So, hi, everyone. Thank you so much for being here today. My name is Vashra. I know we have, you know, a great number in our audience, and I'm very happy to each and every one of you for coming out today. I know it's the middle of the day on the first day, and it can be quite busy, but I promise this will be interesting and engaging. I am currently a PGY5 resident at the University of Toronto, and during this time, I've actually been also completing my Master's in Quantitative Statistics at Harvard Chan. So, I've moved to Cambridge for about 10 months, primarily to actually learn the skills to be able to enact some of the work that we've done today, that I'll describe today. And so, it's become a project that's very near and dear to my heart, and I will start Forensics Fellowship in October. So, you know, it's just really carrying on what this is all about today. So, I'll be speaking to you today about the integration of culture in forensic therapeutics. This is basically a call to action for renewed work in this area from calls that happened in 2007, in addition to 2019, that essentially went unheeded. Some of the work from Lawrence Kirmire, from McGill, some of the work from our dear Dr. Ken Fung, who's in the audience today. The content is really captured in a paper that we had published in 2022 in the Journal for the American Academy of Psychiatry and the Law as well. So, you're welcome to review that paper. It's also in the references that will be provided as part of this work afterwards. So, these are some of the learning objectives from today. What I've chosen to do is really move a lot of the interactive components towards the end, just so we can get the didactic things out of the way, and then I was hoping that we can kind of pair up and make some discussions and evaluations. But really, it's to assess how culture can actually be integrated into forensics and into your general psychiatric practice as well, evaluating how those outcomes can actually be examined, and then the role of measurement-based care, which is really why I chose to pursue my master's, because once you do measurement, you have to be able to evaluate and use that data in a wise manner that actually makes sense from those quantitative aspects. So, this is a very basic question for all of you, and I wish that I had hid this so I could have asked first, what exactly is culture? So, I wondered this for myself, you know, earlier today and really earlier this week, like how do you actually define what is a culture, and how do you define it within the context in which you are working? So, I looked up what is culture in medicine, and it had described, you know, oncology, and like the practice of culture in oncology, and it had described how different areas of medicine have different types of culture. But this is the one that I found from the World Psychiatric Association that was published in 2009, which is really about the behavioral norms, meanings, and values, or reference points that are utilized by members of a particular society. And you're really constructing a unique worldview that helps you to ascertain your own identity. And I think, yes, if I was to encapsulate culture, yeah, I would actually write it that way, perhaps not as eloquently. And so then I went to ask myself, what are the other important things for people to know in culture? There's cultural competence, that's really who you are as a practitioner and how you're able to engage in work related to culture in your practice. There's cultural safety, which is a little bit more difficult to describe. So it can be conceptualized more broadly as knowledge that's actually paired with a constant kind of critical evaluation reflection regarding the patient's experience with instructors of power, and the structure in which the health care itself is delivered. But it's ultimately also the lived experience of that person, and the perception of how safe they feel engaging with the health care system that they are currently a part of. It's more specific than cultural humility per se, which is actually you reflecting yourself on your own personal and cultural biases that you bring to the clinical realm, and being sensitive to the needs of others, which I think can at times be difficult to pick up if it's not something that you've considered or trained for or thought about in the past. So you might ask yourself, why is culture actually important? And I think, especially at the APA this year, we have had several talks, even today, about culture within psychiatry. And really it's because there are people who are of different ethnicities, different origins, different intersectionalities that are now present within the forensic system, and we're always there. But now it's that we are actually starting to pay more attention to their lived experience within the health care that we deliver them. So specifically in forensics, this becomes more important because there's more structural aspects, and there's more criminal justice aspects and restrictive aspects that are present within forensics that there may not be within broader general psychiatry. And so it's difficult when you have erroneous explanations which actually don't take culture into account, for example, in the context of a report that is issued to court. So it's really important to be able to actually pin what that looks like. I just wonder if we would be able to shut the doors at the back just because it's, like, quite loud. Sorry. Thank you. My apologies for interrupting. I just felt like it was- we were talking about something sensitive. Thank you. Okay. And the importance of creating a culturally inclusive narrative, which are people who are actually able to feel comfortable speaking about their cultural narratives within the context of a clinical setting and a clinical encounter, which may not have always been the case either, right? If individuals didn't have the appropriate training, there could have been issues that were created through a clinical encounter. So making sure that you do it in a meaningful, safe way as well. And so this speaks to some of the work that has happened in the past. There have been a number of calls in 2007, 2012, and 2019 that had advocated for increasing culture within forensics. And it was difficult because contextualizing these actions to what could actually happen and how they could actually have an impact on prevention rehabilitative justice is where, kind of, we missed the mark. And we continue to kind of try to catch up with the different health policies that we're creating and the different designs of work within our hospitals that we're creating, but we're still kind of behind the needle. So we aren't the first ones to suggest this, and I think it continues to be quite important. Dr. Kirmire and his colleagues were the ones that had initially started this work in 2007 when they had advocated for the integration of culture and forensic assessments, and they had rationalized that it was really important to the individual actions leading to criminal justice involvement, in addition through the lens of lived experience as well. I think another component that becomes quite important in that is that cultural understanding within the judicial system actually allows for people to have better prevention and better rehabilitative justice that can actually be accomplished because once somebody has specific needs that are addressed through the criminal justice system, that helps to eliminate that need becoming a problem in the future. For example, in the Canadian system, there, in the criminal justice system, there's a function of GLADU workers who work to specifically work with individuals who are of indigenous backgrounds, and so specifically addressing their needs within the criminal justice system. It's not done perfectly, it's not always done well, but it is done, and that's, I think, one stepping stone towards getting to do this work more appropriately and longitudinally and in a better manner as well. And so the team that worked with Dr. Kirmire had actually rationalized that it was important to contextualize the individual actions, and they had also said in 2012 that the dominant culture actually is the one that shapes the health policy in the practice. So for example, if you were to pick yourself up and put yourself in a different country, in a different culture, in a different time, you can imagine how that might impact your health care and the health care that your family and loved ones receive, which is why this is so important, because that shouldn't be the case. So if we were actually able to incorporate the perspectives of different people and intersections within criminal justice and forensics, I think we actually would be able to treat patients a lot more fairly, which is where we're missing the mark in criminal justice right now. And so there's some other work that's been done by the European Psychiatric Association, which is a little bit ahead of, I would say, the American Psychiatric Association and even the Canadian Academy of Psychiatry and the Law in this sense, is that racism really does contribute directly to poor health outcomes and mental health, and they actually have stated this in their recent paper from 2021. Hello to my colleagues. Racism and its effects are inadequately investigated in psychiatric research and in practice, specifically in the realm of criminal justice, and the multi-level and complex impact of racism can actually be internalized by people, both through an interpersonal, structural, and institutional lens. And the science that has actually been used to shape some of these attitudes itself has been melded within all of these different realms. So you can kind of see it's difficult to devoid the system from the system that actually creates the whole overall architecture, and so we need to start to address the different parts of it. So what we really do is making recommendations for clinicians, policymakers, and teachers, and what they recommended is really focusing on the meso and the micro levels, because the macro levels are just too hard for us to address. You need to start to address individual action, and hopefully through that work you can start to address some more of the macro work as well. And so how this comes into forensics becomes more important. So the issue of culture can be considered more broadly in the DSM-5, where specific diagnostic criteria, as we all know, don't actually address culture. They tell us in each iteration that you have to be mindful of culture, that you have to think about whether this diagnosis is one that you would see in this individual's culture, but it's not necessary for that to actually be a part of the criteria. And also, how is it even possible for one specific psychiatrist or trainee to know what is normative in another person's culture, when it's not the lens in which you have trained, in which you have lived? What is normative in reality? So in previous iterations of the DSM, the cultural access was actually not included, and this was framed as a missed opportunity to emphasize the importance of culture and practice. The DSM instead, as I just described, has individual culture has to be taken into account, but a lot of the times it can be excluded, especially by psychiatrists practicing from a North American lens. And myself, especially as a person who straddles two different intersectionalities, still continues to have this issue, even when I am practicing with individuals who look like me and who are of similar background to me. So this leaves individual clinical discretion as to what is culturally bound or not, and potentially this can actually create and perpetuate pre-existing biases, unfortunately. And so instead of culture being discussed directly, the cultural formulation interview was actually developed to rectify this issue for the lack of cultural integration in the DSM. It's of note that the CFI itself can at times create challenges as well, which we will talk about. And I see Dr. Irfan nodding, which I appreciate as well. So for example, it may not be seen actually as relevant to the person's presenting complaint, and it might actually create discomfort for a patient to talk about culture, religion, with somebody who they don't actually perceive as potentially safe, or somebody who they potentially believe will actually understand their perspective. And so why would you share such a special, such a unique, such a personal part of your lived experience with somebody who you don't know, if they actually know what they're talking about, or if they're actually safe to talk about it with. So it can be difficult to engage patients with also more severe presentations, like for example patients with severe and persistent mental illness is what we see in the forensic population a lot of the time have difficulty even labeling and identifying their experiences with culture. So we are left to ask ourselves really, what do we do? So we do an assessment and we use diagnostic frameworks and we ask ourselves, do they actually have any cultural understanding whatsoever? And so no, they don't, as the answer is up there already. As I mentioned earlier, the DSM has really rejected the cultural access and the culturally bound syndromes really only go further to create a sense of othering with patients. So Dr. Irfan aside, for example, who can tell me what Sustu is or Kufunjia. So they're culturally bound syndromes in the DSM-5. They are in the DSM itself, but you know in being able to label those and appropriately identify them becomes a problem for people who are in psychiatry ourselves. So is this really a syndrome that we should be considering as something that should be in our manual of psychiatry? Is this really a syndrome that is actually useful for us to identify? Or is this just another perpetuation of bias that we might see? So even tools that are designed to be culturally blind, such as the ones that I just described, may not actually be helpful and may actually be inattentive and may perpetuate bias itself. So in the recent text revision of the DSM-5 TR, which I'm sure that all of us have read and I definitely did read in preparation for my board exam, my recent board exam, you can see that an attempt was actually made to integrate culture and to make it more central. So you see that culture, racism, and discrimination were collapsed into a special attention category in the DSM, but this section itself unfortunately still remains a bit broad and refers to other conditions that may be a focus of clinical attention, including suicidal ideation, abuse and neglect, amongst others. And although this is useful, it still is insufficient and we have to recommend more MESA level changes to actually integrate the CFI. And so there are some emerging models which I will speak to after I go through the CFI. So what is the CFI? It's a structured interview that you can be trained in or you can just start to practice and it comprises of 16 questions and it's many years in the making. It's used intentionally in specific clinical contexts and there's both clinician and collateral informant versions and it basically is used to create a narrative by which you can really understand about the contribution that a patient's culture has to their current mental health. And there are a number of subtopics that are included, things like barriers, preferences, clinician-patient relationships, amongst others. With respect to the questions that are actually asked in the CFI, a lot of the times you ask patients, their friends, and their family to actually use their own words to describe their experience and to label what, quote, problem they think they have. For example, asking really broad questions like, are there any kind of stresses that make problems like this worse for you and your family? How would you actually even describe this problem to your family? And being able to use the patient's narratives to understand what this means for them. I've used this in my own practice and it's quite interesting, the different answers that I've received which are not always rooted in pathology and I think we have to remember that as well. And this is what we'll practice a little bit later. So what does the CFI itself yield? So there's a narrative that's created, it's very personal, it's about the lived experience, the values, the beliefs, the identities that a person has, and it's really used to bridge the data that you create clinically through a general psychiatric interview and really pull out the themes of culture that become more important and are more dynamic forces moving forward and ones that you could potentially impact as a person providing care to these people. So the themes that emerge are really about shifting cultural identities, family honor and obligations, modes of symptom expression, and models of illness and healing, which become really important in settings, for example, for individuals who live in cultures that they perhaps have family that were not raised in that culture. So for example, having a second-generation child for individuals who had immigrated to the United States or to Canada, for example. So there's data to support that the CFI can actually help with refining a diagnosis, especially in the context of severe and persistent mental illness, recognizing more situational problems that may not come about from a general psychiatric interview and which may be more difficult for patients to speak about as well. Treatment adherence and then of course the clinician-patient relationship. But there's actually no data that actually evaluates whether or not the clinical outcomes that we think are happening are actually happening, so hence the need for my masters. This is the part that I'm working on. And so we move into culture and forensic psychiatry and we really have to establish what actually contextualizes individual action through the lived experience, as I mentioned, and the values which is key. And then now we actually have to focus on how we do this through both assessment and care. So first off, accounting for culture and forensics can be broken down into these two regions and there's a number of, you know, guidelines and tools that have been brought about specifically within the forensics realm. So in 2015, Apple released the practice guidelines for forensics assessments and they underscored a requirement for culturally responsive forensic assessments and this has been recreated in Canada as well. And they're really bread-and-butter evaluations for things like capacity to form criminal intent, issues of culpability, sentencing, and they could all really use a culturally informed view and culturally informed lens. The guidelines can be a useful tool for people who are to provide an overview of ethnic disparities and diagnoses, the role of cultural identity and formulation, and then language differences as well. And they focus on things like actions and steps that providers who want to be more culturally fair can actually include in their practice. But the guidelines unfortunately don't actually cover how to integrate culture, how to address the rehabilitation or the recovery part, and so are still unfortunately at the early stages. And then in relation to the Royal College of Psychiatrists in the UK, they also published similar standards in 2019 and an update in 2001, again calling for very similar things. So across the board we're kind of seeing similar problems that there's no standardized approaches to admission, physical health care treatment that are rooted in people's culture. This is some of the work that has come out of Canada more recently and out of the United States pertaining to general psychiatry with respect to how the training and culture is important in both contexts, but yet continues to be a factor that is being worked on even outside of the forensic setting but is still not necessarily being addressed within the numeric realm. So in this journey of forensics and psychiatric practice and general psychiatry there's a lot of challenges. There's a paucity of literature, as I had mentioned, with very limited novel findings. There's really no tools that we were able to specifically find in our systematic review of the literature to see how you can actually understand the impact of culture on forensics and mental health. And there's an absence of any structured professional judgment tools, really, in forensics that assess for risk, managing, monitoring that use culture. There's difficulties in enacting the calls to action that I described. And there's also difficulties in integrating cultural safety in a really sustainable manner that's not just a one-off kind of experience that you have that's just an unconscious bias training or an anti-racism training. There really has to be kind of a systemic, across all levels, sustainable change. And we really have to try to foster cultural understanding in a non-tokenistic manner. But how do you actually do that is the question. So none of the calls I had mentioned actually tackle this issue. So forensics continues to struggle with this consistently. And what we have to consider is potentially doing something novel, which is obviously what I think Dr. Simpson and I were considering in our paper from 2022. And so there's evidence that has been published in the broader literature that, using specifically broad-based search terms, there's actually no studies that we found that had formally evaluated or addressed culture explicitly. So we had to actually develop and encourage these types of studies. And some of the work that had come out of Europe, specifically in 2020 and 2022, had showed how culture had been attempted to be integrated but not evaluated. So what we're describing in our literature review is the proposal and support for literature that actually speaks to how governance and forensic services can happen, and establishing core standards, and then from those core standards, actually evaluating those core standards. So here, I'll give you a comparison. In oncology, when a patient gets a diagnosis of something like cancer, they can expect to have a specific type of health care delivery, a specific type of standardization across the different sites, potentially even being enrolled in an RCT. But that type of similar interaction does not exist within general psychiatry, broadly speaking, or specifically within forensic psychiatry, even when things are so regimented. So what we had recommended is having that same structure across all forensic settings, specifically in the hospital that we are doing training, which is the Center for Addiction and Mental Health, and then carrying that forward. And that's some of the work that we'll be doing moving forward. And so this underscores the importance of things like measurement-based care. How long does it take you to get your first appointment? How long does it take you to have your fitness to stand trial assessment? How long does it take you to move into the criminal justice system? How long does it take you to have a not criminally responsible finding happen? And those don't exist in forensics. But they do exist, for example, in the parallel of oncology. So we have to do this in a systemic manner. And we need management plans that kind of address all of these different things. So we have to use tools within forensics, like DASAs, dendromes, the CGI, to actually start to do some of this work and, again, try to integrate culture into it. And then finally, the point that Dr. Simpson also wanted to make is that data analysis at each level of the system is really important at making sure that you address equity gaps not just for specific populations, but for every level of the population. So for example, for the type of psychiatric care that's afforded to somebody, it has to really be equal to the psychiatric care that's afforded to others. It doesn't have to be just because they're in the criminal justice system. It's OK for them to get not as good medical care or not as good psychiatric care, which is, unfortunately, sometimes, for those of us who work in corrections or who work in forensics, know that a lot of the time, because of the risk and the safety risk, you don't get care that is an equitable outcome that other people do in other settings. And so how do we measure cultural responsiveness is the first question that we have asked, because this is actually one that we can start to do in the hospital where we're doing training. So standardization of care across different clinical experiences vary. And we can actually start to integrate culture into the service design and streamline this using things like cultural experts and cultural consultants. As I mentioned, the CFI earlier is a great tool. It has issues, but it's the one that we can use. So we had chosen to use that. And using a really person-centered cultural assessment tool, like the CFI, to inform things like diagnosis and treatment planning within the forensic patients that we were seeing, using cultural understanding and formulation in the context of this, and then using a needs assessment, really, to understand and address what issues in terms of cultural safety were coming up within the forensic population that we were seeing. And so what we used is a number of different scales that we had found that could potentially address this. The WARD, the Community Scale, the Good Milieu Scale, the CTE, and the ESSEN Climate Scale. And we had chosen ESSEN, which is the one that's outlined there, because it really can help you to address and measure equity of experience and outcome, which is the one that we were talking about as being most important. So does the patient actually feel like the WARD understands what's happening with them, that other people fear them, that they actually care about what they're bringing to the clinical team? The clinical team cares about them. And so this could be repeated as needed. And you can actually do a QI perspective on a scale such as the ESSEN once you are able to integrate the cultural perspective as well. So in terms of advancing cultural safety, it continues to be a problem. What we have to consider is that when you're fostering this type of work, it's not just the school that you're training at or rather the unit that you're training with, but it goes broader to the education system in which where you are. So to advance cultural safety, you have to be able to train and to integrate culture into that lens as opposed to just the unit where you're working. So we had talked about how using things like the CPA guidelines, as I had mentioned, the CanMeds tools, which exist in Canada in addition to other structures like CBT, that have been culturally adapted to really start to work on integrating culture at different levels so that when you have a forensic psychiatrist trainee come to the unit, they already have that learning built in as opposed to having to teach it from the ground up, which can be quite difficult to do in teaching somebody the importance of something. So when fostering patient safety around culture, you really have to assess your own limitations. It's very difficult to do. There's quite a number of issues that come without it. There's really no measurement. There's not really a ton of sustained attention to it currently. And continuing as business as usual could be a lot easier, but we do have to respond to it. So one model that I'll describe to you is really the one that we've been working with at CAMH, which is where I've been doing the majority of my residency. And so they've created an EDI framework, which addresses a number of different components that integrate culture into it. And they map on to other offices that exist within the organization as well. And the distribution of forensic patients, as you can see, they're not necessarily always coinciding with the identities that patients identify with, per se. But these are the broad categories in which our patients find themselves. So you can see that there are other identities beyond the ones that are predominant in terms of the staff. I wish I'd put that comparator up there. But you can see that many of our patients are racialized or of other ethnicities or of other demographics. And it's important for us to be able to start to speak the language that they come into the unit with. And then, specifically, this is the vision that the unit has also created in terms of creating an equity of outcome, ensuring psychological safety, and then integrating measurement-based care. And then this is the EDI framework, which starts off, really, from some of the work that I had talked about, which is examining the literature and then moving forward to things like actually working on training and supporting people, data collection, and then actually improving those health outcomes. So currently, what we're doing is working from the literature review upwards. So I've done that. And that's what I've described in that there's really tools that examine culture systematically. The CFI itself has issues, but we're using it. We're focusing on the training now. So there's the organization and commitment, which we have, the staff and workforce, the service access and delivery, the teaching aspect, the community outreach. And what we do from this is that we move forward to actually evaluating. So using tools like the ESSEN climate tool that I had described to you and building that into our EMR to actually understand if a patient feels that those who have received training through the CFI, and are they actually approaching these patients with those culturally integrated thoughts and questions on a regular basis, and whether the patients feel like we've actually understood their lived experience. And that's the next part of our evaluation, which is novel. It's never been done. It does not exist in the literature currently. And it takes time to do well, to do the training, and to actually do the examination. But I would rather do that than do most other things. And so that's where we are right now. I understand that it's obviously not a completed project, but it continues to emphasize the need to be doing this work more longitudinally. And I think especially in the forensic system, when you have so many different levels of barriers, it's important to try at least within an inpatient setting where the patients are accessible to us and are willing and are able to actually attempt to do some of this work. And so what I've done now is, in terms of working on the integration of some of this for the people in the room, is to potentially see how you would be integrating the CFI and culturally informed tools in your own practice by seeing how you could actually answer this question from your own lens if you are comfortable. So this is mapped on from a activity that I did with Dr. Fung in Future by Two, as I was telling him earlier, where we had paired up and had engaged with a colleague to see how they would describe something, a bread and butter psychiatric case that we see from their own lens, from their own lived experience, and really see what comes of that conversation. So I wonder if we can do that within pairs or groups of three for about five to six minutes. And then there's another question after that. But I'd love to hear your thoughts on how would you, from your own lens, actually address this question. And I think you'll be surprised to see what actually comes of it from the people that you engage with. So I wonder if we can take some time to do that now. So thank you so much, everybody, for engaging. I'm actually just going to switch it to the next question because there's great discussions going on. And then after, I wonder if people might feel comfortable to actually share what their response is to this was. And how we'll do it is I obviously feel that it isn't fair to you guys to share your personal reflections on these because we did ask you to address them from your own personal realm. So if you're just able to speak to it without actually going to a mic, that would be helpful because that is not recorded. So perhaps you can also just continue the discussion with this question. And I'll give you guys another five minutes. And then we'll kind of go in a Q&A discussion format about what came up in your conversations. And I'll continue to go about the room as well. I think maybe we'll just kind of, yeah. I wonder if we can all just kind of come back to the wider discussion. I'd love to hear your thoughts on both of these questions. If you feel comfortable describing it from your realm or potentially like a clinical vignette that you've experienced yourselves. And then we can shift into question and answer as well if you have it. And as I was going about the room, I was describing between these two questions in the work that I've presented today. It continues, again, to be quite conceptual because the work has not been done. And so a lot of the work that I had to do was seeing what had been done, realizing that the work has not been done, and then trying to figure out a way by which I could quantify and understand and actually start to do this work and the skills that I had lacking and that the profession continues to need development on. And I think that's kind of where the work is. And I think by the people in this room, will continue to be done as well. So again, you don't have to go up to the mic to actually share what you're thinking with respect to these questions. But I thought that these were some broad questions that would be helpful to really understand how depression was actually spoken about. If you were able to take it from your own lens within your own communities with your own families, how would you actually describe something like depression? And how would you actually describe this to others about what is causing depression? So potentially, I'll go first because I know that it can be difficult to go first. So I found in terms of if I was to describe to somebody who was Pakistani, which I am, or who was a first generation Canadian immigrant, which I also am, I would say it's something like sadness, feeling dreary, feeling like you're not able to really get motivated. And it seems like no matter what you do, no matter how many schedules you create, there's no getting past it. And to my parents, I would say that it's not an inability to pray enough. It's not an inability to believe in something spiritual enough. It's something that's happening that I have no control over. And that's how I would describe it from the lens that I come from. And then to others, what they think is causing it, unfortunately, I think it would be the valence of that, which is I'm not praying enough. I'm not eating well enough. I'm drinking too much coffee. And really, every other version of reality is opposed to a issue that is happening chemically in your brain, which I think in certain communities is still not necessarily understood as a reality with respect to things like depression, anxiety, and mental illness more broadly. And I was speaking to some people in the audience around how I've experienced this in patients that I've seen clinically in forensics, where the family has really tried a variety of things, both individuals who are of the dominant cultural realm and also not of the dominant cultural realm, in terms of trying a lot of things. And none of those things are working. And then they've now had to come because things have become more emergent. And really being able to label why they didn't come initially, and it's because of stigma, which persists in mental health stuff. So I wonder if anybody would be interested in addressing or discussing what they talked about in either of these questions, and if you guys had any questions broadly. If a patient doesn't feel comfortable, how then sometimes they refuse to answer, and then that gets repetitive. Are there ways to address that? That is a question that was also asked before, and I still think about. Because I think a lot of the time in psychiatry, when a patient is not able to, or wants to, or is interested in, or whatever their motivation may be, I think we have to understand that as their answer. And so provide that question as an opportunity every occasion on which we have the opportunity to answer it. Because you can't force somebody to answer the question, the same way that I can't force somebody who is different than me to have me understand their lived experience. And so I think if we push specific, you have to answer this if you get this, I think we create more of a coercive environment, in which we receive answers that are not actually valid. So I think it continues to be a sitting with the patient and bearing witness to their experience, and all the things that we learn in psychiatry that the insurance providers do not necessarily care for. Any other thoughts? Questions about that? I have one other question. This is gorgeous. Right now, this brought to mind, we have one patient in particular who is indigenous and a residential school, if you want to put it. So I think it's been really great because we have the indigenous patient navigator who's working, and the social worker, and many people trying to formulate and understand a lot of the behaviors and security of the multiple-told whites. And so it's like, OK, we understand where it's coming from. And so that's the point now where it's like, staff are feeling unsafe to come to work. But then how do you take that next step? How do you use that information? Especially in forensics, where it's like, yeah, I think you understand it. Does it change then how you deal with things? Or does it make sense? In terms of how you manage things? Yeah. I think certainly. I don't know the specifics of your case, but I think a patient's lived experience is that they're not being heard, and they're being treated a specific way. And for those in the room who don't know what a residential school is, in Canada, the government had, through the 60s, systematically taken children who are of indigenous descent out of their homes and put them into schools in which their culture had been systematically eroded, so that they didn't speak the language, they didn't practice the customs, and it has been a source of trauma for the indigenous community. Genocide. Basically genocide. Exactly. And it is a genocide for generations at this point. And so I think what Canada has tried to do is really create a lot of these glancing workers and, I would say, pathways by which their needs and culture can be addressed. But it remains difficult, because if you're not of that background, you don't understand. And also, if a person has had such severe trauma, what does a normal response actually look like for them? So I would say in that case, I actually would continue to struggle. I think it's a very complex case. I think bringing in as many people of cultural background to understand, and also just being able to treat the medical need for that patient, since everybody's safe, is still of utmost concern. But I think that's where the difficulty and complexity of such a severe patient population comes in, because they've already committed a crime. There is already something bad that has happened. And so now you're trying to understand, potentially, why someone did something bad, and how to prevent something bad from happening. Also, not villainizing this person in the process, which is an impossible task, I think. I want to really say thank you. I really appreciated all of your openness and opportunity to speak and discuss with me today. If you have any last questions, I'm available a week here to speak. But I'm mindful of the time and your time. And yeah, I really appreciate everybody being here today. And feel free to keep in contact with me. My information is on the APA app. So feel free to connect and see where this research goes, because now I have all the skills. So I'm excited to do this work. We're going to see you right next. Thank you.

forensic psychiatry

cultural integration

quantitative statistics

cultural formulation interview

measurement-based care

psychiatric training

cultural safety