All right, hello and welcome. My name is Vishal Madan and I'm the Chief of Division of Education and Deputy Medical Director at the American Psychiatric Association. I'm delighted, pleased that you are all joining us for today's emerging topic webinar series, the title being The City and Mental Health, a Social Psychiatrist's Perspective. Apologies for a couple of minutes delay as we were trying to figure out a few things technologically. Next slide please. Today's webinar is part of the APA's Emerging Topics in Psychiatry webinar series. Stay up to date on important topics and trends impacting psychiatry by participating in APA's new Emerging Topics webinar series. Presented by specialists across the field, these webinars continue to explore a range of diverse pertinent topics and offer a chance to interact with peers and subject matter experts. Also, a quick note that the slides from this presentation will be available to you all in a follow-up email. We will distribute that as a PDF. Next slide please. Also, keep in mind that today's webinar has been designated for a one and a half AMA category credit for physicians. The credit for participating in today's webinar will be available for 90 days. Next slide please. And a quick housekeeping thing. Please feel free to submit your questions throughout the presentation by typing them in the question area found in the attendee control panel. We will reserve 20 to 30 minutes at the end of the presentation for Q&As. Next slide please. And now I'd like to introduce the faculty for today's webinar. We are joined by Dr. Mindy Thompson-Fullilove, MD, Distinguished Life Fellow of the American Psychiatric Association, and an honorary member of the AIA, which I'll talk to you, American Institute of Architects. Dr. Fullilove is a social psychiatrist and professor of urban policy and health at the New School. She completed her undergraduate work at Bryn Mawr College, went to medical school at Columbia University College of Physicians and Surgeons, and completed a psychiatry residency at New York Hospital, Westchester Division, and Montefiore Hospital. Since 1986, she has conducted research on AIDS and other epidemics of poor communities with a special interest in the relationship between the collapse of communities and decline in health. Dr. Fullilove has published over a hundred scientific papers and eight books. Among those books is the highly regarded Urban Restoration Trilogy, including The Root Shock, How Tearing Up City Neighborhoods Hurts America and What We Can Do About It, Urban Alchemy, Restoring Joy in America's Sorted Out Cities, and the third one being Main Street, How a City's Heart Connects Us All. She's received many awards for her work, including two honorary doctorates. She is, as I mentioned, a distinguished life fellow of the American Psychiatric Association and an honorary member of the American Institute of Architects. Dr. Fullilove has mentioned that she has no disclosures, and without any further delay, I welcome and hand it over to Dr. Mindy Fullilove. Dr. Fullilove, thank you. Thank you so much. It's a great honor to be giving this webinar today. I wanted to start out with the overview and learning objectives, which you may have already seen when you signed up for this webinar. The idea being that the majority of the world's population now lives in cities, and this proportion will increase, as we know. Managing cities is critical to overall mental health. These are the learning objectives that you should be able to describe characteristics of an urban area, factors that undermine mental health and well-being, and proposed policies. I hope that we accomplish those goals. As a psychiatrist, it's not obvious. It's not always the next thing on people's minds that you would be studying cities and be an urbanist in the way that I have. I just wanted to tell you a little bit about my roots in this kind of work. This is a car that sat outside my offices. I worked for New York State Psychiatric Institute for a long time, but my offices were on West 166 Street, so not in the main PI building, but in the neighborhood. This car sat in front of our offices for three years. If you imagine a car that's dented up just sitting on a city street for three years and nobody comes to take it away, that was the state of New York City in 1990 when I first started working at PI. This was what Harlem looked like in that era. There's basically one time we drove around every block in Central Harlem and found that the only blocks that didn't have a burned out building were federal housing projects. All the other blocks look more or less like this. Complete astounding devastation of the city. What does this mean? What does it look like? I made the acquaintance of Michel Cantal-Dupar, who is a noted architect and urbanist in France. I met him at a conference in Paris looking at homelessness, AIDS, and substance abuse. He took me under his wing to teach me about cities. Here we are in a city called Perpignan. He was showing me that here is a little stream, but somebody had cleverly put a shopping cart in the stream so that people could ford their way across. The thing I want to say is that typically when people say cities and what are mental health issues, they'll start with a list. Then they'll go through the list. Certainly, we doctors love lists. In fact, what I want to talk about is a whole different thing that I've learned from being in cities and really studying cities over this period of time. Really, this thesis, which is probably as old as human history, that change is the only constant. What we ought to be thinking about instead of lists is dynamic processes. I love this photo of this train that burst through the wall of what is now the Musee d'Orsay, back in the day. This sort of miscalculation, this sort of, can we calculate right? Things in motion, a train in motion, how do you stop it in time? Such a fundamental issue. And I found this little video of dynamic processes and thinking in dynamic processes, which, if any luck at all, will work. Hi everyone. In this video, I want to talk about steady state and dynamic process models. In particular, we'll talk about the key differences and go through a couple examples to ensure that you understand. Let's first talk about our favorite thing in the world, steady state processes. These do not fluctuate at all with time, such that if you measured something now versus 10 minutes from now, it'll be just the same. These can be extremely useful in design calculations. But what about a dynamic system? Well, dynamic means constant change. So our measure, whatever that may be, is constantly changing or fluctuating with time. These are much more applicable to real world engineering applications, even where you may not expect them. Just for an example, let's imagine you are operating a piece of machinery that is operating near steady state. But to account for an added order, you need to increase production quantity. Well, the machine is going to have to adjust to your new input step, which we've been talking about in the previous few videos. And as you can see here, in between our two steady state regions, we have a dynamic region. In addition, many systems typically look pretty crazy with time like this. And that is why control systems are needed to mitigate and fix this crazy line so it more closely approximates a constant value. So now that we have an understanding about the key differences between dynamic and steady state models, let's look at a few time to output graphs to make sure we really understand. Just take a second and pause the video. Give yourself a try to figure these out on your own, and then come back and verify that you got the same answers as me. So in this first graph, we clearly have two regions of interest. I'm just going to pause it for a sec so you can all look at the graphs and just think, where would you say it was in steady state and where would you say it was dynamic? Okay, because he said to do that. Now, let's see what he says. First region is clearly steady state as our output does not fluctuate with time. However, in the second portion of the graph, it clearly is changing with time and is therefore exhibiting dynamic behavior. Let's move on to graph number two now. Clearly, there are no regions on this graph where the output is not constantly changing, and therefore this whole region is dynamic. Lastly, let's take a look at graph number three. If you find it easier on these types of graphs, you can denote where important changes occur, like so, and this will help you visually dissect each region. Since region one and three have no fluctuations, they are both steady state, whereas in region two there is oscillations occurring, so this region is dynamic. Thank you for checking out this video, and I hope it helped your understanding about the key differences between steady state and dynamic systems. So, what he basically says, which is profound, is if the graph is moving, it's a dynamic system, and you could look at a graph of anything about life, about nature, and it's going to be moving. This graph, just for the sake of choosing one, is estimated office occupancy in cities, Chicago, Los Angeles, New York City, San Francisco, and you can see it's very, very dynamic. Now, obviously, the COVID pandemic had a huge effect on office occupancy, and if you look at the end of the graph, you can see that we're not back to 100 percent of what we had before the pandemic. We're only back to 50 percent occupancy. That's an astounding change in cities, and cities are kind of like, wait, what's happening, and what are we going to do? That is almost always the case on one front or another. Cities are never, ever stable. So, a group of urban planners and designers called the Design Studio for Social Intervention wanted to help us, you know, how do you think about things that are in motion in this way? And their proposition was that we should think about ideas, arrangements, and effects. It's very clever, very simple, and in fact, their book is a PDF, which you can find for free on the internet, on their website. Ideas, Arrangements, and Effects is also the title. So, they start off with this picture, and this is a standard arrangement of a classroom. So, the teacher is in the front, and the students are lined up in rows, and they're looking at the teacher, and all sorts of thoughts are going on. This particular arrangement has a lot of effects on how the communication is going to go, and about the exchange of ideas. So, setting this up in this manner has really structured all the process that's going to take place. By contrast, they show this, people sitting in a circle, and all the people, you know, they're trying to promote that if people sit in a circle, they're more likely to feel engaged. So, the sort of, wow, that's true for me too. I can't believe I'm leading the discussion. I might even talk today. So, the idea that you can change the levels of engagement by taking the arrangement of the seats is one of the things that they're putting forward. One of the things that I like about this was that changing the arrangement of seats was something I learned early in residency. I saw a very dramatic video of family therapy in which the identified patient was a young woman who was addicted to drugs and coming into treatment. Then she was there with her grandmother, who was the parent-like figure in the story. One of the things the therapist did was move her chair. In the beginning of the therapy, the three are equidistant in a kind of triangle. The therapist picked up her chair and moved it next to the grandmother. She did this to show the hierarchy of the family, to establish the grandmother's authority so that the grandmother could take charge of this troubled granddaughter. The granddaughter did get sober and did get back to work. It was so dramatic the way she picked up her chair and moved it. She changed the arrangement of the room. That was, of course, the day I decided to become a family therapist, which is part of my practice ever since. Ideas influence arrangements. If we go back to these two examples of arrangements, we can easily say the idea behind this arrangement. What is the idea? The idea is that the professor has information and is going to impart it to the students. They're going to absorb it and they're going to show it on the test. That's an idea of how education happens. It is given from the person with knowledge to the people without knowledge. Putting people in a circle is much more horizontal. It's not the assumption that information is going one way, but that there are multiple ways in which information is going to flow. The idea that many people in this circle, all the people in the circle, have information that's vital to the conversation, is very different from the idea that the professor is the one who has knowledge and is imparting it to the students. The idea has led to the arrangement, which leads to the effects. Now, whether or not you agree with my analysis of that or you want to say something else, that's fine. The point is, what's the idea? What's the arrangement? What's the effect? Let's talk about that. Now, they make an interesting point, which is that if we think about effects, so let's say school failure, all the kids are failing, it doesn't naturally make us think, oh, let's change the arrangement, which is why when I saw that video of the family therapy where the therapist moved her chair, that wasn't an obvious thing to do. If I had seen the granddaughter as doing well, managing her addiction, I wouldn't necessarily have said, oh, yeah, that's because the therapist moved her chair. I wouldn't have said that at all. Really saying no, effects are contingent on our ideas, on our arrangements, and on our effects. This is very important. We have found it helpful to use this IAE lens to look at the dynamics of cities, but you could use it to look at the dynamics of anything. Very useful. You may have recently read in the New York Times magazine or online a very big story about Vienna as a renter's utopia. It was an extraordinary story and very beautifully illustrated. One of the things that they point out is that most of the people in Vienna rent an apartment. Now, in the United States, we're always talking about owning, ownership, and building wealth. That is not at all the strategy that they had in Vienna. I just want to point out this one sentence that perhaps no other developed city has done more to protect residents from the commodification of housing. It's like, that's a wow idea and completely opposite to what we've been promoting in the US for a long time. Commodification of housing drives the American system. And so, buy a house and you build wealth. There's many fallacies in this idea, but the point is that in terms of owning a house and then that giving you something, there's also certain truth. Part of the issue is that if you've been able to buy a house, in a way, you've anted into the poker game of having housing in the United States. If you haven't been able to buy a house, then you're really at risk because we have been destroying, through a whole series of policies, much of our housing. And the low-income housing is most vulnerable to this destruction. We are in a national housing shortage. But if you are one of the people that's been able to buy a house, then you've anted into the housing game. And that's probably the most important outcome of buying a house. You probably can stay housed. Now, what if you had a system that didn't say, we're going to have people buy their housing, we're going to commodify it, we're going to make it a commodity. What if you say, no, we're just going to have housing for everybody. And we're going to set the prices so that they don't take too much of people's budgets. We in the United States say that housing shouldn't take more than 30% of your budget. But at this point, a huge portion of our population is spending more than 30% of their money for housing. That has all kinds of ripple effects. So this, having the idea to protect residents from the commodification of housing is astounding. And they point out that 43% of all housing is insulated from the market, meaning the rental prices reflect costs or rates set by law, not what the market will bear or what a person with no other options will pay. Huge shift in the idea of what housing is and what it might be. And here's one of the beautiful pictures of the kind of housing that they've built. Very rational, lovely, so very functional. In the United States, it is important to point out, or to talk about, but certainly obvious, that we've not only had commodification, we've had segregation. The map on the left is the redlining map. It's a portion of the redlining map for Essex County, New Jersey. Redlining maps were made in the late 1930s. And there were about 300 cities that were involved in this original process, which was led by the United States government, Homeowners Loan Corporation. And the point was to rate properties for their viability of loans to tell banks where to invest and where not to invest. And the system was basically two by two the age of the housing and the race of the occupants. So if we think of it as two by two, new housing, old housing, and race, white, non-white. And many people were non-white, so Italians and all the immigrants were non-white, Jews were non-white, a lot of people were non-white. And so in this map, this is the map of Orange, New Jersey, which is my hometown, you can see that this two by two table resulted in four colors. Green, which was white people, new housing, yellow, sorry, blue, there's no blue in Orange, there's blue next door in East Orange, which is white people, pretty new housing. Then there's yellow, which was non-white people in older housing. And then there's red, which is black people typically in old housing. Now, the point of this map is that it tells you where segregation and how it was organized at that time, but it also has intense predictive power. There are all kinds of studies going on now. And the reason they're going on now is that the maps were in the National Archives, but had not been made easily available. So you could go there and see them as I did, but having the maps and the surveys online for everybody to see easily, just click Google and get to your city, that only happened very recently and was the result of a very important project, which has a website about inequality, which made these so easily accessible that all the scholars, not all the scholars, but tons of scholars are now working. Okay, this is what we set up in the 30s. What does it look like now? For example, tree cover. You go to Orange, New Jersey, and you drive around the red area, not too many trees. Drive around the green area, a lot of trees. Yellow area, not so many trees. So tree cover, infant mortality, maternal mortality, all kinds of things appear to correlate with these maps that were established a long, long time ago. So we can see the idea that people should be segregated by race, that resources should go to those of the better races, and that the resources should not go to those of the less desirable races. It has long-term effects, very long tail to those decisions, which is still acting on our society in a very, very active way. The second map, the map on your right, is a map of the school segregation. And the school segregation was the official policy of the city of Orange. And so it had a big effect on my life, because I lived in a small Black neighborhood that was in this area. Part of how you know this is a gerrymander is there's Central Avenue, a big street, and the school districting lines would, you know, usually in a city that was not trying to do gerrymandering, would have gone straight along Central Avenue, which is on the right-hand side. Instead, they have this little cutout, and the carve-out is for the Black community that was to the south of Central Avenue, which is where I lived. So I went to the Black school, Oakwood Avenue School. Now, there were White people who lived further away from the White school than I did, but they were White, so they went to the White school, I went to the Black school. This was overturned in 1958. My parents were very active in this. And instead of going to the Black school, I went to the White school. But a really weird thing that you can see to this day is that the parts of the park, and you can see at the bottom of the map where it's printed Oakwood District, is printed over a park, a park designed by the Olmsted brothers, beautiful, beautiful park. That park is partially fenced, and the fence on that park faces the Black segregated neighborhoods. Where the park is facing, at that time, White neighborhoods, there's no fence. But it's a really bizarre and interesting carryover of the old days of segregation. And it's interesting because what are the effects? And if you saw that fence, would you immediately think, that has to do with the segregation that took place in the 30s and 40s? I don't think you would, nobody thinks that. It's not until we pull out the maps and we discuss the fence that people get. So this is sort of how ideas lead to arrangements, lead to effects. So important for understanding the constant process of change, but also the forces that are creating what we see now. So change is always what was happening, and then what is it pushing forward? This is the heart of real understanding of what's going on in cities. So one of the effects is on the stability of the city. There's a street that was created as a pedestrian street, pedestrian mall street in Baltimore, and this it really floundered, and the buildings are falling apart. And this is a building that I found there, I saw there. Now you can, as I mentioned in showing you the photo of my office, you can see this kind of various kinds of abandonment in all of the older American cities and certainly throughout the Rust Belt of the United States. And I want to tell you a story about dynamic change and effects having to do with moving investment. So Dr. Roderick Wallace and Dr. Deborah Wallace studied the problem of a policy called plant shrinkage. And the maps that I'm going to show you were presented in the Atlas of AIDS by Smallman, Raynor, Cliff, and Haggard. And they, and that's because the Bronx became a real center of the AIDS epidemic in the United States. So the Wallaces had studied how it came to be, where did that come from? And so this is their analysis. So there was, in purple you can see highlighted, the poverty spine of the Bronx. It was an intense concentration of very poor people. Now what's going to happen in plant shrinkage is that in that area, the fire stations are closed under this policy of plant shrinkage. This happened in other New York City neighborhoods as well. It happened in Harlem, it happened in East New York, it happened in hearts of Brooklyn. And as the fire stations are closed with the rhetoric that fire trucks can come from other fireplace, other fire stations, but it turns out that having to travel further to a fire means the fire has more time to burn, creates more destruction, and therefore is, you know, really more terrible. So the, this poverty spine of the Bronx preferentially loses its fire stations and begins to burn. Over time, 80% of the housing in that area is destroyed over a very short period of time. And people have talked about this burning of the Bronx, it's very famous, but what they don't talk about is that it was city policy that led to the burning of the Bronx. It's like, oh landlord arson. And landlord arson, it was surely present in some part of the situation, but it's not what's powering the situation. It's the failure of urban policy to provide fire protection, which is actually one of the fundamental reasons cities get organized at all. So when the poverty spine of the Bronx burns, what happens next? What happens next is that the people have to move. So the Wallaces used the ecological measure of pupil transfers, and that enables them to show the directions in which people are moving, moving to other neighborhoods of the Bronx, and to some extent moving out of the Bronx. Now we know that movement and this kind of violent, violent displacement, so people are losing their homes, some people are dying in the fires, people are losing their possessions, this is very violent experience. And then people have to flee, people are fleeing the fires, they're going in all directions. So social networks are being disrupted. So all of this is happening, it's extremely devastating. So a whole series of kinds of physical destruction of the environment, social destruction of social organization, and devastation of families that were involved in this, all of that is happening very catastrophically in this area. So another way of saying did people move was to look at overcrowding. So you can see that in the upper map, the overcrowding is largely in the area of the poverty spine. But in the lower map, after the poverty spine has been burned down, the overcrowding is in the areas around it. So that also helps us track where was the population and where did they move. A feature of the poverty spine in the 1970s was that there were many people who were addicted to drugs. The heroin epidemic was very important in New York City at that time, and there was a huge concentration of the heroin epidemic in the poverty spine of the Bronx. Now afterwards, so the Wallaces used drug deaths to say where were the addicts. So you can see the overlap in where the drug deaths were taking place and the poverty spine of the Bronx. But after the burning down, the drug deaths have moved along with the people. Now this tells us something very, very important, because we know from studies of addiction that addiction, the way it passes is from person to person, somewhat like an infectious disease. And that if you have very endogenous sharing circles, the escalation of the number of people that are involved is going to be very slow. But if you have dispersed all the people and they have to reestablish their drug using networks, you can have huge changes in a very short period of time in the number of people who are involved in drugs. Now the thing that nobody knew at that time, but that we know now, is that HIV, the virus that causes AIDS, was already in the Bronx. And so as these people dispersed, so did the AIDS virus. So AIDS deaths we can't really know until much later, but we know that AIDS, when we are able to measure them, because we don't recognize the AIDS epidemic until 1981, when we are able to recognize them, we know that they're occurring in that area to which the drug users had been pushed. So the AIDS virus is moving with the drug use, and it's not happening in the poverty spine of the Bronx, which has been burned down. It's happening around it in the circumstantial areas. So the sort of urban policy that's going on in the United States, which is to not take care of minority neighborhoods, to pull resources out, to let them burn down, to displace foreign minority people, those are affecting the lives of really basically everybody in the United States. Now this next quote comes again from the New York Times article about Vienna. So these are the projects. India Walton, a community organizer from Buffalo, said wryly, speaking about Vienna, there was a rose garden, children, black, brown, and white, were running and shrieking in a playground attached to an on-site kindergarten. Walton, now in her 40s, had twins when she was just 19, raised them while working as a nurse. Decades later, she became politically active, and in 2021, she won the Democratic nomination for mayor of Buffalo, only to be defeated by a writing campaign by the Democratic incumbent. Where would she be now if she had the option of living in a place like this? She would have left her marriage sooner, Walton told me. I might not have been a nurse, but a doctor. A child in the kindergarten waved at her, and she waved back. So this is like really fundamental. If we have commodification of housing and segregation, dynamics are set in place that have important effects on the health of the population. In Vienna, where they chose another path, they said, let's give housing to everybody, and let's not make money an option. Let's not have commodification of real estate. Then you have stable housing. People can pursue their life path, and they can live together stably. There's no neighborhoods being burned out and people being traumatized in that way. By the way, the Democratic mayor, the writing campaign for the Democratic mayor, that was the guy who was in office during the huge snowstorm, which we've just read a report about. What a terrible job. People were just completely disconnected and unable to organize and help through that terrible, terrible storm. So that was a bad idea. She might have done a much better job. So some of these things that are long-term effects, you just have to take very, very seriously. Part of the long-term effect is disorganization. If you've done that to your city, you've burned out major neighborhoods, displaced people, given them decades of ill health. You've undermined the social structure, the social fabric of solidarity, of democracy. These are very bad things to do. So planned shrinkage in the Bronx led to drug addiction. It led to the AIDS epidemic. It was major fuel of the international AIDS epidemic. It caused huge increases in infant mortality and maternal mortality, violence, huge problems. But we have, we all know, even bigger problems. What possibly could be even bigger than all of that? So looming ecological catastrophe. So John Bellamy Foster, writing in Monthly Review, which is a Marxist publication, said, in the 21st century, we live in an age of planetary ecological peril, represented by the anthropogenic rift in the earth system. This is associated with the advent, around 1950, of the Anthropocene epoch in the geological time scale, which succeeded the Holocene epoch of the last 11,700 years. Capitalism is presently in the process of crossing planetary boundaries that have defined the earth as a safe place for humanity. If all geological history, as Engels said, is the history of negated negations, today the Holocene, the geological epoch in human civilization, in which human civilization arose and prospered, is being negated by the system of capital accumulation leading to the Anthropocene crisis of today. That's slightly arcane, although I think he's, you know, really trying not to pull any punches, that capitalism, which is the driving political economic system of the world, and which is driven by the search for profit, not by balancing human good with prosperity, but simply by profit, therefore doesn't respect any other boundaries, is presently in the process of crossing planetary boundaries that have defined the earth as a safe place for humanity. That's a pretty remarkable statement. So those of us who live in the New York area, or many other parts of the United States, had our skies basically blotted out by smoke from Canada. And so how does smoke from Canada, well, smoke from Canada, from wildfires in Canada, never blotted out my skies before. So there are certainly lots of things going on that are reminding us that we are going into a very unstable period. And we know that actually, we're at kind of a cliff's edge in terms of species extinction and creating weather and climate that we can't endure as human beings. So this is even bigger. Now, part of this is about dynamic change. And if we ask the question, well, if the weather is changing, what is that doing to human beings? That's really a profound question. We all remember that when all else failed at a dinner party, you could talk about the weather. And I think that's not true anymore. I think the weather is now a topic of anxiety, just like politics. It's better not, if you're at, for some reason, at a difficult dinner party, you don't want to talk about the weather. And what are people feeling about the weather? I think it creates a vast uncertainty, vast, and not just for people in New York who see smoke from Canada, but really the whole world is in a deep anxiety. And one of the things that social psychiatrists have talked about for a long time is that when people feel that kind of anxiety, and especially if there's no coherent conversation, like structural conversation about how it's going to be met and managed, they will reach for strong men to fill the gap, somebody who says, I'm strong. So the terrible situation in Germany after World War I is what sets up Hitler coming into power. And many countries are reaching for strong men, the United States among them. But this is because of the profound anxiety. And certainly the COVID pandemic and climate change have created levels of anxiety that are certainly unprecedented in my professional career, so that everybody's practice is full and it's hard. And part of what makes it hard is that we as a society, but also we as practitioners, lack a language of how to talk about something as comprehensibly as ecological catastrophe. It's like, why are you so upset today? Well, it's because we're in ecological catastrophe. What does that mean? How am I supposed to wrap my mind around it? This is the work that lies ahead of us if we can think in dynamic terms. As things fall apart, as catastrophe comes more and more and more frequently, we got to think differently. We have to think in bigger systems than we are used to thinking at the present. This is a picture that was actually in Time magazine and a lot of other places of a house that was destroyed by Sandy, which was a big hurricane, important for those of us. I live in New Jersey, very important in our region. So as suffering increases, the question that I've thought about a lot is what tools are going to help us respond? And let's go back to our ideas, arrangements, and effects. You know, bigger problems, what are the arrangements, what are the effects? So we know, and certainly George Engle pointed out to us, that medicine operates from the biomedical model. That hasn't changed since he was working in the 70s and 80s. Probably gotten worse because now we know more about molecules and DNA. A social psychiatry, which is my discipline, is much more holistic. So considering the patient, and of course the molecules, but also the influence of the patient's context on presenting complaints and the course of illness. And we are very aware, and it's definitely been what I've worked on, that the patient might be the social group. So if a whole social group is going through upheaval, what is it that might help the social group to feel better? One of the experiences that my team had was what happened when the Twin Towers fell. And at the time, we were doing a study that was called root shock, which had to do with what happens to people when they lose, not a loved one, but their environment, when they lose their neighborhood. And the term root shock comes from gardening, and refers to what happens if you just yank a plant out of the ground rudely, and its roots get torn. It goes into shambles, and it roots get torn. It goes into shock in any event, but if you've done it rudely, it might not survive transplantation. So we were doing this study, and we had learned a lot about what happened to people when their neighborhoods were destroyed, and they were dispersed. The kind of dispersion of the neighborhood that you saw in the Bronx during planned shrinkage. And the World Trade Center was a place where 50,000 people worked, and it's a nexus of transportation. So the whole city was revolving around it. The World Trade Center was an iconic image. The Twin Towers were basically painted on every panel truck that was driving around the region. And so the disturbance to how we thought of our region, how we connected to each other, was massive. It became quickly boiled down in the official propaganda that this was a crisis of heroes who died, and victims who died. And the rest of us were supposed to go to Broadway, go shopping. It was over. Closure. They really like literally announced closure as of January 1st, 2002. People were very upset. So we worked together with colleagues in a project called NYC Recovers, and thought about what to us was a very novel idea. What if every organization in the tri-state area said, we have a piece of this. We have to take care of our constituents. Whether we're a bank, or a supermarket, or a Boy Scout troop, we'll take care of our people. And when we started to think about it, we were like, wait, if everybody thought about holiday parties, so September 11th happens September, holiday parties are coming right up. Everybody goes to three or four holiday parties. What if every holiday party was a recovery party? You'd have a course of brief therapy for the whole population at no expense to anybody. So that's a different idea. And it's a different arrangement. The idea is we as a collective need to all feel better, but we're feeling miserable. We're nervous. We're anxious. We're confused. So let's use our holiday parties, because that's something we're going to do anyway, to really reach out in a different way and to be together with each other. So that idea, let's think about this as the responsibility of all of us, and let's use what's at hand. Organizations gather people. As we gather people, let's infuse the spirit of recovery. That's the arrangement. And the effect is to lift people's spirits. So all the organizations that we got to think about this did it and did things differently. And indeed, people left feeling better. So we know that the effect of that was what we thought would happen from thinking about the idea, the change in arrangements, and the effect. At the end of the year, we had made this banner, which we took to various events. And at the end of the year, we had a party, and we invited all our partners to come, and we invited them to draw on the banner. I wasn't sure what they would draw. But one of the things I want to point out, and I think you can see my cursor, is that the buildings in our logo are not connected to the ground. They're ungrounded. That's like the genius of designers, right? How did the designer know how to depict that we all weren't sure where the ground was? That was an emotional feeling precisely depicted. But you'll notice that when people painted it at the end of the year of recovery, they connected the ground. And there's fire and these little things. All the buildings are reconnected to the ground. I found that extraordinary as a representation of the effect of let's recover collectively. These are some photographs from earlier this month on a project called Hike the Heights, which we started 19 years ago. This was the 19th annual. And the idea was that there were some abandoned parks in northern Manhattan. They were cliffside parks. They had all been left behind. They weren't being tended. And they were a site of... And they had just become fearful to the neighborhoods. They were kind of toxic to the neighborhoods through which they ran. We said, no, these parks should be restored. And they were all cliffside parks. So what if they could become a hiking trail? So we created this hiking trail called Giraffe Path. And part of our project was to have an annual party. So the idea, let's connect a series of parks, cliffside parks. There aren't parks with big ball fields. I mean, they might have ball fields, but they're not those kind of ball field parks. They're on a cliff. What do you do with a cliff? Well, you walk up it. Well, that's good. Americans need more exercise. But what if they're restored? If a cliff... So in the middle of a city, there's a cliff and the neighborhood at the top is disconnected at the neighborhood from the bottom, if the park in between is unsafe. So the park in between has to be safe for the city to have flow. And if the park in between invites you to walk up and down or north-south, then you're going to get fit. You're going to have fun. You're going to see beauty, see extraordinary things. That's our project. And so we really created this Giraffe Path. And the Giraffe Path is like a real thing that's not an official thing. And it's a real thing because communities walk it every year in this big event. And it's called Giraffe Path because the parks sort of look like a giraffe. So that was another idea we had to really work on the arrangement. And one of the effects has been massive reinvestment in those parks. So more than $150 million that has been reinvested in those parks, making them really a livable, functioning part of the city. But also it's meant that people get to know each other. Neighbors go out and have a great day. So it's on that kind of foundation of relationships that cities work well. That's like the fundamental thesis of social psychiatry, that everything depends on the strength of the social relationships. So if we can get people out, you know, working together to make a party, going to the park, being with each other, dancing, performing, eating, then we have strengthened life in all of those neighborhoods. And our path runs through Harlem, runs through Washington Heights, runs through Inwood, very beleaguered neighborhoods, which are now healthier because of this. As I've been an urbanist, the great thing about being an urbanist, in case after hearing this talk, you all decide to become urbanists, I just want to say the great payoff is that you get to go to a lot of cities, like so many cities, and it's really fun. And so I added up when I wrote my book Main Street, I had to add up how many Main Streets have I visited in the course of writing that book. And it was 173 Main Streets in 14 countries. Really fun. So one of the things I do when I go visit cities is go look at, you know, what are people doing here? What have they found that works? And I had the idea that it would be nice to say, And so on the basis of that, I made this periodic table of the elements of urban restoration. But again, it's sort of, the idea is, let's get away from commodifying the land and having segregation. These things have injured progressivism. These things have let's get away from commodifying the land and having segregation. These things have injured, profoundly injured the American city. Let's put it back together. So in ecosystems, we talk about restoration. So the urban ecosystem can be restored. That's the idea. Instead of commodification and segregation, let's restore it. Let's make it whole. Let's make it prosperous, thriving. The kinds of things we talk about are joy and the heart. So given that idea, could we identify these elements? So in a way, this periodic table is an arrangement. It's bringing forward tools that people are using and saying, these are crucial tools. For example, the first element, city and mine, says that we should keep the city in mind, the whole city, not just our neighborhood. That's actually really quite a different idea from how most people in most communities talk about. They talk about my community, my neighborhood. We're saying, yeah, talk about your neighborhood, but keep the whole city in mind. And then, you know, one of my colleagues is William Morris, who worked with his first wife, Catherine Brown. And they came up with an idea called planning to stay, which is really the opposite of planned shrinkage, as opposed to planned shrinkage, which was, let's just let this, let's take out all the resources and let this neighborhood die. They said, no, we're planning to stay. And the effect of that is to really energize people. Oh, no, we want to stay. This is a nice place. What do we have to do to be able to stay? There's always a lot of work to be able to stay, especially when the forces of global capitalism and the financialization of housing are just having such ongoing destructive effects on cities globally. Currently, I'm studying K-drama. Now, you might say, wait, I wasn't expecting that, because you've been studying neighborhoods and cities. But so, yeah, what's the leap? So the leap is, of course, COVID. I was stuck at home. I was watching TV. I stumbled upon K-drama. And I was really stunned by K-drama, because it seemed to me to be presenting a different idea from American television I was watching at the same time, which is that it was taking very traumatized people and then helping to see them recover, rejoin the group and become productive members of society. So some of the people who write about this write about dispersing Han, Han being a Korean word for the depression that follows from being oppressed. And so this is just a scene from one of the very famous K-dramas, Boys Over Flowers. And the heart of it is a young man whose family is a big capitalist. They call them tribal. So a tribal family where the children are tools of the family and not real free to be, not free to be you and me. So he has to break out of that and become a real person. And he does it with the help of a young woman who's from a very working class family, but who is full of warmth. And she helps him. It's kind of a Snow Queen story where the icicle that's in his heart gets melted by her warmth and love. So this sort of like, and that's a new idea. Can a TV show actually, which can meet these TV shows from Korea reach a billion people. And can they tell us things that we need to know to manage these horrible times that are coming down on us? Can they give us hope? Can they give us, can they reinforce what we're trying to do in being together as human beings? I believe they can and they do. So that is the work that I'm currently doing. In fact, I'm just back from Korea and had a lot of very interesting experiences doing this. And I think that's the end of, so those are the references that I sent, which I think you have. And I think that's all I want to say. And I've been talking for a long time and thank you for listening. I really appreciate it. I, so I don't see any questions, but perhaps Dr. Madan has a question. Dr. Madan, are you online? Maybe he was called away for a sec. No, I'm here. I think I'm having an issue with unmuting and starting a video. So Violet maybe can help with that. I can hear you now. I can hear you now. Yeah. If you can turn the video on as well, Violet, that'll be great. Okay. Well, thank you so much, Dr. Fullilove for a very amazing, amazing talk, walking us all the way from at least 1900s, if not before, to K-dramas. Truly appreciate it. I just have a friendly reminder for our audience to submit your questions by the Q&A question and answer area of the attendee control panel. But as you do so, I wanted to check with Dr. Fullilove some other thoughts. And the first one was, can you please share with us how you got involved in your work with architects, a totally unlikely group for a typical psychiatrist to work with? And I would say, what kind of learnings have you gained over time? Yeah, that's a great question. Well, the first architect I mentioned was Michel-Kantal Dupar, who's a very famous architect urbanist working in France. And I basically studied with him over a period of 20 years. And so the thing about studying with an architect in France and Michel-Kantal Dupar in particular, was that much of architecture and urban planning in the United States was involved in urban renewal and other violent policies that affected the African American community. So when I was interested in cities, I didn't see them as a resource. But Michel-Kantal Dupar is very active in human rights and is somebody who spent a lot of time abroad in Tunisia. So he's anti-colonialist also. So he was a great person to study with. But then I began to meet other people, progressive planners and progressive architects in the United States as I was working on this. So it happened slowly over time. Then, yeah, so I just kept meeting people. And then because I was writing books that had to do with architecture and planning. So my book, Root Chalk, is about the American Urban Renewal Program. A lot of people in those professions read them and got in touch. And so I met lots of people. And eventually, I became a public member of the Board of Directors of the American Institute of Architects and served on that board for three years. And that's how I came to be elected as an honorary member of that institute. And then this past year, I served again a one-year term. So it's been a wonderful, wonderful experience. I've loved working with architects. And I've long thought architects and psychiatrists should get together more. We have a lot to teach each other. That's beautiful. Thank you. Now, my next question is, you know, we are well aware that social determinants of mental health play such a key role in the outcomes related to mental illness. Informed by your extensive work, what top two or three lessons can city planners or urban planners take from it that could potentially create an impact on the mental well-being of communities? I guess in this talk, what I'm trying to say is that when you pick up a book like Social Determinants of Mental Health, what you're going to find is a list. And those lists are, I find, not terribly helpful. So the first thing that I've learned is this, that change is the only constant. You're trying to look at the dynamic processes. So for example, we're all thinking about climate change and sea level rise. Sea level rise is going to affect maybe a third of the world's cities. So what are we going to do about that? You may have seen the photographs of water in Jakarta and that the president of Jakarta is thinking of moving the capital, but leaving behind the 30 million people who live in Jakarta. I mean, that's an extraordinary, extraordinary event that's happening. So I think rather than make lists of things like the social determinants of health, it's what are the processes that are going on and then that are changing the arrangements? And then what are the ideas that would help us as arrangements are changing, move them in the direction that we think would be best for human health? So for example, we're in a national crisis shortage of housing. And my hometown, Orange, New Jersey, a recent study showed, needs 2,000 market rate, I mean, 2,000 affordable housing units for its population. Instead, it's getting 2,000 market rate apartments, which is going to bring in a new population and push out the old population. That's, in my understanding of what happens with that kind of displacement, going to undermine human health. What's an arrangement that we could have instead? And could we do planning to stay? So my colleagues and I have started a project called Planning to Stay, because we think William Marsh and Catherine Brown put forward a fundamental idea. People need intergenerational places where they can put down roots and work together in solidarity to build. That's what builds human health. That's my core belief. So that's how I would look at it. Very well stated. Yeah, thank you. We do have a question from Dr. Cynthia Turner Graham, and she asks, do you have any creative ideas about how to effectively mobilize the silent majority of eligible American voters in order to have a more functional democracy that is true representative government? I don't know how creative my ideas are, I have a lot of ideas. If you look at the ways in which public policies, and to no small extent, this commodification of housing have undermined the stability of people's communities on the one hand, and how de-industrialization and all the moves to have this kind of very precarious part-time work that people are forced into have undermined people's economic wellbeing. Those two things synergistically have undermined the foundations of community, and that makes people crazy. So if you don't wanna have people vote crazy and act crazy, you have to act like they deserve stable intergenerational communities that have jobs. So I think access to jobs and education are fundamental. In that regard, I think that the Inflation Reduction Act was a very good idea, and similar acts would be good. And I think that we're in a big crisis of education, and it's being made even more a deepening crisis by all the intolerance that's being placed over it. But I was very inspired by the recent story about education in Mississippi. So the man who was the head of, I believe it's Netscape, retired to his home in Mississippi and set up an educational institute to find the best science about educating kids, in particular poor kids. And they really focused on the science of reading. And they have moved Mississippi from number 50 way up the ranks. And in fact, in the reading scores of poor kids, they're now, I think, number one. How amazing is that, Mississippi? One of the things is that somebody's usually already built a better mousetrap, and our job is to beat a path to their door. So those are my creative ideas. Let's find the better mousetrap and go there and copy it. And I truly love the giraffe path, right? That's something that truly changes how the city looks and where the dollars need to go, actually, to make a difference. Yes, it's true. It really did, really did. Really got some dollars placed where they were needed. Now, you did touch base on some of the effects of COVID, right? You talked about the different cities and the office utilization and other things. How do you see the transformation of our communities as such pre and post COVID? Well, the first thing I would like to say is that we launched a project, a COVID project called the People's CDC. Like many people in public health, when the CDC, January 2021, said that you only had a quarantine for five days, I was just shocked. I was like, what are you talking about? You have to quarantine until you're not infectious. I just found that intolerable. So I called up all my friends who are epidemiologists and say, can't we start a People's CDC and give people accurate information? So we have done that, and the collective work of that group is available at peoplescdc.org. And so I've thought, you know, I've been watching the pandemic very carefully through that lens. And one of the things, so one of the things is that more than a million people have died. That changes communities and are dying, although they've stopped collecting data. So we've gone into a blackout, which I also find very shocking. How do you stop giving information about infectious diseases? We know about syphilis, we know about gonorrhea. Why can't we know about COVID? So I find that very, very disturbing. But aside from that, the other thing that the science is telling us at this point is that after any infection, but increasingly after multiple infections, people can get long COVID. And long COVID is a devastating, indeed crippling disease. So how many people, I mean, there's no accurate analysis of how many people in our country have had COVID, but if 10% of the people with COVID are gonna have long COVID for some period of time, the thing we haven't really started to grapple with is what is that gonna mean for our communities? So I think that in a dynamic model of what a pandemic does, we have to really avoid easy rationalizations. I was on a crowded train yesterday going to my university, and there were only two people on the train wearing masks. I was one of them. And there was one estimate I read recently that if young people get COVID twice a year, which is very possible, COVID stays around, and long COVID, there's a 10% chance with each infection, by 47, 100% of them will have long COVID. How do you, how do you, what do you do about that? That's a dynamic process that we have to be thinking about. What do you do with that level of disability? And COVID is very disturbing to the neurological system and very disturbing to the brain. So what do we as psychiatrists do about the distress? And certainly the distress that occurs if you're disabled, if you have to care for somebody who's disabled. So we have a looming, that's another looming catastrophe. I don't think we're dealing with it all. Absolutely, absolutely. Our next question is, it states, there are times, and much more so lately, when individuals within communities are at an ideological stalemate on a variety of issues. It almost feels like two separate communities within a society. And even micro-communities within extended families. How does one navigate that? Well, first of all, I mean, I'm arguing that if you set up a dynamic in a society, think of the red lining as a dynamic, in which you short sort people by race and class, and then you distribute resources by race and class. You have fundamentally, you have a dynamic, a long-term dynamic of dividing. And politicians love divide and conquer. They promote this. And we've seen a lot of that in the past 10 years. Promoting division, promoting hatred in order to get votes. Well, if there's a long-term process of hatred that's being actively used by the political class, then the fact that people hate each other is not a surprise. So the issue of how do we extricate ourselves how do we extricate ourselves? We have to extricate ourselves from that system. And Dr. Roderick Wallace, who did the study of the Bronx, always says, when I ask him about that, at that point, that in a way, this is a spiritual question. And at the heart of salvation, this is what he says, is the black church. The black church can lead us forward. Now, why does he say it's a spiritual question? Because it's about hatred. And how do you think about hatred? You have to get to the moral questions. Is this how we wanna live, hating each other? But that has to be raised at a very big level. For example, the civil rights movement raised that. It has to be raised now in a new way. So the Poor People's Campaign is raising it in a new way. And one of the remarkable things about the Poor People's Campaign events is that they have people talking about their experience with poverty across the spectrum of people in the United States. So I think we have to look for everything that's promoting love, and we have to support that. And we have to support that in our own lives. How do we promote love? But why is it, we as psychiatrists have a lot to say about these issues. This hatred, hatred, I have always understood, and racism at this level as a psychiatric illness. We have to talk about this in very big ways. I know the APA has been talking about racism more than before, but it's an even bigger conversation that's needed if we're gonna address the partition in the United States. And it's a really bad situation. I mean, in social psychiatry, we've seen it coming for a long time. And what's at the end of it is civil war. It's very ugly. So I share the concern with the question. It's a deep concern of mine, and has been for some decades as I've watched this play out. And one thing about social psychiatry is you're looking at these kinds of dynamic processes all the time, and you can see where it's going. It's like watching a car crash. Absolutely. Now, how best, this is such beautiful information and discussion, amazing, amazing thoughts. As a former training director, how do you suggest residency training directors bring in concepts that you mentioned to their curriculum for their trainees? Because they really need to understand and know these. Yeah, that's a great question. You know, the American Institute of Architects, the AIA, has a fabulous program. It has the worst name in the world. It's called RUDAT. I don't even know what RUDAT stands for. I keep saying to them, you've got to change the name because the best program has the worst name. And this is a program where they go to a community, perhaps a community after disaster, and they bring in a bunch of planners and a bunch of architects, and they start to get things moving again. So they have one film which showed them building a park or other kinds of things. It's quite beautiful and remarkable. I think that what would be cool, I mean, you guys have offices very near each other, is if the AIA and the APA got together and said, how do we make RUDAT national? How do we make it big? And how do we bring psychiatric trainees to these things? They go for like a week or two. So all trainees should go to a RUDAT. RUDAT is very small, so it's not like this could happen overnight. But I think they need to get out in the field. You know, it's sort of like you've got to go into a room with somebody with schizophrenia to understand schizophrenia, but you've got to walk city streets to understand the dynamics of cities. And if they were there with the architects and the planners, they would get the feel of it, and it would be brilliant. And it would be so exciting. Thank you for sharing that. I think both our audience, and obviously this has a bigger, broader need for collaboration, and I'm happy to involve our program directors and organization as well, and to look into that curriculum. So appreciate that. Now, another thing, you know, listening to some of your other talks, you've defined root shock as the traumatic stress reaction to the loss of one's emotional ecosystem. Now, knowing that around 30% of our psychiatric workforce are international medical graduates who uprooted themselves from their home ecosystems and created newer emotional ecosystems, if you would, while still navigating their original ecosystem. What's your message for them? I'll just leave it at that. Root shock is a serious thing. So when I was young, the movie Heidi was very popular, starred the great child actress, Shirley Temple. And the book Heidi was something that we all read. Heidi is a story of a young girl in Switzerland who is being raised by her grandfather, who, you know, on the mountains in Switzerland. And she's basically kidnapped and sold to be the companion to a rich girl in Frankfurt. So all of a sudden she's ripped from her mountain place and put to work in this other, you know, she's in a beautiful house she's taken care of. So it's not brutal in that way, she, you know, but she was basically kidnapped. And she's like, wait, I want to go back home. And they basically are like, no, you're going to be here. This is where you're going to live. We're going to take care of you. We're going to be your family. And so she goes into a decline and can't eat, is sleepwalking at night. And the doctor arrives and he says, wait, this girl has the Swiss disease. The Swiss disease is nostalgia, which Swiss psychiatrists identified as basically a life-threatening illness of being taken from home. And he says, she's got to go back right away. She's got to go back tomorrow. And so the family takes her back and she recovers. And many things turn out from the encounter, many things turn out for the good, but she almost dies of nostalgia because she's been taken from her home. So it's serious. These things are very serious. Now, if somebody says, I'm going to go to America because I'm going to have a better life, it might not seem like that's Ruchat because it's the gentlest kind of transplantation, but it's still a profound life experience to say, I'm going to grow up. I'm going to grow up in Korea and then I'm going to go to the U.S. Had a lot of opportunities since I've been studying K-drama to talk to Koreans who've made that move. This is a huge move. And then in a way they can't go home again because they become Americanized. So these are big things. So I think that that 30% of psychiatrists have this experience, puts us at an incredible advantage for what's coming down on us. Because what's coming down on us is that the whole world is losing the world we've known. We're losing the climate we've known. So nobody's country is going to be the same. You might be in the same country, but it's not going to be the same. So they have an insight, a lived experience of being transplanted that they can draw on to say at the even larger levels of scale, scale of the neighborhood, the community, the nation, we're all being transplanted into a future that's in many ways, very frightening, but this is how we're going to handle it. So I think it's actually an extraordinary moment where they're coming into leadership and helping us manage this through their lived experience is perhaps what will save us all. Thank you. Thank you so much. The last question I have, and I don't see any others in our Q&A, is as a psychiatrist, we obviously use our mental status assessments, right? Examinations and our assessments. What's your way or your lens of conducting a community's mental status exam? Really great question. One of the first things that I invented to do that was called the community burn index. You know, as you know, when somebody gets burned, they calculate how much of the skin sustained third degree burns and survival is linked to that. So if you have too much of the skin has sustained third degree burns, you're not going to make it, right? So walking around Harlem and communities like that, I was like, wait, this destruction of housing, a complete obliteration of the buildings is like a third degree burn in the urban landscape. And so can I use this concept of a burn index to create a community burn index? And so I've used that for many years, typically to walk around with people and look at their neighborhoods, which have suffered such terrible degradation. But I've added many other tools to that from a colleague, Hirofumi Minami, who's a Japanese environmental psychologist. I learned a tool called the stroll and scroll. And the stroll and scroll is basically strolling through a neighborhood, any neighborhood, and, you know, taking photographs, collecting data. And then the scroll in the Japanese sense of like a pictorial scroll is, like a pictorial scroll is making a documentation of what you saw. And so that's the, basically the tool that I use for my Main Street study is the stroll and scroll. And Dr. Minami was very interested in this technique and he developed it for a project he called the psychoanalysis of the city. He was working in Hiroshima. One of the things about Hiroshima is that in many ways, the experience of the war and the atom bomb was buried in the consciousness of the people. And so he was interested in how, as you walk along and as you're strolling through a city, do you see the layers that are not being talked about at present? So that's another tool. There are many others, but those are two that have stood me in good stead. It's different from taking a mental status of a person. And that's the joy of urbanism is, even the joy of family therapy is learning, okay, here's a system, group of people. How are they interacting? Where do I put my chair? That's the question. Where do I put my chair? I've got to figure that out. So reading the dynamics of a family and knowing where to put my chair, reading the dynamics of a city and knowing what the intervention is, this requires that you understand larger social systems. A city is not just a bigger body. It's a different social system. And so that's why I've spent a lot of time in training, why I went and got a certificate in landscape design, so why I've gone to 173 cities in 14 countries to learn about main streets. They're different social systems and they have to be approached with that level of respect. Thank you so much for what has been a truly enlightening and learning experience for me and I'm pretty sure for our audience. Thank you so much. I just have a couple of quick housekeeping things. If you can move to the next slide for me. Next one, we've gone through that. Yeah, just a quick thing to say that you will be receiving a follow-up email within an hour of the webinar concluding. And this will have directions on how to access your certificate. Next slide, please. And I just wanted to thank you all for joining us today. If there are other questions or any suggestions for us for our emerging topic webinar series, please send them to educme at psych.org. Thank you so much, Dr. Fullilove again. Have a wonderful day. Thank you all. Great, thank you, bye. Bye. Bye.

City and Mental Health

Urban Policies

Societal Disorganization

Ecological Catastrophe

Root Shock

Urban Restoration

Traumatic Stress Reaction

Emotional Ecosystem

Collective Recovery

Giraffe Path

Sustainable Communities

Collaboration between Psychiatrists and Architects