Mae Lynn Reyes-Rodríguez

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Rachel Burns: Hello. This is Rachel Burns, interviewing Dr. Mae Lynn Reyes. We are—it is April 18, 2012. We are in the Neuroscience Hospital at UNC Chapel Hill. First of all, thank you so much for meeting with me. I really appreciate you taking the time out of your busy schedule. I'd love to hear a brief history about you and how you ended up at UNC.
Mae Reyes: Okay, so I am from Puerto Rico. I came here in 2008, working in a Minority's Appointment to adapt a couple-based treatment for Anorexia Nervosa patients in Latina population. So that was with the support NIMH and then, I submit a K Award, which is a research project in which you develop some kind of expertise. Also, you have your research project. So the idea with this project is to continue adapting it to eating disorder Latinos in U.S. because this is something I did in Puerto Rico. So NIMH is very interested in continue developing eating disorder treatment for Latinos in U.S.
RB: How did you initial start this work in Puerto Rico?
MR: Well, basically was when I took a course about eating disorder research and I realize that we didn't have any kind of information about eating disorder in Puerto Rico. And for me, it was shocking because we are part of the U.S. and we have a many prevalence—high prevalence of eating disorder in U.S. For me, it was, why we don't have any kind of information about prevalence? We didn't have any kind of with eating disorders measures in Spanish for Puerto Rico. So in that moment, I decided to start working with eating disorders in my Master thesis and continue in the Doctorate dissertation and continue doing it Post-Doc with NIMH in Puerto Rico.
RB: Through your work in Puerto Rico, were people very receptive to your work or was it kind of this new discovery in mental health.
MR: At the beginning, I think that many of my colleagues was asking me why you are working with eating disorders. Maybe you will have any kind of problem trying to reach the sample, this kind of comments. And I say I need to search first and see what happens. At the beginning, was very hard because mostly trying to educate the people about what is an eating disorder. And then, and not only educate the general public but also educating the mental health practitioner, health practitioner in general. So then, when I was talking about eating disorder they realized that there is something happening in Puerto Rico about eating disorders.
RB: How did you find your sample size?
MR: At the beginning, we started doing prevalence study using more college-sample, so general college sample and exploring the prevalence. What I found in that moment was that the prevalence was similar to the prevalence in U.S. Then, when I was working doing evaluation of eating disorder measures, was easy to find Bulimia Nervosa patients and then Anorexia Nervosa patients. So that was very hard trying to find people with Anorexia. But yeah, I think that was—took time to the general public to know more about, this is an eating disorder. I am vomiting. Yeah, I possible have an eating disorder. Was an education process and now this is a big issue in Puerto Rico. And at some moment, I developed an eating disorder clinic as an outpatient project at the University and I was trying to help a small ( ). And it's an issue now in Puerto Rico. This is something that happened here when I came in 2008 and I started working as a volunteer at a mental health clinic. I asked the therapist around eating disorder and they say, we never see any Latino with eating disorder. And for me, it was what? Maybe I am in the wrong place. When I started educating them about what is an eating disorder, how to assess an eating disorder, now they are seeing more eating disorder patients in Latino populations.
RB: So I know that you said that it is now becoming a problem in the past couple of years in Puerto Rico. Was it a problem before or was it just?
MR: I think there was always was a problem and the only issue was that nobody talk about that. In some cases, if the family had the resources they move to U.S. to receive treatment, but now we are seeing more people with less resources. They are seeking for other kind of help in Puerto Rico because they can't move to U.S. It’s very expensive, the translation, and also the treatment process is very expensive to be in an eating disorder it’s very, very expensive.
RB: And is there any education about eating disorders in secondary school in Puerto Rico?
MR: In Puerto Rico? To be honest, no. No. What I was trying to do in some moment was to develop some kind of congress. I brought many experts from Latin America and U.S., trying to educate as much as possible mental health practitioner, people from schools, and trying to help them: how to help these students, how to help their patients, how to refer the patient, how to treat the patient. So this is what I did. Basically, we organized two congress. The idea was to educate and train the physicians and mental health practitioners in eating disorders.
RB: In so, what made you originally come to the United States?
MR: Why? I think that at some point was looking for a more specialized training. I was part of NIMH Fellowship. Usually when you enter it as a researcher, you have a pathway to follow. At some point, it was very hard for me to continue receiving funding in Puerto Rico because I was the only expert in eating disorder. During the process of submitting grants, they were asking me to have more training, high-level training, in eating disorder. So at some point, we had this opportunity to come to North Carolina, specifically here, with Dr. Bulik. We talked with NIMH and they encouraged me to submit a Minority Supplement and to continue doing my work but with Latinos in U.S. because we have many researchers for eating disorders in the U.S., which is other kind of problem. Puerto Rico is part of the U.S. so we don't have to work with the immigration process. Most of the people in Puerto Rico have health insurance. We have more—for example University of Puerto Rico provides treatment for free, psychological treatment. So there is many other kind of resources in Puerto Rico that we don't have here, the Latino population. Maybe they don't have any documents; they don't have health insurance. There is a barrier of the language. There is many other kind of issues. NIMH I think is very interested to work with this population.
RB: Could you tell me a little about your project here in North Carolina?
MR: As I mentioned before, when I came here was with Minority Supplement Support and was part of a big project of Dr. Bulik developing treatment for partner with Anorexia Nervosa, so it was more a couple-based treatment for Anorexia in adult population. This was a very innovative project because most of the time the research on Anorexia is focused with adolescent. Including the family is more ( ) in children or adolescent, not necessarily in adult populations. It was innovative trying to get into the treatment in adult population, the partner of the patient. In that moment, my goal was trying to adapt that treatment for Latino population; for me also very consistent with my work in Puerto Rico. Although the treatment that we have in U.S., which is the cognitive behavior therapy for Bulimia, is feasible with Latino population, something that I found during my process of adapting the treatment is that the family is a key component in Latino population. No matter the age of the patient. So for me, it was very consistent with my previous work. So here, at the beginning, I was doing more qualitative research, exploring with the Latino population how to treat eating disorder. How do you feel more comfortable? What about if I include a family member in the treatment? What do you need to receive the treatment? Where do you need to have available the treatment? So that was my previous work during the first two years. When I submit the K award and was approved, the intention of the project was to compare cognitive behavior therapy, which is the best treatment so far for Bulimia, and compare with CBT+family enhancement, to include one family member. It could be a family member or it could be significant other or another friends because we know that Latino population here. Sometimes the family is very disintegrated due to the immigration process. So the intention is to have this close connection with some relative or significant other to support the patient doing the treatment process. So at the beginning, I did qualitative analysis, doing interviews with patients, Latino patients with eating disorders. Also, interviewing mental health practitioners and see how to part together a treatment model for Latinos. So the idea is to develop a community-based approach because Latino feel more comfortable going to community center, rather than to a university or hospital where they have to deal with the language and many other kind of issues. They are very suspicious also about this kind of new immigrant laws. They are very scared about all of the immigrant process. So they feel more comfortable in any kind of community center: that they feel safe, that they can talk, that no matter if they have document or no. So this is why I in this model that I am developing I have the collaboration with El Futuro, which is the mental health clinic for Latinos. People trust a lot in them, so I decided to train the therapists from El Futuro and provide this treatment for the therapists from the… [INTERRUPTION] ... So the idea is to create this model in which the Latino feel comfortable to this clinic, receive treatment from therapists who are bilingual and very culturally sensitive. Also, trying to use the services that are already in place in the Latino community because most of them don't have any health insurance. My plan is when this grant is gone this clinic can continue providing services for eating disorder treatment. They are receiving the training for eating disorders. They are receiving treatment—training for evidence-based treatment, which is cognitive behavior therapy. They can continue providing this treatment when we finish the project.
RB: Wow, that's great. What phase are you in currently in the research?
MR: We are in phase three. That means that we finished the training with the therapists from El Futuro. Now, each of them have one case for practice the treatment intervention, but also to refine all of the treatment process to see what doesn't work and trying to refine the treatment process. Now we are in this phase. We already enroll three patients with eating disorders. After they finish with this cases, we are ready to start phase four, which is recruiting 40 patients and 20 would be randomized to CBT and 20 will be randomized to CBT+family enhancement. We will follow this two groups through 25 sessions and we have also three month follow up. And see which is the different between having a family member including in the treatment or not having a family member including in the treatment. Although, I think that maybe the outcome in terms of the eating disorder simply will be the same because CBT is a good treatment. But I suspect that maybe the person will be in the CBT+family enhancement would be retaining to the treatment—will complete all of the treatment phase because have someone who can support them through the process. And sometimes, we have family member who don't know what is an eating disorder and they start bullying their relative, using names and doing some kind of comment that is not helpful for them in the treatment process. So, we are guessing that we can work with that piece that is very important for the patient to continue their treatment.
RB: With the family member involved in the treatment, does that mean that they are coming to the sessions or just being that supportive member?
MR: Yeah, we have 25 sessions. From these 25, six will be the border for the family piece component and that mean that if the patient has a husband or partner, they can receive a couple-based therapy. Not necessary working with the eating disorder piece, but sometime it is problem with the communications. Sometimes its problem with sharing thoughts and feelings or sometimes it's parenting skills problem that creates sometimes a stressful situation in their relationship and that reflect in the eating disorder piece. So the idea is to try to identify what is the issues that is affecting the patients in the context of the relationship and trying to help them work with that.
RB: Has it been difficult to find the sample size?
MR: Well, now, to be honest, I was surprised that I found my four patients for the phase three and I didn't put any kind of announcement or advertising about my project, so was more refer from different clinic. I think that is a process that now when the people knows about this project and knows that we having eating disorder program they are referring patients to us. It's an education process that maybe my first two years here was very helpful to other people recognize that okay there is someone working with Latino population in eating disorder. So now I think that it is more easy for me to find the sample size.
RB: When will phase four begin?
MR: Maybe between August, September, will depend when the therapists finish, maybe 35% of session with their current patients and I feel like they are ready to have more patients and also when we evaluate the process and trying to refine any of the procedures of the treatment protocol.
RB: Did the physicians working at El Futuro, during their training and gaining all of this knowledge, did they ever realize that they hadn't thought that they had seen patients previously who had eating disorders?
MR: Yeah. They realized that maybe they had already had some patients with some kind of eating disorder, not necessary the full diagnostic criteria but some of the symptoms. But they were feared to ask because if you feel like you're not competency to assess eating disorder or to treat eating disorder, sometime you just decided not to ask. I think that this is something that was good during this process because they are feeling more comfortable to assess eating disorder with this population.
RB: Is El Futuro one of the only—I know your clinic that you are partnered up with—but are there other mental health bilingual clinics in the area?
MR: I think that basically is the only clinic. We, well I say we because I work with them as a volunteer also and I feel like I am part of El Futuro, but they receive refers from people from Raleigh, from Burlington. So, I'm guessing that is one of the few clinic; maybe we have other mental health therapists who are bilingual, but the sense of a clinic and this big concept, I think it is the only in the area.
RB: How is it insurance free? How is the paying for?
MR: Well because it is a research study. Well, you're talking about the....
RB: Both.
MR: Okay. For in terms of the project, because it is a research, we have the budget to pay for the treatment. In terms of the general policy of El Futuro, they can receive people with health insurance but also they have sliding scale for people with no health insurance. This is why it is so affordable for patients, Latino patients, with no health insurance. It's a very low pay, something that they can pay.
RB: I know you went to la Feria de Salud? Was that they first one you participated in?
MR: No, it's my second year—my second year.
RB: How do you see that your role at the Feria, the importance of that role and the importance of having a Feria de Salud in the community?
MR: I think that working with Latino population is very important to develop a trust. They need to recognize your face, and recognize your face with your project so that they can feel safe. That they know who are you and that you are a safe person and that I can call you and that I can talk to you. I think that this is a process. So for me, it is very important that Latino population can recognize that, okay who I am, that I am here trying to help you and relate my name with my project. In the future, when I was doing the process of recruitment, they can associate the name of the project with this person who was seen in the Fair. This is one of the elements. Second, I think that it is also the networking that you are doing with other people who are working with Latino population. Sometimes, you don't know what is going with I don't know other projects. So, it's good to know other people, so they now know that there is a project. We are providing treatment for eating disorders and it's free and it's in Spanish or English because the therapists are bilingual. So this is an education process that is very important when you have project.
RB: I noticed on your table that you also had all of the plastic foods. Do you also push for nutrition? What was the purpose of that?
MR: As part of the eating disorder treatment, we include three sessions with dietitians. I think that also not only the intention is to provide the eating disorder treatment per se but also it is to educate the people how to eat healthy. So this is why I think this is another road that we can help in this population. The dietitian role is very important to help the patients to adapt. Maybe when they come here, it's a shock trying to adapt with a new food, trying to you know, people who are in their country usually Latino tend to eat food in their house and prepare they food. When they move to U.S., there is like a five year of safe process and after that, after five year, you can see that the health of the Latino get worst because they are adapting the eating behaviors or patterns of the Caucasian populations—eating a lot of fast food. I heard from many Latina that they are struggling about what to eat. Also, we have parents that they are trying to keep with their traditional custom and then we have their kids. They want to eat fast food and it's a struggle for the families. I think also it is very important to teach them how to eat healthy and the challenge is that sometimes health food is very expensive.
RB: For the causes of eating disorder or just mental health issues as a volunteer at El Futuro, for a lot of these Latinos, what is the source of a lot of these issues? Is it stemming form immigrant and their experience from immigration?
MR: I think causes of eating disorder is very complex. I can't say there isn't one cause. I think that is a combination of many factors. There is maybe a biological component, or genetic component. There is family issues; there is some kind of vulnerability in terms of the personality characteristic and also, the environment, the pressure to be thin. There is many, many factors that interact in so moment that puts some people at risk to develop eating disorders. Something that we are seeing in this population is a lot of trauma, which is also common in eating disorder patients. So we are seeing this kind of vulnerability, depression, anxiety. Trauma is something that for me would be very interesting to follow up with Latino with eating disorders because seeing a lot of trauma.
RB: Trauma stemming from...
MR: Trauma from childhood, sexual abuse, also the process to move from their country to here sometime is very traumatic. Now working with this population I realize why they are moving from their countries. Sometimes their situation there is so awful and they just escape from that. This is maybe the reason why they decided to move with no document, with no domain of the language, with no resources, but they are desperate looking for a better life. So we are seeing that in eating disorder patients.
RB: Coming from Puerto Rico and working with the Latino population here, just even with a lot of the America culture, I know growing up there was a lot of exposure to eating disorders, has it been very interesting to see the general education? Is there a general education about eating disorders among Latinos here? Or not in comparison to Puerto Rico?
MR: I think that there is a misinterpretation or misconception that eating disorders doesn't happen in Latino population. There still is this misperception and we need to continue working that this is happening with Latinos. We need to talk about that and we need to address this issue with Latinos. I think that we are in process to educate. You know, this is a process; take time. But I hopefully think that this project is one of the first steps to create this awareness about eating disorders in Latinas.
RB: What's the next step after this project you hope for yourself?
MR: Next step. Yeah, I have this concern with the adolescent population. We know that this is a very at risk population in which started the eating disorder. Many people are talking to me about, we need some kind of project for adolescence because my project is focus on adults population so they need to have 18 years or older to be in the project. I think that we need to pay attention also to adolescent population. So maybe could be also trying to work with adolescent population and maybe could be trying to expand the project to other state: trying to compare Latinos in different states to see it is the same, it is different. Here we have a lot of –most of the Latino here are from México. What happen if you are working in Boston? In which the Latino population is more mixed with Puerto Rican, people from Republican Dominican. So will be interesting to see how that work from many other Latino subgroups.
RB: Interesting. Expanding from this, I know you are Puerto Rican, but you are also an American citizen. Has it been—this unique position you're in affected at your perspective on immigration as an American and as a Latina? And their access to health services as well?
MR: When I was in Puerto Rico, I really thought that what I was doing was very—that I was able to generalize that treatment for Latinos in U.S. Now that have this experience with Latinos in U.S. I realized that is totally different populations. It's very complex population that we are dealing with, many other issues that we don't have to deal with that in Puerto Rico. I create this conscious about, yes we have many, many elements that are very similar, but also we need to pay attention to the nuances, differences between Latino subgroup. I am learning from this process. I am learning to know more people other Latino culture—how to be sensitive to these differences, how to communicate with them because although we speak Spanish, this Spanish is very different between different Latino countries. So this is something that is hard for me trying to be sure that we are having a good communication and they can understand me. I can understand them. Thinking in a therapeutic process, that is very important to have a clear communication, be very sensitive to these immigration processes. At some moment for me was like crazy. Why this people are moving from their country and being in this awful situation here? Now I can understand that they are escaping from a very hard situation in there country. This is like a disparate solution for them. I think that now I am more sensitive to this kind of issues. So this is the difference that I am working here, trying to understand and trying to incorporate in the treatment model.
RB: Has that been difficult having to shift the way you have always dealt with Spanish speakers?
MR: Yes. Yes. In Puerto Rico, I was working more with college population, very high educated. It was very easy to communicate with them, very easy to use cognitive behavior therapy. Here, we some changes. You have to be very concrete. Most of the Latino, they have low level of education so you have to be very sensitive to that and trying to create a process in which use plain words and trying to you know be very concrete with them. What else? Yeah, I think that was... and I also think that was very helpful for me to leave the immigration process. Because although we are part of the US, we are Latino. Puerto Rican, we are very proud to be Puerto Rican. For me it was a shock to move to here and switch the language, switch all of the cultural differences. We are very—we promote a lot of close relationships and the Caucasian use more individualist process. For me, it was a shocking process. I think that although I never experienced this stressful situation of having no documents or having no health insurance. I have some stress due to the immigration process by myself, so I think that some part of the process was very parallel from me. I can understand some of their process, but I know for them, it's like you know it's harder because they're dealing with many other issues. But I think that was helpful to live in some point this stress of the immigration process.
RB: Wow. Have you be able to notice any differences in just health care services here compared to in Puerto Rico? And the services that are available to Latinos, undocumented and documented?
MR: The services are more expensive and it's a challenge. Second, obviously the language. It's sad to hear Latinos talk about how hard is to try and communicate with a health practitioners having an interpreter in the room and feel very uncomfortable talking with a stranger about their issues and then having this interpreter talk with the physicians. I think that this piece is so different with my previous experience in Puerto Rico. I think that we know we need more services, bilingual services, available from Latinos. I think this is the big issue and also the lack of health insurance is an issue that is a political issue that we need immigration reform. This is another issue. But in terms from my perspective, we need more bilingual decisions, bilingual therapies, and access to local treatment.
RB: Has it been interesting to see the amount of resources that are available in Chapel Hill compared to a more rural place in North Carolina? Have you ever thought about the Latinos living in rural North Carolina who are experiencing an eating disorder? How could this expand even more?
MR: Now, because we are working with El Futuro. El Futuro has clinic in Siler City, Durham, and Carrboro. So we are trying to provide services around that area. Also, UNC has a REX clinic in Raleigh as part of the psychiatric department. I will say that are able to treat a patient in Raleigh because. To work with the treatment here and sometimes we need to provide the services very close to the residence of the patient because sometimes they have a problem with transportation, childcare. In that moment, I decided to move to Raleigh and provide the service in Raleigh because more thinking in the treatment adherence, she can continue receiving the treatment because it is very close to her residence. Eventually, maybe, I know that El Futuro is thinking to other kind of clinic in Alamance County that maybe could be another place. But yes. For now, because we are trying to develop this model, I think that some area can help us to develop this model and then eventually try to expand to other places.
RB: Okay, well thank you so much.
MR: You're welcome.
RB: I really appreciate you meeting with me.