Training more mental health providers, to help relieve a crisis
Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
Children's mental health services are in crisis with an acute shortage of psychiatrists, psychologists, counselors, and social workers -- everywhere, not just in Central New York. I'm talking about what's being done to help with child and adolescent psychiatrist, Nayla Khoury. She's an assistant professor of psychiatry and behavioral sciences at Upstate. Welcome to The Informed Patient, Dr. Khoury.
Nayla Khoury, MD: Thank you so much.
Host Amber Smith: Why is there a shortage of mental health providers? Because I understand this was an issue before the pandemic, right?
Nayla Khoury, MD: Yeah, that's right. It's always been an issue nationally and globally as well. And you know, I think frankly the need just has outweighed the supply of mental health providers for a very long time. Mental health disorders such as anxiety and depression are very common. And we know that in the last two years, globally, there's estimates of doubling of disorders such as that, in this pandemic of loneliness now, moreso than ever, the shortage is being felt, which is why we're in crisis, as you mentioned.
Host Amber Smith: Now, what attracted you to child and adolescent psychiatry to begin with, when you got into this profession?
Nayla Khoury, MD: I think as a first-generation immigrant to the U.S. whose parents came from war-torn Lebanon, I've always been interested in global health and trauma. I found a calling for psychiatry and child psychiatry because of the focus on prevention, working with families, being able to support resilience and really try to alter the course for a young kiddo who may be struggling with all sorts of issues, but it kind of came first from my own, experiences. And then the joy of being able to work with whole people, hear their stories and families.
Host Amber Smith: It sounds like it would be immensely rewarding as a career. So I'm wondering what factors you think are preventing people from going into this field.
Nayla Khoury, MD: Yeah, that's a really good question, because I do think that most psychiatrists, even, would enjoy the extra training. We think of ourselves as "whole life psychiatrists," those of us who've done the additional training. I think frankly, it's the overwhelming medical school debt that prevents and prohibits a lot of people from taking on an additional two years when they could be, instead, making a salary that is much more than training.
Host Amber Smith: Sure. Well, now I understand Upstate is part of a collaborative training program with Syracuse University. What can you tell us about this program? And what's its mission?
Nayla Khoury, MD: Yeah, this is an exciting partnership with Syracuse University to help meet the needs and to provide behavioral health experiential training opportunities. So there's a couple of goals for this program. One is to diversify the number of mental health providers and to have them have more experiences in underserved settings with multidisciplinary team approaches. The focus is on the city of Syracuse, as well as Onondaga Nation, which we know have a need for mental health providers and working collaboratively to provide interdisciplinary training for both the trainees and the supervisors on site. So it's very exciting, and I think ultimately will help improve the quality of diverse mental health providers in underserved areas that may not otherwise get to have as much access to care.
Host Amber Smith: So if I understand what you're saying, there will be sort of a commitment to providing training for people so that they can get the training they need and get into practice.
Nayla Khoury, MD: Yeah, that's correct. The target is for students who are completing masters level social work or psychology post-doctorate students. So they're already in training, but it's providing them more enriched experiences earlier on. And, at least in the case of the work with the Onondaga Nation behavioral health collaborative, it's a year-long commitment to really diving in and working with this underserved community.
Host Amber Smith: Well, let's talk about the role and specialization of the various professions in the field of mental health. I know that psychiatrists are the medical doctors, the MDs who can prescribe medication. How do the psychiatrists differ from psychologists?
Nayla Khoury, MD: People often get us confused. So psychiatrists, like you said, have gone through four years of medical school and then four years of residency, and then in the case of child and adolescent psychiatry, two more years of training. Whereas psychologists are most often PhDs who have had extensive training in theory and therapies and testing, psychological testing as well. And then there's other mental health providers too, which I'm sure you'll be curious about. And I often have to look it up. I think it's very confusing to sort through both the training, the lens. But this is actually one of the benefits of our program and one of the reasons I enjoy the collaborative training is that I do think we all bring different experiences and lenses to the work.
Host Amber Smith: Right. You mentioned social workers. I mean, I can think of school counselors and you're right. People in those roles have a varied background. So, you know, one social worker isn't the same as another social worker.
Nayla Khoury, MD: Right. One of the unique lenses that social work brings is a focus on systems as well. So systems of oppression and social justice, as well as clinical practice. So that's something I like to learn from the social workers that I work with.
Host Amber Smith: Now your biography lists "cross cultural psychiatry" among your interests. What is that?
Nayla Khoury, MD: Oh, yeah. And I'm happy to share about that. I first got into and learned about cross-cultural psychiatry in medical school, when I had some time studying and working in Haiti. So it was first sort of learning about how mental illness can be identified, expressed and treated in other cultures. And I think over time, I've come to learn and see how cross-cultural psychiatry also just applies to understanding the culture of medicine and how we interface with different families and cultures, even here in the U.S. and in Syracuse. So even, for example, our DSM-5 -- which carries the diagnoses that we use to diagnose and guide treatment as medical professionals -- is culturally contextualized. And even though I think globally people use the DSM-5, there's also other classifications used elsewhere and a growing recognition that depression here may look a little bit different than depression somewhere else. And just a very interesting interplay and conflict around how do we make sure people learn about the DSM diagnosis, but also be respectful and humble about how our disorders may not present exactly the same elsewhere. And there may be other treatments that are really useful in different communities.
Host Amber Smith: Do you find, are there some cultures where depression is taboo and you can't really call it that?
Nayla Khoury, MD: Oh, absolutely. I think in many communities, mental health disorders that are less severe or not psychotic in nature are, frankly, invisible. So depression and anxiety isn't seen at all. And so patients will be much more likely to present with a heavy heart or a head that's full than with our typical depression checklists that we talk about in the DSM-5. And there's also just interesting thoughts to consider how consciously or unconsciously people learn what's culturally acceptable ways of expressing distress. Depression is a really good example of that. So whereas we might be able to see someone looks depressed because they are shut down, they're not eating, they're not engaging in life -- and I do think depression exists globally, no matter where you are -- people may not come in saying, "I feel guilty; I have low self-esteem." In cultures that are much more communal the focus might be on how I'm not able to support my family or function in that capacity. So it can look a little bit different.
Host Amber Smith: This is Upstate's The Informed Patient Podcast. I'm your host, Amber Smith, talking with Dr. Nayla Khoury, a child and adolescent psychiatrist at Upstate.
We've talked about the different cultures. Do you see a difference in patients from different socioeconomic status, people that have wealth versus people who are poor?
Nayla Khoury, MD: Well, yes and no. I mean, mental illness affects people across socioeconomic status, and yet there's much added challenges for families coming from lower SES (socioeconomic status.) For one, they may have less access to care, to even showing up to treatment, partly because of insurance, partly because of being able to make an appointment during regular business hours, transportation, et cetera. And then when they're able to get into the door to see us frankly, folks with lower SES are just more likely to have many other structural determinants of health, many other factors going on that put them at increased risk for trauma-related disorders or intergenerational trauma. So it becomes even more important to be aware of how to support the whole family in seeking resilience. That it's not just about the kid coming in as the identified patient, but how do we support the whole family as best we can, the parents, the grandparents, the extended family? So yeah, it is an important factor, both for access and for treatment.
Host Amber Smith: We hear about the importance of preventive care, mostly like with health screenings and medical checkups and things like that. Are there ways to proactively identify mental health problems in an individual before they become a crisis?
Nayla Khoury, MD: Absolutely. So one of the other hats I wear is as a child and adolescent psychiatrist working with Project TEACH, where we train and work collaboratively with primary care physicians. So, there are rating scales that can be used to help identify those at greater risk, such as scales looking for depression and anxiety. But in general, I think some of the things that are important to keep in mind is observing people's behavior and noticing changes over time. So if somebody is normally very bubbly and extroverted and is all of a sudden shut down and not speaking, that's a red flag or vice versa. If someone, especially when we think about young people, the areas of function to pay attention to, if a kid isn't going to school, that's a huge red flag. They may already be in crisis. If they're all of a sudden plummeting in terms of academic performance or doing much differently than they did before, that's something to inquire more about. If they're unable to enjoy time with friends, if they're isolating more, these are some signs that we may need to evaluate more what's going on.
Host Amber Smith: How does a parent know, if they suspect that their child needs professional help, how does a parent know which therapist, psychiatrist, social worker, psychologist, how do they decide which person or profession would be the most help for their child?
Nayla Khoury, MD: It's a really good question. And I don't think it's a parent's role to know that necessarily. I think first and foremost, sort of seeking out the supports that exists for that parent. So going to the primary care physician or pediatrician or family doctor and asking for help. And that person can be one person to help guide where to go next. Or within the school system, touching base with the school counselor or psychologist, asking for more testing if needed or some more support. And these professionals can help guide what's needed from there. So there's sort of a tiered approach. Most kids won't need to see a child and adolescent psychiatrist. We're kind of for the most severe kiddos. But there's a lot of steps in between. And I don't think it's really about the professional so much as it is about the connection between the kid and the therapist. The other piece is, it also depends on what kind of therapy the kid needs and what type of training the therapist has had. And so some of that takes assessment before you can know entirely.
Host Amber Smith: Do you have advice for how to choose a therapist, or do they match up a child's characteristics with a therapist's characteristics to find a relationship that's going to work?
Nayla Khoury, MD: Yes, and no, I mean, there's an increased, focus and attention to sort of tele telemedicine and telehealth. And even here within Upstate, we're looking to figure out if we should purchase as a hospital system tele-health options to increase access for everybody. And in some of those systems, they do more matching, like you said. Frankly, most systems don't have the luxury to be able to match as well as we'd like to. We often cannot match based on gender -- it's an overwhelmingly female field -- or race, or ethnicity. And so the choices are often limited. One of the goals and missions of this grant is to increase diversity in the workforce. So there is a focus and intention to picking trainees that look more like the community in different ways, and I do think that's important. The advice I would give to a young person and a family, too, is to give it time, that you don't really know until you start meeting with somebody if it's going to work. And then it takes a little bit of time before, I mean, I would say, give at least three sessions before you make a decision about whether to proceed or not, because relationships take time. And even though a kid might go into a relationship thinking, I want somebody who looks exactly like this or meets this criteria, it may not be in fact, what they need for therapy, for healing. So it's both practical that we can't always match and, I think, really can be very beneficial to know that we can be healed by all sorts of different types of people with different backgrounds.
Host Amber Smith: What should a person do if they aren't clicking with their therapist? And especially now when there's such a shortage, I mean, in one sense, shouldn't a person be grateful that they have a therapist because they are hard to come by right now?
Nayla Khoury, MD: I think it depends. On the one hand, making sure that the patient and family have given it enough time. I also encourage all families that I talk to where there's a question of fit to let the therapist know and give direct feedback about what's not working. Because in fact, some of the most important therapeutic work happens when we repair a misrepair, you know, where the kid is able to say, when you said that the other day I felt judged and the therapist apologizes and says, "I didn't mean that. And now I know." And so that gives the therapist an opportunity to grow and the child an opportunity to speak up for themselves. So, not easy to do. Most often people would like to just switch and avoid the discussion. But that discussion is very important to have. On the other hand, it's so important that a kiddo, and anybody, feels safe and that they have choice. And so having choice is also the choice to say, "this isn't working," and to switch providers. So it's a both, and. I always encourage kids to talk to their therapist and then say, if it's not working, you can always switch or try to switch.
Host Amber Smith: My guest has been Dr. Nayla Khoury, a child and adolescent psychiatrist at Upstate. Thank you for making time for this interview, Dr. Khoury.
Nayla Khoury, MD: For having me today.
Host Amber Smith: The Informed Patient is the podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. I'm your host, Amber Smith, thanking you for listening.