So I'm going to introduce Dr. Dunlap. She's a psychoanalyst and board-certified psychiatrist whose practice is based in Washington, D.C. She graduated from Georgetown University School of Medicine and did her training at GW University School of Medicine and Health Sciences, where she is currently a clinical professor. She has psychoanalytic training from the Washington Psychoanalytic Institute as well. Honors include distinguished fellowship in the APA and fellowship of the American College of Psychiatrists. In the APA, she's super active, and she's a member of the Assembly Executive Committee and the Deputy Representative of the Area 3 Council. So good afternoon, and thank you for your patience. Let me just say, I was trying to get an Uber, and the app was taking me back to my hotel, and even with the Uber driver, we were wondering, like, what's going on? And let me just say, you know how it is. As a psychiatrist, being late just causes so much anxiety. I remember the first time I walked into team report on the inpatient unit, and I was late, and I felt everyone was looking at me. That was my last time running late. So I just wanted to let you know, I do respect your attention. So, thank you, Lama. So I'm going to be talking about the management of guilt and shame and work with social determinants of mental health, and thank you for coming here, because I know that you have many options. I also want to thank the Scientific Program Committee for selecting this submission, and I'd also like to thank Austin DeMarco, the Interim Director of the Office of Scientific Programs, and his staff. They have always been superb with their assistance. I do not have any financial conflicts of interest, and it also occurred to me that I want to acknowledge that I am not an expert on social determinants of mental health, yet I chose this topic, and I think that as we go along, you will appreciate that I am doing this because I think that any of us can work with this information. So, let me just do an overview. What I'm going to do is talk about just some basic emotions and coping mechanisms to manage discomfort and conflict. I'm going to talk about patient's adaptive and maladaptive responses to shame and guilt, but what I'm really going to do is focus more on clinicians. When I conceptualized this, I was thinking of patients, and then I realized, no, wait a minute, we have our own discomfort as well, and then I'm also going to talk about some strategies that you can incorporate in your practice or wherever it is that you're seeing patients, and those are the objectives. So, first, what are social determinants of mental health? In their landmark 2015 book, Michael Compton and Ruth Shem documented how the conditions in which we are born, grow, live, work, and age, the social determinants of health, and they applied them to mental health, impede access to care, they perpetuate disparities, and they undermine health equity. They shifted our attention from a biological focus to the impact that living conditions have on a patient's well-being, and these social determinants of health are widely recognized now throughout medicine. I was speaking to someone recently, and the surgeons are working on this, and so this does not mean that they shifted us from the biopsychosocial model, which is pictured here, Engel's model. I really think that this model incorporates the social determinants. I have layered on here on the biopsychosocial, I've layered historical and political. The social determinants of mental health include adverse childhood experiences, unemployment, underemployment, and job insecurity, poor education, poverty, income inequality, and neighborhood deprivation, poor access to sufficient healthy food, poor housing quality and housing instability, poor access to healthcare, and social exclusion and racial discrimination, and we'll add under social exclusion, isolation, and you know that the Surgeon General has recently issued a report about the importance of isolation. These conditions have a profound impact on mental health, both positively and negatively. For example, people who live in poverty are more likely to experience mental health problems, such as depression and anxiety. People who have access to quality education and healthcare are less likely to experience mental health problems. In spite of this progress, vital information in medical education, residency training, clinical treatment and research, this material is not always, it's understood intellectually, but it's not included and not implemented. So clinicians of a certain age will recall the multiaxial system of DSM that contained the five axes, and for those who remember, axis four recorded the psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders, such as problems with a primary support group, problems related to the social environment, educational problems, occupational problems, housing problems, economic problems, problems with access to healthcare services, and problems related to interaction with the legal system or crime. There is some interest in returning to this system, but what's most important is, what's most pertinent is how to formally identify and codify the social determinants, which is what they were, even though we didn't refer to them as that, but how to codify them, and I'll return to that a little later. In spite of this reversal, in spite of the DSM committee removing a way to include the social determinants, in recent years, the APA has made some progress in raising awareness about the relevance of social determinants in mental health, and they include the following, and what I'm gonna do is summarize some of the work of the APA, including the work of the assembly. I have been serving in the APA assembly since 2016, initially representing the Washington Psychiatric Society, and now serving as the Area Three County Deputy Representative, along with Bill Greenberg, the Area Three Council Rep. Vivian Pender convened a task force from 2021 to 2022, and she made it her mission to raise awareness about social determinants of mental health. In 2018, the APA issued a position statement on mental health equity, and the social and structural determinants of mental health, and in 2020, there was an APA resource document on social determinants of mental health that was made available, and then in March of 2022, with the publication of DSM-5TR, there was an effort to reflect information that would allow us to address the roles that ethno-racial identity, bias, and discrimination have on psychiatric diagnosis, and also in March of 2022, the DSM included a chapter that addresses conditions and psychosocial or environmental problems that may be a focus of clinical attention or otherwise affect the diagnosis, course, prognosis, or treatment of an individual mental disorder, and you'll see that really sounds like the information on Axis IV from DSM-4TR. These conditions are presented with their corresponding codes from ICD-10-CM, usually referred to as Z codes, and so a condition or problem in this chapter may be coded as if it is a reason for the current visit, if it helps to explain the need for a test, procedure, or treatment, or if it plays a role in the initiation or exacerbation of a mental condition. In 2022, a year ago, May of 2022, the APA Assembly passed an action paper to establish a new Assembly Committee on Social Determinants of Mental Health, but because there was a two-step process, there was the Assembly agreed to make the change, but then the second step, which occurred this past weekend, the Assembly had to agree to change a procedure code, and it did that, and so there is now an Assembly Committee on Social Determinants of Mental Health, and I actually see some of my fellow Assembly colleagues here. And then last summer, Speaker Adam Nelson appointed an Assembly Executive Committee Work Group on Social Determinants of Mental Health, and starting in October of last year, this group met with regularity and really did quite a bit of work. And by the way, this work falls under the Division of Diversity and Health Equity. And this is just the top of the position statement. This is a picture of Dr. Pender and her task force members, and I must say it was a very impressive task force, and it's clear that this notion of task force has really taken off, and I think that Dr. Pender really built on the task force on structural racism and also focused on four different areas with a lot of resources, and if you want to access this, it is available on the APA website. This is a list of the members of the AEC Work Group on Social Determinants of Mental Health, a very, very dynamic group. And let me just say something about the work of the AEC Work Group. In meeting as a work group, the rich thing about the work group is not just focusing on concrete tasks. We were able to talk about our various experiences with this topic. So the assembly is made up of members throughout the country, also including Canada, and so some of us work in more urban regions, some of us work in more rural areas. And so in our discussions, we identified a number of attitudes and barriers that might thwart the utilization of these concepts, social determinants of mental health. And so they included lack of awareness about it, lack of time. Some talked about the fear of criticism by others for addressing this. For example, they were concerned about how their attendings might feel, supervisors, even their employers. There's also a lot of discussion about the lack of awareness about resources for patients. Some people also talked about painful affective states like fear and guilt, fear, guilt, and shame. And then there was just apathy. And then there's always the notion that, well, we want to do real medicine, which usually involves neuroscience, or maybe focusing on some interesting intrapsychics, as opposed to listening to patients talk about social conditions. And so these sentiments actually were in line with some information that has been collected by an organization known as the Physicians Foundation. And so this is a foundation that does surveys each year. And there are three parts. This is information from part three. The 2022 Survey of America's Physicians examines the current impact of social drivers of health on physician practice, physician well-being, and their patients, as well as possible solutions. And I'm going to go over some of the responses. So they noted that, from their survey, that nearly all physicians indicated that patients' health outcomes are affected by at least one social determinant of mental health. 23% said that their entire population was affected by mental health. 23% said that their entire population was affected. 54% said that many of their patients were affected. 18% said some. And 5% reported few of their patients. And only 1% of physicians reported that none of their patients were affected by social determinants of mental health. Financial instability and transportation are the top two social determinants of health experienced by patients. 34% of the patients reported financial instability. And 24% reported transportation problems. Regarding the time and ability to address social determinants, I'll just summarize this. Six in 10 physicians, 61%, said they had too little time to effectively address social determinants. However, a majority of the physicians, 87%, want greater time and ability in the future. So the majority of physicians identified limited time during patient visits, 89% insufficient workforce to navigate patients to community resources, 81% as the greatest challenges impacting their time and ability to address social determinants, and a number of other problems. Community resources not available, inadequate time, too difficult to access the resources, inadequate information about the availability of resources, lack of reimbursement for screening, and an existing payer reporting requirements that take time away from addressing these variables. And when it comes to the impact on physician mental health, eight in 10 physicians believe that addressing patients' social determinants of health contributes to physician burnout rates. Six in 10 physicians report that they often have feelings of burnout when trying to address their patients' social determinants. And six in 10 report managing patients' social determinants of health has a major impact on physician mental health and well-being. More than half of physicians report social determinants of health challenges cause them to experience stress or frustration on a daily or weekly basis, including 71% identified limited time, 64% identified insufficient workforce, 63% identified existing payer reporting requirements, and 57% identified lack of reimbursement for screening. And then the following top five strategies are considered important by about eight in 10 physicians to support them and other physicians in addressing social determinants. And they are investing in community capacity, investing in the technological and human capacity to connect patients with community resources that they need to be healthy, screening patients to identify social needs, significantly reducing existing payer reporting requirements and other administrative burdens, and creating financial incentives for physicians' directed efforts to address social determinants of health. And I'll conclude with this section by saying that multiple policy steps were identified by physicians as important. So for example, 86% identified reimbursing, 84% identified incentivizing payers to invest in availability and quality of community resources, 81% identified providing greater flexibility for Medicare Advantage to reimburse for addressing social determinants of health, and 75% identified integrating social determinants of health into payment policy. Now, so as I was thinking about this, and we know what some of the structural barriers are, but I thought, I was just wondering, and because I'm an analyst, but just because I'm a therapist, you know, I was wondering what else might be going on here that would, you know, cause us to back away from addressing something that really is so germane to clinical care. Well, guilt and shame are two strong emotions that can impede one's ability to deal with issues that are tied to social status. For example, the history of oppression, structural racism, and discrimination in the US. And although guilt and shame are ubiquitous emotions that occur along a spectrum, they are often misunderstood by both clinician and patient. Guilt and shame are different. Guilt is the emotion that occurs when one feels they have violated standards of conduct. Shame refers to a spectrum of painful affects, embarrassment, humiliation, and loss of face that accompany the feeling of being ridiculed, excluded, or rejected. Guilt is usually accompanied with the intrapsychic expectation of punishment, where shame is experienced as a personal sense of missing the mark. And it's important to note that guilt and shame can coexist. For example, you might feel guilty about something you did, and this guilt might cause you to feel ashamed. But the awareness of guilt and shame require an ability to acknowledge self and others. It also involves a perceived evaluator and evaluate it. And this is a summary of the difference between guilt and shame. And this is taken from the work of social psychologist Tang Di. And there's a paper that she did from 1991. And truly, it's a dated paper, but it's a landmark paper. And what she did, she studied children. She looked at children who experienced guilt and compared them to children who experienced shame. And so just to review very quickly here, I've already said that guilt focuses on a specific behavior and shame focuses on the self. But for people who experience guilt, there's a sense of responsibility, there's remorse, there's regret. But people who experience shame tend to experience a sense of worthlessness or inadequacy. Guilt can motivate positive change, but shame can lead to self-destructive behavior. And people who experience guilt tend to be prone to being proactive and constructive. But people who experience shame, because they often want to hide and withdraw from the experience, can respond by hiding, minimizing, denying, or even striking out at others. People who experience guilt are more likely to discuss the matter, whereas people who experience shame are more likely to avoid discussion. And guilt activates the conscience. I mean, we know about, you know, tripartite model of, you know, the superego, the ego, and the id. And some people think that Freud, while he was talking about guilt, he might really have been kind of conflating guilt and shame. But certainly we know that those who have a developed sense of conscience, you know, an intact superego, are likely to take responsibility and also, you know, tend to feel bad when they have, you know, engaged in behavior that is not socially sanctioned. Whereas with shame, shame is not adaptive and is not necessarily inhibitory. People who feel guilt are pretty resilient, but people who experience shame tend to be prone to psychological symptoms like anxiety, depression, low self-esteem. You know, we think of also, you know, people who are neurotic as having more guilt. And so what Tangley concludes is, between the two, guilt is the moral emotion of choice. So, you know, clearly there's reluctance and resistance among physicians to deal with guilt and shame. And one of the things that I also, just digging into this, I found out there, there may be something else that inhibits physicians in general from leaning into this work. For example, we know that physicians tend to be perfectionists in part because there's little room for error and aiming to get it right is just germane to the work. But suppose this perfectionism is also causing us to avoid interrogating material and considering important variables that would enrich our work and lead to better outcomes. And I would say that in a society that is becoming increasingly polarized, there's a risk that individual political beliefs have the potential to distract individuals from, and I'm gonna say it this way, from supporting the stated positions of the APA, that is the commitment to support healthcare systems to access and improve their capabilities to screen, understand, and address the structural and social determinants of mental health. In other words, that's what's in the position statements. So let's look more closely at physicians. Physicians are often exposed to the negative effects of social determinants of mental health. They see patients who are struggling with poverty, homelessness, food insecurity, and other social problems. And so there is a consequence for not addressing social determinants of health and shying away. So for example, shying away from these variables causes an interference with establishing rapport and trust. In other words, it can affect the ability to develop a therapeutic alliance. It can also undermine treatment and access to needed services, can cause reduced empathy for patients if we just deny or minimize, and also leads to less willingness to address social determinants. That is if the physician's own, let's say countertransference gets in the way. And also, while the physician may be avoiding the social determinants in an effort to also get on with the work, if you also have a conscience, and if you also know that you are avoiding something, that also can lead to feelings of burnout and compassion fatigue. There's also, in doing so, there's a risk of secondary trauma to the patient. And by the way, so in thinking about this, I was thinking there's the clinician's shame and guilt. There's also the patient, the patients. And many patients who are struggling with the variables that I've described, they are already often dealing with shame and sometimes guilt. And I think they have bought into the notion that if they are struggling, it's an individualized problem as opposed to it being a reflection of a system that we have. So in moving to strategies, one thing I want to say is that we tend to start with the patient, bypassing ourselves as if we are bystanders to clinical care. And what I'm proposing is that there's a shift. And it's what we considered elsewhere an anti-racist pedagogical shift. And I don't want you to get distracted by anti-racist, and that's because I think that can be a charged word. But what that refers to is taking a different approach and taking a different approach to teaching and learning, which begins first with the clinician acknowledging her personhood, her experience, and her subjectivity. So for example, with this approach, the first thing to do is to become aware of your own biases. And so, and it's about anything. It's not just about race. It can be gender. It can be ethnic identity, sexual identity, just whatever it is. Homelessness, just in whatever way a patient may be marginalized. But it's important for us to become aware of our own biases because, by the way, implicit bias, and let me just say this. You know, we've been talking about implicit bias. Implicit bias, by definition, is unconscious and automatic. Let me say it again. Implicit bias is unconscious and automatic. And that also means that we often have biases and we're not aware. And this is where that tool that we've been talking about for years, the implicit association test, is really valuable. If you do this test, you will, most people, I don't know what the percentage is. It has to be really low of people who, the respondents who don't identify any bias. It's very commonly known that most whites have biases against blacks. There are blacks who have biases against blacks. But the point is that, in order to get in touch with whatever your bias is, it requires some kind of tool to do that. Now, in terms of explicit bias, there are tools that can be used. You know, for example, there's a tool that is called, it's the would or should test. So, for example, you can ask someone, should you be uncomfortable sitting next to someone black on a bus? And I think most of us would wanna say, well, no, I shouldn't be uncomfortable. But then, when you ask the question, but would you, some of those same individuals would actually say yes. Would you be uncomfortable, should you be uncomfortable in an elevator with someone, a black man? And some might say, actually, they might say yes. But for those who think they should not be, then if you push a little bit more, they would say, actually, yes, I would be. And that's something that is more conscious that one can get in touch with. Another suggestion is creating safe spaces for dialogue, acknowledging your own shame. And this could be difficult, but just reminding you that shame is a normal emotion. For example, in working with certain patients, if you recognize that you feel ashamed, I'm thinking about there are some whites who have not really been exposed to whites who are impoverished. And because they're not accustomed to that, might be uncomfortable and not sure of how to connect. And I mean, there are many examples, many permutations. But the point here is to talk about it and to create a safe space for you to have your own conversation. But then also, that helps you to create a safe space so that the patient can have a conversation. And I want to just show this slide. It's a slide that I've started to show in different places. And what it is is a slide of America's timeline. And just an overview, starting at 1619, and I'm starting there, that's when enslaved Africans were brought to the country. From 1619 until 1865, we had American slavery, 246 years. From 1865 to 1964, that was a period of segregation, legalized segregation, which did not end until 1964. And starting in 1964 with the Civil Rights Act of 1964, from then until now, just 2023, only 59 years have we had legalized integration. And I share this slide because 59 years is not a long time. And it also is a reminder that we are really very early in our country's development in an attempt to live as an integrated society. I do not say this to make an excuse for things, but I do share it because it really, I think, can help us to understand why it is that we have so much work to do. And there are a number of points here. There's the Declaration of Independence, the Naturalization Act of 1790, which was for white persons. There's the Chinese Exclusion Act of 1882, the internment of Japanese in 1942, the Brown Decision in 54, 2001 and 2016, the increase in anti-Asian discrimination and violence. It didn't just start recently. And I share this because I think that most of us do not know about history. Some of this information I've been learning in more recent years, especially as I've been doing more work in the assembly. But I share this to say that this is our history, and I'm gonna make a point about why it's important for us to know it. In just a moment, I wanna come back to that. This is another timeline. This is the APA's timeline. And just as an overview, the same periods. Benjamin Rush, father of psychiatry, signer of the Declaration of Independence. APA founded in 1844. 1858, Samuel Cartwright publishes Drapedomania, which is his illness for blacks who do not want to be enslaved. Let's see, in 1954, many people may not know this, but the APA refused to support the Amicus Brief in the Brown v. Board of Education decision. And in 2021, the APA apologized for that. So this is important history. And taking an anti-racist pedagogical approach would mean that we would own this history, and we would sit with the discomfort that arises in us, and we take in and process its meaning. And most importantly, what it represents, which is the origin of our own organization, is structural racism. And some might ask, well, why do we need to do this? Well, I think as the leading psychiatric organization in the world, we have a responsibility to face hard truths so that we can assist our patients in achieving their own mental health goals. This is a Ghanaian symbol, an Akan symbol referred to as Sankofa. And it is, I'm sharing this because I think this concept might help people to understand why black, indigenous, and other people of color insist on returning to the past. There's much wisdom, there's pain, but there's much wisdom in the past. And what this banner represents is, it's the visual representation of a proverb which says, go back and get it. In other words, it's not taboo to go back for what you forgot and left behind, especially to go back for something that was not processed. And I think of this because doing diversity, equity, and inclusion work, it teaches us of the importance of acknowledging our past in order to move forward. And I wanna say that I think it was doing the DEI work that caused me to think about guilt and shame. You know, we've talked a lot in the past couple of years since George Floyd about white guilt. And it's not just white guilt, it is just guilt and shame about things that we have difficulty embracing and things that we have difficulty making sense of. I wanna say something else, just as a personal example. So I was thinking about how whites will say, well, I'm not responsible for slavery, I wasn't there, I didn't have anything to do with it. And I think about how I feel about the American Psychiatric Association. And this is my organization. And I'm not proud of some decisions that were made in the past, but I also believe it's my responsibility to make the organization better. So instead of shying away or, you know, dissing myself, I think, okay, let me just embrace that so that I can do something to make it a more inclusive organization. So what I wanna do now is shift to some practical steps and tools that I have found helpful. This is a diagram taken from the American Medical Association. They have excellent resources. And this is taken from one of their webinars, Eight Steps to Addressing Social Determinants of Health in Your Practice. And this is a paradigm for an organization, but it can be a private practice, it can be a community center. And, you know, the steps are laid out here. But what I'm going to do because of time, I'm going to tell you what I do in my practice. So for example, wait, let me just say, these are some of the tools that the AMA has recommended when you go to this resource. Listed here are a number of screening tools for social determinants of mental health. There's PREPARE, Protocol for Responding to and Assessing Patients' Assets, Risk, and Experiences Implementation Toolkit. I'm actually gonna show that in detail. There's the Everyone Project by the American Academy of Family Physicians, and a few others. And I've added here the ACES screening. So this is, and it's going to be too small for you to see, but this is a screening that asks basic questions like, are you Hispanic or Latino? So that's a question about ethnicity. What is your race? Are you a veteran? And it asks questions like, you know, have you had trouble meeting your, you know, paying your bills between paychecks? And so it's a very basic screening tool. This is just one example that patients can be given. And I think most of us who are in private practices with people who have resources would not be using this. Okay. But that's one tool. But here's a tool that I want to suggest that each of us can use. This is the Adverse Childhood Experience Questionnaire. And on the right side of the screen is the ACE questionnaire for adults. There are also screening tools like PEARLS, Pediatric ACES and Related Life Events Screener. And that's given to, it's for children zero to 19. And it's generally given to the caregivers or teachers whoever has custody of the child. But I just want to tell you about my experience. I, in my practice, I do basic screening measures. I do the PHQ-9, the GAT-7, the PCL-5 for trauma, the Adult Symptom Rating Scale for ADHD. And in the past year, I've started to include the ACE screening. And I think that, well, I have found that it yields a lot of useful information. Just stepping back, because many people think social determinants, they think that is only for people who are oppressed. It's like a code word, social justice, social determinants. These experiences affect people across socioeconomic groups. So for example, I can think of a patient, very wealthy, parent was a hedge fund person, arrested, sent to jail. So she endorses that someone was incarcerated before she was 18 years old. Think of someone else, wealthy family. One of the questions is, when you grew up, did you feel that no one loved you or you were not loved? There are people who have very narcissistic parents who are distant and not involved. And not necessarily because the governess is taking care of them or the nanny. But the point is that this is something, if you give the screening, it will elicit, yield a lot of potentially useful information. So that is one that I think can be given to any patient. In terms of approaches for working with patients, one suggestion is, for any patient coming in, I think that the recommendations that you focus on what is called individuation, and that is focusing on the individual attributes of the patient versus the categorization, versus the race, the housing situation. I've already suggested using the implicit bias test to identify hidden bias. I've also already mentioned the explicit bias tool. And then also just accessing opportunities for dealing with race, interracial interactions. So one thing I would say is that guilt and shame are common emotions that can impede one's ability to address social determinants of mental health and clinical care. But these are emotions that serve to inhibit socially undesirable behaviors. One thing I want to say is that, one concern that I have is that if the behavior has now become sanctioned, then this creates a problem. So for example, in recent years, we have found that there is more incivility, and there's more overt evidence of bias and discrimination. This is among trainees, it's in clinical settings, and so it's become less ego dystonic for people to be rude. And the problem with that, especially as we are modeling for trainees, is that it starts to give them the impression that it's okay for them to be rude. And so I believe that just as we say things like, do not talk about patients when you're in the elevator. Make sure that you protect the patient's privacy. I think that it's important for us also to be very explicit about how we believe patients should be treated, regardless of people's political beliefs. Because otherwise, this gets kind of incorporated into the way that we think about patients, that we think about ourselves, and we think about the work that we do. And let's see, I just want to say that I do not think that these are peripheral variables. I think that social determinants of mental health are central to treatment, delivery, and outcomes. And I also, in thinking about this, I've been thinking that what is happening is clinicians are thinking that, when thinking about trainees also coming in, but I think over the years, we've started to think that the social determinants are interfering with our ability to do our work. And so I'm thinking that maybe we should reconsider the way that we portray and promote medicine so that those entering are not blindsided by the real nature of the work. Because it's not social work, it's actually work that is about looking at the whole patient and looking at the biopsychosocial aspects of the patient. Here are some references, and as I said, I'm not an expert, so I hope that you have come with questions, but also information that you might also want to share. And thank you for coming. Thank you. So we'll be taking questions. I ask that you please, if you have a question, get in line behind the microphone so that everybody can hear it. Hi. Thank you for your really beautiful talk. I thought that was very wonderful. I'm a second year, and I put together a social determinants of health and mental health curriculum, or like a small curriculum, because I'm part of a global mental health think tank. And I can tell you one of the struggles of putting that together was, A, what to include, and B, has anyone done this work across the country to see if you have any standardized curricula? There are a few people who have done this, and it's not an easy educational experience to access. So I think a good step forward would be to try to make a homogenized curriculum for everyone to be able to access, just to see, like, something that has been tested and tried and studied, which would be helpful to disseminate information equally. Thanks. Thank you. That's a great idea. I did want to say, and maybe just underscore, you know, while the social determinants of mental health were removed from DSM, and removed, the multi-action system was removed, there is a, their codes, they are now codified in the Z codes, and I think they're just even teaching people how to use the manual. By the way, the manual is a good manual. I have discovered that just from working with it, and just spending more time with it. Of course, my PTSD section is, you know, flagged, and I look at it every time, but there's more information, and I think that even incorporating that into the training would be helpful. Dr. West. Oh, Dr. Reyes? Hi, Dr. Dunlap. Would you be willing to share with this audience one or two ideas about where we might take our committee? Hmm. Let's see. Can you be just a bit more specific, Dr. Reyes? You've been very complimentary about the work that we've done, but I get the sense that we're just starting. So, I'm just curious if you have any thoughts about maybe even just one next step. Okay. All right. Dr. Reyes was a member of our committee, and one of his major values is focus on being a physician, a holistic physician, and being psychodynamic. So, one thing I think, Dr. Reyes, is, you know, as you know, we also developed a questionnaire. It's a demographics questionnaire that we have administered to the assembly, you know, looking at identity. I mean, very detailed. We also developed a questionnaire about attitudes and beliefs about social determinants of mental health. And it's about 25 questions, and together, it's taking an average of about less than eight minutes, seven and a half, but less than eight minutes on average to complete it. So, we're going to keep that open until the beginning of June. And my thinking, by the way, I'm not chairing the committee. I'm hoping that I will still be involved. But my thinking is that once we see how the assembly is thinking about this, you know, for example, one question is, does a patient's zip code determine the quality of health that they receive? When I first heard that, it was kind of difficult to process, but the answer is yes, it does, and that should not, where a patient lives, should not determine. Not where they go, like in D.C., I'm thinking going to a Georgetown, but where they live determines the quality of care. And so, once we know how we're thinking as an assembly, then that will let us know where we need to focus, you know, do we need to spend more information dealing with myths and stigma, and also to help us to identify the tools that need to be shared with the assembly, and then the next step would be to apply this to the district branches. So that's one thought. I don't know if you were able to, if you were there earlier when Heather McGee and Dr. Resnick and Debra Enix-Ross, I think, spoke. Yes, I was. I must say that the way Dr. Resnick introduced himself initially, and sort of acknowledging, you know, where he was coming from, sort of his biases, or sort of just, I thought that was the most powerful modeling and opening the door for other physicians, including myself, to be able to, you know, so I took that as, so the APA may want to be about thinking about how to use a lot of role-playing as a way to foster behavioral change, because Dr. Resnick did a fabulous job, I thought, in modeling good behavior, which I take as an inspiration. Well, can you just comment on what he did? I was there. I know what you're referring to. Well, he acknowledged he's a white male physician. I don't know if he identified his sexual orientation or not, but I mean, but coming from an organization that has a, so he acknowledges that he may not know about, he may not have the same kind of intimate awareness of the history of the experiences of the other people on the stage, and sort of some apology, you know, for the history that his organization has been part of, or I'm not sure, other people who were at there could probably identify other features. But I thought the authenticity and the humility were important. That's what I was going to say. Yeah, he, you know, he. It wasn't just a rote thing. It certainly conveyed authenticity. Yes, yes. And I mean, and he acknowledged that he, I heard acknowledging that he is a white man, and he, their experiences that he does not, he has not had, and, you know, approaching it from a sense of humility, he's acknowledging the things I don't know. And I also heard, and not just an openness, but a desire to also know other people's experiences, like recognizing that the people on the stage have actually something to offer him. And one of the things, I'm glad that you asked about this, because I think that, you know, one of the problems that we've had also doing DEI work is that, you know, many, one, some of it has been done badly, but also we end up with people feeling that they're made to feel guilty, as opposed to being encouraged to be humble and actually be, they want to be open to learning. And that does mean acknowledging that you don't know, and allowing yourself to be vulnerable. And I think people need to respect that. I mean, I think in the work that we do, you know, we tend to respond, you know, with compassion and thoughtfulness. Dr. West. I want to thank you for this presentation. It, again, I was really moved by it. And as a member of the audience who obvious, well, I don't know if it's obvious, but who, you know, recognizing that I've lived my entire life in just about every domain of privilege there is. One of your slides that I think particularly struck me was the timeline. And but in a way that I'm not sure if you anticipated it, which is that, as I looked at the timeline and thought about the feelings of shame, it also offered me, I think, a moment of grace to say that it hasn't been that long to expect the change that I would demand of myself and those around me. And so I was just wondering if you'd reflect briefly on the role of grace in dealing with shame and guilt. I'm not a philosopher, but I can speak from my own experience, and some of this is informed by some of the reading that I was doing. One suggestion that I have is that, and starting with clinicians, is that we start with some compassion, and we start with an awareness that, relatively speaking, we have pretty good lives. And just stay with me, you'll see where I'm going with this. Patients assume that we just have charmed lives. They don't think, you know, there are physicians, there are sections of medical societies for substance abusing physicians, okay? We're human like everyone else, but we do have a lot of privileges, and we do have access to care. We do have, you know, a lot of resources. But I think that starting with, for example, awareness that there may be something that I'm not able to fully identify with, and allowing myself the room to stumble some. And so the way that I approach it is, I give myself some grace, and I recognize that I'm going to make, quote unquote, mistakes. But I think that when patients know that I'm in there, and I have a good intention, and I'm trying to connect because I want to understand, and I'm curious, I believe there's room for me to, quote unquote, make mistakes. That's where the grace comes in. Like, that's my experience as a clinician. Hi. My name is Shella Sisco, and I work in a correctional facility in Illinois. I'm a mental health professional. And I thank you for that timeline, because it really helped me, as a clinician, understand the skepticism when I have an individual in custody before me, and the first thing out their mouth is, I don't trust psychiatrists, and I don't trust mental health professionals. And I used to take offense to that, but seeing the timeline and understanding the racial biases and the social injustice that have been inflicted upon people, especially those incarcerated, because once they're incarcerated, they're supposed to be there to serve time, but it seems like we do a double jeopardy on them. So instead of helping them, we continue to punish them and not get them better. And then they tell me, I don't trust mental health professionals or psychiatrists, so you have nothing to offer me. So thank you for that timeline. You're welcome. Hello. I noticed one of the slides might have a direction forward. It said social drivers instead of social determinants, and that got me thinking about rigidity versus open-ended, and I thought that the drivers had more dynamic quality. So I wonder if that's been any of the discussion in terms of using the terms, using language that feels more full of possibility as opposed to social determinants. This is what has been determined. Okay. And I don't know what slide, I would certainly go back and take a look at it. I know determinant does have a certain connotation. But I think that these quote, unquote determinants are drivers. They are driving what patients are experiencing and what we are providing. I think the committee is in the right hands with you as the Chair. Dr. Vinokur, I am not going to be the Chair. You are the Chair on that. I'm a very old-fashioned physician and a psychiatrist. As you probably know, my career started with DSM-I, and then I was sitting in the classes at Johns Hopkins Affiliated Hospital to learn DSM-II when I came to this country. So I don't mean to analyze you or anybody else. I was fascinated with the movie Marcus Willoughby, M.D. As an old general practitioner and primary care physician, I was fascinated that it was a challenge. Actually, psychiatry was a challenge because we not only took care of the interpsychic problems with Freud's formulations, but we also took care of psychosocial problems and helped them support. And it was a comprehensive care. And then we came up with the Comprehensive Mental Health, Community Mental Health Centers, which were named Comprehensive, and they had 12 components. And we paid attention to all of those. Then the DSM-IV came, and then the DSM-V came. The DSM-IV, you said it abandoned Axis IV, and I'm not analyzing APA, and the committees were erudite and they were very scientific. And they abandoned not only Axis IV, but they abandoned your discipline as a psychoanalyst. They abandoned the psychodynamic etiology of psychiatric illness. Then they abandoned Axis IV, and I think they had a 178 years of history of guilt and shame of APA with Benjamin Rush as their model. So I'm not analyzing you or APA. I think the entire focus on Axis IV is an expiation of guilt and shame that this organization has for 178 years, and more so 60, 70 years of abandonment of basic issues related to human psyche, discrimination, racial issues, and all that. And your graph is so illustrative, the timeline. The basic problem of man's inhumanity to man is the concept that some are chosen people and some are not. The chosen people have a right to discriminate and to put down the unchosen people. And I'm not talking about any particular religion. This is true all over the globe. The narcissistic approach of society and clans and clannishness is a herd mentality of the primitive people also. That primitive mind is still there in this most civilized people. And APA is not an exemption to that. That is the issue. And we can't do everything for everybody. But we have to recognize our limitations, and we are on the right path with what you are doing. So I say that you are the right chairperson, and you are the right person to correct these issues. Thank you very much. Please respond to this. So, Dr. Vinokur, you've said a lot, but let me say this. I'm thinking about Heather McGee's presentation this morning, and she did say something that really resonated with me, that you're talking about people who are chosen and people who are not. And she talked about, apparently she's a lawyer and an economist, and she talked about how our fundamental system started with an economic system where some people could be owned. And that's the basis of our system, our economic system here. And that's still being played out. So I think that everything has gotten organized around that, and I think there are ways that we try to distance ourselves from that. But I also think that with that fundamental paradigm, we also have these caste systems. And I think that we can do more work to acknowledge that. She also talked about how whites believe that everyone should have universal health care, affordable health care, should have equal rights. But then when those rights are offered to blacks and other people of color, they don't want them to be shared. And so I think that we need to do some work with that as well. I think about Jonathan Metzl's book, Dying of Whiteness, very powerful book, helps you to understand why people would undermine access to their own health care, their own needs, because they want to deprive somebody else. That's something that, and I think that psychiatry should talk about that. I think for us to ignore that and not help patients to understand what they're doing, and I don't think it's about having an agenda. When I see that a patient is struggling with a bias, I can gently be curious about that. There are patients that I have that never talk about race, because their marriage is so challenging. That's their focus. They're not going to talk about race. But when race comes up, I do express curiosity and I help them. There may be a patient wondering, what are blacks being called now? One patient referred to someone as an Afro-American. I'm like, well, sir, they're now African-Americans, and some of us refer to ourselves as black, but just helping him with nomenclature. But, Dr. Venekar, one thing you said that caught my attention, and you said a lot, but I think that we made a mistake. It wasn't just getting rid of the multiaxial system. When we decided that social determinants can be minimized, and that came out of my district branch, by the way. I remember when that was presented to the board, and I remember I also did not agree. And so what I can say that I feel good about is that we have, the pendulum went in that direction and we have self-corrected, and I do think we need to give ourselves credit for that. All right. So that was great. Thank you so much for your talk again, and yeah, we're done. We're good. Great.

Dr. Dunlap

psychoanalyst

guilt and shame

social determinants

mental health

APA assembly

DSM-5TR

equitable patient care

adverse childhood experiences

diverse patient populations