For this podcast, we are joined by Dr. Andrés Martin, Riva Ariella Ritvo Professor at the Child Study Center, and director of the simulated participant program, SPP, Teaching and Learning Center TLC, Yale School of Medicine, Dr. Jose Paez, also of the Yale Child Study Center, and Dr. Doron Amsalem, child and adolescent psychiatrist and Assistant Professor of Clinical Psychiatry at Columbia University.
The focus is on their co-authored paper “Destigmatizing Perceptions About Black Adolescent Depression, Randomized Control Trial of Brief Social Contact-based Video Interventions” (doi.org/10.1111/jcpp.13570), recently published in the Journal of Child Psychology and Psychiatry (JCPP).
Andrés sets the scene by providing a summary of their paper, detailing what they looked at in this study and why it was important to focus on Black adolescents in relation to depression.
Doron details the methodology used for this paper and describes the types of brief contact-based video interventions that were used in the trial, before discussing what differences they found in terms of stigmatised attitudes and help seeing intentions between the different groups featured in the study.
Andrés then provides insight into the kind of experiences that were described in the script that the participants watched, before Jose explains what a race by intervention interaction entailed in the context of this research.
Andrés and Doron share additional findings, including the importance of the exposure and dissemination of people’s lived experiences in terms of stigma, before Andrés and Jose discuss the implications of their findings for CAMH professionals working with racially stigmatized groups.
Furthermore, we hear about follow up research, including their work with transgender youth as well as using TikTok to help reduce stigma and to encourage people to seek help.
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Dr. Andrés Martin is the Riva Ariella Ritvo Professor at the Child Study Center, and Director of the Teaching and Learning Center’s Standardized Patient Program, Yale School of Medicine. He is also medical director for the Children’s Psychiatric Inpatient Service at Yale-New Haven Children’s Hospital. Dr. Martin will serve as academic advisor to the CHATogether program. (Bio and image from Yale School of Medicine)
Dr. Paez was born and raised in the Dominican Republic. He went to medical school at the Universidad Iberoamericana (UNIBE) in the Dominican Republic, where he graduated Magna Cum Laude. During his time in medical school, he volunteered at the local psychiatric hospital and worked to de-stigmatize mental health in the Dominican community. After finishing medical school, he trained in CBT, Motivational Interviewing, and PCIT. He worked as a psychotherapist in Philadelphia for four years before starting his residency in adult psychiatry at the Icahn School of Medicine at Mount Sinai (Elmhurst), New York City. He served as chief resident in his adult program before joining the Yale Child Study Center for child and adolescent psychiatry fellowship. He currently serves as one of the Chief Fellows. (Bio and image from Yale School of Medicine)
Dr. Amsalem is a Child and Adolescent Psychiatrist, an Assistant Professor of Clinical Psychiatry in the Department of Psychiatry at Columbia University, and a Research Scientist at New York State Psychiatric Institute. Dr. Amsalem developed programs for medical students and psychiatry residents at Yale University and Sheba Medical Center in Israel. His research focus is stigma reduction, specifically in the areas of psychosis, depression and PTSD. Currently, he investigates interventions to reduce stigma and enhance treatment engagement in youth. He is interested in developing and implementing brief videos, aiming to direct at-risk youth into treatment earlier in the course of mental illness. (Bio and image from Columbia University Department of Psychiatry)
[00:00:30.102] Jo Carlowe: Hello. Welcome to In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing Dr. Andrés Martin, Riva Ariella Ritvo Professor at the Child Study Center, and director of the simulated participant program, SPP, Teaching and Learning Center TLC, Yale School of Medicine, Dr. Jose Paez, also of the Yale Child Study Center, and Dr. Doron Amsalem, child and adolescent psychiatrist and Assistant Professor of Clinical Psychiatry at Columbia University. All are co-authors of the paper “Destigmatizing Perceptions About Black Adolescent Depression, Randomized Control Trial of Brief Social Contact-based Video Interventions,” recently published in the Journal of Child Psychology and Psychiatry.
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Andrés, Jose, and Doron, thanks for joining me. Can you each start with a brief introduction on who you are and what you do?
Dr. Andrés Martin: Thank you very much. I am Dr. Andrés Martin. And pertaining to this paper that we’re going to be talking about, as director of the Standardized Simulated Patient Program at Yale, we’re going to be talking about two of the simulated patients who participated. And I should add that we’re especially proud that both of these actors are underage. They’re under the age of 18, which is something special in the simulated participant world. And I am happy to pass the baton on to my good friend and colleague, Dr. Doron Amsalem. Doron.
Dr. Doron Amsalem: Hi. Thank you for having us. My name is Doron Amsalem. I’m a child psychiatrist. I work in Columbia University as a research scientist. I study stigma, and I’m happy to be here.
Jo Carlowe: Thank you, Doron. And Jose–
Dr. Jose Paez: So my name is Jose Paez. I’m a child psychiatry fellow at the Yale Child Study Center, and I worked with Dr. Martin and Doron on this paper. Thank you for having us.
[00:02:51.390] Jo Carlowe: Well, let’s turn to the paper, “Destigmatizing Perceptions About Black Adolescent Depression, Randomized Control Trial of Brief Social Contact-based Video Interventions,” recently published in the JCPP. What did you look at in this study? Can you give us a summary?
Dr. Andrés Martin: Absolutely. Depression is highly stigmatized in adults and we know in adolescents, as well. And the repercussion of this is that adolescents are reluctant to share their symptoms of depression and even more reluctant to seek treatment or to stick with treatment. Depression can lead, in the worst of outcomes, to suicide. And suicide is one of the leading causes of mortality in this age group. So the stakes are high to destigmatize this disorder.
[00:03:40.123] Jo Carlowe: Absolutely. And why was it important to focus on Black adolescents in relation to depression? Can you set the scene for us?
Dr. Andrés Martin: Absolutely. In an earlier paper also on JCPP with Doron as a first author, we had found that a short video clip of an adolescent talking about their depression, how they then sought treatment, and how they regained their baseline functioning. We found in that paper that a video showing that led to decreases in stigma and increases in treatment seeking intentions when compared to a control video in which the same adolescent talked about something unrelated to depression.
We were thrilled with those findings and with getting it published in JCPP, the leading journal in child psychiatry together with JAACAP, its American counterpart. And one of the secondary findings that surprised us is that Black adolescents had a response that was about half as strong as white adolescents. So going into this paper our original hypothesis was that if we have now a Black adolescent, as compared to a white adolescent in the first paper, that Black participants would respond more strongly and that their response would be similar to that we found in white adolescents in the same paper.
I will leave the cliffhangers here and say that that’s not what we found or not completely what we found.
[00:05:15.360] Jo Carlowe: Can you say something about the methodology that you used for this paper, for this research?
Dr. Andrés Martin: Yes. And I’m going to pass the baton to Doron, who really has been a pioneer in this particular methodology. Doron.
Dr. Doron Amsalem: Sure. So as Andrés described, we used the short videos to test change in perception. And the way we do that we, created videos very short in length. And then we run it by a crowdsourcing platform. We usually have between 1,000 and 1,200 participants for each of our studies. In that specific study we had 1,093 adolescents, ages 14 to 18, as I said, using crowdsourcing platform and conducting the study online.
[00:06:03.210] Jo Carlowe: Can you describe the types of brief contact-based video interventions that were used in the trial?
Dr. Andrés Martin: I’ll first say that we randomized different videos. And, Doron, take it away.
Dr. Doron Amsalem: So the first one was a video of a Black girl describing a story of depression, which was used in a previous study presented by a white girl. So it was a story about depression and how treatment helped me to recover, but not accounted to any race-specific characteristics. The second one was presented by the same Black adolescent girl, now accounting for race characteristics, and basically describing how is it to be a Black girl with depression and how treatment helped her to recover. And the third video was a control video with a story that wasn’t related to depression at all.
[00:06:58.470] Jo Carlow: What was the age of the girls?
Dr. Doron Amsalem: 16.
[00:07:02.160] Jo Carlowe: 16. Thank you. And what differences did you find in terms of stigmatized attitudes and help seeking intentions between the different groups?
Dr. Doron Amsalem: So about basically the results– so following the intervention, the stigma scale, the depression stigma scale that we measured was a change from baseline to the post-intervention across all three conditions. But in terms of differences, the adjusted video showed the greater reduction in stigma. So the video that was accounting for race characteristic differences was the one that showed the biggest change. The second level of outcome was temperature toward warmth, toward the colour of the presenter.
And what we saw, which was a big surprise for us, that the biggest change was among white viewers when they watched the adjusted video. What we concluded was that when you watch a story in a way that was surprising for you, they didn’t know or they didn’t realize what race has to do with depression or how it relates to depression. So then you’re basically showing the biggest change from baseline. So that basically was the second result.
[00:08:23.903] Jo Carlow: Can I just get a sense, if you were to put it in lay terms, what would be the kind of experience that would be described in the script that participants would be watching.
Dr. Andrés Martin: So I should say that the adjusted video was informed by a focus group of six Black women. There were no white people involved in their conversation. And what came out of it, which was extremely surprising and I would say– as you heard from Doron– much more surprising to people like myself who are white, what was surprising were two things from that focus group which we then incorporated into the adjusted video.
The first one, counterintuitive and surprising to me, was how important hair was in the case of Black girls. They felt that from a young age they were subject to this sense that curly black hair is not as quote, unquote, “beautiful” as, let’s say, blonde or otherwise non-Black hair, and that they had internalized that sense of internalized difficult perception about themselves.
The second finding, which is in retrospect not surprising at all, was the role of racism, anti-Black racism in their depression. This was a very important contributor that does not apply to white girls. And we incorporated both of these findings into the adjusted video.
[00:09:57.940] Jo Carlowe: Can you explain what a race by intervention interaction entailed in the
context of this research?
Dr. Andrés Martin: So let me take the first half of it, and then I’m going to pass it to Dr. Paez. What this means is that depending on your race you responded differently to the intervention. If you were a white viewer you responded more strongly, which was counterintuitive to us. And that was because, as I said, being a white person we were surprised to know the shocking difference and to know the internal experience of a Black girl with racism.
I will let Dr. Paez say a little bit more about that. And let me just add that I am a white man. Dr. Paez is an Afro-Caribbean man. And I’ll be interested in his take on this. Jose.
Dr. Jose Paez: Thank you, Andrés. I think the second part to this answer really has to do with what the participants or the people looking at the videos had been exposed to previously to this study. When we think about issues of mental health, we really are exposed to those that are around us. And if you don’t surround yourself with people of other races, then you would be very surprised to see how they experienced depression and how that differs from the way that you experience depression.
So I think that the mere exposure of seeing somebody of a different race in a similar distress, but not necessarily because of the same thing– like Dr. Martin said, it’s quite shocking. But I also think it goes beyond mental health. Dr. Martin touched on the subject of racism. And I think it also touches on that. I think it creates a more even playing field, even for the field of mental health, to know that people– regardless of their race– have no struggles that are unbeknownst to us.
Dr. Andrés Martin: I should add that one of the counterintuitive findings was that Black viewers responded the same to both of the Black videos, to the normal depression and to the adjusted depression. We had not predicted this. We had predicted that Black individuals would respond much more strongly to the adjusted video. And the way that we explained this is the hypothesis– the sense that if you are Black you really are not surprised. You are not surprised to know the pervasiveness of racism. I knew that. What’s so surprising? And a difficulty to really disentangle depression with or without explicit racism– because they know that racism is embedded, whether explicit or not.
[00:12:38.033] Jo Carlowe: Yeah. Really interesting. You’ve already shared quite a few findings. Is there anything else you could share from the results?
Dr. Andrés Martin: Yes. One of the things is future directions. And we just had a manuscript accepted and published that extends these findings with a different population. And, once again, my colleague and trailblazer, Doron, took the lead on that article. So I’m going to pass the baton to him. Doron.
Dr. Doron Amsalem: In both papers, the mechanism of action– the way it works is basically social contact, which means if you expose someone and someone is honestly and directly sharing his experiences, people can identify with and emotionally engage. And that would basically create the change. We did a similar study with a similar mechanism, which means we created the videos depiction of young transgender adolescents.
And they described their story, and how they coped with depression and even suicide ideation, and how treatment helped them to feel better. And we used similar measurements to understand depression stigma and help seeking. And we were able to show that when transgender adolescents describe their symptoms– so first we see similar results in terms of changing depression stigma, but also reducing transphobia, which was a great outcome for us.
[00:14:11.155] Jo Carlowe: Has that been published yet?
Dr. Andrés Martin: It was published, to our delight, in JAMA Open Access, and it had an accompanying, really thoughtful editorial by Jack Turban as the senior author. Jack is one of the world experts on the mental health of transgender adolescent youth. So we were thrilled about that finding. And I should just add that, similar to the paper we are discussing now, straight viewers responded much more strongly than LGBTQ viewers.
As you can imagine, even though we had a large sample of over 1,000, we had too small a transgender youth viewership. But we’re essentially certain that they would not have responded in as strong a way– I am a straight white man– how we responded. And, once again, it had to do with shock, if you will, of meeting a transgender adolescent.
And when I say shock, it was a positive shock. It was, oh, my goodness. These transgender youth are youth who wake up and brush their teeth and go to school. And they’re wonderful kids. And, for some people, this was the first transgender person they had ever met.
[00:15:30.680] Jo Carlowe: So it’s about the exposure and dissemination of people’s lived experiences. That seems to be important here in terms of stigma.
Dr. Andrés Martin: Absolutely, which goes back to the exposure to a world, a population, issues that you don’t know, whether it’s racism, whether it’s transphobia, et cetera.
[00:15:52.658] Jo Carlowe: That’s really interesting. It’s just focusing on the JCPP paper that we’re talking about today, is there anything else that you’d like to highlight?
Dr. Andrés Martin: I think that there is such a pervasive sentiment of racism, and specifically anti-Black racism, whether overt or not overt. Once again, I’m going to pass it to Jose, who as an Afro-Caribbean man will explain, as I said, an experience that is very alien to two white men like Doron and myself. Jose.
Dr. Jose Paez: Thank you. It goes back to what Dr. Martin was talking about, which was the exposure factor of seeing the suffering in a race that you’re not used to seeing it. And that really goes a long way. I think, as humans, we have a lot of tribalistic thinking. And when we recruit others into our tribe, we tend to be more understanding and more protective. And in mental health, you know, it’s so prevalent.
Dr. Andrés Martin: Sorry to interrupt, Jose. May I ask you to just add it about the issues in the United States as opposed to other countries, and the very serious skeletons in the closet that we have in this country, the original sin if you will, of this country?
Dr. Jose Paez: I think that comes back to the exposure. For hundreds of years, African-Americans and minorities in this country have had to hide their struggles with mental health for various different reasons, be it cultural or be it that it didn’t necessarily meet criteria to address it at the moment because they had other, bigger concerns to address like food, shelter, equality. So I think we’re at a point where different peoples in this country coming from different races can start to address these things.
And it’s something that is long overdue, and it’s going to take time for the majority– the race of the majority to realize that just like them, we also struggle with mental health issues and also go through similar plights. So it’s not what it used to be.
Dr. Andrés Martin: Let me add something, even if it’s not smoothly connected to what Jose said. But I do want to add something about the United States. I should add that in the United States, where we did the study, there’s an important additional issue to mention. And that is that for 400 years– 400 years ago was when the first African slaves were taken to this country forcefully. Since then, over the 400 years, we have experienced anti-Black racism in different ways.
Obviously, the first and most terrible one was slavery. But when slavery was ended, as a result of the Civil War, as we all learned related to Abraham Lincoln, that doesn’t mean that overnight after abolition anti-Black sentiment ended. To the contrary, we then went into a different era of difficulty, first in reconstruction then in the terrible years of Jim Crow, in which the racism was different.
Slavery was over, but it was very explicit. White drinking fountains, Black drinking fountains– there are countless examples. When that was done, after that Jim Crow “formally ended,” quote, unquote, Martin Luther King, of course, the hero– but that’s not when racism ended. I would say that racism then went into a pervasive, insidious, more invisible type of racism, redlining you can live here but you cannot live there.
You can get a loan. You cannot get a loan. And that has slowly led into the current stage of racism, which is not explicit. It’s certainly not enshrined in the law. But being a Black person, individuals have to fight in ways that we white people take for granted and do not know. And whether it is implicit or explicit bias, whether it’s micro-aggressions– which, by the way, I have been taught by my Black colleagues including Amanda Calhoun, Dr. Amanda Calhoun, who is one of the co-authors of our study– microaggressions is a misnomer. I would say that microaggressions really should be thought of as everyday racism.
[00:20:10.280] Jo Carlowe: All of which has implications for mental health.
Dr. Andrés Martin: Absolutely.
[00:20:14.050] Jo Carlowe: Importantly then, for our listeners, what are the implications of your findings for CAMH professionals working with racially stigmatized groups?
Dr. Andrés Martin: I would say that if I could give one practical thing to myself and to all of my colleagues is the following. Ask about racism. That’s not a bad word. It’s not a hidden word. It’s a critically important word. And the way to ask can be very simple. Have you ever experienced racism? Please tell me. I think that that’s important. Jose, how would you ask about racism?
[00:20:53.100] Dr. Jose Paez: I think the best way is just to be direct about it. Because the more words we use to disguise it, the less genuine it comes off or it comes through as. So asking directly about racist experiences that they’ve had and how it has affected their lives– and I think it’s something that Dr. Martin said it. It’s very pervasive and it’s quite insidious. So there are things that you may look back on. And me, myself, sometimes I look back at things and I realize only later on that it was racist.
And then I’m left holding that baggage. If my therapist would ask, then I would be able to talk about it. Kind of like one of those things where you look in the mirror and say, if I was there again I would say this. So therapy would allow you to do that. Mental health professionals can do that depending on how they ask the questions. And I think that is just very being very direct and not dancing around the bush.
[00:21:42.830] Jo Carlowe: Do you think many CAMH professionals shy away from asking?
Dr. Jose Paez: Yeah. 100%, yeah. Yeah.
Dr. Andrés Martin: And I would start by blaming a child psychiatrist who I know very, very well by the name of Dr. Andrés Martin. Me. Before these studies, before doing this work in anti-Black stigma– where I go back to Dr. Amanda Calhoun, a real pioneer in this and a proud Black woman. Before knowing this I did not ask. I was concerned. I thought it was, I don’t know, inappropriate going to places that were none of my business.
[00:22:20.070] I have changed my mind. I have started practicing in that way. And I think that I’m a better child psychiatrist as a result. Let me just add very quickly that although this study was focused on anti-Black racism, that for sure is not the last type of anti-X sentiment. I am a native of Mexico. And my colleagues, some 20 or 30 million in this country alone, experience anti-Mexican, anti-Brown sentiment.
We could talk about anti-Asian sentiment. We can talk about xenophobia. We can talk about many, many things. And although there are some singularities to a US experience, certainly this is not just a US phenomenon. Racism, anti-X sentiment, is painfully alive and well everywhere in the planet.
[00:23:09.915] Jo Carlowe: Thank you. And are you planning some follow up research that you can share with us? I know you’ve talked a little bit about your work with transgender youth.
Dr. Andrés Martin: Let me briefly say, and then pass it on to Doron– the findings on transphobia and improvement of transphobic perceptions, if you will, was a diagnostic paper. The intervention was helpful, certainly, but it was a brief intervention. And we think that we can extend those findings in a different and very practical in the real-world way that we can take not just to the 1,000 participants in the study, but throughout. So let me pass it to Doron and talk about this current randomized controlled trial.
Dr. Doron Amsalem: Sure. So this is a study that we conducted among health care providers. And that includes their training and few arms we did a randomized controlled trial in. And one of the arms is the as usual training of how to approach adolescent youth. And we added to the intervention arms short videos with the participation of transgender adolescents who described their experiences in the same mechanism that we just described.
And the third arm is basically the same training and the same videos, but now also with transgender educator that do the training themselves. And we measure any differences in both transphobia or stigma, and how well the training went. This is still a bit early to discuss the results, but we’re definitely excited about it.
[00:24:50.682] Jo Carlowe: Great. Thank you. Doron, can you tell us about the use of TikTok? That sounds very exciting.
Dr. Doron Amsalem: At the end of the day, the short video’s basically creating the daily life of our younger people around us. And they watch short videos all day long, basically. And we try to create content that eventually will help to reduce stigma and to encourage people to seek help. And the best platform to do that is where they spend their time. Right? It’s either Instagram or TikTok. So we basically now are studying ways to replicate the same studies in the TikTok environment.
[00:25:36.170] Jo Carlowe: Thank you. Finally, what is your takeaway message for those listening to our conversation today?
Dr. Andrés Martin: Yes, Jo. If I were to summarize all of these studies and everything that we’ve done, it would be summarized into what I say are the four words that summarize this field that we’re privileged to be a part of. It applies to the broader house of psychiatry, and maybe of medicine, but certainly of psychiatry and child and adolescent psychiatry. And that is that 90% of our job is to make things talk aboutable. And, in this case, it is anti-X sentiment, anti-Black sentiment, anti-transgender sentiment, et cetera, et cetera, et cetera.
[00:26:13.650] Jo Carlowe: Brilliant. Thank you ever so much, all of you. For more details on Drs Andrés Martin, Jose Paez, and Doron Amsalem, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review. And do you share with friends and colleagues.