Hello, everyone. I'd like to extend a warm welcome to everyone today for joining the session. Our title is Highlighting Innovation in Mental Health Services in Rural and Indigenous Populations. My name is Rob Kotez, a psychiatrist at Emory University School of Medicine, and I'll be moderating today's session. We are so fortunate to have three wonderful speakers with us and I'll introduce each briefly. Dr. Mary Russell is a Clinical Associate Professor in the Department of Psychiatry at University of New Mexico. She received her MD degree from the University of Minnesota and completed her residency at the University of New Mexico Department of Psychiatry. She currently serves as the APA Area 7 Board of Trustee. Dr. Russell received the APA Assembly Award for Excellence in Service and Advocacy in 2016. Currently, she works at the Santa Fe Service Unit, which is part of the Indian Health Service, serves as psychiatrist for the La Familia Medical Center, and has a private practice. She is a Distinguished Life Fellow of the American Psychiatric Association. Dr. Marisa Gigi is Associate Professor of Psychiatry and Behavioral Medicine at the College of Community Sciences at the University of Alabama. She received her MD degree from the Medical College of Pennsylvania Hanneman School of Medicine in Philadelphia and completed her Adult Psychiatry Residency, Fellowship in Child and Adolescent Psychiatry, and Forensic Fellowship, all from the University of Texas Health Science Center in San Antonio. Currently, she directs the College's Behavioral Health in Primary Care Fellowship. Dr. Gigi is a Child and Adolescent General and Forensic Psychiatrist, who is Chief Psychiatrist for the Tuscaloosa County Jail and Primary Psychiatrist for the Brewer Porch Children's Center in Tuscaloosa. She is a Distinguished Fellow of the American Psychiatric Association. Her practice population is rural, West Alabama, including the Black Belt and Northwest Alabama. Dr. Lori Rainey is a Psychiatrist and Principal with Health Management Associates in Denver, Colorado. She received her MD degree from the University of North Carolina at Chapel Hill School of Medicine and completed her Psychiatry Residency at Shepherd Pratt. She's considered a leading authority on the collaborative care model and the bi-directional integration of primary care and mental health. Her work focuses on service design and training of multidisciplinary teams to implement evidence-based practices. For 15 years, she served as the Medical Director of a Community Mental Health Center in rural Colorado. She has worked for more than 15 years with tribal populations in the Indian Health Service in remote clinics in the Southwest and continues her clinical work with the Ute Mountain Ute Tribe in Toyawak, Colorado. She also worked as a Staff Psychiatrist and Clinical Director for an Ambulatory Care Center in rural Arizona on the Navajo Reservation. Yá'át'ééh, Abena. I'm Mary Hausbaugh-Russell, and today I'm gonna be talking about the Indigenous focus in this presentation, highlighting innovation in mental health services in rural and Indigenous communities. Next slide, please. A little bit about myself. As I said, I'm Diné or Navajo, and I was raised on a Navajo reservation in rural Arizona. And my grandfather was a Diné medicine man, and so I lived among my grandparents and my parents on the Navajo Nation. And so I got a real wonderful taste of living within a culture that is very vibrant that are the Navajo people and the Navajo Nation, which encompasses four states and, well, our homeland is within the Four Sacred Mountains, and it's a quite vast area there. And so my practice has involved, right now, working within Santa Fe, New Mexico. I've worked in Alaska. I've worked up in Colorado with the Toyawak Nation. I worked for the Northern Navajo Medical Center within the Indian Health Service, which was in the Four Corners area and catchment area in the United States. And basically all of my career, I have worked with Indigenous communities, and I really wanted, especially within this presentation, to share how you can have meaningful access for Indigenous peoples and how you can achieve that if you approach your practice in a really culturally humble way. Next slide, please. So with my presentations, I really like to speak about the land acknowledgement that I feel is really important, Indigenous land acknowledgement. And so where I am now in Santa Fe area, it is the homeland of the Tewa people and the Tewasuke people who are the ones who live here in this Santa Fe area, and they're the Pueblo people of today. They call this place in Santa Fe, Oga Pogue, which is Whiteshell Place. And so it actually is a very special place to me as well. And we've lived here over 20 years now because my Navajo name is Whiteshell. And so it holds a special place for me to know that. And so within this land, carries the stories, language, histories, and identities of the people who came before us and before the settlement, before these lands were taken. And really these lands are unceded territories right now. So as we are in these places where we are, that we know Indigenous peoples have lived and here where I am, our responsibility is to respect and care for the Indigenous territory wherever you're living, while recognizing the disruption and displacement of Indigenous knowledge and lands. And my daughter, a little plug, she just received her MFA at OCAD University in Toronto, and she's a artist. And so what she did though, when she worked up in Canada in another place, she put together this protocol resource paper. And so some of the statements that I'm sharing with you today is from that. And Canada is really at the forefront of really recognizing that we need to acknowledge the Indigenous peoples who came before us and who are still here today. Next slide, please. So just to give you some background, as you are thinking about and working and already are, say working with Indigenous peoples, it's really important to have a historical framework because a lot has happened with Indigenous peoples here on Turtle Island, which is North America. So right now we have 574 tribal nations, which is about 2% of the US population. And I believe with this latest census, our numbers have gone up. And I think we're growing faster than some of the other peoples in the United States. And we have numerous languages, but just think about this. Before contact, there were over 15 million nations, Indigenous nations, and we spoke over 300 languages. So there has been quite a decimation of our peoples since contact. And really the US policies that have been implemented, started with a lot of wanting to take the lands of the Indigenous peoples and really divide us up, conquer us, so to speak. And that has been quite successful, say in the terminology or the words of the US government, really. So the Allotment Act is just one example of that, where Indigenous peoples were given their land and title or ownership, but we didn't understand what that meant. So it was very easy for people to exploit us. And so that's how a lot of the land was divided up and sold. And I know back East that has happened quite a bit, and even in Oklahoma. And then the other thing is that tribal governments and reservations were created, and we were forcibly relocated to these places. Many of these places were not habitable really, and they were certainly not like the homelands where we came from. But for the Navajo, we were pretty much, were able to stay in our homeland, although we did have to endure the long walk in the 1860s, which forcibly removed most of us down into this really horrible place called Bosque Redondo in the Southeastern part of New Mexico. And many of us died enduring that and coming home. And so then there also is the boarding school eras and residential school experiences happening here and in Canada. And again, that was forced removal of indigenous children to attend schools. And it was a very, not a very successful experience. And I know you've heard about things lately in the news about how there have been graves, many graves of indigenous children being found who nobody knew where they went. And so now they found that they were unmarked graves in these residential schools. And so this history of indigenous peoples is not a very good one, but we need to know about it. And so also we were given citizenship numbers and we're called federally recognized Indians. Next slide, please. So just to touch a tiny bit about the Indian Health Service and that's where I work, is that we are the primary provider of healthcare for indigenous peoples and serve over 2.6 million American Indian and Alaska natives. And this is a sovereign treaty obligation. Primarily, if you are a federally recognized Indian with a census number, you can receive services through the Indian Health Service. But just to touch briefly, the Indian Self-Determination Act came up with a law where now a lot of indigenous nations are taking over their own tribal governments and healthcare systems. And so even within the Navajo Nation, they are doing that and having some success with being able to create their own systems of care and especially some that they hopefully will feel is more culturally relevant. Next slide, please. And so with that historical context, historical trauma is really, and intergenerational trauma is really the basis of kind of where we are pretty much. There's this unresolved grief because we've lost our ancestral homelands. Many of us lost our language. We had forced removal to the boarding schools, to reservations, our family schools, our reservations, our family systems were disrupted, and we were banned from practicing ceremonies for many years and now we are just being able to get back for many of these nations, being able to speak our language and be proud of that and be able to practice ceremonies again. And so it's important to know about the historical trauma response and it's the cumulative emotional harm of an individual or generation caused by traumatic experiences or events. And Maria Yolo-Horse Braveheart, who's a Lakota and Hunkpapasu psychologist is the one who coined that term. Next slide, please. So what I wanna share with you today is really talking about a model of care that I have perceived and I strive to have as I practice working with indigenous peoples. And as I stated, I've worked among indigenous peoples, I've worked with First Nations peoples also in Canada. And this is to also say, this is how you can have a practice as well or how you can center yourself as you're starting to practice with indigenous peoples, wherever you are. It could be in an urban setting where you also are seeing non-indigenous peoples, but it's just so important to have this foundation and basis as you're starting to practice in this way. So, the historical context is really important as I stated and shared with you. But it's not to say that we are not here any longer and that we're not a resilient people. We obviously have endured a lot and we're very resilient and resourceful and adaptable. And so that is what you also need to be aware of. And so I'm gonna talk a little bit and so that is what you also need to take away and recognize and see. And I know when a lot of people that I've worked with, psychiatrists within the APA, they come up to me and they say, hey, I worked in Shiprock or I worked over in Kayenta area and I just loved it. That was my most remarkable experience. And because I think a lot of it is seeing how adaptable and enduring we are. I mean, we still practice our ceremonies on the Navajo Nation and we still have medicine people. And so it's really important to know that there's this historical context, but also the other side of that is the resilience and adaptability. And really when you come in, approach your indigenous peoples with cultural humility and cultural humility is terminology that's been around since 1998. And it is the lifelong process of self-reflection and self-critique whereby the individual not only learns about another's culture, but one starts with an examination of his or hers or their own beliefs and cultural identities. So really the bottom line is you see where your biases are and always be willing to grow and approach patients as well from where they are coming from and not from what you wanna impose or impart onto them. What you say, I think you need this, I think you need that. Really get to know the people first, get to know their resilience and what they have in terms of how you can be available and help them and find out what it is that they really might want to be getting from you. And we have obviously lots of resources as psychiatrists as well. We really see the big picture very well really working with patients. Next slide, please. So really what I'd like to share then is get a good history, get to know where you're working, take time to really know that person and their culture, tribal affiliation. I know a lot of, I guess a term is when you're doing the therapy and even the intake, the history, it's really a narrative approach. You're really getting a good social history, getting good family history. People are often very connected and they're related and things like that. And the other part of this all too that you need to know is if you are working within say an Indian health service clinic or a rural area, the janitor might be a medicine man. It's highly revered in the community. And so you got to really have good relationships with everybody. We're not into this hierarchy here. When you work with indigenous people, we are all very humble and the medicine person needs to have a side gig too. And so we are all needing to know that we have to respect everybody that is there working with you. Respect the culture, understand that there are these nuances and relationships that are so important. So that's why the history is really important. And then the other part of that is knowing that there's this connection, like I was stating with the relationships and that there also can be some attachment issues from the historical trauma. Recognize the historic, like I was saying, the educational background, even though you have a patient in front of you that, oh, they didn't finish high school, but yet they're a medicine person. I mean, it takes a whole lot to be a medicine person. And so you don't put the same parameters say on the patients that you're seeing in terms of what you expect to be, oh, this is a very intelligent person in the history. Or you might say, oh, they're just a janitor, but I don't think they didn't complete high school. I mean, what does that say? It doesn't say much, but you just need to put the richness, that tapestry of the person that comes to you. And of course, taking a good trauma history and a substance use history, because that can be also a pertinent part of what that person might be coming in for, or might have a history or background of. And also to do all of this, it does take a few sessions. So just be mindful of that, that you do have to spend that time really continuing as you're getting to know a person, to know that your history and your intake and evaluation might take a couple of sessions. Next slide, please. And so the other part of it is, again, trying to say someone's coming in, or trying to say that, okay, well, I wanna put you in this little box of what my psychiatric model is, my DSM-5. And sure, I use that, and I put these diagnoses down. This is what I'm trained to do, but I also recognize that there are other people and other ways that I'm gonna be approaching patients. And that is something that goes on paper, but really what I'm doing with the patient or how I'm talking with them or working with them is different. And so we also know that we indigenous peoples might come in and out of treatment, come in during crisis times. So you have to kind of assess the commitment for the treatment, not get yourself frustrated or why aren't you coming in for that third session so I could do a treatment plan. You gotta just go with the flow and do, again, why is this person coming in to see you? Really, that's what you gotta focus on. And then because kinship and our relationships with families is so important, we often live, say the Navajo Nation, multiple generations live together. You take care of your grandma, your masana, which is your grandmother. And so, as we found out in the speaking to a little bit about the COVID pandemic, we found out that sometimes living in multiple generations in a household can be kind of difficult and can spread and had spread, say the COVID virus. But then once we figured that out, we were able to utilize our systems because we have lots of homes within one area, say, and separate and be able to do that in a really good way and still take care of our masanas and our elders and our carriers of knowledge. But we need to know then that we need that family support and know that they're gonna be right there helping out in whatever way possible, transporting patients to their appointments, being an interpreter, things like that. So you really have to get that support as well. And then of course, the traditional healing perspective, you have to be very open and accepting of the traditional healing that will be going on in different cultures. They're not gonna talk to you about it, especially if you're non-Indigenous, such as in the Pueblo. But for the Navajo, they might really engage you. They might invite you right away to a ceremony, to be a part of, or even ask to have a ceremony. I mean, I know now COVID, it's a little difficult, but I think they're still making those attempts because of how serious that virus has been and how sick people have been, to bring in medicine people to have ceremonies and things like that. And so being open to that and knowing that that is a valid, very acceptable way of healing for us. And it's still vital, still here with our peoples. And so then along those lines, the medications are not so much a big buy-in for us as well. It's a little bit more difficult. You have to approach it a little differently. And so you might not get the consistency that you're expecting. Next slide, please. And so what I, you know, what I like to say is that, you know, there's precautions here that you need to be aware of. And so know your limitations with evidence-based medicine, establish partnerships with your patients in seeking treatment and cure, like I was saying, it's really important. And then even explore the treatment options through a holistic perspective. And I know that, you know, many of us as psychiatrists do that very well. And be inclusive with other alternative resources in the community. Next slide, please. And a lot of us, you know, we are feeling, you know, labeled a lot of the time. And so of course, be mindful of that. If you're doing surveys or research, be cautious because we often have felt exploited as I was stating with historical issues that have happened. But if you frame treatment approaches and ways of working and what you wanna do with the patient in a positive way, that usually is very helpful. Next slide, please. So I know that I don't have a lot of time to get into real details of what you could do in terms of treatment, you know, specific treatment, but just to know that I stated before, trauma is really embedded within a lot of what we experience and how we come to you. But, you know, in terms of mental health care and even medical care, because it's hard to detect that because traumatized people can carry these epigenetic changes, which affects the next generation, but also, you know, if you use the ACE score, you can kind of have a sense of how things are within that person, what their upbringing was like. And the trauma is the source of historical trauma. Next slide, please. So in working with the, you know, just an example then of the treatment, especially looking at trauma, really, you know, the goal is to not have PTSD, of course, but some people will have PTSD symptoms, but you wanna really reduce the symptomatology. They might be chronic PTSD. And EMDR has been very effective working with indigenous peoples and exposure therapy as well, especially if you're working with veterans. Next slide, please. So one of the main things to discuss is that there often are attachment issues that affect our presentation and maybe the process of treatment and engaging with patients. And again, the historical trauma is really important to know that that can be an underlying factor. So then, you know, know who your family structure is, know who the important people are in the people's lives that they're really attached to and maybe not attached to or having difficult relationships with. And understand the periods of isolation, say maybe there was a lot of separation anxiety being put into care as a young person, parents who were substance abusing and not engaged for them. And grandmothers raising their kids, which can be a wonderful thing. And that's why it's so wonderful to have this kinship because we do have that resilience of having a family stepping in and being available to teach and to take care of the children. And then as you all know, there can be an idealization of romantic interests, emotional dysregulation and a tendency for self-harm or risky behaviors. And it's still true with indigenous peoples because of where we've come from often. And so it's just really important to pay attention to that. Sometimes we are diagnosed with bipolar disorder because of these kinds of issues. And so if you don't take a really careful history ahead of time, that can be a red flag. Even borderline personality or some type of personality disorder, sometimes we can be diagnosed with that because we're not really paying attention to those attachment issues. Next slide, please. So there was a couple of slides here and I can go quickly through them, but it is really looking at the approach with the community and utilizing the community as your ally as well because you might have to do that. And so working with the patient, say who might come in suicidal or emotionally dysregulated, not wanting to be alive, using substances, really focus on the positives, decrease the risky behaviors. In a small community, sometimes you just got to really take it as, make sure this person, we have high numbers of missing and murdered indigenous people's relatives. And so know what's happening and are they hitchhiking? Are they doing risky things like that? And that can be really scary so that no fault rides from trusted family and friends. And so help them to kind of, and help even the community and family know that, don't be putting them down for asking for a ride, but just do it. No questions asked type of thing because that'll help keep our relatives safer, having that kind of access and not being judgmental. Next slide, please. And this is just also just quickly to share before I finish up in the last slide, but that we really do need to be engaged again with our community law enforcement, be compassionate. We have a high rate of incarceration because we do end up entering into the federal system because we're sovereign nations. But just to quote here, native people in the US are more likely to be killed by police officers than any other minority group. Next slide, please. And so lastly, I want to just circle back, really honor the indigenous knowledge and wisdom of the peoples that you work with. Like I said, the land acknowledgements are a place to begin by centering yourself on their ancestral indigenous lands where you're working. We don't have a concept of owning land. It was taken from us before we realized that. And now we know. And so, we're trying to save the land even with climate change because we're deeply connected to the land. And we are often at the forefront of trying to do something about climate change because of that. And then recognize as well this reciprocity concept because that again, as you practice and work with indigenous peoples can be very vital. Because we have a gifting economy versus a consumer economy. And indigenous science is really something that you can explore and understand more as you're working with indigenous peoples. Because we are more focused on observation and relationship and having connection to each other and to the land and to nature. So, it could be a very vital and warm experience working with indigenous peoples. And next slide. So, thank you for your time. And I really appreciate being able to share this and answer questions later on. Thank you. Dr. Russell, thank you so much for those powerful and inspiring remarks. Now, we'll turn it over to Dr. Gigi. Well, I'm so grateful to have the opportunity to speak to you today. I'm Dr. Marisa Gigi and I'm a psychiatrist and I work in Alabama. The University of Alabama is the organization I work for but my practice population is a combination of people who live in my community of Tuscaloosa and rural West Alabama, which includes the Black Belt of Alabama as well as Northwest Alabama. And as we have this discussion, I will explain what that means as far as what the Black Belt actually is. Next slide, please. I have no disclosures. Next slide, please. And so, what I'm gonna focus on today is really how we can recruit and retain people to come and work in rural communities. And it's going to be more of a sort of policy focus but looking at some examples as well. So, the learning and objectives are to just review what is the current state of our health professional needs in rural communities in this country. And then also to think about new ways in which we can try to attract people to come and work in rural communities. And then I really wanna focus a lot on changing the narrative about the perception of our field of what it means to be a rural health, mental health professional. And then finally, I'm going to, as I go through this, talk about two specific programs that I've worked with that are unique to my area and understanding that every community is different. And this is just hopefully a way to encourage and inspire people to create their own community-based programs that are unique to the needs of their community. Next slide, please. So, a picture states a thousand words as they say. So, this slide I think is really interesting. It looks at counties in this country by metropolitan status. And the white area is the area that is considered non-metropolitan. The orange area are what I'm calling ex-urban or formerly rural communities that are now part of urban communities that are being encroached upon by metropolitan areas. And then of course the gray area is metropolitan areas. And I think this is a really important slide because if you look at the orange space, you can see how suburbanized and ex-urbanized our country is becoming. And I'm not going to get into how we define rural versus non-rural, because that's a whole different talk because there are different agencies that define them. And then there's frontier areas. There are different ways to define what a rural community is, but it's changing significantly. Next slide, please. Okay, so this slide looks at where are the mental health professional shortage areas in this country? So, the very dark portion is where the entire county is considered a mental health professional shortage area. The lightest area is where none of the county is considered a mental health professional shortage area. And then of course the sort of medium gray is where part of the county. So, I'm going to focus on Alabama, which is where I'm from. But if you look at Alabama, every county in Alabama is a mental health professional shortage area. And the county I live in, which is Tuscaloosa County is quite large. It's larger in land size by square footage than the state of Rhode Island. So, it kind of gives you an idea of the size and breadth of it. And most of the people that live in my county live in very small rural communities. Now they're within an hour to an hour and a half of the more urban area, but they do live in very isolated places. Many of them do. Next slide, please. Okay, so I just wanted to spend a little bit of time just giving some context as to why this is a problem. So, first what I'm going to do is just state what some of these facts are and then just provide a little bit of context about this. 65% of non-metropolitan counties do not have a psychiatrist and 47% do not have a psychologist. I think we all know that rural hospitals are closing at an alarming rate and pretty much on life support. And suicide, drug abuse and addiction are disproportionate in rural America. And I think this is a very important topic because especially given what happened in the last election and we look at voting patterns and we look at where people are located and how marginalized many people feel in rural America. I mean, it's pretty much been many of the people that live in our rural communities have pretty much been forgotten by our institutions, not just medicine, but also political institutions. And this is a topic I think that's not really discussed very much. So I'm going to just say a little bit about structural urbanism and what that means. It's really when policies and services in our healthcare delivery system and in our educational system really favor larger population centers. And essentially it just basically treats healthcare, mental healthcare as something that's for the individual as opposed to as an infrastructure for the community. And then that also leads into sort of social determinants of health and how these are really amplified by this structural urbanism and disproportionately affects people in rural frontier communities in a disproportionate way. Some of the basics are limited transportation options, longer distances for people to get healthcare, limited internet access, health insurance coverage isn't adequate, lower rates of health literacy and also professional workforce shortages, mental health professionals, other medical professionals. And essentially communities of color, marginalized communities such as indigenous populations, rural queer people and other marginalized communities are faced disproportionately higher rates of poverty in rural communities than in urban areas, negative physical and mental health outcomes, higher suicide rates, higher substance abuse rates. So it's just a historical injustice as Dr. Russell had just spoken about with indigenous populations, but also within the black community. And so I feel like this is something that is really important that we need to highlight. And so there's such a need in this part of the country and we need providers who are culturally competent, who have a desire to make an impact to come and practice in rural communities because the need is so great. So I hope I've convinced you that this is a problem and the fact that we don't have enough mental health professionals and health professionals in these communities is a serious issue. Next slide, please. So these two slides, I know they're a little busy, but just sort of the one that shows the green is the psychiatrists in rural counties per 100,000 population. So the dark green is where we have the most psychiatrists in this country. And the white is where we don't have any essentially. And then the shaded areas are sort of everything in between. So I think it kind of lets you see where most of our psychiatrists are located. We're essentially an urban suburban specialty. And so what I'm gonna be talking about in this brief presentation is how I want to try to convince people who are listening to this to consider working in a non-urban suburban area. And then the red slide has the psychologists in rural counties. And it's interesting, it's pretty similar. So you see all the white areas are where there are no psychologists. I couldn't find a slide that looked at social workers and other mental health professionals, which I thought would have been a powerful slide, but the only slides I was able to find were the ones for psychiatrists and psychologists, and this is 2015 data. Next slide, please. So, what are some of the strategies we can utilize to increase our workforce? Okay, and these are just some really sort of basic things, but I'm going to focus mostly on culture. So, the first thing is, obviously, we want to increase the number of mental health professionals that are going to practice in these communities. That's sort of basic, right? The second part is, okay, well, there aren't a lot of psychiatrists and mental health professionals, but there are a lot more primary care professionals, so let's collaborate more with primary care, and I'm going to briefly talk about that. That's more of a population health approach, and then the third area, which is something that I'm very interested in, and it's been something I've worked on for many years, is how to improve training and behavioral care for our primary care physicians, make them feel more competent to be able to handle a lot of the issues that they have to deal with that come their way. Next slide, please. Okay, so let's talk about some strategies to increase rural behavioral health professionals. The first thing is, we need to change the narrative, okay? When I was in residency in a medical school many, many years ago, it was seen as, that's where you go to pay off your student loan, you do the National Health Service Corps, that's where, you know, it wasn't seen as sort of the first choice for people in our profession, and I think that needs to change. I think we need to change it, the narrative, so that it's seen as a very exciting opportunity to practice. It can be really rewarding, and also be able to make an impact in the community, so changing sort of from a deficit model to more of a positive strengths-based model of how we approach recruitment and retention in rural communities. Highlight what it means to be a rural behavioral health professional, some of the benefits of it, you have more autonomy, you can be more innovative, opportunities for community leadership and building community. So those are some of the things that I'd like to highlight. Next slide, please. So, how do we change the narrative? Our profession has a certain culture around it, it's very urban, suburbanized, focused. And even just the fact that we have this presentation as a special session or a special presentation, wouldn't it be awesome if the entire session, the next IPS meeting, was revolved around this, as opposed to being just one or two sessions? I think, you know, this is something that the culture in our field needs to start to become a little bit more open to this, medical school education as well. We have a rural track in our medical school, I'm on the admissions committee, and we actively seek out students who grew up in rural communities, people who are dedicated to going to work in rural areas. This is something our whole sort of culture needs to change in the medical school, psychiatry, residency, primary care residency world. Because right now, we're facing a major, major problem with burnout in our field. And I think, you know, kind of changing the narrative that if you work in a community that's more rural, that has a great need, that can be an antidote to burnout, career satisfaction. Because when you talk to people who are burning out, and I've gone through some of this myself, is, you know, it's more the systems of care, the inability to feel like you're making an impact. But when you're in a rural community, you can see that impact right away. I mean, it's amazing. And so I think that can be something that we can focus on is, this is a very satisfying way to practice psychiatry. There are lots of opportunities to be an innovator and to be a leader. There's such a need. There aren't that many mental health professionals working in rural communities. Like, we're just in such demand, and people want us to be on the school board, want us to be on the hospital board, want us to help start programs for the community. And so I think, you know, because we have less, you can make a greater impact. So I think that's a positive way to talk about being a rural provider. Quality of life is different. You know, if you like being outside and don't want to be in an area that has a lot of pollution and that's less expensive, it can be a more pastoral, beautiful way of life. The other thing I wanted to mention was Medicaid expansion. Unfortunately, my state did not do that. So I didn't get the benefit of this. But the states that did take the Medicaid expansion, excuse me, money, that those opportunities for growth were great and benefited rural communities. And then also, as far as the benefits of being a rural provider, there is a leadership void. And so it's an opportunity for us psychiatrists, mental health professionals to be able to fill that void, collaborate with our primary care colleagues, and be able to work as a team. So I wanted to sort of switch from here and show a program that really shows how you can make a lot from a little and have a very satisfying rural psychiatry career. And I'm going to talk about Horseshoe Farm. Next slide, please. So Project Horseshoe Farm is in Greensboro, Alabama. And it's a gap year program that was started by one of our psychiatrists, Dr. John Dorsey. And basically, he came from California and plopped himself down in the middle of rural West Alabama in the Black Belt, which is an area of Alabama where it's actually part of the whole Southeast. And it's an area that's been traditionally seen as having higher rates of black people. They were basically former cotton field growing areas. And that's why they call it Black Belt, because the ground is so rich and dark and you can grow things really well there. But they're also former high proportion of slaves that were in those communities. And so the area that we in that area has higher rates of poverty. For example, in Hale County, where Greensboro is, there's an estimate that close to 60 percent of people live on disability checks. So you have a very high proportion of people who are poor. You have 38 percent of the population is illiterate. So you have like a very large part of population that lives in that area that has great needs, higher rates of stroke, higher rates of suicide, lots and lots of problems. So Dr. Dorsey moved to Greensboro, Alabama, about 18 years ago and started this program when there was absolutely nothing. Next slide, please. And he founded this program in 2007 and thought outside the box, essentially. Greensboro has about twenty two hundred people. Like I said, it's part of the Southern Black Belt. The median individual annual income in that area in 2019 was nineteen thousand dollars a year. Gives you an idea of the poverty level there. And what he's in the way that he thought about this, and this is kind of how I think about it as a community psychiatrist, is, you know, when we're in residency, we're really not taught to take care of all of the needs of our of our patients and our patients come into our office and excuse me, they have lots and lots of psychosocial problems. And we only have twenty, thirty minutes to really address some of these issues. And so we know there's such a great need. So in a community based program and what Dr. Dorsey did is he started out small. He said, OK, I'm not I'm new to this community. They don't know me. So let's start with an after school reading program. And that's what he did. He got some of the community members together and he started an after school reading program for middle school and middle school and high school students. And then in 2009, he opened up an independent living program for women with serious mental illness. So he built up sort of goodwill with the community and they got to know him. And because initially they were really suspicious. They're like, who is this person from California who's just coming down to live in the middle of our community? We don't know him. He doesn't know us. And they basically built up trust. And we've worked I've worked with Dr. Dorsey since 2007. And basically, I'm really just amazed at what he's been able to do. He opened up this home for women with serious mental illness that once they're released from the hospital, they have a place to live because our community mental health centers don't offer that in this part of the country. And these women need these kinds of programs and the support. And he used gap year students who were between college and medical school or social work school or whatever graduate school they're interested in going into to come and provide case management, provide a community and provide transportation, whatever people needed. In 2012, he opened up a community center and focused on nutrition, social interactions, wellness, medical support for people with serious mental illness. And this is all funded by donations and community partners was a very limited government support. And so basically, the whole idea behind this program was that our current behavioral health delivery system falls woefully short of the needs of our people. And so he said, I'm just going to build a program that fills the needs of people with serious mental illness with limited resources. So I just wanted to highlight that this is just one example of how one person did something really unique in an area that had no resources. Next slide, please. And so I think the reason why he's been so successful and I want to inspire people is that the mission was the community and every single community is different. Clearly, our community here that we live in is very different than Dr. Russell's community and Dr. Rainey's community and all of the communities that all of y'all come from. And I don't want to imply that this would work somewhere else. Everyone needs to see what's going to work for the culture and the issues that are related to your specific community. And but if you make your community your mission, then you will be successful. It's a goal for all of us, I think, is to improve the health and quality of life of our vulnerable neighbors. And that's why we all went into this field. And psychiatrists are really well poised to do this because we see things from a holistic biopsychosocial model of care. And also one of the things that's really great about this program is that we're trying to build leaders for the next generation. So these gap year students, when they go to medical school, many of them do. You're hoping that some of them are inspired to return into rural communities because they were so had such a positive experience with this gap year. Next slide, please. And the other thing that that was done, and then I think this is really important, is collaborating with other community partners with whatever you're doing in a rural community where she farmed at this. And I'm just highlighting a rural architecture project with Auburn University. They have a program where they send students to rural Alabama to practice for two years and they have a project called the twenty thousand dollar house where they build beautiful homes like nice tiny houses, but two bedroom, typically two bath homes for people who live on a disability check. That's the idea. And to make beautiful spaces for people who live in rural communities that are part of that fit within the culture and fit within the ecology of the community. OK, next slide, please. OK, so I'm going to switch gears now from that sort of highlighting that program to some of the traditional strategies that we've used over time to increase rural behavioral health professionals, which are still very valid. We have financial incentives, typically loan repayment. I'll talk a little bit more about that education and training practice oriented changes. Next slide, please. So let's talk about financial incentives, the National Health Service Corps is always a wonderful option, and that's something that's available for people to repay their student loans. Sometimes the state program, I'm not going to get into it too much, but that's available and it's been a very successful program. The state, different states offer loan repayment programs. In Alabama, we have a Blue Cross Blue Shield of Alabama scholarship that pays for two years of medical school. If the person practices in the state of Alabama as either a rural psychiatrist or a rural primary care physician, there are tax credit programs that will reduce tax liability. If you're working in a rural community, certain states offer that as a benefit. It can be a tax write off. And then also there are scholarships for people who decide to go and work in rural communities. And there may vary from state to state. Next slide, please. I'm going to focus a little bit more on education and training. Pipeline pathways, primary care tracks, behavioral health tracks have been successful. We have one in our university that's been here for quite a long time. I've been trying actively to change so they can add psychiatry as something that can pay for that track. I still haven't been successful. It's mostly for primary care and they're not including psychiatry. So that's something I've been actively working on to try to make psychiatry be included in that for our campus. But there are some places that do offer that kind of a track for rural psychiatry. I think our residency programs need to change and have more of a rural focus. There are more rural tracks that are being offered. Our campus is actively trying to start our own psychiatry residency program. We're in the formative stage with a consultant and we plan to make it a rural psychiatry program. I have a behavioral health fellowship that I've been running since 2009. That's for primary care physicians to do a one year training in psychiatry. And they are obligated to spend a year in rural Alabama when they finish. So they become more competent and more empowered to be able to take care of the things that are going to come their way. And then finally, I think we need to, as a profession, advocate for improved behavioral health training for all primary care specialties. Next slide, please. So there are different practice oriented strategies and there's a collaborative care model. I'm not really going to get too much into that, but it's basically looking at how we can integrate with psychiatry with our behavioral health with primary care. Dr. Rainey wrote a beautiful book about it that I've read several times with my fellows. So I'm not going to get into that too much. So I'm not going to get into that too much, but that is one way to improve services on a population health perspective. Telemedicine, obviously, with COVID-19 has been a major increase in use of that. And that can be a way to expand services to rural communities. But I do want to say that what I'm also talking about is I'm hoping that I can encourage people to want to locate and live in these communities because being a member of the community is really important. Project ECHO and basically ECHO is a sort of telehealth medical education model that provides consultation for rural communities. I'm involved with one with opiate overdose and opiate treatment strategies for Northwest rural Alabama, which has the highest rate of opiate overdose in this part of the country. And then finally, licensure, certification, scope of practice changes. We need to empower our primary care professionals to be able to bill for if they treat someone with depression and suicide, they need to be able to bill for that. But right now, they're not able to do that because of limitations in their ability to bill for certain types of services. Next slide, please. And then the population health approach is really focusing on primary care. I mean, I'm talking about increasing psychiatrists and behavioral health professionals, but we also have to take into account that there aren't a whole lot of us compared to primary care physicians. Right now, family medicine is the only primary care specialty that requires a psychiatry rotation and residency. And the ACGME does not require behavioral health training for internal medicine or pediatrics. So when you talk to primary care physicians and you see surveys of primary care physicians and how they feel about their ability to treat these issues, they feel woefully underprepared to treat substance use disorders and the most common psychiatric disorders. And primary care physicians are more accessible in rural areas. And like I've said, psychiatry, we're more of an urban suburban specialty. I mean, I'm trying to encourage people to consider rural practice. But the reality is that we are an urban suburban specialty. And since most people get their care from a primary care physician, I think it behooves us to try to work to improve their ability to handle most of the issues that they're going to have coming their way. Next slide, please. I'm going to just finish up by talking about the Behavioral Health Fellowship that I've been running since 2009, but just briefly go through it. It's a one year clinical training program where we teach family physicians to treat the most common psychiatric problems that they'll see. We have rural sites and essentially they get didactic time, psychotherapy supervision. And we've had six graduates in 11 years. Last year, we had to put things on pause because of COVID. I'll have two people coming in in the following year. And right now we've got five of them to remain in rural Alabama. One of them just moved to rural Georgia just across the border. And I'm going to claim her is still in Alabama because she's right on the Alabama rural Georgia border. And then there's someone in north rural Florida. Next slide, please. And just to show some pictures of some of the places where our fellows go, this is Brownfield Memorial Hospital in Demopolis, Alabama, about 3000 people in this community. They have a wonderful small community based hospital. We have two inpatient psych units, one geriatric and one adult unit, both 12 bed units that are really well run and fellows and our medical students spend time there. Next slide, please. And then I just wanted to show some really pretty pictures of Demopolis and Greensboro, which is where Project Horseshoe Farm is. Our fellows spend time there as well. Next slide, please. And so I'm pretty much done. I just wanted to close out by saying I realized that my presentation has major limitations. I have a regional focus because this is where I live. And so I focused on some regional programs. But and I didn't focus on indigenous Latinx and other non-black populations in rural areas. Also, the communities that I treat are either rural black or poor world white populations. So I understand this is a limitation. I also did not focus on the queer community, which is something that I have a special, you know, kind of fondness for, cause I feel like this pop, I see a lot of people who are queer who come to me from rural areas that don't feel supported. We're in a highly religious state that they're often demonized and, you know, not allowed to participate in their churches and their communities, and they have a high rate of suicide. So I didn't talk about that. I also didn't talk about the problem in child, I'm a child psychiatrist. I didn't talk about the problems that I've been seeing with the increased suicide in rural communities of younger people, even below the age of 12. In the last year, I've had three 11 year olds with all from rural communities commit suicide. So this is another issue that's really important. And if there's a lack of services for people in these communities, so I didn't really talk about that as well. But I also wanted to recognize that every community is unique. And some of the principles I presented may hopefully be achievable in some of the communities, but some may not because the systems issues. And just to understand that everybody has to kind of live and work in their own space and try to make the best of what is available in their community. So I think that's pretty much it for me. I think next slide, please. Yeah, that's it. So hopefully I've left you with some inspiration to be a community leader and to consider working and living in a rural community. Thank you. Dr. Gage, thank you so much. That was definitely very inspirational. Really appreciate it. And next we will turn things over to Dr. Raymond. Well, thank you so much for that introduction. And again, welcome to everyone here today. I have to say, as I listened to Dr. Russell, that I think I've just followed her around the reservation from Kayenta to Toyoc. Haven't made it to Santa Fe yet, but it's been interesting to kind of track her course. And I'll show you in a minute how that's happened. My goal today is to really talk professionally about the psychiatrist and what it looks like or what it could potentially look like to work in a rural area. It really is an opportunity to cut some of those academic strings and those being in a box from a psychiatrist perspective and really see in a rural area how you are everything. You are, and I'm gonna show you all the different things that I've done without what people would call the traditional fellowships. Because when you get out to a rural area, you are it. It takes a certain personality to go out there, fly a little bit by the seat of your pants and do this kind of work, which is part of what makes it incredibly exciting and part of what is determined really by your personality and your interests. So if we could go to the next slide, please. And I have no disclosures. On the next slide, what you're gonna see is, is to sort of, I want you to think, I want to show you a little bit about my professional timeline. So I did medical school in North Carolina and in medical school, we have six weeks of psychiatry. So I just kind of tally that up. And then I did an adult psychiatry residency at Shepherd Pratt Hospital in Towson, Maryland. And I sort of knew that I wanted to work rural. I am from a rural tobacco farming community in North Carolina. You guys may hear my accent. We have some Southerners here on this presentation. But I am from a rural community. I graduated from a small high school, small graduating class. So I was kind of used to the rural thing. But I had a sense from a colleague who graduated the year before me and went to work for the Indian Health Service that that was something I probably wanted to do. So I wanted to do community psychiatry. And at Shepherd Pratt, we had a clubhouse elective fourth year. We had an ACT team, you know, riding on the van fourth year. We had several electives focused just on community psychiatry. So I took three or four partial hospitalization. I really focused that in my fourth year of residency because I had a sense that that's actually what I wanted to do. So I didn't do a fellowship. I don't even know if public fellowships, I guess there were a few available in the country. I didn't feel the need to do that. But I thought of focus this in my fourth year of residency. And then I did follow my colleague out to the Indian Health Service. I'm going to show you where Cayence is, where Dr. Russell was talking about the other day. That's where I started my work. And I was actually out there for seven years. And I will tell you, when you go to a remote area, when you get there, you're in charge. So I was the director of the, the psychiatrist is the director of the Counseling Services Department. And when I made a switch in the clinic, I was the clinical director for five years. So you pretty much, it takes that person that is willing to take on a leadership role because often in Indian Health Service, you will be put in charge as soon as you get there. So that was my first job. And I stayed out on the, with the Navajo, on the Navajo Diné reservation for seven years. And then it was, it's so beautiful out here that the closest job I could find when it was time to leave the reservation to stay in community psychiatry was, my second job was medical director of a community mental health center. And for those of you that have ever been to Durango, we had a five county area that kind of surrounded Durango, which is, you know, a little, not metropolitan for sure, but at least a bigger town. And I worked in this community health center as the medical director. You know, you show up and you're in charge for 15 years. So that was totally immersed in community mental health. And I'm gonna show you some of the things I did. My third job when I left there is consulting. And I was able to do it from my Mesa top and COVID certainly helped. If you look behind me, that's actually the view at sunset from my east window of my house. And then I've done other things. I've done consultation for a school-based health center, which has been really cool. It's an alternative school. And I have continued to work for the Indian Health Service. I'm up to about 23 years now with the Indian Health Service, either full-time as an employee or under contract with them. So where do I live and work? This is kind of like what it looks like. If you guys have been out to the rural West, if you've gone to Grand Canyon, if you've gone to Monument Valley, you've gone to Goosenecks, Mexican Hat, Utah. These are the kinds of fun, rural, wild places that Dr. Russell and I have lived and practiced. So she mentioned Kayenta, a little town. I should have brought a picture of it, but teeny, teeny, teeny little town, part of the Navajo Indian Reservation, which is about the size of West Virginia and about as sparsely populated as you can imagine. This was so scary to go out here. My colleague is actually working down in a little town called Winslow. I knew he was out there. Me, one psychiatrist, tiny community. And someone had mentioned collaborating with primary care. The first day I went to work, but the expectation was the psychiatrist was at rounds with the PCP. So we were all in a little room together and very much off the bat. Indian Health Service is primary care, behavioral health, vision, and dental, all four. All four integrated into the same clinic. Those are the requirements. We're all in the room together from the very beginning. So at the initial part of my career was really co-located, somewhat integrated care. So that's where I got my start with that back in 1989. And then I since moved over here to Southwest Colorado. It's where the four states come together. Again, rural West. And it's really, it's where I stay and it's where I live today. So I was willing to do this move out here. And I felt so in love with the West that I've actually stayed and I've practiced here, currently live here. And at the moment I'm thinking about retiring here. So this is kind of the landscape and what it looks like out here. You can see Dr. Russell's down here in Santa Fe. So you've got our Southwest crew here on the call today. As I was listening to Dr. Russell, very much agreeing and listening to what she's saying, certainly my seven years of practice and how the multigenerational trauma and the things that go with it, just at times seem, I keep asking, when will it end, Dr. Russell? Because I see so much PTSD. I see so much substance use. I see so much in personality disorders, which are the three big things you should expect to see if you have communities of trauma. But I also see powwows and drumming groups. I did a sweat when I was in Cayenta with a Native American church. I see the attempts to stay and stay connected with culture. It's not enough to overcome what's going on, but I just love it when the whole community drops everything and they say, oh, Lori, don't come out here to do your clinic this week. No one will be there. They're all at bear dance. So we figured out how for me to run my clinics when I'm doing this. There's a detention center here. I see so many detainees, mostly men, all with trauma, all with scars, all with just really a difficult family history. So it is, as Dr. Russell was saying, a very unique population, and you have to anticipate in this indigenous community what you're gonna get when you come out here. But I've been there 23 years, so I clearly have a soft spot for that population. Up here in Colorado, mainly white. My population's mainly white. The Fort Lewis College is in Durango, but mostly white, some Hispanic, some American Indian coming into the clinics, but mostly a white, rural, impoverished area. So that's kind of where I've done my work over the years. What I am, I think I slipped this guy. I wanna just give you guys some tips, and you've heard some tips from the other presenters, but just to make sure, come on out here. It's a lot of fun, but when you get out here, form a network of other psychiatrists. So there were eight service units, I think, in the Navajo area Indian Health Service, because Navajo Reservation, I think it's the biggest in the country. There were eight service units and there were eight psychiatrists. So I made a point of all of us meeting in the middle of the reservation for lunch once a month. So I got everybody together. This is pre-Zoom. This is, you know, even the telephone systems out there, they worked, but conference calls, who knew how to do those? So we would meet up, we would have lunch, we would share. This was actually even almost pre-computer. There was one dilapidated computer in the office when I got there in terms of being able to send emails, but we would get together and we formed a network. So if you're out in the middle of nowhere, find the other psychiatrist, no matter if they're two miles or two hours away, and figure out how to form that network out there. You don't have to be professionally isolated. I went to a lot of conferences, both local and national. So when I got out there, a traumatic event had happened. I went to the APA meeting, picked out all the talks on natural disasters, trauma, you know, all the things. And I would just focus each meeting on whatever it is I was seeing. The first one I would go to all the cross-cultural psychiatry ones, Dr. Liu and others would put on, and then I'd go to the disaster ones. It just sort of, and then I was starting one of the integrated care ones. So I just went to whatever matched what I was seeing, and I would find lots of like-minded folks. Get to know your local primary care providers. I think you've heard that from all of our speakers today. They went with you to medical school, family medicine and psychiatrists. We have a lot in common. I think there was a study in the 80s that showed our MMPI scores were about the same. Half of them wanted to become psychiatrists, and half of us wanted to become primary care providers. It's just something in our soul and about what we want to do, but get to know them. They are a source of not only you helping them feel more confident and confident like you heard earlier, but also for mountain biking, camping, hiking, all the fun things that we did out on the reservation when I worked in that community. And here, even where I live now, most of my close friends and colleagues are actually the local primary care providers. I'm the only psychiatrist in my community right now. The other thing is be a generalist. I did not do a fellowship. I went straight to work. I had had four years of high school and four years of undergrad and four years of psychiatry and four years of residency. I mean, I was at medical school and residency, and it's like, come on, just get to work. I didn't stay, I didn't do any fellowships. I just went to work, and it was really cool. I focused in my fourth year of my adult residency on what I wanted to do, and I ended up doing everything. I ended up doing forensics. I was the jail psychiatrist for 15 years, and now I'm the detention psychiatrist down on the Mountain Ute Reservation. I did CL. I contacted the local hospital, got on staff, and went around and did consults in the morning before I went over to the six-bed ATU that we built. So I did some inpatient work, small, but I did some inpatient work. Pediatrics, you can't be out on an Indian reservation or a small community and say, I'm not a child psychiatrist, I don't see kids. Now, I did what most of us do. I said, well, I'll go to 16. Okay, well, maybe 13. Okay, 10, that's my limit. I won't go below 10, and I went all the way down to five. Find yourself a child psychiatrist, either from your residency or a friend in the community or somebody, put them in your back pocket, and don't refuse to do stuff. You really have to be a generalist. Just find someone to help you. And then addictions, we all treat addictions. We don't need an addiction psychiatry fellowship. We all do this, and you can take an eight-hour course and be prescribing Suboxone without too much trouble. So, you know, we get ourselves in boxes when we're in training and think we have to do certain things and our attendings encourage us to do. I've got people doing two, three fellowships. You don't really need all that. You need to focus your fourth year in residency and then think, is there maybe one I wanna do, and if so, is it in public psychiatry? You really wanna mix it up. This is what made my life interesting. It made it challenging that I did all of these things. I mixed it up. And I mixed it up for my psychiatrist that I hired because I think that's one of the ways of retaining them. They didn't just sit there eight hours a day seeing one patient after another and a bunch of folks with serious mental illness. They would go over in the morning, do consults, swing by the hospital, see a few patients, then come start seeing their outpatients and maybe go over to the nursing home that afternoon. I forgot to put geriatrics. We actually contracted with the local nursing home. So be a generalist and don't think you need five different fellowships or three different fellowships or two different fellowships to come out to a community area to be, and I call myself a community psychiatrist because that really, I think, is the bucket we fit in. Next slide, please. So there's just some tips of doing this work out there and how to actually be successful. I keep saying next slide and I got change in myself. Sorry about that. It's also a chance, as you heard from the other speakers, to be innovative and use evidence-based practice. So I, this collaborative care thing, I didn't know what the heck it was. I was just kind of heard about it. There was an FQHC out in Dove Creek, middle of nowhere in Colorado, and that's where I, one of the places I went and I said, what the heck, let's practice this thing. Let's try this thing called collaborative care and went out there with a social worker, got a registry, paper registry in the good old days, and we practiced doing collaborative care. It was so much fun. The PCPs, everything we hear at the PCPs, level of confidence in treating mental health conditions like we were talking about earlier, went up with those constant consultations and suggestions and recommendations. Way cool. And that kind of launched my interest in collaborative care and wondering why the APA had never heard of it. So I was kind of instrumental early on in pushing the APA to think about integrated care and collaborative care in particular, started out in a tiny rural clinic where I had heard something at the New Orleans APA meeting, and I heard it from Ruth Shim. I had no idea who Jorgen Unister was. We set up a whole tele-psychiatry program across our five counties. We figured the windshield time was killing us. We could see more patients, so we set up this whole thing. When the 2004 APA ADA guidelines came out, I mean, I had put scales out in front of my psychiatrist's office back in about 2002, because everyone seemed to be gaining weight. And the Lilly rep kept telling me that liprexia didn't cause weight gain. Eating caused weight gain. It wasn't the medicine's fault, but I had already put scales out. And then when the monitoring guidelines came out, we just jumped right on. I was like, there's something going on here. We were able to like jump right in there, not have to sit around and think and roll it around in our organization for six months. We just jumped right on it because like, what the heck? Psychiatrists go do it. We also participated in crisis intervention training for police officers. We didn't want the command and control and throw our mental health people on the ground and tase them. So we actually started doing this training. It's just kind of a bubble up from our little community mental health center. We designed and opened that inpatient unit, and we really got involved in culturally diverse communities. So we started looking at clinics out at Southern Ute, Ute Mountain Ute, and how our mental health center could work with our local community. So it's just a lot of fun. There's more stuff we did, but I just wanted to kind of point this out. We brought in lots of long acting antipsychotics for our patients. We started an ACT team, started a first episode psychosis team. And now since I've left, they're actually doing MAT. And we're not a certified community behavioral health center. We're just a cutting edge community mental health center out in the middle of nowhere. So you can be innovative using evidence-based practices and bringing that without a lot of pushback from anybody. Because again, you don't have a huge organizations with levels of decision makers. Next slide, please. So that was really, you know, just kind of a lot of fun for me to be able to do that. It was, it professionally has been so rewarding. I am still out here in the middle of nowhere. I love it. We have reliable transportation on air travel from Durango, we got a decent place. I'm able to mountain bike and hike and just do all those just lovely things that you get to do being out in the West. I told my daughter the other day, there's this thing called forest bathing and we have to chuckle because I guess we're always doing it out here. But it's just been a very rewarding career in rural, out in a rural area. And I would just encourage people to think through your assumptions. What does it take to go out there? What do I do when I get there? How many fellowships do I need? How do I have a support community when I'm there? How do I, you know, get around thinking if I don't have a psychiatrist right here, I don't have a colleague and what am I going to do in this community? Don't think that way. Think about all the other networks and how social media and Zoom and everything actually keeps us together now so that you don't feel isolated. So thank you very much. I'm going to turn this over now back to Robert. Thank you so much, Dr. Rainey. And I just wanted to give a shout out to all three of our presenters today. It was absolutely terrific. Dr. Gigi, Dr. Russell and Dr. Rainey, again, terrific, terrific presentations. And now what we'll do is we'll take about 15 minutes for Q&A from our audience.

mental health services

rural populations

indigenous populations

cultural humility

historical trauma

traditional healing

recruiting mental health professionals

community-based care

disproportionate rates

holistic approach

working in rural communities