Closing the Mental Health Care Gap for Black Teens

SHANOOR SEERVAI: There is a global shortage of culturally competent mental health professionals. And for one group in the U.S., the stakes are unusually high. Black and brown adolescents who struggle with behavioral health and even serious mental health conditions often cannot get care, or if they do get treatment, it may not be well suited to their life experiences. This is critical because early intervention has a huge impact on future outcomes.

I’m Shanoor Seervai, and on today’s episode of The Dose, my guest is Dr. Kevin Simon, a psychiatrist at Boston Children’s Hospital and an instructor in psychiatry at Harvard Medical School. This year, he is also a Commonwealth Fund Fellow in Minority Health Policy at Harvard University.

Dr. Simon, thank you so much for taking the time for this conversation.

KEVIN SIMON: Yeah, thank you for having me.

SHANOOR SEERVAI: I’d like to note, just before we get started, that there’s a distinction between behavioral health and mental health. Behavioral health is an umbrella term that includes mental health conditions, like difficulty coping with life stressors and crises or stress-related physical symptoms, as well as substance abuse disorders and conditions. Mental health is part of behavioral health, and it’s broken down into conditions that are common, like depression or anxiety, and less common but complex, like serious mental illness, like schizophrenia. The two terms are sometimes used interchangeably, but behavioral health is the more comprehensive one and so, we’re going to be talking about that today.

KEVIN SIMON: Yeah, no, you’re correct with regards to behavioral and mental health, and one important distinction is patients themselves don’t distinguish between the two, in that persons with quote unquote behavioral health challenges, which might include substance use disorder oftentimes do you have co-occurring quote unquote mental health conditions, like anxiety or depression, as you mentioned. So it certainly is academic and then it also is within the legislation in terms of policy, but yeah, in the streets, in the clinic, the conditions are hand in hand.

SHANOOR SEERVAI: Of course, we have to keep that in mind, but just trying to be as inclusive here as possible. So, right now there is an acute need for behavioral health care for adolescents, particularly Black and brown teens and even pediatric patients. Can you tell me why this need is so urgent?

KEVIN SIMON: Yeah. So, during the pandemic, there’s been a stark rise in the number of patients who are adolescents going to pediatric hospitals for emergency room visits with regards to mental health. If you actually look at the evidence, that’s actually been an up-trend for the past decade. Just this weekend, I was the on-call physician for our hospital, and more so than I’ve ever seen we had a large number of boarders, or patients who are seeking and requiring higher level of care, such that it’s about occupying about 15 percent of the actual hospital beds, which is very atypical.

In terms of the why, we’re still trying to figure that out with regards to the research. Certainly we know that anxiety is high. We know that depression is rampant. It’s multifactorial in terms of the environment that adolescents are attempting to grow and thrive in, that are presenting some very unique challenges that right now, as a system, we’re attempting to figure out in terms of being able to not just help people get a bed, an inpatient bed, but what types of outpatient services therapy that’s available. There’s certainly an overwhelming demand right now.

SHANOOR SEERVAI: And looking back, even to your experience being on call, is there some sort of emergency system for providing behavioral health services more broadly, or for acute mental health illness more specifically?

KEVIN SIMON: It a great question. Most of the behavioral health emergencies that arise obviously are arising outside of the hospital. So then you have to think about, well, what are the environments that youth are in? And when they’re presenting, or let’s say discussing a concern that they have, I’m going to talk about one environment, that’s the school environment. More often than not, as was the case for a number of patients that I saw, they had disclosed to a school counselor concerning thoughts that they had for themselves, some which might have included the idea of self-harm, some which may have actually engaged in self-harm. As a school counselor, I might be limited in terms of what you’re able to provide in the school. So then the default becomes, “Well, we got to get you an emergency evaluation at a hospital,” but that emergency evaluation at the hospital often leads to potentially, “Well, you don’t meet criteria for inpatient hospitalization. We’re going to discharge you.” In essence, right back to the environment that you’re in.

Then if you do need an inpatient bed, as a number of patients did, there’s a shortage of beds. So, then now we’re in this bottleneck period where people are boarding for days and weeks and weeks. So in terms of, is there an emergency psychiatric system? There is. However, I think right now there are a number of youth who are attempting to access the system when perhaps there should be something else layered in that does not yet exist. So, what you find is the ERs are just overwhelmed.

SHANOOR SEERVAI: Just explain to us, when somebody’s boarding, if they need a lot of support, where are they getting that?

KEVIN SIMON: So, this is a challenge. So the family comes in, they have a 13-year-old who has said they are really thinking about harming themselves, want to end their life. And we say, “Okay, this person meets inpatient level of care, but we don’t have a bed yet.” The reality is we don’t actually know when the bed’s going to become available because person that’s in the bed, we don’t know when they’re going to go discharge home. So the person, the family, is either waiting idly in an emergency room or in a general medical bed on a hospital floor, but they’re not getting intensive therapeutic services. They’re really just in a bed, in a room, in a hallway . . .

SHANOOR SEERVAI: Oh my gosh.

KEVIN SIMON: . . . waiting until an inpatient bed becomes available. But again, given the numbers that we’re seeing now, where boarding used to be okay, a couple of days, and we could accurately predict that for families. Now, it might be days. It very well might be weeks. That’s highly dependent on the type of insurance that someone may have.

SHANOOR SEERVAI: What about less acute situations? You know, we hear a lot about how there are behavioral health apps out there. So are they helping to close the gap?

KEVIN SIMON: In terms of behavioral health apps, the question in that a consumer would have to ask is who’s on the other side of the app. There are apps certainly that licensed professionals, therapists, clinical social workers, psychiatrists are utilizing to engage patients. But then there are some companies that have apps that they may not be necessarily licensed professionals on the other end, but they may be someone that has some form of training. Is that really helpful? The evidence is still out.

I can say for the patients that we see and that I treat, they may not necessarily benefit from an app in that the concerns and the level of impairment that they have kind of exceeds what an app would be able to do. Because sometimes the apps will say, “You have your therapist, they’re readily available. You just text them.” A person may want to feel more than just a text connection with their provider. So right now, given how overwhelmed the system is, I think we’re all happy that some sets of services exist. But in terms of the quality of the services, that’s still open for debate.

SHANOOR SEERVAI: So, that’s one aspect of capacity. Can we talk about capacity on the front of the mental health or behavioral health providers? Are there enough people, and particularly, are there enough people to help Black and brown youth?

KEVIN SIMON: Short answer, no, but I’ll give you a detailed response. So with regards to child and adolescent psychiatrists, the approximate number of practicing child and adolescent psychiatrists is 8,300. In terms of Black and brown child and adolescent psychiatrists, 4 percent to 5 percent are Black and brown. So, I’m in Massachusetts. I can count the number of Black child psychiatrists that I know because we’re all in a group and that’s for the whole state. So, the reality is that racial concordance cannot possibly happen for all of the patients that have some melanin hue to them seeking a individual provider that also has some melanin hue. There just aren’t enough of us.

I regularly receive emails, consultations from families that are interracial, diverse, international where they’re saying, “Oh, we want a Black child psychiatrist. We want a male.” The answer is, “I’m not sure that I necessarily can help you because you’re in Iowa or you’re not in the state that I’m licensed in.” So, it is particularly challenging in terms of the workforce shortage that exists and improving that pipeline is not even a one-to-three-year fix, that is a decade-long fix because you’re talking about graduate school, clinical training, fellowships, post-docs. But we need to be strengthening the pipeline. But in terms of quick fixes, that’s not one of the quick fixes.

SHANOOR SEERVAI: And thinking about that and this shortage in capacity, what made you choose to become a child psychiatrist?

KEVIN SIMON: So, going into medical school, by the time I got to core rotations around third year, doing a psychiatry rotation, which we all do, I was placed in a developmental disability clinic and seemed to be pretty fascinated with the attending that I was with and how he could communicate with patients who were averbal, communicate with their families to recognize what the challenges that they were experiencing. So, I just started to become particularly fascinated with not only the individual person, but in psychiatry you’re forced to think about persons as a whole, how do they exist within their family? How do they exist within society? How is the school system, their job impacting them?

So, I’ve always liked thinking about patients as a whole, rather than specifically just the renal system or pulmonary system. So, I go into adult psychiatry and you start to recognize most mental health, behavioral health conditions actually develop in adolescence, but there’s about a 10-year delay to diagnosis. So, that then prompted me and say, “Okay, well I want training in child and adolescent psychiatry,” and here at Boston Children’s I got the widest breadth of diversity in terms of cases, complexity. Then my particular interest was youth that are in juvenile justice. I should say in juvenile justice systems, Black and brown youth are overrepresented. So, I didn’t have an interest in substance use. Substance use tends to begin in adolescence. So, that’s how I have the training in child and adolescent psychiatry and pediatric addiction medicine.

SHANOOR SEERVAI: So, now pivoting back to the need that has been surfaced by the pandemic. If the pandemic is waning, or at least if we’re or past the worst of it, will the behavioral health needs of Black and brown teens be assessed in new and different ways, either on the system level or individually?

KEVIN SIMON: So, I think it will have to be. When we think about Black and brown adolescent or youth needs, one has to think about all the ways in which our systems can negatively or positively affect our mental health. So for instance, again, I’m going to go back to education. Black females are expelled or have some out-of-school disciplinary action more often than their non-Black counterparts. Black males tend to be viewed as . . . and Black children, let me just say, tend to be viewed as less innocent by the age of five. By the age of 10 they’re adultified, i.e., you have a 10-year-old that you’re physically looking at, yet you’re viewing them as though they’re 15. That’s going to impact how people engage with Black youth.

So, you can see how some of our unfortunately historical stereotypes, can negatively impact how Black youth experience the world. So, whether you’re talking about a 12-year-old child that has a neurodevelopmental condition playing on a Saturday morning with a toy gun, being viewed as not a 12-year-old with a neurodevelopmental condition, that person loses their life.

So, you can see how even doing normal activity as a Black youth, as a Black person in our particular society, comes with certain stressors. So now it will be incumbent for our systems, providers, teachers, parents, to really think critically about how our youth are actually experiencing the world. Oftentimes when I’m talking about this, I will highlight again, normal behaviors. So, getting a haircut, there have been instances in which a 13-year-old Black male gets a fade and goes to school and he has a design of his hair. A teacher says, “That’s not part of school policy,” and they’ve tried to color in his hair, or you’re a wrestler and you’re a sophomore, but you have dreads and they’ve said, “You got to cut your dreads, because that’s not a part of the policy in terms of playing.” These are youth who are just doing normal activity and yet the environment around them is causing them to think critically, I think more so than they should be at 14, 13, “Like, wait a minute. Do I want to allow you to cut my hair or do I want to play this wrestling match?” So, those are, again, normal environmental decisions that youth make, that our society forces them to experience stress and trauma in a way that is not how people tend to think about stress and trauma.

SHANOOR SEERVAI: So, what you’re really talking about is that we aren’t doing a good job of normalizing the life experiences of Black and brown teens. What are mental health professionals going to do going forward so that they are able to do that?

KEVIN SIMON: Right, right. So, this is where training and you’ll hear the phrase cultural competency, I would argue it needs to be cultural humility. Because again, in terms of the number of providers who are diverse, at least in terms of phenotype, we’re never going to be able to have a one-to-one racial concordance of provider and patient. So, that’s going to require non-Black, non-brown providers, to be intellectually and genuinely curious to the experiences of the youth that present to them. When you inquire and you validate the experience, you’ll gain a lot as a provider, but the patient, the adolescent’s going to gain so much, knowing that someone’s actually invested in them and wants to understand, “Well, no, what is this experience that you’re having?” Oftentimes I think just in health care, we tend to be very solution-oriented and we come in and we want to fix something.

The therapeutic process, behavioral health process, is such that it’s not a matter of fixing, but it’s a matter of accompanying someone along this journey that they are figuring out who they are. So again, why did I choose child and adolescent psychiatry? The experience of adolescence, figuring that out in real time is a beautiful thing. So, I think providers, again, they just need to have cultural humility to say, “Wait, I don’t understand this. Help me understand it.” Youth are more than willing to provide information to allow providers to understand. But then also that helps them understand what is this experience that I’m having? How did I feel about X, Y, or Z?

SHANOOR SEERVAI: So, let’s talk a little bit about the history. In the past, how are providers trained in being culturally competent, if they are trained at all? Where does this happen?

KEVIN SIMON: Yeah. So, I’ll speak to psychiatry. In residency we go through core rotations and there are some core textbooks that we read. Then obviously there’s supervision that we get from more senior physicians. But this goes back to the structural challenge. Well, who often are the senior clinicians or physicians? Who’s writing the textbook, which chapter . . . so within the DSM-5 and the DSM is considered quote unquote the Bible of psychiatry, there is now a section that asks us about cultural and diverse interview.

Now to me, I don’t think, knowing my environment, knowing how I’ve lived, when I engage with a family that’s of a diverse background, be it from Jamaica, or Trinidad, or something, I don’t necessarily always think about, let me make sure that I ask the culturally diverse questions. I think it would be a mistake sometimes for providers to think, “Oh, well I have this manual or I have this set of questions and I’m just going to ask these questions and I’m going to get the information that I need.” It is that we need a diverse population of supervisors, a diverse population of patients, a diverse population of trainees, because the learning is bidirectional.

Oftentimes in learning, it’s unidirectional in that the teacher tells you what you should know. In psychiatry there’s a long history that we tend to, or the field has tended to, discount the voices of marginalized communities. So, in terms of the population of child psychiatrists that exist, there have been instances in which I’ve heard of older colleagues really struggling with just being adaptable and then the youth feeling very uncomfortable that they’re assigned to this older provider. There have been challenges, not only with misinterpreting gender, because again, now there’s a gender fluidity that some youth will have. It may be difficult for some providers to adapt and be able to say male to female transgender, female to male transgender, asexual, gender-neutral.

So, to answer your question, this goes back to the pipeline. The pipeline needs to be strengthened. There need to be trainees who become attendings like myself, that stick around in academia, such that we can be available to college students and high school students to afford them an ability to see, “Oh, wait a minute. Someone does look like me and is in the field of mental health.”

SHANOOR SEERVAI: And what are the mechanisms to ensure that this happens? Given all the problems we have with racism in health care, there’s probably an issue with racism and behavioral and mental health care too, right?

KEVIN SIMON: Yeah. So, I can speak to a couple of initiatives within some of our professional agencies that have specific mentorship opportunities, where I’ve been paired with a college student who very early expressed an interest in the field of psychiatry. I can say that from that person’s sophomore year till now, that person’s now a second-year medical student who still has expressed interest in psychiatry.

So, there are some pipeline programs, however, that’s not enough. What will also be important is in training environments, persons who are selecting who will be a trainee need to be diverse, such that when you see a school’s name that you don’t recognize or you see life experiences that you may not assume to be valuable, someone else that has again, different, diverse experiences might say, “No, no, no. Actually, although this person didn’t volunteer at 10 different places, they’ve noted for the last two years they’ve been taking care of their grandmother.” Or they’ve highlighted that they’ve had a part-time job as an Uber driver. That’s a skill that can be dismissed. You’re trying to figure out how to make your life work.

So, I think we need people that, again, that are diverse in terms of trainees, admission committees for colleges, admission committees for medical schools, because so far historically, a certain type of person with a certain type of background finds themselves in certain types of graduate education. I mentor students now out that I say, “Okay, let’s start early in terms of the application to medical school.” Immediately when they start to review that they say, “Wait a minute, it costs how much to apply.” Right?

SHANOOR SEERVAI: Right.

KEVIN SIMON: Not even attend, just apply. It’s like, “Yes. Attempt to submit the application for reimbursement.” So very early on, people are met with, “Wait a minute, maybe this is not for me.” This is what happens with a number of students that are Black and brown is hurdles start so early, where they’re motivated and then they’re like, “Wait a minute. I got to pay $1,000 to apply?” And not get in. Just apply. That becomes a psychological order where it’s like, “Is this for me? Maybe it’s not.” So, it’s a complex set of answers in terms of figuring how we bolster at least the workforce.

SHANOOR SEERVAI: As you say, it’s going to take a very long time for us to have a core of providers that looks more like the patients they’re caring for and that share their lived experiences.

Dr. Kevin Simon, thank you so much for joining me today.

KEVIN SIMON: Thank you for having me.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.