Studying Perinatal Well-being with Dr. Cindy H. Liu (offered in English)

This month's MONA podcast guest is Dr. Cindy H. Liu, who examines the critical experiences of adolescents and college students to understand complex developmental and cultural experiences. Dr. Liu shares findings from a COVID-19-related study highlighting how unexpected residential moves affected college students’ mental health. We also hear about her current fascinating study that examines the intersection between identity, discrimination, and mental health among Chinese American adolescents. This line of research can help pave the way for understanding the perinatal experiences of racially and ethnically diverse individuals.

 
Guest biograph:

Cindy H. Liu, Ph.D., is a licensed clinical psychologist, the Director of the Developmental Risk and Cultural Resilience Program, and an Assistant Professor at Harvard Medical School within the Departments of Pediatrics and Psychiatry. She also serves as the Director of the NICU Parent Mental Health Program at Brigham and Women’s Hospital. Her program of research focuses on the measurement and mechanisms of stress and its impact on mental health across key points within the developmental lifespan and implications for women, children, and underrepresented populations. She is currently a principal investigator for several studies, including the Perinatal Experiences and COVID-19 Effects (PEACE) Study, a longitudinal study that seeks to understand the experiences of pregnant and postpartum women throughout the pandemic and the COVID-19 Adult Resilience Experiences Study (CARES) which focuses on mental health and well-being in diverse young adults. She is also the principal investigator of the BOBA Project (www.thebobaproject.com), a study funded by three NIH grants that examine how Chinese American teens learn about the Asian identity within their family, their peers, and social media. Her work has been funded by foundations and philanthropy and featured in various outlets, including the New York Times, USA Today, and CBS News. In 2023, she received Clarivate’s Highly Cited designation, awarded to scientists with the top 1% of citations. She received her degree in Clinical Psychology from the University of Oregon and completed her clinical internship at McLean Hospital and a postdoctoral fellowship at Boston Children's Hospital.

Transcript

Dr. Lara-Cinisomo [00:00:04] Welcome to Studying Perinatal Well-being. The podcast of the Marcé of North America. This bilingual monthly podcast will allow new and experienced researchers, practitioners, students, and community members to hear about the latest research and community actions on perinatal well-being. I am Dr. Sandra Luz Lara-Cinisomo, your host. Today's guest is Dr. Cindy Liu, a licensed clinical psychologist. She received her degree in clinical psychology from the University of Oregon and completed her clinical internship at McLean Hospital and Postdoctoral Fellowship at Boston Children's Hospital. She is the director of a Developmental Risk and Cultural Resilience Program and an assistant professor at Harvard Medical School within the Department of Pediatrics and Psychiatry. She also serves as the Director of the NICU New Parent Mental Health program at Brigham and Women's Hospital. Her program of research focuses on the measurement and mechanisms of stress and its impact on mental health across key points within the developmental lifespan and implications for women, children, and underrepresented populations. She is currently a principal investigator for several studies, including the perinatal experiences and COVID-19 effects, also known as the PIECE Study. A longitudinal study that seeks to understand the experiences of pregnant and postpartum women throughout the pandemic. She's also principal investigator for the COVID-19 Adult Resilience Experiences Study, also known as CARES, which focuses on mental health and well-being of diverse young adults. Additionally, she is the principal investigator for the Boba Project, which will learn about today, a study funded by three NIH grants that examines how Chinese American teens learn about the Asian identity within their family, their peers, and social media. Her work has been funded by foundations and philanthropy and featured in various outlets, including The New York Times, USA Today and CBS News. Welcome, Dr. Liu. Thank you for meeting with us today to learn about your critical research. Let's begin by learning a little bit about you. How did you become interested in perinatal mental health? 

Dr. Liu [00:02:16] That's a wonderful question. So, one of the things that I found myself fascinated very early on in my life is, understanding babies. And when I was ten years old, my mom and dad had another baby. So, I became a big sister. And when you're ten years old in the fourth grade, you are old enough to really sort of appreciate and start to, you know, identify sort of the fascinating things about life and to be able to make observations. And so, I observed and appreciated my little baby sister. But, you know, I also appreciate the fact that when mom had given birth, there was a new person in our house and all the caregiving responsibilities that now we're taking place, so vastly different than when I was just an only child and when my parents had to take care of me as a fourth grader. So, I was really fascinated more with babies and not necessarily so much about perinatal mental health. It was actually over time in which I, as I pursued my interest in infancy and in childhood and sort of development over time or developmental psychology, that I began to really appreciate the sort of, intergenerational aspects to development and the importance of parents in, when we think about childhood development. And so, you know, as researchers, we start off with one idea and then we add to it. And so, I began to add to my interest, parenting. And then also it was sensible to start thinking about the mindset of the parents and what they bring and also how they feel. And so that's how I became interested in perinatal mental health. 

Dr. Lara-Cinisomo [00:04:01] Right. So, you were able to start with the child and then see them in a different context in a family and then seeing the parents and their well-being. And so, context is important. I have found in your work. 

Dr. Liu [00:04:16] Yeah, absolutely. Context is a is a major character, in my research. You can't understand the individual without understanding the variety of contexts that they reside in. And for a baby, their primary context is with their caregiver, with their parents, right? That's their environment, which we have to recognize. And, you know, what parents bring to that environment is very much impactful to their to the child. 

Dr. Lara-Cinisomo [00:04:41] Yeah, definitely. So, context is important. In fact, when I did the studies that introduced me to your work was one of your important studies on the COVID-19 pandemic. For example, you wrote about focusing on college students’ mental health. You called researchers and administrators and mental health professionals to prioritize students’ mental health using a strength-based approach. Why was that important to you? 

Dr. Liu [00:05:06] Yeah, well, first of all, I should say that, you know, I study babies, but I also study college students and young adults. I'm really interested in that life span, what it's like for you when you're new to the world, but also what it's like for you when you're becoming independent, away from your caregivers and experiencing the world in your own way, as an independent individual. And so, there's something really fascinating to me about the college years and emerging adulthood and in the context of a pandemic. That transition is so much more salient. And I'll just share a bit of an anecdote, which is that, in my lab, I have a variety of different trainees, including college students. And when the pandemic began, we had a college student, at that time, they were at Northeastern in Harvard. Harvard University had just shut down. They had asked all their students to relocate. They were one of the first universities around here to do that. And so, all the other universities and students were wondering, okay, what are we going to have to move as well? Are we going to have to do to leave campus? And so, this was a topic of conversation in one of our meetings, which is like one, for the Northeastern students. When are they going to leave? And if so, where would they go? And, you know, students don't always have you know, it's not always easy for them to just go home, especially for international students, for example, you know, and so, there was a really major sort of concern among the students in our in our lab. And all I remember was thinking like, yeah, where are they going to go? What are they going to do? Where are they going to pack up their things? And what's interesting is that, at that time, the focus about COVID was like whether or not you were going to get it. So, contagion. But really the population that was affected, perhaps more so more visibly, were the college students, because no one had to physically move. But it was the college students who had to physically move. So, they were the ones that were really sort of majorly affected by this. And so, again, I was really fascinated. We know from research both in humans, but also in animal research that relocation or moving is one of the biggest stressors in life. You know, some of the research on rhesus monkeys show that if you move a rhesus monkey from cage to cage, that that increases their level of cortisol. So, so relocation is a major stressor. And I thought, well, you know, we're talking about contagion and the virus and who's going to contract it. But there's this other stressor that is taking place before our eyes, which is relocation and not just even voluntary moving, but involuntary moving, mandated. And so, I was so curious about the effects of that particular stressor, which is so known to be impactful on college students, where their mental health is already pretty problematic, right? Even before the pandemic, we already knew about the high rates of college student mental health. So, I'm thinking, you know, the pandemic, this relocation, how stressful it is, acute, you know, this acute stress. And, you know, what does it do for college students mental health? And so that was the beginning of the work on COVID and mental health and and young people. 

Dr. Lara-Cinisomo [00:08:16] Wow. What an interesting perspective. As a university professor, I also encountered these, you know, changes that our students had to experience. And we have a large international population at the University of Illinois, Urbana-Champaign. And relocation was definitely an important factor that was part of the equation during the pandemic. What did you learn from that work? 

Dr. Liu [00:08:42] In that work, we were fortunate enough to get an NSF grant, and it was a rapid grant, meaning that we applied, and we got the funding within about five weeks. As we were waiting, we set up a survey and so, within a month of the pandemic's start, which was in March, we were able to design and implement this survey toyoung people to really sort of captured in real time what was happening. In that survey, we were able to ask about, were you asked to leave campus? And in addition to a number of different mental health assessments, more symptom-based assessments. And then in addition to that, we were also hearing, too, that people had to leave their things behind because, you know, in sort of the rush of having to leave, what do you do with your things? So that's a very practical thing to have to consider. And I do recall students figuring out like storage options and then, you know for students who weren't well resourced or didn't have those resources to figure out who would actually pay for some of the storage options, too, right? So, we were getting sort of into the nitty gritty in terms of like, literally what do you do with your things and how do you pay for it? Some students had actually funding to support that. Some students did not. Some students heard about the funding but didn't have access to it, right? So those were really real-world issues taking place at that time. So, we heard a lot about this, sort of like, where do you put your things issue? So, we buried that in the survey as well. Did you have to leave your personal belongings behind? We also heard stories, too, of students who are study abroad, right. Or they were on spring break because this took place believe in March, in March. So, some students were abroad on spring break, so they weren't even close to their things, and they had to have friends to move their things into storage and things, and so forth. So, there were some important things that were left behind as well. So, what we found was that for students who had to relocate off of campus, they actually showed higher rates of mental health symptoms, including depression, anxiety and PTSD. Among the students who had to move. We also found, too, that if you had to leave your things behind, that you were also showing elevated rates of these mental health symptoms. This wasn't a longitudinal study because we really only had one time point that we were focused on at that time. But it showed some evidence that, moving was distressing to the point in which it may have been associated with mental health problems. But also leaving your things behind mattered, too. And it brings about various insights, like things that we just might not think about as having an impact on our life. That, like the things around us, the things that are important to us, the things that actually ensure our safety. Things that were left behind included glasses, somebody's CPAP machine, you know, things that they really needed for their survival, but also things that mattered to them and that were meaningful to them. We can't sort of forget that even the tangible items mean a lot for mental health. And so, that was something that we were able to, you know, definitely highlight in that work. 

Dr. Lara-Cinisomo [00:11:43] What an important message about stability and instability and its effect on young adults and the individual who then has to leave. You know, I've interviewed for this podcast researchers in Puerto Rico and in Mexico who were working with perinatal people who encountered the pandemic, but also hurricanes. And what that instability that, isolation that brings. Did you look at loneliness or isolation in that study? 

Dr. Liu [00:12:14] Yeah. Yeah. So in terms of loneliness, if I recall, we did assess loneliness and relocation was associated with loneliness, but the personal belongings finding didn't have an effect on loneliness, which sort of makes sense that, like, losing your things won't make you any more lonely, but certainly relocating from the setting that you're familiar with, your home, certainly that is associated with loneliness. 

Dr. Lara-Cinisomo [00:12:38] And I imagine for those first-year college students or transfer students who finally got to leave home, got to see this as an important developmental milestone for them, to then have to go back, or find alternative housing. And in the first instance of them, probably living away from home was probably very challenging as well. 

Dr. Liu [00:12:58] Yeah. Yeah. And so I all of this is to say that, you know, sometimes as researchers we go, they're convenient sample right. You can gather data from like your undergraduate pool and so forth. And while that is, you know, the case, traditionally we consider undergrads as a convenient sample in our research. That period itself is really sort of meaningful and allows us to be able to answer questions around things like that. Really like there's no other I mean, maybe there's some population that I've overlooked, but nonetheless, that was the population that allowed us to sort of answer questions about mandated relocation. You know, other than that, you see studies focus on like displacement due to hurricanes and other sort of like natural disasters. And this was a very, unique natural disaster, but allowed us to sort of understand like that too, also conferred risks, or at least the relocation was also seen as a risk for college students. 

Dr. Lara-Cinisomo [00:13:57] Other risk factors are discrimination and racism. Your work focuses on those factors among young Asian Americans and their parents. You have this amazing NIH funding to look at that. Can you tell us a little bit about that project? 

Dr. Liu [00:14:13] Yeah, I'd love to talk about it. Honestly, that is sort of what I live and breathe right now is this project that we referred to as the Boba Project. And so, after that we call it the Boba Project because Boba, which is bubble tea, as many people might know, is a such a popular drink and that it originated from Asia. But it's also a drink that a lot that is sort of reflects fun and reflects sort of a social sort of experience, particularly for Asian-American young people, though I think it is now readily adopted by so many different groups, which is wonderful to see being Asian-American myself. But anyway, Boba stands for building our bonds authentically, and it really represents this mission that we have in really trying to connect Asian-American family members, as well as friends in the community, for people to connect over their Asian identity. And this has become really sort of seeing to us again, the pandemic has led to all these different things that we might not necessarily have thought about or was or was part of the forefront of our minds, right. And so, you know, it's not just about contagion or like whether or not you're going to catch COVID, but right during this time we saw. Such increased anti-Asian hate. And it's the most that I had ever seen, in my lifetime. And certainly, it's not the case that discrimination against Asians never occurred before the pandemic. Obviously, that is not true. However, it was certainly the time in which we saw it becoming part of people's awareness. And so, the example that I give is, it's the first time that I'd ever seen lawn signs like my neighbors had lawn signs that said, “Stop Asian Hate”. That's the very first time. And never before would I have imagined that people would actually take this up as a cause or, you know, really sort of raise that as an awareness, including knowledge as, right. And so, I really credit groups such as Stop AAPI Hate, for, they really were intentional about using data and showing the data demonstrating that increased peak within the U.S. But we also saw that in, you know, politicians who are calling COVID as like the, you know, Asian flu or Chinese for whatever. I mean, there were just a lot of negative sentiments and truly just outrageous sort of insults to to Asians. And so, you know, I'm seeing this and thinking, what are we doing with this and how are families talking about this? Certainly, we see these lawn signs. But, you know, I have two kids who can read. What does it mean to them to have to read a sign that says stop Asian hate? Why are people hating Asians? Why does it need to be like, why does that sign need to be there? And then I thought more about other family members in my life, too, and in which, you know, I grew up in Minnesota and it's predominantly white. When I grew up there, but also still, you know, majority white and had to think about family members, older family members there and what it would be like for them to go to the grocery store with wearing a mask. What does it mean to wear a mask? And even, you know, even being in Brookline, which is a pretty progressive area, but also seeing, you know, just a lot of like anti-Asian sentiment, too. So, thinking like, what do I do with this? And so, I spoke with collaborators and thought, gosh, this is we want to know more about how people are having these conversations. Because growing up, I never had a conversation with my family. And so, this was a project that was very much personally driven, but also, you know, having done and continued research along on Asian Americans throughout my career thinking, you know, we need to really understand like how these conversations are taking place. And in contrast to other groups that have research and data, we just didn't really have data on how people talk about racial identity. And so, this is a project where we actually ask parents and teens to get together to meet us over Zoom. And we asked them to have conversations about their racial identity and experiences with discrimination. But we do it in a way that is palatable. That's feasible because, again, if they've never had that conversation, it's probably because it's uncomfortable or they don't know how to start. And so, it's a guided conversation where we ask people to put themselves in the shoes of an individual. And so, we posed three hypothetical situations, and they just tell us if they were in that situation, how would they feel and what would they do? So, we keep it sort of at arm's length. We don't say, please disclose your personal experiences. We just say, well, what would you do? What's your opinion? And we ask parents and teenagers to do that with each other, thus modeling for each other how they might have a conversation of that sort. So, we guide it so it's feasible, but we also want people to come away with thinking “hey, I had this conversation. It wasn't actually hard at all” And that's actually what we've seen in our data so far, is that most have never had a conversation about their identity or about what to do in certain situations. But in doing it, they found that it was actually really enlightening and very easy to do and that they learn something about their family member. So yeah, we're in the middle of data collection, but learning so much about families and also teenagers and how they think about their identity and what it means for them. 

Dr. Lara-Cinisomo [00:19:31] Now, for sure, we are doing an interview on and studying perinatal well-being, and perinatal well-being doesn't start when the person becomes pregnant or is planning a pregnancy. It starts many, many years before. In early childhood we know the exact time our experiences can have an effect on perinatal well-being adolescent experiences can have an impact. How do you see these early experiences among college students and adolescents experiencing discrimination during a very scary, unpredictable time? And how maybe these conversations may or may not help down the line. What are some of your thoughts about that? 

Dr. Liu [00:20:16] I think this is an amazing question, not a question I get from most people. And so, I can definitely, you know, see, you know, your sort of perspective sort of intergenerational, you start seeing what I see as so important and something that we really do need to talk about, which is that we don't see children forever and we don't see as college students forever, right? We grow and many people will become parents themselves, become part of families or part of communities. Again, that context matters and that the relationships also matter still. And so when I think about these early experiences and what it means later on, what I hear when I study college students, right, is I like to ask them, what is it that they learned before and what is it that what they've learned before, how that actually helps them navigate and cope with their current sort of set of circumstances? And we can ask that question directly or we can measure it, right? We can actually assess things like, I don't know, adverse childhood experiences as one that people commonly assess, right, in research, but also in pediatric settings, because we know that those early adverse experiences matter for health later down the line. But I'll also ask questions of college students, for instance. To what extent to your parents, to what extent do they talk to you about experiences related to discrimination, you know, and in what ways have they done that? And so, with with Asian Americans, very few have actually shared that their parents prepared them for anything related to discrimination. And no surprise to me, you know, being Asian myself, but also no surprise, you know, based on other data that we're gathering, too, that young adults are saying, you we didn't ever talk about this. And so that was a driver for why we started the Boba Project, was that people were reporting we just don't talk about this. And yet. Right. And yet I'm feeling like marginalized. And yet I am also seeing and witnessing, other people being marginalized, either Asians themselves or, you know, other racial minority groups or other marginalized identities such as sexual gender, minorities. So, people are saying, “I'm witnessing it is happening” and there's something really important about naming a problem and recognizing it right, as part of feeling validated. Because for so long, people who have been marginalized are experiencing and going through the world, seeing these things and feeling like I am I, you know, am I delusional in feeling that maybe this person is insulting me? You know, because a lot of the you know, we talk about anti-Asian hate or other types of like hate crimes, that's overt. But what's more prevalent is basically the experiences of being marginalized but not really being certain if that is actually happening to you. Right. And so, in those cases where it isn't certain, you do walk around wondering and that wondering takes up so much space. And there's a lot of sort of emotions and cognitive processes that are taking place. If when you're just trying to figure out if something might have happened to you. And so that too, it seems like takes a toll on people's mental health. And so that's one thing that we're now starting to move towards, is really understanding not just sort of direct forms of discrimination, but also like bi curious discrimination or witnessing that happening to other people as well. But, you know, during childhood, there's a lot of witnessing of this sort, right? Because as a kid, you might not be able to have language to it, but you're experiencing it, you're witnessing it, and then you grow up and you wonder, okay, could that have been something that's impacting my mental health now, or has that sort of made an impact in how I cope with things now? And certainly, think when you get to college, you start to have that language right and you start to put the pieces together and you go, gosh, this is why I'm feeling the way that I'm feeling. So, there's this emergence in this sort of like insight that's taking place during college. And then, of course, at that point, too, again, many of them are going to be parents. And so how they deal with that in college matters for just a few years down the line once they become pregnant and so forth, if they didn't get treatment for any kind of major mental health problems, what does that do for them when they're pregnant? What does that do for them when they're in the postpartum and now they're taking care of another baby? Right. So that's sort of the intergenerational effects that we we might be confronted with if it's not addressed, you know, especially in adolescence and that transition to adulthood. 

Dr. Lara-Cinisomo [00:24:38] Yeah, that's definitely where you captured my thoughts, exactly. Thinking what can we expect? So, we are now four years post-pandemic initiation. You know, when the pandemic started, probably a reasonable number of those young people are becoming parents or forming families, as you said. And how are they doing? What are they doing to cope with some of those early stressors? You're, some of your work actually looks at some coping risk taking, binge drinking. Can you tell me how you think some of those coping strategies might affect perinatal well-being down the line? 

Dr. Liu [00:25:16] Yeah, I mean, it's a really good question, right? And as much as we want to forget about the pandemic, even myself, you know, we sort of want to pretend like it never happen. And there's this whole generation that was so affected by it. And you think about sort of developmental windows, right? For those of us who maybe are like in middle, middle, middle-aged individuals, like it was like a three-year period when we're middle-aged, but like the three years, three years for adolescents and young adults is huge because that's where all the milestones take place, right? Graduating, leaving home, getting graduate, you know, graduating again, like getting a job. And so, and like maybe even starting a family. And so, when I think about, you know, what this means, you know, the mental what you're seeing, right, is that mental health problems are far more elevated than the physical health issues that they report. So young adults actually are generally healthy. And in our data, in our cohort, we see that they're generally physically healthy, mentally not. So, there's one area of concern that I have, which is that to what extent does mental health drive any kind of other physical health conditions? I mean, this is an area that's been largely explored, but, you know, hopefully somebody will take this out, which is thinking more about like potential pathways, right? Like with increased stress and problematic mental health that you might have sort of issues related to sort of inflammation, other types of pathways that might lead to physical health problems down the line. We might not see it now, but it's, you know, down the line. So, I think that that's something to keep an eye out for is any kind of physical health problems due to untreated mental health. In terms of coping, that's the other thing, too, is that we might see sort of increased binge drinking. We also saw that there was an onset of suicidality among a number of variety of different sort of marginalized identities and other people with preexisting vulnerabilities as well, that there was an onslaught of suicidality during the pandemic. And so, you know, I think about that as I do this work on college kids, but also perinatal health thinking, okay, we know that one of the biggest risk factors for postpartum depression is a preexisting mental health problem, but that's the biggest one. So for college students who are now sort of engaged in or have this like onset of suicidality in the context of the pandemic, what are we doing about that, especially, you know, in general to address their distress, but also as we think about sort of downward consequences of them, you know, living their life, but also potentially being parents on the line as perinatal, you know, thinking about pairing those who really focus solely on perinatal mental health problems. Are we are, we sort of addressing college age or adolescent health? And I always say that because whenever there's data that that's coming out of the CDC, right, that they're always saying, you know, “adolescent girls, you know, increased suicidality, social media use may be linked to that”, right. And I look at that because I care a lot about sort of adolescence. But I'm hoping that perinatal mental health professionals are also keeping an eye for that, too, because guess what? They're going to be your patients, right? Like in ten years, 15 years, maybe even earlier than that. And so, we do have to keep our eyes out for that adolescent experience, you know, both for practice, but also as researchers. 

Dr. Lara-Cinisomo [00:28:39] Yeah, absolutely. I'm so glad we're talking about this, so critical. There's still an opportunity to capture those individuals because some of them haven't completed their college education. Some of them had to delay it, and so there's still that opportunity. But I also want to talk about protective factors, you know, things like identity and strong identity, perhaps. What are some protective factors that you might have identified in your work with youth and young adults, especially those of Asian or Asian-American backgrounds? 

Dr. Liu [00:29:09] That's a great question and an important one, right? Because we're focused on risk and identifying risk and channeling our energies towards risk. And actually, my lab name actually includes cultural resilience in it, and I purposely put that in there because I really need to sort of be much more oriented around resilience through so much to draw from. One thing that we do see for young adults is that even though there are these high rates of mental health problems or symptom reporting, we also see, too, that there is this willingness to advocate and to hope for change. So, there isn't hopelessness around society necessarily. We do see sort of behaviors that reflect these advocacy efforts, and that's wonderful to see, right? They're the ones who are out there petitioning. They're the ones that are out there speaking. And so, we see a lot more of that in young people. And, you know, maybe this is just true for young people in general in general, that over generations we see young people speaking out. But nonetheless, that is actually very much a strength in that they're the ones that's really sort of pushing the envelope and really ensuring that society is aware of the issues that that matter. So definitely see strength in sort of, advocacy and efforts towards that among young people. And then for Asian-Americans, you know, I think one of the things that really matters there is a sense of like community and feeling connected with your community. And this is not always easy, actually, right? Because there is a, you know, cultural difference between maybe themselves versus like, their parents. But nonetheless, we are seeing, you know, evidence of, you know, Asian-Americans connecting with each other around their identity and sort of a willingness and sort of a willingness to do that. And then also there's means for doing that. So back when I was an adolescent, we didn't have like, you know, Internet was still emerging. Not to completely date myself, but like Internet was emerging. And, you know, there were like chat rooms and things like that, but nothing of the sort here, where people can actually really learn about experiences of other Asians in, say, a Facebook group or some other group or like they're, you know, they're a follower of some sort of organization. So, we've seen a lot of like grassroots organizations led by youth. And that I think is really inspiring because it's very validating for the teens who are feeling marginalized and maybe alone, particularly in areas where it's either rural or they're really just sort of the only for Asian in their school or what have you, right? So, you know, there's these like opportunities there that I think is a strength. I will say, though, that there is a double edged sword right to this and partly, don't you know, due in part to the fact that like as much as you might feel connected, I also think that, you know, we need to be sort of mindful and watchful for ensuring that those ways of connecting isn't the only way in which you connect with others. So, it's not just like online connections that matter, right? That we also need to sort of find ways to foster sort of in-person experiences. And that's really, you know, society's responsibility, right? And sort of policies and community policies to sort of ensure that communities rise to the occasion and really address sort of these in-person needs that young people need to have, because we can't just have them live in online communities. And because of that, you can sort of reinforce, you know, certain feelings that we might not necessarily reinforce. And there's not a lot of sort of like, oversight around those experiences as well. So, I think that, you know, it's nuanced, but I think that there's a lot of like opportunities for building sort of various assets for Asian-American youth. But youth overall. 

Dr. Lara-Cinisomo [00:32:50] In sometimes different contexts can provide those opportunities. Like your research, I love the Boba name because that can bring up some excitement around this cultural identity and, you know, thinking, wow, a Boba is the name of this study, and it can increase the confidence and help them feel more connected to their community. Was that one of the intentions behind the name? 

Dr. Liu [00:33:14] Absolutely. Yeah. There's something really happy about Boba drinks and we made a very cute logo. We made it in-house; we made stickers out of it. And just knowing that that would be widely adopted. And indeed, that's what really both teens and parents love that logo and what that represents. You know, I think out to be fair, though, I'll say that our project, as much as we have found delight in developing and implementing it and we have also heard from families about how it's really changed their relationships. You know, it's actually just a study where we're collecting data. It's not an intervention at all. But when people don't have conversations about race and you ask them to do that, that itself is somewhat of an intervention, isn't it? Right. Like they're changed because they're doing something they haven't done before. And so, we've heard families talk about how they learned so much about the other person, teenagers who say, I appreciate my parents so much knowing like what they went through and that they volunteer this information that they never volunteered before. Like, I really appreciate her. And we've started to have more meaningful conversations. You know, we start to open up with one another. And I find so much joy as a psychologist I'm thinking, “Oh my gosh, like we were able to do that and cultivate that in just like this 45-minute, one hour session, that's not even therapy”. Like, this is amazing. So, I'll say that. But on the other hand, what we are sort of confronted with and a challenge that we're still trying to overcome is the sort of, you know, when people hear about like, you take part in this project, you get these incentives, gift cards and so forth. It's just so typical of the research study. But also talk, you know, sit next to your parents and talk with them and hear their their opinion. No, like not like teenagers, ohh really? Why? You're asking me to talk to my parent. Like, that's so strange. So, we are getting a fair number of teens who are thinking like saying, you know, “that seems strange that you'd asked me to do that” like, I'll do the other stuff, but not not talk to my mom or my dad. When they do, they embrace it. But it's the thought of doing it right? And so, this is now the thing that we're trying to figure out is, again, there's this developmental appropriate response of not wanting to hang out with your parent for an hour. But on the other hand, sort of realizing that when you do and when they go through a procedure, they actually really appreciate it. Right. That's what we're trying to figure out now. A big, big thing to try and solve. And we might not be able to do that fully, obviously, with you know, even though we're well-funded, you know, we're not that well-funded to be able to overcome something that's so developmentally appropriate. And particularly for Asians, you know, for Asian adolescents where it's not just about like, trying to be independent, but also, you know, it's hard to talk about things with a different generation and maybe their language barriers as well. And yet we're still trying to, like, figure out how to how to do that. And one of the things that I've been gravitating towards is, you know, to my surprise, but actually to no one's surprise in trying to execute a study of this sort is figuring out how to actually identify the messages that actually matter for families and meeting using our research and figuring out how our research meets the needs of those families and communities and their priorities. And so really, truly sort of embedding ourselves in the community and figuring out what they actually care about. So that's our that's our big task right now. 

Dr. Lara-Cinisomo [00:36:35] Wow. So many thoughts, so many opportunities. So many challenges. 

Dr. Liu [00:36:41] So many challenges. Yeah. 

Dr. Lara-Cinisomo [00:36:43] Yes. 

Dr. Liu [00:36:44] But all good. Yeah. 

Dr. Lara-Cinisomo [00:36:45] And you're tackling them and you're doing important work that is going to really help us understand experiences now and how they may impact experiences down the line. So, thank you for that work. It's critical for sure, and I think every good project has challenges because it forces us to stretch. 

Dr. Liu [00:37:08] Yes. 

Dr. Lara-Cinisomo [00:37:08] Things beyond what we had planned, and it teaches us we might have to get a little more creative, and if we're listening, that's what we'll do. So, I think that's fantastic that you're doing that. So, I do want to ask about some recommendations or suggestions you have for educators, researchers, including parents and other stakeholders. Well, what can we do to support the mental health of young adults in and out of college, those in college to ensure their well-being now? And if they choose to become parents or when they form their own families? 

Dr. Liu [00:37:43] That's a great question. It's a big one. You know, I think about there's so many factors involved with addressing mental health, you know, not just the individual, but the system itself. Right. Which is so hard to overhaul overall. I mean, I think it needs an overhaul. And, you know, it's so hard with respect to mental health and getting needs met. What I would say broadly is that we need to sort of listen very carefully. And there's different you know; this is sort of a case-by-case basis of sort of listening to the individual and sort of where they're at. You know, they are in a given context. Right? And so understanding their context and what is challenging about that context, why is it difficult to cope? And it's really sort of being very curious by listening. When I talk to teens, they don't want anyone to jump into problem solving mode. They just really want their experiences to be validated, to be heard. And so, I think that that's the number one thing, is to listen and to be curious about what it is that their experiences might be. The second thing that I've also heard from adolescents, too, is they don't want to be known as this generation of having all these mental health problems, but nobody wants to be known as the generation for whom is going through a crisis. And no individual wants to be known as the person who's going through a crisis, right? And so, this is something that I've had to grapple with because on one hand, we are genuinely in a place where there is a mental health crisis at a population level, we're just seeing such high rates of mental health problems. What we're not really gathering, however, there are some groups who are doing this and you know, we are trying to do this as well, is to also understand, not just like the level of mental health problem and the rates, but also what are some of the strengths of this particular generation and how to actually go about addressing, you know, assessing that and then going, “okay, those are the strengths, gosh, even though you have like these high mental health rates there are all these other strengths and assets”, as I mentioned, sort of the willingness to advocate and effect change, but also identifying yourself as somebody who's just resilient can be really important, somebody who's confident in their own abilities to overcome. And I see that that's something that I do see as a strength for young people. And what's important about honing in on that, particularly from perinatal mental health researchers and professionals, is that in our data, on our birth cohort of parents who gave birth during the pandemic, we see that self-efficacy matters so much for both mental health and also for being able to see sort of the strengths of the baby. That has been a factor that is coming up for us that we've been discussing in our lab. And so, to the extent that we are identifying that confidence in college students and young people, that factor shows up again when they are parents. And so, you know, something to not underestimate, I would say. 

Dr. Lara-Cinisomo [00:40:49] Wow, that’s fantastic, there are so many theories that include self-efficacy that then we can apply social cognitive theory is one, context, and it sounds like you're identifying this important construct that is present across the life course that maybe we can draw on. 

Dr. Liu [00:41:10] Yeah, and not to also dismiss other societal issues or injustices that they may face. For instance, discrimination. Like we're not saying that's not real right? But to say that what we can work with includes this sense that you can you can rise to the occasion. 

Dr. Lara-Cinisomo [00:41:25] Fantastic. Well, before we end, would you be willing to share your hopes for the mental health and well-being of Asian American young adults and college students? 

Dr. Liu [00:41:36] Yeah, of course. You know, I really hope that for this generation that that they can recognize and sort of experience empathy for themselves, but for across generations. I think that adolescents and young people, one of the things that we hear about is just conflict, with parents, but also facing injustices from society. And it's almost like, oh, they're stuck, right? And so, what I hope for is this sense that they may feel unstuck by sort of giving themselves a bit of grace, knowing where they, you know, what they're facing in society and in their own families, but also to seeing, seeing different perspectives and understanding where their parents came from and their motivations and so forth. And our Boba Project has really made me much more able to take to engage in perspective taking. And I never thought that would be the case. I came in with a lot of preconceived notions about, like the older generation, what they might say or assume and so forth, and finding “oh when explain it that way. That makes so much sense. Of course, they came to this country, you know, with these hopes and wishes” and, you know, that's how they conveyed to their kids. But it has nothing to do with, you know, what we might have imagined in the first place. And, you know, you know, seeing that and seeing our data has really made me much more open minded. And so, I almost wish that our young people can, you know, perhaps we can convey those results to them so that they, too, can also be accepting of that the sort of different perspectives that that come across in front of them. 

Dr. Lara-Cinisomo [00:43:14] Now, that sounds fantastic. Sounds like a media, social media opportunity there. 

Dr. Liu [00:43:19] Possibly. I don't know if I'll go there yet, but yeah. 

Dr. Lara-Cinisomo [00:43:24] Well, we'll continue to track your work. It's so critical, so informative, and it's so important. Thank you so much for the amazing work that you do and for taking time to speak with us today. 

Dr. Liu [00:43:35] It's my pleasure. And thank thank you so much for this session. Appreciate it. 

Dr. Lara-Cinisomo [00:43:40] Thank you for joining Studying Perinatal Well-being. Please see our show notes on the MONA Podcast website for more information about today's guest. We always look for great perinatal well-being students, community members, researchers and practitioners to interview. So please email your suggestions to monapodcast@marcenortham.com that's monapodcast@marcenortham.com. Until next time, practice compassion for yourself and others.