By Land or by Sea, Increasing Access to Mental Health Care

Adler University students and faculty face language barriers and muddy trails to teach and learn alongside doctors in Panama

Fall 2019

Students in a Chicago Campus class traveled to Panama this summer to help pilot the delivery of mental health care to remote communities near San Cristóbal Island. The team of Adler University students and faculty from the Couple and Family Therapy Department flew 5 1/2 hours from Chicago to Panama City, then took another flight to Bocas del Toro, and finally a panga, or small boat, to San Cristóbal Island.

The group made the journey to spend two intensive weeks working alongside Floating Doctors, a nonprofit that deploys medical teams by boat, packhorse, or on foot to remote underserved areas. There they provide ongoing health services and community development projects for the Ngäbe-Bulgé in Panama, who live in remote poverty without access to basic medical care.

This experience was offered as an elective class and experience for students in the Couple and Family Therapy program: Marcela RamirezParis Thomas, Alejandra Franco,Travianna JonesBriana MorettiCarol Salas, and Catherine Schumacher.

The idea originated with Kristina S. Brown, Ph.D., LMFT, Chair of the Couple and Family Therapy Department. Growing up in the Los Angeles area, she was childhood friends with her younger brother’s best friend, Benjamin LaBrot, who later became the founder and CEO of Floating Doctors. Brown had an idea for a way Adler University students could help, learn from, and teach Floating Doctors clinicians.

“Missing from their services was attention to the mental health issues that are prevalent, especially presented with the medical conditions that Floating Doctors see in their patients,” Brown said, referring to high rates of pregnancy in minors, infant mortality, diabetes, domestic partner violence, and substance use. She thought students could gain valuable experience by working with Floating Doctors while also sharing knowledge for how the organization could simultaneously deliver health care and mental health care in the field.

LaBrot agreed that there was a need for a mental health component to be added to the Floating Doctors programming, noting that many of its patients could benefit from care. However, administering mental health care while also triaging medical care is easier said than done, given cultural differences and a shortage of time. “I’m acutely aware of how behind the door mental health is everywhere in the world, including here,” LaBrot said. “Mental health is often incredibly labor intensive, for even a small return. If it’s underserved here in the United States, imagine other parts of the world.

On the ground (and water)

Brown and the students joined fellow Chicago student Megan Chapman, who began a year-long doctoral internship as part of her Ph.D. in Couple and Family Therapy program in January 2019 with Floating Doctors with the goal of researching and developing a mental health program for the organization. She was the lead on the project, “Assessing Mental Health Needs in the Indigenous Ngäbe-Bulgé Comarca in Bocas del Toro, Panama.

The students were warned ahead of time not to expect a beach vacation. They would sleep in hammocks, walk in the mud, take baby wipe baths, and avoid swimming in the water, because that’s where the toilets flushed.

After the group arrived, they got to work assisting Floating Doctors physicians with their clinics, getting patients’ vitals. They also spent a lot of time building relationships with the people in the community and playing with local children while the clinics were open. Thomas made a close bond with a 7-year-old girl at one of the clinics, despite Thomas not speaking Spanish and the girl not speaking English; they played tag together and held hands.

The group ended up facilitating about a half dozen mental health consults, including for patients seen for HIV, a pregnant woman with anxiety, and a home visit of an elderly woman with spinal cancer. They also gave clinical presentations both weeks to the staff, which included doctors, dentists, veterinarians, students in these disciplines, and Floating Doctors’ volunteer staff. Brown said there was one instance when the doctors went into a home and encountered challenges working with a family.

“We went in and talked to the family and listened to their stories and problem solved,” Brown said. “Then the family received the doctors in a much more open and willing way. The doctors noticed and said, ‘What did you do?’ We told them that we asked questions and we listened. We role modeled that for the doctors about how they can be different in their interactions, and the benefits of that.”

The students were realistic about what they could do with their brief time with each patient—only two of the patients on the consults volunteered a known mental health problem. “We really had to focus on solution-based practices,” Ramirez said. “We asked what patients would like to get out of them coming to meet with us and we worked on that. We focused on their strengths and building confidence, giving compliments.”

Affecting positive change

LaBrot is considering having Floating Doctors provide training on active listening to community members. “Even when I do it, and I’m about as opposite culturally from them as I possibly could be, patients respond with a great hunger for some kind of empathetic ear that can help them disentangle their problems,” he said. “Longitudinally, you might take some of the people who show really good results, give them listening skills, and then more screening, to involve them in mental health surveillance.”

Brown, who is joining the Floating Doctors board, said she, Chapman, and the other students are writing about their experiences with the goal of publication in peer-reviewed journals and presentations at conferences. “It’s about our experiences, the possibilities of adding mental health consultations, and how they can incorporate some of the things we taught into their work,” she said. As part of her doctoral internship, Chapman is writing a feedback report for Floating Doctors about her research and her experiences. They also want to include insights on “What are some of the social justice issues at stake and how do we stay away from being ‘volun-tourists?’”

Chapman cautions that there will be communities who won’t welcome the offer of mental health services. “People will say, ‘We don’t really have any issues in our community.’ They might not welcome it, and the community has to accept the offer. So how can we still use our connections and resources to help communities to empower themselves?”

Thomas agrees. “When I came back, my friends were like, ‘Oh, the Panamanians were living off the grid. They must not have running water,’ and assumed they wanted it.” But the people she worked with, she said, were resourceful and happy. “Just because their living situation is different from ours doesn’t mean they’re less capable.”

A valuable opportunity for Adler University students

Brown said the experience was a confidence builder for the students. For Marcela Ramirez, the trip was her first opportunity to practice her clinical skills in Spanish. “I’m grateful for the opportunity to rip that Band-Aid off,” she said of the experience to test her skills. “I want to keep practicing my clinical Spanish to be the best bilingual therapist I can possibly be.”

Thomas has plans to do her practicum with the Catholic Charities program Inspiring Hope, which provides free therapy and case management services to children and adults in Chicago’s Austin neighborhood. Thomas will work with patients who have been abused or neglected. “I want to use my skills to help people who don’t have access to therapy in the way that other people might,” Thomas said. “It’s really relevant to my Panama experience.”

Both LaBrot and Brown are optimistic about future Adler University groups returning to Panama. “Each of their experiences will make them a better clinician,” Brown said. “They learned things like the ability to tolerate stressful situations, how to work collaboratively with people in different disciplines, with a different language. They’ll be able to ask better questions and be more thoughtful about the different intersections of the life of their clients with their presenting mental health problems.”