And welcome back to day two of the 2021 Mental Health Services Conference. I hope you all had a great experience with our day one sessions and learned a lot. We have a lot of great sessions in store for you today, including discussions of socio-cultural issues, criminal justice, and innovations for rural and indigenous communities. You'll get the absolute most out of this conference if you participate in the 30-minute deep dives that follow each session. Here you'll be able to contextualize the information you've just learned, speak live with colleagues, and spur your creativity by responding to challenge questions. If you're interested in developing creative solutions to complex problems, the deep dive sessions are perfect for you. In just a moment, our Scientific Program Chair, Dr. Sarah Vinson, will moderate a fireside chat with Dr. Peter Q. Blair, Assistant Professor of Education at the Harvard Graduate School of Education and Principal Investigator of the Blair Economics Lab. Drs. Blair and Vinson will discuss socio-political determinants of mental health and mental health care delivery, as well as explore potential future trends. This discussion will draw upon economics, policy, and mental health considerations. While psychiatrists are experts in viewing these issues from a clinical perspective, I think we could all benefit from a better understanding of how economics can influence social determinants and impact mental health care. I'm excited to see how these issues are discussed through an interdisciplinary lens. There are many stakeholders in mental health care who do not necessarily have clinical experience, and it is important that we draw on their expertise to maximize our impact in addressing social determinants of mental health. Once again, thank you all for joining us today for day two of the Mental Health Services Conference. I know today will be just as enlightening and productive as day one. Thank you. Good morning. Good morning, Dr. Blair. Good morning, Dr. Vinson. I'm so pleased to welcome you to our APA meeting and to have this fireside chat with you. Just by way of introduction, and thank you, Dr. Pinder, for teeing us up, I don't know if this is a first. It's, I think, a first for a conference I've been to, to have an economist as a plenary speaker. I wanted to share a little bit about how that came to be and introduce you all to Dr. Blair as well. And we know, as psychiatrists, as people who are trying to do this work but see these bigger issues at play, that the social determinants of mental health are largely shaped by systems outside of mental health care, as it's traditionally defined. And that mental health is not merely the absence or attenuation of psychiatric symptoms. It also includes the ability to realize one's capacity for agency and take an appropriate role in the larger society. So issues like educational opportunity, occupational skills attainment, and meaningful employment matter in mental health, especially in patient-centered, recovery-oriented approaches to care. And there's also the aspects of how we provide care and the way that we're seeing that shift beneath our feet as professionals. And so in this session, we have Dr. Peter Q. Blair joining us. And here's a roadmap for what's ahead. We'll start with the fireside chat, and we have three big categories that we're going to discuss. Economics and those we serve, economics and how we serve, and economics and the broader society. And in the last 20 to 30 minutes, we'll open it up for what is sure to be a rich discussion. A little bit about Dr. Blair. He's faculty in the Graduate School of Education at Harvard University, where he co-directs the Project on Workforce. He serves as faculty research fellow of the National Bureau of Economic Research and is the principal investigator of the Blair Economics Lab, a research group with partners from Harvard University, Clemson University, and University of Illinois Urbana-Champaign. His group's work first focuses on the link between the future of work and the future of education, labor market discrimination, occupational licensing, and residential segregation. Additionally, he served on the Council of Economic Advisors for the Biden Harris transition, where considerations of both financial and physical health were key considerations as we were thinking about how to get back to normal or normal-ish as a society. Dr. Blair received his PhD in applied economics from the Wharton School at the University of Pennsylvania, his master's in theoretical physics from Harvard University, and his bachelor's in physics and mathematics from Duke University. He is the youngest of his parents' seven sons and got his start understanding markets by selling fruits and vegetables in the Bahamas in the Nassau Straw Market with his brothers. Dr. Blair, welcome. Dr. Vincent, a pleasant good morning, and to everybody here at the AP, good morning, and thank you so much for having me. Yes, it's our pleasure. And so, you know, I imagine this is your first psychiatry meeting. I'm sorry you don't get to be in a room full of us, but, you know, as psychiatrists, we like people's journeys and their stories, and that, you know, physics, undergrad and master's, but now you're doing economics. I think the audience might like to hear a little bit about your journey to what you do now and why. Yeah, well, Dr. Vincent, thank you so much again for having me here, and I'll share my story through the following lens. So here you have an economist speaking to a room full of psychiatrists, and I want this to be a mutual exchange, and in sharing my story of a transition from physics to economics, I hope that there will be some themes that will animate the rest of our conversation that will, in a sense, make the case for some of the value of an economics framework for understanding how do we go about speaking to policymakers and change advocates to communicate some of the stories that you, as clinicians, practitioners, and folks who are mental health providers, that you see and you know what needs to be done, but how do you translate that into a language that can also connect with folks who might have different frames of understanding? So that'll be the spirit in which I'll share my own story. As Dr. Vincent mentioned, I grew up selling fruits and vegetables in the straw market. I don't know how many of you have been to the Bahamas before. If you have, just type Bahamas in the chat so we can just get a sense of how many of you have been there. If you haven't, a plug for the Bahamas maybe for, like, next year's conference, hopefully if COVID is away. And so, you know, that experience was quite powerful for me because we did it because we needed to survive. I fell in love with physics in high school because I had an amazing teacher, and what she would do, her name was Miss Author, she would show us a circuit, for example, and explain the theory behind it. And then the following class we would get to build a circuit. And I thought, this is awesome. I can understand the world around me. Even if I don't do anything ever in my life with physics, I just need to know this stuff. The desire to do economics came about as a result of seeing a need. And I know many of you in the room, you look at the communities, you hear the stories of your patients, of your peers who might be, you know, sacrificing to work with underserved groups, and those stories shape your career trajectories. And so in a lot of ways, my own career trajectory was shaped by seeing the need for economic policymaking in the developing world. And I thought, quite inspired as a kid, well, I want to make models, economic models, and so I'll learn physics so I can know how to make models, and I'll study economics so I can know how to bring those two things together. And when I went to, I got my start at a community college in the Bahamas, and when I finished that, I went to Duke. And at Duke, I was majoring primarily in physics because I just loved it so much, then went on to grad school. And midway through my time in graduate school at Harvard, I found myself looking at models of quantum magnetism and thinking, gee, these models look like they can explain residential segregation by race. I wonder if I can work on that in my spare time at midnight after I finish all my physics homework on these models. And so I just got so engrossed with this, Dr. Vinson, that I realized that it was a passion that I had to answer that call. And so midway through my PhD in theoretical physics at Harvard, I switched fields and switched schools and moved to Penn, and I started over again at the ripe age of 25, when most PhD students are coming in at 21, so I felt like the grandpa. And it was such an education. I'll say something else, too, that is an important inflection point. During my time in graduate school, the financial crisis happened. How many of you remember where you were when the financial crisis happened? If you do, just pop it in the chat so I can get a sense of what career stage you were in. Were you in residency? Were you attending? Were you just starting undergrad? And that had a profound impact on me because I saw people losing their homes. I saw people losing their livelihoods. And it was hard for me to think about the massive Higgs boson when the world around me seemed like it was collapsing. And we find ourselves now in a very similar moment with the COVID pandemic, its economic impact, but even more importantly, its physical health impact, but also the mental health impact of people being isolated from communities that they've grown to know and trust. And something happened very profoundly during the financial crisis. The Secretary of the Treasury at that point, I think, was Hank Paulson. And he went to President Bush at the time with a three-page letter and he said, look, we need $800 billion to bail out the financial system so that the economy doesn't collapse. And based on that recommendation, we had the TARP program that was rolled out. And it was incredible to me to see the power of economics and economists to speak to policymakers, to galvanize resources, to respond to crises in real time. And that opened my eyes to the fact that there was something that economists understood about how the world functioned and how to connect with policymakers. That is really important for taking the stories of the people who are struggling and losing their homes and also the banks that were losing money to policymakers to generate action. And that was a critical moment for me where I thought I need to go and learn this way of thinking. I need to understand how it is that you can mobilize individual stories into data and translate that into action. And so that was also a very pivotal moment for me. And I think that many of you right now might be in your private practices or at the hospitals where you work or the community centers thinking, what are the ways in which I can be serving the communities that I care about most deeply during this time? Regardless of our financial station in life, so many of us have wrestled with mental health issues during this pandemic through either losing loved ones like I have. I lost an uncle and also a cousin and a mentor. But then just being isolated from people and from community. And so that's a bit of my own story. And I hope that the transition that I made can be instructive of the ways in which some of the tools of economics can be helpful to each of you as you think about taking the stories that you see in your private practices and then saying, how can I operationalize that in ways that connect to public policy? Thank you so much for sharing that, Dr. Blair. And I think it's always helpful to talk about terms a bit. And I have some folks who are economics majors and undergrad in the virtual room, but probably not many. So I think it would be useful just to hear from you a thousand foot view, explanation of economics, what it is, and why it's relevant to mental health and mental health care delivery. Yeah, no, that's great. I want you all to pop in the chat, like, what's the first thing that comes to mind when you hear the word economics? If somebody says that they're an economist, what do you think they do? And I'm interested to see what people think. Nate Silver, money, still got a computer, that's pretty true, crafts, money, academics, stocks. Stocks is a great one. I always hear, if I jump in an Uber or Lyft, hey, like, which stock should I buy? And this is the conception that most people have of economics. And it is rooted in a historical truth. And so let me start from there and then bridge to a broader conception of economics, which some of my colleagues, you know, David Laibson and Jason Furman at Harvard are trying to really get out to the world. Economics at its core is about the production, the consumption, and the allocation of resources. And typically economists think about resources as being scarce. You can ask whether or not that's in fact true. But given that resources are scarce, then you have to think, how do we produce them? How do we allocate them? Who gets them? And for economists, an important mechanism for determining how to produce resources and how to make these decisions in a decentralized way is a marketplace. So in this market, you have a side that's producing. You have a side that's consuming. And you have these two sides, like, interacting through the exchange of currency, of money. And so economics is fundamentally about production, consumption, and resource allocation. Now, it has been traditionally viewed as the purview of predominantly finance. But when you look at even healthcare, healthcare is predicated on markets. You have your patients who are consumers. You have your clinicians who are producers. You have a market. And what's been fascinating over the past, I would say, 60 years of economics has been this deep understanding that markets are all around us. And when we understand the fact that markets are around us, there are certain design principles that become very important to the way in which markets function that are relatively general. I'll stop by sharing just two anecdotes of the ways in which economics has impacted healthcare. One of the key architects of the Affordable Care Act was an economist, John Gruber, who's a professor at MIT. One of this year's winners of the MacArthur Genius Awards is my colleague and friend, Marcella Alsun. She's both an MD as well as a PhD in economics. And she did some pioneering work documenting the impact of the Tuskegee syphilis experiments on eroding trust that African-Americans have in the healthcare system. And what she finds is that about a third of the life expectancy gap between African-American men and white men can be explained by the fact that this very grossly negligent historical incident happened and it eroded trust among African-Americans with the healthcare system. And so here you have someone that's at the intersection of clinical work and economics using these mutual tools to help us to more deeply understand the social determinants of health. Thank you for that. And I want to talk about a few specific topics now in thinking about markets and opportunity and scarcity and how that plays into how we do our work. So we know that the ability to earn a living and even what people do really shapes their identity, shapes their autonomy, and is a big issue for people who are living with mental illness, especially when we think about the population that often ends up in public sector settings. As the National Institute of Mental Health describes severe mental illness as disorders that are accompanied by major limitations in life activities over a prolonged period of time requiring long-term treatment. And we know that this is a group that is underemployed as a whole. And so issues of job markets and opportunity and disability are really key considerations when we're thinking about people as a whole and not just as patients. And so when you're looking at the market now, and there's been a lot of discussion around diseases of despairs and how fewer job opportunities for people who are not skilled is having a mental health impact on populations. And so I wanted to get your thoughts on what you see in the job market for people who may not have specialized skills, or I know you do some work too about alternative routes that people get to getting a marketable skill set and being able to enter the job market successfully. Yeah. And I just want to highlight just how brilliant Dr. Vinson is. Whenever I speak with Dr. Vinson, I always get smarter. And just in that question, there are at least three or four really important ideas. And so what I'll try to do is to maybe parcel them out and we can put them into a part A, a B, and a C. And so Dr. Vinson, I'm going to need your help with this because you're so smart. I need to hold all of these ideas together. So I think the first piece, so we'll have a part A that talks about mental health. And I want us to pull back a little bit and first discuss mental health for a broad population of individuals. I think one of the things that we see coming out of the pandemic is historically we've thought about mental health as being siloed to particular demographics and to particular disorders. And especially when you see very pronounced symptoms. But we can think about mental health a bit more broadly as in the same way that we think about health, right? When we think about health, you might say, I'm really fit or I feel sick. And so let's think about mental health even for people who are not yet manifesting some of these very severe symptoms. And I want to again pull back and connect this to economics. So in economics, we're thinking a lot about production, right? And two of the key inputs into production are labor and capital. Capital you can think of as machines. And one of the innovations of economists like Gary Beck has been to say that things like education and things like health are also a form of capital in the sense that they make your labor more productive. So this cell phone that I have right here, this is a piece of capital. This is a machine that makes me more productive. If you see, you know, Peter Blair without his phone, it's like he cannot do a lot of things. How many of you here could function at even 50% of your capacity without your phone? If you're one of those people just pop in the chat, that's me. If you're not one of those people, just pop in the chat. I cannot function without my phone. Okay, we have some people. So Rocky says gladly. I cannot function without my phone. And so why is capital, why is conceptualizing health and mental health as capital important? Because without health, without mental health, we can't do the work that we need to do, right? As we think about the great resignation that's happening here, like a lot of folks are very legitimately afraid of the public health situation. And that can play a significant debilitating effect on your ability to go to work and to do your work if you're concerned that you might catch COVID, for example. And so when we start to think about mental health as a form of capital, it's something that is to be invested in proactively. It's something that if we don't invest in, it'll depreciate over time. Just like our phones, we upgrade these every three years. And so when we start to think about it as capital, it also has a return on it. When you use a machine that makes you more productive, that allows you to make more money, too. Now we're thinking not just about folks who are experiencing really extreme symptoms, we're thinking about each of us, like what is our level of mental health right now in this moment? And what are we doing to invest in it so that we don't get to the point where it becomes symptomatic and then you might need to be hospitalized or you might need to have more severe treatment? So I really want to signpost that. And within the culture, we've seen very brave athletes, for example, Simone Biles and Naomi Osaka, who from the outside, they weren't manifesting perhaps the typical behaviors that you might think are associated with having mental health challenges. But internally, they were experiencing it. And their bravery in coming up, these two Black women coming up to the front and saying, yes, I'm making millions of dollars. Yes, I'm winning grand slams. Yes, I'm winning Olympic gold medals. But there are times when I struggle and I need help. That has given so many more people permission to stop and to say, I need to invest in my mental health to the point where before it gets to the point that it deteriorates. And so I want to really signpost that. And I hope that one of the big takeaways from today is, yes, we want to think specifically and concretely about how do we help and serve those who are marginalized and who are expressing very severe symptoms of mental health challenges. But we also want to, from a preemptive standpoint, think about mental health as a form of capital that we need to invest in that depreciates, that has a return, and that we need to think about for everyone. So that was part one of your question, because your question had four different parts. So I want to stop and get your reaction. No, no, no. You're brilliant. And I have to make sure that I contain the brilliance and parse it out so that I can keep pace with you. So that was part one. I'd be interested to get your reaction to that, Dr. Vincent, in terms of reconceptualizing mental health as a form of capital in the same way that we've done with education, thinking about education as human capital, which makes your labor more productive. Yeah, I mean, it makes me think actually about how we frame, like, continuing medical education as a responsibility that we have as psychiatrists, that we have to stay up to date with our field. You know, it's not enough to graduate from medical school and pass your boards and pass your steps. You have to continue to learn more. But I don't think we have the same messaging as it pertains to continuing to stay passionate and rejuvenated and on steady ground ourselves, right? There's no continuing self-care requirement. But maybe we should think about that, even if it's not a top-down thing, but that if we're looking at our education as something that needs to be maintained over time in a very intentional way, that we think about our mental health as something that needs to be maintained over time in a very intentional way, and that that's a big part of us being able to continue to serve. Because I do think that we see our formal education as resources, but the piece about our own mental health, sometimes I don't think we are taught to think about it in those terms, too. And I like what you said, too, Dr. Benson, which is we've successfully been able to convince people that education is a form of human capital, and it's something to be maintained. And just to build on your point, too, we see physical health in the same way, too, right? How many of you in here got a Peloton during the pandemic? You could just pop Peloton in the chat if that was you. I actually moved my Peloton from behind me for this talk, so it wasn't in the background. Exactly, right? And so even with physical health, we invest in that, right? And as we get older, or as things start to fall apart, we invest even more in that. And we have a physical checkup, twice a year. We get blood work done even before anything is wrong. And a question that I want to ask you is, how would you imagine it looking for us to have the equivalent of a physical checkup being a mental health checkup, and that being as much a part of your natural rhythms as you go to get your teeth cleaned from the dentist twice a week? What would that look like for the profession? I'm interested as someone who's an outsider to the profession. Yeah, I don't know what it would look like for the profession. I think that that's part of our challenge, is that medicine as a whole, and psychiatry, too, there's really more of a focus on pathology and illness and diagnoses. There's less of a focus on health maintenance. We don't have a mental health care system. We have a mental sick care system, right? People don't enter it until there's a problem. And so it would really require a reimagining of our field and what we do. And you would probably even get some pushback about whether that's our place. But I think that if we're thinking about prevention in mental health, or as it pertains to mental illness, it's a shift that we would eventually need to make. Part of our challenge, I think, is that we are dealing with a situation where we don't have the resources to do the task we currently have at hand, right? There's a shortage of mental health care providers. And some of the issues that we're dealing with, like job opportunities for those we serve, seem so big. And so I think it's a question worth asking. But I think it's one that gets kind of put on the sideline because of all of these other issues. Yeah. And if I can press into this just a little bit more, too, so those of you who are in the viewing audience, you probably see that you can see the teacher in me coming out, and the educator who works at an ed school, it's like having this conversation. Something that the pandemic really brought front and center for me, and I will just be very candid, is that for me, the human relationships are really important. About two weeks into, so Harvard shut down right before spring break. I think it must have been like March 7th. And I mean, we were one of the first universities to close and to send students home as a mitigation strategy for the pandemic. And I just remember, I started working longer, I started to feel a lot more irritable, and I couldn't really pinpoint it. And at some point, I started to be less productive. And thankfully, I have a coach, and we started to talk. And as we were talking, one of the things that came up was that for me, I'm a very relational person. And so a big part of my ability to work is being in community with people. And that helped me to dial into the fact that what I was experiencing was that sense of that loss of community. And even the language around physical distancing was like social distancing. And so even that language I felt was alienating. And so as a strategy, it became very important for me intentionally to say that I am going to make sure that I have an hour scheduled each day, where I have a Zoom chat with somebody, whether it's we're watching a movie together, we're just talking to catch up, we are cooking meals together, to have that social element to remember that I am human. I also started with a group of friends a morning session where we would hop in a Zoom together. We'd have like three hours blocked off in the morning from like 9 to 12, like a writing session, other professors and folks in industry, where, you know, first five minutes we check in, how are you doing? How's your family? What do you plan to do during these three hours? We would say a prayer. And then after that, we would get to work for the next two and a half hours. And there was just something about physically being in that same room with everybody else that made us feel more human, that made us feel more connected to other people. And that ultimately allowed us to be more productive. Again, mental health is human capital. And there's an element in which what the pandemic did was it forced us all collectively to slow down. And, you know, if we took that invitation to introspect, I think that there probably, and you can pop in the chat too, what were some things that you found that were ways that you invested in your mental health specifically during the pandemic because that surfaced for you? And, you know, coming out, we're not fully out of the pandemic yet, but something that, you know, has remained a practice for me is as I go into my work week, you know, I write down what am I going to do relationally each day? Where it's something that's going to feed me relationally, that's going to remind me that I'm not just someone that's producing, you know, peer reviewed research papers. And so I really want to foreground for us mental health as a form of capital that depreciates, that we need to invest in, that we need to maintain, and that we need to do preemptively before we get to a situation where we're sick, right? To your point, Dr. Vinton, we don't want to have like a mental sickness approach, but we really want to have a mental health approach that is proactive. So thanks for letting, thanks for allowing us to press into this a bit more too, because I hope that this conversation is expansive and it's generative in non-traditional ways. Yeah, and it's something that, you know, we're learning, and we've definitely had sessions on things like burnout during this conference, and made it a point to try to still have connection, even though we can't have the same, you know, random meetings in the hallway that we get just as much out of when we're able to meet in person as we do from the prepared remarks and the lectures and the things like that. And so a plug for the breakout groups and for the LinkedIn group that will form afterwards, because that was something that we knew was really a value, and I think some would argue is the most valuable part of these conferences. So we tried to create, recreate it to the best of our ability. So shifting gears a little bit, as we're thinking about coming out of the pandemic and job opportunities, especially for those who may have already had gaps in their resume because of mental illness, or who are maybe entering the workforce for the first time, what do you see as ways that we can support people who are looking to enter the workforce? And I shared with Dr. Blair ahead of this, the idea of supported employment and that being a program that we've talked about in the mental health care field before. But just like your thoughts on sort of what you see the market telling us in a big picture way about opportunities to get people back into the workforce who are interested. And we know that most people, even those of what we consider severe mental illness, want to work. Yeah, yeah, this is really good. And this is, this is like part two of that four part question that you had before. And so I'm going to continue to pull on that thread. And this is the educator and me coming out to, you know, Dr. Vinson, there's also this element that you mentioned, too, which is, you know, oftentimes mental health issues can disproportionately affect marginalized communities, too. And I want to pull on that thread, because something that happened concurrently with the pandemic was George Floyd's brutal murder. As a watershed moment, you know, we have had just a continuing like running list of, you know, black and brown folks who have been, who have been, you know, killed while in custody with law enforcement or while having being stopped, and that to kind of like added to it. And there's a way in which, you know, when, so this happened to all of us, as an entire country, and even as a world. And then there's also a way in which that impinges on people of color in particular, right. And I think for many of you in the room here who are in, who are in the mental health field, there are ways in which you may have been dealing with your own trauma from the pandemic and from all of this. And then now, the need for your services and for people who look like you and who have your expertise becomes even greater. And so now you have to serve even more from a place where your, your mental health capital is further depleted. And the temptation is to say, I'm just gonna give more and more and more. And then you're depleting that capital more and more and more instead of saying I need to invest more and more in order to be able to give more and more and seeing that connection. So there's a link between this first part of the question. And this this second part of the question. And so the investing in oneself is critical for being able to provide that care. Now, on to how do we create more opportunities, something that we as economists can learn from other social scientists is that, yes, jobs have an instrumental value in terms of providing people with earnings. But there's also a human dignity component to it. In terms of work, there is something very, I believe, sacred about work. That is a part of us expressing kind of like from a deep place who we are, like who we are, comes out through the work that we do through the where we work. So for those of you who, you know, work with underserved populations, you could be earning a lot more money being in private practice, but you're saying this aspect is important to me. And similarly, for people with mental health challenges, having access to work provides a human dignity that itself can be a form of treatment. And so I think we have to, first and foremost, quantify that and be very explicit and clear that for companies, a part of their corporate social responsibility is that they're providing work that gives people a sense of meaning. And so that's well-paid work. That's also work that is going to be accessible to a broad class of people. I want to tell you just a little bit about some work that I've had the privilege of doing with an incredible group called Opportunity at Work, which is a DC nonprofit, where we have focused a lot on workers who don't have college degrees. And I suspect that for, they've completed high school, but they don't have a college degree. And I suspect that a lot of the populations that Dr. Vinson was mentioning, who might wrestle with mental health challenges that are very pronounced, will come from this population of workers who may not have these advanced educational credentials. And so hopefully there's an overlap between this population that I've had the privilege of studying and the population that Dr. Vinson and many of you in this room care so deeply about. And what we found is, first and foremost, the way in which these workers are referred to, it matters. In economics, we tend to talk about people who don't have college degrees as unskilled, unskilled labor, and people of college degrees as being skilled. And there are tremendous normative implications to just naming someone as unskilled. And what we saw during the pandemic was a lot of people we thought were unskilled were actually essential workers and they were heroes. My nephew, Moses, who was a, he graduated from high school but has no college experience. During the pandemic, he worked in a grocery store. And he was responsible for making sure that people ate, right? Would you call that labor unskilled, right? And so we have to change the way that we talk about that labor. And something that my colleagues at Opportunity at Work and I have done is we have reclaimed that narrative. And instead, we say that these workers are stars. Namely, they are skilled through alternative routes. And the core idea behind the stars work, which you can find on my website, www.peterqblaire.com, is that as somebody is on the job, a lot of that learning happens on the job. And so universities and educational institutions, formal educational institutions, aren't the only places where learning happens and where skill development happens. In fact, for many of you in the room here, you learned a lot of what you now practice through residency, through internship. You had a lot of on-the-job training. And the labor market works really well for providing people who have education with opportunities to learn on the job and to make money while they learn. And so a key component of the stars framework is that we have been pushing for companies to remove college degree requirements for jobs where those degree requirements are not necessary. Because what that does is it allows for HR managers to look at the resumes of these workers who we call stars. And so that's something that we would strongly suggest and advocate, to say, look at job postings and see where are there unnecessary barriers to entry that could screen out people who might have mental health challenges. The second place is to think then about how do you create a more inclusive work environment, recognizing that once you bring in workers who might come from very different backgrounds, how do you create a context where they can thrive? Many of our workspaces are configured for certain types of people to flourish. And they would be people like us who have college degrees, who have the right types of socialization. But if we configure the workplace to be a place where workers who are coming in from a diversity of backgrounds, not only can get in, but that they can thrive and they can build relationships and they can move up to the corporate ladder. I think that the connection of those two things and the intentionality of that can go a long way in making sure that jobs provide earnings for people, but that they also provide a sense of dignity and a sense of meaning, which in and of itself could help to treat some of the symptoms of the mental health challenges that you might see that worker presenting with. Yeah. And thank you for that. And the routes people get to do the work is something that I think is perhaps tangentially related to another big issue that's in the sort of practice of mental health care provision. And I asked the APA staff to send over some of the questions because it's hard for me to scroll and listen to you at the same time. And they sent me over something that came up on the chat around medical student debt and people with different credentials providing mental health care. And this is something that Dr. Blair and I had talked about in the pre-planning for this, right? This maybe battles too strong a word, or maybe it's the right one, but around a scope of practice and who's providing care and a two-year training versus three-year training versus an eight-year process. And for psychiatrists who have put in more of that time, perhaps on the front end, and seeing how the need for more providers is profound and undeniable, and there aren't enough of us. And at the same time, we're having these sort of scope of practice wars about who gets to do what or how that looks. And I saw in the chat too, this is something else we talked about, was medical student debt, right? Because that process is so long, you're looking at $200,000 plus for the average medical school graduate, and that's not even counting undergrad or other things that they had. So we have this situation where there's a very clear need, where there's a diverse group of people who have taken various routes to providing mental health care. And there's, I think, concern about people wondering how much that time they've put in is valued or their expertise is valued. And so is there something that we can learn from your work about how you have people from different backgrounds, with different training, doing the work, and how you do that in a productive way that serves people? Yeah, this is another brilliant question, and I am just lighting up inside because you are ticking all of the buttons that animate my research. So I do work on trying to understand why a lot of elite universities have not expanded. And that work can relate to why is it that the American Medical Association has been really rigid in terms of the number of schools that are certified to provide medical training. It's not budged in a very long time. So that relates. So you can think about, let's leave the system the same and bring more people through the door by expanding the number of slots that are available in medical schools and then in residencies and so on and so forth. And just broaden the pipeline, but don't change the system, right? So that's one approach. And there's some work that I do that's related to that. Then there's the other approach which says, okay, given that people are in the system, how can we change the system to say who can do what? And this is where the scope of practice piece comes into play. And I've done a lot of work with one of my former PhD students, Bobby Chung, who's now a professor at St. Bonaventure University in New York, where we look at occupational licensing. And then that licensing, as you teed up, Dr. Vincent, really relates to, well, you have folks who've invested in this profession. And when they invested, they were thinking about a particular return. And so when you change the scope of practice, what you're doing is that's having an impact on the return on their investment. And if you're not compensating them for the loss of those wages, then they have an incentive to dig in their heels and to say, look, no, I paid the price. I need to make sure that I can recoup my investment, right? And so there's that component to that relates to some of the work that I've done on licensing. I want to pull up and share with you a framework that has been really helpful for me in terms of thinking about decision making. And this is something that I share with the master's students that are in my class and the PhD students. And the reason why I share it with you is because many of you are in the field. You know the issues better than I do because you're living it. This is your life. And so I think where I can add the most value is not in terms of telling you like the way in which the medical profession should operate, because that would be completely out of my depth in talking about that. But where I can be helpful is saying, what's a framework for trying to analyze these problems through your perspective, but then also to see these problems through the perspective of somebody else, and then to recognize where are the bottlenecks, where are the places of disjuncture that lead to various constituents or stakeholders arriving at fundamentally different conclusions so that you can really telescope in on what are the particular pain points that need to be solved. So let me let me start with that framework that I'll share with you, and then I'd love to get Dr. Vincent your reaction to that, and then we can circle back and like dig into like the specifics of like school expansions, and then also like scope of practice too with that framework as a lens. How does that sound as a game plan? I like it. All right, awesome. So the framework, and I thought a lot about how to adapt it to this particular audience. I'm going to call it DOCC, and so I want you to type in the chat D-O-C-C, DOCC, and I'm going to do it too. All right, okay. How many of you can remember DOCC? Is that an easy acronym to remember? You guys got this, right? So whenever you come to analyzing a problem, and remember I talked about economics as being this science of trying to understand the production, consumption, and allocation of scarce resources, right? And DOCC is going to help you to think about this through the lens of different stakeholders. So the first thing you need to do in DOCC, the D is going to stand for the decision maker, and so this is who is the person whose eyes we're seeing the problem through. Is that a clinician? Is that a patient? Is that a state legislator? Is that a president, right? And so who is the decision maker? So that's D. So just write in the chat decision maker. D is for decision maker. The O stands for objective. What is this person trying to do? Are they trying to increase access to care? Are they trying to improve their personal health? Are they trying to reduce costs? What is the objective? So that's O. And then C is what are the choices that they can make in pursuit of that objective? Is it expanding the number of colleges, of universities that can train professionals? Is that expanding Medicaid? Is that having mental health as a checkup, right, in the same way that we have like regular health checkups? so that's what are the choices that are available to the decision-maker in order to advance the objective. And there's the last C, right, which is going to be what are the constraints that the decision-maker faces when trying to make choices to achieve a particular objective. And these constraints could be financial constraints, and so, for example, for folks from a marginalized community, it could be, well, I would love to get psychiatric help, but I can't afford it. I'd love to buy psych meds, but I can't afford it. Are they political constraints? It might be that you have a particular governor that's in a state where, although she might support a particular policy, if she were to advocate for that policy, she could lose an election and not be able to push some other agenda. Is it time? Is there a time constraint, or is there a technology constraint? We just can't do it because, well, we're on Zoom, and we need to be in person to do this, right? So, D-O-C-C, DOC, so let's write DOC again in the chat. Can you remember that? Does that work? And so with this framework, you can pick whichever issue you want, right? So, for example, you can say why don't medicals, why doesn't the AMA expand the number of slots? Okay, the decision-maker is the AMA. What's their objective? I'll let you speculate as to what the objective is. And then you can say, you know, what are the choices that they have? Well, the choice could be, you know, change the requirements for who gets to count as a medical school that's in the system or who gets accreditation. That could be a choice. What might be some of the constraints that they face? Well, some of the incumbent medical schools might say, look, if you do this, we're going to revolt and this is going to cause a problem for the association, right? Now we've looked at that situation through the lens of one particular decision-maker. Now if instead we said, let's look at this through the lens of a decision-maker being a student who is thinking, do I go to medical school or not? Well, the decision-maker is that student. The objective could be to maximize lifetime earnings. The objective could be to do the most good for the most people. The constraint could be a financial constraint. You know, I want to go, but I don't have the money. I can go, but like, I'll have to get a bunch of debt. And the choice that they have to make is do I go or do I not go? And so you see, you can take the same problem and you can run that problem through this framework and that can help you to understand why might it be that a student comes to a very different decision about whether to go to medical school or not versus, you know, the AME choosing to expand, right? Now what exists kind of in tandem with this framework is that each person or each stakeholder or actor running through this framework is making their own decision in a way that's personally or privately optimal. It could be the AME, it could be the individual doc, it could be the individual insurance company. Now, however, an individual's decision can have implications or consequences for somebody else who is external to that decision. And the person who's the decision-maker may not necessarily internalize those consequences, right? And so you get a situation in which what is privately optimal could actually be suboptimal for society. And this is where we now have to come to a broader question of like, what are the values that we want to possess? Who should be the decision-maker? And to what extent should the objective that the decision-maker have taken into account not only what the decision-maker cares about, but take into account the implications or the impacts on other folks too. Now we have a way of looking at some very internecine, very difficult questions where there's lots of disagreement from various stakeholders, and we can identify at which point in the doc is the discrepancy in terms of why one constituency is thinking that this ought to be the case versus another thinks the other thing is to be a case. And then we can move from demonizing each other and then recognize where these points of disagreement are, and then really illuminate a path forward that tries to resolve like some of these differences if they in fact are resolvable. So I'll stop there and just having offered that as a potential lens through which you can look at a lot of the policy questions that might be relevant to the group that's gathered here. And I'd be interested, Dr. Vinson, to get your response to this as a potential way of looking at some of these really deep, important policy questions. Yeah, I think it's always helpful to be able to have a framework to fit things in when there are things that are close to us. And I know in my home state, my adopted home state now, Georgia, that what comes up often during these discussions is, well, isn't something better than nothing, right? And when you're looking at it from the perspective of a lawmaker who's hearing about primary care doctors not being able to find mental health care professionals to send people to, you know, arguments about credentials and time spent training don't resonate to them in the same way that concerns and stories from mothers and people trying to seek treatment and families that are struggling do. And so it makes sense that that is something that they would want. And so I think it's an area that we as physicians aren't really taught about when it comes to advocacy and thinking about these broader systems issues. But it kind of goes back to one of the things you talked about earlier in terms of what is our objective, right? If our objective is to extract as much money and stability from the current system as we can, that may lead to a different outcome than the objective is population mental health and being able to serve more people. And I've wondered, and this is a conversation I've had with a lot of early career psychiatrists and members in training who are interested in public sector work, you know, how that's going to shape what psychiatry looks like in those settings moving forward. Is our role going to be more as administrators and supervisors rather than being able to provide direct clinical care? And I'm not saying that I have the answer. That's what it should be. But if the goal is to help more people, it's clear, given the gap between what we're able to provide and what needs to be provided, that something fairly radical needs to happen in order to bridge that. Yeah, that's powerful. And just hearing you talk about this was really instructive because you used the decision maker being the individual psychiatrist and in particular, someone at the early stages of their career where they might have this objective, which is to provide the broadest level of access, but then a constraint could be, I have to pay off my student debt. And you might look at the actions of someone to say, have only clients that are very wealthy or to go into private practice. And someone might look at that person and judge them and say, oh, she really sold out. I can't believe she came in all like, I'm here for the people and for the community. And now I see Sis driving a Beamer with her Fendi purse, living that life and not taking care of the people. But Sis has bills, right? And so we can make the wrong inferences about that. But what it does, it helps us to think about what are the leverage points, right? And so one of my hopes would be that from this group and also from the LinkedIn group, forms that folks can sit and be very real and authentic with each other and say like, what has drawn me to this profession? What is my highest hopes? And what are the choices that I have towards fulfilling those highest hopes? And what are the constraints that are standing in my way from being able to do that? And it could be the case that when people compare notes, what you find is that there's alignment and objectives across many people in this room. There's similar constraints that folks face. And then what happens now is you can say, well, what if we all came together in ways just like you're coming together right here? Are there ways in which us coming together, like our ability to push back against some of those constraints or to reimagine or to re-resource some of those constraints? How could us coming together collectively reduce that constraint for all of us and then in turn result in us having different individual and collective decisions that we can make too? And so that's one of my hopes that coming out of our time together, that there could be this kind of self-examination, but also collective examination where you can pinpoint where are the leverage points, not just individually, but when you come together collectively, how do those things that seemed to be constraints in the past, how can they be lowered? And that leads to new possibilities, new imaginations of what is possible. I'm curious in your work with companies, trying to get them to think about who's qualified to do what work or how that looks, what you found helpful with these conversations? Because I imagine there are some people at the company who have their degrees that they may be in debt to pay out, right? Or in debt to attain. And so I can imagine that there's some pushback and I wonder, and of course, it's not a one-to-one situation, but I'm just curious about how that's impacted people who are already there, who are already in the system or what you found helpful in terms of having those conversations. Yeah, yeah. This is a great question. And I think you're really drawing on the connection, which is as people who are already in the profession, who are incumbents, who've already made the specific investments, there is this internal tension where maybe I do want to create broader access and that might include relaxing scope of practice restrictions, but then do I want to do that at my own expense, right? And so there are these two kind of potentially conflicting things. So I see that as the broad connection. What we have found to be really effective is first understanding the problem. And in our work, one of the things that we highlighted is that just the way that economists and folks in the labor market were talking about workers without college degrees, it explained why we were able to treat them in such an exclusionary way. Because if you say that they're unskilled, then, well, they're unemployed because they're unskilled. It becomes a tautology that's self-reinforcing. And so I would say the first step is, how are we talking about the things that we want to change? And what are the normative implications of that nomenclature? And so, for example, at the beginning of our conversation, we were talking about reimagining mental health as a type of capital, as a type of human capital, because it makes your labor more productive. In the same way that we think about education and continuing education as human capital, that depreciates over time, but that needs reinvestment, and that can have a return, right? Just starting there in and of itself begins to open up new possibilities. So number one is, how are we naming the problem and naming it in ways that doesn't assume that the status quo is the only answer? So that's the first step. The second, and really surprisingly, you find that just that one step does a lot of the heavy lifting. So, for example, in our work, we'd written this paper on STARS, I think, in February. And by, I think it was maybe June, the federal government had said that they're going to push for hiring based on skills and not degrees. And during the summer, George Floyd's murder happened, and the whole world was horrified by it. I certainly was, as a person, especially as a Black man too, you see the faces of people that you know your own self in that experience. And I thought, what is it that I can do? And so with a colleague of mine from Opportunity at Work, Shahid Ahmed, we wrote an op-ed that was published by the Wall Street Journal. And the genesis for it too was recognizing that there was something significant about this moment. I believe there's something significant about this moment when it comes to mental health. If you agree, type in the chat, yes. If you disagree, type no. Don't feel any pressure. But we have a unique moment given the confluence of the pandemic, the confluence of what's happened with Black Lives Matter, what happened with the insurrection, and what's happening with really successful, highly accomplished people like Naomi Osaka and Simone Biles recognizing their own mental health struggles. And when Naomi, there was a cascade of three Black women. You had Meghan Markle first coming out, right? And when she came out, it was kind of like, eh. Some people were very pro, and some people were a little bit on the fence, right? They were like, boo-hoo, you're a princess. And there were other people who were like, no, she's a princess, but she experienced this. And then you had Naomi Osaka coming out. And when she declined to play, I think it was at the French Open. And then she was roundly criticized. And it was, again, mixed energy. And then you had Simone Biles. And then when she came out, it was like three strikes. And then this trio of Black women just broke through. We have a moment where people are talking about mental health. And not just in the way where you're thinking about folks who seem symptomatic, but you're talking about highly successful, highly trained championship people who know how to deal with and who have overcome a ton of stress. So these aren't folks who, you know, these aren't folks at the margins. This is a mainstream thing. So how do you lean into that moment? So coming back again to our work with STARS, we recognize that there were a lot of companies who started to say, we recognize systemic racism is a problem in our society, and we want to do something about it. And their initial blush was, let's pledge money to this. And our thinking was, there's more that you can do than pledging money. What you can do is begin to remove the barriers to economic mobility to Black workers within your companies. And a big part of that is recognizing that degree requirements, when they are unnecessary, negatively affect all workers, especially people who are doing low-wage work. And in particular, have a disproportionate impact on minorities. And so we wrote that op-ed by saying we need to change the way that we talk about these workers and call them STARS. And number two, there are specific things that you can do institutionally to respond to this moment. And so I would say to you, nomenclatures, number one. Number two is don't miss this moment and really press into this. And something amazing happened. We had CEOs from Fortune 500 companies just reaching out to us and just saying, look, this is something that we care about. And right now, there is an initiative by 37 Fortune 500 companies that have committed to hiring 1 million Black STARS in the next 10 years. 1 million. So if you go to 110.org, you will see the initiative, right? And so this was a moment where there was a convergence between what we were saying about the naming, the research that we did. We pressed into the moment and we got a huge response from policymakers, but also a huge response from folks in industry. And I think that the moment is incredibly ripe for the kinds of things, Dr. Vinson, that you and everybody in this room is working on. Thank you for that. And it makes me want to sort of go all the way back and think like complete big picture. And this is something that came up in some of our sessions yesterday. This is day two of the conference around just income inequality in the United States. And as mental health professionals, we know safety and security are foundational for mental well-being. And when you have a society where people's basic needs aren't met and when large populations or large proportions of the populations don't have those needs met or don't have them met during really critical developmental periods, that that matters. And so income inequality is one of those things that has a certain political flavor to it in some settings. But I think it is a mental health issue, especially when you're talking about sociopolitical determinants of health. So I wanted to get your thoughts about income inequality in the United States and where you see that going, what you see that can or is likely to be done. And then after that, I will open it up to other people to have the opportunity to ask some questions to or filter through their questions. Yeah, yeah, yeah. And this has been really wide ranging, and I've loved just the contours of this conversation and just the way in which it's been very generative in real time. It's almost like we're playing jazz, right? With income inequality, it's important for us to recognize that this didn't just come down from God like the Ten Commandments, right? This is the state of the world. And we have to ask the deeper question of like, what is the source of this? Oftentimes when we see inequality, there is a normative story that we tell ourselves, right? The people who are not earning money, they're not earning money, well, because they didn't work hard or because they didn't make good decisions or so on and so forth. And you probably see very similar things too around mental health as well. Well, maybe this person is experiencing mental health challenges because it's something that this person didn't do. And so we have to first acknowledge that whenever we observe very striking inequality, that even if we don't vocalize it, there are certain normative assumptions that are at the foundation of that. And so let's lift the hood and say, what are some of the normative assumptions there? Well, either you can think, well, this is the natural state of the world, and it just reflects the fact that some people are more productive than others, and that's why they earn more money. They are the rainmakers, and we should not hate on them because of this. That's one view. Another view is, well, this is a manifestation of structural racism and huge imbalances in power and so on and so forth. And until everything becomes fully equalized, we know that the society is fundamentally broken. So you can think of these as painting the two corners, right? And the truth is probably somewhere in between, right? Yes, we do live in a society where there's tremendous opportunity, but that opportunity has historically been very closely guarded, first extended to men and to white men in particular, and then more slowly to women, white women in particular, and then episodically to African-Americans in this country, but then extended and then taken back. And there's been a bit of a back and forth, and that matters, right? When you think about the fact that many universities were segregated, that K through 12 education was segregated. To the extent that we believe that education is a mobility ladder, a lot of the current inequality that we see now has been baked into past social policy. And so there is a debt going back to the founding of this nation that is owed to many people who find themselves on the short end of the stick. And we have to be honest about that. And we see with things like the 1619 Project that when we start to have an honest reckoning of history that there can be some seriously uncomfortable conversations, but first we have to recognize that what we see is coming from, it is value laden, and there is a context there. So I would say that that's the first thing. Now, where this conversation enters around the importance of mental health is just the existence of that in and of itself, not only can it be a function of mental health, but it can also compromise your mental health. Like if you think that you're in a system that's fundamentally unequal and regardless of what you do, it's going to be hard for you to move up the ladder. Because that in and of itself cuts against what is the American dream that I can pull myself up by the bootstraps, right? And I want to make this point because it is a subtle point that we sometimes underappreciate, which is that the manifestation of income inequality and sclerosis in terms of people's ability to move up if they do pull themselves up by the bootstraps itself is, it pushes back against this narrative of the American dream. And to the extent that we're invested in this idea of the American dream, it should bother us philosophically. And it should bother us especially that folks who are coming to, that for people outside of the U.S., that still is the American dream, but for many people inside of the U.S., that American dream feels like it's slipping away and it's disappearing. I know that this has been like very abstract and very philosophical. So Sarah, I mean, Dr. Vinson, please feel free to like tether it back to ground. Because you've got me going for such a long time that I'm in full professor mood now. No, no, no, you're good. You're good. Yeah, and I think that, you know, it's an issue that it's hard for people to talk about because of that attachment to that idea of what America is and some of the difficulty with accepting the times when it falls short of those ideals. And, oh, go ahead. No, no, no, please. Well, there's a quotation by James Baldwin, and I'm not remembering it exactly, but he talks about, he criticizes America because he loves the country, right? That there's a way that we can be observant and honest, and it's not out of a place of putting anything or anyone down, but holding it accountable, right? So, well, I want to address some of the questions because I know we could just keep talking. And there's actually two that came in close together. I don't know if they were in response to each other, but I think they actually are related in terms of what they raise. I'm not sure if people wanted me to say their names or not, so I just won't. But one said, I agree that mental health is capital. However, many of us have been making a business case, yet our work is underfunded. So mental health care services compared to other medical services are underfunded in a prejudicial and discriminatory way. How do we factor prejudice and discrimination into how decisions are made from an economic perspective? Some forms of capital are invested in, others are left behind. So that's one comment. I'm going to ask you guys to hold that one. The one that followed it said, are you concerned that thinking about mental health as capital, as a framework, inherently diminishes the value of folks with severe mental illness and perpetuates the idea that people are only worth what they can produce in society? So when I read those two things, I actually saw them as related because in thinking about it as capital, we are putting it in terms that society can understand and that perhaps are not going to be as easily dismissed or subsumed under these discriminatory and prejudicial ideas. And so I think there's actually a potential for seeing it that way. To help the broader society understand why everyone is worth investing in and why addressing this issue in a way that is accessible to more people should be a priority for us as a society. And that was the frame, that was the intention behind the frame. Because for a lot of people who see the value of mental health work, they don't need to be convinced of the moral imperative of making sure that these services are accessible. And for folks who may not see the value of it, the frame of looking at it as capital helps to pinpoint the fact that there is this inequality in terms of the resources that folks have and that this type of investment can be a potential way for equalizing. The framework itself is not normative in terms of saying that given that folks have this initial level of capital, therefore, this says something about them. But it's positive in the sense of saying that, well, if someone has this level of capital, then this is going to impact their ability to produce. And if we are invested from a value standpoint as a society, of everybody having the capacity to be able to produce. And this isn't just produce widgets, right? But this is about human flourishing. And so whatever that output is, you can think about this capital as helping to provide human flourishing within that context. So my mental health is really important for me being able to fully engage with my niece and my nephew. Because if I'm not in the right place physically and spiritually and psychically, I could have all the money in the world, I could have all this other stuff going on. I don't have to be economically poor, but that can still impact my ability to connect with them emotionally. And so I think it's really about elevating this component of who we are to the same status of a lot of other things that we actively invest in and we actively monitor and we actively want to raise up to a higher level. And so the way that you imagine it, Dr. Vincent, was the intention behind framing it that way, not to say it's something to be commodified and something by which we just classify people and say, oh, this person has X capital and this person doesn't have that, no. And another question that says, are you concerned about this DOCC concept and others like it within economics and how they selectively ignore the implication of how white supremacy undergirds who we have as decision makers and what their objectives are? Yeah, that's an excellent question. This framework can help to uncover that. So, for example, we can look at existing inequality and we can say, well, who are the decision makers? What are the choices that they've made? What are the constraints that they face? And then to what extent are those constraints themselves a function of white supremacy and racism? So, for example, if you look from a political standpoint, you see certain policies being pursued that are discriminatory. You can say, well, OK, why is this person doing this? Right. Are they doing it because they're trying to appeal to a base? And so within the context of this framework, you can begin to very clearly delineate the difference between someone's preference for racism versus the extent to which they might perceive themselves as facing a constraint. Because you take that same person, if that decision maker is a politician and what they care about is getting reelected, and it's really the electorate that harbors this prejudice, well, then one theory of change could be, I need to talk to my neighbors and I need to engage with my neighbors to get them to change their perspectives. Because if my neighbors change the way that they view the world, then our elected officials would recognize that they can't get elected with really discriminatory policies and practices and then they would change. Now, if it's not the constraint that's affecting it, but it's really the objective of the policymaker, then the framework also helps you to really recognize that, well, you take that same person, you put them in an environment where politically it makes the most sense for them to have inclusive policies, but then they still choose to dig in their heels and have really discriminatory policies. And then you can say, well, actually, it isn't a constraint. It's that this person has the objective of trying to visit white supremacy on us. And so one of the things that I try to do a lot in my public speaking and also in my work is to redeem the economics, the way that economics is viewed. I think oftentimes, you know, I had someone say to me once, you know, Peter, you know, I think that, you know, economics and statistics and numbers are an exercise in white supremacy. And this was someone who was a white woman who said this to me. And I'm a Black man teaching economics. And so in that moment, right, like I feel attacked. But it was a very instructive comment because it helped me to realize that the way in which statistics, the way in which economics has historically been used has been tainted, has been tainted. But that doesn't mean that it can't be used as a tool of liberation. And by understanding this framework, by understanding this as a tool, really the way that we use it is what determines whether it's an object of white supremacy. The same fire that can burn down a house is a fire that can feed a village. And one of my hopes from this really rich exchange that Dr. Vincent and I have had, as well as the rich engagement with the chats, is that, you know, there are ways in which we can repurpose these tools to, these tools in a way that can like cook food that can feed the village rather than burning down the house. So that's the that's the humble hope and desire and ambition of this. Thank you so much for that. And I think that there is certainly applicability to that as it pertains to the mental health care field and the ways that we haven't gotten a lot of things right, but that there are things that are a part of our training and a part of our lens that can be used to start to actively undo some of the harm that our field has been part of perpetuating. We have another question. With the pandemic, the turnover in the workforce has been significant. What are the conversations in the world of economics as far as improving the longevity of their human capital? Yeah, no, this is something that we've seen is a lot of firms have recognized the importance of their workers as people. Right, because you see many workers saying, I'm not coming back to this company because of the health situation, or I need certain assurances, or I want to be able to work remotely from home so that I can spend more time with my family. And in the past, a lot of these policies would have been considered completely untenable. How many of you have asked a company that you worked for to telecommute before the pandemic? If you have, you can just pop yes in the chat, that was me. And how many of you have had that request turned down? We're living in a fundamentally different world now, where employees are recognizing that they have this power to demand better working conditions. I'll give you one quick example. I have a lot of friends who work in finance, and finance is notorious for having really difficult, long working hours. And when I would talk with my colleagues, I would say, this is ridiculous. Like, why don't they just hire more people and just have shifts? You don't need one person working 90 hours a week. And I would get pat responses like, you don't understand, this is the system, this is the way it is, x, y, z. And what you saw during the pandemic, I think it was one of the big banks where some of the associates leaked just how horrendous the experiences were. And you saw across the board companies saying, we're going to send you a Peloton, we're going to give you an extra $50,000. And the companies found the resources to compensate workers, to change norms around how they work. And so I do think that in many ways, what the pandemic is doing is it's giving us an opportunity to renegotiate the social contract between firms and workers and also between firms, workers and the government in ways that could, you know, as we press into it, lead to a working environment that more better respects and appreciates the depth of our humanity and the fact that we are more than just what we produce. So I have another question for you, and it's kind of a big one, or maybe it'll be a simple answer, I don't know. But it is, do you believe the business of medicine and in particular mental health care would be better served by a single payer system? Under which conditions? In America or like in general? In America. The thing about America that is really, you know, can be both amazing and frustrating is. It's such a. And I am like, I'm like in between the ball and the curve. I see the wheels turning. Yeah. And so it's like and I yeah, I love yeah, I love this country. And I say this as someone, you know, who I'm from. The Bahamas, and I've had the privilege to come to the US and to work in public institutions like Clemson University, to go to private institutions like Duke, Harvard and Wharton. And. It's a it's a wonderful country with like so many different contradictions, so I'm thinking through the framework in terms of saying, well, do I see it as the world as it is? Here's here's my view. I'm going to lean into something that my my colleague, Dr. Ebony Bridwell Mitchell, she studied she's a sociologist and she studies organizations. And so oftentimes we think about policies and reforms and then we do evaluations of those policies. And she says, well, in the middle of this is what are the institutions and the social relationships that mediate policies and then create the kind of outcomes that we measure? And so I don't I don't I think the answer is not so simple as if we have a single payer system or we have like a system where there are multiple payers, I don't think it's about that. I think a lot of it has to do with how are we as individuals and how are we as institutions kind of engaging with whatever the policy environment is, because we could have a multi-paired system like which we have right now and there could be tremendous amounts of inequality. We could have a single payer system and that could be systematically defunded if folks feel like, well, why should I be paying for the health care of this person who I think is not working hard enough or who's making health choices that I disagree with? And we see a lot of that in many of our publicly funded institutions. If you look at K through 12 education, which is an area that I've studied, you know, when you have redistribution of resources in heterogeneous environments, either racially or income wise, you have a situation where you can see disinvestment from some of those public systems. So it's not just about the system. It's really about how are we as people going to faithfully engage with whatever system we have? Right. It's really about the people. The moment we start to think that we can create a system that is going to work irrespective of the people, I think, I think, you know, it's going to be a lot more difficult for us to be able to I think. I think that's where the wheels come off, and so I'm not a believer in like here's a system that's going to give us a silver bullet, I really think fundamentally we have to think very integratively about who are the stakeholders, what are their objectives, what are the constraints that they that they face and how can we design a not just a system, but a set of like practices and ways of dealing with each other and being with each other that will reinforce whatever the institutional arrangement or system is that we agree that we agree to. My late colleague, you know, Derek Bell talked about the importance of interest convergence, right, like setting a table where people's interests are aligned so that it's in their best interest to cooperate. I think I think that has to be a fundamental component of whatever system it is that we create for health care provision that's going to work. And the last thing that I'll say, too, is I think, you know, Dr. Vincent, you mentioned this earlier, we have to we have to consider and contemplate more actively how can we proactively invest in mental health and how can we how can we do that before things really begin to degrade? Because otherwise we have a system that's just focusing on like, you know, sick, like just taking care of people once they're ill. And that's both expensive. And I think that's where you get a lot of the the policy disagreement about who pays for what because it's expensive and because it's like, well, how much of it is a system problem versus an individual, an individual's decisions leading to that outcome? That's where things become more contentious, I believe. Yeah. And I think that that's such a great point about the mediators, because that is often left out. But we know that that is important, even if we look at mental health parity and how the policies there, but the acceptance and implementation of it is far from universal. And I think that that mediator question is a big piece of it. Yeah, that's a great point. Like, take, for example, even like, you know, leave policies. There are lots of companies where you're formally like you formally have leave for two weeks or however, but most people know institutionally as a norm, you only take one week if you want to progress to that company. Right. And so like policy is going to be mediated through institutional practices and norms and not just based on like what the reform is that we have in mind, per se. So stepping back again and realizing we only have a few more minutes left, I'd like to take a little bit of time to look ahead. So as we're thinking about these issues of opportunity and inequality and advocacy, you know, what are some things that you think should be on our radar, things that we should be thinking about as we move forward? Yeah, and this is going to echo a theme that has come up throughout the course of this conversation is the moment is now. Everybody is talking about mental health. And really, literally grabbing the microphone as professionals and also creating interdisciplinary exchanges like this one here where you bring me in as an economist who. To talk and be in dialogue with you, because now I'm thinking a lot more about these questions, you know, I posted on my Twitter at PQ Blair dot com, a PQ Blair to just ask people about studies in economics related to mental health, and like I just learned so much about the fascinating work that economists are doing with respect to mental health. And so I would say I would encourage the APA to be at the center of this discussion. Right. You know, going back to the financial crisis, you know, where Hank Paulson was at the center of the bailouts or even thinking about the way in which, you know, my colleague at MIT, John Gruber, was at the center of designing them, helping to design the Affordable Care Act, being at the center of this conversation and really creating a multidisciplinary space where you can get the best thinking from clinicians, from folks in underserved communities, from policymakers to help to design, I would say, approaches, not just policies, but even like the right nomenclature for talking about what the problems are. What are the potential resources that you have for solving these problems? And just do this in an incredibly collaborative way where the APA is very central to this. If there's one thing that you take away from this, it's the moment is now and what you're doing is, what you're doing, Dr. Vincent, is squarely aligned with this. That's the one thing that I want you to take away. Fair enough. And I got a question. Man, there are two really good ones. I'll go. Well, I don't know which one is simpler. But the future of work, more broadly, we'll go with that one and this idea of people being de-employed and the discussion around basic income. So your thoughts on that? You really want to end on that? I know, I'm giving you two minutes to talk about the future of our community. This is something that's really interesting to me. So I do some mentoring for founders of early stage startup companies and one of the companies that I mentored got into Y Combinator in Silicon Valley. And a lot of the founders at YC, I think Sam Altman and others, they had lots of ideas about the future, about basic income. And so he asked me about it. And so I wrote something many years ago. I'll share a redux of this. A lot of the basic income conversation in the U.S. has been pushed by very wealthy people in the U.S. And I think that should make us ask the question of why is it that wealthy people in the U.S. are pushing the basic income discussion, right? And people are living in places like Silicon Valley where you literally have people on the streets who are homeless that you have to walk past to get to your billion-dollar company, right? So why is it that we can create electric vehicles and a social network that connects the whole world but you can't provide like a standard of living for the people that live in San Francisco? And when I interrogate this, and I can run it through the doc framework, right? The decision-maker is, you know, a tech billionaire. Their objective is to continue to make their money. And their constraint is a political constraint, right? There's one of them, and there are millions of ordinary Americans who can vote. And so if these ordinary Americans who can vote feel like the situation has gotten out of hand, then that's going to potentially compromise their ability to continue to make a lot of money. And you will get calls to deregulate tech, to break up tech. And what's a way to quell that? Well, make sure that people have basic income. And so I think that that's a part of it, that the motivation and the energy that's coming with a lot of the basic income, especially from – it's coming from a lot of wealthy folks in the U.S., and I think a part of that energy is a bit self-preservationalist. I would feel more hopeful if it were coming from the people themselves, right? I think what you hear from people themselves who are struggling is they want an opportunity. They want access to health care. They want educational opportunities for their kids. They want a labor market that doesn't discriminate against them, right? They want the dignity of being able to not just work, but to have the government invest in their communities, invest in their growth and their development. If basic income is viewed as the charity from the rich to the poor, that's a fundamental – that's a fundamentally unequal society when the taxes of folks are going to support innovation and tech, or the taxes of folks went to bail out the banks, right? And so the government is providing lots of resources to the rich to get richer, and creating a policy environment with tax cuts where they can hold on to more of their money, and then in return, the handout that ordinary folks get is like a check every day in the month. The political power that the people have is much stronger than just getting basic income. I think they can get basic health care, basic education. You can get a lot more things, and then you can create your own destiny instead of having it be in the hands of someone. These are my unvarnished thoughts on this very important topic. Thank you so much, Dr. Blair, for that and for joining us this morning. This has been an absolute delight, and welcome to hanging out with a bunch of psychiatrists. This has been phenomenal. Thank you all so much. I would love to keep in touch, and I'm just going to pop my Twitter handle here. Please feel free to follow me on Twitter and to keep the conversation going. Thank you so much for inviting me, and I think this is – you're leading the way in terms of taking the moment now, setting the table, and inviting others to participate. Kudos to the APA, to your president, and to your leadership. A huge honor to have been here. Thank you, Dr. Vinson, for just the courage to invite me and for just doing such a phenomenal job with the preparation. I just want us all to just clap in the chat for Dr. Vinson. She is amazing and an absolute gem in this profession. Thank you. All right. I'm actually not sure if we're still live or not. We probably are, because I see the chat continuing, so just – yeah. Okay.

socio-political determinants

mental health care delivery

economics

social determinants

interdisciplinary collaboration

mental health issues

investment in mental health

inclusive work environments

medical student debt

scope of practice issues

DOCC framework

productivity

income inequality