Well, good afternoon. It's so good to see all of you here to join us for this session that is based on some, I would say, the spirit of John Lewis. The title of this session, of course, is Making Good Trouble in Psychiatry, Creating More Equitable Systems of Mental Health Care. To set the stage, we all know the current mental health care delivery model is unlikely to ever meet the needs of all Americans. And I would even dare say it wasn't designed to. We have taken the something is better than nothing approach, systematically justifying fewer resources for the under and uninsured among us, as well as certain population groups, whatever their insurance status. In this session, we are determined not to rehearse the problems, repeating the same dismal statistics we know all too well about health equity. Instead, we will look at etiologies in order to better understand how the inequitable system of care has become our standard, and most importantly, explore potential solutions, looking at alternative models of mental health service delivery that have been successful in the world. One of the approaches to decreasing health care inequities has been to raise awareness, of course. This is a good thing, as you can't repair what you cannot see. However, the DEI industrial complex has not resulted in either more equitable service delivery or health outcomes, at least in the literature that I could find. Admittedly, it has amplified awareness and has produced a measurable decrease in implicit bias, but once again, this has not been translated into more equitable care and health. So today, we have come to make some good trouble, and we're going to blow some things up, but no, not really. What we're going to do, figuratively speaking only, we want to explore some fresh, new, and innovative approaches, and I believe we would all agree those are needed. Much of what we do as psychiatrists works well within the current system, but it is woefully inadequate to meet the increasing demand for services, especially for black and other people of color. Admittedly, there's a need to reconceptualize what we as psychiatrists can do differently, can promote and advocate for, to make healing and wholeness a more attainable goal for more of our population. We have two amazing speakers that I'd like to introduce. Of course, the program said we would have three, but Dr. Sampson will not be able to join us due to an unexpected health issue that arose. Dr. Jonathan Shepard will be our first speaker. He is an award-winning mental health professional named top doctor in the field of psychiatry. His holistic approach to wellness has made him a highly sought-after and well-respected motivational speaker, a graduate of the University of Illinois at Chicago Medical School and the Adult Psychiatry Program, as well as the Johns Hopkins University Child and Adolescent Psychiatry Fellowship. Dr. Shepard blends professionalism and compassion to create healthier communities. He is currently employed as the chief medical director of the Hope Health Systems Incorporated, which has its headquarters in Baltimore, Maryland. He is a fellow in the American Psychiatric Association and a distinguished fellow in the American Association of Child and Adolescent Psychiatry. Dr. Shepard. Our next speaker is Dr. Janelle Blocker. She is currently a fourth-year chief psychiatry resident who will be graduating from Howard University Hospital and matriculating to a clinical integrative medicine fellowship at the Marcus Institute of Integrative Health at Thomas Jefferson University. She sits on several executive boards, one of which is the Black Psychiatrists of America, for whom I'm the president, and we are just overly excited to have her with us. These board appointments include the Committee for Interns and Residents, where she serves as the New Jersey, D.C. regional vice president, and this past fall, she was awarded the 2022 Outstanding Resident in Training Award named in honor of Jean Spurlock, Dr. Jean Spurlock. She is genuinely committed to using her power and privilege to educate, treat, and advocate for marginalized populations and help minoritized students successfully matriculate in medicine. You are in for a real treat, and so without further ado, I present to you Dr. Jonathan Shepard. Good afternoon, everyone. All right. Good afternoon, everyone. There we go. Wonderful. I have a booming voice, so I am not going to be up on that mic. I'm not sure if anybody's in here who can help with that. There's just a big echo in here. Thank you for being here, for taking time out of your Sunday afternoon to help me make some good trouble up in this place. Yes, we are here. Thank you, Dr. Cynthia Turner-Graham, for asking me to speak. I appreciate you and your leadership for what you have done through APA and also the Black Psychiatrist of America, and it's been a privilege to work with you and Dr. Janelle Blocker, who will be finishing up her residency, and we're so happy for her. So I have no financial disclosures or conflicts of interest associated with this presentation, and neither does Dr. Janelle Blocker have any. So for some of the objectives, we're going to review through the historical evolution of cultural slash transcultural competence concepts. We will see the application of these principles to create effective, equitable, and just mental health care delivery systems, and I will include an example of that system and how that is done well. Dr. Blocker will cover the next three objectives, and she may review them once she stands up before you. Here's a picture of John Lewis taken on March 1st, 2020. If you can believe it, that was only, what, about 10, 15 days before it was declared a COVID-19 pandemic. Imagine that. And here he is, standing at the famous Edmund Pettus Bridge, the quote, get in good trouble, necessary trouble, and help redeem the soul of America. Such a powerful quote helps validate me sometimes, since I like to get in good trouble to make sure that people and myself stay on point. What we're going to do is look at how we can get into good trouble, necessary trouble, and as we do that, we're going to look at some terms. When I present, I normally like to start out with terms and make sure everybody is on the same level, understanding what things mean, because words mean differently to different people. So in our society, there are people who believe that the color black means incompetence, all the time. Whether it be black people or just the color black, it means incompetence. We know that that is wrong. One of the reasons why there is something called implicit bias, if you don't know what that means, it's the inclination of temperaments or outlook or prejudice that is present, but not consciously held or recognized. And that word temperament is important because it's a characteristic or habitual inclination or mode of emotional response. Then you look at the word incompetence, it means the state of lacking the qualities needed for effective action. Unable to function properly, or aka disorder. And I love talking about distress versus disorder, and as we know, that disorder has nothing to do with color. So there are some people who would literally say black people are incompetent means they can't function properly, that there's a disorder associated with them. We know that that is inaccurate. One of the things that we want to tout, and for those of you, I see some familiar faces from yesterday at the Solomon Carter Fuller Award, we talked about how racism is an important determinant of health and health disparities. So this is helping me to lay the groundwork for where we're going, making sure that we understand these definitions. I am a black man in America. Yes, I am. On the left is Freddie Gray. I am residing in Baltimore now, originally from Chicago, but I've been living in Baltimore for 14 years, and I was there when the riots occurred after Freddie Gray was murdered in 2015. I remember that very clearly. And you may not be able to read it, but I specifically wanted to put that in there because the spinal cord injury was similar to one that would have been diving into a pool of shallow water. That's something to think about. This man died in the back of what we call a paddy wagon, and how did he get a spinal cord injury like he was diving into a shallow pool? It doesn't make sense. Then to the right, since we're in San Francisco, I thought I would bring out somebody who was playing for the San Francisco 49ers, Colin Kaepernick. We know he took a knee during the anthem, and so he was viewed by many as being un-American. It became a real big issue, and still is, a lightning rod for some people in regards to how he took that stand because of the injustices that were occurring within black people. And then in the middle, there's a young person right there. He looks similar to me. That is me. It's not because I like that picture. I put that because when I was a resident at the University of Illinois at Chicago, I was dressed similar to this. I was coming from being on call overnight, and anybody who knows anything about the west side of Chicago, that's not the safest place to be. I was coming out after midnight about 1, 2 o'clock in the morning, dressed like this, and I noticed that a police car was rolling up on me, and so I thought I had an escort back to my car. I was like, oh my lord, I'm in safe hands, Dr. Thurgood, not knowing that they were actually not there to escort me, but they were there to pull me over. I was in the car, so they stopped me. I was walking, and sat me on the side of the curb and told me that I looked like a person dressed like that who had been stealing and robbing vending machines in the hospital. True story. Now, I have not seen people rob vending machines looking like this. Yeah. Black man in America. One of the things I want to share with you, and I see I have your attention, which is what I wanted to get, I want people to understand that it doesn't matter the title, it doesn't matter how you're dressed, it doesn't matter even how you talk, but just based off of the color of your skin, people will stop you and put an allegation or a falsehood or whatever it might be attached onto you. This is what I live every single day that I wake up in this country, and really, honestly, throughout the world. Some places are better than others, but yes, living as a black man in America, this is something that I have to endure each day, and learn to manage, and learn to manage well. And this is why I speak with such fervor, because getting in good trouble, because I want to make sure that people understand that it's okay. I'm a black man in America. There may be racism, but I'm not going nowhere, and I am going to make sure that we fight for equitable mental health care systems. So let's talk about the importance of black doctors. There's two studies that I'm going to mention here. The first study is talking about black patients who are assigned to a black doctor. These are black patients who were seeking out cardiac health from their cardiologist, and it's a very interesting study. Again, local, here in Oakland. You can go and look this up. It was printed in August of 2019, and what it showed is how the black patients who were assigned to a black doctor increased their demand for preventatives, preventative measures or exercises, especially those that were invasive. It was so interesting that as the people studied and they were randomly blinded, that it was interesting to see how those persons, when they saw someone who looked like them, they became more comfortable in sharing what was happening within their own particular systems, whether it be cardiac or whatever it may be. But then they also trusted them more and it allowed for them to be able to do the invasive procedures. I don't know if anyone has ever been in here where you suggested a recommendation to one of your patients, and they'll say, Doc, I hear you, but I don't trust you. That's something. Because they hear you, they can believe you, but they just don't trust you enough. So it's interesting that when you look at the study, they showed how the black doctors who engaged with those black patients, that they actually could reduce the black to white male gap in cardiovascular mortality by 19%. That might not seem like a lot to you, but it's a lot to me. Because you have to understand that black men in this country live 4.5 years less than any other ethnicity in this country. So that's a big issue for me. I always tease people, I say, I'm not dying any time sooner than when I have to. Yeah. Number two, it's very interesting that this happened just last month, that Dr. Michael Deal, who's part of the Association of American Black Colleges, showcased that black people live longer in areas where there are more black primary care doctors. For every 10% increase in the relative representation of black primary care physicians, we saw a one month increase in life expectancy for black people living in those same counties. And what was interesting about the study is that they might not even have been directly connected to that black doctor. But just the fact that that black doctor resided in that county increased their life expectancy. That is something to think about. Which is again, why we have to increase our numbers of black physicians. All right. Moving right along. So when we talk about creating equitable mental health care systems, we have to look at the anti-racist approach to clinical care. All right. So there are five steps, and we'll continue to move swiftly through here. Number one, we have to admit to being racist to become anti-racist. There are biases that clinicians do have and that we're likely to do more harm when we deny that there are actual racial biases. People are racist when endorsing or supporting racist ideas and policies. And conversely, they are anti-racist when endorsing ideas and policies that promote racial equity. Wow. That's something to really think about. It's hard to admit when people are wrong. Ooh, y'all so quiet. And I good. And I told Dr. Block I'm going to set it up for her real well so she can go ahead and just make things so smooth. But I want to really capture your attention because it makes people feel a little bit uncomfortable. It really does. And I get it. I really do. But in order to be able to admit that there are racist issues, we have to admit to also being anti-racist. Not just, oh, I'm okay, or they don't bother me. No, anti-racist, which means endorsing those ideas and policies. You want to look and hear those people who are endorsing those policies that move and promote racial equity. Not people who are on the sidelines who are like, nah, I'm good. I'm quiet. I'm just going to sit here and just let things happen. But we want to make sure that we endorse those ideas and policies. The number two, slow down, pause to heighten racial consciousness, and prepare for challenging racism. This is part of the anti-racist approach to clinical care. And as you do that, you're going to pause long enough to heighten racial consciousness that can challenge a clinician's implicit biases, thereby curbing the discriminatory behaviors, and instead positioning them to dismantle the racism shaping the patient's experience. We just heard recently about, I believe it was yesterday, about ER physicians who were prescribing high doses of antipsychotics to black patients. Just doing it out of force of habit, because that's how they were trained, that's how they were taught, and yesterday we learned, slow down, think, why are you doing that, who taught you that? Well, my supervisor did. Well, where did your supervisor get that information from? Where did he or she get that from as far as information, articles, and research? Because if you look in the research, you would note that black people actually require lower dosages of antipsychotics. So we have to stop and think, why am I doing what I'm doing? Am I doing it because it's just what was, well, Dr. Shepard, that's what it was always done, so I'm just used to doing it. No, let's pause and slow down and think about racial consciousness and prepare to challenge racism. Because let me tell you, it's going to be a challenge. Anytime where you challenge the norm, it will be a challenge, it really will. And you have to be thoughtful about your approach when bringing these policies and procedures that will promote equity. Number three, name and identify racism to challenge it. Diagnosis determines treatment. So quote here, the only way to undo racism is to consistently identify and describe it and then dismantle it. In addition, the diagnosis, the proper identification of racism, then determines the treatment of combating it. Explicitly acknowledging the racism that children experience validates and supports parents and families, renders structural racism more visible, and potentially protects against further harm. You know, it's something when you recognize that something is happening to you as a black person, and you just kind of brush it off to the side, or you even witness it, or you see other people where it's done to them. You know, I was talking with a couple people, even since I've been here, about the importance of naming things. The name and diagnosis is very important, that's true. But we shouldn't stop there. We have to make sure that once we name it, identify it, but also talk about how do we dismantle it, all right? Because I think a lot of people stop at that one, two step, Dr. Shepard, I can't dismantle that. That's outside of my scope. That's outside of my practice. I'm, you know, I don't, you know, I'm not, you know, I just don't have that power. Well, I hear you on that, because even sometimes for me, I feel powerless. But one thing I do, and we'll talk about this as we talk about how the personal steps, is sharing your voice. And hopefully this particular talk can empower you so that you will be able to stand up and be courageous enough to not just name it, identify it, but also look to dismantle the racist action that you may see occurring, whether it be in your home, whether it might be in your facility where you work, whether it might be within your office, wherever it might be. Number four, keep moving here, learn the legacy of racism in American medicine and beyond to avoid perpetuating it. All right. Dr. Shepard, I didn't know there was racism in American medicine, what are you talking about? Oh, man, if you go back and study it, it's something. I just gave one example here in the 1960s. This is where John Lewis would have found himself. Psychiatrists categorized or characterized angry, politically active black men involved in the civil rights movement as having reactive psychosis. Wow. That would have meant Dr. Martin Luther King, Jr. That would have meant John Lewis. And we actually have that documented where they were. People saw them as having reactive psychosis. There are other things that you would note through the racism in American medicine, where women, black women who were in prison, where they were sterilized. Yeah. I know a lot of people don't talk about that. I like to talk about other things, but I want to lift that up for black women, where they had hysterectomies and other things that would happen to them where they could no longer bear children anymore. These are women who were institutionalized. That is a part of the legacy of racism in American medicine. Why do we talk about that? I know a very somber move, and that's why Dr. Blocker had to take this part, because if we're going to do the anti-racist approach, we have to know the legacy so we don't repeat it. Because guess what? History has a tendency of doing what? Repeating itself. Number five. This is five steps. This is the last one. At the end, there's the reference where you can get this article. It's a wonderful article. First, do no harm. Prevent the toxic exposure of racism in the clinical encounter. Inadequate or neglected care of minorities who have weathered or even died of racism across generations, particularly within a caregiving profession that violated its most basic oath, actually constitutes grave medical error. Accordingly, the risk of racism should always be acknowledged and accounted for by clinicians as if it were a vital sign. That really spoke to me. I know sometimes I've been hearing in some of the teaching and residencies and fellowships, they tell people do not include race as identifying information. I don't know if they're teaching that at your institution, but I know that that was taught. That we're not to include, but I want to hear what the race is. And I'm telling them, you need to know what the race is because it is very important. Because it helps to set the foundation as to how you're going to move forward, even in treatment, even how you speak to that person. So there's a little bit of debate on that. And I got some pushback when I was in fellowship and residency. I still continue to do it to this day because it does make a difference in being able to identify a particular patient that I'm working with. Yeah, I see it, as it says right here, really as a vital sign. And for me to be negligent of the care for the minorities who died of racism, man, you know, yeah, it really pulled my heart even as I was preparing for this presentation to think about that. Really, that's a grave medical error. These are just five steps. We'll move on from here for anti-racist approach to clinical care. Again, the reference is right there. Here's some personal steps to promote equity. Some things that you can do, some personal steps to promote it. Number one, be transformational and not trendy. All right? Be transformational and not trendy. All right? Actually, I'm going to do something a little different and a little bit unorthodox, but I'm going to have you repeat that after me. Be transformational. Be transformational. And not trendy. And not trendy. All right, one more time. Thank you. So, great example. I can't go through all of them. Starbucks, 2018. The two black men that were in Philadelphia that were, I believe, arrested as they were sitting there. And then, for no reason, honestly, and then Starbucks what? They closed down all the Starbucks to do DEI training. I don't think it was called DEI training in 2018, but, you know, some racial awareness training. I do like that. And two years later, the same organization had a problem with the employees wearing Black Lives Matter shirts. Hmm? You know, like Scooby Doo. Huh? Like, what? I don't get that. Yeah. You know, it was nice in 2018, but let two years roll around. So, we don't want to do things like that. You know, National Football League is another example. I don't want to just lay out all these examples, but there's several different examples of where people catch on this whole DEI and racial equity bandwagon. This is kind of the trend. We don't want to do that. We want to be true. Transformational. Number two, say with me, become an ally. Become an ally. And not just an associate. And not just an associate. All right, cool. That means listen carefully to understand the needs of black people. And then accept leadership from black people. I'll say that last one again. Accept leadership from black people. Being a black male in medicine can be very difficult when it comes to leading in various arenas and circles. And one who was a shy person, I know it probably doesn't look like it now. Yeah, that was very hard for me. And to learn how to be able to still assert myself when people would not accept the leadership that I knew that I was able to provide. And I was qualified to provide. Yeah, and so that's a struggle. And I'm sure we'll have more conversation about that. So become an ally and not just an associate. And then number three, avoid common traps. Don't get stuck. Feel personally attacked when black people point out racism. And then rely on black people for education about my own institutional racism. If I get asked to say one more time, as the only black person in the room, to talk about racism, I'm like, do you understand that's traumatizing me every single time I got to do it? I didn't create it. Trust me. It wouldn't be alive if it was. So don't rely on me to educate everybody about racism. That's not my job. It's not my job. So we have to make sure that we don't do that to those black people where we work and who we're in association with. Second to last slide. Prerequit, prerequit, I always have a hard time saying that word, for pathways to healing. Number one, be passionate about resolving the ills and disparities that exist in our present day communities. Most of us are passionate. That's why we've been here on a Sunday afternoon, spending our time in this conference. We're very passionate. So utilize that passion to resolve the ills that we know and disparities that exist. Number two, be courageous. I've talked about that already in confronting the problem. Number three, listen and learn how the problems affect, impact the lives beyond your immediate sphere of influence. And number four, invest your time, energy, and resources in developing partnerships to address the ills and disparities. And that one is so big. Even today, this afternoon, just spontaneously, I spent an hour and a half speaking with a gentleman who I just met here. We had talked over the phone, but we met in person today. He's a senior psychiatrist. And just invested some time. Does not look like me. Come from two different worlds. But it was so impactful on both ends of where we talked about how we could dismantle the various structural racism ideas that we both face. He's in Richmond. I'm in Baltimore. And that's what it's coming about. I was supposed to go back to the hotel and change and my t-shirt on everything. I said, no. I'm going to invest this time that I have right now so that I can help make a change for later. Who knows what that conversation will lead to. I felt empowered. I felt like I was heard. He even told me that I helped him and helped him be able to respond to an interview that he has coming up next week. Ooh, dude. But that time, that sounds so menial. But I challenge you while you're here in San Francisco to do just the same. This is how we break down the walls. And this is how we create more equitable health care systems. All right, my last slide. Democracy cannot thrive, this is John Lewis talking, where power remains unchecked and justice is reserved for a select few. Peace cannot exist where justice is not served. Sorry. Here's one more. Culturally sensitive mental health care resources. I must do this. Cynthia would get me if I didn't. These are some of the organizations you can join. Things are already in place. You can join a mental black mental health alliance, Black Psychiatrists of America, National Medical Association, National Hispanic Medical Association. Dr. Shepard, I'm not black. OK. Doesn't stop you from joining these organizations. Mentor a young person to choose a career in mental health. Support HBCUs, absolutely. Advocate for increased funding for mental health resources. And educate yourself about racism with your majority counterparts, for discomfort is a requirement for growth. All right, I am done. Thank you. Thank you so much, Dr. Shepard and Dr. Turner-Graham for setting the stage for me. I am very humbled to be here today to speak to you all about the community part of our presentation. I have been making good trouble since I can remember. And I will start by saying that I made good trouble when I was a young girl. And I was a young girl who was in a relationship and I was in trouble when I was told as an IMG who had failed step one that I was not going to be able to be a psychiatry resident or a resident period. But here I am as a PGY-4 chief psychiatry resident going into integrative medicine. Awesome. We're not going to talk about that today. That's a story for another time. But what we will talk about is community. And with all of the unjust murders happening around the country, community relative to where our healing is going to come from is vitally important, probably more so for us as people of color than for others. And I'm sure many of us that are in the room have been part of situations whereby there would be discussions about families and boys and girls clubs, maybe even big brother, big sisters, mentor mentees. And some would say, that's not going to help. What they really need is the right diagnosis and the right medication. Well, that's often only part of what's needed, right? Let's not forget that you're also going to need that belonging, that connection, and that healthy attachment which can be received from your community. And now there are various definitions of the word community. And we could go on for hours speaking just about that. But we don't have enough time. So I'll briefly discuss a few definitions and then move on. According to the Oxford English Dictionary, community is a body of people who live in the same place, usually sharing a common cultural or ethnic identity. The American Psychological Association defies community as socially organized set of species members living in a physically defined locality. Human communities are often characterized by A, commonality of interests, attitudes, and values, B, a general sense of belonging to a unified, socially integrated group, C, members of self-identification as community members, D, some system of communications, governance, education, and commerce, and in general parlance, the community means society of general public. For some, it can also be defined as the functions it serves, as providing services, resources, and support to its members through entities like schools, hospitals, and community centers. But for me, community means village. The African proverb, it takes a village to raise a child, that's how I grew up. My community was my village. And that community consisted of my immediate and extended family, and I had a large one, y'all. My great-grandparents, my grandparents, my mom, my godparents, aunties, uncles, cousins, neighbors, my church family, babysitters, the Boys and Girls Clubs, like I mentioned earlier, they all poured into me to ensure that I had a positive upbringing. And that saying, it takes a village to raise a child, that refers to the idea that a collective effort from a child's family, community, and society to ensure optimal growth and development helps the child to thrive. And this concept emphasizes the importance of creating that supportive environment, which is something that I actually had. And so for many in the black community, this system does not translate to I, but to we. This shift is a critical step in building a more connected and healthy and equitable world, which Dr. Shepard was mentioning earlier. It highlights the significance of collective action and the power of community. In today's society, a lot of our care's focus has become more about the individual and the personal, and what's important to me, which is OK. That's not a problem. But we're doing all of this because we want the people to individuate into their full expression of who they can be and who they are. And we also want to make sure that we want them to grow and to develop as well, and not just reduce their symptoms. And in order for them to be able to grow and to develop, we should consider that the end goal may not be just to have individualized care, but rather care that supports individuation of a person. And so because what brings joy and satisfaction is people not just feeling good, right, but them growing and learning more about life and themselves, that individuation occurs when they realize that they are a part of a community, when they have the responsibility not just to themselves, but to a community, when they work together with their community and they have the care and support from their community, and they recognize that everyone's value in the community and we work together, they can thrive, and in those communities a more equitable world can be created. So in order to support patients in thriving communities, we have to gain optimal and to gain optimal mental health. As psychiatrists and mental health professionals, we must remember that we have to confront and check our potential biases due to our upbringings and our own cultural beliefs, which we know is cultural humility. We must be willing to look beyond the surfaces of our own experiences and our worldviews to truly understand and emphasize, empathize, I'm sorry, with our patients' experiences and perceptions. And you know, Dr. Shepard, he already just did a really good job of talking about that, so I'm not going to dive back too deep into that. But I just want to reemphasize the importance of when we treat our black patients, especially our non-BIPOC psychiatrists or our white psychiatrists, please be sure to be willing to actively listen to your patients, to your black patients' experiences. Make sure that you don't say, oh, well, are you sure it happened that way? Because it probably did, more than likely it did. Be also curious enough to ask questions in order to understand how those experiences shape their mental health. Ask questions. Don't just assume. You know, you also want to know what their preferences and their values are so that you can work together. You want this to be a collaborative effort. You don't want it to be, I'm the doctor, you're going to do what I tell you to do. Patients have rights, too. And so you want to have a mutually agreed upon, culturally sensitive, trauma-informed treatment decision plan that is medically evidence-based and that meets both you and the patient's goals and desires. It is also essential for the white psychiatrist to be aware of the potential for racism and sexism and other forms of discrimination, again, that Dr. Shepard has already mentioned, but we have to talk about this, y'all, because it is hurting our people. We have too many of our black patients that are dying left and right, too many of them, because our white psychiatrists are not treating our patients with the respect and the dignity that we deserve. And so patients need to understand that they can trust their doctors. When you do these things, when you provide them with mutual respect, then patients are more willing to feel heard, they're more willing to, they're inclined to feel trusted, more comfortable to open up and discuss their symptoms, their concerns, and their medical history openly and honestly with you. And then they'll feel like they're actually part of the treatment team. And this, again, goes back to shifting that narrative from I to we. They want to be included, they need to be included, they should, we should be included. And we know that patients tend to follow recommendations provided by physicians when we are perceived, when physicians are perceived as trustworthy, respectful, and empathetic. So now we're going to shift our gears slightly to discuss some work that's being done in the communities to promote healing and provide treatment either for black patients with mental health disorders or some treatments that I think could actually benefit the black patient population. These initiatives are three very different initiatives that I've been exposed to, but I have not necessarily participated in. But I wanted to highlight them because I think they're all unique in their own right and they're doing amazing work and could eventually be utilized on a grand scale because they appear to be getting it right. The HEAL Initiative, the NADA Protocol, and the Dream a World Cultural Therapy. So the HEAL Initiative is a formative community-based quality study that was conducted, it is conducted in Washington, D.C. It is initiated by my chair, Dr. Schottenfeld, and my former chief, Dr. Ebony Caldwell, on the basis of directly addressing the discordant impact of opiate use disorder in African-American communities in the nation's capital. As many urban communities, as in many urban communities, they found that African-Americans in Washington, D.C. were more likely to experience opioid-related overdoses and less likely to engage in medications to opioid use disorder treatment than white patients. And the focus of the study was to address two areas in Washington, D.C., Ward 7, which is where I grew up, and Ward 8. And those are overwhelmingly African-American areas, greater than 90 percent, which are separated by the East, by the Anacostia River, which is known as the area as called East of the River. These areas have the highest proportion of opioid-related deaths in the entire district and market examples of long-lasting impacts of systemic and institutional racism and inequities, including having 20 percent of the residents living below the poverty line, holding 88 percent of the city's food deserts, being classified as mental health resource shortage areas, and having the highest number of rates of HIV cases, possessing limited public transportation options, and having poor access to medical care. Despite these disparities, many community organizations actually have come together, including churches and faith-based organizations, to play an active role to meet the needs of the population in that area through various programs and initiatives. Black churches particularly led the many efforts to bring services to the areas and give a voice to the needs of the community. The study aims to use the strengths of the African-American community and black churches to provide evidence-based care to a community long neglected by traditional health models. Because of this study, there is now a collaboration between Howard University Hospital and a faith-based non-medical care facility called the DC Dream Center, where they provide substance use disorders, particularly for opiate use, via telehealth to the patients in that area. And we were going to watch a video talking about the H.I.E.L.E. Initiative, but unfortunately, I don't think we have it. No? Okay. So next, we'll talk about another initiative called the NADA Protocol. Now although this is new to me, it's actually been around for 50 years, and some of you may know about it. In fact, the Black Panther Party helped to establish it. I learned about it two weeks ago when I started my integrative psychiatry elective rotation at Edward Hines VA in Maywood, Illinois, near Chicago. So the NADA Protocol, also known as the National Acupuncture Detoxification Association Protocol, developed in the 1970s, is a non-verbal approach to healing that promotes the use of auricular acupuncture through training, education, and research. It is an evidence-based, clinically effective, cost-efficient, and drug-free compatible cross-culturally program that uses acupuncture to treat both substance use disorder, cravings, insomnia, depression, and anxiety. Acupuncture in general has been an integrative approach to healthcare that originated in China over 2,000 years ago, and it has been shown to be an effective method in maintaining health and mentality. Acupuncture treatment works to restore balance and flow of the body's innate vital energy, restoring balance to the body, the mind, and can help with a variety of conditions, some of which I've already mentioned, and research supports the use of auricular acupuncture in combination with conventional treatment. So auricular acupuncture uses five points, uses five points on the outside of the ear corresponding to the different organ systems of the body. The points have unique healing functions. This sympathetic nervous system points, balances the body's fight-or-flight response. The shin-men point, which I have actually needled nine patients now in the last two weeks, and I'll be getting certified of the next week. Now this point is known as the spirit gate, which helps with inner relaxation. The kidney point purifies the kidneys. It releases fear and relaxes the muscles. The liver point purifies the liver and releases anger. The lung point purifies the lungs and releases grief. And while auricular acupuncture was first developed in individuals in addictions recovery, today it's a treatment of choice for people with mental illness, post-traumatic stress disorder, insomnia, anxiety, depression, as well as anyone seeking a chemical-free way to reduce stress and advance one's own well-being. It is my belief that auricular acupuncture is an untapped community resource that should be utilized in the black community, and like it had been used in the 1970s by the Black Panthers. Granted, it is not a cure, but it allows those patients who may have mistrust towards Western medicine to still be able to receive care. And it provides a sense of community, and it's able to be done in a group setting. It is cost-effective, and if more psychiatrists are able to get trained and certified in it, it can become accessible as well. So it's just something for you all to think about. So, while in Jamaica, I was there last month for a global mental health rotation that I helped to start at Howard with a partnership with the University of West Indies with my co-chief, Dr. Elizabeth Arnold, thanks to my PD, Dr. Danielle Harrison, and in attending Dr. Flavia D'Souza. I had a very rich educational experience, and I learned about the phenomenal works of Professor Fred Hickling. One of the works that he did, which I will discuss, is the group psychotherapeutic modality known as psychohistiographic brief psychotherapy. He conceptualized this in the 1970s at Bellevue Hospital in Kingston, Jamaica, and it is a group psychotherapeutic modality that he used in adults with psychiatric disorders. However, in the 2000s, he actually adapted that modality to use in children ages 8 and 9, and this concept used adult, I'm sorry, art forms to engage in groups of individuals in the exploration of themselves and their collective lives, and in doing so, generating insight using cultural activities such as storytelling, poetry, dance, theater, and as a deinstitutionalization intervention to stimulate change in asylum cohorts. Although it originated for adults with psychiatric illnesses, it has expanded successfully, and it started in one school back in 2006, and has now been used across all schools in Jamaica, and because of the partnership that myself and my colleague had established, we're planning to bring it to Washington D.C. in the near future. After I am done speaking, we will watch this video because I, my words cannot explain what Professor Hickling has done. The late Professor Hickling, because he passed away, unfortunately, in 2020, his work is phenomenal, you all, and I really would love for you all to see this video, so I am not going to even try to conceptualize this in my own form. I wouldn't do it justice, so we're going to get this video playing in a second, but these works, all of them, though different, they are very similar because they all address patients and community in a different light, and they show that it is very important in utilizing nontraditional healthcare models to address something that clearly what we've been using is not working, and they recognized that something else needed to be done. Communities are extremely vital to helping our patients thrive, and I need you all to recognize and understand that. So, I know that although community itself, or the work that I have shown you here, are not our textbook prescription medications, and that's okay, because these methods are effective, too. So, I urge all of us to listen to our patients, be open to exploring new treatment options, consider putting your boots to the ground and asking your patients and the communities that you serve what do they want, what do they need, and once you all figure those things out, work together so that the job can be done effectively, because what is happening now is not necessarily working as well as we would like it to. Thank you. Wow. I knew these guys would do a great job, but this has been phenomenal today. Thank you so, so, so much. You've given us a lot to think about, and we have a lot of work to do to bring the best services possible to our patients that meet their physical, their mental, their emotional needs, and there's some folks out here doing some amazing work that stretch our concepts of what mental health service delivery looks like, and like Dr. Blocker said, these videos will give us a good idea, a better idea about what she was describing, and I agree with her, it's hard to put this into words. So, we have a technical person here who is going to help us pull these up. I actually saved this, these presentations on three thumb drives, okay, so that we wouldn't have this problem, but we have it anyway, but we're going to fix it, and I'm going to pull up the videos, and we will see them momentarily, but in the meantime, in the meantime, I'd like to bring attention to this amazing artist we have here. And give him his props. You know what? I would like to give him an opportunity to come and tell us a bit about his process. He is capturing the spirit of what it is we're trying to do here. Please. I don't know if the other sessions you have provided to students, but we're verbal. Psychiatrists, we like to talk, we like to hear information conveyed in words as well as in art, so. All right. So, just a little bit about what I'm doing over there. I am a visual note taker. It's also called sketchnotes, and essentially what I do is I listen to keynote presentations from all different sectors, and I capture the high-level concepts as a way for you to recall what was spoken about in those sessions. A lot of times you attend a lot of sessions that have a lot of value, however, after about one or two sessions, you may not be able to remember about one thing from each. So this helps to kind of capture those gold nuggets and keep them in a little sack on your belt for you. Afterwards, I'm going to take photos of each of these. I'm doing six total. This will be my fourth one, and they will be, I believe, disseminated, I don't know if that's the right word, sent out to everyone in e-mail form for you to have. So, thanks so much for having me. We so appreciate your presence here, and I cannot wait to get over there and to see how you have captured the essence of what we've been trying to convey today. We do have the videos, I do believe we're going to be able to play the one for the HEAL initiative, and for the HEAL initiative developed by the Black Panthers as well. Oh, I'm sorry. The HEAL initiative at Howard University. At Howard University, I'm sorry, I'm sorry. This has got me all upset, you all have to forgive me. And the one on cultural therapy from Dr. Hickling in Jamaica. We are so sorry, but what can we do about the volume, we need to turn this off, yeah, thank you. In the meantime, does anyone have any questions they'd like to ask of any of the speakers or myself? We're glad to hear from the audience and have some interactive time here. Hi, I'm Tresha Gibbs and I'm a child and adolescent psychiatrist, it's great to be here, thank you for the presentation, I think the main question I have has to do with the upcoming changes in the Joint Commission standards, so now they're requiring hospitals and everyone to be focused and have emphasis on health equity, and I wondered if anyone in the audience or anyone here had ideas, certainly for best practices or things to push forward, and so I think many of the main themes from Making Good Trouble come through as actionable points and I think the programs that were highlighted, looking at community-driven activities and alternative even approaches to care that include the voice of the patient, but I just didn't know if there were other ideas in the room, thank you. Repeat the question one more time, make sure I get it. The ideas for systems, facilities, and what you might be doing locally to promote health equity, yeah, because it's actually now a standard for accrediting, it will be in July, so it's a really great time to generalize some best practices, I think, again, a lot of what you said does apply, so I just wondered if there were other ideas as well. I'll just start with, we did our best today to give some ideas and some things for people to think about, because I think people forget that there are already systems are in place that work well, and we just have to know what those systems are and push them and emphasize them. You know, you mentioned about hospitals and certain medical systems that may be requiring I don't think they can hear you, speak into the mic a little bit, you're not shouting like you usually do. Okay. You all can hear me? Yes. Okay, all right, all right. But what I would say is that if you look at the various hospitals, it really, it depends on maybe what region you're in, certain hospitals have already put certain things in place. One thing that I would just say kind of, because that question really is one that is kind of difficult, if you would, to answer, because you really have to talk about systems across the whole United States of America. I would say please make sure that you are sensitive, that you communicate, that you know what is expected of you. I think people make mistakes for lack of knowledge and not knowing what's expected, not knowing how to speak or what to speak towards. So I really would just encourage people to look at the ideas, look at the concepts that we've presented today, these ideas. I don't have anything new for you, but I would just appreciate that, you know, whatever system that you're in, make sure you're familiar with it, make sure that you communicate with them. There may be someone out here, you know, an audience was open up to you all, if you have any other ideas. We tried our best today to give you some ideas that you can utilize or just emphasize back at your home. We have one more question. Yeah, hi. So I am a psychiatry resident from Virginia Commonwealth University. I was just wondering, I've seen several patients throughout my training, particularly white patients who sometimes bring up what they call like reverse racism or, you know, I can think of one who said he quit his job as a cop because blue lives matter, that kind of thing. So always in the moment, I am just kind of quiet and then move on during the visit. But I don't know if you all have any like tips or suggestions for, you know, how to respond during those moments, because part of me does feel guilty for just kind of ignoring it. Sometimes I feel like I have more of a responsibility to try to say something, but it's always really difficult during those moments. Yeah, that's a, that can be very tricky. Absolutely. What I do now is I make sure that I listen to people and I hear them out, but also what I, if the person allows me, and that's where the discussion comes in, so I'll ask them and say, is it possible for me to just share with you just a couple, two, three facts and say, you know, yes, I know that you may believe in reverse discrimination. Do you also realize that in this country, that our constitution states that black people were two thirds of a person? Do you realize that when we came over here, we didn't have a choice, black people wouldn't have a choice as to where we lived, how we lived, and that a lot of that still exhibits today. I would also challenge regarding test scores, standardized test scores. A lot of people bring up reverse discrimination when it comes to admissions, college admissions, medical school admissions. If that was the case, we would see more equitable admission standards between whites and blacks. There wouldn't be this large gap. You know, it's, I was posed as a question. I wouldn't get into an argument, I'd just say, help me understand why these things may exist, and sometimes, you know, people say, oh, I didn't think about it like that. Sometimes they back off, but you try to remain non-confrontational as much as possible. I hear you, but you just let them know there are other facts out there. You know, that, how can you speak to those things and realize that those things are facts, they're not fantasies. This is, you know, this is what, you know, it is what it is, what they say. I'm not sure if anybody else has anything else to add to that. Good afternoon. Don Phillips, Senior Program Manager with the Foundation, to say thank you all for this presentation. Very lovely to hear. Previously, before coming into mental health, I spent some years working in higher education at public white institutions, and I would love to talk to anyone about the disparities of education and post-secondary education to our minority students, because yes, as you said, it is, there are facts that, again, can be difficult to talk about, but facts that we do need to talk about. I just have a specific question towards your statements on, when we're talking about the personal steps to promoting equity. During the George Floyd, Black Lives Matter era, working in higher education was very difficult. As a black man, again, being pointed at it like, what were your personal experiences? And I got to the point where, again, it wasn't my responsibility for you to be educated. And looking at the two differences that you talked about of being an ally to being an associate, I'm just curious to understand as I'm kind of just looking forward into the future conversations of understanding of when someone is being an ally to when someone is being an associate, when it is acceptable or reasonable to either share personal experiences or even just talk about just future education. Living in D.C., it's quick for me to say, well, go to the African American Museum as a quick cop-out, not want to talk about experiences. But then I also feel like there's importance when speaking to other individuals that don't understand the lens from my eyes of whether it's walking on the metro or even just walking to work wearing a shirt and tie. But again, just curious of where is kind of that gray area of understanding when someone is being an associate to when someone is wanting to be an ally to when we should, you know, as black men and women, talk about either our experiences or just talk about the education understanding of racism within society today. Absolutely. That's wonderful. But the example that I think of is when I'm in a meeting and I have my non-black counterpart, white counterpart sitting next to me and something happens and they can tell I'm offended and they say, oh, Dr. Shepherd, I understand. It's going to be okay. That's an associate. The non-black counterpart who stands up in the meeting and says, that was not right. We're going to change this. I support such and such. That's the ally without me even having to say anything. So that's the difference between the ally and the associate for me. So that's the best way I can explain that. I do have non-black counterparts. I don't have to say anything. And they will speak up on my behalf. I've seen it since I've been here in San Francisco, to be honest with you. But then I have some who have been associates since I've been in San Francisco. I've experienced some racist actions since being here for the last two days now, two and a half days, believe it or not. It's just, oh, Jonathan, it's going to be okay. I'm looking like, okay, yeah, thank you. I know it's going to be okay. But when I have other people who say, no, no, that should not be. This is how we're going to rectify that. We actually have the video ready to play. So I will go ahead and do that now. The Dreamer World Cultural Therapy Program was designed for nine-year-old primary school children in inner-city Kingston by the Caribbean Institute of Substance Abuse and Mental Health, CARIMENSA, of the University of the West Indies, Mona. The program started with a deputy headmistress of the Algonquin Primary School selecting 25 students who had failed the Ministry of Education Grade 3 examination in 2006. The children were also having behavioral problems and being disrupted in school activities. Based on their previous experiences at the school, the teachers expected that the children would fail the National High School Entrance Examination, or GSAT, that they would sit in the nearest dining room. Our aim was to change this expected outcome. The workshop was in the first three weeks of the summer holidays in July 2006 on Mondays to Thursdays, Fridays when it was for a weekly review by the staff and teachers. At the start of the program, the students were observed to be hyperactive and significantly uncomfortable. I certainly know that the first view I saw of them, I was really struck by the hyperactivity that I saw in them. I'm proud to be a part of you. I want to say that we've done a lot of work so far. What our teachers have seen has brought me to this world. As is characteristic of most inner-city communities, the children lived in conditions of poverty. They lived with single parents or grandparents and many reported significant physical and emotional loss, as well as other horrendous life experiences. That's why we are moving on. Many of the children were also undernourished, with dietary deprivation, so the program first focused on their nutrition. The children were provided with breakfast and lunch on a daily basis. The first two hours of each day were devoted to computer-based remedial mathematics and reading, tutored by teachers from the school. With this, the children were divided into small groups of six to eight. The workshop following these classes allowed them to participate in psychological work, also done in small groups. In the initial sessions, they were asked by them to write themselves. We took photographs and made laminated identity cards for each child. These identity cards seemed to be a source of self-esteem, as the children wore them proudly, and at times conflict arose when they were expected to relinquish the card at the end of the day. As a main focus of the workshop, the children created a cave. They were asked to identify the things that they liked and did not like on their planet Earth. They were asked to create and name fantasy planets with animals and plants that inhabited them, and to imagine the things they wanted on these planets and those they would get rid of. They were required to dream a world. In these small groups, the children had to select videos, learn to make decisions, and carry out activities as completed teams. The psychological activities were also accompanied by cultural and creative arts therapies. They played video games, drew, painted, and recreated animals and objects from their newly created worlds with face masks of paint or machine. For this, they had to work in pairs, and in so doing were encouraged to work creatively, intimately, and non-conflictually with each other in their intimate spaces. Together with the teachers, the children created music, dances, songs, and poems about themselves and their new worlds. Their musical instruments were all improvised shakers, scrapers, pop covers, and drums. Basically, each song about the process and their world was called, Alan is Your World. A major part of the project was the field trips. Many of the children had never left their community, so simply walking to Connelly House, a mere block away, was a new experience for them. It was remarkable to see their excitement at visiting Casey's Bay the only hurdle, as this opened a whole new world of possibility of moving outside of the confines of their community. At the end of the workshop, the Dream World drama was presented as a show-and-tell at the community's Anglican Church Hall. The audience consisted of the children's choir members, community members, and the local media. All were excited by the performance. The local newspaper made a full-page report on their performance, with photographs of their drama and some of the children. During the school term following the workshop, two-hour taco cultural therapy sessions were held every other week. Another 40-hour workshop was held the following summer in the first month of their summer holidays. The second shorts were performed in the name of the children at home, and had moved from the bottom of their class to now being the leaders and cultural activists in the school. The taco sessions were discontinued at the end of 2008, as the children prepared for their upcoming GSAS examinations in March 2009. In December 2007, the children gave special performances and interaction with 60 psychiatrists and their families. The children gave special performances and interaction with 60 psychiatrists from around the world who were attending an international psychiatric conference at the Pegasus Hotel in Kingston, Jamaica. The psychiatrists were amazed at the children's ability to perform peacefully. The parents and teachers reported the incredible improvement of these children in math, reading, and social skills following the cultural therapy process. There is powerful qualitative evidence that the cultural therapy workshop has had a significant transformative effect on the behavior of these innocent children. All right, so that gave you a sense of a system that works well to really address the social determinants of health. By giving these children a sense of purpose, meaning they created a sense of what an ideal world would look like and what it would take to create it. And it just has produced international results. Actually, this program has been reproduced in other countries now. So, I think we have another question. Someone didn't get to ask it earlier, and this will be our last one. We're almost at 3 p.m. Hi, I wanted to comment on what you had said actually about the social determinants of health and how we, I'm sorry, I think that's what you said, right? About how we prove that we're doing it as a hospital for accreditation. So, at our, I am also from Baltimore, I live and work in Baltimore, and at our hospital we use Epic, which I'm sure a lot of people do. And they have a, the way that they, I don't know if it's the hospital system or Epic seems to be solving this, is to have this little social determinants of health like wheel that you're supposed to fill out in people's like social history that will say things like, you know, like difficulty accessing food or housing or something like that. But it feels to me as if you're like putting a badge on people's charts that's like, I'm homeless. And I don't, I understand the idea of like trying to draw people's attention to the fact that these are difficulties that the person, that you need to address if you're going to ensure somebody's health. But at the same time, I don't, it feels very, I guess, performative. And I don't know if you all have thoughts about, I mean maybe I'm reading it wrong, or if there are other ways that we can go about, you know, alerting other providers to something, you know, real issues in people's social history but without it labeling the person. Thank you. I hadn't thought about it that way and actually could very well be. Where I work at Hope Health Systems, which is also in the Baltimore area, we have supportive services. And this is one of the wraparound programs that we realize that most people need if they're going to be able to be successful in treatment. So a part of that is care coordination, psychiatric rehabilitation programming, and those such services as is that. But I hear you because, you know, some people don't want to even receive those services when we offer it to them because it's considered a handout. I've heard that word. So again, I think you have to do it on an individualized basis. I think the way in which you present it is also important. I hear what you're saying. It is weird to open up somebody's chart and it says homeless, food, you know. I hope it doesn't say it like that. I hope them. It's not great. Yeah. Yeah, I'll have to see it. It don't sound good. But again, the presentation is huge, especially when you're attempting to help people. And we must never forget that when you're helping people, there has to be a certain humility that you must have with that. You just can't come in and say, oh, I'm here to save the day. We didn't ask you to do that. And actually, they've been surviving without you anyway. You have to remember that. And so there's a certain humility that we must have in asking people for that help. And normally we do that regardless of race. People will be amenable for that. And that is why when you consider providing these resources, you have to ask your patients, what is it that you need? What is it that you're looking for? You can't just go in and say, oh, you need a Dream a World program, so I'm going to bring that to you. And then that's not what they want or what they need. Right. So you have to ask those certain questions first. Thank you all so much. But I think we're out of time. Have a great day.

mental health care

equitable systems

John Lewis

activism

cultural competence

implicit biases

anti-racist approaches

community-centered models

HEAL Initiative

NADA Protocol

Dream a World Cultural Therapy

health equity