Clinical psychologist Dr. Ricardo Muñoz grew up in one of the latino strongholds of the U.S.: The Mission District in San Francisco. Not unlike a very popular Latino icon: Carlos Santana.
Both Dr. Muñoz and Santana’s fathers immigrated to San Francisco in 1960. Dr. Muñoz grew up on 14th street, Santana grew up on 14th street. Dr. Muñoz went to Mission Dolores Grammar School, Santana went to Mission High School which are only a couple blocks away from each other.
You could call Dr. Muñoz the Santana of health.
Santana was a pioneer of music in the 1960s and Dr. Muñoz is a pioneer in psychology. He found a new way to reach out to his patients: through the web. But growing up, Dr. Muñoz did not want to be a rock star psychologist.
“When I was a child, my nickname was ‘el cura’ or the priest. I actually did want to become a priest. I almost became a priest when I was 10, 13, and 18. By the time I got to be 18, I had a lot of doubts about the Catholic dogma. So I didn’t really think I could become a priest because I couldn’t teach people something I wasn’t sure about myself.”
In college, Dr. Muñoz took his first introductory course in psychology.
“I fell in love with it because psychology is dedicated to doing what I wanted to do as a priest, which was to help people lead good lives.”
In 1985 Dr. Muñoz began a clinic that offered therapy for things like depression and smoking cessation – both in English and in Spanish. But it was very hard to get Spanish speaking smokers to come. One possible reason is that many Latinos have more than one job,
“Or they are taking care of their kids and don’t have anyone else who can take care of them,” Dr. Muñoz suggests.
There was another barrier – a cultural one. Many Latinos feel very uncomfortable going to the psychologist.
“No estoy loco, right? I’m not crazy, right?” Dr. Muñoz says is a common phrase Latinos who don’t want to go to the psychologist imply.
So Dr. Muñoz decided – if people weren’t going to come to him – he would go to them. Or at least send them material through the mail.
“And we did the study and we found that in fact sending a smoking cessation guide in spanish helped about 10% people quit smoking,” says Dr. Muñoz.
Eventually they were getting quit rates as good or even a bit better than the nicotine patch.
“That was amazing,” Dr. Muñoz says.
But there was a catch: the price.
“It cost to create these brochures. Very nicely printed color brochures, ”
This limited how many people they could reach. So Dr. Muñoz got to thinking,
“This is 1997. And the web had begun about six years before. And… it occurred to me that if we could do this via the web we could reach a lot more people.”
Thus stop smoking.ucsf.edu was born. It’s a free smoking cessation site that can be found in english and in spanish.
“First thinking that we were going to help people in the San Francisco bay area but then people started coming from throughout California, throughout the country, and throughout the world,” says Muñoz, “It was just so surprising that through the web we could reach so many people. Now of course this is not surprising at all but back in the 1990’s it was.”
Dr. Muñoz kept putting materials online.
“We set up a website not just for the smoking stuff but other things. And we put the manuals we had been developing.”
A few years ago he went to a conference in Lima, Peru.
“Some psychologist came up to me and said Dr. Muñoz would you mind coming with us? We wanna show you something.”
They took him to what’s called un pueblo joven.
“In english it would mean like a young town right. I guess it could be called a shantytown. It’s a very poor community.“
In the town they had a health center that had been established by Jesuits.
“And in that health center there was one room that was dedicated to mental health and in that room they were running a depression group using the manuals we had developed here at San Francisco general hospital. And I can tell you that’s one of the highest points I’ve had.”
“With technology what you can do is you can reach people even in places where there are no services for them. Let’s say you’re a smoker, spanish speaking smoker in Wyoming or someplace where there’s not a lot of Latinos and certainly no Latino psychologists or smoking cessation counselors. You could get on the internet and reach our spanish speaking cessation site anywhere.”
Some people doubted that online mental health treatment could be effective for a demographic like Latinos.
“Back in the 1990s when I began doing this work there was the big issue of the digital divide. And sometimes we would get criticized by other Latinos that here we were doing stuff with technology and that was not really appropriate.”
But Dr. Muñoz takes issue with this idea. There’s a book called Mountains Beyond Mountains by Tracy Kidder that Dr. Muñoz really likes.
The book is about the true story of a doctor named Paul Farmer who became obsessed with bringing healthcare to Haiti. There’s a part in the book where farmer and a local priest are talking about technology. Dr. Muñoz likes to quote from it:
“But Farmer asks, ‘Are they appropriate technology?’ He had picked up the term at Harvard. What does the priest say? ‘Do you know what appropriate technology means? It means good things for rich people and shit for the poor.’”
Dr. Muñoz can relate to the priest.
“That was the kind of response I was getting early on.“
He never saw technology as an obstacle in and of itself.
“And now i’m finding out that latinos are actually way ahead of other ethnic groups in the us in terms of smart phones.”
When Dr. Muñoz was developing his smoking cessation site this data about Latinos and their connection to their phones wasn’t available.
But fast forward 20 years, and Dr. Adrian Aguilera – who actually was a mentee of Dr. Muñoz, is well aware that a good way to reach his patients is through their phone – Specifically through text.
“On a daily basis, people get a mood question: ‘What is your mood right now on a scale from 1 to 9? Respond with a number and what you’re doing or thinking right now.”
Dr. Aguilera focuses on depression. Ge reaches out to his patients throughout the week using an automated text messaging system.
It sends text like:
-“Were you able to notice your negative, unhelpful thoughts this week?”
-“Can you think of any thoughts that improved your mood today?”
-“Take time to focus on the present, the past is left behind and the future is for later.”
It helps patients to do something psychologists have nicknamed “homework.”
“When people show up to the treatment, they end up not completing the homework. Maybe because we we are calling it homework,” says Dr. Aguilera.
Homework for people in depression treatment means keeping track of how you’re feeling.
Wo figuring out how you feel on a scale of 1 -9 and noticing what sorts of behaviors are triggering what feelings.
So are you happier when you go for a run? Are you sad when you’re about to go to sleep?
“So what we do is instead of asking people to fill out a piece of paper with their mood throughout the week and maybe how many healthy activities they do each day, we’re doing this via text messaging.”
Dr. Aguilera then charts this information and shows it to his patients during session.
“With that data, we can start identifying some low points, some high points, make those teaching moments.”
These texts also serve another purpose: to offer motivation and support to his patients.
“They’re mostly made to help people think about these issues that we’re talking about. I often talk about how we’re in the therapy sessions for an hour and a half every week, but there are many more hours throughout the week. the goal is to continue practicing those skills throughout the week.”
Dr. Aguilera and dr. munoz actually found that spanish speakers and english speakers who received the texts felt differently about them.
Spanish speakers said the texts made them feel supported while english speakers said the texts made them more introspective.
In general, more healthcare providers are embracing technology.
“I think on the front lines, there has been a move towards incorporating technology in a lot of interventions.”
Dr. Aguilera says that there’s is a movement away from self-reporting – things like entering what you had for lunch in a diet app – towards something called “passive sensing.” There’s an app being developed at Northwestern University called ‘mobilize.’
“It’s a combination of active and passive sensing. It would ask you what your mood was, but it would detect where you were geographically. It would predict when you might be feeling down or up based on where you were.”
Some people are spooked by the amount of personal data that can be collected through apps like these.
“It’s scary and exciting. I realize that. For those of us in the field, it’s mostly exciting. The way I see it is the Googles and Facebooks of the world are already doing this to try to sell us things. I see our work as trying to take this data, but try to help people to be more healthy.”
Dr. Aguilera worries about something else. He sees the development of fancy health tech stuff like Fitbit and Nike Fuel,
“And that’s great, but those types of technology are in the hands of those that are most well off. In order for these interventions to truly reduce costs and have a wide public health impact, they need to be targeted towards lower income backgrounds and people that have the highest burden of health disease and health problems.”
It’s not that latinos can’t handle this expensive technology, it’s that they sometimes can’t afford it. This question of access is what inspired both Dr. Aguilera and Dr. Muñoz to get involved with technology to begin with.
All of Dr. Muñoz’s online programs and materials are still online and completely free.
And the Santana of health has no plans to slow down….
“I think what drives me is that I realize that even through the web we’re only reaching a small portion of people. Every time I see a patient that hour I spend with a patient is gone forever. It’s consumable, it’s used up. But through the internet, the sites I create can be used again and again and again by people all over the world anytime it’s convenient for them, anywhere. There should be a therapist, a physician, a health care provider for every person in the world who needs it. But until we do that, I think we need to develop other kinds of interventions like digital interventions, web apps and internet sites.”