All right, I'd like to welcome everyone to our second component of our presentation representative of our APA Global Mental Health Curriculum Working Group. We have several members of our Global Mental Health Curriculum Working Group here today. We had the first part of our presentation yesterday with Kenneth Fung, Rick, and Victor Sanchez Pereira, and Barbara Kamholtz. And today we're having our second component where we'll be talking about perspectives on developing a global mental health curriculum, education, research, and policy. So we have no disclosures. The objectives of our talk today are to describe innovative approaches to integrating global mental health training into residency training programs, to recognize how global mental health training provides opportunities for bi-directional learning with applications within the U.S., to identify diverse perspectives regarding the development of novel training curriculum focused on global mental health. I just want to walk you through the agenda for today. First we'll be talking about, first we'll be kind of providing an overview of the APA resource document that was developed regarding the Global Mental Health Training Curriculum that will be led by Dr. Manal Khan, who was part of the initial program. We'll also be talking about a trainee-led initiative on developing a global mental health training program. Secondly we'll have Dr. James Griffith discussing the clinician-educator perspective on developing global mental health training program and curricula. And lastly we'll have Dr. Pamela Collins talking about the science policy perspective and the importance of prioritizing global mental health in public health. I'll start with some bios and then we'll get started. So I'm Siva Anam. I'm an associate professor at the University of Chicago and my background in global mental health starts with my complete dearth of lack of mental health global mental health training and cultural psychiatry training in my own psychiatry residency program. That drove me to kind of pursue this kind of training on my own during my residency training and fellowship program. I was fortunate to get connected with the SSPC or the Society for the Study of Culture and Psychiatry along with Kenneth Fung where I joined the education committee and subsequent to that started really kind of focusing some of my efforts in global mental health training and curricula development. What I found was that despite the fact that I had a very strong interest in this topic and this content area and I found other people who were residents and fellows who were similarly interested there was no availability of training curricula within our core curriculum. That led me to develop a pilot study and along with SSPC members in finding that were similar challenges faced by many of my colleagues and faculty that I admired. So that led me to kind of develop a more systematic needs assessment for global mental health and related residency and related training and residency training programs. And I just will provide a very cursory overview. This was a kind of systematic study of all residency training programs within the U.S. nationally representative generalizable sample. And what we really wanted to do is have a sense of an understanding of what is the scope of training on global mental health cultural psychiatry structural competency and social determinants of health within core curricula for all psychiatry residents within the U.S. And I limited to the U.S. only because the scope was too large and I wanted to be able to have something cohesive to say. And what we did was we tried to balance program by type by location region affiliation community based academic affiliated VA programs or military based programs are really a representative sample of all programs and all residents not just those who are particularly interested in global mental health or the related topics. And we also tried to have a balance of trainee representatives. And what we found was that the majority of residency training programs or residents who responded to the survey were not offered curricula training in global mental health. What we did find was that they were quite interested. So this again is not a sample of people who are particularly interested in global mental health. This is all residents. The majority of the trainees surveyed expressed having at least somewhat being somewhat interested or very interested. And equally importantly they all found the topic to be important. So they found it was very important to receive global mental health training within their residency training programs. And I just wanted to close out with a few quotes that were captured within the survey. One of the trainees said that all these factors meaning the four topics that we surveyed them on played a role in daily practice. Training in these areas was prudent to become a competent psychiatrist. The problem with another trainee participant shared the problem with GMH or global mental health track trainings and fellowships is that it suggests that certain people should specialize in these topics rather than every psychiatrist being competent in these areas across the board. And lastly I thought this was a particularly salient quote. This trainee shared that I would like to see curricula that explores how we can learn in the U.S. system from learnings from low and middle income countries. For example with regards to community based mental health care. And also change the narrative from here is what lower and middle income countries can learn from the U.S. to what can lower and middle income countries and the U.S. learn from each other. Which I thought was a really nice way to frame the rest of our talk today where we really want to focus on bidirectional exchange of ideas and bidirectional learning. So I thought we could start with some reflective prompts on global mental health education. After that, before each presenter, I'll be sharing their bios. So one of the thoughts that we, one of the questions that we had was what as a group do we think should be included as key learning objectives in global mental health curricula? Interactive, so please feel free to share. Yeah, so my question was when you talk about global mental health as an objective, how global do you want the health to be? How relevant is it going to be? Do you want eastern and western perspectives? Does it need to be relevant to the clients that you're treating? So just some more elaboration on that, thanks. Thoughts? From the group or from our panel? Would anyone like to share their thoughts on, I think other people had the same concerns or same questions? Who are we talking about when we're talking about global mental health, right? Yeah, absolutely. Yeah, I mean I might take one shot at it because I think as with a lot of words that we use all the time, like love and home, we mean many different things. One history which Dr. Collins could speak to really was the global mental health movement which came out of studies showing the impact of suffering, you know, with a mental ill plus the economic impact. I've got a slide with the 2007 Lancet series. So that was one history, but as it's come to be used, I know within the APA, it's in a much more generic sense, which I think is something we'll discuss here today. Do you want to? Yeah, I love this question about what are we talking about when we say global, and I think there are many different perspectives. Some people would say that global actually does not have to do with location but the scope of a problem. So if we find that, wow, everywhere in the world, there are challenges in getting people access to the mental health services they need, promoting mental health, maintaining mental health. We could say that that's a global issue, and for that reason, we need the bigger the community we have to address that, both at the perhaps the issue of global policy down to the very local needs that people have in their contexts, that's what I think of when I think of global mental health. It's how do we have a global community that is able to tackle the challenges, advocate for mental health, provide care when people need it, and sustain mental health in communities. So this has nothing to do with whether you're a high income country or a low income country. It's about addressing a global need that every country has. Please. I have a comment. Okay. Well, yesterday, during the presidential panel, the president mentioned that without Ukrainian crisis, we realize how much it's important to talk about the global mental health. I'm originally from Syria, and I've been involved in the Syrian crisis for the last 12 years, and I've been writing about the Syrian crisis for the last 12 years, and I've been a member of the global mental health for the last long time, and nobody, nobody talked about it. But then, and now, when I look into the Ukrainian crisis, which is important, I'm not downplaying it, it's very much, it's attracting all that attention. When the crisis in Syria, it's huge, it's half of the population is displaced, 1 million people have been killed, half a million tortured, 200,000 people are missing, and yet, zip. Nobody's talking about it. So I would like to know more about that. So that's a great kind of way to open up this conversation about who are we talking about when we're talking about global mental health, who are we thinking about when we think about forced displacement. So these are some of the topics that we wanted to address today and think about what should we be including in a curriculum, and who should we be referencing in our conversations. So please keep these thoughts in mind and keep percolating them, we'll move on to our next speaker, Dr. Khan. As she's coming up and setting herself up, I'll read her bio, so that we have the most time to save for discussion. So Dr. Manal Khan is an assistant professor of psychiatry at the University of California at UCLA. She received her medical education in Pakistan and she developed, she completed her residency training at the University of Washington, Seattle. She served as chief resident of recruitment and wellness. She graduated with an area of distinction in global mental health and cultural psychiatry, perinatal psychiatry, and advanced psychotherapy. She went on to do her fellowship in child and adolescent psychiatry at UCLA, where she served as the inaugural justice, equity, diversity, and inclusion chief. She currently serves as a co-chair of the IMG caucus at ACAP and is also the deputy representative of minority and underrepresented groups at the Southern California Psychiatry Society. Her areas of interest include cultural psychiatry, South Asian mental health, immigrant parenting, structural determinants of health, psychotherapy, and anti-war advocacy. Welcome Dr. Khan. So we'll talk more during the question and answer session, but anti-war advocacy is an area of interest and I would love to connect over that. So my name is Manal and I have been tasked to talk about my experience of developing global mental health and cultural psychiatry track as a trainee. However, before I do that, I want to share some parts of my personal story that might be relevant to this topic. I'm an international medical graduate and I came to the US in 2015 from Pakistan, where I grew up and received my medical education and completed house job. The two hospitals that I trained at in Pakistan were tertiary care public sector hospitals, one located in a major city and the other in a mid-sized city, both caring for underserved populations from an extended urban and rural area. During my training at these hospitals, I was directly exposed to the challenges associated with access to care in low middle resource country, where there is a dearth of physicians, healthcare workers, and healthcare settings. This also meant that we had to be creative in how we stretch that access, whether it entailed converting prayer areas in our wards to accommodate more patients and patient beds during a surge, to many providers sharing a desk and simultaneously seeing a large number of patients in the outpatient clinics. I also want to hold some space to acknowledge the moral injury one accumulates by working in a resource-limited setting, where you are tasked with delivering care without having access sometimes to basic life-saving medications and equipment, such as IV cannulas, and also the moral injury one accumulates when they choose to leave that setting to pursue, quote unquote, a better life in the US. So I currently serve as the Chair of Training and Mentorship Committee of Pakistani Psychiatric Organization in North America, and also chair the IMG Caucus at ACAP. Therefore, I come across many hopeful IMG applicants who dream of pursuing training in a high-resource country, where evidence-based medicine is practiced and novel treatments constantly emerge in a cutting-edge research milieu. I was such an applicant myself. One of my first homes in the US was Seattle. I had moved there with my husband while he interned at Amazon during his business school, and I studied for USMLE Step 2CK and did an observership in a clinic in Bothell. I vividly remember the shock I felt when I saw an unsheltered man in Seattle sift through trash can for food. It's not like that I had not seen poverty before, but in my naivety about the US, I could not reconcile how a high-resource country, the world's superpower, the beacon of human rights, a country that invaded mine and consistently chastised it for not upholding human rights, could let such a thing happen. How can dearth and excess exist simultaneously? How can a country have billionaires and also homelessness, food deserts, physician shortages, a healthcare system that is inaccessible for many, and a prison industrial complex where our patients are housed? The dialectics of it. Human suffering, especially human suffering in low-resource settings, is universal. Whether those settings are a product of colonization and resource pillaging, or classist and racist structures that manufactured dearth, and also is the opportunity to advocate for equitable access of care for everyone. This takes us to the definition of global mental health and the purpose of teaching it to psychiatry trainees. I'm quoting Dr. Pamela Collins here. I'm very lucky to share the podium with her. Global mental health is an evolving field of research and practice that aims to alleviate mental suffering through the prevention, care, and treatment of mental and substance use disorders, and to promote and sustain the mental health of individuals and communities around the world. Alleviate mental suffering of individuals and communities. Isn't that what psychiatry is all about? Then how did global mental health get siloed and packaged as something we do to those people in those countries? As Dr. Collins quoted right now, just before us, the global and global health refers to the scope of problems, not their location. Therefore, my position is that global mental health is relevant for psychiatry trainees in the U.S. because it encapsulates the principles of humanity, interconnectedness, advocacy, cultural humility, social determinants of health, structural competency, decolonial and liberatory practices, and equity. And with that, I will share my experience of developing the global mental health and cultural psychiatry pathway at U-Dub. U-Dub stands for University of Washington, Seattle. I joined U-Dub as a second year postgraduate trainee. When I came to the U-Dub, there were some career enrichment pathways and some interest groups. Cultural psychiatry was an interest group led by Jay Gandhi. I don't know how many people here know Jay Gandhi. When Jay was graduating, he asked me if I was interested in leading this group. I was. And I was also interested in elevating it to a career enrichment track. The interest groups were mostly loosely structured. They met after work hours, read papers assigned to them by the group lead, and then discussed the papers at their meetings. Also, the meetings were quarterly. By becoming a career enrichment track, we could pair with faculty, be allotted a slot during business meetings, during the direct afternoons, and have various faculty at U-Dub and through our connections in the community presented these meetings. Therefore, when Dr. Collins joined U-Dub, it represented a perfect opportunity to elevate our status to a career enrichment track. This entailed serving the residents about their interest in global mental health and cultural psychiatry and identifying gaps in our learning. As you can see, 80% of the respondents were interested in such a track, and 91.4% of respondents shared that they did not receive adequate training in global mental health and cultural psychiatry. We then presented the survey results at the resident education sharing committee, and after their approval, we were granted the status of a career enrichment track. There are many ways in which global mental health and cultural psychiatry are embedded in different psychiatry residency training programs across the country. These largely include educational programming, service opportunities, and opportunities for research. These program-specific opportunities can be supplemented by opportunities offered through psychiatric and other mental health organizations, such as participation in the global mental health caucuses and councils. This can also be followed by fellowships offered by some programs in global mental health. Regarding educational programming, they exist in the form of specialized grand rounds, journal clubs, entrust groups, specific lectures and presentations, career enrichment pathways, a dedicated block during didactics, a series of blocks across postgraduate training years, et cetera. Wherever you exist on this lateral to central continuum, the hope and the goal is to move it from peripheral position to being a central and core principle in how we approach mental health care. We need to embed the principles we talked about earlier, the principles of humanity, interconnectedness, advocacy, cultural humility, social determinants of health, structural competency, decolonial and liberatory practices, and equity in all of our educational programming. Also, by doing so, we open up a lot more opportunities which otherwise would not be considered global mental health. The hurdle of not having trained global mental health faculty is often cited as a barrier to teaching these principles, but as we have discussed earlier, if we can expand our conceptualization of global, we can partner with community psychiatrists, social workers, those who work in integrated behavioral health systems, those who specialize in trauma and ACEs, adverse childhood experiences, those who work with disenfranchised immigrant and minoritized populations in the U.S. to create a curriculum. Even with our career enrichment track, we saw overlap with our community and integrated and collaborative care tracks and had a couple of joint meetings. Regarding service, again, think about a continuum. There will be programs that will have established relationships with international institutions and hospitals and can participate in exchange. However, most programs do not have that. These opportunities for service, even in the absence of such, there are opportunities for service even in the absence of such partnerships. There are community clinics. There might be clinics for immigrant populations, for indigenous populations, for Spanish-speaking populations. There are opportunities through physicians for human rights, et cetera. Now with telepsychiatry as an avenue to increase access, there is a lot more that can be done with creativity. At UW, we had international, regional, and local opportunities for participants. Regarding research and scholarly activities, think about mentorship. It will be mutually beneficial to the mentor and the mentee to collaborate on topics of mutual interest and cultivate enduring professional relationships. Also set the bar low. If there are no K or research opportunities available, you can start with writing a paper together, presenting at a conference together, putting a lecture for didactics, any way in which scholarly activity can be facilitated. These were the things that we incorporated in our career enrichment track, and upon successful completion, the graduating residents received an area of distinction. I will be happy to chat more about our model with anyone who is interested. However, I do anticipate that some of you might have questions about the operations of the track. We had a task force that oversaw the operations of the track. The task force consisted of faculty and trainees from different years. It was also important to identify trainees across the years to create a pipeline for trainee leadership of the track. We had monthly didactic meetings during a dedicated time that was reserved for pathway meetings. We also offered, as discussed previously, opportunities for service, research, and scholarly work to entrusted participants. For setting the curriculum of our didactic meetings, we did a broad search of topics that are taught under the umbrella of global mental health and cultural psychiatry. We identified 22 such topics for global mental health and 24 topics for cultural psychiatry. We then distilled them down to eight topics, one per month. This meant that we had eight months' worth of educational programming identified. Then we had to find people who could teach us. Between our faculty and their connections, we were able to identify the speakers. I'm guessing with Zoom and other online platforms, this will now become much easier. International speakers within and outside psychiatry can be invited. We reserved three meetings for experiential learning and for trainee presentations. We anticipated that there won't be a meeting in the month of December due to holidays. Some of the lessons that we learned along the way. Trainees are more likely to show up if you reserve a room right next to the room that they were previously in. If there are too many pathway meetings at the same time, it creates the conflict of competing in trusts for trainees. It is important to ensure that the topics and presenters draw trainees in, make things relevant for them. However, if you look closely, all of these challenges highlight the issues we try to address in global mental health. Access, priorities, and resonance. When I was working on this pathway, I was also serving as the APA's diversity leadership fellow on the Council of International Psychiatry, which was developing a resource guide on developing global mental health curriculum for psychiatry residency programs. The resource document can be found on APA's website. Can be found on their website. Go to their page on global mental health, scroll down, you will see a tab, and click on this tab. The resource document will highlight some of the points we have already talked about today, provide some select readings, share models of how different programs in the U.S. approach global mental health, and propose some topics for consideration when designing curriculum. If you are program leadership or trainees who are interested in bringing global mental health education to your program, this resource can be a great place to start. Even though I have not pursued a career in global mental health per se, I carry the teachings with me as a clinician and as an educator. I am cognizant of the hierarchy that exists in a physician-patient relationship, and therefore feel strongly about not doing something to the patient, but being with them and feeling with them. Therein, bringing a de-colonial lens to my practice, I have also tried to take my education back to my country of origin, where there is a severe shortage of child psychiatrists by participating in teaching activities for primary care physicians. And with that, I think I'm almost out of time. I'll chat with you folks more during the Q&A session. Thank you so much. Thank you, Dr. Griffith. Thank you. Thank you. I know I'd like to. James Griffith is a professor of psychiatry and neurology at the George Washington University School of Medicine and Health Sciences. He served as the Leon Yockelson professor and chair of the department from 2011 to 2021. As a psychiatric educator, Dr. Griffith developed psychiatric training at George Washington University, distinguished for its curriculum in cultural psychiatry, global mental health, psychotherapy, psychosocial care for medically ill patients, and building resiliency to adversity. He's published extensively on his clinical research, including The Body Speaks, Religion That Heals, Religions That Harm, addressing the destructive uses of religion and ideology in clinical settings, and he's received the Creative Scholarship Award from the SSPC. He's provided psychiatric care for immigrants, refugees, and survivors of political torture at Northern Virginia Family Services and Falls Church VA. He has received the Human Rights Community Award from the UN, Association of the National Capital Area, and the Margaret B. and Cyril A. Schulman Distinguished Service Award from George Washington University Medical Center for both the training of mental health professionals and the development of mental health services for survivors of political torture in the Washington metropolitan area. As an educator, Dr. Griffith has received the Distinguished Teacher Award from the George Washington University School of Medicine and Health Sciences. He was selected by the Washington Psychiatric Society as its 2003 Psychiatrist of the Year, and for its 2014 Distinguished Service Award. He was the 2017 recipient of the Oscar Pfister Award from the APA for his contributions to the field of religion and psychiatry, and has been selected by Washingtonian Magazine as a top doctor in Washington. Welcome, Dr. Griffith. Thank you. Yeah, I'm gonna be speaking from the perspective of an educator. Two decades, I directed program director for residency for a decade, chair in a department where our main thing we focused on is education and global mental health was sort of our signature. I'm gonna talk for 20 minutes and then stop, because we want to stay with time for discussion. I will say, I never spent much time trying to think about what did we mean by global mental health so much as what we did. I never intended to develop a program in global mental health. What I wanted to do early in my career was to develop a psychiatry that would be useful and usable by people, regardless of what culture they were in, how much education, whatever may be other markers. And I think what I had in mind, thinking about this, preparing for today, was four or five generations of dirt farmers who were my forebears. I grew up in a part of the country where going to see a psychiatrist would be the reason you would commit suicide, not the place you would go after you tried and failed. In 1999, as the fighting in Kosovo had just ended, and we were there out in the villages interviewing families, all the male members, grandfathers, grandsons, all shot, killed, put in mass graves, the women hurried down the road to Macedonia. And we were at a farmhouse, and it had been a long drive, we were about to go back to Pristina, and realized we really needed to go to the restroom. It was very awkward, but we asked, and they showed us the outhouse out in the middle of the backyard. So we trunked through the mud and the manure and the chickens and the sheep and the cows, and I realized I'm back home. This was my grandmother's home before they had running water. And that has been my connection. Poverty and political oppression look a lot the same wherever you are. So for myself, it was not grounded in studies, it really was grounded in wanting to create a psychiatry that would be usable wherever you are, whoever you are. And so another piece that took it, I've been talking some about our program at George Washington, and somebody mentioned this, and I'm glad that you did. We mostly felt like all of this needed to be embedded for all the residents. So being in the track means that you come to meetings if we have them, and you do a special project that's worth publication. But for the most part, everything that we do, all the residents get. Meaning that we just have a very humanistic, people suffer, disorders have symptoms, we treat symptoms and remission in the interest of relieving suffering. But we've got skill sets that are very effective for many forms of human suffering that don't have to do with treating psychiatric disease. So what I'm gonna do, we've kind of jumped into the discussion a little bit, so I'm gonna just not spend time with that, but to go right here. I can tell you, for all these years, you know, if I talk to program directors of the programs, they have three questions. We have no faculty, we have no space in the curriculum, we have no money to be sending residents to another country. So I thought I'd organize what I talk about kind of around those three questions, but also bring into it some of the things that already have been referred to that have changed as global mental health has matured as a discipline, because it's in a very different place now than it was 2007. One of the biggest ones, and thank COVID too, Zoom, teleconferencing. One of the biggest complaints is time away from work, no money for travel, and this doesn't eliminate all of it, but it certainly has expanded the scope of what's possible. So as Dr. Collins said, remote no longer means physical distance. A bigger impact has been also alluded to, which is that inequities between populations within countries can be as great or greater than those between countries. So it's not just a matter of finding a low middle income country to go to to do global mental health. This can really be illustrated by Appalachia. We have a small project which got stymied by COVID, we're trying to get it restarted. APA sponsors it out of the Office of Diversity Health Equity. Dr. Larry Merkel at UVA kind of heads it, has about six of our departments in it. But if you look at Appalachia, this goes from New York down to Mississippi, 13 states right down the spine of the Appalachian Mountains. In every state, except my home state of Mississippi, if you're in the Appalachian part of the state compared to the non-Appalachian part, you've got a much higher mortality rate due to the diseases of despair. And it's just a very striking example of that these are gaps within the U.S. So where can you find a global mental health population to work with? Near home. For us, it always was our refugees. I still have this USA Today, it had a picture of Annandale High School on it near where I live, 186 countries, 100 languages. It went on to say that at this time, it's changed, there were five school districts in the U.S. with over 100 languages, four were in the Washington area. So we looked at this and said, this is our population. And we also knew within that population, there were probably around 40,000 people who had been politically tortured. So focus on refugees, focus on recovery from torture, came to be our focus. But one thing that I think teleconferencing and the appreciation that these are not localized problems to low income countries, is that it helped to see more clearly a couple of other things, which I'm gonna spend a little bit of time with, because I think this is still, as we said, remote doesn't mean far away, it's not physical distance. But many of the people we're working with are still remote, but they're remote for a different reason. It has to do with gaps in culture, language, social exclusion due to political, socioeconomic events. And our technology makes it worse because it makes these groups invisible, you don't see them. Ivan Illich back in the 1960s was calling alarm about this, about the interstate system. Interstate highways being built where you could go flying through the slums of New York 70 miles an hour, you don't see anything. And we have getting communities now, technology with digital technology is also creating zones where people simply don't exist because they're off the grid. But it's also the case that these people are aware of it and they know what's going on. And that makes it a particular problem when if we do come and we've got good intention, we've got resources, we wanna be helpful. After our Kosovo project came to a much far more successful conclusion than I ever imagined it could, we tried to bring it back to the district. Ward seven and eight, the other side of Anacostia, 100,000 people without a major medical center that's really functional. And I remember very clearly going over there and I remember setting up psychiatry in the primary care clinics and people asked, why are you here? Are you gonna do experiments on us? Now I immediately made the association to Tuskegee except I thought this had been old history. And it's clear that that's the first question that they had. Which we over time developed a relationship with. But this is something that we have not seen so clearly, at least in my experience from the early days of global mental health where we've got compassion, we've got goodwill, we've got resources, we will come in and we will help. But people, in Kosovo our colleagues there called it the NGO caravan. They realized that they were sort of the crisis of the month and the NGOs would be on to another. So, our late Carl Bell explained that was in the African American community, you don't do business with people that you don't trust. And where there's been a history of betrayal, exploitation, neglect by the dominant culture, histories of colonization, slavery, extraction of natural resources as an appellation, you gather them more than simply come with goodwill, knowledge, skills and material. So this is what I think is a real cutting edge is, how do we respond to people in a way who need what we have and to find it welcome? And I'm just gonna put up here, I think the missing piece if you only look at population, we do population studies, we can see what the needs are, we've got an idea of what to do, but we don't start with a relationship. And so I think the big focus, and this is something we've really been trying to bring it into our residency training, is that, and again I'll go back to Carl. Carl Bell went to Meharry African American Medical School, trained in psychiatry at UIC in Chicago, mainly of white. He said the difference between the black and white healthcare systems is that in the white, it's more of a business transaction. We've got skills, you pay some money, you get the skills, we're done. Whereas in the African American community, you create a relationship, there'll be some act of healing, the relationship continues, you think about this as an investment in the person's life and in the community. And that's really the sense that I think we're trying to bring back, I think there's a real cutting edge on engagement that easily gets missed because certainly I am in most touch with the fact that I actually have empathy and I do have compassion and I do have goodwill. So I trust me, that doesn't mean trust comes automatically from the other. And a couple of things which I'll just mention, you know what, I put my clock up here and then didn't start it, sorry, okay. Is, okay, just two words, honor struggle. Focusing on a resilience perspective does two things. One, if you've got high demands, few resources, it's almost always a smart thing to do to shift to a resilience perspective, get clear about strengths, build on strengths that people have. However, this is also an effective way to respond to the skepticism when people have been stigmatized. Learn about the unique history, the physical setting of the people, psychiatry of places, I often think about it. I come in, see somebody at bedside in the hospital before ever getting to any other discussion to talk about, you know, where do you live? How long have you been there? And to honor people's struggles and with our residents to value your role as a physician and being a moral witness to what their lives have been through, because I think people watch how we respond to their stories. And I have one resident who was doing a brief psychotherapy supervision with someone who was a refugee, who said, I'm really doing a moral witness therapy, I've never heard that described. But that's really much of what he spent his time doing. Okay, so I'm sort of talking around about what skill sets the Council on International Psychiatry and the Governmental Health Caucus are putting together, a lot of resources, I'm not gonna, what I'm gonna do mainly is make a couple of points about just a little bit on how to think about what you put into a curriculum. You probably recognize the WHO pyramid. You know, at the bottom, you do a lot of psychoeducation, halfway up, you do a lot of task-shifting, task-sharing to expand access. There's always up at the top a little space there for some psychiatry, but we've had very little discussion about what that should be. And it would make the case that as laid out in the ACGME, everything there is good, but there are things that need some shifting. So we published this article in Academic Psychiatry that took the approach from cultural psychiatry, we know a good bit about what traditional societies, you know, their practices. One of the biggest ones is, my first trip to the US, I was in the United States, is my first trip to Kosovo, I often believe it, who the chair of neurology sat me down and said, you need to realize, in Kosovo, a person is not an individual, they're a family member. And I came to understand what that meant over the years there. In the family, two sons would be in the fields with their father, there'd be two in Germany making money, sending it back, the youngest might be in university, but everything is for the sake of the family. And we teach very little in American psychiatry about how to engage families, not to do family therapy, but really for the family to be the unit of treatment. Point two, distinguishing distress from disorder. We do a awful job, I think, in terms of distinguishing normal syndrome to distress, leading with demoralization, grief, loss of dignity, that aren't mental illnesses, nor do they respond to antidepressants. I think some of this is an artifact of our reimbursement system. To get paid, you need to put down. Ethnopharmacology, I give exams. I teach 30 psychopharmacology lectures a year to our PGY2s. On their exams, there'll be questions. I've been told there's more Ethiopians in the Washington area than in any city other than Addis Ababa. So a question will be around, your patient's not responding to antidepressant, not responding, not showing side effects. 30% of Ethiopians are super metabolizers. Most aren't, but that's a high rate. And so you need to know things like that if that's your population. But thinking about human rights advocate is just a routine part of what you're gonna do. You have to do that. And collaboration, here there's no time to elaborate this, really, but community-based participatory research puts it into the research framework that every step of the way, you create a relationship first. You create a relationship and then discuss what might be questions that need to be answered or addressed. And I know in Kosovo, we made it a rule that every workshop, it was American, Kosovo, American, Kosovo, every publication was that way. If we had money, we split it that way. And when we finished with the project, there was a meeting, it was handed over to the Ministry of Health, mandated care, it's drunk grown, fourfold, family psychoeducation for patients with schizophrenia. And I even got a call from our intelligence services before the last Iraq war, could I come and talk about the successful handoff? How was it we did something in the country? It flourished, we left, and it grew. But I think it was all embedded in prioritizing and starting with relationships first. Getting to know each other's kids. And this may kind of wrap me up, you won't be able to read this, but you don't really need to. If there's up there a dozen different skill sets, and the point I want to make is the top 10 are all embedded in other seminars. Like the ethno-pharmacology, that's just added to pharmacology. There are some seminars that we have that you could say these are global mental health, but we would want to do them anyway. I teach a seminar on assessing stigma, expect residents to learn how to do an assessment, formulation, and intervention. Around the world I would say that when people meet hard adversities, they turn to relationships, and they turn to their personal spirituality of some sort. So learning how to work with access patient spirituality from a secular perspective. And the thing that I think has been most successful has been, we'll call it hope modules, it's the only thing I've ever developed over the years where it had sort of legs of their own, that senior residents started teaching it to junior, they started doing it out in outpatient settings, but it's a, technically it would be a point of contact, trans-diagnostic, purely resilience building, the expectation a resident in 20 minutes should be able to talk with a patient, get a sense about their best competency for staying in a posture of hope, facing adversities, and then to build on it. So I'd better stop, because I'll be in Dr. Collins' time. Thank you. And we'd like to welcome Dr. Collins. Dr. Pamela Y. Collins is the Professor of Psychiatry and Behavioral Sciences and of Global Health at the University of Washington. She is the Executive Director of the International Training and Education Center for Health, ITEC, a global health implementing center that supports health system strengthening in the Caribbean, Eastern Europe, Africa, and Asia. Dr. Collins also leads the UW Consortium for Global Mental Health, a research center dedicated to improving the care of health, the care of people with mental health conditions in low resource settings locally and globally. Prior to her current role, she was the Associate Director for Special Populations at the NIMH and Director of the Office for Research on Disparities in Global Mental Health and the Office of Rural Mental Health Research. Her leadership led to the launch of research initiatives to extend mental health services globally and to reduce mental health disparities within the United States. Welcome, Dr. Collins. Thank you so much, and what a great panel to be a part of. I feel privileged to be with this group. So I'm going to start with two stories as well. First, my own introduction. So I'm, as Dr. Anam said, Pamela Collins. I was born in the deep south, the United States, towards the end of the Civil Rights Movement. Grew up in a setting where race was a dominant part of my identity, my ethnicity, my race, my cultural environment. Lived in many parts of the United States. And by the time I went to medical school, entered medical school knowing that I wanted to train in psychiatry and also knowing that I wanted to do cultural psychiatry and I wanted an international focus. And that international focus had to do with a real curiosity and a desire to know about frameworks outside of those I was surrounded by. So understanding what are other approaches to thinking about mental health and well-being outside of European or North American approaches. And became committed to the idea of understanding culturally congruent forms of care and interested in learning how to create more of that. My first global mental health experience actually occurred in southern Argentina, in Patagonia. And I was invited along with my mentor by a community psychiatrist there to see the work that they were doing. And that really expanded my vision of what community psychiatry is because they, this team was involved and they engaged with primary care doctors, they engaged with teachers, with judges, with the police, with the insurance companies, with the artists in the community. I mean they saw a role for everyone to be involved in both the care of people with mental health problems as well as advocacy around those issues. And from that experience many others occurred and I'll say a little bit about that later. The second experience which we talked about as we were all thinking about this particular session, the second experience occurred for me on December 31st, 1999. And I don't know what all of you were doing but one of the things that was happening that day which was the last day of the millennium was you could see all of these celebrations of the new year from around the world. If you were watching television in the United States, and I lived on the east coast at that time, from early in the day you're watching Australia bring in the new year and then, you know, went on and on and on until it got closer to us. But I remember sometime in the evening, like around 6 p.m. in the evening, there was a newscaster standing in the dark, you know. Every other image had been of lights, fireworks, da-da-da-da-da, right? And this person was standing in the dark. There was not really much sound behind and you could see when the cameras showed the light, they were, the light was shown on tents. And this was a refugee camp. And it was striking that this is an occasion where the entire earth is actually lit up because people are ringing in the new millennium. And this place was dark. And it was dark because it was not included in this celebration. And that image stood in my mind in terms of thinking about, okay, who's not invited to the celebration? Who's not invited to the party? Who's not invited to the table when we think about mental health care and what constitutes a healthy community? And in our case, a healthy global community, right? Who's not invited? Who's not included? So a lot of my thinking around global mental health, I think, comes from those, my own personal experience, but also observing this, I think, getting very, being very enchanted and maybe excited about the idea of a global community and what a global community can do and what is the power of actual inclusion of a global community to change things. So with that, I'm going to start with things that I think psychiatry residents should know about. And let's, what is our current situation with respect to the major causes of health loss around the globe? So this is showing us from 1990 the proportion of healthy years of life lost due to noncommunicable diseases. And you can see that the darker the blue, the more that particular country has noncommunicable diseases as the reason for loss of healthy years. And those mental disorders are included in noncommunicable diseases. And the paler the country is, those are countries where maternal mortality, infectious diseases tend to dominate in terms of years of healthy life lost. And these are data from the Global Burden of Disease Study. In the intervening years, we have seen that health loss has shifted significantly towards a growing burden of noncommunicable diseases and away from communicable maternal, neonatal, and nutritional diseases. So that's been a rapid shift over the last 30 years such that today, much more of the world is in this dark blue. And even those countries that are paler yellow and green, they're experiencing multiple shifts at the same time. They still may be experiencing the communicable diseases, but they're also experiencing the noncommunicable disease, the growth in that, including mental disorders. So if you look at the summary of what we know from the most recent Global Burden of Disease Study, disability is now the main driver of global disease burden and mental and substance use disorders as a group are leading causes of disability around the world. Depression remains among the top 10 most important drivers of burden since 1990. HIV is also among the top 10 important drivers. I say this is important because as we know, depression, anxiety, mental health conditions co-occur with these other conditions, right, whether they are communicable or noncommunicable. Deaths due to drug use disorders rose sharply over the past decade. In fact, more than half of those overdoses happened in the United States. Also, increased death from violence in Latin American countries has been a particular risk or a particular event in the last decade and certainly the last 30 years. And this just reminds us that social adversity also drives morbidity and mortality. And all of these, I believe, are part of the purview of global mental health. And these are things that are worth understanding. How do we respond to these? Global mental health operates within a larger global health system. And that system, as many would describe, includes setting an agenda. You know, countries set agendas. Health departments set agendas. You allocate resources according to that agenda. You research and develop new ideas. You then implement and deliver services. You monitor and evaluate and then you learn from what you've done. And that cycle then continues. In the context of global mental health, the grand challenges in global mental health was one of the agenda-setting activities. The more recent Lancet Commission on Global Mental Health and Sustainable Development was another agenda-setting ideas. And these agenda-setting ideas have actually generated the allocation of resources in many cases. But what I want to focus on today is the idea of research and developing new ideas. And what does that mean for residency training? What are the opportunities for residents to engage in global mental health in this way? So one of the takeaways from some of these priority-setting activities has been that these are some of the, I won't say that these are the, but these are some of the primary goals of global mental health research. To understand how best to reduce the treatment gap for mental disorders, but also to reduce the care gap, right? How do you develop and implement the best treatment interventions, the best psychosocial interventions, manage the co-occurring medical problems for people? And how do we reduce the prevention gap, right? That's a huge one. How do we do a better job of preventing the conditions that lead to mental health problems? And I'll talk a bit about reducing the care gap. I think this is where certainly a lot of the funding goes right now, and therefore a lot of the attention has been focused on that. I mentioned my earliest experience in kind of being introduced to global mental health, but my next experience was really about research, and that research experience happened in the United States and simultaneously, primarily in sub-Saharan Africa. And that started by focusing, recognizing the need to pay attention to HIV risk among people with serious mental illness in New York City, and recognizing the vulnerabilities among women in particular, recognizing that this required understanding the influence of stigma and other intersecting stigma and contextual risk factors on women's vulnerability and their relationships. That work led me to collaborating with the Department of Health in South Africa and the Mental Health Directorate specifically around HIV and mental health. And later, after HIV treatments became available, both obviously in our country and beyond, this led to collaboration around psychosocial needs and mental health of people living with HIV in New York City, Zambia, Uganda, and Rwanda. And this is where my research career began, coming out of residency, doing a post-residency fellowship, and then transitioning into faculty. And I will be honest to say that at the time that I was doing this, in the mid-90s, mid-to-late-90s, there really wasn't funding for mental health. There was HIV funding, however, and I think a lot of people with an interest in mental health got funded through HIV-related research, and of course, that was and remains an incredibly pressing global public health issue. But still, you couldn't just go and study and be supported to do mental health research in many places. So that was one of my experiences. The second experience, though, I had the unusual experience of being recruited to the National Institutes of Health and leading the office at NIMH that was responsible for mental health disparities research in the U.S., as well as global mental health research. And in that capacity was able to launch a set of opportunities, research opportunities, over the course of the time that I was there that helped us to both listen to what people were identifying as priorities and then invest in those. And I would say the advantages or I think the approach that we took was, well, a few things. One was we had the opportunity to fund institutions in Latin America, Sub-Saharan Africa, Asia directly. You don't have to fund a U.S. institution through NIH. Actually, foreign institutions can be funded directly. To fund those institutions directly, we started with an initiative that we called Collaborative Hubs, in which we funded an institution. We asked them to identify partner institutions in their region and make a commitment to providing research capacity building for partner institutions in the region. We required that people were showing that they had a relationship with Ministry of Health or someone who would be able to sustain the work once it was completed, of course, if they found efficacy in what they did. And we asked people to ensure that they had end users of the research. So the views of service users, clinicians, all needed to be demonstrated in the application that this was going to be research that was informed by people who would sustain it, as well as informed by people who would actually utilize the work. So this hub model was one of our approaches to both building capacity for research, but also answering some key questions around, what are the best ways to deliver mental health care in very diverse settings? How do you utilize the resources in a particular setting to extend mental health care, as well? So that was my other immersive experience. Out of that work at NIMH, we defined a set of, I would say, I guess I would call these sort of points that we recognized could help research that was focused on addressing the global mental health treatment gap. So first, recognizing that the two-part goal of global mental health research must be to advance globally relevant science while also meeting local needs. That equity, as has been mentioned before, is critical in all aspects of global mental health research. That a diversity of researchers, study participants, environmental contexts, research investments, enriches research into the root causes of mental illnesses as well, and in how to prevent and treat them. That engaging policymakers and providers early and often facilitates the uptake of research findings and can facilitate the sustainability of innovation. Fostering research partnerships and regional networks facilitate multidirectional learning. Pilot studies and locally relevant data pave the way for more sustainable innovation. That there can be a tension between services and research in low-resource and conflict-affected settings that has to be explicitly addressed. And global mental health research must improve local public health. And this is also challenging in the context of funding that comes from a different country, right? We became very enthusiastic about the idea of bidirectional or multidirectional. I would say multidirectional learning. That, in fact, I think that this is a skill that should be a part of a global mental health curriculum. How do you learn? What does it take to translate what you've learned in one setting to another setting? What does it take to observe something that's happening in your setting that looks like it works? How do you go from that kind of practice-based knowledge or even community knowledge to an intervention that can be more widely utilized for the community, right? How does that happen? More widely utilized, sustained, and tweaked in the ways that it needs to be. So I think these are skills that we need to include when we think about training in global mental health. Equity, as I mentioned, is a key issue in global mental health. These are data from the most recent WHO Mental Health Atlas. Just showing number one, if you look at the y-axis, this is the percentage of mental health research output with respect to the total research output. So first, just note that 8.2% of total research output, this is from in Europe, is mental health research. That's not a lot. So mental health research is not amongst the largest body of research that's funded globally. But of course, you can also see that there are considerable differences across regions. These are WHO regions, so Afro region, the Americas region, the Eastern Mediterranean region, the European region, the South and East Asia region, and then the Western Pacific region. So we have a ways to go, both to increase, I think to stimulate support for global mental health research, but also to ensure that this is happening equitably. So that said, I think NIH has actually been a wonderful ally for enabling training opportunities in mental health for people who are both from the US, but also particularly from countries designated as lower middle income. And if you are a trainee in the US who's looking to say, how could I actually develop a research career pathway? Well, there are opportunities that start with both for medical students as well as residents, so pre- and post-doctoral opportunities through the Global Health Fellows Program, which is an institutional training grant, a T32, that Fogarty International Center sponsors. The picture in the corner is just of one of those grants that represents what's called a Northern Pacific group. It's a set of universities. You can see there's UW, the W, Michigan, Indiana University, and I can't see what the green one in the middle is. If you know your university symbols, you can discern what that is. But anyway, this allows people a year to spend working on a project in one of the priority countries that these groups are collaborating with. Career Development Awards, or K awards, are usually for folks in the early career stage of faculty positions. And then, of course, Research Project Grants are grants that anyone at any stage who has enough experience can apply for. But the same opportunities exist for trainees from countries that are designated lower middle income. Post-doctoral training through the Global Health Fellows Program can be a step in. The Emerging Global Leaders K Award, and then other Research Project Grants through NIMH or other institutes at NIH. And I want to highlight that Welcome Trust and other funders are also directly funding opportunities for research training. This is the AMARI program, the African Mental Health Research Initiative, that has been through several iterations now that is successfully training a wonderful group of researchers across multiple countries in sub-Saharan Africa. The other piece of our training, what we do now, has to, I think, engage in the conversation around power and equity in global health, in global mental health specifically. Understanding how are resources allocated? Who has the power to make these decisions? Who gives them that power? Who backs up that power? Who decides? And how does one negotiate the kinds of power to be shared when one is working with others? So all topics, I think, for all of us to engage with and to continue to navigate as we move through our careers. Thank you. Thank you to our wonderful panel who has given us a lot to think about and discuss. And I know that we don't want to waste too much time because we want to get right into conversations and discussion. So we've got about 15 minutes to engage in kind of open discussion about any of the points that were brought up from our audience, kind of picking up the conversation that we had started about global mental health and who are we talking about when we talk about global mental health or any of the points of discussion that were kind of fostered along the wonderful talks that we've had. So with that, I'd like to open it up to the group. And I also have a phone. Dr. Collins, this might be your phone. Oh, please. And if you wouldn't mind, please come up to the microphone so that if we have questions that are streaming, they can hear. Can you hear me? Okay. Hi, I'm Bhumika Shah. I'm like a psychiatry resident at University of Louisville. I think that was a really great discussion, very insightful. I think kind of the starting off with the statistics of which programs actually have global mental health information and tracks, that was pretty eye-opening and to see how many people are actually interested in it and the division between that was really interesting. I had a question regarding, I know we did briefly go through it, but what were the qualities required? I think you briefly skimmed through it, Dr. Fairfith, about psychiatrists in global mental health. I would like to hear a little bit more about that. Thank you. When you said what qualities, can you just elaborate a little bit? Oh, skill sets. Skill sets. Yes. Oh, I can answer it different ways. I often have said that I think a consultation liaison fellowship is about the best preparation you could get. There's a lot of overlap with community psychiatry in terms of the collections of skills. I think one thing that's clear is that as we go forward, psychiatrists are gonna be spending a lot more time teaching, supervising, being available for complex cases. Versus carrying the weight for the direct provision of care. And I think that varies across residences as to how well. Some I think very well and others probably not at all. I would say it is very important to learn how to pick up patients' and families' strengths. You know, this is sort of my resilience. I don't mean that you go through horrible things and you're not affected by it. I mean, thinking about resilience in terms is learnable. Having to do with skill. But being able to do that kind of assessment, which you spend a lot of time with. I think it's important to learn how to separate. I use the term normal syndromes of distress or idioms of distress, grief, demoralization. They have ways of being effectively cared for, but it's not a different version of depression treatment. But how to distinguish. These are some that come right to the top, you know, right, that I would think about. Others? My name's Carl Goodkin and I've had the pleasure of working with Dr. Griffith before in the past. My interest area is HIV psychiatry. Apropos of Dr. Collins suggesting that HIV and depression are both very important aspects of the global mental health agenda. And I just wanted to give a little bit of my experience related to this since I started working with HIV in the early days before combination antiretroviral therapy was available. And what I found was that when I was doing a study at Bereavement in the University of Miami, that I needed to reach out to the groups that were interested. That again, as was indicated in Dr. Griffith's talk, good intentions does not necessarily imbue trust. And so the populations that I was interested in, I needed to go out and meet with them. I needed to go to Florida Memorial University, predominantly African American institution. I needed to go to La Liga Contra El Sida and be there and work with the community leaders there to build trust, to get participants to come into a study like that. Over the years as HIV started to become better treated with combination antiretroviral therapy, the movement generally was to try to expand this great knowledge that we had in the high income countries to the rest of the world. And so the AIDS Clinical Trials Group Network, for example, which I'm a part of, was becoming globalized and had sites all over the world, which it does today. And I have worked in a number of different countries, the Netherlands, India, South Africa, Argentina, and Brazil. But what I found at each of these places is the same, that going there wasn't the issue, that making effective strategies to partner was the issue. Yes, physical distance is associated with greater difficulty of providing access to care, but the real important part is mental distance. And you can have mental distance right here in the US. And I have experienced that with my work in Northeast Tennessee in Appalachia that Dr. Griffith was talking about working with HIV and depression there, as well as now in the Rio Grande Valley, where we have the lowest mental health care accessibility generally in the US, and HIV is on the rise. So I wanna say that my takeaway from this is that what's really important is trying to look at global mental health from the point of view of decreasing mental distance, be the place far away or nearby, and trying to develop effective partnering strategies to do that. I just wondered what the thoughts of the panel might be. Well, I would say your thoughts are pretty close to my thoughts. And I would say Dr. Goodwin was doing telehealth into rural Appalachia before there was Zoom. Oh. Yeah, I also agree with that. I think learning how to collaborate is important regardless of where your collaborators are. So those, and yeah, those are skills that people need to learn, right? They're not, those aren't just intuitive necessarily. I don't like to ask questions usually, but I work in the climate and mental health space, and we've been sort of tasked recently by the UN with developing this thing called COP Squared, which would be a global initiative with, in North America and South American hub that would provide psychological support, psychological resilience to communities going through this chronic toxic stress of climate change. And it just seems like a really natural overlap with this panel. And so I was curious how you guys would think about developing a kind of global mental health program to climate effects, and if that's something that's on your radars at all. One of the slides I didn't get to had Dr. Emily Schutzenhofer's photo up there. She just did her master's, 50-page master's thesis on a piece of Dr. Brandon Court's work in New York City. But she was also on your symposium. She was, yeah. And yeah, and she thinks about her future as global public health. And much of that she thinks about in terms of climate change implications. It will be a big continuing driver of migration and poverty. I'm actually, for those of you who are part of training programs, is there a climate element to your training program now? Is climate health included at all in psychiatry training? No. We're trying to develop a curriculum that people can use several hours. Okay, now that's great. That's great to know. And how have you guys done things like, initiatives where things can be given to everybody in a community? Like what are sort of the mechanisms for that? Some sort of health intervention can be distributed in that way. So yeah, thanks. Thank you. Hi, thank you to put this symposium on. I'm Raymond Tempier, I'm from Ottawa in Canada. And I'm very interested by global mental health, especially French-speaking African countries. I went about in March in Benin because we have a program from the University of Ottawa and the University of Cotonou in Benin to exchange students, researcher, and on and on. Unfortunately, because Canada is a bit of a closed country, we cannot bring in researchers as well as students from Benin. However, when we are there, we are welcome. And I understand that African countries want to get the knowledge from us, which is fine. But also when we go with especially residents and students, they understand what is Africa. And Africa has a lot to give in terms of cultural issues also how they manage their problems and how they're in certain way, they are sometimes poor, but the quality of life I think is much better than us. There is no isolation in Africa. Family is very important and on and on. And by the way, it's important also to understand that when we are in Africa, we are the visible minority. It's not them, it's us. So you understand what does it mean to be a visible minority in a country anyway. I could go on and on about these experiences. And the only thing I would like to ask you, how do you promote among us, among our students, our residents going to Africa, going to Latin America, going to other countries? Because the feeling I have, the young generation is not very interested. However, in Ottawa and I guess in your cities too, we have a lot of immigrants. We have a lot of people coming from this country and there are some bicultural and bilingual, by the way. So, and when they feel sick, they get back to their own culture, which means that we have to be very culturally sensitive. But if we don't go there, we don't understand why they do things. I can give you a last anecdote. If an African patient come from a country, an immigrant and so on, he would come with a sister, with mother, with his father, who is not his biological sister, but she is from the same ethnic background and on and on. So if you don't understand this, you miss the boat. No, I think what I would say in our program, and this may be very different than a lot of the others, is I don't ever start with what I hope the resident would do. It's much more of a process of trying to get clear about, you know, what is your life about? What really matters? And to provide resources and guidance, so that, you know, I've had residents that really just made it a special expertise just in working with political asylees. We did have a resident who went to Nigeria to do a needs assessment in one of the regions that basically had, so we've done many different things, but it always has come from the resident. So I don't really have a, there's so many needs in so many places. I personally try not to bring my image too much to what they do. Yeah, I would say that we don't try to promote people going overseas either, because I think global mental health is much broader than having to leave the country to do something. And so, yeah, that's not something we necessarily promote, but some people are looking for those kinds of experiences, and we do have a lot of partnerships with institutions. I also think, though, that I know, you know, I know Canada's had a lot of struggles with visa issues or enabling people, but I think that's actually a really important thing to fight, right? So that it's not just you sending people over and your colleagues from the other institution can't come to your institution, because then it's not really, you know, it's not really a partnership in the same way. So I would say, you know, use the power of your university to try and change that, so that it really does become a true partnership. I mean, this is what we need to see more, true partnerships, right, where everyone is able to take advantage of the opportunities and to grow from those. Thank you. Dr. Griffith, would you please tell us more about building hope? About building hope? I worked a lot with refugees. Yeah. And this is something very difficult to build hope. I can do a very short version, which is, it's not about working to help people feel hopeful. It's about hope as a practice, thinking about it as you would an ethical practice, something that you do, rather than to focus on what you feel. And what you do is you get clarity about a deep commitment, a deep value, something within yourself, and find a way to take one step towards it. And so, you know, the work I do with the residents is for them to have basically two conversations with someone. The first is, what you've been through is awful. It's something that should never happen to anyone. What has it been like? What has it taken from you? And fully, eyes wide open, to take it all in and make that empathic connection. But then, to turn the question, how did you respond? When you've been through hard times in the past, how did you respond? And use that to get clear about what is their strong suit for staying in a posture of assertive coping. But it really is about how to practice hope, which, because I think it can be a trap to try to encourage people to feel hopeful when you can't change anything. Exactly. And you wind up, Nietzsche said, hope is the greatest of all evils, for that reason. Thank you. Hi there. Can you hear me okay from the back? I'm Nico. I'm actually a third year psychiatry resident at the UW in Seattle, and a part of the Global Mental Health Pathway and Cultural Psychiatry Pathway. I was just reflecting on global mental health during this session, and when, Manal, you presented on why in this first world country in Seattle, people are homeless, or there's so much, there's such lack of empathy, even in public spaces. Like, the first thing that came to mind was money. It's like the way money is distributed. And even when we talk about global mental health funding, it's like, it's really a question about values. Like, what is the NIMH, or global corporations, valuing, and how are those values changing? And so, I think, at the APA, and in the U.S., where capitalism is king, like money talks, and it's like, it's hard to sometimes, yeah, like, press against those structures, yeah, with the values of global mental health. And I think just, as residents transition to attendings, it's, you know, like, we work in this capitalist system, and so, in a way, there's something very subversive about global mental health, and thinking about, like, how do we actually redistribute money and our values in a different way? And maybe that's why it's hard to sometimes implement global GMH in a curriculum, because it is subversive, and it's asking, like, very uncomfortable questions. So, yeah, I think when we were talking about, like, oh, it's not represented in our curriculum, and we wanna integrate it, that came up. It's like, oh, is it hard to talk about these things, or hard to learn about these things, and feel enabled, or have the agency to act on these things when we also work in this paradigm of, you know, capitalism? But then I thought about the semantics of global mental health, and we, you know, in this discussion, are constantly reminding ourselves, so it's about the scope of the problem, but it's almost as if, like, calling it global mental health almost distances us from those problems that are, you know, right outside our backyards in Seattle, and so, yeah, it's interesting. I feel like it's this group of people who are, like, asking, like, underneath the surface, like, what are we valuing as a professional organization? So, and that goes beyond, like, global or, like, cultural mental health, and, yeah. I don't know if that reflection makes sense, but, yeah, when you presented that slide, Manal, yeah, that particularly struck me. No, absolutely, thank you so much for that comment, and as I was preparing, I will be honest, as I was preparing, and I was talking about colonization and resource pillaging, and I talked about racism and classism, I paused for a second, and I was like, should I put capitalism in there? And then I was like, oh, this is gonna be livestreamed, and I have taken an oath as a Greek godholder that I'm not going to be promoting communism or something like that, so I was, like, very aware that what the tone of the room might become if I put in a word like that, so I really appreciate that you're highlighting and calling it what it is. At the heart of it, capitalism, or hyper-capitalism that the society is around us does play a huge role, and I think moving away from, like, some of the things that have been, I think, have been really valuable for me is collectivism, bringing back the meaning, expanding how I conceptualize my role as a healer and not just as a transactional provider. Somebody mentioned that the way that, in African-American communities, the way that care is delivered is very relationship-oriented as opposed to transaction-oriented, so I think that has been a big thing for me, especially as I have moved from being a trainee to now a faculty, because when you're a trainee, you have this level of, like, angst against the system, and then, once you are an attending, you become, you have to kind of reconcile, am I the system now? Am I, do I represent what I have never wanted to become? So, I mean, again, I'm just, like, jumping off with what you were saying, but it really, yeah, it really makes sense to me and it resonates with me, and thank you for calling it what it was. Thank you, panel, for a great discussion, and thank you for the last comment, especially. I'm Arya Garamani, I'm currently finishing a training in global mental health at the Lisbon Institute of Global Mental Health. I have been reflecting on some of the topics you mentioned, including the need, whether or not we need to actually go and visit a place in order to call ourselves workers in global mental health. What I've gained most at the Lisbon Institute, and through the past year, visiting and writing about the mental health reforms in Brazil, Cuba, Mexico, Morocco, Andalusia, Spain, Italy, and Portugal, is a kind of cultural humiliation that's required when we approach or broach this topic. And that cultural humility is really enhanced when we have different voices in a room from different cultural backgrounds, different perspectives, colonial backgrounds, areas that have been devastated by those processes who can really help us understand these topics better. Now, this cultural humility, how can we try to help promote that in a residency program in which it's completely embedded within one system, let's say in a U.S. residency training program, where topics of deinstitutionalization, for instance, or neocolonialism or colonialism aren't front and center, how can we help in a global mental health training in a psychiatry residency program in the U.S., as I enter a psychiatry residency program in the U.S.? I mean, it's something that I've actually spent a good time thinking about this, so I was, and what I'm gonna say may well be a minority position, it is very hard to make the standard I'm gonna always get it right. I'm not gonna commit any microaggressions. I decided to really put the focus on how to be easily forgiven when you're wrong, you know, to develop the kind of relationship, because you will be. And it's kind of, I guess, corollary to that, I actually spent some time talking about, one of my mentors wrote the book On Apology about how to tailor apologies. Ideally, to have an active enough dialogue so that things can be talked about. So I very much believe what you're saying is very important. I think probably not everybody would agree with what I just said. Thank you, doctor. I know there's a lot of wonderful engagement in the room, but I think we're past time. We might need to leave the room, but please feel free to come up and ask questions as we're setting up. But I wanna say thank you to our panel. It's been a really fruitful discussion, amazing panelists, so thank you to everyone. Let's give them a round of applause. Thank you.

global mental health

psychiatric training

curricula

cultural psychiatry

structural competency

social determinants

educational programming

service opportunities

research initiatives

equitable relationships

multidirectional learning

cultural humility

institutional barriers