In this podcast, Dr. Aisha Sanober Chachar, recent ACAMH Awards 2020 Winner (Clinical) Trainee of the Year, talks about the many different roles a CAMH professional has, be it researcher, clinician, carer, and even storyteller.
Aisha talks about the global dearth in CAMH specialists and the impact for mental well-being of young people, and how to enhance cross-cultural learning to foster a more global approach to child and adolescent mental health.
We also learn about Aisha journey as a clinician in Pakistan, Nigeria, and the UK, as well as her thoughts on health disparity, and the disadvantages faced by those populations who have been neglected.
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Interviewer: Hello, welcome to the In Conversation Podcast Series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today I’m interviewing child and adolescent psychiatrist, Dr. Aisha Sanober Chachar, Medical Director of the AAS Trust in Pakistan. In 2018 Aisha started her second fellowship in child and adolescent psychiatry and has a special interest in transcultural child and adolescent psychiatry. Aisha has just won the ACAMH 2020 Clinical Trainee of the Year award. If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with the rating or review and do share with friends and colleagues. Aisha thank you for joining me and congratulations on your ACAMH award. How was it to receive that recognition?
Dr. Aisha Sanober Chachar: Thank you, Jo, for inviting me to this podcast. Yes, it was very exciting and entertaining, though two of my seniors and very good friends nominated me and I wasn’t really sure if I was going to be selected, but when I did receive that email it was huge. In itself the nomination was something that I was very happy about. The award was something that I wasn’t really expecting because nomination made me so happy. But it was really interesting how the entire ACAMH organisation made it like a game, sort of like a mystery game. It was really exciting the way an sent an e-mail and then the books that they sent and we were not supposed to open, and I think it was the day before the awards ceremony I received an email that I have to stay there or I should be there in case I was planning to leave because I was nominated for both categories, which to me was again a shock that, Okay, it was huge.
It was encouraging in terms of I also talked about in my short speech there in the awards ceremony. It’s huge for Pakistan.
Interviewer: Aisha we’ll look more closely at your work in a moment, but can you give a brief introduction about who you are and what you do?
Dr. Aisha Sanober Chachar: Yes. As you introduced me do that me I’m considering child and adolescent psychiatrist in Pakistan and I have recently, I mean it’s been three months that I’ve joined this new almost like leadership position as a Medical Director at AAS Pakistan. So my work is, the major part of my work is clinical. I see children and teens with mental health problems, disorders, and now that AAS most of my clinical population is around teen substance use disorders and even child substance use disorders. So that’s my clinical work and I do a lot of scholarly work and medical education based activities. So training, capacity building and programme evaluation, and also I am a Balint Leader. So I’m currently getting my leadership pathway to become Balint Leader from UK Balint Society.
Interviewer: Aisha, how did you come to be interested in child and adolescent mental health?
Dr. Aisha Sanober Chachar: I believe this is something called psychic determinism, and I really believe in this phenomenon, like mental health chooses people. It’s not that people choose child and adolescent mental health.
So I think during my residency the concept of developmental understanding of everything, be it psychopathology, be it anything, education, learning, at what stage is what expected of me or anyone.
It could be a teacher, it could be a student, it could be a child, anything. Developmental understanding. At what developmental stage are you right now? So that is something that really was fascinating and then in Pakistan, at that point in time, there was no pathway to become a child and adolescent psychiatrist and I wasn’t planning to go abroad and get that. So I had no idea that I was going to get into it. I think it was just I got lucky, that my mentor Doctor Ischaemia, he moved to Pakistan around six, seven years ago and he introduced child and adolescent psychiatry, and then she started the very first fellowship programme there. So I was graduating and I didn’t really know if I was going to get into it and my friend got into the fellowship programmes and then I ended up taking student psychiatrist positions and as a student psychiatrist and also junior faculty at our university. I waited for two and a half years to reapply and a lot of people told me that I should think about it. I could easily be Assistant Professor, but I was adamant that no, this is something that I want to do. So I waited for two and a half years and then I got into it. I applied and I got it.
Interviewer: Right, you really have to persevere then. In a recent blog for ACAMH you described CAMH professionals as having a multidimensional role as clinician scientists. What does being a clinician scientist entail?
Dr. Aisha Sanober Chachar: Well, it’s something clinician scientist is a term that was used in a paper. I think it was in 2014. Reflections on the current and future roles of clinician scientists signed up for that. So this term is used for specialists who are engaged in both clinical and research based activities. So as a child and adolescent psychiatrist and this is how my training has been, so there are only few people, let’s say in Pakistan, max seven to eight if someone has recently moved in.
So there’s a lot of capacity building, programme development and task sharing. A lot of empowering others. So when I say clinician scientists this term is really to me, I think this really describes the essence of what a child and adolescent psychiatrist does.
Interviewer: In the same blog you highlighted the global dearth in CAMH specialists. What is the scarcity attributed to and what does it mean for the mental well-being of young people?
Dr. Aisha Sanober Chachar: It’s really interesting because it’s something that we talk about it now, but historically speaking childhood, children it has been a neglected area and childhood was never acknowledged. It was only recent in the past two centuries. Paediatrics per se, as a medical speciality was not very well recognised and I think similar, sort, of like parts were taken out. Hereditary was taken by challenges as well. So, and it also is a highly specialised field, a speciality. So there’s medical school five years, and then if I talk about Pakistan, then there’s one year of internship and then there’s very competitive land that you take, and then four years of adult training and then there’s an exam and then two years of training and then one becomes a psychiatrist.
So I mean, if we just talk about Pakistan. If I start from Pakistan. So there was no fellowship programme to begin with. There are no trained professionals and then if there’s no trained professionals there are no training programmes or minimal training programmes and then there are no training programmes. People don’t understand the importance of it. I mean, today I’ve been asked from many, many people what do you mean by child and adolescent psychiatrist.
Do children or adolescent even have any psychiatric problems? So, yeah, I think there’s a lot of hypocrisy that’s needed for it to be recognised. So this is also causing the overall shortage of workforce.
Interviewer: I’m quite shocked by that. So there’s really this belief that there’s just no… That it’s not a specialism almost.
Dr. Aisha Sanober Chachar: Yes. This is something that I often joke about, that I have to justify that what do I do for, like whatever I do, and usually my response is that you can’t really understand what is a deviation from normal when you don’t know what is normal. So a lot of times and most of the times, what is normal childhood behaviour? People don’t know.
Interviewer: Aisha, what schemes exist to fill some of the gaps that you’ve highlighted.
Dr. Aisha Sanober Chachar: I think one of the excellent initiatives taken by organised child psychiatry and international organisations like ACAMH. I think these organisations have really identified and then have taken measures to bridge that gap.
So since we are… and this not just Pakistan. Overall, even US has, I think, around 9,000 child psychiatrists. There are not enough for the population. Overall internationally there is a shortage and it can’t be taken care of if everyone will work in their silos.
So it has to be collaboration and then also something that I firmly believe in is that we should discount. We should not reinvent the wheel. If something is done somewhere and we can collaborate we don’t have to spend that amount of energy in our ATPs and replicating that and reinventing that. Of course, replication we can do. So last year I was fortunate enough to become helmet research seminar fellow. So that brings around 20 fellows from the region and there’s a robust one week training and a lot of clinician scientist related. So ACAP has now started a research college. So there are these short fellowships that are identified by these organisations, and I also feel that the very fact that ACAMH has this opportunity to acknowledge someone internationally and especially from developing countries. Someone like myself, who is trying to justify my speciality, I think a lot of advocacy is done through this award process.
Interviewer: For your CAMH elective rotation I understand… So this is going back a bit, but that you worked at the Maudsley Hospital in South London, and I’m wondering what insights you gained as a trainee from a developing country working in the UK.
Dr. Aisha Sanober Chachar: It was really interesting. My very first was with Doctor Godana and then I worked with the Child Sexual Abuse Team, that was Doctor Tara. And it was really interesting how the detailed assessments were done. How systems were in place. How the referral system was so robust. People used to get…parents used to get the forms beforehand and whenever they would come in they would bring in those forms. I was really amazed at how much of thought process is put into this.
So I learned that, but most importantly, I think it was in South London, it was this place where I was rotating and the way it was all structured. I mean, it was so friendly. It was very well thought. I mean, I’m saying this now and I’m just thinking maybe now it’s not a big deal for me, but at that point in time it was almost seven years ago, I was really fascinated by how much trust that is put into everything from infrastructure to, like, paperwork and everything. So the system in place was something that I was fascinated.
Interviewer: Then as part of your Child and Adolescent Psychiatry Fellowship, you experienced an international elective rotation in Nigeria and again, really, what insights did you gain from being a trainee in a developing country?
Dr. Aisha Sanober Chachar: That was altogether a different experience, very different. I think I was very, very lucky to have Professor Langa. She was my supervisor there and now she’s become my mentor. The goal of my rotation was mainly to understand how in such limited resources, Professor Oma Gooran was able to develop this entire Master’s programme and I would say robust clinical as well as research based training that has been done there, and that’s Africa I’m talking about. That’s Nigeria I’m talking about. So, yes, there was those London, but then here I was in Ibadan and it was really interesting.
I mean, yes, things are possible. I mean, what I felt was that a lot of creative leadership is needed, especially in those settings that you can do things. It’s not that you can’t and this is something that I had in my mind when I was going to Nigeria and I learned a lot.
Interviewer: Why, in your view, is exposure to different health care systems such a valuable part of CAMH training?
Dr. Aisha Sanober Chachar: I think it’s mainly because, as I mentioned, that they’re very minimal trainers and psychiatrists.
So we have to focus a lot on what other resources are there for children and parents and families to tap into. So if they can’t access to health and mental health services, how about we bring or we take on child health and mental health services to them. So, through schoolteachers and religious communities and then parents and in order to do that we really have to understand the health care system policy that’s in Pakistan on paper you see, yes, there is primary care, secondary care but you also have to see the referral, the pathway of care and that’s mainly coming from religious scholars and people who tend to go to them first before coming to a primary care physician or GPs.
So I think to understand the nuances and local context of one’s health care system is not just important. I think it’s essential. As someone who is going to be a child and adolescent mental health professional.
Interviewer: What more would you like to see done then to enhance cross-cultural learning and to foster a more global approach to child and adolescent mental health?
Dr. Aisha Sanober Chachar: I think it’s also important to have more regional child and adolescent mental health associations, and then how they represent a certain country or parts. A lot of the regions do have that. Africa has that. Europe has that, but I think more of that and also the fact that, as I mentioned, more rotations, elective rotations from developed countries to developing countries and the other way around.
I think the more transfer of knowledge would happen and I think the best time is when the person is doing the training or a fellowship, because that’s where you start forming a certain kind of practice or clinical set. So I think if that is the very critical point, sensitive point I would say where the more exposure a trainee would get, I think the broader the vision would become.
Interviewer: Aisha, as you mentioned earlier, you are the Medical Director of Alleviate Addiction Suffering Trust, AAST based in Karachi. The AAST Trust provides treatment, rehabilitation and aftercare to adults and children, which includes residential treatment programmes for street children. Can you give a brief overview of the work you do with children affected by substance misuse?
Dr. Aisha Sanober Chachar: So, as I mentioned, that I have recently joined this position and I’ll be honest this is, you know, I have for the past ten years I’ve been associated with our university and there’s a different sort of way of working. S different, sort of, like academic decorum that that goes on. Very structured and this is a non-profit organisation and completely and almost in the middle of a pandemic. It’s a very, very different kind of, I mean, I know if I had not done my child analysis fellowship, I think I would not have followed up with this because a lot of work that I just mentioned, capacity building, sort of like assessments of children, but also inter-agency collaboration, let’s say working with schools.
Working with teams, and child abuse and neglect and then also working with local police and the juvenile system, not the police. The juvenile system, and these children are street children. I don’t like the sound of it. The children who are coming from disadvantaged backgrounds and it’s really, I would say, challenging to see an eight year old or a seven year old misusing, at times abusing drugs. So there’s a lot of executive leadership. There is also a clinical component to it but I’m navigating my way.
Interviewer: And do you think it has, the type of work has global implications? Could it be replicated elsewhere?
Dr. Aisha Sanober Chachar: Absolutely, yes. So the fact that I think in my blog I did mention that there’s a lot of learning that can go both ways, from developed countries to developing countries and the other way around. So, you know how, let’s say if I talk about the US, for example, a lot of the whole Black Lives Matter and the moments like that and the health disparity, the disadvantage and the populations who have been neglected, a lot of those things are a burden to a healthcare system of a developed country, no matter how much developed the country is.
But these are the challenges that now these countries are facing. So definitely this is something, this kind of model is something that can be replicated to other places where there is significant population from disadvantaged and marginalised communities.
Interviewer: Aisha, what else is in the pipeline that you’d like to mention?
Dr. Aisha Sanober Chachar: If I say a short-term plan. So I have coming up. I recently chaired a meditative session at ACAP. I’ve been working on a lot of manuscripts and as I mentioned, Balint leadership pathway is what I’m sort of working towards.
So that is something that I’m doing. I’m also in the process of manuscript writing and winding up a lot of research projects, and then my intermediate plan is to have a robust programme evaluation of this place that I’m looking at, but in terms of intermediate to long term, I see more of programme development, more of like informing policies and more creating opportunities, developing clinical services.
That is, you know, the broader areas. So whatever I do, the core of it has research and evaluation part of it. So that is something that is very close to my heart.
Interviewer: Thank you, and finally what is your takeaway message for those listening to our conversation?
Dr. Aisha Sanober Chachar: One of the most important lessons that I’ve learned throughout these years is that, yes, I’m a medical doctor by profession, by training, but there are multiple roles that people really need to understand, and when I say people, yes, the general population, but there’s also medical fraternity that I’m referring to because in terms of stigma and limited knowledge, there is significant limited knowledge even among medical fraternity. So as a child psychiatrist, yes, I am a clinician, but I’m also an educator, a researcher and I’ve realised that I’m also a storyteller. The way we talk to parents in the clinics. It really is about telling a story when we are talking about formulating clinical case. I’m an advocate and someone who builds the capacity of others that I didn’t know, that somewhere in my journey I would become a leader in terms of my circle of influence. So it’s important to identify and respect all of these things because this immense hard work that is put into it and I think it’s through this platform, one of the major takeaway message for whoever is listening is that child and adolescent mental health is something that we can’t now put on hold. The best time was yesterday, but it’s not too late.
Interviewer: Brilliant. Aisha, thank you so much. For more details on Doctor Aisha Sanober Chachar please visit the ACAMH website www.acamh.org and twitter@acamh. ACAMH is spelt ACAMH and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating on review and do share with friends and colleagues.