Good afternoon. My name is Dr. Jacqueline Moss Feldman. I'm from the University of Alabama at Birmingham, and it's my distinct honor and privilege today to be able to introduce Dr. Sarah Vinson. Dr. Vinson's a physician who specializes in adult, child, and adolescent and forensic psychiatry. She's the founder of the L'Oreo Psych Group in Atlanta, Georgia-based mental health practice providing expert care and consultation. Dr. Vinson is also the founder of L'Oreo Forensics, which provides consultation in a wide variety of cases in criminal, civil, and family court cases. I was going to read a session description, but I predict you all have read it. That's why you were enticed to come and listen to Dr. Vinson speak. So let me cut to the chase and introduce Dr. Sarah Vinson, who's going to speak to us about social injustice and mental health. Good morning, everybody. I have not quite mastered having to get dressed and wear shoes and make it places, so I apologize that I was running late this morning. But I'm so glad to be able to share this talk with you in person. It's my first time being able to do that with a psychiatry audience, so I'm really grateful for this opportunity. So we'll be talking about social injustice and mental health. And the disclosures are that I have the practice and the forensics company. I receive book royalties from the Social Injustice and Mental Health book. And not a disclosure, but an acknowledgement that I must make is to Dr. Ruth Shim, the book co-editor and my mentor and dear friend. So I wanted to start with an indigenous land acknowledgement. I want to acknowledge that we are on a traditional territory of the Chitimacha and Choctaw people. Their genocide and forced removal is but one example of this nation's roots in injustice. And the second acknowledgement. This week, I want to honor the lives of people who did not lose their lives, but who had them taken for the cause of white supremacy. I also want to acknowledge every person who grieved silently or without support or acknowledgement of this trauma and were expected to go about business as usual. So the agenda. So we'll start with an introduction, talk a little bit about mental health care, then about child trauma, the carceral system, substance use disorders, advocacy, a call to action, and a discussion, which I'm really looking forward to having with this group. So we'll start with, how do you define mental health? And it sounds like a basic question, especially to ask mental health professionals. But the reality is, we spend a lot more time talking about illness, diagnoses, medications, therapeutic modalities, than we do about what health actually looks like. What is our goal? What is our why? This is a definition from the World Health Organization that says, mental health is a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. And I welcome you to reflect on that. It doesn't say anything about symptom attenuation or rating scale scores or whether they're compliant with their medication. A lot of it has to do with relationships in families, in communities, and with the broader society. So this issue of health is so much bigger than the things that we routinely address, assess, treat, intervene around in our clinic settings. The next kind of foundational thing I'd like you to hold is this idea of the American dream. So we are taught to stand and say that this is the land of liberty and justice for all. This is a land of opportunity, where if you work hard enough, you can succeed. And that is the narrative that we are given over and over again through various forms throughout our life. And it's a nice narrative, but what it does is allow us to other people who don't achieve, to other people who don't pull themselves up by their bootstraps. And the reality is, for those of us who are privileged enough to have a job that takes so many years to train, our experience of America may be very different than the people that we're serving. And if we are in historically marginalized and under-resourced communities, it's starkly different. Because as a whole, psychiatrists, nurse practitioners, psychologists start off middle, upper class more so than the rest of the society. And for those of us who didn't, the dream worked. Working hard in school worked, and you were able to have a different station in life. That is not the reality for many in our country. And if you're in a public sector setting, it's not the reality for many of the people that you are trying to take care of. If you've ever been to London, you ride the train, they say over and over and over again, mind the gap. They have it on t-shirts, it's a whole thing. It's annoying how often they say it. But it's important, because if you don't mind the gap, something really bad could happen. And I think it's the same for what we do as providers, as leaders, as teachers, as educators. We have to be mindful of the gaps between our lived experiences, and our privilege, and the people that we say that we are serving. So I do want to acknowledge that the House of Medicine is divided on this. Everyone doesn't think about this the same way. By virtue of you self-selecting to come to this talk at 10.30 on a Saturday morning, I can guess what camp you stand in, but we can't say that we are all on the same page. And we need to take a minute to think about that. So Take 2 Aspirin and Call Me By My Pronouns, by Dr. Stanley Goldfarb, was an editorial in a major publication, and he bemoaned the fact that curricula will increasingly focus on climate change, social inequities, gun violence bias, and other progressive causes only tangentially related to treating illness. And so will many of your doctors in coming years. Why have medical schools, and maybe he would ask why has the APA, become a target for inculcating social policy when the stated purpose of medical education since Hippocrates has been to develop individuals who know how to cure patients. And one of the responses to that editorial was social and health policies have always determined who gets sick, and who gets care, and where and how. Understanding the social drivers of health and illness is not peripheral or tangential to health. It is key to diagnosing and meeting a patient's fundamental needs. So social justice is one of those words that has become politically charged, polarized, whatever label you want to apply to it. Sometimes it's useful to just go back and see what the definition is. And it is assuring, and this is one by John Rawls, assuring the protection of equal access to liberties, rights, and opportunities, as well as taking care of the least advantaged members of society. And some principles of social injustice. And as we go through these, I welcome you to reflect on your medical school training experience, your residency, maybe even some CMEs you've gone to, and see if any of these things have shown up there. So one is essentialism, the belief that there are distinct, unchanging, and natural characteristics that define social groups and facilitate their categorization. An example of this might be those well-intended cultural competency seminars that say things like, Latinx people do this, Asian people do this, black people do this. Erasure of context, failure to consider sociohistorical context when seeking to understand the ideology of inequities. So one of the things you may hear people say, again, in some of these well-intentioned seminars, is that black Americans have cultural distrust that keeps them from engaging in treatment services. That fails to account for the fact that systems often have not served them well, if they've served them at all, and that it's an experience-based mistrust, not something that's based in black people's culture. Biological determinism, the false belief that racial groups are biologically and genetically different. Types of oppression. So with this one, I welcome you to think about how these experiences would undermine those elements of mental health that we went through earlier. And also think about how they inform your patient's experiences and how they may report symptoms to you. Exploitation, the unequal exchange of one group's labor and energies for another group's advantage and advancement. Cultural imperialism, establishing the ruling class culture as the norm, othering of groups that are not part of the dominant culture. And this is another thing we see in medical and psychiatric and mental health education a lot, right? How many of you have been to a cultural competency seminar where they talk about white culture? One. We got one in a room of a lot of people. That is an example of cultural imperialism. Powerlessness, oppressed groups lack power and are blocked from routes to gaining power. Marginalization, expelling specific groups from meaningful participation in society. And violence, threats and experiences of physical and structural violence. And what is meant by structural violence there is when systems, as they routinely operate, are actually sources of harm. So health disparities. These are differences in health status among distinct segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability or living in various geographic localities. I'm sure you all know that. The point of me putting that up there is to challenge you, as my dear friend Dr. Shim always does, to think about every disparity as an actual inequity. And what's the difference? With inequities, you are explicitly acknowledging that these differences didn't just come about. They're not just interesting findings, but they are the result of systemic, avoidable and unjust social and economic policies and practices that create barriers to opportunity. So we are talking a whole lot more about social determinants of health now. We have committees and task force and presidential commissions and reports from SAMHSA and all of these things. And we talked about it more, but our outcomes haven't really become more equitable. And part of that, I think, is that we're not looking at the determinants of those social determinants. And by the time we start talking about homelessness, adverse features of the built environment, food insecurity, trauma, underemployment, people not having the education they need to advance, at that point, they've already been exposed to the thing that is raising their risk. We got to go more upstream. And how is it that in a society with as many resources as ours, that we routinely expose large swaths of the society to things that we know are harmful, not only for their mental health, but also for their physical health? And this is fundamentally a question of social justice, because that unfair and unjust distribution of opportunity leads to people being exposed to these social determinants of health. And what drives that, the bedrock for it, are our public policies and our social norms. And those social norms and that narratives and those policies work together to create this society that is so ripe with inequalities. Next, we'll go into mental health care. So the chapter authors for the health care system chapter did a fantastic job, and they led with the argument that the health care system is actually a misnomer. And here's why. They said, the name implies provision of health, but providers and policies focus on the provision of clinical services. Care suggests services involve meeting the needs of patients, but services are more centered on the needs of providers and bottom lines of payers and shareholders. System implies an organized, cohesive, connected structure, rather than the public-private patchwork of hospitals, clinics, private offices, and health system conglomerates that make up health care. So we're thinking about social injustice in mental health, how people get care, what shapes their experience of health care. Private health insurance is a major one. So it's a mediator of access, but it's concentrated largely among middle-class workers and skilled labor and white-collar occupations. Well, who's set on a trajectory early in life to have those occupations that come with that private insurance? So structural processes, such as underinvestment in K-12 education, job location mismatch, hiring discrimination, all produce inequities in overall employment and types by gender, race, ethnicity, immigration status, and disability. And by way of one example, black and Latinx people are disproportionately represented and uninsured in those with public insurance. When we look at hospitals, we don't have the most hospitals where we have the most need, or the hospitals with the most services where we have the most need. We see inequities that arise from the confluence of residential segregation, hospital imperatives to generate revenue, and state policymaking. And hospitals may not say, we don't take these kind of people here, but they may not have an ER, or they may be on another side of town that's not on a bus route. So there are ways of denying people care and perpetuating inequities. And then physicians. So we know that there's a mismatch of providers versus the population, with the medical profession reflecting the consequences of economic and social inequality of the U.S. society at large. So in 2019, only 5% of medical students reported parental incomes in the bottom quintile of the U.S. household, versus 51% in the top. From 2010 to 2016, while mean debt did rise, the percentage of zero debt, so people with families who can just write a check for medical school tuition, rose from 16% to 27%. Perhaps the most consistent predictor of practice in communities with chronic underinvestment is that you have some tie to that community. The medical system, the training system, is structured in a way that makes it very hard for people from those communities to make it through. And so in 2018, 69% of black adults with any mental illness received no treatment, 42% of black adults with serious mental illness received no treatment, 67% of Latinx adults with any mental illness received no treatment, and 44% of Latinx adults with serious mental illness received no treatment. And we know that there are inequities within healthcare in terms of how mental health is treated. So we're dealing with things, even with parody on the books, like capstone coverage, cost sharing, benefit limits, and lower reimbursement rates. And what this causes at a systems level is that a lot of people opt out of the system and a lot of hospitals, quite frankly, aren't incentivized to devote precious real estate to mental health care. The proportion of mental health services received out of network is 3.6 to 5.8 times higher than in other medical specialties. So what that means is societal inequities in income and in resource allocation are going to have a disproportionate impact on people's access to mental health care. So again, those well-intentioned cultural competency seminars, they're going to talk about stigma, they're going to talk about people going to church instead, they're going to talk about people not understanding what's going on. But there was a study where Lang and his associates actually just asked black people, why don't you get mental health services? And what they said is cost. Cost was the most commonly cited reason for not seeking care twice as often as minimization of symptoms and nearly five times as often as stigma. When have you ever heard that raised as an issue in these cultural competency seminars that are looking at inequities? And there's a purpose to that, right? There's a reason that the focus is on that instead of this. Next we'll go into substance use disorders. So this is a nice illustration of that cultural norm narrative part of the social injustice in mental health. So with substance use, someone or something, or we could probably say a group of people that's associated with the substance is perceived and defined as a threat to social norms. News media and communities depict the threat in symbolic ways. Widespread public concern is aroused by these portrayals. Authorities and policymakers respond to the threat with new laws or policies, and these actions lead to social change in the community. And so we saw this, of course, with the cocaine epidemic. And by the way, people are still dying from cocaine now, even though you don't hear it talked about much. And Ernest Drucker in A Plague of Prisons said the fundamental clinical accountability of drug treatment professionals to individual patients has been subordinated to the goals of the criminal justice system. And in part, this is because the group of people that was associated with this particular pandemic or epidemic was one that was already othered, marginalized, thought of as bad, framed as criminals. And so the substance use issues in this population were placed in the criminal justice system. And I'm sure you're aware of the crack cocaine disparity, which has since been adjusted, but you still have a generation of people, families, and communities that were affected by it when it was in place. Let's contrast that with how the opioid epidemic has been responded to. With the population, that is the face of the opioid epidemic. And the differences that we've seen, not only in the narrative and how it's talked about, but in research dollars, in treatment dollars, in training, go to the APA substance use website and look at how much is there about cocaine or meth and how much is there about opiates. Because the people we associate with this epidemic are people we value. So one headline is children of the opioid epidemic in the midst of a national opioid crisis, mothers addicted to drugs struggle to get off them for their baby's sake and their own. In contrast, that with crack babies, the worst threat is mom herself. We know that they are both substance use disorders. It is the social framing of them that has led to the difference in response. And so when we look at those inequities for accessing treatment, they're even worse with substance use because that narrative, that marginalization, that othering is even worse with substance use. Eighty-nine percent of Latinx adults with substance use disorders reported receiving no treatment, and 88 percent of black adults with substance use disorder reported receiving no treatment. Next we go to child trauma. So I had the incredible privilege of training at Cambridge Health Alliance for my general psych residency and working directly under Dr. Judith Herman, and it's one of those things that you look back 15 years later now and see all the ways it's shaped my career and how I think about things. But she wrote this book, Trauma and Recovery, and in the book she's focused on interpersonal traumas that take place within families that happen over periods of time. And one of the things that she says is the developing child's positive sense of self depends on the caregiver's benign use of power. So she wasn't talking about structural trauma there, but when she describes the trauma that children in these households experience, to me there are clear parallels to structural trauma because it's at the hand of someone who's more powerful. It's inescapable. It happens over an extended period of time. So I think there are things that we can learn about understanding structural trauma from thinking about complex trauma as it's defined by Dr. Herman in this book. And I would posit that when we're thinking about mental health, the World Health Organization definition that talks about how you operate in society, your relationships, that's broader. The caregiver, I would argue, includes the societal systems that are supposed to position children to be productive adults. So as Dr. Feldman mentioned, I wear a few hats, and these are three people I've met in very different circumstances. One was an adult defendant in a capital murder case, so I was brought in as the mitigation expert. And he told me, as we were going through his history and talking about his childhood, I was proud to make it to 21 even though I was in prison. The second was a software programmer in my private practice clinic. When I asked him about his childhood, he said, school was all I ever really had to worry about. And the third was a teenager in a regional youth detention center who said, they say I'm supposed to care about people when ain't nobody cared for me. And so we know that when it comes to mental well-being, there are protective factors. There are things that set people up to be able to achieve that definition of mental health. Things like a true home with housing stability, food security, and having basic needs met. A reliable caregiver, somebody who is consistent, available, can instill a sense of worth, and can advocate for a child. Educational opportunities, things like safe schools, that they're prepared for a career or college, and that they have special education resources, and health care, be that medical care or mental health care, and thinking about both adequacy and access. So child poverty is something that affects one out of six U.S. children. And it's always useful, I think, to put what the threshold is because it's $26,500 for a family of four. We know lots of families live in places where $40,000 doesn't consistently meet their need. So that one out of six, even though it's a really high number, is an artificially low number of when you think about the families that can't consistently provide for their children. Seventy-three percent are children of color, and the child poverty rate is nearly one and a half times higher than that for adults ages 18 to 64. Sometimes when we talk about disadvantaged groups, we don't think about children as one of those groups, but by every statistical measure, they absolutely are. And this is allowed to happen in a country that spends over $700 billion a year on defense, which is more than the next 10 countries combined. This is not a matter of not having the resources to allocate. It's a matter of choices. It's also in a country where the majority of U.S. lawmakers are millionaires. Bryan Stevenson, the attorney advocate, I could go on talking about all the things he is, but he says that part of our problem is that the people making decisions and trying to solve the problem have no proximity to the problem, right? And this is a key example of that. And so when you have one out of six, and we all know that number is higher because that number is artificially low, children in our society living in poverty, you're setting them up. You're setting that family up to have things like no true home, strained caregivers, unmet educational needs, and limited access. So to go back to Miguel, and I have changed his name for the purpose of the presentation, who told me, I was proud to make it to 21 even though I was in prison. So he was proud to make it to 21 because so many people around him had not made it there. And he was incarcerated from the age of 17 to 21, and he mused that maybe that was part of why he made it to 21. He was incarcerated during this really critical developmental and social stage for violation of plan after being found in possession of a small amount of marijuana. And the original charge was something that was nonviolent. And what we see is that these unmet needs equal Department of Juvenile Justice risk factors. There's a parallel between those adverse childhood experiences and things that we know statistically put people at risk. That is not a coincidence. So when you look at those physiological needs, poverty, community instability, community crime, and availability of firearms were all part of what he grew up around. So his sense of safety, this idea that he was going to grow up to be an adult or even make it to 21 was not something that he grew up with. And not only was it something that was threatened in the broader society, but also within his own family where he was a victimization of maltreatment, family conflict and violence, erratic and harsh parenting, and inadequate educational resources. He was placed in a series of foster homes, had poor supervision, couldn't attach to anybody because he kept moving, had a sibling with some significant antisocial behavior, and low school attachment is the risk factor that forensic psychiatrists talk about. But he couldn't really be attached to a school because he kept being moved. And he had unmet learning issues that were never addressed. So he developed a negative attitude towards school. He developed an external locus of control and a resignation to justice system involvement. And with all of those things in play, he didn't even trust that he was going to have a future, let alone believe that his actions were going to play a major role in what that future looked like. And so when we think about this from a structural standpoint, how is it that somebody's incarcerated from 17 to 21 on a nonviolent charge? He was part of a state that had low mental health spending, some of the lowest in the country, child protective services understaffing, and it was a time when there was a narrative that you do adult crime, you do adult time, right? He was placed in 12 different foster care placements, which meant his educational needs weren't met, his mental health needs weren't met. He attempted suicide for the first time when he was seven years old and had forgot about it until he was facing the death penalty. And of course, he dealt with these other things at the neighborhood and family level. And so all of this sets the stage for the overrepresentation for youth with mental illness in the justice system. It is the de facto mental health care system for kids in many communities. 70% have mental illness, 30% have serious mental illness, and I would say that that is probably an undercounting because of the undercounting of trauma, which we will go into shortly. Oh, next. So whose trauma counts? And again, this goes back to inequities. This goes back to who we value. This goes back to whose experiences we value. Whose trauma counts in our diagnostic criteria, in our widely used instruments? And then there are times when we are the bystanders. So actually, I'll go back to this. So if you look at the criteria A in PTSD, it doesn't count for things like race-based trauma, community violence, things that absolutely have implications for how people think, feel, or behave, but that occur in neighborhoods, communities, disproportionately to people that medicine hasn't valued in the same way. In our widely used instruments, one example could be the original 10-Question-Ace study, or the 10-item questionnaire. That questionnaire was normed on a middle-class, largely white group of people in Northern California that were mostly college-educated. It doesn't represent the people I take care of in the clinic. So it left out some things that impact them, and yet this has been adopted in many places without accounting for the fact that it ignores a lot of traumas that are quite relevant to the people that you're serving. And there's a way that not having that in our criteria, not having that in our screening material, not having these traumas that disproportionately impact marginalized groups in how we think about what we do results in us being bystanders, results in us having people who are dealing with these traumas and the repercussions of them in front of us and not recognizing what's happening. And what I've seen as a forensic psychiatrist is that there's a way that our failure to acknowledge these traumas, to see them, to account for them, to capture them, to describe them, actually perpetuates that trauma when they end up ensnared in the criminal justice system. How so? Well, if you label a kid oppositional defiant disorder, conduct disorder, antisocial, he's a black or brown boy in an over-policed community, what do you think that diagnosis says to a judge, to a probation officer, even to their own defense attorney who doesn't think to order a mental health evaluation for them because they just think they're on this antisocial trajectory? I have seen kids who have had their parents murdered in front of them, who have been placed in trunks of cars, who have been shot repeatedly, and their formulation makes no mention of their trauma. Over and over again, where their first real trauma evaluation is when they see me when they're facing the death penalty. Our system is a part of that, and our failures in our system have implications for a system that sometimes is literally deciding life or death. Our blind spots have implications, not just for how we think about our patients, for how we treat them, for the harm or the help that we provide, but for how they're seen in the broader society because your pen, your diagnoses, your notes have power. This is a still shot of a clip of a young boy who was playing basketball in his own front yard. He wasn't doing anything wrong. He saw the police officer driving by, he stopped playing, hid behind a car as the police officer drove by, and then once the police officer is out of the frame, he resumes playing basketball. His father saw him, saw this play out on the home security footage, and asked this young man why he did that. The young boy's response was because they killed George Floyd. When you see people who look like you murdered by people in positions of authority, whether you know that person or not, that affects how you feel, how you think, how you behave. Sounds a whole lot like mental health. I'll leave it there. The thing about the criminal justice system and the inequities there is that what happened to Mr. Floyd and to so many others is the tip of the iceberg. That is the part of injustice in the criminal justice system that goes viral. There are many layers to injustice that have implications for people's lives that we just don't see in such graphic detail. Most judges actually acknowledge that the system is racist, and 80% of state judges are white, and what we see is that we can demonstrate over and over and over again that sentencing outcomes, controlling for past record, controlling for the crime, sentencing outcomes are different by race, and once you look at black people, not only are they different by race, they're different by how dark-skinned you are. This brings me to advocacy. There's inequality where there's unequal access to opportunities, equality where you're trying to evenly distribute tools and assistance, equity, custom tools that identify and address inequality, and justice, fixing the system to offer equal access to both tools and opportunities. James Baldwin said, ignorance allied with power is the most ferocious enemy justice can have. You are privileged people, and privilege is not always a bad thing if you decide to intentionally leverage it for good. You are physicians. You are people who can diagnose folks. You make more than most folks in the United States. You are people that have power. Being ignorant to these issues simply is not an option. So I had the privilege of interviewing Raymond Santana, who some of you may recognize. He's part of the now-called Exonerated Five, formerly known as the Central Park Five. He was imprisoned at the age of 14, was there for seven years. Once he got out and they acknowledged that he shouldn't have been there, it took another 12 years for his civil suit to settle. But one of the things that he said is that we need all hands on deck. I don't need all of you to go become legislators and push out some of those millionaires. Not to say that none of you are millionaires, I'm sure some of you are. But what he was saying was, wherever you are, there's something you can do about these issues. I don't know how many secession fans we have here. Maybe some of you recognize these characters. I'll explain a little bit about them if you don't know them. But there is a character named Cousin Greg, who just kind of gets swept into this really rich, dysfunctional family, doesn't really know what's going on. He's everybody's kind of patsy, really gullible, goofy. Maybe the one person out of this family of terrible rich people that you feel a little bit sorry for. Then you have Roman, who's one of the siblings in this really rich family. And he's a wise aleck, he's always cracking jokes, he doesn't take anything seriously, uses a lot, a lot of profanity. And Kiernan Culkin, the guy in the middle, actually auditioned to play Cousin Greg. And he didn't get the part. And as he was reading for Cousin Greg's part, he was seeing Cousin Greg interact with this character named Roman. And he was like, I should be playing this guy. I could do really well in this role. They weren't casting for Roman yet, but he was so convinced that he should be in this role, he sent in a video of himself running Roman's lines. He was cast as Roman, and he does a beautiful job as an actor in that role. The point of that story is that every role is not for everybody. And I want you to be curious about what your role is, and not be discouraged when you find out roles aren't for you. So three questions. What do you feel deeply inspired by? What are you particularly talented at? And what addresses injustice in your world? So four steps to advocacy. Develop a knowledge base. Recognize injustice and your role in addressing it. Respond to injustice and iterate and sustain. I'm really, really glad y'all are here this morning, but this is not the work. Two, three, and four is the work. And by way of some examples, Your Advocacy Ain't Like Mine, and that's a homage to B.B. Moore Campbell. A few examples of how people have forwarded justice through medicine. So in the top right corner is Dr. Joe Bona, who passed away a couple of years ago, but he was a tremendous mentor and sponsor of mine. And he was a white male physician's son from Buffalo, New York, who took a lot of folks like me, who are first generation physicians under his wing, and taught us about local advocacy and leadership, who was a tremendous leader in the state of Georgia. And then Women Recovery, the book by Dr. Judith Hartman, that centered the experiences of women and children, victims, in a way that really hadn't been done before she did that. And it's an example of doing that through scholarship. Dr. Annelle Prim, who I'm sure many of you know, was a mentor and sponsor, and continues to be for me, but really for a generation of psychiatrists of color. And in thinking about how we do it in education. I'm the director of a child psychiatry fellowship, and we have a black child psychiatry course as part of that fellowship. So there are ways you can infuse it into whatever you're doing, and using whatever power you have. So one of the things that comes up in talking about this is, these issues are big, they're heavy. Yes, that's true. And one of the things that may be hard to maintain is hope. And this is something that a friend kind of mentioned to me in passing, and actually, the economist who I'm doing the Monday plenary with, he's the one who brought this up to me. He has an appointment in the Harvard School of Education. But we were talking about some of these things one day, and he's like, you have like a critical hope orientation. And I was like, do I? What is that? So I learned a little bit about it. And it's an educational approach where a student learns theories in the classroom and at the same time volunteers with an agency and engages in reflection activities to deepen their understanding of what is being taught. And I would say that this has parallels for us in residency education, fellowship education, those kinds of things. And what it does from the outset is pair that hope with the embrace of emotional elements, including tension, ambiguity, and discomfort, just owning that this is part of the process. It is not naive hope or blind faith. Things will get better. Things are going the right direction. None of that platitude stuff. It's not hokey hope based on the bootstraps narrative. It's not mythical hope based on false narratives of equal opportunity emptied of its historical and political contingencies. And it is also not hope deferred or critique without engagement. It means that the person is involved in a critical analysis of power relations and how they constitute one's emotional ways of being in the world while attempting to construct imaginatively and materially a different, and I would add, more just life world. And understand, too, the work is hard. And part of it is going to challenge the existing hierarchies and structure. And people who benefit from the existing hierarchies and structure are not going to like you challenging it. And so part of you making progress is that there will be retrenchment. There will be ways in which this progress and those who champion it, maybe you, are going to be challenged, neutralized, or undermined as part of the process. So I end with a question. How can every individual, well, don't quite end, got one more slide. How can every individual realize his or her own potential, work productively and fruitfully, and make a contribution to her or his community, that definition of mental health, in a society that fails to assure equal access to liberties, rights, and opportunities, and chooses not to care for its least advantaged members? And I would posit that society simply cannot. And now I end with a quotation by John Lewis, who said, do not get lost in a sea of despair. Be hopeful. Be optimistic. Our struggle is not the struggle of a day, a week, a month, or a year. It is the struggle of a lifetime. Never ever be afraid to make some noise and get in good trouble, necessary trouble. Thank you all. Dr. Benson, thank you very much for that inspiring talk. Thank you. We now have an opportunity. We have plenty of time for questions. This session is being recorded, so I would ask that if you have a question or a comment, please come up to the microphone and say your name and ask your question or make your comment. Thank you for this wonderful presentation. I think most of us in this room would be committed to all the ideals and the views that you present here. The challenge, of course, is half of the country, which does not share that, does not share empathy for us, and so I'm just curious how you hold that tension. Thank you so much for that, and that tension is there, but sometimes I think you'd be surprised at how, on some issues, maybe you can still find a common ground, and I'll ... Well, we're being recorded. I wish the Q&A wasn't recorded. Let's just say I live in a place where the governor campaigned on rounding up the illegals, and he's appointed me to two different commissions, me. Very clear about who I am and what I'm about, right? Sometimes there are ways that we can still use the resources of people who may not be entirely aligned with us to serve our purposes and our goals, and one of the questions that I think we all are going to grapple with is that balance between being righteous and being effective and some of the trade-offs we have to make sometimes, especially if you're in places that are ... Where leaders may not see things the way that we do. The other thing that I'll say is important, though, is that if half feels that way, there's another half that doesn't, right? Let's make sure that we are building each other up, that we are sharing best practices, that we are resources for one another personally, as well as we're doing this hard work, and so not allowing that to take all of our energy and focus from the things that are absolutely within our power and our control to do. Thank you for this wonderful session. I wanted to ask a question as someone who works within a jail as my primary clinical site, and one of the things I've really struggled with is this tension between working within an incredibly oppressive system and yet feeling called to be there in part due to the incredible need that's there. I know in forensic work, there's some tension between, again, being part of this system and having to ostensibly be neutral within that system, and yet wanting to ... Being an advocate and being a champion of social justice at the same time, and I'm just curious if you could speak a little bit more to reconciling that tension in terms of working within, yet being opposed to the way a system operates. Thank you so much for that question, and it's one that I get a lot and have thought about. Hopefully, I remember. I was going to say there's three parts. Hopefully, I remember my three-part response to your question, but the first is that one of the things that I think is helpful is to work with what you have now and try to also be a force for change so that it looks different. Right now, a lot of people are in that system who need our help. We can help those people while also trying to change it so that so many of them aren't there. I'll give an example, and I see Dr. Champion. Dr. Champion, wait. Dr. Champion and I are in the Judges Psychiatry Leadership Initiative, and we work with judges, and we train them about people with mental illness, and we encourage them to get them out of jail and out of the system, and so we're not just working in the system. We're actually working on the system and speaking to people who have power and ability to make it different, and so I think that if you want to think about this, there's the service that you can do in the system but also on the system, and you would be surprised at what happens when you show up with your credentials, your experience as a physician in places where they're just not used to seeing us show up. The reception that we get from judges is tremendous, and I think it's because they're not used to hearing from us because we just don't take the time to do it. It's not something we're taught to do to show up in that way, so that's one piece of it. When it comes to serving people who are in an oppressive system, some could argue that there are aspects of the mental healthcare system that are oppressive, too. Every major system in American society has elements of these things. They're the systems that do it in a more egregious way that lends itself more to going viral, but there are ways that inequities in the healthcare system kill people as well, and so it's not something that is escapable as long as you're operating and functioning in this society, and I will say that as a forensic psychiatrist, when I was previously doing treatment in a juvenile justice facility, one of the things that I appreciated about the opportunity to work there is that so many of the people I saw had had people in positions of authority who were supposed to help them not help them, not see them, not hear them, so to be able to be the person who does that for somebody at a critical juncture in their lives when critical decisions are being made, regardless of what the outcome in the case is, I want to be that person who hears and sees them, and I have had a number of legal teams that say, you were the first doctor he ever liked, you were the first doctor he ever told about that, and to me, that is a reason to be there despite all of the other issues, and then as a forensic psychiatrist, again, I wrote the book, Social Injustice to Mental Health, so they know who I am, what my orientation is, and what I'll say is that even the people on the other side, a lot of judges want to actually get it right, so when I'm able to talk about things that impact the people they see and help them understand it in context in a way that other forensic psychiatrists cannot, they respect that. I had an Alabama judge who I did an evaluation for, the next time he did an evaluation for a client, he ordered the lawyer to hire me, me, right, so I would, that narrative that you can't think about social justice or you can't be an advocate and be a forensic psychiatrist is one that I think is put forth by people who want things to stay the same. My experience with the, in business world, what you would call the end product user, is that they really respect it, actually. Hi, Dr. Vincent, thank you so much for your talk, and also your advice, what I'm hearing a lot is the importance of relationship building, and being in the space, and showing up, because there's a lot of ideas about, but it might not have even been explicitly told to people about how something will or won't work out, so grounding in this, you know, advocacy through relating to others, I appreciate that guidance. I was, one thing that was brought up for me during this talk was this, well, aspects of what people might call the cultural war that we're, it seems like we're always in, but this idea that it's the news that's the problem, you know, if things weren't so inflammatory, then people wouldn't, you know, have these issues, and it's more that, you know, it's people are more aware of things, and so that's kind of like a self-perpetuating cycle, rather than necessarily acknowledging the root problems. In your experience, is that an ideal that you've dealt with, and then how do you approach it and work with people who have this idea that, you know, people are just so sensitive nowadays, or, you know, everything's getting, you know, blown out of proportion? Thank you. Thank you for that. How many of you have read Caste? If you're in this talk, you would love it. Read it. It's great. It, and I had a really interesting conversation about Caste with one of my classmates from residency, so, you know, I'm dark-skinned black woman from deep south. He's a white male from the Midwest, but he was my best friend out of our residency cohort. And as he was reading Caste, which is a book about social inequities in America, and really compares it to caste systems in other countries, and talks about the parallels there. It's brilliant. As he was reading this book, he was distraught. He was upset. He couldn't believe that this was American society. It was disturbing for him, right? As I was reading this book, I was like, this explains so much. This is one of the most validating experiences of my life, personally and professionally, right? Same book. Same exact book. And so my answer to your question is that I think, well, sorry, I got sidetracked on that. So one of the things she talks about in Caste is lynching. And that when this was routinely done, not to say that it's not ever done still now, because it is, but that people would send out lynching postcards, pictures of lynched bodies. So that was the media in that day, right? It's new at a rate, now it's Instagram, but they were lynching postcards back in the day. So this idea that injustice, inequity was spread, that people knew about violence that perpetuated against people of color or against marginalized groups, not new. What's new is that you marginalized groups are talking back now. And people don't like it, right? What's new is, and we could have a whole other talk about like social media and those kinds of things. But there's something that social media has done that I think enabled Black Lives Matter and some of these other movements to take hold, because what it did was it democratized the narrative in a way that it hadn't been before. So if the murder of Ahmaud Arbery had to go through traditional media channels, be filtered through traditional editors, and you know what I mean by traditional and the code words I'm using there, does that get the same traction and attention if you don't have Twitter? If you don't have Instagram? If you don't have a group of people and a community that can help drive a narrative that then gets it into these other spaces? Without those things, his killers don't face prosecution. And there are people who don't want people like his killers to face prosecution. They're going to have a problem with a narrative that is democratized, right? Because it's serving to disrupt the existing hierarchy where one group has decided what story gets told. So it's not that it's causing the problem, right? The actual problem is you're murdering and killing people, right? The problem isn't that we're talking about it. Hi, thank you for the presentation. My name is Julio. I'm an IMG. I just matched this year, so- Congratulations. Thank you. Thank you. Thank you. Welcome to the field. Yeah. Thank you. And for a little while, I've been doing research on DEI. That's one of the things that ended up getting me this opportunity that I'm having now. And there is a lot of resistance. Medicine is really hierarchical. And a lot of the things that we've been talking and discussing, there are people outside of these walls. They are not happy with all of those things that we're talking here, that you're talking here. And I've experienced that firsthand on the research that I've been doing. And I'm really worried because starting my career in psychiatry and how hierarchical medicine is, I'm always afraid of talking up about those sorts of things. You gave some wonderful advice for being an advocate. Do you have a little more for those of us who are trying to do that, but still being pressured by that hierarchy? Thank you. Thank you so much for that lovely question. And one thing I'll say is, I pick up mentees everywhere. So please feel free to contact me and I'll help you. But I think that one of the things that you have to do in medicine, and again, this is one of those things that's not really taught, is to think about who you are, what matters to you, and then be intentional about creating a career that centers those things. And you have to be clear on what those things are, because if you're not, other people will decide for you. And as you said, medicine is very hierarchical. And so what I often find is that once people aren't residents, aren't fellows anymore, they still think like they are in some ways, where they don't realize the privilege and the agency that they have. So there may be ways where you have to bite your tongue at certain moments now, but learn, observe. And when you're in a position to shape your career, understand that you have a lot of power. And that's not to say that I picked up everything when I was a trainee, because I definitely did it. I felt like I couldn't, and that's okay. There's something to be said about being strategic and being in a place where you're in the room. And actually, this is something that Ruth and I talked about, it's like, there are ways that we played the game until we're at all the tables, and now we're there, and you're stuck with us. And this is how we think about things. Some people didn't see it coming. So there's a way that you understand the system, right? You check off the box, right? So you go to residency and you learn the things they want you to learn in residency, but you're learning about stuff like this too. So when you get out and you know their language, but you know this other stuff too, you are going to have a skill set that people are going to respond to. So understand it's a long road. And also, the other thing I'd say too, though, and this is going to be different depending on where you are. I have seen residency programs that have come a long way because residents decided it was important and residents pushed for it. And it was a, if we're looking at the hierarchy, bottom-up progression. And I think a lot of what we're going to see in terms of medicine moving forward is going to come from your generation. I feel like, you know, we got reinforcements coming with people like you in the pipeline. I'm serious. And that is part of what makes me hopeful about the future of mental health and in medicine. So don't underestimate what you can do now too. I have a question about your forensic work. Do you have to sort of get through to each judge individually? And what does that feel like when you do? Where are they coming from? How open are they to look at mental health in a different way? And then would there be a way of reaching them in a more broad way and not individually? Sure. And so, you know, judges are people. So some get it, some don't. Some are open, some aren't. But my goal is that I get to the people that are open or workable. And also, you know, just the way the legal system works, even if it doesn't work with that judge, maybe it works with the appeals judge or with some judge who sees it down the line. And part of that job too, the way that I see it, is that I'm also educating the legal teams. So even if it doesn't work with this judge, this legal team now knows to think about structural trauma and racism when they're thinking about their client. So their next client, they get an evaluator who can help them with those things, and maybe that's in front of a different judge. And so it's not just about that case, but the way that I see the job, I'm a consultant and educator to everybody on that team. In terms of reaching multiple judges at a time, so as I mentioned, the Judges Psychiatry Leadership Initiative, which is a partnership with the APA Foundation and Center for State Courts, we are able to be part of training judges throughout the country. So we work on a curriculum, we do trainings, we have a series of judges' meetings. And so that's part of sort of trying to do it on a broader scale. And at this point in my career, I do as many CLE talks, Continuing Legal Education talks, as Continuing Medical Education talks. That's on purpose. I make time for it, because I understand they make a lot of decisions about people's mental health that we don't have a hand in otherwise. Good morning, Dr. Vincent. Hi, Chidi. Hi. Chidi's one of our rockstar residents at Morehouse School of Medicine. Thank you. Thank you very much. Well, thank you, and thank you for the talk. I was wondering if you could share, I guess, a specific example of how misdiagnosis, in terms of children, adolescents, like you mentioned with conduct disorder, DMDD, whatever the new DSM term is, how that manifests in the legal system and funnels them into more severe sentencing and those aspects. And then secondly, within the child adolescent arena, do you view any specific areas that are unique to that population versus adults in this social injustice space that we could advocate for? What was the last part of your second question? You said that lead to? For the first, for the second question? Are there any specific areas with children, adolescents that is unique from adults that we can utilize to advocate for that population? Gotcha. So I see it, I would say I see it more often than not, actually. It's not the exception, where there's been a focus on the behavior, right? They've been sent to anger management classes or substance use groups or drug tested, and nobody has done anything to address their trauma in terms of the treatment that they've received. So I'm looking back at someone's record and seeing they found their mother dead from a drug overdose, and yet that trauma's not mentioned in their formulation or in their treatment plan, and everybody's telling them to stop smoking marijuana. Like these are the treatment records I'm going through. This is a recent case. And this is actually somebody who was sentenced to life without parole as a juvenile who's, they're looking at it. So it's the rule that things that are trauma responses aren't framed that way, and they're given these diagnoses that we know are kind of code for they're a bad egg, that aren't like really mental health or thought about as mental health. And so they're not thought of as having a mental health history when they're looked at by these deciders in court. And these things aren't explored. The young man that found his mother dead from the drug overdose, he's now in his mid-30s. He's been in prison since he was 17. That was never addressed till after he was convicted to life without parole. And so it happens a lot. And one of the questions I get is, well, if it doesn't, I mean, that's something that should have caught somebody's eye, but if it's some kind of trauma that maybe criteria A of PTSD doesn't neatly capture, well, how do you capture that if the criteria doesn't? Well, there's trauma and stressor-related disorder in OS. There's your formulation where you're supposed to be writing about the different contributors to how somebody is presenting in front of you. There are ways to make sure you document it. The other thing that I would say too, as a physician and thinking of our charge not to do harm is really being thoughtful about ODD and CD in a kid's chart, especially a kid in an over-policed communities chart, because it helps, it helps if they end up in the system, if that's not there. And not to say that you shouldn't have accurate medical records, but I think we should be critical of those diagnoses, how they're used, where they were created, and what they miss. And if trauma is a better explanation of it, making sure that your note reflects that. And there's actually a chapter in the book written by George Woods, who I call my forensics godfather, and a psychologist that really walks through antisocial personality disorder and all of the problems with it that I think is a helpful read. And then in terms of what we can do, like I said, being really careful about those diagnoses, and then being really intentional about asking about those traumas we're not taught to ask about, knowing about the communities where the people you're serving are coming from. So you have the original 10-part ACE questionnaire, but you also have the Philadelphia ACEs. Have any of you used those? If you're in public sector psych, that's the one you should be using, not the 10-question one. Because it asks about things that are relevant to folks in those communities. And the other thing that I'll say as a clinician is often we don't live in the places where our clients do. And so you don't wanna assume, right, but it is useful for you to be educated about those areas. So I remember being in clinic one year, and one of the residents was telling the family they should go on walks together, and he didn't realize how many homicides have been within a two-mile block of where the kid lived, right? You should have some awareness of the things that are happening in the communities. One of the things that, and it's embarrassing to say it, but I was working on a side of Atlanta for five years doing child psych before I looked up information about the school system there. And the graduation rate actually wasn't terrible compared to the rest of Georgia. It was like 74, 76%. But the interesting thing was of the people who graduated, only one out of three were college or career ready when they graduated high school. So when the kids tell me we're not learning anything in class, this is dumb, this is pointless, there's actually some truth to that, right? But my experience of school was that I actually learned, and it prepared me to go to undergrad and med school, right? And so being, understanding that part of service is knowing, mining the gap, right, and doing some education around it. Thank you. Hello, Dr. Vinson. Hi, Ru. I wanna say that I found your discussion truly invigorating. And as a program director, I'm curious, how can institutions make a conversation around social injustice, social determinants of health, a part of their curriculum, like truly integrated into their training practices instead of checkbox item? I know now the ACGME requires that it's to be discussed, and I think that's a great step in the right direction, but a lot of times I feel like sometimes programs may miss the mark when it comes to talking about implementing actual, real change. Thank you for that. And Ru's a fantastic alum of our Morehouse School of Medicine and Psychiatry Residency Program. Thank you. And now a Chief Child Psych Fellow at Yale. And so the, you know, that question of how you make it meaningful, one of the things that I challenge people to do is not to see it as the equity stuff, or the equity course, right? Like this has implications in everything you're teaching, in everything you're doing. So you wanna think about ways to integrate it. And so one of the things that people say is, oh, we don't really have the expertise on our faculty to do it. Hire it. You hire expertise for other things you value and care about. So if you value and care about this, hire somebody with the expertise, give them not only a seat at the table, but also a voice, right? And listen to them. And those are the things that you have to do in order to make it meaningful. And there are a lot of institutions that still aren't willing to make those investments, but that is ultimately what it's going to take. Thank you. Thank you very much for a very interesting and inspiring talk. My name is Jacob. I am from Norway. And last session I was in, we had Northern Europe was hailed as the goal of American legislation and where you wanna end up. But I can tell you that we have very similar, you know, traits of injustice in our society as well. And I recognize several of these issues in our country, even though we're, yeah, and we're far away from America in some sorts as well. But I was wondering in Norway, we've spoken quite a lot about the importance of trust as a universal way of binding societies together. So do you have like a four-step way to trust for America? And also an advocate's guide to trust in America? Thank you. Oh, you gotta stop killing people, number one, right? And I don't just mean killing people with guns. I mean killing people with segregating them in communities where they're exposed to toxic chemicals, right? Like I can't, you can't ask groups. Trust has to come after action that meaningfully and systematically addresses white supremacy, colonialism, all the isms and inequities, right? You can't trust somebody who's actively working to destroy you and your communities. Like you just can't. And if you do, then that's a whole other like question of how connected you are with reality, right? And so the onus cannot be on the groups that have been mistreated to just be more trusting, right? I saw a, and it's true, like the ramifications of white supremacy and all these isms fall on the groups that are mistreated, but fixing the problem is white people's problem, right? Like that work has to be done. That has to be remedied. You can't ask people to disregard not only historical violence, but ongoing violence. I don't know about y'all, but I didn't sleep right this whole week after what happened in Buffalo. I didn't, because they were shot, grocery shopping, because they look like me. And so I would love to have a trust conversation, but there's a lot of things we got to get right before we can do that. Hi, I'm Siobhan. I'm a fourth year medical student at LSU Shreveport, and I'm interested in psychiatry. Yay. I was so inspired by everything you said. I'm like, can't even elucidate. I can talk about that with you later, but I wanted to ask you a question. So basically, I'm a bit of a natural activist, big advocate. I'm one of five students, black students, out of the 137 cohort of classmates of mine that also reflects the physician population as well, and during my third year, I saw vehement racism, and I called it out each time, whether it was my attending, whether it was whoever it was, I called it out politely, obviously, strategically, but I called it out. And I'm like, what advice do you have to fight against systems like that? I'm one person, you know what I mean, and I can't expect everyone to listen. I also can't expect everyone to be as brave, or, you know, and I'm like, how do you, what advice do you have as far as residency? I can't help but, you know, I believe in always standing up for what's right, even if it's hard, even if I'm scared, and I encourage others to do that as well, but what is the realistic solution to not getting burnt out, not becoming too angry, not becoming too emotional, like, how do you gauge that? Well, thank you. I'm so glad you're interested in psychiatry. Yes, forensics as well, too, in addiction. Oh, fantastic, reinforcement, killing, yes. You know, well, first, I just wanna acknowledge your bravery for doing that, right? I talked about knowing what's important to you and organizing your career about it. It sounds like you're already, you know, five steps ahead of me, which is awesome, and what I would say to you is that part of the process is understanding your role and your place, right? So, you're not gonna fix the whole Shreveport hospital system, but for that patient that sees you walk into the door, and knows you're advocating for them, you've changed their hospital experience. For the people who are in maybe your SNMA or your MSAT at your school, you're an example to them, and you're helping them get through it, and one of my good friends from SNMA when I was in med school, we're still good friends now, I got a promotion at my job, same time she got a promotion at hers, and she's now a program director, right? So, someone who I was part of mentoring and sponsoring through her medical school journey, kind of as a peer mentor, but that she says that I was part of helping her get through, is now setting a whole curriculum for a whole group of doctors, right? And so, understand it's a long game, right? And the dividends are gonna look different, and sometimes you're not even gonna see them, but centering a career on things that matter to you is key to making it sustainable, and the other thing I'll say too is that the idea, that quote about find something you love and you'll never work a day in your life, nonsense, because if you care about what you're doing and you like it, you'll work a lot, because you care a lot about it, and you're passionate about it. So, you do have to think about how you do this in a sustainable way, and any of my residents, former residents are in the room, they've heard this spiel, I'll give it to you too. I vacation quarterly. I get seven hours of sleep every night. I exercise five days a week, and those are non-negotiables. I am unapologetic about them, because I do hard work, so I need to take breaks, and in order for me to do this work in a sustainable way, those are things that have to happen. That's my list, or part of my list, right? I also have a spa day once a month. So, come up with your list, and execute, and prioritize executing that list over everything else, because you're not gonna be able to execute on a long term, which I know you want to do, which I know you can do, without taking care of yourself first. You are your most valuable asset for doing this work. Thank you. You're welcome. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Are you willing to stay afterwards, if people want to chat? Great. Sure. Anybody else with a question? No, no. Go ahead. I'm still here, so go ahead. I feel like we've talked a lot about the need for more training and specific curricula, but I wanted to ask specifically about the different forms of structural competency curricula that are already out there. Any endorsement or suggestion for alternative? I don't know that I would make an endorsement per se, but what I would say is anything that's put before you, really think about it critically and put it up against those principles of injustice and see if it's falling short in some of those areas, because as this very astute young man who is new to the American mental health system has noticed, it is very hierarchical, so the curricula that make their way through may still have some shades of that in it, right? And so applying a critical lens to it I think is going to be really important. Thank you all so much. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you, Tanya. Thank you so much for doing this. Thank you again to Twitter for not downloading more books that 되게 much talks about

psychiatry

social injustice

mental health

well-being

poverty

marginalized communities

access to mental health care

child trauma

advocacy

systemic change

equity