JMEPP staff writer Lynn Ezzeddine interviewed Dr. Brigitte Khoury, the first psychologist in Lebanon’s most reputable hospital, American University of Beirut Medical Center, and the current president-elect for the international division of the American Psychologist Association. The following discussion covers mental health in the Middle East: stigma, needs, access, and barriers to care. We look forward to having Dr. Khoury at the Arab Conference on April 5th, where she will continue the conversation about mental health in the Middle East.
Q1. Please tell us about your experience working as a health professional in the region. What have been your greatest accomplishments? Alternatively, what have been your greatest obstacles?
A. I was the first psychologist in the newly established psychiatry department at AUB-MC back in 1997, and hence the first t to be both a faculty member and a clinician in the hospital. It was a great opportunity to start establishing psychological services at AUB, at a time where the country was rising from the war, many expats were back, and new blood was pumping in Lebanon. My greatest accomplishment was founding the Lebanese Psychological Association in 2004, which after years of lobbying, succeeded in passing laws for guidelines of practice and a licensing process for practicing psychologists. We are currently in the process of establishing an Order of Psychologists, which is like a professional syndicate with compulsory membership.
I was also asked serve on the advisory board of the revision of the International Classification of Diseases (ICD) by the World Health Organization and coordinated the field studies for the Arab region. This led to the establishment of the Arab Regional Center for Research and Training in mental health at AUB, which I currently lead. I also chaired the task force for gender equity and Title IX at AUB and helped establish the policies and procedures against harassment and discrimination, making AUB the first institution to implement these policies in the region. I am currently the chair of the advisory board for gender equity and the advisor to the president of the university on these issues.
Another experience very dear to my heart was when I was invited to speak on the issue of Syrian Refugees in Lebanon, in front of country representatives and ambassadors at the United Nations headquarters in New York for Psychology Day in April of 2016.
My most recent accomplishment was being elected as the president of the International Division of the American Psychological Association (APA) last year. I am currently president-elect, planning to serve in 2020. I am the first t Arab and international psychologist to be elected to such a position at APA.
There are 2 awards I have received which I am particularly proud of since they speak to work and accomplishments in the community and with vulnerable populations. The first one was the “Presidential Citation for Human Rights and International Awareness” presented in 2016 by the president of the American Psychological Association, Susan McDaniel at the time. The second one is the “Leader in LGBT Healthcare Equality Award” which I received in 2015 from the Lebanese Medical Association for Sexual Health (LEBMASH) as a recognition of my efforts to promote training healthcare providers to be more LGBT friendly.
The obstacles were many, including being the only and first psychologist at AUB medical center to having to explain what psychology is,and how our services are essential to the treatment of mental health as well as a crucial component in the treatment of many medical problems such as cancer, women’s health, pediatrics, etc.
Another obstacle was lobbying with stakeholders in Lebanon to establish legislation protecting the profession of psychology and establishing guidelines of practice. I often met with the health commission in the Lebanese parliament to push for such a law, I lobbied doctors/parliamentarians who often saw psychologists as professionals unable to work independently but rather under physician’s’ supervision.
Finally, an obstacle I faced was working in the Arab region where mental health is dominated by male psychiatrists who often did not recognize the importance of psychology and even less when promoted by a woman. However, I was lucky to also encounter and receive support from many of them who were open and willing to collaborate for the benefit of individuals needing help and the advancement of the profession in the region.
Q2. In your experience working in Lebanon, what would you say are the barriers to access for mental health services in Lebanon?
A. There are two main barriers to access services in Lebanon: the cost and the accessibility and availability of clinicians. The cost of mental health services is often prohibitive since they are seen as secondary to other medical complaints. Psychotherapy is often seen as a luxury and not an essential part of the treatment which patients need to pay for. However, there is more awareness in this issue and our low fee training clinic has a long waiting list of individuals wanting psychiatric as well as psychotherapeutic services. Another main issue is that no health insurance plans in Lebanon cover mental health services including psychiatry, except for the AUB health insurance (for a limited number of visits). The National Insurance and the Ministry of Health cover psychiatric services but at a very low cost and for low income individuals. Accessibility is another main problem whereby most services are located in urban areas and in cities, while rural areas are rarely covered by MH professionals.
Q3.In 2011, you founded the Clinical Psychology Training Program at the American University in Beirut which is the first of its kind in the region. Can you tell us a bit more about the program? Since establishing it, how has this impacted the conversation surrounding mental health in academia and Lebanese society more generally? Have there been similar programs established in other academic institutions either in Lebanon or the region?
A. Since I started working at AUB there were always graduate students who were interested in volunteering and gaining some hands on training experience in clinical psychology. After a few years and with the support of the AUB administration, I proposed opening such a program which was very well received by the university, the students, and the MH community at large. There needed to be a structured training program in clinical psychology for Masters Level and higher to graduate professionals who could work in the field and provide much needed services. Our program is a two-year training program including didactics, patient observations, patient contact, inpatient experience, psychological assessment and testing, partial hospitalization program, and consultation liaison with other medical services who ask for psychological help. Students are closely supervised individually and in groups which gives the real value of the training experience. Since 2011, we have had 30 graduates who are now psychologists making a difference in the community. Although there are a few training sites in Lebanon where psychology trainees can get some observation or hands on experience, it is not necessarily enough training to become independent clinicians.
When we opened our program there were none similar to it in the Arab region, and I am not sure if there are any formal ones now. This is a major reason behind the lack of formal training of psychologists and the lack of high-level psychological services in the region.
Q4. In recent years, the refugee crisis has become an increasingly imperative issue for many countries in the Middle East. What are the specific mental health needs of the large numbers of refugees in the region/Lebanon? Can you tell us about specific projects taking place on the ground that seek to address these needs?
A. Mental health needs of refugees revolve around various levels of care, from basic support and counseling to more intensive psychiatric and psychological treatments. Contrary to common belief, being a refugee does not make everyone suffer from post traumatic stress disorders. Most are very resilient, rely on their social support and their inner strength to navigate an extremely difficult situation that they found themselves in. One of the projects I led through grants from UNFPA since 2012 was the training of health workers to run women’s groups teaching them problem-solving skills. We have trained over 50 workers in different workshops and from all over Lebanon who have reached out to around 600 refugee women at least. The workers then became trainers who trained other workers, hence sustaining the project and increasing capacity building. This past year we implemented a pilot trial on male refugees in Beirut, after adapting the intervention to them, with plans to start training health workers in this new adaptation in all regions in Lebanon.
Q5. In your new role as the president of the International Division of the American Psychological Association, what are your priorities in terms of strengthening the current mental health system in the region? Additionally, have there been any significant changes made in specific countries in MENA that you believe could be emulated across the region? Given the current political climate that has resulted in violent wars such as those in Syria and Yemen, what are the types of preventative measures and services a country needs to make it more resilient to disasters such as conflict and war? Assuming these were not in place prior to these conflicts, what is being done today to mitigate the traumatic impact of these events?
A. Being the first international president in the 20+ years of the establishment of the international division at APA speaks to the increased globalization of psychologists and their desire to work and gain experience in international settings. The two initiatives I have adopted are: the recognition of the various roles psychologists need to play in high conflict zones which is different from the traditional view of psychology (i.e. sometimes psychologists need to be advocates, cultural mediators, social mediators, etc.).The second initiative is focused on collecting information on various licensing practices and guidelines around the world to facilitate the mobility of psychologists interested in engaging in international work. This will allow an easier exchange of knowledge and expertise, as well as capacity building in regions where psychology is still at its initial steps.
In the MENA region, there is more recognition for the need of mental health. Lebanon is leading in having established a mental health strategy for the next 20 years, through the Ministry of Health which 5 years ago created the Office of Mental Health.Unfortunately wars and violence cannot be prevented , and I don’t know if any country is prepared for them. Having a crisis intervention plan, funding for emergencies, and most importantly having enough manpower to manage such crises is the key factor in alleviating trauma and other consequences the general population may suffer from. This has been mostly the role of NGOs, who collaborate closely with government bodies to establish the much needed programs. This is what Lebanon has witnessed time and time again through its long history of wars and crises.
Q6. There still appears to be a certain stigma around mental health in the region that makes it difficult for patients to seek professional help. How can we overcome the stigma around receiving mental health care in the Middle East? What programs are currently being implemented to correct this stigma? Additionally, what type of social change needs to take place in the region to make citizens more receptive to mental health programs?
A. The more we talk about mental health the less stigma there is. Awareness campaigns on the levels of the population, the health professionals, the insurance companies, and the various stakeholders are needed. Also once mental health is covered financially as any other illness, this will decrease the stigma around it. There have been many initiatives in the region around that. The media plays a major role in this endeavor and can make a big difference in informing, advocating, and destigmatizing mental illness. Primary care physicians should also be trained to acknowledge and counsel less severe mental health problems, which will allow for greater care and counseling accessibility.
Q7. What disparities and inequities in mental health access and quality exist among different populations in the Middle East?
A. Countries differ as per their mental health policies, coverage for their citizens, and the number of professionals that offer services. For example the UAE offers all individuals working in the country MH coverage. Yet the professionals working there are mostly expatriates, trained in various countries and not necessarily acculturated to the Arab or UAE culture. It is very important for countries to have proper training programs, forming professionals in evidence based MH care, culturally sensitive and ethically principled.