybe you don‘t have to worry about, and there‘s a lot of static in that.” I told them, “It‘s like a radio station. It has a lot of static, and mindfulness helps you have a clearer sound—so that you know what you‘re listening to and you know what you want to do about it.” It worked and we ended up taking that version and doing another adaptation for Latino immigrant adults, in the US and in Spain. It was very helpful as well for mental health issues and improving substance use. 

Psychiatry is in an interesting position with the mental health crisis. People are thinking about mental health as critical or important. We have to keep with this wave. It does not mean doing things the same way but instead thinking about different ideas for how to do it. Not re-creating disparities in the technology-driven interventions. I guess my closing thoughts at this moment are, that this whole thing about the community-partnered component to me is more than jazzy or trendy or whatever. I think it‘s essential. I actually don‘t think we‘re going to make a real dent in health disparities and inequities unless we really share power with the community in innovating and figuring out how to address these needs. They have critical solutions that need to be heard and need to be integrated into our plans. Whatever happens in our clinical services or as professional organizations or as states who are trying to make a difference and impact on behavioral health needs, we need to be able to integrate community voice in a real way, not just a little bit of feedback, focus group, but a real partner steering approach to include community voice and youth voice. To be able to really change our paradigms. I think psychiatry is in a very interesting position right now with the mental health crisis.