So, for those of you who I haven't yet met, I just, first of all, I want to thank those of you who came that I do know for your support in coming out to hear my lecture this afternoon. And to those of you who I haven't yet met, I'm Helena Hansen, and I am an anthropologist and addiction psychiatrist. Why do I start with that self-identification? Because really what I'm going to do today is tell you the story, not only of how I got to combining social science and psychiatry, but also what I aspire to work toward using that joint training, together with colleagues of mine who also share some combination of training in medicine and social science. And you'll see that in the title here, biosocial, that's a term that I've been falling back on quite a bit lately. And it's a little bit different than biopsychosocial, which many of you have been raised with, I know that I was, the biopsychosocial model, George Engels of 1971, I believe. It shares a lot in common with the biopsychosocial model. But what has happened since George Engel in 1971? Some really interesting developments in life sciences. I'll just give you a few examples. The microbiome, epigenetics, neuroplasticity, those are things that directly impinge on the model of the brain that we should be working with. I actually don't think that psychiatry has caught up, to be honest with you. So the premise of my talk today is actually that we have a wide open opportunity as psychiatrists to join our life science colleagues, including neuroscientists, who are more and more recognizing that the genome and the brain and so many human biological systems that we had thought of as very kind of simple mechanical models, and we had thought about linear relationships between, say, the genetic sequence that a person has and the outcomes, the health outcomes that come from that. We're beginning to realize that human biology has evolved so that our brains and our biological systems are very, very tightly coupled with the social environment, very adaptive to the social environment. So we're a species that evolved to survive in complex social systems, and that understanding the social environment and how it interfaces with human biology is at the core of understanding the brain, and definitely at the core of understanding what we call mental health outcomes. So at last year's APA, as one of the few jointly trained social scientists, psychiatrists in the organization, and as I said, in my case, anthropology and psychiatry, which specifically took the form of addiction psychiatry. I'll get to that in a moment. Last year, I talked at the APA in San Francisco about the acute need for social science concepts and methods to be embedded within psychiatric knowledge and practice as a corrective to the very reduced and molecular, and as I was just describing, mechanical model of mental health drivers and solutions to those drivers that our healthcare industries continue to promote and that hasn't really gotten us very far in terms of improving mental health outcomes. It's not a secret that we're in the middle of a nationally declared mental health crisis. And yet, we're in one of the more biological moments in a kind of a simplified way, biological moments in the field of psychiatry in the past century. There's something definitely missing. There's something missing, and we're paying the price for it. Professionally, our patients are paying the price for it. So the corrective that having a more robust model of what is the social and how it engages with human biology and the brain, this corrective would really foreground systemic and social structural influences on mental health, and it would lend itself to deliberate design of health-promoting social environments. We spend an awful lot of our healthcare resources on that next magic bullet molecule that will save, really save our species, and save and solve our patients' problems, and what we haven't done is really taken a very robust look and attempt at intervening on the social environments that are so pathological. So I'm gonna tell you my personal story today of the ways that I've been working alongside colleagues that have been engaging that bio-social nexus. I'm gonna be talking about, really, a paradigm shift that we've been working toward in the research that informs our practice in psychiatry, and then in what the practice of mental healthcare actually is, where it happens, who is involved in it, and what are the targets of our intervention. So I think I talked already about the magic bullet way of thinking that we're still embedded in, kind of a celebration of new pharmaceuticals and biotechnologies, and really at the expense of what surrounds the person that would be taking those, using those biotechnologies and pharmaceuticals. Conveniently, this is quite a lucrative way of thinking about mental healthcare for many of the manufacturers and healthcare industries involved. In a society where we, by far, spend the most on healthcare of any country in the world, and get the worst outcomes of any industrialized nation, this was a soundbite that was put out by then Institute of Medicine, now National Academy of Medicine, 10 years ago now, in 2014, in a report on the matter, and they pointed to our neglect of the social structures, the environment that surrounds the human being. There's so many ways that we don't invest in transportation, food supplies, and produce, walkable, safe living spaces. Look at our gun laws. There are just so many ways that we don't invest in a public health approach and a systemic approach that our peer countries actually do, and we're showing the impact of that. So the real question is, how can we retrain our gaze and our efforts onto the social structures that are driving the suffering and inequalities that we see in the clinic? And how can we not only remedy the structural drivers of that suffering and those inequalities, but also create an alternative, and I would say more ecological approach, that attends to the ways that social environment influences our biology? So this is a talk that will come back over and over again to the idea of ecology, both as a metaphor in thinking about, rather than a mechanical, linear genetic determinism or biological determinism in mental health, the interactive nature of the social environment with human biology. So it's a metaphor, but it's also really a lived reality as I'll get to in a moment. We begin to recognize that the natural environment and the destruction of our forests and our natural resources are actually having a direct impact on our mental health, and that investing in actual ecological systems is also the path forward in mental health, and in a more systemic approach, a complete approach to mental health. So the personal part of my story. I had some early lessons in the upstream drivers of well-being and mental health in my childhood home. I grew up in Oakland, California. I was raised by a single mother and by my grandparents. And I, in my childhood home, watched my uncle's cycle in and out of my grandparents' home, in various stages of discharge from mental health care, from, for addiction treatment. So this was kind of a lived reality. Coming home to my grandparents' house at the end of each school day, I did not know if I was gonna encounter an ambulance, a patrol car. And I wanna share with you a photo that I ran across when preparing this talk, which is, this is the only photo that I could find, family photo, that had two of my four uncles that I grew up with. My family rallied together to give me the equivalent of a sweet 16 party. And so you see in the front, my mother and my grandmother seated, and then in the back, the really tall one is my brother. And then you see across from there, my uncle Bubsy, my grandfather, Johnny, my uncle Billy, who's the only surviving uncle of my four uncles, and myself. And I just wanna hone in on my uncle Bubsy, who was the one that taught me how to drive. He was the one that shared with me a copy of Abraham Maslow's book on the hierarchies of need when I was in high school. He didn't know what seed he was planting at the time. He's also, he's a very beloved uncle. He's also someone who died after many, many, quick hospitalizations and discharges to very little mental health care in the moment of deinstitutionalization in California. This was the early 70s, and this was a time when under then Governor Reagan, the mental hospitals were closing, and there was nothing on the other side. There was not community mental health care on the other side to catch him. So sadly, he died, I think my second year of college, in one of the few remaining state hospital, mental hospital beds in California at the time. And so this was part of my childhood experience, running home from the bus stop, because there were so many people on the street talking to themselves and internally preoccupied, having been released from Napa County Mental Hospital. And then I came home to a household where my mother, who was a social worker, and my grandmother, who was working in the school system, were doing a very careful structural analysis about what landed us in this place, which policies, which practices, and how oppressive they had been for my uncles, who were coming of age at a very confusing time for young black men and facing a lot of brutality in the education system and with police force. So these were my early lessons in structural drivers of mental health. And by the time I reached college in the late 80s, it was the height of the AIDS pandemic. I was a biology student who also went across the street to the Kennedy School to listen to health policy lectures, because I knew that somehow these things were all interrelated. And I was really inspired by AIDS activism. This photo, I think, was taken not too far from here in New York City at the peak of ACT UP, very well-known AIDS activist organization. And what I saw as a student who eventually got hired out of college to work at the National AIDS Fund was just remarkable things being achieved by a partnership of the HIV-positive and directly HIV-affected activists with forward-thinking clinical practitioners and clinical researchers who partnered with them to make all kinds of changes, change the way that the NIH set scientific priorities by requiring that people directly affected by HIV, either HIV-positive or taking care of HIV-positive family members be involved in setting the scientific agenda all the way to the Ryan White Care Act, which, you know, one of the big innovations was that the infusion of federal money that the activists finally achieved for AIDS had to be guided at the local level by councils that were required to have, again, people who are HIV-positive from directly affected communities participating in decision-making. That led to a lot of innovations, including what we now refer to as peer navigation, you know, and peer mental health workers. That started off as buddy systems, people who had HIV had been able to navigate the healthcare system and actually got paid to be a part of the healthcare team to help others. It also led to housing as healthcare, if you remember. So prior to that, the idea of spending federal health money on housing was a foreign concept, but these community councils pointed to the literature on how impactful stable housing was on health outcomes. And so to this day, we're talking about housing as a part of healthcare. This was my coming-of-age moment, very impactful. I didn't have the language to talk about it in this way at the time, but what I wanted to do, inspired by that moment, was to practice translational social science. So I'm just gonna pause for a second. So I wanted to use social science methods, having cut my teeth on HIV community research, community participatory research. I wanted to use social science methods and concepts to inform healthcare systems of practice and translate insights from the community to the bedside, so to speak, not only from the bench to the bedside. And that's what led me to pursue an MB PhD in social science and anthropology in my case. So many of our health resources are squandered on an individual molecular concept of disease management rather than a systemic concept of upstream drivers of health and cultures of health, as Robert Wood Johnson Foundation now is putting it. And so I have used my joint training since that early inspiration. I've used my joint training in social science and medicine to work with other colleagues who are like-minded around importing social science into psychiatry and into medicine to develop an approach that I call, that we call structural competency. And I'm just gonna very quickly walk you through the logic of that approach. So medical training in our country reflects the same blind spot as our society and its focus on individuals, blaming individual bodies and their inheritance for pathology. And there's another version of it that I learned when I was a medical student and then a trainee. Cultural competency at the time actually boiled down culture to the beliefs and behaviors of the patient. So if the patient happened to come from a cultural group, for example, I was taught that, we call them Latinx patients or Latina patients. At that point, we were calling them Hispanic patients. They like families. So in order to convince them to go along with a treatment protocol, bring family members in. There's an even more simplified version of it that Asian immigrants, not even specifying which part of Asia, like the color red. So prescribing red pills would improve adherence to treatment. This was the level of understanding of culture at the time. It's the patient's individual belief and behavior that needs to be addressed. So on that backdrop, Jonathan Metzl and I. This is the report I mentioned earlier from the Institute of Medicine, now National Academies, on the failure of U.S. healthcare system in comparison to 17 peer countries that was replicated just last year. But this is what I meant to put up. So Jonathan Metzl and I, and then a growing network of colleagues began to try to systematize a way of number one, training clinical practitioners, and number two, influencing healthcare practice to address the systemic and social drivers of health outcomes. Because you might ask, what role does a physician or psychiatry have in this? Shouldn't this be left up to social workers or others to do? It turns out that it's most powerful when coming from the heart of the proponents of the downstream model. So we as a society invest so much in healthcare systems and healthcare industries that if those of us who are inside of healthcare practice and industries begin to push the envelope in the other direction, we have a special role to play and a special allotment of symbolic capital. For example, in talking about policy, we have a special ear of lawmakers when we speak as healthcare professionals and defining laws and policies as health-relevant housing policies. We know those are incredibly relevant. Law enforcement, we know those are incredibly relevant to our patients' health outcomes. So I'll just very quickly walk you through structural as opposed to structural drivers of health as opposed to social determinants of health. In healthcare and clinical training, we're getting more and more comfortable using the term social determinants of health. The way that we operationalize it tends to be rather limited. It focuses on screening patients for unstable housing or legal involvement, for example. What we don't do as clinical practitioners and researchers is to step back and ask about the population-level patterns that we're seeing. Why is it that patients from certain neighborhoods or groups are subject to higher rates of homelessness or higher rates of involvement in the criminal legal system? And that requires looking at policies, neighborhood conditions, other segments than healthcare and how we interface with, say, housing or school systems or law enforcement. And then structural competency, the term structure we use to shift the focus above the level of the individual patient. And the term social structure itself is imported from social science. It's foreign to contemporary medical practice and training. So just by inserting that language, calling attention to this vast area of knowledge and intervention that we haven't begun to scratch as clinical practitioners. And then competency to indicate there's actually something for us as clinical practitioners to do. And we, in fact, should take on responsibility. But that doesn't mean acting alone. And we don't have, there are lots of forms of knowledge we don't have in order to act effectively in this way. So we need to work in partnerships with community organizers, policymakers, people who have types of knowledge, institutional and community knowledge that we don't have. And this, in brief, are the competencies that we've systematized. Let's see. I'm going to try to get rid of... Okay. Good. All right. There we go. So, and then I'll just very briefly walk you through a rubric that I've developed to start thinking about on a very practical level how we can begin as practitioners to think and act on a more systemic and structural level. One is what's already happening in the clinic where we are. At my institution at UCLA and across the country, we're beginning to incorporate prompts in the electronic medical record that we use to do assessments of patients to remind us to ask about housing stability, involvement with criminal legal system, food access. There are so many things that we're beginning to ask about that really directly bear on health outcomes that we can address. And my colleagues who've studied the impact of this kind of prompt in the EMR have shown that it leads on its own to a big uptick in referrals for social services. Then there are medical legal partnerships, which means partnering as clinical practitioners with pro bono lawyers or law students to pursue cases. In our case, in psychiatry, for example, our patients are often evicted in violation of the Americans with Disability Act. And that's something that can be influenced once you bring a lawyer in as an advocate. Then there's social prescribing, which involves writing a prescription for a patient to get, for example, assistance with social security disability applications. And handing that prescription over to a peer navigator or to an organization that can assist them and walk them through the system. And then speaking of peer navigation, just adding people with lived experience and with training and mental health care to the mental team is itself a structural change. And then at the community level, there's so much room for us to partner with community organizations to deliver care and to support following through on care in community. Here are just a couple of examples. My friend and colleague Ayanna Jordan, who I just saw an hour ago in the center of this Imani breakthrough on the right hand side, she and colleagues, she's an addiction psychiatrist who's partnered with black and Latinx churches to put addiction treatment, recovery support, and harm reduction in black and Latinx churches. Lots of success there, and particularly because these are trusted local organizations that can engage people in a way that biomedical systems of care that have often violated the trust of people are quite marginalized and discriminated against in biomedical clinics. They can't get a similar program locating addiction treatment in Native American spiritual centers on the left hand side. The next level of structural intervention involving collaborating with non-health sectors, and I mentioned housing already. So if you take that to its logical end, this is Minnie Fullylove, who I also saw an hour ago. She is my friend and mentor, kind of mentor in life, a psychiatrist who is now mistaken as an urban planner or sociologist to be an urban planner or sociologist, because after decades of studying the very toxic and negative health impact of segregation of US cities by class and race has now turned to collaborating with urban planners and architects in cities ranging from Pittsburgh, Pennsylvania to Orange, New Jersey to redesign cities, take out the highway overpasses that were deliberately placed in between neighborhoods to physically enforce segregation, replace them with green spaces, parks, and also common economic zones with local businesses with a very positive health impact. And then lastly, public policy itself. So I am an addiction psychiatrist, so I live in the world of drug policy. On the lower right hand corner is a group called From Punishment to Public Health, New York based, which I was a member of when I was here up until 2020. And this is a group that it's a collaborative of mental health practitioners and researchers with formerly incarcerated people and also disenchanted law enforcement criminal legal system officials who have done a lot of things to redirect our patients away from the criminal legal system and towards mental health care. But one thing they do is they train clinical practitioners in advocacy, public policy advocacy, how to testify for policymakers and how to write op-eds, for example. So this is just one way that we can begin to, as a group, address the public policies that are so harmful to our patients' health. And this is a website, just an invitation to this project. But I'm going to switch gears for the last part of my talk. There's another way in which I and my colleagues have been working to bring social science to medicine, academic medicine. So by the early 2000s, when I'd finished my MD, PhD in anthropology and arrived at Bellevue Hospital, New York's largest public hospital just across the island from where we are, there I was training in psychiatry and addiction medicine. Addiction had snapped into focus as a condition that's truly biosocial. I'm just going to give you this image. So addiction is quite sensitive to the social environment in which people live. Yet it has clear biological consequences. So we're, right now in the US, experiencing the highest rate of drug-related deaths, overdoses, in recorded human history. And it keeps accelerating. So that's a very concrete biological outcome. And when I was at Bellevue, I watched on the one hand. I saw the crisis, the overdose and opioid-related crisis, unfold in front of my eyes as I helped to treat the river of patients who showed up with overdose injection-related infections and trauma. And I documented stark contrasts by race and class and how those patients were treated. After a while, I realized that I was watching the birth of two tiers of drug policy in the US in the face of an overdose crisis that, until recently, was seen, largely seen, by the American public as a white crisis affecting suburban, affluent, white Americans and youth, as well as white rural Americans. This apparently white crisis called for biomedical intervention in the form of a new field of addiction medicine, making possible private office biomedical treatment with opioid maintenance buprenorphine, otherwise known as Suboxone. Even as the drug war incarceration of black and brown people struggling with substance use continued. So my observations turned into a decade-long field research project, culminating in my book that was released just last year in 2023. It's a story of the strategies for making profit off of racial stereotypes, such as the idea that white Americans are less vulnerable to addiction than Americans of color, and therefore don't need the same level of drug regulation, with a brand new crop of opioids that are developed and marketed for an affluent and largely white clientele. That these ideas, these ideas about, in racial terms, who is vulnerable to addiction and who isn't, that these ideas are lethal to white Americans, along with Americans of color, white people, along with people of color. It's also a story about how a broken brain concept of mental health is toxic, because social environment is erased from its explanatory model. So in fact, in our society, the blind faith in magic bullets that has driven our bioeconomy has led to many previous cycles, a whole century-plus series of cycles of quick fixes gone wrong. And so I'll take us to heroin, for example, 1898, marketed to white Victorian affluent housewives by Bayer Pharmaceutical as a non-addictive alternative to morphine. This was at a time when those with means were getting injections of morphine for lower back pain, menstrual cramps. And this cycle repeated itself in post-World War II suburban America, where largely white and affluent housewives and affluent patients with access to private doctors were subject to heavy marketing of barbiturates and later benzodiazepines that were the cause of an overdose crisis that rivals the one that we're seeing today. So this is a repetitive cycle. And if you think with benzodiazepines to, for example, Valium, otherwise known as Mother's Little Helper in the suburbs, this was a separate medicalized tier of legal narcotics for white Americans, largely women, that was nonetheless lethal. So by the 1990s, on the heels of the Human Genome Project, excitement about economic opportunities in biotech combined with a chronic relapsing brain disease idea of addiction and what it is. Now we know it as substance use disorder or opioid use disorder. This led to a belief that biotechnology alone could protect against addiction and its harms. OxyContin's sustained release capsule, for example, would make oxycodone non-addictive, because it was only releasing a little bit of oxycodone at a time. It doesn't give the same rush of high-dose oxycodone to the brain. And this was a belief that was sold to the FDA, as well as the DEA and other regulators. But of course, we know the story. As soon as OxyContin hit the market, the social use of the capsule came into view. People quickly learned how to crash and snort or inject the contents of this sustained release capsule. And it was this magic bullet thinking and the brain disease model of addiction behind it that led regulators to forget everything that would happen in the social uses of the new opioids. So NIDA has spent, National Institute on Drug Abuse, has spent little time on social determinants of health. They've ignored housing, employment, social support, all strongly associated with the harms of drug use. And most of the spending at NIH and taxpayer dollars has been on public-private partnerships to develop and market new medications and technologies. So the results speak for themselves. This is a graph prepared by an MD-PhD student in social medicine, Joe Friedman, who did an analysis with me as the senior author of the longitudinal acceleration of overdose deaths by race and showed that in 2020, the racial gradient reversed of opioid overdose deaths, overdose deaths generally as well with black Americans exceeding white Americans in overdose death rates and continuing to accelerate. Native Americans always had been at the highest rates and continue to be. But if you step back and look at this graph, all racial ethnic groups represented here are showing accelerated overdose death rates. And that's after billions of dollars have been invested at the federal level in trying to correct. So there is something wrong with our focus in what we are investing in. As sociologists have documented, overdose death rates are highest in the de-industrializing regions of the US experiencing unemployment from the departure of manufacturing, mining, other local industries. And accompanied by that, or accompanying that, thin social networks, impoverished civic organizations. So now, having brought you to a very depressing point, I'm going to shift gears. In the midst of this death and destruction, I saw that while training in addiction psychiatry at Bellevue, I was also witnessing something very inspiring. The director of our outpatient addiction clinic, Anna Tina Miescher, was not only a master psychiatrist, but she was also, she is, she's just no longer at Bellevue, she's an accomplished visual artist who brought a completely different vision to the clinic of what it meant to treat addiction. So under her care, over a 25-year period, she built a community garden. That was one of her major interventions. Certainly, this is a clinic that provided all of the state-of-the-art medications for not only opioid maintenance treatment, including buprenorphine, but also medications for comorbid depression, psychotic disorders, mood disorders, et cetera. But this was greatly enhanced by the social systemic interventions that she and patients and staff together created. So the sobriety garden was one of them. This is one image. This was a place where patients and staff worked together to cultivate and harvest. There is also a kitchen in the center of the clinic where patients who had been referred from, many of them referred from homeless shelters across the city who had not had the opportunity to make their own food in a long time. Some of them never had learned to make their own food. They cooked and broke bread together. This clinic also had a piano in its center and music groups, also visual art studio. She was a believer in art therapy, Anitini Mishra, and is a believer in art therapy, peer support, and the expertise of people with lived experience to support each other. I sought her out as a mentor, and she told me, psychiatry is art with found objects. Your job as a psychiatrist is to take the broken shards of people's lives and help them put them back together again in a new and beautiful way. So another mentor of mine, Mark Gallanter at Bellevue and NYU, who has done a lot of studies of spirituality and mental health, defines spirituality as something that, as opposed to religion, is that which gives life meaning and purpose, and that also contributes to a sense of connectedness and belonging in a community. So it's this connection and meaning that's at the center of successful mental health interventions. And I was forever marked by what I saw happen in that clinic. My idea of what mental health care could be was so much broader and deeper than it would have been had I not gotten to know and work with these amazing psychiatrists and patients. I saw people who had experienced horrible trauma in foster care, jail, and prison, shelters, homeless shelters in the street, completely transform their lives within the adoptive family structure of this clinic and develop a positive identity and sense of their own ability. I'm just going to take one second to honor Ruben Lopez, featured in this slide, who I met when I was a psychiatry intern at Bellevue in an anger management group in this clinic. He had never done visual art before being referred to the clinic from the men's shelter next door. He gravitated to the art studio and could not be pried away from the art studio at night. And he went on to win a bunch of awards in statewide art competitions and have his work featured in art galleries as a, quote unquote, outsider artist, someone without formal training who's very accomplished nonetheless. Sadly, I learned of Ruben's death just last month. So Ruben is no longer with us. He's somebody who's greatly inspired me and my colleagues at Bellevue in thinking about what can be possible in a setting where meaning and connection are really primary. So I'm just going to give myself a moment. And so I'm going to try to make a transition from that sad note to really the highlight of what I know Ruben would want me to underscore with you, which is in this very collective and arts and gardening-based approach to mental health and addictions that I learned to practice side by side with Ruben, we really came to understand the power of narrative, what people tell themselves, what they tell themselves they are, and what their future is. And in the process, one of the more creative and inspiring things I did in the two decades that I spent at Bellevue Hospital was to participate in a group therapy, a therapy group that centered on filmmaking. So it was founded by a former patient who was a filmmaker and then continued in partnership by him in partnership with an art therapist, Lena Friedman, working at Bellevue. So I'm just going to show you very briefly a quick trailer that was made. It's kind of a faux trailer. You'll see what I mean by that. Made by members of the video group, the filmmaking group at Bellevue. So you can get an impression of the collective nature and meaning-making nature of the group. So I'm going to go back to... So, storytelling, the arts, gardening, cooking, these are things that might seem frivolous. They don't seem like powerful or high technology mental health interventions. But they were responsible for a lot of the success that we had in treating people who were struggling with addictions and mental health problems on the backdrop of long histories of trauma, dislocation, structural violence. And I've come to call these social technologies because they involve specific techniques that require practice, investment, and skill. These are not accidental. And they have tangible effects on the outcomes of patients. So, in my research on policy, institutional, and community drivers of health inequalities, and my clinical training on structural competency to address these drivers, I often end up giving examples that involve gardens, the arts, spiritual practice, and community organizations. Understanding how these alterations in the social environment of our patients and, you know, people in general, how they directly shape human biology, is an emerging field that I call biosocial research. As I started off, let's see if I can, there we are, okay. So this is a website from a project that I started when I was at NYU, almost 10 years ago now, with Dorothy Roberts, the renowned sociologist and legal scholar, and Dolores Malaspina, who is a well-known epigeneticist of mental health and schizophrenia, now based at Mount Sinai, and many others. So it was a collaborative of life scientists with social scientists who came together to develop, you know, in the title, Symbiosis, a Biosocial Research Network. How can social scientists and life scientists work symbiotically together? And in the beginning of our work together, until COVID hit, actually, we had six conferences, a number of papers, and collaborative projects come out of that. But in the interest of time, I'm going to hop forward to what I'm involved in now at UCLA, which is, I migrated across the country literally at the peak of COVID in fall of 2020. And it took me a while to discover exactly how the Biosocial was taking shape and could take shape at UCLA, but in fact, it is and it has. So I'll leave you with two projects that just illustrate some of these collaborations between social scientists and life scientists that also involve psychiatrists and clinical researchers. So these initiatives at UCLA really represent a critical mass of people who understand ecological, meaning relational and multifactorial, as well as systemic approaches to health and mental health. Those that foster life-sustaining webs and networks of support between people, and even between people and plants and animals, you know, the natural environment. These are approaches that fertilize and nourish networks with creative activity. And in fact, it turns out that fostering mental health and well-being is more like gardening than fixing a mechanical device. So despite our current fascination with broken brains and neuromolecular magic bullets for mental health, the most powerful promotion approaches for mental health, mental health promoting approaches are like gardening in that they help people to grow and flourish in ecological balance with each other and the environment. It involves individuals offering each other different skills and abilities in symbiotic relationships, you know, forms of mutual aid. And I aspire to build on this wisdom through projects like this one. So we're actually hosting a conference that I should circulate a flyer for to any of you who are interested. So this Friday at UCLA, we're hosting a national and now international conference on the intersection of ecological medicine with psychedelics therapies. And the thinking behind this initiative around ecological medicine and psychedelics therapies, this being a flyer for our monthly affinity group meeting featuring different speakers who are working at that interface somewhere, is to take advantage of this moment of incredible excitement about psychedelics, which as psychiatrists, I'm sure you've been exposed to, you know, because there has been so much bad news about the disappointment of prior magic bullets and pharmaceutical solutions when the positive clinical trials of psychedelics came out, I think there is a natural and understandable tendency to invest the same kind of hopes and aspirations in psychedelics. Psychedelics do offer us, if we look very closely at the indigenous and traditional uses of psychedelics in societies that have used them for a long time to benefit, they offer us an opportunity to look in another place for the therapeutic impact of these molecules. And that is in what psychedelics researchers call set, as in mindset and setting. Set and setting. What surrounds the person? Who is there? What is there with the person as they take a journey with these medications? And how does the medication actually enhance their sense of connection to plants, to animals, and to other people? With traditional indigenous uses of psychedelics really focused on the natural environment, plants and animals, and our place as human beings in a larger system in relationship. So that is why right now in our psychedelics initiative we're foregrounding ecological medicine and how ecological medicine on its own promotes mental health through a sense of deepened sense of connection and meaning and how that might be enhanced by the administration of psychedelic medications. So that's one place. And then the second place, let me see if I can pull it up, the second place that we're operationalizing connection, meaning, and social technologies through social technologies is through our newly launched Dana Foundation-funded Neuroscience and Society Center at UCLA, which is launched in collaboration with Charles Drew University. So I worked with a number of neuroscientists at the Semmel Institute at UCLA for neuroscience and human behavior and clinical researchers and social scientists at UCLA, as well as a very talented group of researchers and clinicians from Charles Drew University, which is, for those of you who don't know, probably at this point the nation's only historically black medical school, HBCU Medical School, and Hispanic-serving institution at the same time, located in South LA, formed on the heels of the Watts Rebellion, otherwise known as Watts Riots in the late 60s, devoted entirely to rectifying health inequalities. And that has led them to develop a lot of approaches that the rest of us can learn from. So number one, 100% of their research is community participatory research. So they're very strong in that. Number two, they have a form of faculty member on campus who does not have an MD or a PhD, rather is a community organizer and a community leader who has had a lot of success in health promotion. And so these are community organizers and leaders who are teaching the clinical trainees at Charles Drew. That's a really impressive way to go about educating the next generation that really lends itself to a systemic structural approach. So what I'm going to do is show you a one-minute video so that we can then go into a conversation. One-minute video that we made when we were developing a pilot project for this center. So this was before we got major funding from the Dana Foundation. And the way we decided this group of neuroscientists who were committed to developing, in partnership with our community faculty and South LA community members, a community participatory neuroscience that would focus on South LA as an area of LA with members, community members who've been very poorly served by neuroscience up until now. So South LA was a place where research subjects for studies of the federal violence initiative, for example, in the 1990s that tried to locate the cause of criminal and violent behavior in young black men in the brain somewhere. Those studies were conducted by UCLA neuroscientists in South LA. So this is an area of LA where residents are understandably very suspicious of neuroscientists and have not had a good experience. So we're trying to reinvent in collaboration with them by starting with human-centered design workshops. So what we did was we held a set of workshops with South LA residents, many of them young people in their late teens, early 20s, around what neuroscientific questions, questions about the brain, would be useful and interesting to you. What problems or what questions and issues are arising for you that would lend themselves to neuroscientific research? First, we started off on a strong note of their interest was the toxic nature of the environmental, both social environmental and literal environmental, as in pollution and toxic dumping in the area. What is the impact on our young people and our children's brain development and learning? And then also, what are the multi-generational effects of this kind of exposure? How is it transmitted from generation to generation? It's a very big question. So we had to break it into a much smaller question that would shed some light on the larger question. And what came out of our workshops was looking at the impact of the sheriff's helicopters that have constant presence over South LA that fly at low altitudes late at night, early in the morning. They're jokingly referred to as ghetto birds in South LA. I'm seeing some of you who know South LA nod. So the South LA community residents and leaders in these workshops said, we want to know what the impact of being woken up in the middle of the night, night after night, is on brain development and learning of these sheriff's helicopters. So what we did as a team, a multidisciplinary team across UCLA and Charles Drew, was first to map the flight patterns of the helicopters and to demonstrate that, in fact, they did focus on South LA and, in fact, certain housing projects in South LA for surveillance purposes. So we were able to document that. And then South LA residents, most of them youth, went into the lab with our neuroscientists and began to model the impact of that kind of noise-related sleep disruption, first in rodents and then later in Drosophila, in fruit flies. Why? Because fruit flies multiply so quickly that you can begin to look at the intergenerational transmission, you know, the epigenetics of sound-related sleep disruption. So I'm going to show you this one-minute video, just as kind of a visual of what this work was like, and then I'd love to get into a discussion with you and hear what your thoughts are on approaches like these. Music We're a multidisciplinary group of people, including community members who are collaborating with us in research and academia, who want to reimagine neuroscience, what would it look like if we actually deliberately started with the concerns of communities that historically haven't been well-served by neuroscience? Could we develop a method for doing this differently? Music Okay. All right, I know the sound dropped out a little bit on that one. But on that note, I'm hoping that we can have a conversation about your own thinking on the future of psychiatry and what I've been calling bio-social research and interventions. The Neuroscience and Society Center, to me, represents really the future. If we start to hone in as a field to that interface between the biological and the social, including in the way that we develop research questions and conduct the research side-by-side with heavily affected community members, if we can begin to do that more systematically, we'll have a whole other concept of what drives mental health and what our role is in promoting mental health. So thank you for listening, and I'd love to have a conversation. Thank you. So any thoughts you want to share? Thanks for joining us. Thank you. Thank you. Hi. It's so good to see you. I wanted to say thank you. Great talk, by the way. I'm Tyson Boudreau. I'm here in New York. I work for the New York State Office of Mental Health. I'm on faculty at Albert Einstein School of Medicine, child and adolescent, and an adult psychiatrist. I really like your talk about engaging the community, which I think is important. Our medical practice is really based on the heteronormative Western colonial patriarchy, which is a lens that doesn't work for the BIPOC community. And connecting with faith-based organizations and also engaging in social prescribing is really steeped in indigenous ancestral practices, which I think is where we need to go. In the Bronx, we're creating a wellness center that focuses on social prescribing and connecting people with mental health conditions along with anyone else who's in the community who's interested in connecting on shared commonalities. Tai chi, soul cycle, sound bathing, aroma therapy, light therapy, community gardening, rooftop gardening with hydroponics. Sign me up. Yeah, right? And the whole idea is to really connect the people with mental health conditions with anybody in the community because we're all part of the same community. And our medical practice over-pathologizes people. It others them. It contributes to health inequity and health disparities specifically for people of color. But this is something that's new, something that a lot of the bureaucrats in New York are having a hard time with, but the commission is going to help us to get there. But we think that's the way to go. That's a new way of addressing this problem. And thank you for your talk. Thank you, Dr. Boudreau. As always, way ahead of the curve. You know, there's something implicit in what you said that I want to draw out for a moment. We are in a profession that has systematically been about establishing and reinforcing a hierarchy. So even the differentiation between professional and patient has been quite clear. And, you know, it's interesting to think back to over a century ago, a time when, you know, Freud himself recognized publicly that we're all crazy in some way, right? We're on a spectrum. Absolutely. We're on a spectrum, but all of us have defenses and ways of reacting to our environment that don't serve us well. And there was a time in psychiatry, I understand from my more senior colleagues, when everyone was expected to be in analysis, some form of therapy, if not analysis. We're now in a moment of time where it's actually a shameful thing. You know, in many residency training programs, people don't want to admit, the residents don't want to admit that they're in therapy, and they make other kinds of excuses for absence in clinic. It's remarkable how strongly right now we reinforce the distinction between ourselves as psychiatrists and patients and the rest of the community, when actually what I saw in action in Bellevue, in the garden, and in these arts groups was people working side by side who happened to be credentialed, who happened to be staff, who happened to be professionals, with people who happened to be patients at the time, but in a way that really brought everyone together in a robust mutual aid vein. And that's what I heard you describing when you talked about your interventions, that there's something that's very inclusive and leveling and participatory about the practices you were describing. Yeah, you know, it's very healing to connect with people. And it's a bit of epistemic injustice to believe that the sources of truth, wisdom, and knowledge only from the psychiatric provider. I learn a lot from the peers. I am a person with lived experience and am an instrument of healing, as we all are. And how do we connect to that instrument of healing? It's by connecting with one another. I think that's the only thing that's going to really help us, more than the prescriptions that we send out. I am so glad you brought that up, because that also brings up one other thing. How do we save ourselves as psychiatrists, right? We're in a moment where people are dropping out of clinical practice at record rates. They're experiencing tremendous burnout. When they're interviewed about why they're leaving practice and why they're so burned out, they talk about the systemic barriers to actually helping people. And I will now admit that the reason that I participated in therapy groups such as the Video Stories in Recovery, the filmmaking group that you saw a faux trailer from for two decades, was that that's what saved me. That was sustaining for me. That reminded me why I was doing mental health practice. And having those relationships over time with people in those groups, that's what kept me going in psychiatry. So we can't ignore that either. We need to be of service. We also need to support ourselves so that we can get through what is a really difficult time for anyone in the mental health field. So thank you for bringing that up. Thank you, and congratulations on being a human being. Thank you. It feels odd in a room this size to have people coming up to the mic, but I think it does help, right, with the audio. Dr. Barber. I'm Jack Barber, and I am a community psychiatrist in South Los Angeles. And I've been aware of some of the amazing work that's being done at UCLA and CDU. And I want to just share how compelling it is and also how difficult structural systems are that interfere with being able to have work like this flourish. Because I run a community clinic. I have five sites. However, with peer navigation and peer support services as a linchpin of our services, there are still these structural components that make this type of work difficult to achieve and to be reimbursed. And so in some respects, I'm talking about money. And so that is some of the hard knocks of some of the challenges that we experience. We're in the middle of really establishing a crisis stabilization unit in South L.A., and what I'm thinking about all the time is about land and what does land look like in South Los Angeles and how in one time and a second time, and you have to be very resilient. We've run into land, started to build, and then we found out that the phase two contaminants of the land from generations in South LA are just so, it's such a systemic problem. So we must be very, very strong to continue this type of work. I'm just very excited that the community collaborations that you've been able to establish have been so positive because the community is really what drives all of our outcomes. And just thank you for your work at UCLA and you are a gift to Los Angeles. Oh my goodness, thank you. Back to you, Dr. Barber is just an amazing force of nature in public mental health. And I wanna acknowledge a friend that we have in common and close colleague that we have in common, Denise Shervington. I'm not sure she made it to the meeting this year, but she is the chair of psychiatry at Charles Drew. And one thing we support each other in is it's, it is, as you said, Dr. Barber, so difficult to do. And also Dr. Boudreaux brought this out too. So difficult to do this work against the grain right now, because there is still such an investment in this magic bullet kind of thinking. And one thing I will say is that we've gotten such enthusiastic buy-in from so many different sectors and people so far with our neuroscience and society center, because we're not the only ones in psychiatry that are starved for a different approach. So our neuroscience colleagues have been incredibly easy to bring around. They want to get outside of the lab and they wanna bring community members into their lab. They wanna know the relevance and the utility of their work. And they also know how limited the contributions have been to improving mental health outcomes to date of the neuroscience that has made it into psychiatric practice. So I think it's that kind of enthusiasm that's gonna carry us forward. And our community partners too, incredibly important. It's only through a groundswell of support and collaboration across community members, professional groups, and researchers that we can turn this ship around. And it's not an accident that we tried to document the process by involving filmmakers and involving those who have artistic talents in this, because a lot of it is about changing the cultural logic. We are so limited. And if we leave it up to healthcare industries to define what mental health care looks like, and we have, we get the result that we've got. And so we need as much representation and conveying in as many different mediums as possible of how it could be otherwise. How could it be otherwise? So, and artists, that's another thing I wanna underscore. Artists are so critical to mental health promotion. Every time we partner with an artist, whether it's being a musician, a visual artist, I would say that gardening in the hands of Dr. Sheridan Ross who you saw at the Compton Community Garden. He's an artist in his own right. He has gotten a huge network of community gardens going across Los Angeles, starting in South LA in areas that are food deserts and been able to feed hundreds of families, but also to bring young people into gardens and have it be a site of learning, biology, chemistry, cooking on many, many different levels. It's an educational tool, which is why the LA Unified School District now has committed to starting community gardens in each school in the system. But also bringing elders to the garden, some of whom have deep embodied knowledge of how to cultivate the land. Because in South LA, a lot of the black residents and also definitely Mexican American residents, Central American residents migrated from agricultural areas. So Sheridan Ross himself, his grandparents lived on a farm in Alabama and he was sent back to the farm as a child in the summers and learned how to grow food. And he's now imparting that knowledge to the young people in South LA. And that's something that other elders in the area have been able to reinforce. So, oh, I was talking about artists. So the arts are incredibly important to the set of social technologies that we need to move this forward. And they're also incredibly important to conveying a different vision of what psychiatric practice and mental health care could be moving into the future. And on that note, I see some of you nodding and I wonder if there are any other, there's someone who was about to make a point, yeah. Oh, sure, go ahead. Hi, I'm Catherine, I'm a medical student in Miami. So I'm very inspired by this talk and all the work you're doing. My question is more so kind of logistically and dealing with now as a medical student realizing insurance is a big factor on how we treat patients. Do you see a world in where kind of insurance can take care of community gardening, cooking classes, prescribing, these type of social therapies? Like how do we get? You ask such an important question. So I think that that is kind of the, that is the big barrier that we have to overcome. And there was a time in American mental health policy where these kinds of innovations were supported, were supported with public mental health funding. So for example, those of you who know the history of addiction treatment in this country know that there was a time where people, including some very famous jazz musicians who inspired my husband, who's a jazz musician, Charlie Parker, a whole litany of famous jazz musicians ended up at the Narcotic Farm in Lexington, Kentucky. I would not say that the Narcotic Farm, which was also a prison, is overall a model that we wanna pursue, but one thing that they excelled in was what they called moral therapy at the time. It was a very enriched program. They're involving actually a lot of music because they happen to have a lot of fantastic and kind of path-breaking historical figures in jazz and other genres of music, but also farming. It was a farm. The Narcotic Farm was a farm. And there have been other experiments like that in outpatient care through US history. So we can point to periods of time when government mental health funding actually did go to a systemic, relational, and community-based model of care. Sadly, in the 70s, the deinstitutionalization that my uncles fell victim to really had to do with overall budget cuts. And this is a moment, actually, this is a moment when mental health is getting more attention than it has in a very long time. I don't know if any of you have encountered that. And more commitment of government support. You know, I'm from California, which has the millionaire's tax on mental health. And so we have the highest per capita level of funding for mental health care in the country. What we don't do right now is a very good job of really highlighting how we're gonna get the best impact for that investment and tracking that. And so that's where these collaborations with not only community organizers and community leaders, but also social scientists, people with the methods to document the mental health impact of the connection and meaning promotion that we know is connected to good mental health outcomes. We need to document it. And I think that the bio-social research that's emerging from partnerships among neuroscientists, clinicians, and social scientists to look at epigenetics, the microbiome, neuroplasticity, as well as relationship to plants, animals, and the natural environment nature connectedness in our era of climate change and climate anxiety. These things we need to study and operationalize in using a wide array of methods. But we need to document it. We need to show how it works in interventions and lobby for government support. This would be the moment. This would be the moment because number one, mental health is a national crisis. It's getting loads of public attention. Everyone has had somebody personally affected by the mental health crisis. And number two, we know that the current models aren't working. They're not effective in the U.S. So this is a wide open opportunity for us to collectively lobby for and develop a whole other approach. So I'm glad you raised that question. Thank you. Hi, thank you very much. I really enjoy this. I'm Larry Merkle. I'm a psychiatrist and also an anthropologist from the University of Virginia, and I've followed your work for a long time. We met many years ago at an SSPC meeting. Great to see you. Thank you. I really appreciate all that you've done and I'm impressed by how far you've gone. Structural competence is a wonderful idea. I support all of that. I have to confess though, I cringe every time you put an asterisk on talking about white populations on saying rural populations because I work in central Appalachia. And that's not your typical white suburban population. That's a population that's been discriminated against, has been marginalized, is poverty stricken, has been exploited by these drug companies and everything. And most of the drug money has not gone to this group even though that's where most of the opiate crisis started and is still going really strong. And so it kind of essentializes the white experience. And so I, and their main treatment has not been treatment. It's been criminalization. And we're just now trying to turn that around some. So a little asterisk there, please. Thank you for that. So I did distinguish white suburban from white rural populations in this talk, but it was so brief that it probably slipped right by. I'm glad you raised it. And I don't want to restate my entire book because we don't have the time for that, but I'll hone into, I did have to with my coauthors delve into the fact that there were really two different populations that were heavily marketed to in the late 90s after OxyContin's legalization. And they were two different markets that were potentially lucrative to the manufacturer for different reasons. So there's the white affluent population of people with excellent private insurance and who often can pay out of pocket actually. If there's a narcotic or anything that could potentially be stigmatizing for a medical record, they pay out of pocket. And so that's the normal first target for manufacturers who are marketing expensive new patented medication. So that was a big one. And then there was a second population of rural people in white areas of the United States that were in occupations that involved a lot of injuries because they use their bodies. So construction workers, miners that get workers comp. So the manufacturers managed to get OxyContin and sister products covered by workers comp early. And they saw that as a second market. And so what you got was really these two different groups who were not subject to the same kind of surveillance and regulatory skepticism as other groups of Americans would have been because they were white. So there was a racial protective factor in the fact that both of these markets were largely white communities. But these were two different markets. And what happened afterwards was a very bifurcated by-class response. As you pointed out, there are areas of the Appalachian Mountains and other rural areas across the United States where poor white Americans are subject to not only law enforcement, incarceration, separation from their families by foster care, at similar rates to poor black and brown Americans, but they're also portrayed in the media in similar terms as people who are lazy, who don't take care of their families. And I have colleagues who have studied this phenomenon and argued that there's been a sort of racial blackening of white Americans, poor white Americans in areas of the country that are predominantly white, where they're the other, they are othered in a way that's analogous to the way black and brown Americans are othered in other parts of the country. So it's a complicated story. But the way that the response has been different has been quite remarkable. With more affluent white Americans getting a medicalized approach with buprenorphine, that is the market that that private office-based treatment was intended for, bar none. And the last nationally representative studies of who gets buprenorphine and who doesn't demonstrate that, because not only are white Americans with opioid use disorder three to four times as likely as black Americans to get buprenorphine as kind of gold standard treatment, but if you look at the form of payment, the out-of-pocket payment most common followed by private insurance. You know, and those out-of-pocket people are able to afford thousands of dollars for the treatment out-of-pocket. And then much further down is Medicaid and other forms of public insurance. So you bring up a really important point that, and this is where social science is handy, okay, because we often gloss race and we will gloss class and we don't quite get into the nuance of how these things intersect and interact with each other. And what even is race in this country? You know, we're now, because of scholars like Dorothy Roberts beginning to say race is a social construct. You can't find a gene for the given races that we label people with. And in fact, the categories we have in this country don't match up with categories in other countries because they were an American invention and they came about in the office that handles census and accounting, right? The budget office. It was not developed by scientists. And so to understand how race is socially constructed and how white people can be honorary black and brown people in certain settings and how it's a relational construct, social science is really handy. These are not ideas that come out of medical sciences. Not US medical sciences. And that's why we need much more interaction and collaboration among social science and medicine, which is not a new argument to you. It's great to have another anthropologist in the room. Yeah. Thank you. Oh, hi. Dr. Hanson. First, thank you so much for the generosity in sharing a story of her childhood. That was really, really impactful. So I'm a medical director in Connecticut's largest state hospital or largest inpatient psychiatric hospital. And one thing I'm seeing a lot is the effects of like legalized marijuana on my patients of psychotic disorders. And I'm wondering as an addiction psychiatrist, what's your like structurally competent, like some nuggets of knowledge I should have for wanting to be structurally competent in this particular situation? Thank you. I think that's a tangled one. The relationship between cannabis and psychosis, which is perhaps emerging now that many states have legalized marijuana for medical, if not other uses. So that's again, an area where I think, I can't give you the answer in a nutshell, but I can just highlight some places where much more sensitivity to the structural drivers of many outcomes in relation to each other would be very handy in collaboration with social scientists, including policy analysts. Because one, two very strong arguments for legalization, at least of medical cannabis, if not beyond. One of them has to do with incarceration and who gets incarcerated and what the consequences are on society. So of course, marijuana-related arrests being one of the really big drivers of the disproportionate incarceration of black and brown Americans, despite the fact that actually white Americans use just as much cannabis. But it's a pretext for incarceration. And in our legal system, a lot of the discretion is left up to judges. So as you can imagine, so much race and class bias comes into judgments about how to intervene and how to sentence for a marijuana-related arrest. And then of course, we know the disproportionate surveillance and arrest rates in certain neighborhoods. And so this has led to just generations of people who now have a criminal record and don't have access to a lot of public benefits, employment, the things that will sustain them with downstream effects on their families and communities that have been well-documented. Okay, and then the second, oh boy, it escaped me, but there's a second large driver that has been well-examined by social scientists and policy analysts that will come back to me in a moment. But I wanted to highlight that with that, oh, I know what it is, okay, opioid crisis. So about a decade into the opioid crisis, social science and epidemiology colleagues were able to document that those states with more liberal cannabis policies had lower overdose rates, overdose death rates. And when they really looked into it, they noticed that the same kind of self-medication uses of opioids for pain and emotional, physical and emotional pain that people engage in with opioids, some users were substituting cannabis, which is a much lower risk substance and with positive impact on pain, at least perceived positive outcome on mental health conditions. And so the argument was, this is a form of harm reduction as well. You know, this could be one way of lowering our overdose death rates. And I bring that up to say that now enters these other factors, which many people predicted that there are some harmful effects potentially of cannabis use. But if you don't have the larger context in mind, you can't do an adequate cost benefit analysis of that. And you don't know where to intervene on the source of the problem. So I'm just laying those out as a few things that if we were to really collaborate with our social science colleagues, including policy analysts and think in truly informed structural ways, we would take those things into consideration and coming up with a structurally informed response or intervention. But that's exactly the point is that these things are not simple or easy. They do require a knowledge base. They do require collaboration with people with serious expertise in social systems, including policy and their impact. So I'm glad that you raised that because these are actually hard questions that we need that kind of multidisciplinary collaboration to address. Thank you. Sorry to have you come up, but it's the OP. Oh, yes. We've got 29. Oh my gosh, okay. The next one is bad, let's say over 250. Oh, okay, so we're gonna end here. I really appreciate all of your wisdom. Thank you for coming. Thank you.

Helena Hansen

anthropology

addiction psychiatry

biosocial model

mental health

social science

biopsychosocial model

systemic structures

translational social science

community engagement

structural competency

ecological approaches