Good afternoon. On behalf of the American Psychiatric Association, I would like to welcome you to the Professional Advocacy through a Health Equity Lens. I'm Nadia Woods, the Associate Director of Workforce Inclusion here at the APA. Today's speaker is Dr. Stephen Starks. This webinar is under the Striving for Excellence series. This webinar has been funded by SAMHSA in partnership with the African American Behavioral Health Center of Excellence. The APA designates this live event for a maximum of one AMA PRA Category 1 credit. Handouts are available and here are visuals to assess them based on how you joined the meeting. We'll be accepting questions and here's how you submit them. We will hold on to questions for the end but please feel free throughout the webinar to add questions to the chat. There are no relationships to disclose at this time. Stephen Starks is a Clinical Assistant Professor at the Tillman J. Fertitta Family College of Medicine. His interests lie in understanding the cultural and social effects of mental health conditions on patients, families, and communities. He has designed programs that integrate mental health practices into home-based care, long-term care, and primary care practice settings to ensure individuals with mental health and substance abuse, substance use disorders receive compassionate and effective psychiatric care and treatment. He serves for Fertitta Family College of Medicine Departments of Clinical Services and Behavioral and Social Sciences with roles in education, curriculum development, and community partnerships. He has a passion for mental health advocacy serving individuals and communities that have been marginalized and made vulnerable by social and institutional factors. He has completed formal trainings in both health equity and health policy and has directly engaged in federal legislative process as a Health and Aging Policy Fellow and American Political Science Association Congressional Fellow. Please join me in giving a warm welcome to Dr. Stephen Starks. Dr. Starks, the floor is yours. Thank you so much, Nadia, for that introduction here, and I'm so excited for the invitation from the APA to be a part of the Striving for Excellence series addressing mental health disparities among African Americans through patient care. It's a very exciting partnership between the APA and the Morehouse School of Medicine's African American Behavioral Health Center of Excellence, and just really excited to be a part of this fantastic series. I've learned a lot from some of the other educational programs and hope that our audience today learns something from my presentation as well. My focus is specifically on a passion and a topic of mine, thinking about the role of mental health professionals, professional societies, and organized psychiatry institutions to really think about ways to effectively advocate for policy changes in patient care. So my objectives with today's session is hopefully by the end of this presentation that you're able to clearly define health equity and to understand historical challenges to achieving health equity in mental and behavioral health, to identify policies that have promoted equity and justice in psychiatric practice, and hopefully identifying those policies, those historical policies, help to inform us of future work that still needs to be done in terms of policy reforms, and then finally to recognize the role of professional organization in advancing equity in practice, profession, and patient care. So being an important stakeholder, as many professional organizations are, there is a lot of impetus and opportunity for transformative change in the systems that we operate in. So just to start off with some clear and clean definitions. So what is a health disparity? I know a lot of times this language is new for some, not new for others, and sometimes the definitions themselves often depend on your perspective and your context. So here, I clearly define health disparity as a health difference that is closely linked to us with social, economic, and our environmental disadvantage. Health disparities themselves adversely affect groups of people who have systematically experienced greater obstacles to health. And so when we talk about health disparities, I always just like to reinforce that these are direct harms that are occurring. People often think about the historical context of health disparities as if these events only occurred in the past, but I like to remind folks that patients and communities are still being harmed by differences in the access and differences in the quality of care that is dispensed to different subpopulations. And then health equity, of course, is that ideal. So it's the attainment of the highest level of health for all people. And it's also important to think about what health equity requires. So it requires that we have this foundation and structure of understanding that we value everyone equally. You can think about our history and context in our country and how values have shifted over time. It's also important to note that when we think about equity, that we have to think about it in terms of ongoing social efforts to address avoidable inequalities, historical and contemporary injustices. And finally, the most important aspect that we're trying to achieve is to eliminate health and healthcare disparities. So you can kind of see that health disparities and health equity are oftentimes two sides of a coin. And I always like to begin with just placing things in a historical frame or historical context here. And so it's important to think specifically when it comes to mental and behavioral health about the origins of policies that impact the American healthcare system and impact what we see in terms of responses to mental illness. So it's important to note that during the antebellum period, the enslavement of African Americans was purported to be a protective factor for their mental health. And so we have this distortion of the impact of slavery. And of course, that is clouded by and based in Eurocentric race supremacy. And really, this propaganda was really to argue against the abolitionist movements at that time. There were false claims that were circulating, even in the medical and scientific literature, by physicians of increasing rates of insanity in states, newly free states after enslaved Africans emancipation. So the numbers were distorted in this data and information, the scientific data and information was purported, again, to influence what was occurring at that time. And it's important to note that physicians have always been influential. And so physician leaders at the time exerted their influence. And this influence did have impact and effect on local and state government responses to the mentally ill. And so it's important to think about the responses to treatments of mental health nowadays and who supports that. So we think about our local mental health authorities, our state mental health authorities. We think about federal programs that support it. Again, at that time, there was no difference. And so when we have this propaganda that distorts what's occurring in African Americans at that time, that leads to changes in financial support for programs that are offered. So we see that the support for custodial care and treatment of African Americans was oftentimes in this separate, but quote unquote, equal world. But as you may be aware, these separate wards and institutions were oftentimes underfunded and inadequate to support the needs of those individuals needing treatment and care. And just as an example here, we have the Central Lunatic Asylum for the Colored and Sane, which opened in 1868. It was one of the first asylums, mental institutions that opened specifically and exclusively for persons of color. And we see some of the nursing staff that supported the wards of the state at that time. And so it's important, again, to realize that local municipalities and state governments provided care and services in these wards. And again, that care was largely inaccessible, scant or of poor quality for African Americans. And also to frame that context too, I do think it's important to discuss the challenges at that time when it came to supporting the education of Black physicians and doctors, oftentimes who oversaw the care of our Black communities at the time. I think we're back on track and back on target. Apologies for that. So it's also to remember the forgotten history of defunct medical colleges of the 19th and 20th centuries. So again, after the Civil War, African Americans did not have adequate access to medical care, and that caused significant crises at the time. In response to that, medical colleges were created by Black physicians. Medical colleges were also created in response to what was going on in the South, where the majority of the Black population resided, 90% of Black Americans at the time. Nearly 10 million individuals lived in the South, Black individuals lived in the South at that time. So it was the missionary groups and Black physicians who kind of developed these independent medical colleges at the time to support and sustain a workforce that would care for those most in need. Unfortunately, in 1908, there was a survey that was done, the Flexner Report, but the survey by Mr. Abraham Flexner, who was hired to assess the quality of medical schools by the AMA Council on Medical Education, and also by the Carnegie Foundation for the Advancement of Teaching. The model at the time that medical education was modeled after was the Germanic model, which focused exclusively on scientific and laboratory medicine as an ideal. And there were concerns about this report at the time, because individuals knew that this would influence which schools would remain open and support the workforce and which schools would remain closed. As Mr. Flexner evaluated these schools, he overlooked kind of patient-centered ideals, and he also overlooked the social issues at the time. So the issue of race and racial discrimination among Black communities, often being made vulnerable at the time. At the time of his report, which was finally concluded in 1910, there were about nine, 10 Black medical colleges at the time, and you can see some of those listed here on our list. But at the conclusion of his report and recommendations, he advised or recommended the closure of all but two Black medical colleges, Harvard University Medical Department and Meharry Medical Department of Central Tennessee College. So there were, again, other options that he had and could have chosen at the time. He had support for women in medicine, and so changes in terms of entry of women into academic medicine changed at that time. But again, his report actually reinforced segregated and unequal medical education, and again, led to some of the concerns that we see in terms of the psychiatric workforce, which today, again, is consistent with poor numbers and disproportionate impact on Black physicians. That number remains about 5% of less of the physician workforce and about the same number in terms of the psychiatric workforce. And just for context as well, for Native American individuals, a segregated health system also existed. So despite a federal trust relationship since our nation's establishment, one that has built with our Native American and indigenous populations that was built on formal agreements, treaties, and actually in the law, we know that tribal lands receive minimal resources and funding from the Bureau of Indian Affairs to support the health needs of these communities. In the 1920s, there was only one hospital that was in existence for the treatment of Native American individuals with mental illness. And we know that a 1928 report to the U.S. Secretary of the Interior by the Institute on Government Research, the Marion Report, assessed the administration of resources to the tribe and found that their infrastructure and workforce were far too inadequate to meet the needs of these tribal territories. And it's also important to note the impact of health amongst the individuals who serve to protect our freedoms. In this image here, you see the Harlem Hellfire Fighters, as they were noted. This was the most celebrated African-American regiment during World War I, and they fought on the Western Front at that time and were amongst the most gallant fighters at the time. They spent more time in continuous combat than any other American unit of the same size with more than 180 days in the frontline trenches. And you might be aware, again, that services were inadequate to support the needs of these veterans. So, despite their service, they did not have access to the VA health system and really were one of the key activists in helping to transform what we know in terms of healthcare and access for Black Americans, and also really did a lot to serve and advance activism in terms of access to care within the VA health system. So, they are our unsung heroes, and they were influential and impactful in helping to advance policies that really established what we see today in terms of responses for mental health treatment and services. In response to World War I, in response to the impact as we're entering into another world, into World War II, in 1946, we do have the establishment of the National Mental Health Act, which was signed into law into 1946 and really served as an answer to strain public health services and resources in the wake of World War II. As the mental health workforce addressed the needs of the military service members and veterans, there remained significant gaps. So, in state hospitals that supported individuals who were mentally ill, as well as correctional institutions, immigration services, and also in terms of access to substance use services at the time, this was the act that really spurred federal programs aimed at research, aimed at prevention, and really aimed at the development of our workforce. But of course, Black Americans were not really a part of the conversation at the time, and it really failed to address the needs of African Americans in our communities. The same can be said for our Hispanic and Latinx communities. We do know that Hispanic and Latinx veterans additionally faced racial discrimination post-war in terms of accessing care and services in states like Texas and Arizona. And again, the legislation's provisions would ultimately direct funding for the development of the National Institute on Mental Health. But again, that development of that institute really did not serve racial and ethnic minorities at that time. So, what we have kind of moving forward is this overlap. So, we have this development of mental health programs within our country, and we also have movements happening, civil rights movements, civil liberties movements, that are really kind of addressing larger national concerns and responses to race and to racism. In this image here, we have Dr. George Simpkins, Jr., who was discriminated against in terms of his access and privileges to his hospital at the time where he needed to serve his patients in his community in Greensboro, North Carolina. And we have him really kind of pushing these legal agenda at the time. So similarly to what we know in terms of advancements into desegregating schools, now we have similar concerns about issues in terms of segregation in our hospital systems here. And so it's important because I think sometimes people sometimes forget that we still have segregation in our hospital systems and settings, and it wasn't until we have our advances in the civil rights movement that really propelled changes in our health system and our mental health system as well. So we have federal appeals court decisions that institute non-discrimination in hospitals receiving federal funding that were fully mandated through Title VI of the Civil Rights Act of 1964, but it's again, individuals like Dr. Simpkins who really propelled those changes that we see. And so 1963, we do have the Mental Rehabilitation Facilities and Community Mental Health Centers Construction Act. This is really the catalyst for developing community mental health programs. So we have individuals moving out of state hospitals, out of institutionalized settings, and these individuals, the hope is to develop programs that provide care for individuals in their communities. I think we do know, as the story continues, that much of this contributes to what we've seen with deinstitutionalization, but many term that instead as contributing to trans-institutionalization, so moving individuals from state hospital systems to nursing home settings and to criminal justice involvement. And again, we have further legal precedents with our Civil Rights Act and Title VI that prohibits discrimination in federally funded programs, but it wasn't until our amendments of the Social Security Act that established the Medicare and Medicaid programs that led to desegregation of hospitals and healthcare systems. And while the law was written into law in 1965, we do know that it took several years for hospitals really to get on, targeted on stage to really support what they needed to do in terms of improving access to services and care to historically excluded communities. Concurrent with that, as I alluded to and mentioned before, as we have this growing concern in terms of racial discrimination. So despite Civil Rights Act, despite Voting Rights Act, we still see concerning laws, particularly in Southern states, as it comes to really thinking about the emancipation and freedoms for Black Americans. So we have this very violent and tumultuous social fabric that's occurring in the 1960s that actually places racism at the forefront of societal concerns. Societal concerns, again, that are requiring immediate national attention. And we do finally have some impetus into our national government for a response. We have the development of the National Advisory Commission on Civil Disorders, the Kernel Commission, which actually described racism as the primary cause of violence in the country. We have the Joint Commission on the Mental Health of Children that defines racism as the primary public health problem in America. So we see that this is at the forefront, but at the time there was little action and impetus for change and development within organizations. So we have this development of this transition of activism in our country that's also translating into more action, advocacy, and activism within organizations. So we have scenes like this, which are actually reminiscent of scenes we've seen in the 21st century, but we'll get to that. We have images like this occurring across our country and really, again, a push for a change, a critical change at a time in our country. And we have activists, again, that are occurring in organized medicine. So within the American Psychiatric Association, within the American Medical Association to really address these concerns. This headline is pulled from the New York Times in 1969 during the APA's annual meeting. So racism is called a health problem, Negro psychiatrists make demands to the association. And here we have the image here of Dr. Charles Prudhomme, Dr. Chet Pierce, and really a push and an urge for organized medicine to address the concerns that were happening in black communities and among minoritized groups at the time. And why do we have these changes? So what was going on and what was the role of American medicine and American psychiatry at the time? So we have this distortion between these social concerns that I mentioned. So racism as a public health problem, and we have just non-response or really kind of reinforcing Eurocentric race ideals with American medicine. In 1948, the American Psychiatric Association opposed desegregation of the Veterans Administration Hospitals. And again, I talked to you about the gallant charge of the Harlem Hellfighters and other veterans of color who desperately needed access to care because they served their country. In the 1950s, we have the APA that withdrew its involvement in really focusing on the movement tied to school desegregation. While we know Brown versus Board of Education was a major legal victory through our Supreme Court, again, we have a large organization that is supposed to be focused on transformative care and thinking about and cognizant of the mental health of Americans, really not focusing on the mental health of black communities at that time. And again, we have the 1960s that had well-studied and well-documented national impact of racism on the health of black Americans that, again, were unaddressed by this association. The black psychiatrists at the time were quite active in urging for transformative change. And so that led to a sit-in at that 1969 annual meeting in Miami where they urged the APA, the National Institutes on Mental Health, and the American Board of Psychiatry and Neurology on aspects of leadership. So developing black leadership, placing black individuals and leaders of this organization in order to address the concerns of these communities, and spurring the hiring of black psychiatrists as staff of the Minority Group Program. The National Institute Center for Minority Group Health Program really was focused on increasing research and training opportunities for black physicians, and really thinking about how we really define and measured and combated racism in all forms. Black psychiatrists also urged the development of the Minority Fellowship Program, which now supports the professional development of not only physicians, psychiatric physicians, but nurses, social workers, licensed families, licensed marriage and family therapists, professional counselors, and other mental health professionals to really address growing concern. And again, black psychiatrists also propelled and promoted the Minority Group Program to expand in scope to develop itself as a Office of Minority Affairs within the National Institute on Mental Health. And so the work that black physicians promoted at the time really helped to stimulate some of the changes that we do see as we shift into the late 20th century and really kind of addressing the concerns that were noted throughout black communities across the country. We have, as I mentioned before, the Nixon Administration's establishment of the Center for Minority Group Mental Health Programs. We have later in 1980, the Mental Health Systems Act that was designed and designated to develop a National Institute on Mental Health Associate Director of Minority Concerns for services, research, training, and workforce programming. And we have later the HECLA report, the report of the U.S. Department of Health and Human Services report and the Secretary's Task Force on Black and Minority Health that really leads to creation in federal programs of the Health and Human Services Office of Minority Health. And then finally in 1986, we have our State Comprehensive Mental Health Services Plan Act that really impacted the provision of case management services and community-based systems of care. And much of that law particularly was focused on the differences and disparities located in catchment areas tied to community-based supports and services at that time. And so it really stressed the need for the care of all people with severe mental illness and for new research and service delivery plans, particularly for individuals who were homeless with chronic mental illness. So overall, what I'm just trying to highlight here is we have this slow progression of national reforms during the 20th century that resulted into advancements in federal oversight that led to and was tied to implementation of national mental health programs that really helped to transition care and services from state mental hospitals to community-based systems of care and really to think about this interconnectedness between health and social services to really kind of think about solutions for both. So viewing racism as a social concern, linking that to what we see in health and really thinking about how we defined mental health for our society and really how we could aim to ensure equity and parity of mental health benefits. And we still, again, at this time are continuing to have consistent evidence that shows gaps in racial and ethnic disparities in mental health care and outcomes and so pushing and propelling forward about how we really promote equity for minority populations, minority highs populations is something that we continue to work on. And so thinking about kind of what that looks like now and where are our targets from and so we have, again, this shift from institutional care but really thinking about how we're really addressing that effectively because, again, not everybody is de-institutionalized and reintegrating from state hospitals and reintegrating into their communities, but we really have failed many individuals because we just see that there is instead of reintegration is just basically a transferral to other systems that are ill-equipped to provide adequate high-quality mental health services. So we have justice involvement through incarceration, which particularly disproportionately plays and impacts African-American individuals and this transition, again, to nursing facilities where care is often inadequate. And so as we're transitioning, again, historically from 20th century to modern times, we're thinking much more about health disparities. And so here in 2001, we have our 16th U.S. Surgeon General, Dr. David Satcher, who releases a seminal report on disparities in mental health through mental health, culture, race and ethnicity. And although the document wasn't a clear policy guideline, it's not a policy document at all, it did, in fact, outline a strategy for achieving equity in this American healthcare system. And the supplement, in fact, it was a supplement to the 1999 report to the Surgeon General, really outlined mental health needs of specific racial and ethnic group members and described the differences in access to service for these groups. So it really detailed the disparate outcomes that we know for Black Americans, for indigenous communities, for Asian-American populations, for Pacific Islander populations, and for Hispanic and Latin ex-Americans at the time, and really delineated a clear public health approach to addressing those needs. And I'll point out here again, so this document, this 2001 supplement, Mental Health, Culture, Race and Ethnicity, really was largely attributable to the work of this woman, Nelva Chavez, who was a strong proponent of advancing the causes for really kind of reviewing what was occurring in minoritized communities at the time. She was actually a part of the report writing for the 1999 Surgeon General report on mental health, and she actually refused to sign on to that report because that Surgeon General report did not talk about the impact of race and did not talk about minority mental health. So that 2001 report was actually due to her work. Dr. Chavez was the first administrator of SAMHSA, and she was the first Hispanic woman to head a U.S. public agency, and so we largely have to thank her for her work in really kind of addressing and highlighting what was occurring to racialized and minority communities at the time. And then, again, we have this growing advance to really kind of look for and seek out change. So we have our 2001 Surgeon General supplement, and the following year we have the Institute on Medicine's Consensus Report on Unequal Treatment that described and clearly outlined racial and ethnic disparities in health care, and so we have these slow incremental changes here, right? So we have, in 2008, our Mental Health Parity and Addiction Equity Act. We finally have the Affordable Care Act, so Obamacare, as it's widely known, that expanded access to mental health coverage through Medicaid expansion and insurance definitions and subsidies, and we have really one thing that people sometimes forget about in that act as well, an expansion of mental health impact by really designating offices of mental health within key federal agencies, so not just HHS, but all key health-related federal agencies opened up offices of minority mental health. And we do see that the Affordable Care Act had a tremendous impact on impacting access to care, which is one facet of really thinking about health equity. So it conferred the largest advances in access to benefits and service racialized groups, and we see here in this image the changes kind of noted in terms of access to care. So we see that the rates of uninsurance for individuals from those communities steadily declined over time. And as we kind of think about kind of where we are today, so we do know, again, we have consistent burgeoning social justice movements that have continued to really have institutions, states, and our federal government to think about where we are and where we need to go. In 2020, we have numerous extrajudicial killings of Black Americans, Breonna Taylor, Maude Aubrey, and George Floyd, obviously, were household names at the time, and continue to be household names since the spring and summer of 2020. But there was a larger transition. We now have institutions, so professional societies, or organizations that are really looking to figure out how to address the race problem. And so we moved very quickly from speaking in terms of euphemisms of health disparities and equity to really talking about the impact of racism and how we can really address anti-Black racism. The associations that you see here all made statements that aligned with that goal of addressing structural racism, addressing disparities, addressing the issue of leadership, addressing their practice and profession as tied to the diversity of their workforce. So we have all these associations really thinking hard about what to do, and many of them knowing not where to go. What is the next best step to take? What is our role in really addressing these concerns at an institutional level? And what is the role of us really addressing these concerns and becoming more active in advocating outside, in state laws and within federal laws? And then on top of that, we have COVID-19. And I'll just remind you at the time that a lot of that conversation really started about how it was an illness that only impacted communities of color. So it's seen its broad impact on Black communities across the country, in Brooklyn, in New Orleans, in Philadelphia, seen its impact on Hispanic Latinx communities, in our indigenous communities, Navajo Nation, Los Angeles County. And we had initial conversations in reporting, particularly in popular press, that they didn't give a very nuanced kind of framework for understanding it. It was kind of really them purporting scientific racism as if individuals of color were vulnerable only based on their race, but really not really thinking about it in the frame of what we define as a syndemic. So a synergistic epidemic, synergistic pandemic at the time that really was not only about the illness, the virus, COVID-19, but also thinking about the preexisting conditions that these individuals have, but really as they relate to the racism and economic and social vulnerabilities that these communities face. And so thankfully, over time, that conversation started to shift to look more, again, at the impact of racism and economic and social vulnerabilities. But again, it's important, particularly as we think about advocacy, to kind of step away from looking at things from a myopic lens and a myopic point of view, to really kind of think about it and color it more so along the lines to understand the intersectionality and understand how these various concepts are integrated with one another. And as we think about solutions and ways to kind of advance and continue to reform policies is again to address those related factors like racism and like income inequality, like food insecurity, like housing inequality that we see in our country today. And so as we think about our path forward, what are our aims and what should we do? Again, we have a good framework that has been set up in terms of really thinking about how do we improve access and integrating mental health and primary care, or really kind of coordinating services for high need populations and the means in a manner that they want. We have health systems that tend to be stuck in themselves and only operate in traditional clinical settings, but we don't really see a lot of community-based supports and services when it comes to treating mental and behavioral health issues. We don't have neighborhood, we don't think about space and place and placing facilities and services within neighborhoods. And we don't really think about ways to improve quality and really kind of developing culturally responsive services that align with the needs and values of community members. And we really think little about community engagement and community partnerships and how we really kind of rely on families and communities to be a part of developing services, treatments, and support that they would like established. We also have to think about developing our capacity. So how do we effectively train and support mental health professionals? What's the role of our professional societies in doing so to ensure that professionals are reduced and kind of mitigate their biases to actively be anti-racist in their practice? And then really, how do we kind of shift the power dynamic to encourage consumers, communities, and families to be a part of defining their support and capacity in their leadership? And then also thinking about how do we globally promote mental health? We know that stigma exists most often or in a greater intensity in a minoritized community. And part of that is tied to the foundation that I discussed with you earlier. Again, if you have limited access or if you're not a part of the development of policies, oftentimes there can be some hesitation on your part to actively engage. And so really thinking about how we might address social adversities and also build on national supports and strengths of communities, of individuals, and of families so that we can really develop and promote mental health in a ways that is connected to our community values. And so as we think about our approaches, we should always shape them and shift them to a community-informed policy approach. And so that's actually by thinking about our institutional, our local, our state, and our federal policies and thinking about ways that we kind of can maintain and achieve targeted engagement. So how do we engage our community members to be a part of developing reforms and service delivery? And how do we restructure our incentives in such a way that we can continue to maintain that cycle? So giving back or reaching out and propelling individuals forward. And so as we think about advocacy, which is kind of defined as an action that speaks for, in favor of, recommends, argues for, cause, support, or defend, or pleads on the behalf of others, we really have to think about ways that we are active and ways that we can act. And that can be a number of different mechanisms. So that can be public and community education, that can be evolved and regulatory work, that can be thinking about ways that you can engage in litigation and law, that can be working with administrative bodies, that can be lobbying with the little else, just engaging and knowing who represents you and how they're representing issues that you can care about, that can be a part of voter registration and educating people about the power of their vote. And we can also think about professional activism as well. So really developing meaningful campaigns for change. And it doesn't have to, again, be this one dimensional or one frame for being an activist. One can use many methods in order to bring about change. But that action, again, has to be intentional with the goal of bringing about critical solutions that impact our mental and behavioral health system. And so thinking about health policies, again, thinking about health goals that are set at this local, state, and national level, that really kind of specify decisions, plans, actions to achieve the goals and solutions we talked about. And so that involves clarifying the values on which the policy is based, defining a clear vision for our future, establishing objectives and clear priorities, and also facilitating. So that's, again, establishing clear objectives and principles, and then facilitating target setting and kind of facilitating milestones in terms of developing meaningful policies and actions. And so what I hope today is that I contributed a little bit to your understanding of identifying historical roots of inequality in our mental health system. I hope I was able to describe some steps to achieve equity by utilizing community-informed policymaking. And lastly, I hope that I've offered you a little bit of a practical guide on advocacy engagement. Thank you, Dr. Starks, for that wonderful presentation. It was really comprehensive. At this time, we're going to transition into the Q&A portion of the webinar. Please remember to add your questions to the chat. I would like to start us off with our first question. So what role do you see psychiatry playing in current advocacy efforts in this space? Yeah, that's a great question. So I think it's multifactorial. I think one of the biggest things, and I talked about it, was really thinking, again, about what we can do in terms of workforce development. So if you only have psychiatrists who are from underrepresented communities, or communities that are underrepresented in medicine who make up 10% or less of your workforce, but we know in total, if we think about those groups, Black Americans, Hispanic Latinx Americans, Puerto Ricans, Indigenous communities, so Native Americans, Alaska Native, Native Hawaiians, right? All of those individuals make up 10% or less of our workforce, but we make up about a third of individuals in this country. I think that distortion itself leads to the work that we need to do. So really thinking about how we can accelerate the pipeline to ensure that we have a diverse workforce. So from a psychiatric standpoint, that's thinking about our role in terms of achieving high numbers of diversity in undergraduate medical education, and that's also thinking about the signals that we place in our system. So our association is focused on developing professional ideals, and oftentimes those ideals are not shaped by groups who have been historically excluded. And so, again, if we have a lack of input from those groups, we have issues that we see in terms of what we face, in terms of providing care, and in terms of our professional standards of practice. And so we see what we sometimes see in those communities, right? We see disengagement. So we see a low uptick in those individuals reaching out and seeking mental health services. We also see some of the harms that I alluded or talked about at the start of it. So we see those disparities in terms of misdiagnosis of individuals or over-diagnosis of individuals, or we see that those individuals may not receive things that are consistent with standards of care and things that are associated with practice guidelines. So they're less likely to receive certain treatments and, again, are less likely to seek care, again, in crisis or in emergency instances rather than really seeking the support of our mental health systems at earlier or more preventive stages. Thank you so much, Dr. Stokes. That's really important. I'm glad that you brought up advocacy and workforce members. The next question I have is, how has the advocacy landscape or health equity changed since you've been a psychiatrist? Yes. Well, I guess I'm transitioning from early career to the mid-career, and I would say, unfortunately, it's changed a little bit but not much. I do think our mental health system, particularly as we think about professional advocates, does have an issue because mental health and behavioral health mean so much to so many, right? We have a number of different professionals that are engaged in advocacy, and many of them don't share the same priorities in terms of what they see. So we sometimes, in our advocacy, don't have a specific focus, and I don't think that that serves us very well, specifically when it comes to engaging in political processes. So if I have psychiatrists on one hand coming to advocate to our policymakers on one issue, but I have another group of mental health professionals coming in to advocate on a separate issue, I don't think that that helps us to really kind of advance very far in terms of our goals and objectives. And so I think sometimes goals can be distorted because we all, as professionals, are vying for our own priorities. And so I think clearly defining our priorities is the most important, or at least kind of clearly defining areas of consensus is important. And I think especially that that doesn't just serve as to racialize or minoritize communities because we don't have a clear guideline or outline on our path toward thinking about mental health equity and what that means. So I do think that there is broad agreement on the issue of workforce, but I think some of the other aspects, so how and when we engage in advocacy on the other social determinants and political determinants of mental health is sometimes, I think, a challenge for advocacy in this modern age. Great. That's so important. And since you were speaking of advocacy, I wanted to ask about can you expand upon the role that local municipalities play in providing access to mental health care for African-American communities and other historically underrepresented groups? Absolutely. Yeah. So we know that there's broad variability in terms of how our state mental health authorities are set up. It varies state by state. I'm here in the state of Texas, and we have specifically unique challenges in terms of access to care because we are one of the states who have not expanded access to Medicaid. And so it's kind of a dual system here in terms of the role of our state hospital system or that state mental health authority that predominantly engages in care for our state hospitals. And then we have our local mental health authorities here within our state that really kind of deliver the community-based support and care of patients locally. And we do know that there are broad range of disparities there. So as an example about tied to your question is where are these settings, where these mental health facilities are located, sometimes in areas that are not easily accessible to minoritized communities, or in terms of also access that ties to individuals who live in rural settings as well. So inner city and rural communities oftentimes are overlooked. And we oftentimes see kind of a difference or distortion about what type of programs these facilities provide. So we would like to see the full range of supports and services for individuals who have needs in crisis, for individuals who have chronic severe mental illness, for individuals who have substance use disorders, and individuals to be able to receive the type of care that they want. So whether or not that's tele-mental health services, whether that's programming for psychotherapy services, oftentimes we do see a disparity and a distortion about which programs are available for minoritized communities. Great. Thank you so much, Dr. Specks. And in closing, I want to share with the group that you can claim credit for this webinar. Here are instructions how to do so. And please, if you have any questions, the email is on the screen, learningcenteratsite.org. Thank you all so much.

professional advocacy

health equity

webinar

Dr. Stephen Starks

mental and behavioral health

African Americans

advocacy efforts

policy changes

workforce development