Thank you for joining us today for Racial Inequity and Discrimination in Mental Health, Promoting Equity in Crisis Services and the Criminal Legal System. Today we're going to be joined by Dr. Matthew L. Edwards, and this is part of our series that I will continue to share a little bit more on the next slide. Our Striding for Excellence series is made possible by a grant from SAMHSA of the U.S. Department of Health and Services. The contents are those of the authors and do not necessarily represent the official views of nor an endorsement by SAMHSA, HHS, or the U.S. Government. Next slide. By attending today's session, you are eligible for American Psychiatric Association Continuing Medical Education Credits. The APA designates this live event for a maximum of one AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation and activity today. Next slide. Today, as a way to be engaged, please make sure if you'd like to download the handouts. To download the handouts on the desktop, use the handouts area of the attendee control panel, as shown on the left side, or on the NCENT Join viewer, on the right side, click the page symbol to display the handouts area. Next slide. How to participate in Q&A. We'd love to hear from you. We'd love to gather questions from you, and there's options on how to do that. On the desktop, which is on the left side, use the questions area of the attendee control panel, or as shown on the right side, NCENT Join webinar, click the question mark symbol to display the questions area. Again, we very much encourage your questions, and we look forward to being able to ask those questions at the end of the presentation during Q&A. Next slide. Today's speaker has no financial relations to disclose, and as I mentioned, we're joined by Dr. Matthew L. Edwards. He is an assistant professor and an assistant director of residency training for the General Psychiatry Residency Program at Stanford University of Medicine, sorry, Stanford University School of Medicine. Originally from Dallas, Texas, he graduated from Princeton University with a bachelor's degree in sociology and received his MD with honors in research from the University of Texas Medical Branch at Galveston. He has completed his general psychiatry training and chief residency at Stanford University School of Medicine, and recently finished his fellowship training in forensic psychiatry at Emory University School of Medicine. Dr. Edwards' clinical interests are in community psychiatry and forensic psychiatry. At Stanford, Dr. Edwards treats patients in the Division of Adult Psychiatry and the Center Space Clinic. This recovery-oriented clinic provides culturally contextualized and trauma-informed care for people with marginalized multiple intersecting identities. His research interests lie at the intersection of medical history, bioethics, and public policy, and numerous grants and fellowships have supported his research. He teaches the history of psychiatry to general psychiatry residents and forensic psychiatry fellows. Please welcome me, help me in welcoming Dr. Edwards as he will continue on the next slides with his presentation. Thank you so much for the warm introduction, Gabriel, and I'm really happy to be here speaking with everyone today on promoting equity in crisis services and the criminal legal system. Our session today, focusing on racial inequity and discrimination mental health, we'll discuss some of the concepts, the literature and limitations of our crisis services system, our mental health system, and our criminal legal system. The objectives for today are to define prejudice, discrimination, racism, and structural racism in turn. Then we will discuss how structural racism and discrimination impact individuals with mental illness, individuals involved in the criminal legal system, and we'll consider how structural racism also impacts individuals with mental illness in the criminal system. Lastly, we'll consider some of the work around crisis services, crisis services reform, and various policy interventions aimed at addressing structural racism in these systems and contexts. Let's first start with some terms that will help us orient and understand the conceptual basis of structural racism. We'll begin with prejudice. Prejudice is different from discrimination and racism, though it may often lead to racism. Prejudice is an affect, an affect that's based on preconceived beliefs or attitudes, often negative, that are held by one group toward another. While these groups can be based on any particular characteristic or identity, here we will focus on racialized groups, and that is we'll consider the prejudice that stems from the affects of individuals who make differential race-based assumptions about the abilities, characteristics, or motives of others based on their race. These beliefs are rarely rooted or based in evidence. Discrimination refers to the behaviors that create unequal treatment or differential access to resources for individuals belonging to a particular group, or in this case, a racialized group. Whereas prejudice generally refers to an affect, discrimination refers to behaviors and actions, actions that are motivated by these prejudicial ideas and that lead to discrimination. This leads to treating racialized individuals differently on the mere basis of the racial category to which they are assigned. Much of our objective today involves a discussion around structural racism, which is often demonstrated by the persistence of racial inequities and disparities. Racism itself is defined as a system of structuring opportunity and assigning value based on the social interpretation of how one looks. And it's also been defined as an organized system premised on the categorization and ranking of social groups into races, one that devalues, disempowers, and differentially allocates desirable societal opportunities and resources to racial groups that have been regarded as inferior. Yet anytime there is a disparity by race, it is important to recognize that there is no biological basis for race. We often use race as a proxy for racism, but the actual mechanism driving the disparity or the inequity by race is not the race itself, but it's the social process of racialization, prejudice and discrimination. And so many of the studies and scholarly works that are described in this discussion today don't include racism as a conceptual category, but rather use race as a proxy. But we must remember that it is racism rather than race itself that is the driving factor in these processes. And so said again, or in other words, racism rather than race is the driving social process that contributes to racial inequity. And so what do we mean when we say structural racism? What makes racism structural? Well, structural racism is often thought of as the differential access to society's goods, services, and opportunities that are formalized in society's institutions. Racism can be institutionalized or structural with the various goods, services, and opportunities being stratified at every level. In every society, a social structure emerges, one that stratifies roles and positions such that some individuals end up on top while others end up on bottom. In the United States, race has often been the defining characteristic for this stratification of discrimination. And this stems from a longstanding history of racial oppression, ethnic discrimination, displacement, violence, and oppression in the United States. And certainly discrimination has affected many groups in the United States from religious minorities such as Jewish and Muslim individuals to ethnically oppressed persons, immigrant populations, Latinx populations, Asian and Pacific Islander individuals, Native Americans, and many others. We focus here today on racial discrimination and structural racism predominantly directed toward Black Americans as the research to date has largely focused on this group. The past patterns of racism from institutionalized enslavement of Black people in the United States to the period of reconstruction after the Civil War, to Jim Crow, to residential housing segregation, these formalized means of allocating resources and restricting opportunities based on race have structured the inequities we see throughout our social and our health system today. And so it's these past periods of institutionalized racism that structure more contemporary forms of institutionalized racism. And importantly, we should note that racism is strongly associated with health outcomes in the United States. In fact, it's twice more strongly associated with mental health outcomes than physical health outcomes. And so it's very germane and very important and vital to the work that we discuss as mental health clinicians and psychiatrists. Many studies have found that Black and Latinx individuals receive worse treatment in the legal system than their white counterparts. And this occurs at every stage or phase of the criminal legal system, from surveillance to sentencing. Racialized legal status is one way in which this broader discrimination directed towards racially and ethically oppressed persons appears. The consequences of these statuses also dictate how individuals with these statuses are perceived and treated, and it shapes their outcomes irrespective of their actual legal statuses. Racialized legal status refers to legal classifications such as immigration status or criminalization status, for instance, if one is an immigrant or if one is an ex-felon, that disproportionately impact racially and ethnically oppressed persons. And this influences the perceptions, the treatment, and the health outcomes for members of the racial group more broadly. Examples, as I discussed, being an ex-felon, for instance, can then be generalized to the population that is also largely associated with that status. So that is the negative associations, the attitudes, and the prejudice beliefs about immigrants or, for instance, Black men who are disproportionately overrepresented in the carceral system can affect the outcomes of native-born members of the same ethnic groups, or individuals without a history of criminalization who might belong to that particular marginalized racial group. And so racialized legal status is one example of how discrimination and prejudice leads to inequity at a systemic level. We will now turn to other systems to examine the range and the extent of inequity and inequality that has also been built into those systems. Consider that racially and ethnically oppressed persons have poor access to mental health care, that Black patients are less likely to receive life-altering interventions such as Clozapine and ECT, that effective psychosis is more often misdiagnosed as primary psychosis in Black men compared to their White counterparts, that there is a higher rate of prescribed first-generation antipsychotics and a lower rate of prescribed second-generation antipsychotics among Black patients. And these disparities exist, and we talk about them as racial disparities, but it's important to also remember that there is no biological basis for race. So when we think about this lack of availability or provision of services of ECT and Clozapine, that exists at a racially unequal level. The lack of the availability of ECT in a treatment setting, for instance, and other features haven't accounted for these racial disparities. We also know that African Americans are more disproportionately put in restraints, for instance, in emergency departments and other settings, independent of their demographic factors such as a history of violence. And we see a higher use of restraint for non-White patients compared to White patients, despite there being no difference in the number of violent acts. We also know that Black men, for example, are more likely to be diagnosed with personality disorders such as antisocial personality disorder. We see racial inequities that are stratified by age, so Black youth are 2.5 times more likely to be diagnosed with conduct disorder and five times more likely to be diagnosed with adjustment disorder than ADHD compared to their White counterparts, assuming similar presentations. Black youth are less likely to be referred to psychiatric care. And we also see this existing across class lines, so middle-class Black clients are less likely to receive psychotherapy and psychological services when they call for appointments compared to their White counterparts. This recent audit study found that Blacks were considerably less likely to be offered an appointment. And so by studying and analyzing middle-class Black Americans, this study allowed us to see that racism, distinct from class-based access to care, is a unique social determinant of health. We also see in the mental health system that Black patients in many settings are more likely to be involuntarily committed, that non-White patients have a greater incidence of restraints despite no difference in violence risk and are more likely to be replaced in restraints in psychiatric emergency services settings. We also see that undocumented individuals have a greater risk of affective disorders and a lower likelihood of health services utilization. And they're less likely to interface with the health system, often for fears of deportation or legal endangerment. We know that Black men are 14 times more likely to be routed to the criminal justice system for substance use issues than the general population, that racial and ethnic minority youth demonstrate increased use of crisis mental health services, and as such are more likely to enter these mental health services through coercive agencies such as the juvenile justice system, other systems that are not voluntary. And it's well known that the groups that are overrepresented in the criminal legal system are also similar to the groups that are marginalized and underserved in the health care and mental health care system. African-Americans are markedly overrepresented in the criminal legal system. Black people are imprisoned at a rate six times that of White people for drug-related offenses, and the likelihood of imprisonment of Black men is one in three compared to one in 17 for White men. And these disparities include individuals from low-income and minoritized backgrounds, communities that tend to have higher police surveillance, criminalization, overpolicing, especially among individuals with undertreated mental illness. And this increased contact of individuals with mental illness with the criminal legal system perpetuates the overrepresentation of these individuals in the carceral setting. And so the individuals are more likely to be criminalized for substance use, yet also less likely to receive substance use treatment once in a correctional setting. And there are interactions between mental illness and the criminal legal system without parsing out race as a variable. Consider that 7% of police contacts are with a person thought to have a mental illness, that 1% of police dispatches and law enforcement officer encounters involve an individual with a mental health condition, that 25% of individuals with mental illness report being arrested, and that among patients in the public mental health system over a decade, 28% experience at least one arrest, with 25-year-olds having a 50% risk. Yet racism is a defining feature of our criminal legal system. Law enforcement officer use of force accounts for over 4% of homicides in the US, with at least 25% of fatal encounters involving individuals with mental illness, with 76% of individuals killed in law enforcement encounters having no prior treatment, yet Black people have a fatality rate 2.8 times higher than that of White people. And so we've talked about the ways in which race, mental illness, and the criminal legal system intersects. These interactions and equities and disparities persist despite no significant link between actual mental illness and criminality. When isolated, mental illness accounts for at most 3-5% of violence in our society. Violent incidents involving persons with mental illness are not significantly different from the community in the absence of substance use. And it's really substance use in the setting of trauma histories that have a greater role in violent encounters than mental illness, such that individuals with mental illness are more likely to have substance use challenges. And so the bottom line is that people with mental illness are more likely to be victims of crime than perpetrators of crime. But these associations between mental illness, criminality, race, and the many interactions between those various variables are persistent. And so here I have a Venn diagram to kind of show the overlapping, the intersectional, the multiple ways in which these systems intersect. And as I've discussed, within the mental health system, there are racial inequities and inequalities that persist at a racial level, despite the fact that race has no biologic basis. We've talked about the ways in which African-Americans and their white counterparts have vastly different outcomes, rates of surveillance, criminalization, arrest, convictions, and sentencing, despite no comparable differences in propensity to commit offenses. We've talked very briefly about the societal or social systems that set people up for inequality, and these have been largely institutionalized, whether it's through the housing or labor forces, and there are many books, texts, scholarly works, and tomes that attest to this. Considered diva pagers marked finding work in an era of mass incarceration, Douglas Massey's American Apartheid, and other really seminal works that show the persistence of racialized discrimination in housing, in labor, in health, in education, in the financial sector, and in the employment system. And so we can see how these multiple identities, statuses, designations, and other characteristics intersect, and intersect in a way that they create unique lived experiences and multiple burdens for individuals who represent these intersections, these parts, these darker parts of the Venn diagram that overlap. And these patterns and circumstances are not new. They persisted throughout history. The medical system has recognized the precarious nature of the criminal legal system interaction with the black community for decades. Let's consider a program, a novel program in history developed in 1967 to illustrate this point. And so I want to talk a little bit about the Freedom House Enterprises Ambulance Service. Cities throughout the United States were rife with racist systems that precluded equal access to education, housing, employment, political opportunities, and social services throughout the 60s and 70s. And the social conditions affecting black Pittsburgh residents in the 1960s were similar to those that black Americans more broadly face today. In fact, the National Advisory Commission on Civil Disorders concluded that the urban riots of the 1960s were a response to structural racism and socioeconomic inequity. Many of the same factors and drivers that undergird our disparate systems today. And so in short, black citizens faced more punitive treatment by the carceral system and poor access to medical care. And Freedom House was a black-run EMS service that was developed out of the coalition of local Pittsburgh residents who were looking for meaningful employment, ways to increase transportation to local hospitals and clinics for black residents in Pittsburgh, and economic opportunity. And this occurred at a time when most emergency medical care was provided by police and morticians. And so it emphasized a practice called scoop and run, where police officers or morticians would hurriedly transport patients in the back of paddy wagons or hearses to the hospital. And so Freedom House really was at the cusp of formalized, organized emergency medical services. And prior to Freedom House, no national standard really existed for emergency medical services. And so out of this movement to combine social needs within the black community in Pittsburgh with medical needs in the black community in Pittsburgh, Freedom House was born and conceived as a community-based sociomedical program that sought to increase socioeconomic opportunity. And it trained unemployable black men and women to provide emergency medical services. And it was markedly and widely successful. It set the national standards for EMS service and education and delivery. It provided superior medical care compared to earlier models and compared to preexisting police care. And it advanced the development of a new group of emergency medical technicians and codified the birth of a new allied health professional. It improved community morale for paramedics. It improved race relations between white and black citizens throughout Pittsburgh. And it encouraged social enterprise among African-American citizens in Pittsburgh. And I give this example as an example of ways in which power and resources were shifted from police to health services. And this will echo in many ways, some of the movements that are being advanced today in order to move police response for individuals with mental health challenges to a community response. Pittsburgh's Freedom House ambulance service not only supplanted the police in a role in which they weren't as effective, but it also re-imagined the role of black citizens in improving their own health, improving the city's health and establishing in turn national standards for emergency care. And kind of echoing some of the discussions we've had about the criminal legal system, during the 1960s, black citizens faced discrimination and disparate treatment by police. Similarly, then as now, they had disproportionately high rates of arrest and incarceration. And having to rely on police officers for transportation for many felt sort of gave a sense of indignity. And as we think about growing out of hospital behavioral health crisis responses today, we see that communities are now motivated to develop new partnerships, to shift law enforcement responses to ones that de-emphasize law enforcement involvement. And we see this in many contexts. We see this, for instance, with additional branches to the 911 call for mental health emergencies, to new mental health crisis lines that utilize respondents from the public behavioral health system. And so when we think about how these programs are evolving, we recognize that police and community mental health, community mental health clinicians work in tandem. They often work through crisis intervention teams. And these crisis intervention teams are not a violence prevention strategy, but really partnerships, co-responses, and formalized protocols for police response or for mental health response. And what we found through these programs that really kind of grew out of, after a fatal law enforcement officer encounter during the 80s in Tennessee, that the idea is that CIT will create better responders to individuals in crisis, have alternative dispositions for individuals, and allow people to have more familiarity with the local infrastructure. And one of the ways that you can sort of think about these new out-of-hospital or pre-hospital responses is through the sequential intercept model. And the sequential intercept model is one way of thinking about the chain or progression of services, institutions, and contacts throughout the criminal legal system that structure an individual's penetration further and further into that system. And previously, the sequential intercepts started with law enforcement, and then it progressed through pretrial and detention. Then there was jail and courts and sentencing. And then there was community reentry and community level corrections. And over time, scholars, advocates, policymakers, revised this model to include intercept zero, which are community services, which crisis services, jail diversion programs, and other programs that we're discussing now became a primary way to help prevent deeper and deeper penetration into the criminal legal system. So the addition of intercept zero was developed to help communities target community crisis responses with jail diversion and law enforcement deflection efforts. And studies have shown some positive results related to jail diversion and reducing the likelihood of individuals with mental illness being routed to the criminal justice system. Yet, despite these improvements, issues of racial equity and jail diversion outcomes persist such that whites are more likely to be diverted than black individuals. And so the sequential intercept model, in sum, is a strategy for identifying individuals with mental illness at any one point or multiple points or intercepts along the carceral system continuum. And that's the sort of sequential part of it. And it aims to intervene, to reroute, and to direct them to services. And so mobile crisis support and stabilization services are becoming better recognized, and they too exist along a continuum. Whether a police-only response, a combined type of response, or a community-based non-law enforcement response to the crisis, communities have been examining this triage process and determining how to best forge partnerships so that the law enforcement response is shifted from one of defaulting to the criminal justice system to one that only utilizes these entities when needed. And many communities, you know, with the addition of mental health crisis services lines and mobile crisis support services, have shown some improvements in the care and referral of people with mental illness to more appropriate forms of care. So Alison Edwards' article on crisis services and the role of 988 really creates, I think, a helpful typology or categorization of these types of programs and partnerships, first being the police-based specialized police response in which law enforcement officers who are specifically trained to manage behavioral health crises and have knowledge of and access to the system help support their response, to one that involves police-based specialized mental health co-response. And so this starts with behavioral health clinicians who are hired typically by police departments. They accompany police officers and other personnel on a scene where there might be or there's a large suspicion for a behavioral health crisis. And in that, they work kind of in a co-response team to sort of give the most appropriate action. There's also mental health-based mental health response, and these are what we've discussed or described as mobile crisis services, where a mental health unit or a person or members of a team respond directly to the scene of a crime. Law enforcement is not necessarily looped in. They may or may not come. They may or may not work cooperatively at the scene. And then there's sort of this last category that's more variable, what we call blended and innovative, and those are services that involved unarmed officers, for example, or peer support collaborations or community response teams that utilize various efforts on a scene above to enhance the types and options for responding to these kinds of situations. And related to the sequential intercept model, there are specialty court and court-level diversion programs, and these grew in number, particularly after 1989 when a Miami-Dade County drug court emerged from local people's efforts to reduce recidivism, especially related to drug offenses, and this led to more specialty courts. Today we have mental health courts, veterans treatment courts, reentry courts that admit people and divert people based on their various aspects for treatment. There are specific courts that are related to drug-driving offenses or homelessness, and the idea is that in these courts, the judge will align with the treatment team, defense and district attorneys, they all work together. Participation is voluntary. The activities might be mandated. They typically have regular appearances. They might provide rewards for good behavior or for progressing through the program, yet they might also sanction. So it's important to note that these two are parts of the criminal legal system and so can also have consequences for not fully meeting their expectations. Studies have shown that these have had fewer jail days, they've had improved outcomes, yet jail diversion defendants are disproportionately white. So when you look at various programs, whether they be crisis intervention programs, jail diversion programs, the number of these programs have really risen over the past several decades. Yet when we think about programs like crisis intervention training, there's really not much data available to support their effectiveness in reducing lethal outcomes, lethal use of force, or even further and further deeper penetration of the criminal legal system. What we can say that they do is lead to an increase in referrals to mental health services, and one might see this as a good thing. You increase the contact between an individual and the mental health system. But sometimes these contacts don't always remain sustained through time. They might be fragmented. And there's a large literature that looks at the sort of fragmentation of care around the crisis services system. And so simply increasing the number of referrals to mental health services to a system that has limits, it's overstressed, overtaxed, and often not equipped to meet the needs of its various communities is in itself not the end. We know that these programs can reduce an officer's self-perceived likelihood of using use of force in hypothetical mental health encounters after undergoing CIT. But these haven't really been tested in actual mental health encounters. And someone's self-perceived likelihood of using force is quite different from their actual propensity to use use of force in these encounters. So no data show actual positive benefits of CIT on outcomes or lethality. And further, as we talk about racial inequity, no specific CIT content on structural racism or the carceral system inequities is often present. And so it's really important that these programs, which are being pushed and touted as a way to address racial inequity in the mental health crisis services and criminal legal system, be aligned with the anti-racist, structurally informed, and evidence-based practices within mental health. And yet there are still more missed opportunities. Education often provides a unique window to treat substance use and addictions. But the majority of those who meet the criteria for treatment don't receive treatment. According to some early studies in the 2000s, from 2005 to 2009, only 40% of state prisoners who met criteria for substance use disorders, of which 56% of them did, received treatment. And most of that treatment was modeled on education and self-help, despite the fact that we have many evidence-based treatments for substance use disorders that we know to be more effective. Moreover, 10% of individuals received psychotherapeutic residential-based treatment rather than medication-assisted treatment. And less than 1% received medication-assisted treatment in these settings. And so, we see opportunities. We know that the mental health system, there's a large burden of substance use disorders in the mental health system. We know that individuals with drug-related offenses, are more likely to encounter the criminal justice system. And we also know that this is an opportunity to treat them, yet we see that less than 1% will receive medication-assisted treatment, which creates a real void. And so people are being ostensibly punished through the criminal legal system, yet not given the opportunity to recover, leading to recidivism and sort of this revolving door of incarceration, particularly for individuals with mental illness. And so kind of coming to our end here, we have to think about future directions for our mental health system, for our criminal legal system, especially as it relates to racial inequity. Clearly, these systems have highly structured race and racism, such that racism has become a unique social determinant of health. Yet even beyond race, the role of mental illness, gender, socioeconomic status, and other characteristics also structure these experiences. These intersections or this intersectionality should be considered in these programs and trainings and often are not. It is not merely enough to recognize that a person is in a mental health crisis. It's not enough to merely recognize that a racialized person may demonstrate an erratic behavior in a particular situation. Training should teach the intersectionality such that individuals are encouraged and taught to consider race, racism, mental illness, and the social structures in which they exist in tandem. How do we determine who is scary versus who is scared? Programs aimed at decoupling police response from crisis mental health services have put forth a number of suggestions. These include, you know, as we discussed, recognizing the multiple intersecting identities and training and programming. As we've discussed in our discussion of various support programs, embedding social workers and behavioral health officials with law enforcement officers, increasing evidence-based treatments that impact health and social outcomes, increasing behavioral health expertise to EMS responders, decoupling EMS response from police response, engaging the community and lay public to respond with peer support. This is an important one that's really being sort of brought to the fore in the context of, you know, current efforts to strengthen the 988 dedicated line for mental health emergencies. Yet when we think about people coming from the community, we must consider how our interventions may contribute and worsen the inequities that exist within that community. So it's important for these systems and reforms to be structurally informed. Peer support programs often utilize individuals from the same community, individuals who may be more likely to experience some of the same stressors and trauma. So it's important to provide adequate support resources so as to not further burden these individuals' communities by contributing to the stress, vicarious trauma, or overtax in these communities. And lastly, we must consider how our interventions may contribute to and worsen inequities. One example that we've discussed is with jail diversion courts, where even in a system where persons of color are vastly overrepresented and diversion is seen and touted as a means to prevent further penetration into the criminal legal system vis-a-vis our sequential intercept model, we see that white individuals are more likely to be diverted than black individuals, which further creates and perpetuates disparity and inequity. And so this concludes our discussion on racial inequity and the crisis mental health system and criminal legal system, or at least the presentation portion. So I'm happy to think about and talk about some of these topics with you. I've also provided a list of sources that informed my presentation that will be on the handout as well. Well, thank you very much, Dr. Edward. And as we begin the presenter Q&A, I'd just like to encourage anyone in the audience to please submit any questions that may have came to mind that they'd like for me to ask. But if not, I can kick it off with a question. Well, first, I just want to say phenomenal job. I think you've given us a lot to really think about, especially all these interconnected areas that are, I don't want to say they're dependent on each other, but they definitely do have an impact on each of the areas that you touched upon. And I do want to thank you for some of the key words that I think I know stood out to me in addition to all the content that you provided, but it's really this concept of being able to repurpose and shift resources and power. And I think that's very important because I think a lot of everything has been so politicized in our country that sometimes when we hear terms like defund the police, people don't necessarily understand what that means. But I think the way you really brought it to light, it's really this understanding that in order to best support our police department, we have to really realign our resources of what's going to be, because ultimately police are meant to be a benefit, a social benefit to our communities. So I say that, when you think about this, and it's a two-prong question, I know you focused on shifting resources, but in addition to your future directions, would you say that's how you would reimagine these areas to ultimately best meet the needs of our community members with mental health issues? Thank you, Gabriel, great question. I do think that reimagining, reshaping is one way in which these kinds of responses can be better fit and equipped to serve the needs of people. Just to kind of state, I think what you referred to, calls to de-center or defund the police, to promote unarmed mental health or other clinicians to respond when they're in crisis. So on the one hand, you find that some people say that these are unrealistic, and on the other hand, you have folks that are saying that they're actually quite possible. And I pointed to the Freedom House Enterprises services, ambulance services, one example of a program during the 60s and 70s that did reallocate and repurpose resources, specifically not just resources from one entity to another, but from an entity that was less equipped to perform a specific role or function to one that was more capable of doing so. And so it's important to note that even during this time, police were not excited or energized about providing emergency care. And yet you had this cadre of people who were very interested in doing so. The sort of sad part about the Freedom House Enterprises program, one which I didn't discuss as much in the history, is that, you know, despite its marked success, it only lasted from 1967 to 1975. And it was able to create all of this momentum and actually become the model, one that was recognized by the U.S. Department of Transportation, and it became the pilot course for the U.S. Department of Transportation, and the White House Interagency Council on EMS became sort of the model and the blueprint for these types of programs. And despite all of this, that program was ended. They cited a growing expenditure. Yet the program that replaced the Freedom House was a predominantly white service that largely used the same model of Freedom House. And so you see this sort of, you know, while they explained that this sort of retreatment was due to finances, it really appeared to be more in racial terms as the people understood it. And so I think when you think about repurposing or reimagining, you know, there are these examples of Freedom House from history, which show that, yes, it is possible to reallocate, but they also show shortfalls and limitations. And I think one of the shortfalls and limitations of Freedom House was that there was a misalignment of the community goals with leadership goals. And so the people who worked in Freedom House were the boots on the ground, really saw it as this sociomedical program. It was as much about improving the health of the citizens as it was about improving their social outcomes. The leadership that largely drove Freedom House, that helped it get its accreditation, that allowed it to sort of become a model for the country, really stressed nationalization, bureaucratization, and standardization of the program. And so what you sometimes see in these types of programs is this misalignment with local and national goals. Nationalization, standardization has rarely sort of benefited communities that have been marginalized. And so it's important to always sort of recognize that various entities and groups might have different motives and motivations for these programs. And in the case of Freedom House, I don't think that nationalization was necessarily bad, but I do think that it was definitely misaligned with the community goals. And so when you have one that sort of wins out over the other, you can get the situation where these programs that have really been built on Black innovation or the efforts and work of marginalized communities disproportionately can also end up not serving them well. And so I think when we think about the shift to reallocating resources, it has to come with the same sense of power. And so I think that goes beyond just having a community member on a board. But a large representation of individuals from the community who know the context, who know the political, social, and other constraints, and who are able to really kind of veto these kinds of power structures. And so it's not enough to just have the sort of, frankly, the token voice there from the community, but really to have real representation. So I do think that reimagining, that repurposing, and that shifting of resources can be really beneficial. But it also has to come with the power that often these communities lack in these types of programs. I think I answered. If I didn't answer your question, then I'm sorry. Help me. You thoroughly answered the question. So it's very much appreciated. One of the areas also, I know, again, you were speaking about multiple levels here. If it's the judicial system, if it's at the police enforcement level, if it's at the community intervention level. So when we think about training and programming, and it did stand out to me when you mentioned helping individuals de-socialize and de-program them from these implicit biases and unconscious biases that they may have with this concept of who's scary versus scared. I know there's always more to be done. But if you were to point to one item or one, I'm not sure we can pinpoint it to just one. And I say that because we continue seeing what law enforcement, unfortunately, not everyone by no means, but now with social media, we're learning even more than just this happening. But also just recently on August 17th, there was an article from the AP News released about kids for cash for judges that were ordered to pay more than $200 million because they literally orchestrated a scheme to send children to for-profit jails in exchange for kickbacks. So if I say that, if you were to begin with one area, where do you think we could potentially better inform them or how would we better inform them on the mental health needs of the community and how they can be an advocate? They won't become experts, but many of these levels need to become advocates. Great question. And you mean levels like judicial, police, community intervention. Yeah, great. I mean, so I think there's actually quite a lot of momentum around these. I think the APA is involved in some of them, at the judicial level, there's the APA's Judges Psychiatric Leadership Initiative that I think, my understanding is also sort of partnered with the National Coalition of Chief Justices. And these individuals have earmarked mental health as a key issue for them and are being very intentional and focused about education. They're interfacing with psychiatrists, the leadership of this program is really looking out for psychiatrists to help train judges, court personnel about mental health. We have various forms of these mobile crisis response, jail diversion programs, and largely I think a lot of medical programs and social programming is sort of built on, oh, here's a model and we can sort of copy it without really sort of recognizing whether that works. It's one of the challenges when you do this kind of research, when you go to look for success or evidence, you find that often there isn't. And so I think funding is a big issue. So funding at the local level, at the federal level to not only implement these programs, but to study them, to see how they're sustained, to find outcomes is really important. I also think that when we talk about, community policing, I think has been a loaded term. There's some work done by Nick John Ramos who is a historian at Drexel who wrote a really influential paper called Pathologizing the Crisis, which looks at race, violence in LA and how the community mental health movement that was sort of promulgated to really deinstitutionalize people to provide more support actually worked in tandem with aggressive policing practices, sort of broken windows era policies that actually increased surveillance and pathologized communities while at the same time not providing adequate resources such that you really didn't get deinstitutionalization, but you got transinstitutionalization. So we have to think about the things that we are doing and sort of, I think that involves more than just sort of top-down decision-making. So it's not enough for the civic officials to say, we're going to create this mental health community policing initiative, but it really needs to be one that's envisioned with the input of all the stakeholders, the community officials, the public, the crisis behavioral health responders. And so that's where I kind of mentioned really having a board, a body, and a planning sort of structure that looks like the community that it serves. And I think that is one of the lessons from Freedom House. While its leadership was largely white physicians, its medical leadership, its business leadership was a biracial group of folks from the community and its actual composition was a people made up from the community. And so I think having community involvement at all of these levels is really essential. And I think, lastly, sort of at the level of training and programming, you just have to be intentional about the ways in which you're teaching, that you're promoting safety, that you're allowing people to voice their concerns, but also about the realities of the system, one in which an individual might be able to recognize that someone is in crisis and they might be able to recognize that this person might have mental illness, but how do you account in real time for the various biases that might cloud your thinking or that might shape your response? And so I think really robust anti-racist programming is needed. And some of this work is being done with the help of psychiatrists, mental health clinicians. I think more programs like co-response where mental health officials work alongside police would be helpful in sort of teaching and promoting education and familiarity and comfort with mental illness. So I think these are all ways that we can start to think about restructuring the current responses to our system. Thank you, Dr. Edwards. And I think, again, I'll say again, I'll restate that you've given us a lot to think about, and I appreciate your time today with us. I appreciate also the audience being here. And as Dr. Edwards mentioned, if you know anyone that would benefit from the Judges and Psychiatrists Leadership Initiative, please do have them visit the APA Foundation website. And on that note, we are out of time, but we have one more slide, Dr. Edwards. Yes, we do. How to claim your credit. So please be sure to follow the instructions below. Don't feel like you have to capture them real quick because if you downloaded the slides, this slide will be in there too, but follow the instructions below, email the learning center at psych.org with any questions you may have. And once again, thank you, Dr. Edwards, and thank you to everyone for attending. On behalf of the American Psychiatric Association, have a great day.

racial inequity

discrimination

mental health

equity

crisis services

criminal legal system

prejudice

racism

structural racism

mental illness