Hi, everybody. Thank you so much for being here today. I've got a group here with me and today we're going to talk to you about advocacy. And I wanted to make the point that our country has been founded on ideals of racism that have been going on for centuries. And today we're here to talk about what psychiatrists can do about that. So today we'll be talking about advocacy for anti-racist policies that expand equitable access to mental health care, the role of the psychiatrist. My name is Divya Chhabra. I am a second year child and adolescent psychiatry fellow at Columbia Cornell, New York Presbyterian and a SAMHSA fellow. And I'll be introducing the presenters and discussants who you'll meet later today. So our presenters are Craig Obie, JD, and Matthew Goldman, MD. Craig Obie is from the APA and Matthew is at UCSF. And our discussants are Stephen Starks, MD, and Christina Mangarian, MD. And we will all be meeting later on. So here are today's learning objectives. The first is to be able to conceptualize the meaning of anti-racist policies of specifically anti-Black racism and how they both influence mental health at systemic and individual levels. To identify the importance of serving as a clinician advocate. To describe key equity and equality issues impacting mental health and healthcare and anti-racist solutions. To identify tangible ways psychiatrists can effectively engage in advocacy individually and also through professional organizations such as ongoing work that's being done by the APA that you will hear about. And then we will describe current efforts being undertaken at the local, regional, and national level to address inequities and inequality in mental health care. So a little bit of an overview of how the session will go. First, I'm going to be presenting cases and some vocabulary that will be helpful for understanding the frameworks presented in this session. Then Dr. Goldman will be presenting about the development and application of an anti-racism resource document for mental health care advocates. And we'll be later applying this document to the case. And then Craig Obie will be presenting on current APA advocacy efforts and how to get involved. And then we'll be joined by Dr. Stephen Starks and Dr. Christina Mangarian to have a rich discussion on the importance of addressing structural issues beyond healthcare and what the role of the physician advocate will be. And hopefully we'll have time for questions at the end. So I won't be going over all of these terms, but I just wanted to point out a few different terms that are key to understanding this talk. So race is a social construct or creation of a social reality based on physical characteristics such as skin color and hair texture. And the key here is that it is a social construct. BIPOC is a word that's used for black indigenous and people of color. Some people use BIPOC and other terms are used as well. Intersectionality is a concept that really takes in many aspects of people's identities. So it is a cumulative way in which the effects of multiple forms of discrimination can combine or overlap in the experiences of particularly marginalized individuals, but we all have intersectional identities. For example, I am a South Asian woman and those two identities of mine interact together. And then in this talk, we'll be talking a lot about racism. So there's three types of racism, individualized and interpersonal racism. So those are the kinds of things that happen face to face and interpersonal situations where there's some kind of bias or hate or prejudice that's happening in conversation or in individual events. Then there's institutional structural systemic racism. They're not all the same thing, but they generally apply to racism that occurs from a higher level and across institutions or across a country or across the government, things like that. And basically public policies, institutional practices, ideologies, the social force of a country, all those kinds of things can generate and perpetuate racism. And then the third type is internalized racism, which is internalizing racial oppression by the racially subordinated. So the group that is actually oppressed begins to have feelings against themselves. And that's in a very simple way said. And then understanding structural competency. So historically, when we looked at people from different cultural backgrounds, we had started with cultural competency, which was a movement to basically be competent in understanding different cultures. And that was not sufficient because it's not a monolith. And then cultural humility followed this, which was being more open to understanding different aspects of cultures and how individuals relate to that. And then there is also this piece that is developed by Helena Hansen called structural competency. And basically this talks about inequalities that can be conceptualized in relations to institutions and social conditions. So if you think about this, you would really want to think about structural racism and how those go hand in hand. Equity and equality are basically, equality means everything's the same. And equity is adjusting things in different ways to have the same end result because some people start out at a different spot to begin with. And then I'll go past some of these. Yeah, we don't need to do all of these. And then here are some examples. So microaggressions often can occur in interpersonal racism, but also in other types of racism. And basically are verbal, behavioral, or environmental indignities, whether intentional or not, that communicate prejudice, slights, and insults towards any group. So this could be towards someone of a specific race, but also someone from a specific gender, sexuality, all different kinds of aspects of identity. Racism is basically the system of structuring opportunity and assigning value based on the social interpretation of how one looks, which I described earlier is race. And anti-Black racism is what we will be specifically talking to in a lot of this presentation, is the prejudice attitudes or beliefs that are particularly directed at people of African descent. And they are rooted in their unique history and the experience of enslavement and colonization, particularly in the United States, where that has not happened to people of other, in the same way to people of other races. And then anti-racism and anti-racist policies is what we'll be presenting and trying to get people on board with, which is the active process of identifying and eliminating racism by changing ourselves individually, as well as our systems and organizational structures as those go hand in hand. And lastly, trauma-informed, and that's, I put this term here because I think it really, you know, race, racism is a form of trauma. So I'm thinking about what has happened to this person versus what is wrong in all the care we give, and thinking about all of this in the lens of trauma. So here are the two example cases. And as you hear these, I'd love for you through the rest of the talk to keep these cases in mind and think about how different policies and different racist structures could be affecting these two cases and how we could problem solve these issues. So the first case is an 18-year-old Black male who lives with his aunt, and he's in 12th grade and has impulsivity and school refusal and a history of physical fights in school, marijuana use, and has previous interaction with juvenile detention, residential programs, and foster care, and he was put in foster care due to substance use in a father who is now incarcerated. And then the next case is a 36-year-old pregnant Spanish-speaking female who's a migrant farm worker, HIV positive, undocumented, and comes into the clinic with suicidality and a history by PV. She lives with her partner and two-year-old in a rural area that is far from the hospital and does not have access to a car. So now that I've given you some terms and also presented these cases for you to have in mind, I'm going to pass off the mic to Dr. Matt Goldman to talk through the anti-racism resource document. Hi, everyone. Thank you, Dr. Chhabra, so much for that introduction, and I'm excited to be talking to everybody today about the development of this APA resource document on advocating for anti-racist mental health policies. So again, I'm Matt Goldman. I'm Medical Director for Crisis Services at San Francisco Department of Public Health, and I'm also a volunteer faculty at UCSF in the Department of Psychiatry and Behavioral Sciences, and I'm here today in my role as a member of the Council on Advocacy and Government Relations for the APA. So the vision for this resource document really stems from the reality that racial injustices have long contributed to mental health disparities for minority and underserved populations, and APA members have forcefully called for doing everything possible to advance anti-racist policies by effecting change in the systems that perpetuate health disparities. This has become increasingly a strong priority of many of our members. While the APA has advocated strongly for addressing policy issues that are relevant to disparities in mental health, so things like reimbursement parity, collaborative care, crisis services, etc., things that Craig is going to talk about a bit later, there still does remain a need to critically review the APA's advocacy portfolio for its impact on anti-racist policies. And so through the process of writing, reviewing, and revising this document, we went about this as a council and in collaboration with other councils, which I'll describe in a moment, to really prioritize the centering of BIPOC voices. That's been paramount throughout our process, and it is something that I just want to give voice to from the outset. I also want to acknowledge that, you know, I am a white cis man who's here presenting to you about a resource document on anti-racist policy, and that's been a role for me to navigate, you know, as a person who has privilege to be on a council that has power and to be able to create a document that will eventually become an APA official document. You know, it's been a process of figuring out what my role is as an ally and as an advocate for these things that I care about but have not directly experienced to make sure that I am both helping move a process forward while also making sure that the process that I'm helping move forward is centering the voices of the people who are experiencing racism on the daily and who often are the ones who are leading this work for our field. So just wanted to acknowledge that. The authors also determined for this document that the core focus would be on anti-Black racism and the need to dismantle white supremacy. Definitely, we also acknowledged that and recognized that the impact of Black racism is tremendous on other BIPOC communities, so Indigenous, other people of color, Latinx, Asian Americans, etc. But the focus of this document was to focus primarily on anti-Black racism. So the objectives of this process were to define the issues, so describing existing structural racism in mental health, describing the need for anti-racist policies, etc., to identify anti-racist policy solutions at multiple levels, and you'll see the document is organized around these levels. So we wanted to address patient level, provider and staff, practice, institution, community, health system, local and regional government, state government, and federal government levels. We wanted to address the centrality of anti-racist policies that impact the well-being of BIPOC communities beyond psychiatric and mental health systems themselves. So not just focusing on mental health care policy, but also thinking more broadly about the idea of well-being and how mental health care advocates should really play an important role in anti-racist policy advocacy more broadly in order to really benefit BIPOC communities in the most effective and impactful ways. And also promoting advocacy best practices for the APA and other mental health groups to advance identified structural solutions. So the councils that were involved in the writing of this were CAGER, Council on Advocacy Government Relations, the Council on Minority Mental Health and Health Disparities, CMMHHD, and the Council on Health Care Systems Finance, or CHS. And we had a really wonderful group of authors. We're still in the process of writing this, I'll describe a little more about process, but this is the group of core authors who have really just been a wonderful collaborative group. We have members from all three councils that I described, including Dr. Kiki Kennedy, who's the chair of CAGER, and Dr. Bob Trestman, who's the chair of CHSF. Dr. Starks, who's one of our discussants, is an author. Veronica Searles-Quick and Divya, who are both CAGER fellows, were involved, as well as Gabby Hodgins. And then other fellows, so Joshua Anthony, Amanda Calhoun, and Tricia LaMelle, and Timothy Shea were all fellows who brought such hopeful perspectives to the process of writing this. And then finally, we also had Laura Halpin from CHSF, and Enrico Castillo from CMMHHD, who also were really expert, and especially on the structural competencies piece, contributed great material for this document. So it was a real collaborative effort. You can see people from a lot of different backgrounds and perspectives, and also career stages that really contributed to this document. As we've been putting this together, the process has been really important. So we focused strongly on having an inclusive, proactive, and transparent communication strategy with stakeholders, including the APA councils, our council liaisons to the APA Assembly, which the Assembly includes MUR caucuses, the APA Presidential Task Force to address structural racism throughout psychiatry, of which Dr. Starks is a member, the fellows, as I mentioned, and also APA staff from the Department of Diversity and Health Equity, and also the Department of Government Relations. We've been deliberate about creating opportunities for input. So we're currently in the process of inviting direct input from stakeholders to the councils. I should mention APA resource documents, they are technically products of the components or the councils of the APA. So that has been something for us to figure out. That's a sort of structural feature of the APA, as we have tried to create this document, that we have to make sure that we're going through the approved pathways to get input, and making sure that we're still maintaining the integrity of the process of this being a council document, while also doing our best to really engage stakeholders and meaningfully invite input to have this be more of a product that really reflects the needs and views of APA members. We've also engaged leaders in dissemination strategies, and that's something that, as we get closer to actual publication, we'll focus on further. And we're also interested in creating a platform for future iterations of this document to try to make this a living and updatable type resource. The goal is to submit this document to the APA JRC by early May 2021. Right now it's still late March, we're recording in advance, of course, and so hopefully by the time that you're seeing this, we'll have successfully submitted the document to the JRC for their review. The document itself, so it runs just over 30 pages. Here's the structure of it. So we'll start with an executive summary, which we're actually waiting on writing the executive summary until we've gotten input from stakeholders. We then have a forward intro definition, similar to what Divya went through. We start with a description of structural competency and structural action and anti-racism mental health policy advocacy. And then we go through the different levels that I described. So we start with patient provider level, clinic and health system level, community level, local and state levels, and then federal level. And then at the end, we go to advocacy best practices describing specifically the role for the psychiatrist and advocacy before then concluding and listing our references. And so what I get to go through here is briefly, each of the sections, there is a ton of amazing content in here. And again, this is a draft. So there's still room for input here, but I do want to give some sense of what's included in this document. And so I'll quickly go through each section to give us a sense of the shape of the document in its current form. So this first section on structural competency and structural action, I love the statement that it begins with. We must look beyond healthcare and health policy, structural determinants of mental health and wellbeing. So from a public health perspective, the majority of what leads to mental health has little to do with healthcare and health policy. Unmet social needs worsen mental health outcomes and addressing social needs improves them. So to help patients and populations achieve mental health and wellbeing, advocates working from within healthcare systems must look beyond health policy and healthcare interventions and advocate for anti-racist public policies. And so the authors of this section then went into describing anti-racism advocacy efforts beyond mental health, including in the realms of criminal justice reform, education, housing, and poverty and income inequality. They also really laid out some nice principles for identifying anti-racist policies, including things like focusing the work on anti-racism and the eradication of health inequities, especially for vulnerable and racial ethnic minority, minoritized communities, rather than on partisanship or other political concerns. This is not a partisan or political issue. This is a society issue. We must recognize the historical context of structural racism in our organizations, including the APA, and also in our work and the ways that racism, classism, and privilege continue to propagate power dynamics and inequities. We must first develop structural competencies and in particular structural humility as we move towards interventions and advocacy. We must recognize the role of listening, collaboration, and learning from community members first, and before typical interventions of leading, acting, and subject matter experts and decision making will be essential. And the needs and benefits of BIPOC and under-resourced communities should be prioritized over the needs and benefits to all psychiatrists. So, and then importantly, as a researcher, I really believe in this last point, we also have to monitor the effectiveness of this work using measurable outcomes, including with a specific eye towards race and ethnicity in measuring those outcomes. The first section on levels, so we begin with patient, provider, and clinic level, and the authors identified many problems. So racialized diagnostic and treatment systems, lack of access to outpatient care, lower utilization rates, lower quality of care and satisfaction with care, higher dropout rates among minoritized populations, and also the reality that minoritized populations are overrepresented in restrictive and coercive treatment environments, a severe lack of diversity in behavioral health workforce, providers' implicit bias, overwhelming cultural ineptitude, historical neglect of racism and other social determinants of health and psychiatric training, and as a result, the reality that disparities in mental health care reproduce and reinforce structural racism in other sectors. And the authors then describe a whole list of anti-racist solutions, and so addressing things like access to care and diagnostic and treatment inequities, increase in the relevance of care to oppressed groups, diversifying and expanding the workforce, and inequities and coercion and mass incarceration. At the health system level, the authors described problems such as insurance coverage, so both what insurance patients have available to them and which hospital systems accept that insurance, and also significant racial disparities in both overall coverage, so insured versus uninsured, as well as types of coverage, public versus private. They describe physical barriers, so for example, distance from BIPOC neighborhoods to health facilities, scheduling disparities, law enforcement personnel in the clinics, which may discourage access by those who experience systemic racism and violence, and other important issues. And in their solutions, they go on to describe insurance status, the barriers to access, security measures of law enforcement presence and recommendations for how to arrange those in more anti-racist ways. Community-based care, so reducing the risk of falling through the cracks, and then also increasing representation of the workforce. At the community level, the authors listed a really, I thought, powerful summary of ways to really engage the community and maximize the role for community participants in informing advocacy priorities. So things like listening to and learning from community members, especially those studying acts of omission, study professional and organizational acts of omission, acknowledging the stakes and atoning for harms, identifying strengths and assets of the community itself, assessing community needs through a health equity perspective, analyzing sociopolitical factors, investing time, funding, and resources into community-based organizations, developing goals, visions, and aims under the guidance of community-based partnerships and relying on insights of community-based organizations, activists, and leaders, responding quickly to community distress and concerns, for example, targeting community mental health interventions in the wake of an extrajudicial police shooting, which, of course, has been one of the instigators for a ton of the focus on structural racism in recent years, despite this being a decades-long issue. Establishing local pipelines and education and training programs that support a diverse mental health workforce, providing services, supports, and resources in non-medical community-based settings to cover gaps that limit access, utilizing community health workers, pairing up with organizations that are already involved in the work of providing employment, housing, and nutrition support, extending community engagement beyond superficial advisory roles that instead offer key leadership positions to community members, avoiding biased evaluations of services and programs and instead evaluating professional and health system impacts by garnering ratings from community members, and measuring success, so re-evaluating anti-racism outcomes and course-correcting as necessary. I know that was a long list, and sorry for rattling that off, but this section I think is just so important. It warrants that attention because I think that often as physician advocates, we don't necessarily partner with the community in ways that might really actually impact the ultimate results that we're going for. And so I just really wanted to highlight these super important points. At the local and state levels, anti-racism advocacy has many problems to contend with, so policies that may have been actively put into place to harm BIPOC and especially Black communities, policies and regulations that may be poorly implemented and or not enforced, loopholes that make it so that patients may fall through the cracks, poor coordination and fragmentation of services across agencies, and also poor coordination between local, state, and federal-supported care. And also variance in policies between localities. And the authors of the section did a really nice job of kind of laying out the groundwork and the foundation of what even is the structure of state policy and local policy, because that's so important, of course, for being able to effectively advance anti-racism advocacy. And then some of the solutions that they addressed include social determinants of health, perpetuation of white privilege at the expense of BIPOC communities, access to mental health care, nature of mental health services, community representation, and the quality and number of mental health professionals. And then finally, in terms of the different levels, so the section on federal level anti-racism advocacy first makes the point that it's important to apply an equity lens to all advocacy activities, so not just specific bills or rules or regs that are, you know, just focused on anti-racism, but really everything that happens at the advocacy level should include equity as a consideration. In those policies, including really thoughtfully analyzing potential policies for unintended consequences on BIPOC populations. For those policies that do focus specifically on anti-racism, the section lists things like funding for mental health services, demonstration programs and grant opportunities, partnerships with social services in coordination with law enforcement agencies to improve services and reduce crime. Alternative payment models that link reimbursement to measures of equity and incentivize reduction in disparities, accreditation and accountability programs that require equity analyses as a routine part of continuous quality improvement activities, initiatives aimed at increasing diversity in the workforce and in leadership, and also research funding into disparities, social determinants of mental health and services interventions tailored to BIPOC communities. At the end of the document, we present some advocacy best practices, and I really like this step-by-step kind of guide that's provided. So step one is to engage in self-reflection and perform a self-inventory to evaluate for our own implicit assumptions and biases and address our own behaviors that may negatively impact others. Next is to assess relevant indices of mental health and inequities resulting from systemic racism in order to be able to decide on which systems to focus most deeply. Next would be to identify the system which you plan to evaluate for racist mental health policies and practices, including kind of getting specific between institutional and governmental type systems. Next is to develop a strategic approach and a focus, really designing a focused campaign. And finally, as I've been kind of saying throughout, is to work in collaboration with communities to advocate for anti-racist mental health policy, because that's just so imperative. So with that, this is the contact information for the authors of this resource document, antiracismresourcedoc.gmail.com, so you can contact the authors directly that way. But also, you know, through whatever other means. We're really excited for this document to be taking shape. We're excited to see where it goes as we continue to get additional input from the many voices that I know have a lot to contribute. And yeah, really excited to now be handing off the presentation to Craig Obie, our Chief of the Division of Government Relations. Hopefully, Craig, I got that right. But who I just want to say Craig's been a really wonderful and important partner in this work, both figuring out how to navigate APA governance, but also he's a brilliant resource and has a wealth of knowledge around policy at many different levels. And so we're very grateful for your participation and for your energy around this effort. Now that you've heard about the need for anti-racist policies to advance equitable access to mental health care, including substance use treatment, I'll highlight some of the actions APA has been taking in this important area and guide you through various ways you may become engaged in promoting anti-racism related legislation. As Dr. Goldman said, my name is Craig Obie. I'm Chief of Government Relations for APA, and it's a real pleasure to be presenting with this panel to you today. I thought I'd begin with two quotes from Isabel Wilkerson's powerful new work, Caste, The Origins of Our Discontents, which begin to lay out the context that makes the legislative pursuit of anti-racist policies so important. Ms. Wilkerson writes, race is what we can see, the physical traits that have been given arbitrary meaning and become shorthand for who a person is. Caste is the powerful infrastructure that holds each group in its place. She further writes, the hierarchy of caste is not about feelings of morality. It's about power, which groups have it and which do not. It is about resources, which caste is seen as worthy of them and which are not, who gets to acquire and control them and who does not. It is about respect, authority, and assumptions of competence, who has accorded these and who has not. I chose these excerpts from Ms. Wilkerson's book because they highlight the structural power dynamic that has been at work in the United States of America for four centuries. A dynamic perpetuated through a system of laws that was built on, in part, this infrastructure of caste. And caste itself is a racist construct that drives health disparities. In fact, empirical data from researchers, including David Williams, support the notion that racism, not race, is a risk factor for disease and a contributor to racial disparities in health. Ibram Kendi, in his recent book, How to Be an Antiracist, calls a racist idea, any idea that suggests one racial group is inferior to or superior to another in any way. Racist ideas argue that the inferiorities and superiorities of racial groups explain racial inequities in society. And Daniel Dawes further connects the dots and drives the health-related effects of racism home in his book, The Political Determinants of Health. He writes, it is not a fluke that some groups experience poverty for generations, blocked from attaining the American dream. Sometimes we do not see the depths of the problem until we start digging and examining their root causes and distribution. And then it becomes apparent that one major factor has exacerbated the disparities in health status, our political system. No single or simple response will address the inequities that systemic racism and caste have produced over hundreds of years. However, legislative advocacy provides an essential tool for making progress, one that APA has been putting to use. I'll spend the next few minutes going through some recent legislative activity in which APA has been engaged. These include legislation in Congress recently enacted, as well as legislation that APA is working to enact, and funding we're supporting for various programs. Then I'll walk through various advocacy engagement opportunities for APA members, depending on your interest, and share how you can connect with APA staff about them. APA staff are guided in our legislative advocacy by APA policy. APA policies are available through the APA Policy Finder on the website. And here are a few policy statements with relevance to anti-racism. They include statements that focus specifically on the adverse impact of racism and racial discrimination on mental health, as well as mental health equity and social determinants of health. In addition, APA position statements on mental health parity and universal access to care also have relevance in this area, given their impact on healthcare access for diverse populations of patients. APA pursues, evaluates, and acts upon a variety of legislative and policy initiatives. In the brief time allotted today, I'll highlight a few examples to give you a sense for the types of anti-racist proposals for which APA has been advocating on the legislative front. There are many more on the regulatory side that we engage in, but for the purposes today, I'm focusing on legislation. These generally range from proposals specifically intended to focus on issues like diversity, equity, cultural competence, and discrimination, as well as proposals with a wider scope but significant equity implications. I'll begin by focusing on a few broader issues with equity and anti-racism implications, and will then highlight a few more specific examples. One broader area of significant APA activity is mental health and substance use disorder parity. More than a decade after enactment of the Mental Health Parity Law, Mental Health Parity and Addiction Equity Act, insurance discrimination against those with a mental illness or substance use disorder remains rampant. From an equity standpoint, people of color tend to be uninsured or have inadequate insurance more often than others. APA led efforts the last two years to enact legislation at the federal and state levels that would strengthen enforcement and compliance with the law. APA drafted the legislation, secured congressional champions, guided advocacy efforts among our colleague organizations in the mental health community, and succeeded in enacting these parity compliance reforms in December of 2020. The APA proposals that became law in December secured greater leverage for the U.S. Department of Labor over the 2.4 million health care plans that cover the vast majority of patients across the country. The bill also applies to all state-regulated plans. In a nutshell, it requires plans to conduct and share, upon request, analyses that demonstrate their compliance with the law. Plans that are found out of compliance will be publicly shamed if they don't come into compliance timely. Many APA members advocated to enact the parity legislation either by directly lobbying their congressional representatives or sending communications to Congress. Now that the Strengthening Behavioral Health Parity Act is law, APA is leading efforts to boost funding to enforce the law at the federal and state levels. And ensure that parity is implemented effectively. And we will continue to depend on actions of our members to get congressional attention about the need to make these important resources available. Although the primary purpose of these parity efforts is not anti-racism, they have significant anti-racist implications. When insurance is inadequate and plans discriminate against mental illness and substance use disorders despite parity law requirements, Black, Indigenous, and people of color, and those with the lowest incomes, are the most apt to confront access limitations. Those who can pay their health care costs that go beyond what insurance pays tend to be white, like me, and have greater means. This means our parity work has an important nexus to anti-racism and health disparities. The same can be said for telehealth. Some forms of telehealth expansion during the COVID pandemic, and hopefully beyond, are quite important from an advocacy standpoint. Many patients have been unable to access telehealth through video by virtue of having limited access to broadband, a major equity issue in rural and urban areas alike, from the Bronx to the Navajo Reservation. Continued access to audio-only services, where appropriate and made necessary by virtue of an inability to obtain access through video or in-person care also has significant equity and anti-racist implications. In addition, APA has been a leader in advocating to enhance crisis services across the country, an issue with important implications for the frequency of contact that individuals experiencing mental health crisis have with the criminal justice system. APA worked in partnership with NASHPD, the National Association of State Mental Health Program Directors, to lead a national effort to boost crisis funding through the Community Mental Health Services Block Grant for evidence-based approaches that include crisis call centers, mobile crisis units, and stabilization units. Intervention by appropriately trained crisis teams and local systems has been shown to diminish unnecessary contacts with the criminal justice system that have helped turn our prisons into de facto warehouses for patients with mental illness. Recent examples in Rochester, New York, where in February, police restrained and pepper sprayed a nine-year-old girl and where Daniel Prude died at the hands of police in a crisis are only a small snapshot of the impact of criminal justice system encounters on those with mental illness, including Black Indigenous people of color. Studies have shown that once arrested, Blacks are more likely to remain in prison longer and await trial for minor offenses at a higher rate than Whites. According to the Prison Policy Initiative, local jail incarceration rates in 2018 were 592 per 100,000 for Blacks, 401 per 100,000 for American Indians and Alaska Natives, and 187 per 100,000 for Whites. And Black and American Indian youth are confined at disparate rates over three times the rate of White youth for the lowest level offenses. And statistics also show that Blacks are more likely to receive an aggressive response in 9-1-1 situations. Consequently, diverting those with mental health crises, including BIPOC, means that they have a far better chance at avoiding the criminal justice system and receiving appropriate care. Studies in Maricopa County, Arizona, have shown that appropriate crisis services can significantly reduce unnecessary emergency room boarding and divert patients to appropriate care and away from jails. APA also has been supporting the Medicaid Reentry Act, which was introduced by Congressman Paul Tonko of New York. The legislation would enroll incarcerated individuals into Medicaid 30 days prior to release. It was actually included in an early draft of the large $1.9 trillion COVID relief package, the American Rescue Plan, that Congress passed in March. However, the provision was struck on procedural grounds, so APA and our colleague organizations are seeking other opportunities to move the legislation in this Congress. Moving to legislation that's expressly focused on anti-racism, APA is supporting the Anti-Racism and Public Health Act, which was introduced this year by Congresswoman Ayanna Pressley and Senator Elizabeth Warren, both from Massachusetts, and Congresswoman Barbara Lee of California, and would declare structural racism a public health crisis and confront its public health impacts through two programs within the Centers for Disease Control. The bill would also create a law enforcement violence prevention program that would apply a comprehensive public health approach to ending police brutality. APA has also been devoting significant focus to legislation sponsored by Representatives Bonnie Watson-Coleman and John Katko, Democrat of New Jersey and Republican of New York, respectively. The bill which passed the House last Congress, but not the Senate, is the Pursuing Equity in Mental Health Act. That legislation was the outgrowth of policy recommendations developed by the Congressional Black Caucus' Emergency Task Force on Black Youth Suicide and Mental Health, which Representative Watson-Coleman chaired. Task force advisors, whose counsel helped lead to a report entitled, Ring the Alarm, the Crisis of Black Youth Suicide in America, included former APA President Dr. Alpha Stewart. Two years before COVID-19 laid bare the health inequities that impact minority and vulnerable populations, the impetus for this effort was a 2018 report published in the Journal of the American Medical Association Pediatrics, which indicated that the rate of suicides for black children between the ages of 5 and 12 exceeded that of white children for the first time ever. And according to a 2019 study published in the American Academy of Pediatrics Journal of Pediatrics, self-reported suicide attempts by black teenagers rose despite falling for other groups. In fact, suicide attempts among black teens rose 73% between 1997 and 2017. In order to combat these alarming developments, the Pursuing Equity in Mental Health Act authorizes slightly more than $800 million in grants and other funding to support research, boost the number of culturally competent providers, support outreach programs to reduce stigma, and train healthcare providers to effectively manage disparities. Among the provisions of the bill is a reauthorization and expansion of the Minority Fellowship Program, which is a key program producing a physician workforce that is better prepared to serve our diverse population. Then there's the Improving Social Determinants of Health, which APA supported during the last Congress and hopes to promote this Congress after it's reintroduced. The bill was introduced by Representative Nanette Berrigan of California, and the companion bill in the Senate was introduced by Senator Tina Smith of Minnesota. The bill would require the Center for Disease Control and Prevention to establish a program to improve health outcomes and reduce health inequities by, for example, coordinating activities across the CDC. As part of the program, the CDC must award grants to eligible organizations and build capacity to address social determinants of health. The Senate version requires a set-aside for Indian tribal governments. APA is supporting many additional legislative measures that are focused on anti-racism. Too many to enumerate here, and obviously there are more opportunities and needs to engage than there is legislation existing at the moment. But examples include improving the Social Determinants of Health Act, which is intended to improve health outcomes and reduce inequities by coordinating relevant activities across the CDC, as well as improve capacity of public health agencies and community organizations to address social determinants. We're also supporting the American Indian and Alaskan Native Veterans Mental Health Act, which is designed to ensure that Native veterans receive culturally competent care. Finally, APA has also taken action in support of legislation condemning anti-Asian sentiment, bigotry, and violence that increased in the context of COVID-19. So how can you get involved in APA's advocacy on these efforts? There are three easy ways for you to connect as an advocate with APA. These include signing up as an online advocate, joining the Congressional Advocacy Network, and contributing to APA's Political Action Committee. Signing up as an online advocate is easy. You simply go to the Advocacy Action Center on APA's website and sign up for the mailing list. You'll receive emails when there's a need or opportunity for constituents to reach out to their members of Congress. In contacting their member of Congress, APA advocates can customize a pre-written email on the relevant topic and easily send it along. So when there's a need to rally support on an important initiative like the Equity in Mental Health Act or the Mental Health Parity Compliance Act, this is an easy tool for you to use in asking your members of Congress to support it. The second way you can engage is by joining the CAN program, APA's Congressional Advocacy Network. CAN members get one-on-one support from APA's Government Affairs staff in building a relationship with a member of Congress. We can help you set up a meeting with your lawmaker and his or her staff, organize an event or develop some other strategy. Relationship building with members of Congress is an invaluable way our members can work with APA to advocate for psychiatry and our patients. They want to hear from their constituents much more than those of us in Washington. When those members know who you are before a crisis occurs, they're more likely to listen when genuine need arises. And right now, issues related to mental health, substance use, and racial justice are very much top of mind. So this is a great time to start plugging in with your legislators. Third, you can contribute to APA PAC. APA PAC is a democratic tool that helps APA build friends and champions in Congress. PAC is a mechanism through which psychiatrists can pool funds to boost the APA's voice on Capitol Hill by contributing to congressional campaigns. APA PAC is one of the most important tools available to you in advocating for your profession and your patients. APA PAC is only as strong as its membership, and psychiatry must show strength in numbers to be successful. In addition to joining CAN, becoming an online advocate, and contributing to APA PAC, APA staff develop a monthly update on legislative and regulatory activity that's available to any APA member who signs up through the website Advocacy Center. You can also pursue the Gene Spurlock Congressional Fellowship, through which APA places two psychiatrists onto Capitol Hill in a congressional office every year. And you can become involved in the governance of APA, provide your advice as a member of a council like the Council on Advocacy and Government Relations, and you can become involved with your district branch. Choose what's right for you. Please contact us. Contact APA's advocacy staff with your questions and ideas. We are here to help you engage in the advocacy process because we work for you. Ultimately, it's in the interest of APA members that drives our advocacy agenda. You have an opportunity to use your voice within the APA and with your legislators to focus on important issues like health disparities, equity, and anti-racism, as well as the many other important issues on which APA represents you every day. Thank you so much, Dr. Goldman and Dr. Obey, for presenting a lot of the work that the APA has been doing to show dedication to anti-racist policies. I'm very excited to introduce, again, our two discussants today, Dr. Stephen Starks and Dr. Christina Mangurian, to get a little bit more in-depth on all the topics that we've discussed so far, and then after that, we'll be taking a visit back to the cases. All right. You can go ahead and introduce yourselves. Hi there, everyone. I'm Stephen Starks. I'm a clinical assistant professor at the University of Houston College of Medicine and also an APA member who is currently the chair-elect of the Assembly MUR Committee and also a part of the APA's structural task force to address racism throughout psychiatry. Thank you for inviting me to be a part of this discussion. Of course. Yes, and hi. My name is Christina Mangurian. I'm a professor and vice chair for diversity and health equity at the University of California, San Francisco, and I was formerly chair of the Council for Minority Mental Health and Health Disparities in the APA. Thanks for having me. Of course. All right. I'm so happy to have you both here and to be talking about such an important topic with so much breadth and so much depth that this can't do justice to the topic itself. I'm curious if there are any initial thoughts after hearing both Dr. Goldman and Craig Obey's presentations. So that's a great question, and it was great to kind of see the content presented by both Matt and Craig today. It's been very interesting over this past year to be a part of this conversation and this discussion about addressing racism in medicine and psychiatry, and it was interesting for me, obviously, to see all of the kind of outpouring of statements that were made last year tied to addressing structural racism, so statements that we had never seen before. We were often using what I call kind of euphemisms beforehand to talk about issues of disparities, issues of health equity, or trying to achieve health equity, but finally kind of putting the term racism was actually kind of shocking for me, at least at the time, but one thing I struggled with is the fact that we were in 2020, and so racism was not a new idea, a new concept, a new struggle. We were very aware of the numerous health disparities that were kind of going on. We were aware of excessive police force and violence. We were aware of racism in the financial services industry, in education systems, in the criminal legal system, and so from that standpoint, in trying to kind of really kind of center around a specific agenda, I've noticed that a lot of institutions have struggled with that path, so it was nice to see kind of the outline of the document, that resource document that is being conceptualized and put together, which I think is a wonderful framework and a starting point, and also nice to see from Craig's presentations some of the kind of policy and political agenda that the Department of Government Relations is really working towards, so I think it's a great start for us and kind of leads us on a great path. I'm a little kind of cautiously optimistic or optimistically cautious about now what this will actually lead to, so there is this impetus for change, but we've seen these situations before, so I'm just wondering what that transformation will look like three, five years down the line, or even in terms of a more immediate response. Definitely, that makes a lot of sense, and I'm curious what your thoughts would be as to, at this point, how medical organizations can, in an effective way, address anti-racism. If that's aimed toward me, and Dr. Mangurian might jump in as well, if that's aimed toward me, I think the theme that comes to mind for me is really thinking about leadership, so leadership really drives change, drives kind of a new focus, a new direction in terms of leading this charge, and so I think it's up to our leaders here within our association, leaders within health systems, to really kind of propel any changes that we see, and we've seen some organizations effectively address that. I think the AAMC, or the American Association for Medical Colleges, has started to lead a path toward equity. The American Medical Association, again, with some of their work, some recent challenges in terms of their journals and publications, but aside from that, are kind of leading the charge for health equity, but I think it takes some vision, and I also think it takes representation, so when we talk about the concepts of DEI, talk about diversity, equity, and inclusion, I think that starts with justice, and that starts with really having the involvement of persons of color, as we talked about today, leading those efforts and helping to lead that path. Right, right, and I'll just echo some of what you've been saying, Dr. Starks. First of all, it's an extraordinary document that was put together, and extraordinary work that's been done through the council, and through Craig, through your office, with all the legislative work, is excellent. I think regarding the document, I think what I really liked about the process in creating it is how inclusive it was. As usual, it included a lot of fellows. This is very typical. They're our future, and so I thought that was great, and I also liked that the work wasn't just done by people of color, but it included a diverse, or women, so a lot of times this kind of work is done by women or people of color, and so I think that I really liked, as Matt, you were mentioning that, you know, you recognized your position. Well, I actually think that having, you know, white men, as we've got two examples here, involved in this kind of work is critical. We all need to be part of this, so I really like that. I also really appreciate the strong legislative action that's been happening, you know, that I saw in your presentation, Craig, and the focus on policing, the work that Altha Stewart and Dr. Alfie Brinal and Noble did with the Black Caucus to really push forward pursuing equity in the Mental Health Act is really extraordinary and important. I think all of this work, to me, reflects the best of the APA. This is the best of who we are when we do things like this. I remember when I was a fellow, and I sat in on a JRC meeting, Annelle Prim was there. She's just this extraordinary psychiatrist that so many people know, and she really took me under her wing, and so many others she took under her wing. She had very big wings, and she was able to really hold a lot of people, and so did many other people, Nata Stotland, Renee Binder, Marie O'Kendall, Althea Stewart. They made me feel included and important. And there were peers that were like this, too. And it felt like the organization was really dedicated to bringing up our diverse workforce. That said, as Stephen said, I'm cautiously optimistic now. This work has been going on for a long time. Our history is important. 69 was when a group of Black psychiatrists stormed the board to demand representation. This is many, many years later, too many years later. It wasn't so recent that we had our first Black president of the APA and our country. Those aren't coincidences in my mind. And so I think that it's just important to recognize our history, as Stephen was saying. I think there were a few thoughts in general that I have about this. First of all, I think when Matt showed the slides and Craig showed his slides, there's so many targets. And I'm thinking about the people watching this and going, oh my gosh, what can I do, feeling a little overwhelmed. And so I encourage each of you, no matter where you're at, if you're a staff, if you're a trainee, if you're in practice, to think about what you're most passionate about and work on that. Try to use your power to move the needle in that area. I really believe that these positive little ripples with everybody putting in some energy in areas will help to really move the needle much further. So I think another reflection that I have is that, which I don't know which was brought up so explicitly, but I consider people with lived experience with mental illness to be a health disparities population in and of themselves. And so they, and by proxy, we as psychiatrists who may or may not have lived experience ourselves, are also a group that's oppressed, right? And so that often there's the intersectionality of those issues that come up that put people who may be experiencing mental illness and may be a member of a discriminated group. I think that, you know, while we talked a lot about externally facing work, my, I think a growth area for us is to do some more internal self-reflection. And this, you know, for all those watching, this can be done for yourself as an individual, but also of your own practice, your clinic, your hospital, your university, your organization. I think the APA is beginning to do some of this work. I think the task force, Stephen, that you've been on is starting to do some of that work, but I really think that there needs to be a lot of internal reflection. I'll give an example. If we looked at the APA, so this is an example, but I think all of you should think about your clinics, right, or setting, is think about, okay, you know, because it's in ways easier to think outside and say, oh, outside are all those people with the problems, not at home, but it actually is everywhere. And if we start really thinking about home, it's helpful. So I think for the APA, it's like, well, who's leading the councils? Who are the leaders there? Stephen brought up the leaders. Who are the leaders? Are they white? Are they men predominantly? Let's count. Let's have vice chairs so you have kind of tracks to really get into the full leadership roles. You know, I think there are ways that we could start partnering more closely with BPA, find out ways in which, why should the Black Psychiatry Association would want to be partnering with the APA, you know, whether they would want, you know, can we do this in a more formalized way? You know, what are we investing in? Where are we putting our money? Does our money align with what we say? We say we care about diversity and equity. Is the money following those wishes? I think also diversity in our membership, diversity in our fellows, are all the fellows of color going into the, you know, SAMHSA diversity fellowships or are they spread across leadership, public psychiatry, the Spurlock Fellowship? Are we getting diversity across all of them? And I think we do have an opportunity to also look at our journals, you know, the journals that the APA holds, the American Journal of Psychiatry is really doing a lot of self-reflection, so is psychiatric services. Look at their authorship, look at the reviewers, look at the editorial boards, who's there, who's making the decisions because these decisions have an impact about what we consume and learn about. And similarly in the annual meetings, you know, I think there's, we are all subject to implicit biases and there are ways in which I think some of that can be, you know, addressed in some processes when we're looking at who gets to present at the annual meetings, how are things selected, et cetera. And so those are some of my preliminary thoughts. I think it's like to do this work that you all have done is so critical and it's just as critical to do a really hard self-reflection of our organizations, which feels, can feel scary. But that kind of work I think is important as well. I actually wanted to pick up from there because I think it's a good point. A lot of the discussion that I've been having or hearing lately centers around the sensitivity to identifying, you talked about that self-reflection, but how do you identify yourself as a racist, right? People have this idea of, you know, one extreme, but I think asking yourself the question rather than am I, maybe kind of owning and reflecting on the fact that there is that aspect of racism. And then thinking about how that kind of operates in your practice, in our profession, in your institution. So, you know, how do I, you know, advance? Divya talked about the levels of racism, the individual person mediated kind of institutional aspects, structural. So thinking a little bit about that, you know, how are we kind of creating environments that kind of focuses on or kind of elevates ideas that are traditionally kind of white or Eurocentric and how do we then kind of start to, you know, think about how we negate other persons of colors in our interactions and how we operate. And we see that in terms of, you know, the disparities that we have in health. We see that in terms of diverse representation in our organization, right? Black psychiatrists make up around 5% of the psychiatric workforce. Was that ever concerning for people to think about the fact that it's only 5% when black Americans make up 14% of the population? Is that problematic in some way, in any way? Do we seem bothered by that? And to your point, kind of tied to, you know, how we kind of look to restructure leadership. So how do we restructure it when the BIPOC community are in the minority? And I mean, a little minority in terms of the actual representation in terms of those numbers. So I think starting there with that kind of self-reflection with identifying kind of processes, thinking about that kind of consistently in our work and in our practice is incredibly important for us all to do and just take some ownership of that into maybe kind of, you know, decrease some of the defensiveness about the term or a label as it makes you bad. It's just an opportunity and room for growth. And I think specifically as psychiatrists who are so good at reflecting on the kind of broad dynamics in terms of, you know, formulations that we make really kind of making those formulations about our own actions, about the actions of the psychiatric services that we provide in several settings and thinking about the patients who do and who do not have access to care. I think all those things are incredibly important as we try to advance these, you know, anti-racist ideas and policies. Yeah, and I think, you know, to build on what you're saying too, Steven, I think there is a fear. And so everybody who is watching this should try to take the IAT, the implicit association tests and look at that. Because I think what you're saying, Steven, is we should be good at knowing we have these unconscious biases, right? That are built into us. It doesn't mean we're bad. I consider myself a feminist, but when I take the IAT, it looks like I think that men should be, you know, more in careers than women should be. That's extremely upsetting to me. That doesn't mean that I don't behave in ways that are very much promoting gender equity, but it's part of who I am or how I grew up. And so I think owning that, and I think you were alluding before to the experience in JAMA, which was very, very much of a public expression where people were showing that they were afraid. I'm not a racist. I, you know, and that's hurtful and painful to those of us who are paying attention to say like, you know, this whole system is baked in with a lot of racism, you know? And I also wanted to come back to the cases that were presented earlier on, specifically the one of the black male kind of adolescent that was discussed earlier. I'll go to that slide so that I can see. I think that kind of, that overview, that presentation of how brief it was really kind of highlights, I think, some of the great work of the resource document. So if we talk about some of the behavioral issues that are associated with this specific case, and we think about how that overlaps with our health system, how it overlaps with our education system, this discussion here about the father who was in the carceral system. So we think about all those factors, economic, criminal legal, health, education. And we think about what is happening in our environment. We as psychiatrists have to be mindful about the full context. So this young man, I'm sure, and maybe some of his interactions with a mental health professional, will they get or garner those details? Will they kind of understand the complicated history? I'm thinking about his age now and his potential access to healthcare, perhaps through CHIP. But as he becomes a young adult, a young man, turns 19 and no longer has access to health services or health benefits, what does his life look like in terms of his activities, his opportunities to really have the types of successes that he hopes and wants for? Where could he be kind of led in terms of his path? Thinking about the work of the resource document to really kind of address needs that are at the kind of local level, thinking about kind of community health services, thinking broadly about kind of our impact on state and federal kind of policies that may kind of influence his trajectory. So if he had access to certain services, employment opportunities, access to sensitivity surrounding his substance use and treatment, access to mental health and behavioral health services, how that could really kind of impact his day-to-day life and wellbeing. Definitely. I mean, one thing that, as the child psychiatrist in me, one thing that really stood out to me about this case was actually the other day I had read something about how there's been less kids going to juvenile detention this year because the school-to-prison pipeline has decreased simply because COVID has taken us to remote schooling. And I imagined this kid, whenever he did interact with the system, if it was because of something that happened at school and if it wouldn't have happened that way, had he just been at home, which is a really sad thing to think about. And it makes me think about when school does begin again, what, how can we change policy as the DOE is changing in the fall to not have the school-to-prison pipeline dramatically increase because of all the transitions that are gonna be going on? And that's just one aspect of policy that could affect this kid, that's just education and policy related to criminal justice but you have nutrition, the foster care system, access to care, maybe misdiagnosis, so many different things that could have happened. Early childhood policy, trauma-informed policies, that's kind of where my mind is going. Yeah, and my mind also goes to some things. I mean, you brought up ACEs, I think, or you mentioned it. And I think what I'd like to see and I'm thinking of Carl Bell now, who is one of our great psychiatrists and champions here, is more on the prevention side, right? Like what would have happened had every kid whose parent is incarcerated gets hooked up with a counselor? What would that be like? Those are the types of things that I think, since we know there's more likelihood that this father who was, I'm assuming this is assumption, was also black and was using substances, right? He was more likely to be arrested for this because of the color of his skin. But when he was arrested, could they have done this to help protect this child? Because he already had substance use in the home, potentially mental illness in the home, and then an incarcerated relative. So that already put him at risk. And I think, I'm not sure, Divya, I like how you're thinking about this, but I'm not sure if it's better at home. I'm not sure what's really happening. I am very worried about the differences that we're gonna see in mental health outcomes for a long time based on the just disparities that exist, structural disparities that exist. My kids are at home, but you know what? They've got, both of their parents are working from home. We're here. It's just a different, they were born into a different situation. Yeah, I mean, that's why I said it was a sad thought for me to even cross my mind that in some weird way being at home and all of these other problems happening could be protective from getting arrested in school. And the fact that that's where my mind went when it's not a, it's a very poor alternative that's causing a bunch of other problems. So- And I also wanted to point out, because I also think about his father as well, right? Who may be struggling with a substance use disorder, who now, because he's incarcerated again, what does he face in terms of economic opportunities, access to his voting rights when he is released? So again, in terms of the full picture of family dynamics, this kind of generational kind of continuation of these ACEs, adverse kind of experiences that people have. It's just mindful about why we continue to struggle with the issues of race in America. Yeah, I would just add one point to this really wonderful discussion. I think that something that the resource document does too, just to bring it back a little bit to that, is it's outlining for psychiatrists how to be advocates, but it's also saying, if you're gonna be an advocate, you have to understand the system. And that idea of structural competencies, it also applies clinically just as much as it applies to advocacy. Like if you're gonna actually be able to help this kid, you gotta understand the systems in which he is experiencing his daily life and all of the different barriers that he's gonna push up against. And to be able to actually deliver an effective treatment to that patient, like thinking about that clinical context, it's the same types of constraints that we're thinking about advocating in a more sort of systems or policy sphere. So I say that just because I think that the idea of being a psychiatrist advocate, what's the role for a psychiatrist in advocacy, that there's so much overlap there and there should be, we're not necessarily trained that way. That's not necessarily routine in our psychiatrist upbringing to think about the systems in that structural competency type way. Although I think it is increasing more and more, but yeah, I think there's a lot of give and take between both of those ways of looking at these different structural determinants. Exactly, I think we're running low on time. So we'll stick with that first case. I mean, just to kind of summarize a few things that really stood out to me about some of the great points the discussants have made. I think the take home for me is that activism can look, and advocacy can look very different. So reflection is a form of activism because how can you really be an advocate if you haven't reflected, if you haven't educated yourself, and if you don't understand things. Yet reflection alone also does not make change. So you have these two pieces of advocacy that are just so important, education and self-reflection, which I can even, even if you are a person of color, even if you are from the background in which you, the oppressed background, whatever that looks like, self-reflection helps there, and it helps if you're not part of that group. Because I don't know if anyone in the audience has read Ibram Kendi, but he speaks to the fact that we are all racist. We all have racism within ourselves because we live in a society that's based on white supremacy. So no one can just escape it and be immune. And if we share the task, I think we can get very far. So I don't know if there's any last comments, but I wanted to thank you all so much for joining us today and encourage the audience to get involved in advocacy in your own way, whether that's reflecting right after this or later on, or alongside the APA. ♪♪

Divya Chhabra

advocacy

anti-racist policies

mental health care

racism

clinician advocacy

legislative activity

APA's involvement

health disparities

crisis services

diversion programs