Episode 5: I’m Not Crazy: Breaking Down Stigma in Mental Health
Lorraine T. Benuto, Ph.D.
Key terms: mental health, stigma, depression, anxiety, latinx, health disparities, domestic violence
CASAT Podcast Network
Hello and welcome to season three of CASAT Conversations.
I am your host, Heather Haslem.
This season we will explore the weighty topic of health equity within each conversation.
We will discover insights from researchers, practitioners and experts on this complex and important topic.
We hope you enjoyed today’s conversation today.
We welcome dr Lorraine Benuto, who’s an associate and clinical psychologist with the University of Nevada reno.
We are happy to have you here today.
Thank you so much for having me.
So as we get started, please tell us a little bit about yourself and what inspires you to work that you to do the work that you do in health equity.
So I am a clinical psychologist and associate professor in the Department of Psychology.
Um I grew up just outside of reno in a small rural town called Portola.
So on the California side um and I became interested in psychology when I was very young, just kind of I was the only um or as one of very few ethnic minorities in my town.
And so I became interested just in how culture impacts people.
And so later when I was able to um I kind of understand my interest a little bit better.
When I got to college I realized I was interested in house or how culture impacts one’s mind, you know how we view things, how we see things.
And so that led me to focus on psychology and specifically on mental health.
So that’s kind of my trajectory in terms of getting to where I am currently awesome.
Well we are happy to have you here today to share your wealth of knowledge and experience with us.
So can you describe, I know you’re working on quite a few wonderful novel projects working to reduce health disparities.
Can you tell us about some of those?
So one of the projects that I’ve been really excited about since starting my tenure at the university as a professor is um what has evolved into sort of a broad, what we call kind of the telenovela project.
And so, telenovela is a um latin american soap opera and it has dramatic storylines.
It’s very engaging and interesting and fun to watch, very dramatic.
And when I first became a professor, I became interested in how we could adopt this genre to help address some of the stigma in mental health.
That really contributes to a lot of the disparities that we see.
And so originally I was very interested in creating a single episode telenovela, very short um focused on targeting stigma.
And so I had a graduate student who is now a psychologist, she’s all finished dr Francis Gonzalez who undertook this project as her dissertation.
And so we ran different focus groups with the latino community and um did some consulting with experts in the field and we developed about a four minute video that shows a really fun storyline where there’s multigenerational family.
So there’s like some nieces um some ants kind of what you would expect to kind of see in a traditional um latino family gathered around having panic cafe which is a very common practice.
So it’s a sweet bread and coffee that you might have actually usually in the evening and as a way of kind of unpacking your day.
And so we see this family in the kitchen and they are talking about um one of their family members, she’s there and they’re struggling, she’s struggling with some depression.
And so through a conversation they have um you know we show the different types of stigma that come up when we talk about mental health.
So we have like a character who is an antagonist who kind of you know says like are you saying you’re crazy?
What exactly is it you’re saying?
Um which would be a prototypical response that we would see within that context.
And then we see another character kind of saying like no, no, no, hold on a minute, this is what mental health is, this is what mental health services are.
So that was the first video that we developed and it was um um it was live action and we had my team had a plan to develop then a series of videos where we would see um originally it was gonna be that same character struggling with depression going to see a psychologist and then kind of walking through, what does it look like to see a psychologist, what’s that intake session look like?
How do you call and get an appointment?
Um and then actually watching the person go through psychotherapy.
So what are the skills that we would teach in a prototypical session?
Um We have big plans for that to be, like I said a spin off of that original episode, but then Covid hit and so we had to pivot and we used um animation instead.
And so we came up with a new plot line and new characters and things like that.
And so um I love this project because what it does is it still targets um stigma, but it really increases accessibility.
And so one thing we see that really contributes to health disparities is that this population tends to be under resourced.
So for lots of different reasons, they have a hard time accessing mental health services.
So um it could be financial, it could be contextual, you know, they might not have transportation to services, they might not have child care to go do this, they might not have health insurance and so um you know, they could sit there at home and they could watch these episodes learn these skills uh and so it really reduces a lot of the barriers that we commonly see.
So um yeah, I’m very excited about that.
We finished filming and right now we’re about to test run it with um some participants and see if they like it, see how well it works.
And then we have a number of other similar projects using that same framework in the pipeline.
That’s so cool, I can’t wait to see it and experience it, can you highlight for us?
Um it sounds like in those focus groups, some of the stigmas were really um brought to light, can you share with us what the stigmas are?
So we we saw when we ran these focus groups and we did them with um we played around with a lot of different ideas, but ultimately we decided to focus on women because there’s a higher prevalence rate of depression among women.
Um and latino women specifically, and also we wanted the characters to be really relatable and we kind of had a hard time figuring out how to do a multi gendered um video that would be broadly relatable.
And so instead we focused on one population with the end goal being that eventually will want to do the same thing with men, but we saw the stigmas to get back to your question, the stigmas that we saw among the latino women that emerged from the focus groups were things like fear of being labeled.
That was kind of a big one.
And the original video that we created is called, which translates to relates to I’m not crazy and that language specifically came out of the focus group.
So there was a lot of concern that if we if if we as Latinos expressed that we were suffering from a mental health affliction like depression or even anxiety that we would be labeled or viewed by our community as crazy.
And so we really tried to target that and stigma video that, you know, that that’s not what this means, that um kind of trying to normalize the, you know, common psychological maladies like depression or anxiety.
Um so that was a really big one that came about.
Um there was also a fear of uh this somehow making one weaker, you know, so there’s this, I think cultural value of strength and so there was this stigma around having either a mental illness or seeking services that might be viewed as a week, you know, instead of being strong, you’re viewed as weak.
Um there was also a lack of what we called mental health literacy.
So a lot of the stigmas arose out of people’s misunderstandings of, you know, what does depression mean?
What does anxiety mean?
What does it mean to see a psychologist, you know, am I going to be hospitalized?
Am I going to have to, you know, take medication um those types of things.
And so we, we saw this sort of interesting connection, although not surprising between literacy, mental health literacy and stigma.
And so people who have lower mental health literacy seem to have more stigma around things and we, I wanted the video to be educational in nature because we felt that by correcting some of the misconceptions.
We could kind of in turn reduce stigma.
That is fascinating and so cool to hear.
I love focus groups for that reason and highlighting you know, some of these things that we’re just not aware of.
Um I’m curious was there anything surprising to you in the focus groups or did it play out the way you sort of thought it would?
I think that I having grown up in this culture, I think a lot of the things we noticed really resonated with both myself and my team because my team at that time and still is the case now was Latina.
So we were kind of like, oh yeah, you know, we’ve seen these same trends in our families.
I don’t think that that element was as surprising.
Was surprising per se.
But what was kind of surprising was that there was this enthusiasm and this desire for access to resources by the participants.
So even though it was like I don’t want to be labeled as crazy.
I don’t want to be perceived as weak.
I don’t really know what seeing a psychologist entails.
It was like but I do experience sadness and I do experience stress and I would really love to have some resources that I could access that could help me with those things.
And so I think there was this general openness to help and I don’t know if I think that that was a little bit surprising to me that there was that that perhaps there were less psychological barriers than I expected there to be?
That sounds like it was validating just based on your own personal experience.
But then also, I’m curious if that enthusiasm and desire for resources really fueled your passion or the projects that you’re working on.
Yeah, I think we were very excited by that.
Um, and then we kind of, you know, as a team, we’re like, okay, now what, you know, we I run a clinic where we provide free services to latino victims of crime or violence and then a sliding scale clinic where people who are spanish speaking can access services at a lower cost.
But I know for a fact that the resources available in northern Nevada and across the United States for spanish speakers is not sufficient to meet the need.
And that’s where we see a lot of those access disparities to take care.
And so we became I think very enthusiastic and excited about like, okay, how do we develop novel ways to get people who really need services services.
And so then from there, we kind of said like, okay, here we create a series, you know, the video was very well received and can we show skills, we would teach in therapy in that series in a fun and engaging way so that we don’t lose our audience.
And that’s how we ended up down this wonderful rabbit hole that we’re in right now.
Um and what are some of the ways that you’re working to reduce some of the access disparities?
Yeah, so that was, you know, I’m I’m very interested in access as a means of reducing mental health disparities.
And so uh in some of our brainstorming sessions um when I first started running my clinics, I had very few bilingual providers, and now I haven’t way more bilingual providers, which has been wonderful.
But um at that time, about 56 years ago I didn’t.
And so I kind of what we were at our cap of what we could do for the community.
And so we started to ask ourselves, okay, what could we do to reach that spanish speaking community who I really can’t access um services in uh you know, in northern Nevada and and more broadly just across the country.
And so I became interested in um using interpreters or translators in psychotherapy.
And so we, you know, my team and I looked at the literature and we said, okay, what do we know about the use of interpreters and translators in psychotherapy?
And there’s some research on it, there’s some some guidelines, but there’s not a whole lot.
Um and one of the challenges, you know, I’m teaching a diversity class right now, and I have a economic students in my class.
And he was funny because he said, you know, I would as an economist, I would never um employ a professional interpreter as a way to reduce to address the gap in service providers and the clients who need it because it’s so expensive and he’s right so interpreter services run um I don’t have to figure out the top of my head but it’s very it’s very expensive, it’s like 100 bucks an hour or something like that.
So if you’re thinking about the cost of a psychotherapy hour plus the cost of an interpreter, suddenly this is a really hefty price tag for a population that already has challenges accessing service.
So I looked um two I said to myself, okay well what resources are available to you that are either free or low cost, you know?
And so I thought of the undergraduates here at UNR.
And I thought there’s all these undergraduates who speak spanish who are psych majors or you know human development and family studies measure majors or social work majors there in like this helping area could and they already have some foundation in psychology, could I train them as part of like a class that they take like an experiential class to do interpretation in psychotherapy and then can I train my therapist on how to effectively work with a translator?
And so we ran a project that when I think for about two years until I got more bilingual staff um where we utilize undergrads and they got this very valuable and interesting and fun training experience and we got to use interpreters who were native speakers for the most part who had some foundation already in psychology.
So that up training was not as profound as if I just pick someone off the street who had no background whatsoever and a helping profession.
And so we did that like I said for a couple of years and I always am evaluating my programs.
You know, I want to know what’s working, what’s not working.
And we looked at the program evaluation data that we’ve collected and we had a really excellent treatment response rates.
So, um, we do like quality improvement in my clinics as well.
And so one of the things I did was I talked with the clients after they had met with the therapist and the the interpreter and just said like, how’d it go, you know, what was your experience and what we found in general is that the clients loved the interpreter, like they love the interpreter, they have a lot of camaraderie with them and rapport because they felt like there was a shared cultural heritage.
And then we also found that they loved the therapist, you know, they were very grateful to the therapist and they got better, you know, they learned skills to help them with primarily we treat anxiety and depression and they got much better over the course of that.
And so that was, you know, that was kind of our attempt at how do we address the bilingual treatment provider gap in a cost effective way, because we, you know what we do.
I mean, I’d love to not have to think about financial resources, but the reality is that we do have to um and that was just a project that we ran and the students really loved it.
And then the therapist, you know, a lot of them reflected that this was the first time they had ever gotten any sort of training on, how do you work with someone as a therapist who doesn’t speak the same language as you do.
So they also found a lot of value in that.
And I’m curious what were some of the best practices that you found for clinicians working with an interpreter and their patients.
Yeah, one of the key things was that they’re really, you know, we really wanted to look at this as a team based treatment approach.
And so, you know, um I know this is a podcast and not a video, but you know, you know, kind of making a triangle with my fingers.
And so the idea being that they’re the team was comprised of a therapist, the interpreter slash translator and the client and that they were all working together.
Um collectively, we, you know, one of the concerns that then this is in the scientific literature, when we look, I knew this concern um existed and I saw this concern reflected in the therapist is that there’s this kind of worry that the you know, in psychotherapy, the relationship between the client and the therapist is really important.
That the there was a story that the relationship between the client and the therapist would be thwarted by the interpreter because there’s this kind of third party there and we didn’t see that exactly, but we did see a strong bond through the therapist, I’m sorry, through the interpreter and the client and the therapist at times could kind of maybe feel a little bit left out because you know, they’re speaking a different language and things like that.
And so one best practice was what we called pre briefing and debriefing um which was that prior to every session, the therapist and the client, the therapist and the interpreter would meet and they would discuss like what the plan was for the session.
And then at the end of each session they would process the session.
And so they could talk about like, you know, um whatever, you know, came up like perhaps like it seemed like the interpreter and the client kind of got off topic a little bit together, just things like that so that they could problem solve.
And then um have this very strong working relationship where the end goal is essentially to help the client move forward.
So that that came out kind of as a best practice that this is a team based approach and um and debriefing and pre briefing can really help facilitate that kind of team effort.
I am also struck by um you know, that this idea really came from this economic student that you had in your class and how cool it is when students, you know, bring up these questions or concerns that then lead your research and your programming down this fascinating path.
Yeah, it was funny too because his, his reflection was, you know, if I was running a clinic, it would be more cost effective for me as the, you know, from an economical perspective, to send a non spanish speaking therapist to learn spanish than it would for me to perpetually pay for the cost of an interpreter.
That was kind of like another comment that he had made that I’ve been rolling in my mind, like, you know, um this is like, so interesting, I think oftentimes we get stuck in a rut of like, okay, these are the challenges and barriers that exist and um they’re not solvable, you know, like there, you know, I can’t pay an interpreter all this money to, you know, make the clinic run.
And so I just really believe that trying to be creative, even if that creativity is imperfect is one mechanism for helping our field progress and move forward.
I think that’s really highlighted by these awesome projects that you’ve been doing is that creativity definitely seems to be a strength of yours and you know, thinking outside of the box like okay so this is this is what we find to be where we’re at right now and the facts of where we’re at now and then how do we move forward with what we have?
There’s a lot of ingenuity in there.
Um So I want to go back to the beginning when you talked about why you got into psychology and you said that you’re really interested in how culture impacts people and then that led you to how culture impacts one’s mind.
And so if you can share with us really some insights on that, I think that would be great or yeah, I was a peculiar child, you know having these thoughts without a conceptualization of psychology or what it what it was, but I just knew that you know um and inside my home like inside our home, it was very much Mexico, you know like we, you know all the customs, the customs, the things that we did, the values that we held um were based in Mexican culture.
And then when I would exit my home um you know it’s kind of put into this very american context which for me as a child felt very different.
And so um I I also, I think I felt I didn’t feel that other people really understood me that people who I was around did not understand me and I at some level felt like that had an impact on me.
And so then when I um when I was a little bit older, About 12, I was reading a book and the book had a therapist in it.
So there was, there was a storyline about this teenager who needed, who was struggling and needed to see um someone and so then I learned what a therapist was and but you know what a psychologist was and I was like, this is what I want to do with my life.
So then I, you know, went on to college, majored in psychology and there was kind of better able to understand, okay, what you’re really interested in is how cultural differences affect people, you know?
Um and so then, you know, that kind of led me to um being interested in research and that kind of intersection of clinical science, you know, essentially of how do we do research to make things better for people?
And the population I was really interested in was the one I grew up with.
And so I went to graduate school and then um through a lot of, I think fortunate circumstances ended up in reno, which is where I wanted to live, all that kind of stuff.
And so I feel like all my dreams have come true essentially.
So grateful for him.
Um but um yeah, I’ve been able to, you know, essentially, um study research, developed programming on the things that I’m, I’ve always been really interested in.
I think I got on a tangent though and I’m not sure that I answered your question.
I loved the story.
Um the question is how culture impacts one’s mind.
And I think, you know what you’re highlighting is this difference between home life and values and customs and then american culture and not feeling seen and valued.
And I’m curious like how do you see us being able to bridge that gap?
Yeah, I think um I’m, you know, I, I was, you know, teaching earlier before this, I was teaching and I’m teaching this class on cultural diversity and we talk about all kinds of different topics and one thing that we talked a lot about is what we call diversification of the profession.
And so when we look at statistics and this isn’t specific to psychology, you know, we can look across lots of different fields.
Um we see that ethnic minorities tend to be underrepresented.
It’s not rocket science.
This is just essentially kind of what it is in um uh in lots of different sectors, mental health being one of them, which leads to kind of the, the challenges, You know, I’ve observed trying to develop solutions for.
But I think, you know, one way that that has begun to be bridged is through diversification of the profession.
And so we see when I started, I came back to reno in 2009.
It was and At that time I want to say that there were maybe three Spanish speaking providers in northern Nevada.
Uh and I’ve really seen that number grow.
And so I think the way we bridge this is through diversification of the profession, you know, it helps us and allows us to reach more populations.
It allows us to kind of infiltrate positive um messages around mental health and other elements of health into communities that were harder to reach before.
And so um I think we’ve made a lot of progress and it will continue to kind of trend in that direction.
And it makes me think about your um series, really reducing that stigma and showing, you know, Latinas in treatment, but then also um as clinical psychologists and so that you see that as a possibility as well.
Um as we look at diversification and profession.
And I think um you know, in in in academia or in especially in programs where there’s a focus on science, in that intersection between science and kind of mental health.
There’s a lot of um pressure or maybe for lack of a better term and or focus on, you know, producing students who will graduate and go into academia.
So they’ll go on to be researchers and I always tell students when they interview to work with me that I’m very comfortable with their aspirations being whatever they are, whether it’s they want to go in are the workforce is a clinician um or they want to go and be a researcher.
They want to go and teach whatever it is they want to do.
Because I see all of those pieces as making a really big impact on the field.
And so, um, so, you know, they’re, my students are always coached to pursue what they’re passionate about.
And if that is, you know, going into the workforce as a clinical psychologist and seeing clients, I think that that that helps us reach that population that we’ve kind of struggled to reach in the past.
Yeah, that makes a lot of sense to me.
Um will you tell us about some of the clinics that you um are the director of and the services that are provided.
And we’ll make sure those get added to the show notes as well.
So I, you know, when I first started um as a professor, I got I got an invitation to apply for some funding and I applied and I got it.
And so I was able to start kind of my first clinical program with that funding.
And I developed what we call the clinic AVIva.
And that clinic is specifically targeted for spanish speakers who have a history of exposure to violence um who have been victimized in some way.
And we’re able to provide services now for, I think the sixth or seventh year for free um to anybody who meets that qualification.
And so, um I was very excited about developing that program because it was it is a culturally specific program targeted at a population who had access to very limited services.
And so through I you know I’ve sort of seen like in I think this is probably somewhat specific to Nevada kind of being a smaller state population wise is I found that you know as I’ve developed programming that it’s open, that programming has opened other funding doors and so it’s allowed me to additional programs so then I end up being very very busy running lots of different programs.
So we have we have that program, we also run thrive which is therapy and healing for um um I’m going to miss the acronym acronym up from interpersonal violent experiences and so that is for people have experienced domestic violence, they can be english speaking or spanish speaking um that were again able to provide free services in the community about three or four years ago I got a grant um for to create a child prevention abuse prevention program.
Um and so we developed what we call Sierra families and we um don’t advertise it as like come CS will help prevent you from committing child abuse because probably people would not come if that was our our approach.
And so instead we focus on teaching um families, healthy, healthy parenting skills and coping mechanisms and things like that.
Um And then because I feel bad for the catchment of people who are spanish speaking and who can’t qualify for any of those free services, we also just do a sliding scale um services where people can come in and they can see us and receive services in spanish based on their income.
So that’s awesome, huge, awesome resources for the community.
Um is there anything else that you feel is important for our listeners to know about health equity?
Um I think you know the I think that I think the thing I really hope people understand is that there are a lot of systemic challenges that people, especially people of color experience in terms of accessing health care, whether it’s mental health care or physical care.
Um and um I think you know you asked me a question earlier about like what was surprising to you about, you know what you learned from your focus groups and I think when keeping is that it’s oftentimes not because people don’t want to access these these resources, you know, even if they do have stigma um it’s much more likely to be that there’s significant barriers, be they financial or logistical um that keep them from accessing resources and I just think it’s really important to figure out how to break those barriers Absolutely well as we close um with all the hats that you wear, I’m curious what do you find to be most meaningful in your work.
Um I think it might the I’ve had to think about this a lot because I’ve had to think about how to categorize um you know, kind of how to compartmentalize like how much of my time I spend across like the different domains.
And I think ultimately that the the most important hat that I wear is one as an educator because, you know, I work with a team of graduate students and undergraduate students and ultimately they’re going to form the workforce that is going to really address the issues that I really, really care about.
Um and so it’s almost a way of casting a wider net.
You know, I I do love, you know to do like, I love to do therapy with um you know, I love to treat.
It’s a little bit of a weird statement, but I love to treat people with drama and I love to do that.
But then I can only target that one person I’m working with vs when I’m training students, I know that they’re going to go out and do and a lot.
So I think that that the head of educator is the one that I see is most important.
Well, thank you, thank you for all of the work that you’re doing and for helping to shine a light on some of the stigma as well as to tell us about some of the novel projects that you’re working on.
We really appreciate your time.
Thank you so much for having me.
It’s been really fun?
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