Luana Marques, PhD: Bringing Cognitive Behavioral Skills to the Community

Q:   Even today, in 2021, there is still a stigma around treatment for mental illness. The National Institute of Mental Health tells us that nearly one in five adults in the United States lives with mental illness. And according to the American Psychiatric Association, more than a third of people say that the coronavirus has had a serious impact on their mental health. And yet, when many people experience symptoms of mental illness, seeking medical help from a doctor may not be the first solution that comes to mind. This may be particularly amplified in underserved communities, where in addition to the social stigma, people may also face barriers related to language and resources. 

Dr. Luana Marques, a clinical psychologist at Mass. General, specializing in bridging the gap between science and practice through implementation of cognitive behavioral therapy, understands the importance of accessible mental health care for all. In 2014, Luana was part of the Mass. General team that founded Community Psychiatry Pride, a program that brings evidence-based treatments for psychiatric disorders to under-resourced communities. 

At the core of this initiative is the important work, mission to work with, and train community-based, non-licensed professionals, to deliver these treatments and address mental health problems. Welcome, Luana. It is so wonderful to have you here today.

A:   Thanks for having me, Kelsie. 

Q:   I’d love to jump right in to learning about your story and just how you became interested in psychology and mental health. What were your experiences with mental health growing up?

A:   I grew up in Brazil. And mental illness was really a stigma. Most people didn’t talk about mental illness at all. In fact, I really didn’t think much about mental illness until I came to the US. 

Q:   And so what brought that up?

A:   So I came to the US to study. I first came as an exchange student. Loved the American dream, and decided to come back for college. And so when I was in college here, I started to really get excited about research. And I ended up volunteering at community clinics. It was really my first glimpse of what mental illness looked like, and what it took to treat people in diverse communities.

At that point, I really fell in love with psychology. And I think really allowed me to think about, what does it look like to work with individuals on the ground, to get them to get better, and to understand the science behind it?

Q:   Yeah. And so I’d love to go even further back, and just learn a little bit more about your childhood in Brazil. Did you have any personal experiences with mental health that really helped you build the knowledge around the tools that you now provide people in your practice?

A:  I grew up poor, with a single mother. And it was a struggle. I really learned a lot from my mother, in terms of work ethics. And not until very recently, when I really thought about the arch of my career, that I really understood that I learned a lot of cognitive behavioral therapy, as strategies for my grandmother.

My grandmother, who had no college education, was really pivotal on teaching me how to face my own fears. I moved in with her when I was about 16. And I moved from a small town to a big town. And, all of a sudden, really was afraid of talking to strangers, was feeling shy. And at that point, she really forced me to get out of my comfort zone, and to approach others, and to talk to strangers.

And, when I got to graduate school, I learned that that’s called exposure therapy. That there is a way to actually face your fears, that allows you to overcome it. 

Q:   So when you talk about those fears that you had that your grandmother really helped you to overcome. Are those fears things that you sort of consciously saw in yourself?

A: My grandmother probably picked up on it more than I did. They looked like things like, I didn’t want to really hang out with people outside of school. Or I wasn’t answering the phone when somebody called. Or I was having some trouble making new friends. 

And so my grandmother saw that I needed to figure out a way to really be able to communicate with others in a way that wasn’t limiting my life. 

Q:  Did she talk to you about it? Was it more subtle? How did she approach you in helping you conquer your fears?

A:   There's nothing subtle about my grandmother at all, ever. She just, one day, said we’re going to go have lunch in the mall. And we got to the mall, we got the food. And she says, “Let’s sit with that person and talk.” And I was like, “Hmm, I don’t really want to talk to that person.” It was like, “Yep, we need to talk to strangers.” 

And so we did it again and again, to force me. And she was brilliant, right. Today, I teach people how to do this, that you’ve got to face your fears. You can't start 100. You really have to start much lower. And then eventually, she would see a bunch of very cute teenage boys, and was like, “Oh, let’s talk to those boys,” which terrified me. 

But, in the end, pretty quickly, allowed me to see that, you know, the monster was in my head. And I have never ever thought about it again.

Q:   Wow, that terrifies me. So moving from Brazil to the United States. What was that experience like for you?

A:   At first was really exciting, and challenging. I spoke very little English. So having to conquer the language, having to make friends again, having to adjust to cold was extremely hard. Growing up in a very tropical country. But education was really my ticket. It’s what I really loved, and that allowed me to continue to anchor on what helped my brain thrive, and myself in that way.

And so it’s really through the lenses of pursuing education for my undergraduate, to my Master, to my Doctorate, and staying engaged, and thinking about, how do I learn more about this? How do I help more people? That really helped that transition.

Q:   Yeah. And so you mentioned having to make new friends. So those skills that your grandmother taught you about, meeting new people, kind of throwing yourself into the fire, or how did you reengineer those in that situation?

A:   I certainly had to. And I think the language barrier magnified that early on. And so what I did, as an exchange student, I joined the ski team. I never had skied before. I had no idea how to ski. But we were stuck on a bus together for an hour and a half. And I figured, well, what better way to make friends, and to force myself to talk to folks?

And by the end of my my senior year in the US, I knew everyone in my senior year class, which was 400-plus students. And I think it was really my grandmother’s early teaching that allowed me to sort of engage, and to stay with it. Most of us, when we get uncomfortable, we take that as a signal to walk away. I find it completely different. Whenever I get uncomfortable, that’s where the juice is. And I really think life is about being comfortably uncomfortable.

Q:   That’s so amazing. So these types of situations, I imagine, come up throughout your life. Would you say that that’s true, that any fears you might have had when you were younger you get the tools to try to combat them, and try to strengthen yourself in those situations. But you have to sort of reemploy them throughout your whole life?

A:  So what we know nowadays is that we can really rewire our brain, right. If you take about those skills, exposure therapy, as something that, if you practice enough, you will actually tighten the neurons’ connections, and you can sort of automatically do it, it then eventually becomes very easy. It does not mean they won't develop other fears. 

But for me, nowadays, public speaking, talking to strangers, I get really excited. It doesn’t even cross my mind, very likely, because I do it all the time. If I avoided it at all, if I started to decrease my engagement, then perhaps I would have to employ the whole technique again. 

But the secret juice here really is, once you learn to overcome fears, to continue to find opportunities to approach it, to change your mindset, instead of like you know, I'm forcing you to do this, this is exciting. I want to do it. I don’t want to even think about it. 

Q:   Sure. So in those early days, were there mental tricks that you would use, or statements that you would make in your mind, that you found really helpful when saying, “You know what? I'm going to go on this ski trip and make these friends.”

A:   It’s interesting that you're asking about mental[?] tricks. So in cognitive behavioral therapy, we separate thoughts, right. Your mental thoughts. And then your behavior. And then your emotions. And in exposure, really is about doing, not thinking. And it’s sort of counterintuitive. Because if you start thinking a lot, then you get yourself paralyzed. Because it activates your brain.

And so for me, it was anchoring on, this worked before. So I'm going to do it again. But I didn’t really focus on thinking much. And quite honestly, didn’t think about my thinking until I got to graduate school, when I learned about changing your thoughts, and restructuring thoughts.

In Latin culture, we don’t talk a lot about thoughts. In fact, when somebody asked me early in graduate school, “What are you thinking?” I said, “Well, I can tell you what I'm feeling. I have no idea what I'm thinking.” And so it’s really more about trusting the process, and approaching it. 

Q:  Do you see a benefit in sort of focusing more on your feelings as opposed to your thoughts?

A:   I don’t think there is a benefit, Kelsy, for one or the other. It’s really about your entry. So if you're thinking about cognitive behavior therapy, nowadays we call it in our research lab here at Mass. General, we call it thoughts, emotions, and behavior cycle, the TEB cycle. And, if you think about it, most of us, a situation happened. I'm in the mall with my grandmother, and she says, “Let’s sit with that hot guy over there.” 

And either you're going to feel something, right, your heart’s going to pound, you might sweat. Or you might say to yourself, “Hell, no.” Or, you might want to do something behavior. You might want to just avoid. “I'm not doing this. Forget that food. I'm going to go home.” And so each one of us tend to have a little entryway in that TEB cycle. For some of us, it’s really like, something happens, and you start thinking about it. For some of us, you feel it immediately. And for other of us, when it gets hot, you want to avoid it.

And so there isn't a right or wrong way. It’s sort of like know your entryway in that cycle, and to know that you're spinning, and then finding ways to pause it. 

Q:   So Luana, I know we've talked about cognitive behavioral therapy a little bit. Can you just describe what that means for anyone listening, who might not know?

A:   So cognitive behavioral therapy is a type of therapy that is based on scientific evidence. It’s action-oriented. It’s present-oriented. And the core of it is really teaching individuals to understand their thoughts, what they're saying to themselves, to evaluate thinking. So is a thought like, “If I talk to this person, they’ll make fun of me.” Is that an accurate thought? Is that a valid thought? And if not, to arrive at a different kind of thinking.

It also teaches us to approach our fears through something called exposure therapy. And in many ways, teaches us how to sort of live a better life by decreasing anxiety, decreasing depression, through, again, thoughts, emotions, and behaviors. 

Q:   You mentioned part of it is defining if the thought is accurate or valid. How do you go about making that judgment?

A:   So the basis here is something called cognitive restructuring, or easily put, exploring your thoughts. Often, our thoughts are taken as facts. We say to ourselves something over and over again, and we just believe it. And in that technique, we take the thought out of your head. You put it in front of you. And you ask a few questions out of that thought. 

For example, what is the data that I have to support that, if I talk to that person, they will make fun of me? And by data, I mean something that holds in the court of law. Not my emotions, no. Feelings are valid, but they are not facts. And so, you use people’s history. You use their ability to sort of talk about other times that they did this.

And then, eventually, you get an alternative thought. I am not sure if that person is going to make fun of me. But I’ll try to talk to them and see what happens. And so in that, you arrive in a more flexible thoughts. And flexible thoughts allow you to be less uncomfortable into decreasing anxiety and depression. 

Q:   Interesting. And you had said earlier, too, it’s about being present oriented. Can you provide just a little context around what that means?

A:  In CBT, really, we want to anchor on what's going on right now? It's not that your history doesn’t matter. But in many ways, focusing on the present gets people unstuck.

And at times, we have to go back and say, “Okay, how did you get here?” But we try to really anchor on, how do I get you unstuck currently, with the thing that is really affecting you the most? 

Q:   So I know at Mass. General, you were part of the team that founded Community Psychiatry Pride. Can you talk a little bit about your work with that initiative?

A:   Absolutely. So Community Psychiatry Pride, Pride stands for Programming Research and Implementation and Dissemination of Evidence-Based Treatments. And it’s a mouthful to basically say, “We believe that everyone deserves mental health care. And this should be scaled to every community.” 

And so Pride is really, has its mission of getting out of the ivory tower, and getting to the streets. Getting what we know that works, and getting it access to everyone. And what drives me here is this idea that 20 percent of the US population needs help for mental health care. And yet, only 0.17 percent are trained professionals. 

So the gap between access to care is humongous. The supply and demand will never match. And that has gotten even worse with COVID. So we really think about, how do we reengineer the workforce? How do we get skills to everyone? I'm not suggesting everyone needs therapy. But the idea of having flexible thoughts is something that can help everyone to manage difficult times. 

Q:   And in the very beginning of this effort, how was the need for this really identified?

A:   So I got trained on something called implementation science, which is really matching theory and practice. So research tells us it takes 17 years for science to reach practice. And only 14 percent of what we know is evidence-based gets to our communities. 

Now think about that. If your loved one was sick, and they need an antibiotic, and the doctor said, “Oh no, you're going to wait 17 years to give you antibiotic,” would that be acceptable? Absolutely not. In implementation science, we think about, how do we bridge that gap? 

And for me personally, I learned that it really exists in our communities, when I went to MGH Chelsea, and I was volunteering, working with Mary Lyons-Hunter, who is an incredible Chief of Behavioral Health. And the providers were saying things like, “I don’t know how to treat trauma. How do I treat this trauma?”  

And so really, understanding that all of the things that I learned on the main campus, that were science-driven, was not getting to MGH Chelsea. That, to me, was unacceptable. And that’s really what drove me early on. 

Q:   And can you talk a little bit about MGH Chelsea and that community in particular, and what the needs were that you were seeing there? 

A:   So Chelsea is really a LatinX community. It’s an immigrant community. And when I first started to working there in 2011, we saw that about 80 percent of the patients come in through the door in behavioral health were reporting a trauma history.

And so the community really needed support in interventions, to help with trauma. But also a little bit of prevention. How do we go upstream and help them decrease some of their trauma loads that they were experiencing? And it was really an amazing experience working with those providers. They were incredible. 

And we did a training on cognitive processing therapy, which is a science-based type of treatment for post-traumatic stress disorder. And through five years, we learned not only they could learn, they could implement. Patients that had been in care for many, many years actually got better in 12, 15 sessions.

Q:  It sounds like there were some challenges when you first went about creating this initiative. What barriers did you face in the early part of this work?

A:   I think early on, because implementation science was so new, and it’s so different than your typical randomized control trial. So when I started, for example, working with a nonprofit called ROCA, that really, for 30 years, have worked with young men coming out of the prison system, who really no one else wants to work with.

So, when I first started to work with ROCA, and we designed this incredible implementation to try to understand how do we design something that was flexible, that those young men could learn, that was CBT, a lot of my colleagues didn’t understand it. It was like, “Well, aren’t you scared?” I wasn’t scared. I was excited. I was excited to be on the ground. I was excited to design something that was scientifically solid.

And so really, it was a mismatch between what I was doing, and what everybody else was doing. I think as the years passed, fortunately, a lot of people now know a lot more about implementation science. So I think that gap has decreased. But it’s certainly, I felt a bit an outsider early on.

Q:   Yeah. And so when you started to work with these young men, was this their first experience getting this kind of treatment, and getting this kind of support?

A:   So Molly Baldwin, who is the CEO of ROCA. For many years, she had tried to bring cognitive behavioral therapy to ROCA and wasn’t able to. The young men that come through ROCA, they're not mandated to be there. And often, they do not want to be there.

And so asking them to sit for a group therapy session, wasn’t going to happen. So, when she came to us, the mandate that she had was like, “How do I get them to learn this in a way that they can actually change their lives?” And so, although they had tried, they hadn't been able to succeed. And it makes a lot of sense, because we can't think about this as treatment, really. We need to think about this as skills.

The same way my grandmother taught me skills, right. And if we think about skills, then we need to think about dosages. If somebody is not willing to take a full course of antibiotic, can we give them one little dosage to keep that infection down? And that’s really what we found at ROCA. We just published a paper showing that young men who practice at least one of the skills spends 70 percent more days at ROCA. 

Now think about that. The program that they're not mandated to be there, and not only are they there, they might not be on the streets, on a gang, or shooting someone. And so they have a bigger shot of actually changing their life. And that’s significant. 

Q:   Sure. And so this unwillingness that some of these individuals might have had, I'm sure you’ve experienced that in other settings as well. Where does that come from, do you think?

A:   I think we need to separate a couple of different contexts. So if we’re talking about the young men at ROCA, we’re talking about individuals that are marginalized, individuals that are stigmatized, individuals that people don’t want to talk to. And part of their own history, it’s a lot of trauma. When you have trauma, the ability to trust others is gone. 

And so I don’t think it’s just that they are unwilling, they are unable, right. That trust is not there. And, of course, there is a stigma related to mental illness. And individuals sort of fear that what will people think of me if I approach care? And so I think most people still have some difficulty thinking about emotional trouble as brain health, instead of mental health. 

Our brain is just a part of our bodies, another organ, the same way as your heart. And if you have a heart condition, you're often not embarrassed. You're seeking help. And so I think part of what we need to do is really change even the wording, and talk about people’s anxiety or depression or sadness as brain health. And that they need something to help their brain work again. 

Q:   So when you think back, to that Community Psychiatry Pride work, building those trusts and those relationships and those communities, was that a difficult thing to do in the beginning? 

A:   So whenever I need a community partner, I walk in through the lenses of something called community-based participatory research, which are basic principles to suggest that we’re equal partners. And all of us have responsibility for respecting each other and learning from each other. And so my approach is, I walk in, and I ask, “How can I be of service? What can I do?” instead of what I have to offer you, I don’t assume that I know something that they need. 

I sit at a table, and I listen first, and I get to know them. And that approach in my career has been really important, because by listening and learning, is how we get to better treatment, is how we build trust, is how we change the landscape for mental illness. And so for me, fortunately, it hasn’t been challenging. But I think perhaps, also, because I grew up in Brazil, and I grew up poor. 

And so, if I'm sitting with a single mother, who’s talking about struggling to feed their kids, I can see how that was for my mother. And I'm not ashamed of that story. I think that taught me lots of really important messages. And I often share that. I say, “Yep. I remember that. I remember a time that we had one potato for the three of us. That wasn’t easy, right.” 

And I also think there is a way out. And so I think sometimes my own story allows me to be able to develop a relationship with community partners that’s meaningful, right away. 

Q:    Yeah, I can imagine. I mean it’s so powerful that you're able to use your own experiences, and sort of offer those on the table for someone else to share their own. So what other kinds of difficulties are people in these types of communities facing, mental health wise, that are really central to the work that you're doing?

A:  My passion is to help individuals in resource restricted settings. And data suggests to us, if you looked at people’s assets, their wealth, right, the less wealth you have, the more vulnerabilities you have, and the more likely you are to struggle with not only emotional health, but also physical health. 

And in those communities, you not only have low levels of wealth, you also have a lot of violence, perhaps. You have immigration issues. You have discrimination, systemic racism. Let’s just anchor in COVID for a second. 

The solution to decrease the spread was for people to stay home, and to social distance. And if you were to get COVID, then you needed to isolate yourself. There's a lot of assumptions on that, that cannot be met in communities like Chelsea, the city opened a hotel to get individuals to be able to isolate, because they lived in a small house with six people. And they couldn’t isolate. 

Well now, a lot of people can't  actually work from home. And if they stay home, they can't feed their family. And so it’s really challenging to really think through the lens of, like, how do we help this community the best we can? And the effect of everything—poverty and trauma and systemic racism, it’s exponential in those communities. 

Q:   How have you seen CBT training be particularly effective during COVID?

A:   So the nice thing about CBT is that it has more than 450 randomized control trials. On top of that, it has been done everywhere in the world. So there's good training, good research, and so we knew that CBT worked in our communities. And during COVID, what we have done, is find the ways to disseminate skills, as much as we could.

Instead of thinking about CBT as therapy, how can we teach individuals in our community to use some of those skills as prevention/early intervention? So I'm going to give you an example. This summer, we partnered with the Chelsea Collaborative and the folks from the Center of Excellence at MGH, and we created a summer scholars program. We had about 150 high school students from Chelsea.

And we basically, through a four week module, taught them basic principles of CBT. So like I talked earlier today, the idea of thoughts, emotions, and behaviors, understanding when you're feeling low, how to charge up. Eating, sleeping, exercise. How do you get yourself out of that hole? How to explore your thoughts. And that’s a lot of what we've done during this pandemic, is to try to really, as best as we can, get skills to as many individuals as we can. 

Q:   So what's been your approach in the era of COVID?

A:   During COVID, everything that we did has changed significantly. Not the skills themselves. CBT is the same. But the delivery and the engagement is different. We had to find a way to engage teenagers and young adults on Zoom, at times when they really don’t want to be there. We had to find ways to reach kids that didn’t have access to internet, or computer. 

And we’ve been successful doing that. It’s less challenging now, given that we’ve done it for a while. But once innovate and find creative ways to engage. 

Q:   And I know we talked a little bit about sort of the stigma just around mental health. So I'm really curious. Has COVID reduced some of that, just with bringing the need for more mental health support to light? 

A:   I think one of the perhaps nice side effects of COVID is that mental health has become a priority and a conversation. Since April, the CDC suggests that one-third of Americans are having clinical levels of depression, of anxiety. And that’s significantly higher than we had before. And so you see mental health being discussed in the news. You see it being discussed in our own circles academically, and in the communities.

So I think the elevation of, there's a real crisis in access to care. Mental illness was on the rise, and now it’s even worse, is a positive side effect of COVID. Not sure how that actually affected stigma, because I still see that individuals in the community have a level of shame. They feel broken when they have depression or anxiety. So I think there's a lot more to do in the domain of stigma, to overcome the barriers.

I do think that being creative about providing skills to individuals, not saying that, you know, you're broken, and you need therapy. But listen. The same way you learn how to ride a bike, there's a skill that can help you actually jumpstart your battery, so that you don’t feel so stuck. Instead of talking about depression, we can talk about just feeling low, and how all of us in the last nine months had moments that we hit the wall. And it felt hard to keep pushing through. And then, what can you do about it?

Q:   And have you seen that reframing of calling it treatment, but rather calling it skill set, be effective? 

A:   During COVID, I've seen moments of light bulbs. So I gave presentations to our organizations with 900 to 2,000 individuals. And questions often came up, is like, “Wow, I hadn't thought about it that way.” And companies, in general, are starting to talk about, how do they help their employees? It makes a lot of sense.

You know, research shows us that depression, for example, even if you show up to work, costs about 30 days of loss of work a year, and about $2,000 per employee. And so I think this idea of getting ahead, and finding ways to use skills, is one the organizations are starting to think a lot more. At the individual level, I certainly have seen people feel like, “Oh, that’s easier to take than you telling me that I'm broken and need therapy.” 

Q:  In relation to sort of that stigma, is that something that you see to be more prevalent in these communities that you work with? Or is that just sort of a universal truth? 

A:   I think it’s different, in different communities. But I think it’s universal. I've worked with very high power CEOs who are terrified to get help for mental illness, because they felt like people are going to see them, they're broken. And then, I've worked with Latino or African-American individuals who really have a lot of stigma within their community. I grew up in Brazil. And if people had emotional trouble, they were crazy. And that’s still some of the narrative you hear. 

Q:   I just wonder where it comes from. It’s so interesting. 

A:   Historically, there's lots of reasons why we’d have stigma, right. We put individuals with emotional trauma in mental hospitals and lock them out. And so the idea that you had anything wrong with your brain meant, you know, the worst case scenario. And then I think, also, the news drives a lot of the narrative. If you look at the percentage of news before COVID that talked about mental illness, the majority of them has the underlying tone that individuals with mental illness are dangerous. 

The fact is, that is not the case. Data suggests that the majority of individuals with mental illness are not dangerous at all. But that underlying current[?] in the news, of like, wow, if you have a mental illness, then you're going to be violent, or you're going to be dangerous to society, that maintains a stigma. 

Q:   Sure. So thinking about COVID and people everywhere feeling that quarantine fatigue impact on their mental health, in some communities of course more so than others. What are a few things you would want listeners to keep in mind while thinking about, how best to support their own mental health during these times?

A:   The first thing I think most of us should remember is that it’s okay not to be okay. That we are facing a real threat. Not only COVID-19, but systemic racism, unemployment. And our brain is biologically wired to respond to threat, by activating the emotional part of our brain, our limbic system. And that accounts for, you're watching the news, your heart starts to pound. And you feel tense. And you feel anxious. That is normal. 

So up to a point, anxiety in that stress response is adaptive. The first piece is, if you're having moments like that, it’s okay not to be okay. Then, I’d really think about, if you're having those moments all the time, and you find yourself really hitting that wall, and having trouble getting started, and you find yourself sluggish, really thinking about some basic things you can do. 

Often, when we feel tired, we don’t want to do anything. But our bodies are like the batteries of our car. We need to actually drive our cars to recharge the batteries. And so the basic stuff of eating enough, exercising, just moving your body, getting good sleep, social support, really finding ways to charge up, is extremely important.

And then, also identifying, if it’s feeling too much and you need professional care, and really listening to the idea that your brain is an organ. So think about brain health. And allowing yourself to seek help early enough, really can decrease the amount of time that you're suffering. 

Q:   I've heard this statement before, that COVID-19 is this slow unfolding trauma for all of us. How do you anticipate trauma playing a role post-COVID-19?

A:   So if you look at other major events, September 11, but what we know about September 11 is that 10 years out, 10 to 12 percent of first responders still met criteria for post-traumatic stress disorder. So I'm only anchoring first responders for a second here. 

Today we have approximately 18 million first responders in the US. That means that once the pandemic is over, we might still have 10 years out, 1.8 million individuals needing care for post-traumatic stress disorder. And that’s not talking about the rest of us, who are still struggling. This is a real threat to our emotional health.

And so it really is important for us, collectively, to start thinking about how do we get ahead of this wave? It’s not only coming, but it’s coming really large. And how to really give people as much as we can, resilient skills, to help them have a shot of not developing emotional health problems. 

Q:   And from your perspective, how do we get ahead of it?

A:   I'm very biased on the answer to this. But I rely on cognitive behavioral therapy every day. And so the basics of understanding what I'm saying to myself, and how that’s affecting facing my own sort of discomfort and continue going. And then helping others. We know that being of service to others can actually decrease your own emotional health difficulties. 

Q:   And I think you had mentioned earlier, you touched on just a little bit of maybe some of the research that’s being done in this area. Can you talk a little bit more about what the research is that’s being done in CBT training. 

A:   So a lot of us are really trying to think about how to scale CBT to many communities. And so there are a lot of trials thinking about, can we do this through digital health? Can we do this through apps? Can we do this through training paraprofessionals? So for us, in particular, what we've done is launched a training institute that trains unlicensed professionals. And we've studied, what does that look like? How much do we need to train them, so they deliver fidelity?

And when they deliver it to individuals, what is the right dosage? So we’re asking questions more about dosage of CBT, instead of if CBT works. 

Q:   When thinking about working with some of the communities that you work with, is there great inclusion in a lot of the clinical trials and research going on?

A:   I don’t know the current data. But the last time I looked, the majority of clinical trials, randomized control trials had a very small number of diverse populations. And that standard, often some of it is the stigma. Some of it is that it tends to be done in the ivory tower. So if we do our studies at the main campus at Mass. General, the majority of individuals coming there are white.

And so we still don’t know exactly how to translate the trial communities. And I think that’s why our work focused on diverse communities. Because often, they don’t have access to the things we know would work. And so I'm not alone in this. A lot of my colleagues who care about communities and do work with communities, are really trying to design studies that really are inclusive to communities. But I still believe that’s the minority of studies out there. 

Q:   So, you know, I have to ask. Do you find it difficult to separate yourself from your work. 

A:   I love what I do, in every domain. So for me, the separation is not as hard. Because when I'm in, I'm in. And when I'm out, I'm out. And I really believe in boundaries, and being able to sort of walk away for a little bit. And we know that’s extremely important. We know that when you have breaks, you are able to make better decisions. 

We have studies that show us that the ability to make good decisions decrease as you're on all the time. So for me, that idea of sort of working hard and playing hard, and maybe part of being Latin, that’s something that I grew up with. 

I think family for me is the thing. I have a three year old at home who keeps me pretty grounded, in the present moment. Cooking, exercise, and being of service. Not through only my job, but moments like this. I'm so honored to be here with you in this podcast, sharing the idea with your listeners that, it’s okay not to be okay. And you can do something about it. And that kind of service to our community really recharges me. 

Q:  Thank you so much, Luana. So before I let you go, I just have my final set of questions that I love to ask every guest. What's the best advice you’ve ever gotten?

Q:   What rituals help you have a successful day?

A:   Breakfast with my family, dinner with my family, and some exercise. 

Q:   Great. If you weren't a doctor, what would you be?

A:   I think if I wasn’t a doctor, I’d be a motivational speaker. 

Q:   What advice would you give your younger self?

A:   Slow it down. Don’t have to do it all right now. 

Q:   What do you consider your super power to be?

A:   My genuine care for humanity and the person right in front of me. 

Q:   Luana, thank you so much for your time and for the opportunity to speak with you. It’s been such a pleasure.

A:   Thank you so much, Kelsie. Thank you for inviting me. And it was really an honor to be here.