Seeing the Unseen: Caring for the World

In May of 2001, I attended Dr. Craig Katz’s Grand Rounds presentation at Mount Sinai, discussing disaster psychiatry work during an earthquake in El Salvador. Straightaway, I volunteered with the organization he had co-founded in 1998, Disaster Psychiatry Outreach (DPO). The rest is history, and I’ve worked in the field since then. DPO became part of a larger organization and continues as the Crisis Emotional Care Team at Vibrant Emotional Health (Vibrant runs the 988 Suicide & Crisis Lifeline as its largest program).

In the course of disaster response work, Dr. Katz was inspired to become a global psychiatry leader, addressing problems before they become disasters and building baseline community capacity in regions where resources are lowest, and needs greatest. In addition to his considerable academic and clinical accomplishments, Dr. Katz has shared his experiences in a just-published memoir, detailing his work of over 25 years through the eyes of fictionalized characters, Sam and Berko. His distilled and masterfully written volume chronicles the experiences of our protagonists as they navigate the spartan landscape of mental health in underserved regions of the world.

I hope you enjoy this brief interview with Dr. Katz about his writing, work, and vision for global health.

GHB: What is “global psychiatry” and how did you get into the field?

CLK: I began working in disaster psychiatry first, which is a story unto itself, but when I began to find showing up places to provide psychiatric care after a disaster is usually too little, too late when it comes to mental health care that was usually limited pre-disaster (mental health care too often was already a disaster unto itself), I shifted to doing global mental health (which I prefer over psychiatry), i.e., psychiatry that tries to improve access to mental health care in general. Running off to disasters also started to become an ill fit for my life when we had a family and I started to build up my patient caseload.

I was always interested in international work from the beginning for whatever reason. But, more specifically, when we went to Sri Lanka following the 2004 tsunami, a teacher stood up at a school we were visiting to teach about how to identify and help kids in distress and, after thanking us for coming, more or less asked, “But where were you before?” I wish I had their name, as that moment really shifted me to thinking about going places in non-crisis times to help improve psychiatric care, focusing on development rather than crisis work in global health. That is when I was lucky to join colleagues from emergency medicine, pediatrics, and internal medicine in the nascent Global Health Center at Mount Sinai, where I work, who welcomed psychiatry to the table and enabled me to start our program in Global Mental Health.

GHB: What is Unseen about and what inspired you to write this book?

CLK: Unseen is a story about what it’s like to have and to try to treat mental health problems in the “developing world.” It tells the story of two fictional men, Sam and Berko, saddled with major depression and schizophrenia, respectively, in an unnamed country that is a mash-up of the many places myself and my colleagues have worked through our global mental health program. The book attempts to capture the challenges they each face understanding what is happening to them and getting and accepting help, and the various people, helpful and less helpful, along their journey. At the same time, Unseen portrays how “there” can be “anywhere” by providing glimpses of the mental health issues of a relief worker’s mother back home.

I decided to write it as a form of advocacy for better funding for mental health, to open people’s eyes to the “mental health gap” that exists between mental health needs and resources around the world, including here in the U.S. Hence, the name Unseen. Mental health care in general is underfunded, and if you try to do it in low-resource settings, that deficit gets even worse. Frankly, I have grown weary of the year-to-year funding existence of our global mental health program.

GHB: What would you like readers to glean from Unseen?

CLK: I am ambitiously trying to reach several audiences as well as convey several messages about mental health. And, I wanted to do it by showing rather than telling. For all readers, I wanted to bring mental health problems to their awareness as a major source of worldwide suffering. After all, the category of mental illness makes up the largest cause of worldwide morbidity among all health problems. I wanted to show readers less familiar with mental illness what it is like through the stories of Sam and Berko, which I think are very poignant. I also wanted to humanize sufferers and address stigma. Despite living in an impoverished, faraway place and speaking with an accent, Sam and Berko possess a humanity that looks a lot like “ours,” and they suffer just like us. And, I am speaking to potential funders like foundations and even agencies like the U.S. Agency for International Development, hoping to move them enough to make mental health part of global health. As the World Health Organization says, “No health without mental health.”

At the same time, I wanted to get out of the donor-recipient model many people hold about global health and have a smaller plot line about a relief worker whose mother back home in the wealthier but unnamed country from which she hails lacks access to a psychiatrist for her manic depression. Finally, I want to inspire mental health professionals to go out into the world and not just expect the world to come to us. Even if America and the rest of the “West” have their own mental health gap, we are still the haves and have a duty to help the have-nots.

GHB: What do you view as the greatest successes of global psychiatry?

CLK: I think that global mental health efforts that focus on training and education of people in low-resource settings around the world are a real force multiplier. We do not go and treat patients but instead, try to expand the number of people who are equipped to treat them. This means doing what’s called task-shifting and teaching what WHO calls nonspecialists—community members, community health workers, teachers, nurses, physician assistants, and primary care providers—how to address, or better address, mental health issues in their communities and their practices. We plant a seed that can grow without us by leaving behind knowledge, skills, and confidence around mental health. Psychiatry has for too long often been a stubbornly reactive, clinically focused field that arrogantly expects people to come to it, but global mental health pulls psychiatry in the direction of proactivity and public health. We consider communities and countries to be our patients, and we make house calls.

GHB: What are the challenges lying ahead for global psychiatry, and what is your vision?

CLK: I believe that too much of the limited funding in global mental health goes toward research, which is the focus of most American global mental health programs. More needs to go toward service. First, I think of a colleague in the eastern Caribbean who responded to my desire to conduct a needs assessment among their primary care staff before we launched into training them in mental health. She waved her hand at me and said, “I assure you no training you do will be wasted here.” Second, there are landmark studies of task-shifting where community members effectively learn and apply evidence-based psychotherapies for such conditions as major depression and PTSD, but when these amazing studies end, so does the service. We should go back to all of the places where these studies happened and transform the findings into sustainable treatment programs.