Honoring Black History Month: Q&A With Dr. Stephanie Le Melle
Stephanie Le Melle, MD, Columbia’s Director of Public Psychiatry Education runs the Public Psychiatry Fellowship where she trains the next generation of psychiatrists devoted to the recovery of people with serious mental illness. She grew up in a politically active family and early on had a sense of public duty. Dr. Le Melle eloquently shares that Black History Month “reminds me that my predecessors had to deal with a lot more than I have to deal with now. They had to deal with injustice and physical brutality, and they still tried, they continued to pave the way for me to be where I am now and that it’s my job to continue to pave the way for the next folks who are coming along. None of us got here by ourselves, whether we’re minority or not, there were people that paved the way and had to work hard to get to where they were to allow us to follow in their footsteps. And so, for me, it’s the celebration of that passage from one generation to the next and to do what I can to pave the way for the next generation."
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Communications: Tell us about your work.
Stephanie Le Melle, MD: I’m the Director of Public Psychiatry Education for our department. I run the Public Psychiatry Fellowship Program, which is a one year, post-doctoral fellowship for 10 fellows a year. Our fellows come to us 2 days a week for didactic training and supervision and they work 3 days a week, as part time attending psychiatrists, in public behavioral health programs throughout the city. They tend to work with people that have serious mental illness and complex needs in the shelter system, CPEPs, Rikers Island, ACT teams, crisis centers, essentially in any community behavioral health program that serves this population.
I am also the course director for the community psychiatry curriculum for our residents. We have didactic curriculum across all 4 years of residency training. Pre-COVID, we also took the residents to recovery oriented, community behavioral health programs so that they could get a sense of what’s available in the community. Residency training is primarily focused on acute care and on a private practice model of care. Residents, therefore, see people in the emergency room or inpatient settings when people are at their worst. Residents don’t get much exposure to how people actually live when they are well in the community. So we try to provide this exposure for them.
Communications: Why community psychiatry? Why the Public Psychiatry Fellowship? And what’s the current state of community psychiatry?
SL: Social justice, civil rights and civil liberties have always been something I was interested in. My family was very politically and socially active, so I think I grew up with a sense of my civic duty to be a good citizen, take care of others and to provide for underserved populations.
When growing up, I had never really been exposed to psychiatry. I didn’t know anyone who had ever gone to a psychiatrist. So it wasn’t on my radar. But in medical school I was drawn to the folks who had serious mental illness and I spent time in the “back wards of the hospital” and would sit and talk with the people there. The more I learned from people who had serious mental illness (SMI), the more I realized how marginalized they were. I realized that although their symptoms were being treated, the other conditions of their lives were not being addressed. I became aware that even my peers, other medical students, residents and attendings, were not giving people the same sort of attention or consideration as they did other patients. Also, people served in the publicly funded systems of care are poor and people of color are over represented in the public sector healthcare system.
I have this habit that when I get angry, my advocacy button gets pushed and I start to try to figure out, Why is it that these folks are being treated differently? Why is it that they can’t get the kind of treatment that they need? Why is it that they keep ending up in the hospital? Seeking answers to these questions, led me to try to better understand community and public psychiatry and the importance of social determinants of health.
I also had some really terrific mentors, one of whom was Merrill Rotter MD, the Director of Law and Psychiatry at Einstein – Bronx Psychiatric Center, who at the time, was starting the very first mobile crisis team and CPEP program in NYC at Elmhurst hospital. As a med student, I did an elective with him and that solidified my commitment to psychiatry. I think working with Merrill and seeing how he worked with clients, how he helped to develop a system of care for clients who had complex needs, and how important continuity of care was for these clients, led me to community psychiatry. This was my first exposure to recovery oriented systems based practice.
When I found out about the Public Psychiatry Fellowship Program here at Columbia, I applied to the residency training program at Columbia because I thought I would have a better chance of getting into the fellowship. As it turns out, that was not necessarily true, but it worked out for me anyway. I met Jules Ranz MD, former director of the PPF, when I was a PGY1 and immediately told him that I wanted to be a fellow and we discussed public psychiatry at the yearly resident cookout. He basically said, “Yes, you’ll be a fellow; you just have to finish residency and you’ll be a fellow.” I also had Francine Cournos, MD, the Director of the Washington Heights Community Services (WHCS), as a mentor. I spent a lot of time, as a resident, in the WHCS. When I graduated residency and then graduated from the Public Psychiatry Fellowship, Fran asked me to join her as the Associate Director for the WHCS. I guess it’s just my calling. Public/community behavioral health fits with my beliefs, my curiosity and my desire to advocate for underserved populations.
Communications: You were at the Washington Heights Clinic when it began to be seen as cutting edge community psychiatry.
SL: Yes, I think WHCS really was cutting edge. The Washington Heights Community Service was the only clinical, nonresearch, service in our department. WHCS provided continuity of care from inpatient care, to outpatient clinics, to the CPEP. Our outpatient staff knew our inpatient staff, we had recovery oriented multidisciplinary teams that communicated regularly with each other across these services. Washington Heights was designed intentionally by our first Director, Chris Beels MD, to be a community program that was client centered and where the expertise of each member of the multidisciplinary team was recognized and respected. Everybody contributed equally to the care of people. It was patient-centered care and recovery-oriented care based on what individuals needed including addressing their social determinants of health in a culturally informed way.
Communications: The view that mental illness is not a crime is getting traction. 988, the new psychiatric response number will be implemented in all communities. Health staff, not the police will respond. Your thoughts?
SL: I think that 988 is a starting point. However, what we really need is crisis systems of care and right now we have emergency rooms, inpatient units and the criminal justice system. We really need to have a spectrum of collaborating services and preventive services. We also need to address police brutality against people with mental illness and people of color. Police are not clinicians and should only be involved in mental health emergency responses under very specific conditions.
Communications: Planning grants have gone to the states, and Bills are being introduced in Congress to finance the continuum. Make sense?
SL: One of our fellows this year is working at the Support and Connect Center, through Project Renewal, which is a diversion program that was just started. It tries to address the need for “a spectrum of services” for people in crisis. Programs like this act as diversion sites for police to “drop off ” people who need assistance, social services and peer support but are not acute enough to require emergency care. These programs have overnight beds where people can stay for several days, get services, treatment and avoid having to go to an emergency room or end up in the criminal justice system. Clients can actually get their needs met and remain in the community.
Communications: So many pockets of excellence that are unknown to most. The fellows are involved in diverse agencies and programs. Do you have thoughts on how we can help the public, those in need, know about what’s out there and how to navigate the possibilities?
SL: That’s a complex question. I think that part of the problem is that we, as a society, have so many preconceived notions, bias and misconceptions about people with SMI and complex needs that most people have no clue that these sorts of programs exist, nor would people even think to look for such programs. I think we have to educate the public and the health care systems, in general, about the need to provide recovery oriented, systems based practice and evidence based practice for people with SMI. These services also need to be viewed through the lens of social justice. We have to address the collective fear that the general public has about people with mental illness then we can introduce people to the excellent services out there and they will better understand the mission of these programs.
I think in an ironic way, the opiate epidemic, which was initially more prevalent in non-minority populations and across multiple socioeconomic groups, has actually helped us by decriminalizing substance abuse and mental illness associated with substance abuse. This has allowed people, who have complex needs, to get care/treatment and not be arrested for drug use and possession. Mental illness and substance abuse are now less often seen as volitional or moral weakness but instead are seen as illness that requires treatment. I think the more we can see people with behavioral health needs as needing treatment and not label people as weak, bad or dangerous, the more the lay public will be willing to support community treatment programs-- even in their own neighborhoods. Then we can talk about the excellent services available in the community and have opportunities to tell different stories about people with SMI. We can have people talk about their life stories and about the impact that having effective, efficient behavioral health care and support services has had on their lives.
I’ll give you an example of how we are trying to implement change in the perception of behavioral health care — six years ago, in our fellowship program, we started what we call the Peer Advisor Program. We work with 10 peer advisors who are people with lived experience in behavioral health care and who are working as peer counselors in different sites throughout the city. They are each paired with one of our fellows. Each month, the peers meet with the fellows and they talk about all sorts of different topics. We started the program really out of our own self-interest because we wanted our fellows to have an opportunity to learn about recovery from people with lived experience. We also wanted fellows to think about the work that they do through a recovery lens and to address their own biases in the process.
We weren’t initially thinking about the impact this program was going to have on the peers, but, as you can imagine, humans are humans, and it had a significant impact on our peer advisors and fellows alike. We are now in our 6th year of this program. I believe that how our fellows view people with lived experience, and how our peers view psychiatrists, has completely changed. Fellows and peers now see each other “as people” with life stories. They have had the opportunity of engagement without the power differential of I’m the doctor, you’re the patient. Instead, they are just two people sitting down together, curious about each other, talking and sharing ideas. I think our fellowship program is the only program in the country that’s doing this and we are hoping to write it up. It is one of many things on our list of things to do!
I think we have to see people as people. We all have the same needs and desires but some people have more privileges and advantages than others. When you can speak with someone honestly and have a shared curiosity, then we can talk about all sorts of topics including changes in the behavioral health systems. We have peers and clients, talk about their lives, goals and dreams. This allows fellows to see people as people and not seen as other, as different, as less than, but just people who are striving to live their best life like everyone else.
Communications: It’s Black History Month, recognizing and celebrating the contributions of Black Americans. As part of a university, how should we be thinking about race and change?
SL: Well, I think what you’re talking about is systemic and institutional racism that exists in all aspects of our society. It exists in healthcare, it exists in housing, it exists in business, it exists in education, everywhere. So we have to address this systemically at all levels-- personal, organizational and societal levels. I think there are lots of ways that we can do this, but first we have to be willing to do it.
Addressing racism is not a minority issue. It is actually a majority issue. Minorities have been trying to address these issues for years and it has had some impact for sure. The fact that I’m sitting here talking to you as an Associate Professor at Columbia University and running a program in our department I think speaks for itself. However, the fact that we have no African American full professors in our department also speaks for itself. So why is that? Why do these disparities and inequalities exist? There’s a long history to this. But I think we should focus on what can we do about it now?
Communications: Say more?
SL: I think we have to get over our “fears of other;” that if we empower and support other people that somehow that diminishes us. We have to address our standards for measuring people’s value and measuring success and measuring contribution. In our society, our “baselines” are based on majority standards and this is an arbitrary measure. This standard of measurement diminishes all other standards and labels differences as “abnormal, deviations from the norm.” So anything other than the white standard is outside of the bell curve. There are other measures, besides standardized test scores, number of publications, like life experience, that should be considered and valued.
So I’ll focus on our department for a moment — if we look at our faculty pipeline, our residents, we have had some increase in diversity over the years. I think that much of this diversity is due to Melissa Arbuckle MD, our Residency Training Director. Melissa has made a concerted effort to recruit more minority applicants to our residency program and we have accepted more under-represented minority applicants. We, however, don’t seem to keep them. They are accepted in residency, get trained by us, but then they don’t stay. Why is this? Is it that they don’t feel welcome? Is it that we don’t offer them sufficient financial support to stay? Is there some other reason?.
I think we have to look seriously at who we encourage to stay or not stay. We also need to look at how we distribute our resources. If we really are interested in growing our faculty’s diversity we have to look at retention of our minority residents and we have to actively recruit minority faculty. We’ve done ok but I think we can do better.
We should recruit from the historically Black colleges, universities and medical schools. There are other Ivy League schools that do this successfully. Once we diversify our training programs, and not just in our residency training programs but all of our fellowships as well, we need to figure out what we need to do to get them to stay. By increasing the diversity of our faculty, I think we’ll naturally begin to diversify our research focus and the people participating in research. Faculty diversity may also diversify some of the funding streams that support our research and clinical services.
Communications: Talk about retaining trainees?
SL: Some faculty members will leave for their own personal reasons. Other faculty however, leave because they didn’t feel welcome or have not had a position made available for them to stay. There are meaningful ways that we can address this. One possibility is deliberately investing resources in minority recruitment, retention and meaningfully engaging with underrepresented faculty members and residents. We should make sure that people get support for the advancement of their academic careers, promotion from assistant to associate and from associate to full professor. In terms of research, we should prioritize support for minority researchers. We should provide space and fiscal resources to help bridge their research in a meaningful way.
On a clinical level, we’re right smack in the middle of Washington Heights, which is a very diverse community, yet when you look at who we recruit to be research subjects, or who we admit to our free resident treatment program, we’re not treating people from the community. Diversity takes place on lots of different levels and I think there are some real meaningful ways that we could change the way we are interacting with the community. Community engagement would be greatly enhanced if we had a more diverse clinical research focus on health care disparities and community needs, and diversity of researchers and others who provide clinical care for the community.
Communications: How do we begin discussing these issues? Where should these conversations take place?
SL: I think it has to be from the bottom up and the top down. It has to come in both directions. I think we can start with our trainees by helping them to be reflective of their own biases and stigma and how that impacts the way they interact with each other and also with the clients we care for. Like in our emergency room, when we’re doing an evaluation, but not just in an emergency room — in any clinical evaluation -- we put down “African American female.” Why is that even relevant? It’s just a female who needs care.
Having cultural sensitivity and cultural humility is hugely important in the ongoing treatment of a person so it shouldn’t be ignored, but it shouldn’t be the criteria to decide who gets what type of treatment or who goes to which inpatient unit. So we can start with our trainees and help them to understand when it is necessary to address racial or ethnic identity and when it not. Again, prioritization of resources, who gets hospitalized and where? Who gets referred to which clinic? Who gets invited to be a patient in the resident clinic and who’s not?
I think that part of education is actually exposing people to what they don’t know, so there’s all sorts of knowledge that needs to be gained, and I think that the Office of Equity, Diversity and Inclusion will help with some of these educational goals. It should not be that this office alone is responsible for change. Departmental culture change needs to be supported by our administration, everybody needs to be involved and once we are more aware of our own bias as a department, we can begin to look at the data addressing bias/discrimination, in specific areas of care, that we prioritize to address. We can come up with program evaluations and design implementation of change projects around the analysis of the data in a meaningful way. So it can be done, but it requires buy in from both directions, from administration, faculty, staff and trainees.
Communications: On a final note, tell us what Black History Month evokes for you?
SL: Black History Month really reminds me that my predecessors had to deal with a lot more than I have to deal with now. They had to deal with injustice, humiliation and physical brutality, and they still tried. They continued to pave the way for me to be where I am now. I feel it is my obligation to continue to pave the way for the next generation of folks who are coming along behind me. None of us got to where we are by ourselves, whether we are minorities or not. There were people that paved the way and had to work hard to get to where they were to allow us to follow in their footsteps. And so, for me, it’s the celebration of that passage, from one generation to the next, to do what I can to pave the way for the next generation.
Communications: That’s a beautiful note to end on. Thanks so much.