Good morning. Welcome. My name is Eugenio Roth. I'm the immediate past president of the American Association of Social Psychiatry and we are here today to honor our Abraham L. Halpern Humanitarian Award winner, Dr. Marilyn Benoit. It is my pleasure and privilege to introduce to you Dr. Benoit. Dr. Benoit was born in the beautiful islands of Trinidad and Tobago and immigrated to the United States as a young woman. She graduated Phi Beta Kappa from Howard University and completed medical school at Georgetown University where she is currently an associate professor. Dr. Benoit also holds a graduate degree in health services management and policy from the George Washington University School of Public Health. She is the past chief medical chief managing officer and chief clinical officer of professional affairs of the Devereux Advanced Behavioral Health Organization and she is also an associate professor at Drexel University Medical School. Most importantly Dr. Benoit is the past president of the American Academy of Child and Adolescent Psychiatry. During her presidency of that organization she led a joint initiative with the Academy of Pediatrics and the Child Welfare League of America which involved 70 national child serving organizations. Dr. Benoit has had a distinguished academic career providing training and supervision to residents and fellows for several decades and even a more distinguished service career in the public and private sectors. She currently provides psychiatric school consultation to several residential treatment centers and organizations involved in the prevention of child maltreatment. She is also the founder of the Suicide Prevention Initiative at Gallaudet University which was founded in 1864 as one of the world's first institutions for the education of the deaf and hard of hearing. Dr. Benoit serves as a board member and trustee in a number of organizations such as the Chance Academy, a school for underprivileged children in Washington D.C. and the Field Center for Social Work and Social Policy also in the Welfare League of America and the Devereux Foundation just to name a few. She has been a recipient of numerous awards including Georgetown University President's Visenial Award and the following awards from the Academy of Child and Adolescent Psychiatry. She has been awarded the Jean Spurlock Award, the Virginia Anthony Award, the Mentorship Award and the Child Maltreatment Committee's Passion Award and in honor of her many contributions to the Academy of Child and Adolescent Psychiatry, this organization endowed an award in her name. It's called the Marilyn B. Benoit Child Maltreatment Award for Child Psychiatry Trainees and Early Career Psychiatrists. Dr. Benoit is also the happy grandmother of five children, two of whom were adopted from foster care. On a more personal note for all of us who have the privilege of knowing her, Dr. Benoit is a warm, wise, humble, welcoming, generous person who provides leadership by example and by the presence of her human qualities. This committee could not have found a more deserving person to receive this award. And now I will introduce Dr. John Halpern, who is the son of Abraham Halpern, after which the award is named to honor Dr. Benoit. Applause Applause So, also the current president of the American Association for Social Psychiatry. Please, if you're not a member, please join. And yes, it's also a little bittersweet because I'm also thinking of Pedro Ruiz, former APA president and tremendous friend to the American Association for Social Psychiatry and for many people here. And I'm thinking about him especially with my father because they were both very simple people in some ways. My father's first suit was when he enlisted in the Navy in World War II. And the area that he grew up in in Montreal is under a four-lane highway. And so one person, he would often say, one person can make all the difference. You know, he who saves one man saves the world. And when we save our children, the impact keeps compounding and compounding. And I can't think of a more important person to single out than Dr. Benoit because it's our future in these children. And we don't know who's going to be the next Pedro Ruiz or Abraham Halpern or Dr. Benoit or any of us. They're all special like that. Everything matters like that. And to just have that energy through your career, it's a real inspiration and honor to confer the 2023 Abraham L. Halpern M.D. Humanitarian Award to Marilyn B. Benoit. Thank you so much for your career. applause Good morning and thank you, Antonio. Thank you, Dr. Halpern, for this honor. And I'm very humbled by it. I was so surprised when I got the call and I said, how did this happen? So it's my pleasure to be here this morning. Thank you for coming out early. And first, I want to mention your dad, Dr. Abraham Halpern, who was a forensic psychiatrist. And what he did that was different is that within psychiatry and within the House of Medicine, he was essentially a social activist and wanted to bring attention of medicine to social issues that we felt that we should be concerned about. And I feel very strongly the same way. I remember when I was starting out and doing some research on child maltreatment that I read where actually a past president of the American Academy of Child Psychiatry had said that these social issues don't belong in medicine. And as we now know, and I'm so pleased to see that we're talking about social determinants of health, all of medicine is finally embracing this. So I'm glad about that. And I want to let you know, you don't need to take pictures of slides. All of this is available through the APA to download. Okay. I have no conflicts of interest to declare. And the goals of the lecture are to emphasize the critical importance of attachment in the first day of life. I can't tell you how much this is so important, how much I believe it. And when I do case consultations and, you know, they give you a brief history, all I hear is the history of what medications the kid has been on, what has been added, what has been subtracted, what has been increased, etc. And I would say, well, but tell me who little Joey is and what happened in his first year of life. And people are not taking histories. And I encourage you, please, please, please, that is part of what we do in medicine. We take a good history. To establish a relationship between attachment and trust. To understand how and why the above form the underpinnings of social relatedness and connectedness. And appreciate the critical role of social connectedness in maintaining mental health. I'm pleased that we are even hearing more about this happening. In fact, our Surgeon General, Dr. Murthy, recently declared a crisis of loneliness in the country. That's good. So, when we started out with psychiatry, most of us learned the term biopsychosocial. And for some reason, well, I don't have to say why, the word social seems to have been eliminated in recent years. And I would like to emphasize how important that is. Like this, sociocultural factors play an important role in socialization, thinking, behavior, feelings, and perceptions. Therefore, they have significant impacts upon the mental health of individuals and upon the population. We saw recently what the COVID pandemic did, and it presides an excellent example of the increase in population in psychiatric morbidity, especially in adolescents. As you know, AP, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry jointly declared a mental health crisis for youth. Unemployment, poverty, violence, socioeconomic and health disparities, racial and ethnic discrimination, all leading to demoralization, despair, and hopelessness contribute to mental illness. I'm sure that not one of you has crossed the street in San Francisco where you haven't seen the homeless all around us. Even the taxi driver who drove us over said, you psychiatrists, you need to do something about mental illness. 69% of these people are here because of mental illness. And I like to think of Maslow's hierarchy of needs, and Dr. Eugenio wrote them. Yesterday, when you gave your talk, you mentioned that psycho Freud and his patients were really middle class and educated, and that what we are dealing with a lot of the time is not that we don't deal with middle class and educated, but we have such a need in a more vulnerable, poorer populations that we can't just think of what's going on intracyclically. We've got to look at people's real needs. And so think of Maslow's hierarchy of needs. When basic needs are not met, individuals react with anxiety, depression, abandonment fears, and uncertainty about survival. I recently read Viola Davis's memoir called Finding Me, and she grew up, as she said in her writing, she said, which is a level lower than poor. And she described how she and her siblings would actually go and steal food from one of the neighborhood stores. And she went on to say, when you are so in need, she said, morals go out the window. So we have got to address that, and it worries me that even as we speak, our government is talking about cutting the entitlement allocations to people who are needy when they aren't really enough. And we saw that during COVID, when people were given more money, the rate of poverty went down. But of course, all that money is gone. But we have to be part of the solution, and not just think about what's happening intracyclically. So, I started with attachment, and it is so critical. I was talking with Andy's wife. We were talking about schools yesterday, and preschools, and the idea of child development. And I am very fortunate that my two granddaughters are going to an incredibly wonderful school where they don't get grades, they get a child development narrative, essentially, is what they write out. And we were saying that teachers need to have courses in child development to understand. So, starting with attachment, and I just wanted to share the ACAP definition of attachment. It may be defined as the organization of behaviors in the young child that are designed to achieve proximity to a preferred caregiver at times when the child seeks comfort, support, nutrients, or protection. Typically, preferred attachment appears in the latter part of the first year of life, as evidenced by the appearance of separation and anxiety. So, and you know, there's a whole other lecture we could have on the neurobiology of attachment. That a parent and child, they have so much going on in both brains, and the child's brain is being built as a result of that attachment interaction. So the architecture of the brain is being built. And we need to, I think we can put that in simpler terms to parents, I do, and to say how important parents are. Not to blame parents, but to really give them the knowledge, the understanding, the education to help them to be the best parents they can be. I'm going to try using this. I don't think it works that way. Okay. So, attachment. I said it begins in pregnancy. It doesn't happen just when the baby is born. Any of you who have been pregnant, have been around pregnant people, once somebody understands that they're pregnant and that is a wanted pregnancy, you can see the sense of joy that somebody experiences. And that goes on through the whole pregnancy. It's a major driving force, as I just said, for development of regulatory processes in the brain, and is essential for healthy social-emotional development. I want to tell you a story about my granddaughter. So, I'm fortunate to have a son and a daughter-in-law who wanted me to be at the birth of their first child. They live in Costa Rica, so I was down there. And the week before the baby was due, if you've been pregnant, that last week is hell. It's hard. You're waiting. So, I would take my daughter-in-law and we would go walking. Let's walk this baby out. And then I went to the final meeting with her GYN. And during that visit, he did the sonogram and so I saw the baby girl in there and she was just, you know, licking like she was hungry. So, I tell my granddaughter this story. And I have to tell you that we have a wonderful attachment, even though I live here and we visit often. But she loves me to tell that story again and again. Grandma, you saw me in mommy's tummy and I was licking when I was hungry. Give me some food. We make a whole game out of it. But I tell you that because my own attachment to that fetus actually began before she was born. And then I had the joy of being present at the birth. And that was just, you know, par excellence. We all know this. We have to learn that in order to understand folks. Different kinds of attachment. Secure, of course, the best. The insecure, which is avoidant and resistant. And the disorganized, which is most associated with clinical psychopathology. And the disorganized, I have to tell you, I see that so much in kids in foster care. Because of the, you know, it's just the chaos in terms of what so many of them have had to go through. Charles Cena, who is a child and adolescent psychiatrist in New Orleans, and his colleagues propose that disturbances of attachment really become clinical disorders when emotions and behaviors displayed in attachment relationships are so disturbed as to indicate or substantially increase the risk of persistent distress or disability in the infant. And so, you know, infant psychiatry was born. That instead of having to wait until the child gets into school and has negative school behaviors in order to be identified, we have moved on down to infant psychiatry. Which is a really good thing. The more we can move into prevention, the better. And I love this statement by Bowlby. Again, he talks about attachment and that the disruption of attachment is in itself a primary form of trauma, which may intensify the effects of other stresses, particularly if that disruption occurs at critical stages of development. So, when you take a history, now, we can take a history of even an adult and you can begin to hear attachment patterns and then you can delve a little deeper and see exactly, you know, you don't know exactly but you can have suspicions about what may have happened in early life. I have one patient who really cannot find who it was that actually helped her have a mordicum of some set of self-regulation. And the best we could find out is that maybe it was the parent of a friend whose home she went to because it just didn't happen in her own home. I show you this, and forgive me, this is my granddaughter. This is the first one, and she is now second year of college. But I love this picture because I said, this is attachment in vivo happening right there. She's cradled in my daughter's body in the bed and good night moon, which everybody knows, wonderful. But I said, this picture just kind of captures it. I love it. So that's my attachment picture, and then my attachment story of my other granddaughter. But before I go on to trust, it is within an attachment relationship that a child begins to regulate because in psychoanalytic language we view the parent as the external ego. And the parent, in that attachment relationship, helps to regulate that child. You feed when the child is hungry, clean when it's wet, when it's uncomfortable. And again, Dr. Roth, yesterday you took us back to some basic principles talking about aggression and sex, sexual drive and aggression. And those are present in that child, and it is the parent who helps to modulate. So you think of Erikson's Infantile Sexuality, and I just love all of those works because it really helps describe what goes on in that child. I remember my son being really kind of worried because his daughter obviously was getting some sexual pleasure from emancipating and I had to say, Mark, leave her alone, she'll be okay, you know, because these people can be frightened by things like that and if we can help them to understand, I think it's good. But back to attachment, what happens in more secure attachment? What happens? We get that basic trust, you know, we learn that we need that basic trust. The acquisition of basic trust is the goal of the infant's first emotional developmental stage and established in that first year of life and that is why when I take a history or I do a consultation, I ask about the first year of life. I'm going to tell you something else about it. So everybody knows about the DMDD edition, you know, instead of so much bipolar, we got the DMDD diagnosis and Ellen Liebenloft, who is the author of that, I was with her and I asked her, I said, Ellen, did you take a, you know, look at the first year of life? And this was in a public setting, so it's okay for me to say it in a public setting and what she said was that would be retrospective, so it's not valid. But we take medical history, is it all retrospective? You know, so I thought if you develop this concept and you haven't taken a history of the first year of life and what happens in that attachment relationship and regulation of emotions and behaviors, I think that I have some trouble with it, as you can tell, but it's been a lot of controversy about it. So what happens with trust, it develops within that positive attachment relationship where the infant feels secure, nurtured, appropriately responded to by attuned parents. So again, these are the basics. Once trust is established, the parents function as external regulation, regulators of the infant-toddler who then internalizes that regulation over time. I have to tell you that, I mean, even as an older adult, I still have that memories and regulation that I learned from my parents. I really do. And one of the things my father was a diehard for punctuality and up to this day he always said, count the time you need to do whatever you have to do and add 30 minutes in case something happens, you can fix it and still get there on time. And it works. So what's this regulation all about? We regulate learning, eating, I mean the basics, sleeping, affect, expression, attention, interpersonal interactions, aggression, of course, and impulses that take place within the context of the attachment relationship. I have to stop and I have to welcome my president, Dr. Warren. Hello! I have to, thank you for coming. So there's secure attachment behaviors, we see it when we find it, pro-social behavior, empathy, you talked a lot about empathy yesterday in your talk, the sense of well-being and self-esteem and the development of a coherent life story. One of the things that I do and it's pro bono is that I like to go to places where parents, teachers, anybody who deals with children gather. And at one of, it was a Baptist Church in DC, it was a basement family evening and I was giving a talk about child development and after I finished, this gentleman who had his daughter sitting on his lap, he asked, he said, Dr. Benoit, how do you build a child's self-esteem? And my answer to him was very simple. I said, continue doing what you're doing right there. Being with that child, being attentive, making her feel secure, that's how you build self-esteem. And again, the attachment style determines how one navigates social interactions. So you see, we start with even pregnancy, birth and we are coming up the developmental line. All relationships, we know, are challenged at times and such ruptures are followed by the experience of disappointment. Every one of us has had this experience. In childhood, when attachment is secure, the rapprochement occurs with the subsequent repair of the relationship and trust in the caregiver is restored. And I'm going to give you another personal story about my granddaughter. This is one in Costa Rica, the same one whose birth I attended. So she and I have a really great relationship. All we do is play. When I go there, I play all day. No TV, nothing. We are on the ground, we are running outside, we are playing. And at one point, she has a younger sister, she had done something and I can't even remember what it was, but whatever it is, she violated the interpersonal relationship between the two of them and I reprimanded her. She was devastated because this was felt like such a pure relationship between the two of us. She ran up to her room and she was bawling. I subsequently followed her and I held her. Her name is Emma and I said, Emma, grandma loves you, but you know, it's not okay to do whatever she did to Kylie. Very interesting. So I read to them a lot and there is a little Spanish book called Cinco Bonitos and it's about five little monkeys who disobeyed their mother. And there was a crocodile in the water and they were at risk of being eaten by the crocodile. And anyway, they survived, nothing happened, but the mother was really angry with them. And there's this picture, it's well illustrated, where she's pointing, don't you do that anymore, you cannot tease a crocodile. And then subsequent to that, they all got together for a picnic. My granddaughter has me read that hundreds of times. Why? Because it reflects what happened between the two of us and the repairing of that relationship. So this is something that we all have to go through, but it's how is the repairing gonna take place? When there is a good foundation of attachment, the repair, of course, is easier. When there isn't, and we know that in what we just talk in borderline personality disorder, this is one of the inflection points of sort of the genesis of borderline personality disorder, the inability to have that repair in the relationship. So I have to tell you, though, that I enjoy both my children and my grandchildren, because as a child psychiatrist, I'm always thinking about what is going on, and just loving to see the evolution of development, because it's fascinating. So an insecure and disorganized attachment is actually an erosion of trust. And this can lead to a pattern of lack of trust and predictability in others over subsequent developmental stages, and also the genesis of mental health issues in the lifespan. So now I have another story, another grandchild, different grandchild. So my daughter and her husband became foster parents, and the very first call they got was for siblings, they were half siblings, two different fathers, same mother, and they were from the reservation, because they were living in Montana at the time. So they get these two children, one is two, one is four, and the way they came to them is that there was a brawl in a bar in downtown Helena, the police were called, and they found the woman who was in the brawl with a monitor, a baby monitor on her, because she had left the babies unattended in a motel room. CPS, but they had already been known by CPS, CPS got involved, the kids were delivered, and my daughter and her husband were told, grandma will come and get them on Monday. Monday never came, and it's now 12 years, and they are my grandchildren. But the difference between that first child whose picture I showed, and these two children, and the rocky road that went on was incredible. So one of the things we did as a family is that we didn't require my daughter and her husband and them to travel at all, they stayed put, and we went to them, and the we were only my husband, myself, and my son, nobody else from the family, and we did that for many years before they then traveled to her husband's family's home in Michigan, and then my family went there, and we embraced them into the family. So it was very systematically, carefully done, so that we weren't exposed to too many people and too disorganized, but we had a tough time. They are teenagers now, and still some rough times, and of course, a lot of mental health treatment all along the way, which I think sometimes may go on for life, because as the developmental phases go on, I think different things come into focus. But so, within my own family, I am noticing and observing and learning so much, and it's exciting. So, we've talked about a trauma, and I don't know, but I think that the whole world is traumatized right now. You know, three years of COVID, the number of millions of deaths that went along with that, natural disasters with climate change, the wars, I mean, really, it's a lot going on. And, you know, you have to sometimes just kind of block it out and just focus on what's in front. That's why we need so much mindfulness right now, and it's taking, you know, gaining momentum. So, the infliction of trauma and that physical sexual abuse, neglect, witnessing domestic violence, emotional abuse, in what should be a trusted and safe relationship environment, but of course, it shatters attachment. And this is what we saw in my two foster kid adoptees. The longing for repair persists and sets up a process of repetition compulsion that often leads to dysfunctional and destructive interpersonal relationships. I was just reading, and I can't even remember, I think it was in one of the journals, exactly about this. The wish to repair, the wish, the hate, you talked about that yesterday, and the dysfunctional back and forth that goes on because of that early lack of proper attachment. And one of the things that we know is that the failure to thrive syndrome early in babies, I worked at Children's Hospital in D.C. and we got quite a few consultations around that. So, we have the waterfront of diagnoses. How many of you have seen children come to you, adults come to you with multiple diagnoses? And what happens when they get multiple diagnoses? You get a pill for every ill, and then you have, you know, a cocktail of medicines. And I still say that we, as a medical society, we have not really done the work of looking at these cocktails and saying, you know, which ones are really appropriate. So, I think that each one of us, in our own way, is doing what I call the end of one kind of experimentation as we deal with our patients, trying to be as safe as possible. So, the plethora of diagnoses, and I see them at a therapeutic day school, the kids come in and all I have is diagnoses, no supporting evidence. ADHD, RAD, DSMD, PTSD and other trauma disorders, bipolar, you know, conduct disorders, oppositional mood disorders, everything, psychosis, dissociative, anxiety, borderline. One of the areas though I would like to pay a little bit more attention to is dissociative disorders. I think that they are not being diagnosed, they are not being identified as much as they should. I see these children, these youth in my school, and you see them dissociating, and when they tell you what has happened, there's that gap. And they often are called psychosis NOS, but I think that the history of trauma has not been elicited and not understood. Some of the kids even describe it as, quote, blackouts. So, I think that I'd like to just make a special emphasis on dissociative disorders. Reactive attachment disorder, well, I have two grandchildren who came with exactly that. They have a history of being reared in abnormal environments, of maltreatment, depriving institutions, child abuse. We don't, at least I don't hear about it as much anymore, but I still have a patient who is now an adult, I started seeing him at eight years old, who was adopted from a Russian orphanage. And, I mean, he has all of these evidence of just absolutely no attachment, no trusting, and even to this day, he says, I don't trust anybody. I think I've made a little leeway with him, because he will see me, but he has a hard time. So, he doesn't have any friends, he has no preferred teachers, and even within his home, he sees his parents only as people who are there to provide for him. These kids demonstrate inhibited or disinhibited interactions, hypervigilance, and this goes into adulthood. Poor regulation of sleep, affect attention, aggression, impulse control. So, what happens in the adolescent passage? A secure attachment in childhood prepares adolescents for a healthy separation process, as they move into that second separation individualism phase, and being prepared to navigate other relationships outside. Whereas a disorganized attachment would lead to a more tumultuous adolescence, with challenges, which tend to compromise the work of adolescence as they move towards independence. And what you see, and if you work with, well, I'm sure many of you work with teenagers in high school, and they sort of have that first falling in love phase, and you see what the nature of the intensity is. Now, intensity is pretty normal in adolescence. Then you see those kids who are unable to deal with a difficult relationship, one that breaks up, and they need to move on to the next one, and they keep, even as young people, going this back and forth that really says that they're still trying to repeal an unhealthy attachment relationship. This is taken from the most recent CDC youth report, and it talks about, because they were talking about what's happening with the school issue, with kids being out of school for COVID. Protective factors are the characteristics, the conditions and behaviors that improve health outcomes, or reduce the effects of stressful life events and other risk factors. And I have to say that that is what we, my family, we paid attention to with the kids adopted from foster care, to really pay attention to what are the protective factors that we can build in around them to mitigate the effects of the early damage. So school connectedness, which is a feeling among adolescents, the people at school really care about them, their well-being, is very, very important. How many young people will say that, you know, it's teacher X or coach X who really made a difference in my life? And we're all familiar with the statement that every person needs at least one person to care just unconditionally about them in order to have a chance. So when kids go to school, it's a place where they can form these secondary relationships that can prove to be emotionally restoring. And by not having school for almost three years, a number of kids, particularly the more vulnerable kids, really suffered because, you know, an online friend is not the same thing as when you meet Joe at school and you touch and feel and eat together, et cetera. So it's... We have a real crisis still going on. And I know my president, we talked earlier about ACAP and AAP really calling that mental health crisis for youth. So youth who feel connected at school are less likely to experience risks related to substance use, mental health violence and sexual behavior. So school connectedness is a very important protective factor. I'll tell you a brief patient history. She grew up in a home where essentially parents were absent, had an older brother who was kind initially, but then he became a teenager and he went off on his business. And she would be left at home overnight by herself. And this is a very poignant story. She remembers just crawling behind the sofa and sleeping there and hiding in order to feel safe. She hated weekends. She said it was school was the place that she loved to go. She excelled in school. She... Self-esteem came from that. She had a social connectedness and she hated weekends. Whereas so many kids, you know, look forward to the weekends to get a break from school. School was her saving place. This is what we had mentioned before. And I mentioned that ACAP and AAP jointly declared a youth mental health crisis. That was the traumatic interruption of not just school and academics, but again, what do kids do? There's so much after school stuff that goes on that also promotes their social growth, their intellectual growth, and also life skills growth. And they were missing out of all of that. So, you know, different things, theatre, sports, dating. Dating, that was something that came up that during the COVID years, kids weren't dating. And so, you know, you hear about things like phone sex and internet, that can't keep the place of two people sitting next to each other in the cafeteria, you know, flirting or whatever it is. So, as I mentioned, they said, above this going to school, being with their peers allows them to grow emotionally. I said, even with some drama, because, you know, there's always some drama. The isolation took its toll, and more so among girls. The very internet that connected them was a place, and you mentioned it yesterday, the cyber bullying that took place, particularly for girls. And, you know, the emergency room visits for youth went up, the self-harm, I mean, kids were being boarded in emergency rooms for like days upon end. And so we are really still in that crisis because we just don't have, number one, not just the space, but we don't have the workforce to attend to all of these kids. Another important protective factor, we know this, is parental monitoring. And I have to say that I feel so lucky that I had a lot of that in my life. I resented it sometimes. I remember my father would come to pick me up from the dance and I wanted to stay a little longer. And then over the loudspeaker, because this is a school dance, said, Marilyn Bartolo, your father is here to pick you up. You know? But you know what? You felt safe. I felt safe, I always felt safe. Okay. And so this monitoring is associated with decreased sexual risk, decreased substance abuse, experiences of violence, suicidal thoughts and behaviors. So we ask parents, again, that it's not being intrusive if you do monitoring. It's okay to say, yes, I'm gonna come and look around your room from time to time. Some parents feel that they have to give their kids all this, quote, privacy, but you know what? The kids prefer when they're involved. I know that in my own work, that when situations would come up, of course, I felt, and I would tell the teenager, that if I think that there's a risk here, I will have to get your parents in. And I will never forget this one situation where this young girl, she was kind of messing around with drugs a little bit, but I thought a little bit, until the day she told me that she used heroin. And at that point, I said, I've got to get your parents in here. Got the parents in there with her and introduced an intervention. And happy to say she is a young lady now, thriving, has her own business, but it was really calling in the troops. The parents, come on and do a better job of monitoring and be consistent with it, because sometimes you can start and then you sort of dwindle away, but be consistent with it. So the severely mental ill patients, with hunger for social connectedness, formed friendships that allowed her, this is one of my patients, to experience socializing, dancing, joining a group, et cetera. This is a woman who, a great story of social connectedness was important. When I first met her, she lived alone in an apartment and she saw nobody. Diagnosis, schizophrenia, paranoid type. She came to see me, made the diagnosis, and talked about medication, but she said she would not take medication because if she took a pill bottle and took one out, then the rest of the medicine would get contaminated. So in those days, they had family pharmacies, and I had a relationship with the pharmacist. I went to the pharmacist and I asked him, would you be willing to dispense one pill a day to this patient? And he said yes. So then I took her to meet him. We met in the back of the pharmacy. She met with him and I was there with her. And she started getting, because it was within walking distance of both my office and where she lived, she started taking that medicine one pill a day and the paranoia decreased. Once that happened, then she could get a prescription and she started taking the medicine. And this is the person I'm talking about. She formed friendships. She loved socializing. She would go dancing. This one was important. She couldn't drive before. She learned to drive. She joined a summer beach house group and would go down to the beach for weekends, and then decided that she wanted to give back. And she was at Martha's table and also helping pass out blankets to the homeless. What a difference it made. But I want to point out there about the social stuff there. Number one, I had a relationship with the pharmacist, okay? I used that relationship to bring her in. I had a relationship with her. I used my relationship with each of them, we formed that triad, and because it was trust, now she had developed in me, we were able to get her started on medication. And, you know, going out to brunch and really getting joined a gym, started getting very fashionable, amazing. And I mentioned earlier about my own adopted grandchildren who were victims of maltreatment and went foster care, fostered by my daughter and her husband. They both now have sustained friendships. I was so proud of the younger one. She was able to go off on a school trip. She went audition for a play and got the lead role. And so you just see that the social functioning increased so much as a result of connecting all these people to serve them. Everybody is now familiar with the ACEs study. What amazes me about the ACEs study, that was published in 1998. 1998, and it took so long to get down to really being talked about and being used. So, what it has done for us is to cause medicine to focus not only on physical health, but considering the impact of the toxic elements of the non-physical environment and people's morbidity. And causing multiple chronic illnesses. And the data is just so amazing and so clear that if you have so many ACEs, you have so many more chronic illnesses. And also, it's also clear for suicide. The more ACEs, the more the suicide potential. Public health practitioners have known of this for years, but it wasn't until recently medicine adopted this. And we should be doing it now. Everybody should be marching on Capitol Hill. That the social ecology within which population lives has significant impacts on physical and mental health. But we have to go further. We have to show them the ROI, the return on investment. If we invest here, then we can have, yes, the next time you come up for appropriations, we can have less money in the bills for health. Because we are helping people to prevent these illnesses. And so much of it has to do with mental illness. And I want to share this with you. So just as that ACEs study came out in 1998, this slide I now have had for 20 years. When I was president of the academy, I went to the AMA's meeting where they bring all of the presidents of all medical specialties together. And what medicine was focusing on at that time, and still is, I think, is insurance. Insurance, insurance. And this woman from a futuristic institute, who had joined with the CDC, produced this slide, and she was kind enough to share it with me, where she said, we are barking up the wrong tree with insurance. And this is what it says here. Our health status, and this is population-based, only 10% of your health status can be accredited to your insurance, seeing the doctors. That's it. But if we look at the environment, 20%, and I'm gonna skip down, the genetics is only 20%, health behaviors. So you add environment and health behaviors, 70% of population health is related to that, not seeing the doctor. And the public health people in the audience knew this, but at that time, they had no voice, essentially. And then, the slide next to it, and this was 20 years ago, it was $1.2 trillion that was being spent on access to care, and only about 4% on behavioral health. Now, in the year we have the latest figures, 2019, we are spending $3.8 trillion on access to care, and what's being spent on behavioral health is still nominal. So we have it upside down, and we, as psychiatrists, I think we need to have a bigger voice, and we just have to pounding at it. Luckily, we had Patrice Harris, who was the president of the AMA, and I know that she went around doing a lot of talks on the social determinants of health, but I think that we, wherever we are, we teach, we give pro bono lectures, we need to use this slide, and you're free to use it. So we're talking now about the social determinants of health and culture, and the importance of integrating and teaching all of this. We know that the USA is one of the most ethnically and racially diverse countries in the world, of which we are very proud. I mean, I'm really very proud of that. But we have that the social economic status and health disparities may co-vary with minoritized group, and when we look, again, population-based, we find that our black and Hispanic populations are the ones that are most vulnerable. I know that the APA is making valiant efforts to promote culturally sensitive practice of psychiatry. There are a number of talks I see during this program, and my concern, and I really want to stress this, because when, early on, I'm talking about 30 years ago, Jean Spurlock and I and Harry Wright would have a symposium on diversity that was accepted by the program, and we would be up here, and nobody showed. Nobody showed, okay? And then I, of course, would do grand rounds at the different universities that I was involved with about diversity, but I stopped doing it, and I'll tell you why. Because it's a one-off. You give a lecture, and somebody checks a box that we have done diversity. And until the supervisors, the faculty, is appropriately trained, I'm gonna tell you, just talking to the trainees is not good enough, because every supervisor, when they are consulting on a case, should bring up these issues, not just talk about what medication. They should be asking about all of these issues, the social history, and how to really, you know, the old-fashioned, we used to do the dynamic formulation, and all that used to go into it. But it's not happening. But I think that we've got to ask the training programs, stop just doing grand rounds, just have special training for faculty members. So that's my little soapbox. ACEs, we talked about this. The most basic and long-lasting cause of health risk factors, mental illness, social malfunction, disease, disability, healthcare costs, and death. I mean, this is really quite a breakthrough, and unfortunately, it took so many years, because it's been around for. The other thing I wanted to say about ACEs is that ACEs was done at Kaiser Permanente, and it means that all these people had insurance. So we are talking about a demographic that's very different from the lower socioeconomic classes that we often work with. And so there's another concept called urban ACEs, where we add to that the kinds of disparities and adversities that people in urban environments are exposed to. So I want to talk about the community psychiatry of the 60s and 80s that provided opportunities for the mentally ill to go into, they had communities. It may not have been all that great, but people did have communities. With the loss of government funding, we then turned to philanthropy to fund organizations like clubhouses. How many of you know about clubhouses? Can I see a show of hands? Okay, more than I expected, but thank you. So clubhouses, it's an international effort, and we have not one in Washington, D.C. I'm a patron there. And it's really very encouraging that it provides, number one, a good, clean, safe place for people with serious mental illness, with addictions to come and to be participants, and not just be looked down on or be served, but they participate in the running of the organization, the governance. And it's really been quite a success, but we have to write grants, we have to raise money, and there's a fundraiser later this month I have to go to. But the people who go there really appreciate having an opportunity to really develop their skills. When I was a resident, we still had community psychiatry in Washington, and Georgetown had a place right close to the university where it was an old school that was being used and was doing the same thing the clubhouse does. And I remember that on Wednesday nights that all the residents who were on that rotation and our attendings, we participated in cooking and we ate with the patients. It was a sense of community that was just very inspiring, and it's too bad that that type of thing has gone. Okay, how am I doing? Healing, this is Tom Insell's book, which everybody should get. Well, I shouldn't be promoting anybody's book, but anyway, I love reading it. Our Path from Mental Illness to Mental Health. And what's very moving about Tom's book is that after having spent so many years at the head of the NIMH, and as he says, spending billions of dollars, he's come to a realization that really social psychiatry is the place that we should be focusing on. Not that we shouldn't be doing the brain research and all the brain's research, but that perhaps there wasn't enough focus on this. The way I describe it, I say it's a treatise on the need for psychiatry to refocus on strengthening social connectedness. This is critical to promoting healing while utilizing the various evidence-based treatments available. He emphasizes the three Ps, and I like this. People, place, purpose. We all need that. And I wanted to briefly tell you about my father's story that I can tell you. I have a lot in my own family. So there's my dad, Lionel Francis Bartolo. And this is my family. I'm one of nine, and there are two grandchildren there. And my father was physically abused as a young boy by a stepfather. And actually, it got so bad, he ran away from home at age eight. They lived in a clearing in the forest, and he ran into a village where he then ran to a Chinese store. The Chinese in Trinidad had the stores, and they took him in, but then they used him for child labor. So that's twice now. Physical abuse, child labor, and so he ran away again. And he was picked up by a nurse, a single nurse who lived on the hospital grounds. And she took him in, and she became his mother. My father told me this story. I have it recorded. And when he told me that the day she found him, he said, that was the best day of my life. And he just wept as he said that. Fast forward, he was brilliant. He did very well. He went on to teacher's training. And he and my mother lived in the same town where the hospital was. But he left and went to the city where he went to teacher's training school. I say this because at that time, at 18, people were getting married, having babies. He went away, came back, and my parents at that time did not get married at age 25. They were both born in 1910. At age 25, I already had a two-year-old. So what I see there is what he got from this nurse, Nurse Gill, was a sense of purpose, a safe place to be, and the development then to get back on track developmentally. And he did that. The other thing he got was what I call the role modeling from Hu as a wonderful woman. And so he found a wonderful woman to be his wife, my mother, and I am forever grateful. There's another piece which I will chat about if we have time. So I think whenever I see a patient, I look at the mental health tripod I call love, work, and play. I know Freud only talked about work and love, but I think that we have forgotten to play. Adults still need some joy in their life. When I see patients, adult patients, I say, what do you do for fun? And in DC, which is the triple type A area, I'm supposed to have fun. Yes, yes, yes, please do. So being in community and forming social relationships, forming an intimate relationship, creating a family, having meaningful work, demonstrating the capacity to have fun and experience joyfulness. That is really important. Retirement years and mental health often marked, of course, by physical health problems with increasing morbidity. We see that a lot. People are living longer, but they're living longer with a lot of morbidity. And for many, the quality of life is questionable. In American culture, the families often are separated by large distances. Though I think in some ethnicities and immigrant families, they're more likely to have multi-generational families with high grandparent engagement. And I have to tell you, in Costa Rica, that is so, it is really incredible the kind of support my son and his wife have. This is a period of losses of people, place and purpose, resulting in depression and anxiety about one's own mortality. As I said, our Surgeon General declared loneliness as a crisis in America. Loneliness and isolation set in and contribute to both physical and mental illness. Now, in doctors' offices, they're actually screening people for depression and anxiety, which is good. And senior centers around the country attempt to fill that void by providing activities and outings of senior citizens, maintaining connectedness, connectedness, connectedness, connectedness. Family engagement. In South States, families long blamed on failure as a source of the problem are in fact critical for the solution. And I tell you, I find that in many cases, we often dismiss the families. Oh, the father is not in the picture. I say, whose picture are you talking about? It's in the picture in that child's head. That father is. let's find out more. Most mental illnesses have a way of not fading away. This is Samin. So I love this. Instead, I love the word, they tend to metastasize to substance abuse, relationship problems and disability. And ultimately, they contribute to homelessness, incarceration, chronic medical problems, and too often, an early and lonely death. And I listened to one of his podcasts, and you could kind of hear Tom's sadness coming through in this. There are efforts that inspire hope. SAMHSA has building bridges and the peer support initiative, which I think we don't take enough advantage of, the Harvard, the global health and social medicine initiative. And there's a lot of lay population training and underserved areas. Some examples in Tanzania, San Salvador, Puerto Rico, India, South Africa, where they're using lay people, training them to be a support system for people in the community. And I mentioned the international clubhouse movement. Current research priorities are developing and evaluating non-specialist providers delivered to help out, developing and evaluating digital technology. And I see that here, there's a lot of the digital therapeutics being talked about. And developing and evaluating approaches for improving the quality of mental health care delivered through primary health care systems. The problem is that in this country, the primary health care providers are so overworked, they don't have time. And they will tell you that. So what they do to try to minimally meet expectations is give people these forms to fill out. And I'm not even sure they ever read them, to be honest with you. So what does SAMHSA do? They promote recovery, which is described as, it is holistic, addresses the whole person in their community, supported by peers, friends, and family members. It is characterized by continual growth and improvement in one's health and wellness and managing setbacks. And a young man spoke to us at the clubhouse recently about his own setbacks. And he said, you know, it's been 10 years, but now by, you know, I go back, but I step forward, he's actually working in mental health, he's getting his master's degrees, but it takes time. In conclusion, healthy attachment is critical in promoting healthy social connectedness. As a society, we need to invest heavily in families. Believe me, I think that's where the money should go. In promoting family planning, healthy infant parent attachment and child care, addressing mental health needs of parents. So often, in child psychiatry, sometimes we think about the children, but we don't think about what the parental needs are. We give them parent management training and homework to do, and they need a lot of their own care. Ensure that family's basic needs for housing, food security, and health are met, underline, underline. Be aggressive about preventing child maltreatment, domestic violence, neighborhood violence, drug abuse. Reboot and generously fund community psychiatry. I think that we've got to rethink that. Regain our focus on social justice, equity, diversity, and inclusion, and really be serious about it. Not just give it, you know, have a document that says you do it. Just do it. And to Tom Insell's conclusion is, and this is really telling, I have come to think of mental illness as a medical problem that requires a social solution. Tom Insell, head of NIMH for many years. And I just love this quote. It said, you are born alone, you die alone. The value of the space in between is trust and love, and that's by a poet, Louise Bourgeois. And thank you very much for your time. Thank you. So now we have plenty of time to ask questions. I'm serving as the discussant. And let me just share with you, this woman is phenomenal. It is such an honor to be up here. And I just have to share a short story. It has been about years ago. I was here in San Francisco, which was the last time I saw Dr. Benoit, and I was receiving the Norbay and Charlotte Regan Award for Scientific Achievement from ACAP. And Dr. Benoit was the president of ACAP at the time. Come full circle today, I'm serving as a discussant when she receives an award. You don't know how much I am so warmed to be here with this phenomenal woman who has done so much for children. And let's just give her another round of applause. So I'm going to start off with the first question, and then I'm going to, oh, we have someone already. Well, no, no, please go ahead and introduce yourself and where you're from. Thank you. I'm Cynthia Myers Morrison, and I'm a food addiction professional and licensed, inactive at the moment in California as a licensed marriage and family therapist. So a little bit different from psychiatry, however, very devoted to families. And thank you, Dr. Benoit. What a delight to be here. I feel the same honor to be present with you. I'd like to ask a question with regard to food and with regard to particularly the weight and overweight, obesity and overweight and food addiction prior to conception. So prior to conception for mothers and fathers and the intergenerational effects over three to five generations of that obesity, food addiction, and overweight prior to conception, how might we intervene in all of that? The research has been around with Dave Barker for years now. And International Journal of Integrative Pediatric and Environmental Medicine now has a recent article in number eight that I created that brings together that review to say, let us intervene early before conception. So with children and adolescents to really get them to be at optimal weight and health prior to conceiving those children, that then come all of these other, the myriad of difficulties that come, including asthma and the long... That's a great question. And you are absolutely right that it's multigenerational, goes on from one to the next. And as a society, it takes the village to change that. How do we do it? Well, number one, we know that in many cases of obesity, particularly in low-economic groups, they don't have the money to buy what we call the healthier food. And guess what? The cheaper food is what is not good for you, it causes obesity. But people have to eat. So I think that we have to look at this such as a huge multi-pronged issue. You can't just talk about obesity. We have to talk about wellness in general. And then how do you promote wellness? Well, you know, in nutrition and diet, we can talk about that. But how do people get that food? I don't know if you know about Geisinger Hospital. It is phenomenal. It's in Danville, Pennsylvania. But in fact, their CEO, he has now left, but he was a child psychiatrist who had come from UCLA. And one of the things they created was what he called a pharmacy, F-A-R-M-A-C-Y, where they put fresh foods for people to go and get there as all part of the hospital. So I think they need that kind of big vision and thinking, but then you need the funding. I wish I had got an easy answer. The Public Health Collaborative UK, PHC UK, has resources online that show the costs of real food compared to our substances that we call food. And that's a real resource. Public Health Collaborative, PHC UK, and they're doing it. They're putting it out there and preconception to toddlers and then on through the ages. So did you say UK, meaning the United Kingdom? Big difference in health care. They have a universal health care system. But this is focusing specifically on children and families. But they still have a universal health care system, which makes it very different. Very different. It does. It's true. I appreciate your work. Well, thank you. And thank you for your question. Dr. Benoit, in the name of the Association of Social Psychiatry, and in the name of inclusion and diversity, one of our past presidents, Dr. Ramah Rao Guggeneni, has a gift for you. Please, Dr. Guggeneni. Oh, I shall wear it. Joyfully. Thank you again for your talk. It's phenomenal. I'm Katie Lewis. I'm the Director of Research at the Austin Riggs Center. So we talk a lot about attachment in our work at Austin Riggs and think developmentally about the primarily adult patients that we treat. You mentioned briefly in one of your slides about the importance of dissociation and how this is sort of under-evaluated, under-addressed in treatment. I just wanted to share, you know, this is something I hear directly from patients at Austin Riggs as well. I do a lot of educational programming for our patient population there and sort of share information about the research program that we're doing. And they are very interested in both attachment and dissociation and really report that many of them, especially with these sort of complex trauma histories, have frequent experiences of dissociation that, even if it's evaluated, sort of gets swept to the side as, you know, the more primary symptoms are being addressed. But, you know, I spend time with them sort of looking over the ways that dissociation has been assessed through self-report measures. It's sort of an imperfect, imprecise way to get at that. But they feel it's so importantly connected to their relational difficulties, you know, that it comes up when people get too close. That's when they tend to dissociate and it really interferes with using relationships in this way that you've talked about. So I'm just sort of curious, with your wealth of experience and insight, you know, if you've thought about ways to integrate that more into treatment for attachment difficulties, you know, how you would address dissociation in your work? Well, history, also observation. I can see patients dissociate during therapy. If you're tuned into it, you look at, you know, the facial expression, the way they sit, the way they look at you or don't look at you. But I think that what is lacking is the history-taking and really getting the nitty-gritty of behaviors and the antecedent and then what happens afterwards, because that, to me, is where you really begin. And you know, it's not just one instance, but over and over again. But you have to have people who are thinking about it. So the teachers I work with, I bring it up with them and then they begin to look at it more carefully. And actually, the kids have used the word blackout and that, because, you know, after they have destroyed something and sort of have no memory of it, those are the things that I try to help people look at, you know. Thank you. Dr. Benoit, my name is Kirk James. I work at SAMHSA. I certainly appreciate the information you provided about SAMHSA. But my question is, you mentioned earlier in your presentation all of the things that we're sort of traumatized today in this world. One of the things we keep on hearing about is these mass shootings in the school system. So I was going to ask you, given your wealth of experience and insight, what are your thoughts? I know there's a lot of theories about what's going on out there that we're seeing so many of them day to day. We're hearing some crazy records. You know what? I think there's some contagion going on, honestly. And I think that, you know how we, psychiatry, talk to the media about suicide and not to make a big deal of it, and they stopped because it was causing contagion? I think that's happening with all these mass shootings right now, that there is so much. It goes on for days on end, talking about it. I think there's some of that. You know, of course, there are all the underlying conditions that promote people doing that type of thing. But the fact that it's happening often, I think there's contagion. I'm sure everybody's looking for a magic pill to sort of correct it, but it's not out there. I'm sure it's multi-pronged. Oh, absolutely. Absolutely. Thank you again for your talk. I really appreciate it. Thank you. James Griffith. I, until recently, chaired the George Washington Department. And I first wanted to thank you for highlighting Tom Mentzel. I think his years were often misunderstood at NIMH. We would not have the global mental health movement now had he not made it a real priority of NIMH. And I think that his commitment to globally, the disparities, the inequities, and seriously thinking about how can we scale up interventions that would matter has, I just really appreciate you doing that. I did, the question I had has to do with, under the literature, moral injury, there's sort of two literatures, one a perpetrator one, as in the military, where somebody commits an act. I remember talking with a Marine who told me about the first time he killed someone. He said, I wanted to vomit. The other literature is more, much of it is in the nursing literature, it's about being in a system where you're required to do things you feel like are fundamentally wrong, but you have in a low power position. And I wondered about your thoughts in terms of, these are often what happens later in life, where the kind of basic trust you're talking about, you either violate it or it has been violated. I just wondered if you had thoughts about that. That's a tough one. And I think I'm going to ask Eugenio to address that. The other book I just recently read was Prince Harry's book, Spear. He talked about having to kill, and he had to do it. And did it with sort of a mechanistic kind of a way. But then he comes back from war, and he suffers PTSD. And I think that a lot of people have these after sequelae, having been in wars. And what I have noticed, and I work with a group that work with veterans, is that they shut down. They don't talk about it. And we recently saw where, in fact, sometimes, people who have passed services, have been in the veterans, were actively doing some of these shootings. It's hard to kind of, you know, each person is different. So the substrate on which they have to do that is different. And I think for most people, from what I have learned, is that they just don't talk about it. Eugenio, I'd like you to comment on that. Will you please help me? Thank you, Marilyn. I feel like I'm talking to my professor here, Dr. Griffith. There's a term, moral injury, which I'm sure you're all familiar with. And it's when people have to do acts that go against their values. And I just want to mention something personal. I have a colleague that I, of great esteem, we did our training together. And her second husband is a police, a former policeman. He was an Indiana patrolman who had to fight to death with somebody on the road that he stopped. And the person told him, it's either you or me. And it's what they call suicide by cop, where a person challenges a policeman with the intention of either killing or be killed. And we have become good friends. And he quit the police department, moved to another state, and was living on a boat, working as a handyman for two or three years, trying to recover from the experience. Then went to therapy and his life was turned around. But just as you mentioned, I think the silence is really the problem when people keep that pain inside. But I think, Griff, you know more about this than I do. Thank you. I just wanted to remind everyone that we have a few minutes left. So the last question will come from the president. And then you can come up and ask Dr. Benoit your questions. Oh my goodness. This is such a privilege. I'm so sorry to the other folks. No, they can come up. They can come up. Oh, OK. That's fine. After. OK. I just wanted to thank you, Dr. James. And Dr. Benoit, you are truly a gift. And I think this presentation was pillars of mental health. I think you're pillars of humanity. And I just thank you. I wanted to say that in terms of one of the points that you made with regards to young people, particularly now, and that sense of being seen, being heard, and belonging, I just wanted to acknowledge that there's this quote that says, to the world you may be one person. To one person you are the world. And I think that that's what you are to all of us. So thank you so much for all of your work. And my question. Yes, yes, yes. And I think for all of us in the room, and myself included, I think like Dr. James, you are a hero to me. You are a true inspiration. And you definitely help me be a better person, a better leader, particularly during the most challenging times. And so one of the things that I'm wondering is with all the people in this room, as well as those who aspire to the level of humanity and heroism that you are, what keeps you going? What is your source of joy, love, and purpose? You know what? I think that Tom and Sal summed it up. People place on purpose. I have in my own intimate life some good people. I feel fortunate for my family. In my professional life, I have people like you, and everybody, you know, the ACAP has been my professional home. And I love the work I do. So I still work. And I consult to school, and I still have private practice. And I'm involved with the academy. He makes me work. He appoints me to do things. And I also serve on nonprofit boards doing some visionary kinds of things. So people place on purpose. That's it. And oh, must have fun, okay? Must have fun. Andy from Arriaga, 20 years ago, we danced in Miami. And last night, we danced again. I told him, we can't wait 20 more years, I'll be dead. So I think that is a fantastic way to end this fabulous presentation. It has just been so wonderful to just sit here next to Dr. Benoit as she shares her pearls of wisdom. Everyone stay to the end, because we were just all just bated breath just waiting to hear what you're going to say next. Thank you, everyone. Yes. It has been fabulous.

Dr. Marilyn Benoit

social psychiatry

Abraham L. Halpern Humanitarian Award

child and adolescent psychiatry

Suicide Prevention Initiative

Marilyn B. Benoit Child Maltreatment Award

attachment and trust

social determinants of health

dissociative disorders

global mental health

societal trauma

community-based psychiatry