Welcome, everyone, to our session titled How to Teach Social Cultural Issues in Psychiatry. My name is Aurelid Padilla Candelario and I'm the Program Director for the Psychiatry Residency at the University of Massachusetts Medical School, and also the Director for Diversity, Equity and Inclusion at our department. I am delighted to serve as the moderator here today and to introduce you to our esteemed panel of speakers. First we have Dr. Arden Dingle. She is a Professor of Psychiatry and Behavioral Sciences and the Psychiatry Residency Program Director at the University of Nevada, Reno. Her career has focused on medical education with considerable experience running and teaching in psychiatry and child and adolescent residency programs, as well as in medical student curricula. Dr. Dingle's research focuses on medical education. Nationally, she is involved in the American College of Psychiatrists as the Editor-in-Chief of the Pride Editorial Board, a member of the American Association for Community Psychiatry, Curriculum Committee, a member of the American Academy of Child and Adolescent Psychiatry Ethics Committee, and a member of the AMA Accelerating Change in Medical Education Consortium Chronic Disease Prevention and Management Interest Group. Dr. Dingle clinically has worked extensively with children, adolescents, adults, and families in a range of settings, primarily using interdisciplinary and or integrated care models. Next we have Dr. Ayanna Jordan. Dr. Jordan is an addiction psychiatrist, Assistant Professor of Psychiatry in the Department of Psychiatry at Yale School of Medicine. She is dedicated to creating spaces and opportunities for more people of color, specifically Black women in academia who are vastly underrepresented. The fundamental message of equity and inclusion has informed her research, clinical work, and leadership duties at Yale and beyond. Dr. Jordan was the first Black Associate Program Director for the Yale Psychiatry Residency, a large group of 64 physicians providing mental health and addiction services throughout Yale medical systems in the state of Connecticut. And lastly, Dr. Enrico Castillo. Dr. Castillo is an Assistant Professor in the Center for Social Medicine in the Department of Psychiatry and Behavioral Sciences at the University of California, Los Angeles. Dr. Castillo's research focuses on health equity and health justice, serious mental illness, and community-public academic partnerships. He is currently leading an NIMH-funded project on the jail-to-homelessness pipeline experienced by individuals with serious mental illnesses. He is also an Associate Director of Residency Education at UCLA and teaches about homelessness and structural competency. First, we're going to start with Dr. Dingle, who's going to talk to us about using the clinical encounter in teaching sociocultural issues in psychiatry. Dr. Dingle? Welcome to this presentation on sociocultural issues in psychiatry. Thank you for having me come present. My name is Arden Dingle. I am the Psychiatry Training Director at the University of Nevada, Reno. I am a child psychiatrist, though I run a general program, and I've run two other programs in the past, one at Emory and one in Texas. I'm just going to review a more practical aspect of implementing this type of curriculum, particularly in programs that don't have a lot of resources, either in terms of people or in the community. I work for the University of Nevada. Some other educational things that I do is I'm the Editor-in-Chief of the PRITE Editorial Board, and I am a member of the Ethics Committee for ACAP, which is the Child Psychiatry Organization. The goal here is to help trainees and faculty and, in general, psychiatrists understand the importance and impact of cultural and social issues in medicine and psychiatry and figure out a more systematic way to incorporate this content area and these resources into training. It can be very challenging to meaningfully integrate the didactic content with having people be able to apply this information clinically in a meaningful and reasonable way. I think it's really important to understand that everybody has a culture and everybody has social issues, and they vary significantly depending on your class and what group you're in, and that it's important for people to understand that it's a very broad set of constructs and that it's important to consider the economics of people's lives and their environments, the systems of care they are getting their care in and that they interact with, and sort of issues related to discrimination and racism, particularly not just individual biases but also structural and system issues. So the goals here are basically to get everyone to consider patients as people who have lives, relationships, families, values, and circumstances that inform them as a person and really contribute to their functioning. And that is different than what their psychiatric problems are. And I know this kind of sounds obvious, but I will tell you, having done a lot of training over the years, that often this gets very difficult for people to think about that people are not their disorders, particularly, you know, when you have residents working in systems and faculty working in systems that really stress efficiency and time management. And so I'm going to talk about a little bit about how I think about it and other people have thought about developing a structure to teach this content and skill set that can be used across all clinical situations and does not actually require experts. Because this tends to be an area where often people are like, I don't know enough about this so I can't do it, which then means they don't even think about it. And what you need to be is a curious person who's respectful and inquisitive and able to think about this area and figure out how to, you know, acquire information and both read and ask people but and also, you know, collaborate with your patients and families to sort of figure out what makes sense. So again, patients are people. Many times people, faculty and the residents kind of forget that. And apologize since I seem to be having some trouble with this. And it's really important to understand the background, sort of who they are as a person, where they're, what their background is, what their current circumstances are, you know, what do they value, what do they prioritize and what's going on in their environment that either helps them or is contributing to the problem. And that this really should be a routine part of all psychiatric assessments and treatments. And that this is a very helpful way to teach, I've found, social and cultural issues simply because most practitioners, even if they are not particularly interested in this area, can identify that this is an important issue for individual patients and can see the relevance. Okay, it also I found easier to get people to use this content area and skill set if it's a part of routine practice, and it is to attach to other expected components of what you're supposed to learn as a psychiatrist, and that it is also easier when you have residents and faculty working with patients where they see the patients over time. Also, when people work in different systems, so for example, having residents work in different systems, so they get, they understand some of the impacts of the institution, and that the differences between patient populations, and that is helpful to try and connect your didactic and clinical curriculum so they inform each other, and that you connect it to the populations you're working with, although don't define it to just the populations you work with, because often you're in, like I've been in regions where you don't have very many people in certain groups, so that it's helpful to sort of try and have both around who you're working with currently and who else is there in the world that you might want to consider. It is important to understand what community you're working in, and so I found it very helpful to, the United States Census has all this information about who's in your community and what the characteristics are, and they break it down in terms of race, some ethnicity data, age, economic status, I mean it can be very helpful. The other sources of information that can be helpful is your state often has various statistics on who lives where, and as do the Chairman of Commerce and Historical Societies, and she'll say enough. And then the other thing that can be is helpful is to sort of really understand that the institutions you're sending the residents to, and how they work, and who, where are their patients from, and the characteristics of their patients. And in terms of how I think about it, I sort of think about sort of doing program development, and then the specifically didactic development, and then critical clinical development, and then faculty development. All of these are obviously intertwined and connected, and that really you end up working on them simultaneously, but it can be helpful to think about them in separate parts, often when developing the information, deciding who's going to do what. In terms of program development, I find it helpful to just disseminate the view and have a mission statement, and the overall plan, that basically all aspects of psychiatry, the knowledge, and practice include biological, psychological, and social components, and that that includes both the didactic curriculum, and the clinical curriculum, and that even institutions that you know the program does not run, are expected to sort of think about these issues, and help learners understand them, and be able to incorporate them into practice. And that it is important to recognize the, and support the diversity you have. So for example, where I am now in northern Nevada, is there is not an incredible amount, well there's more than you think, but the racial and ethnic diversity is, the population is overwhelmingly white, with a significant proportion of people who identify as Latino. However, we have a fair amount of diversity, as within the training program, and within the patient populations of people who are from rural frontier environments, who come from adverse circumstances, particularly economically, and that many people, particularly the trainees, are first generation college people, or and many of the population are people who are the first person in their family to go to college. And it is also important that to try and target recruitment around, you know, the patients that residents see, as well as the type of resident you have in faculty, around a range of diversity, and that even if it's a struggle to have a broad representation of diversity, to at least acknowledge that and continue to work on it. Okay, again, in terms of curriculum, and this idea that psychiatry is biology, psychology, and social, and that just basically have a model where both the faculty and residents are expected to explicitly think about and talk about the cultural and social issues in all didactic and clinical situations, and that these are a typical part of practice, that you don't really need to be an expert to think about this, but that you need to consider it, and then part of what you're considering is how relevant this is to this person's difficulties, and really sort of keying it all to the idea that the patients are people, and you really want to understand the whole person, even if, you know, for example, you're the person just doing the prescribing, but that you really need to understand the circumstances of this person, and sort of how they got where they are, and sort of what is helping them, and what is sort of standing in their way. The other piece that I think is essential is understanding the systems, because it is very helpful to understand why you can or cannot get things done within a system, and what the system is supporting, what the system is communicating, and sort of how that is contributing to the patient's difficulties in patient's care, and your difficulties as a practitioner in terms of doing whatever it is you think should be done. Okay, so in terms of the curriculum is the idea is all courses and all experiences are expected to incorporate cultural and social issues in a meaningful way as relevant to the activity. In curriculums I've run, culture and society are explicitly taught in development of systems and care, and that is because, you know, while we have a certain view of development, development, what is considered typical and expected in terms of the various stages of life is really connected to what your culture is and what your societal expectations are. That case formulation and treatment planning across all clinical experiences are expected to be taught using the biopsychosocial approach with the deliberate incorporation of cultural and societal issues, and along with a discussion of what are this person's environment strengths and sort of challenges. I've also found it helpful to systematically include these issues in the psychotherapy curriculum because the psychotherapy curriculum is often easier to do this because the patients get to be well known to the residents and faculty because they see them frequently and see them over time, and so a model I like is you have a four-year weekly psychotherapy clinic, so the residents start that as a PGY1 and continue it through their PGY4 year, so they have the opportunity to work with the same set of patients over time, and then you have a four-year didactic curriculum, so you run a psychotherapy class every year that is connected to the clinical experience, and then the other model I found helpful is to help them also with the idea of understanding this content and skill area in medicine, so that they have a one-year weekly outpatient primary care clinic so that they can really get to know their patients and really understand how societal and cultural issues impact medical care as well. So some examples that I found very helpful, one of my favorites which I think has been incredibly helpful particularly early in training, is you have the resident write up a life story of a patient, so this is a patient that they have assessed, so they have to write a life story that is not a psychiatric evaluation write-up, and that really just discusses how this patient's background, demographic characteristics, and life events and circumstances have influenced their health care, and then how can this information be used helpfully in terms of thinking about their diagnosis and their formulation and their treatment plan. I've also done things like activities like have residents, you give them case vignettes, and the only thing you vary are the demographics of the patient, and sort of then are able to have a discussion of how people get treated differently based on characteristics that really shouldn't have anything to do about their disease. I've also had people sort of explore and understand, you give them patients or you have them do it with real patients, is you know for example the difference between access of services of people who have federal insurance, specifically Medicaid, versus people who have private insurance and what that means for their access of care and what resources have available. Similarly, having and then having people just sort of learn more about what interacting with these various systems that are relevant to health care but are outside of health care, so for example having residents visit people's homes, going out to community institutions like schools, detention facilities, service agencies, group homes, to really have a better idea of what people's lives are like, homeless shelters, and then having residents fill out to understand sort of what do you need to know and share and what is the process like to get social security disability, to get accommodations from work, to get special services in schools, because I think that gives them a much better idea of how some of the challenges and also how other systems view people's medical and psychiatric conditions and sort of what they need. Another important part, and actually I think this is actually often the most challenging part, is helping the faculty sort of systematically teach this in a reasonable way in their, particularly in their clinical area, right, is that you need them to to sort of incorporate this as something that you consider with patient care and also are able to talk about sort of how that's helpful and not helpful and that you want people to think about it thoughtfully and reasonably and use it to help people in terms of help residents understand patients and also, you know, help them get better care and more accurate diagnoses. And sort of the other piece in terms of helping the faculty sort of support this in terms of how you assess and manage patients, but also supporting the idea that residents should run around in their various clinical sites learning about what everyone else does and learning how they work with patients to help them, you know, get the adjunct parts of treatment that they need to be successful. So our example like housing, like, you know, financial support, like family work, these things that often get conceptualized as non-MD work, particularly now in this sort of push for everyone to be efficient, but that residents really need to understand how various systems work and what everyone else does and how those other people and those other institutions and agencies help patients and families get to their optimal level of functioning. Some of the challenges are residents and faculty really varying their level of interest in this issue. In general, it's like many things where the people who are interested spend a lot of time learning about it and you don't really have to do that much except sort of facilitate that. And then the people who are often, they aren't hostile, but they're just not that interested. I found that connecting it to individual patient care has been really helpful because everyone can get on board pretty much with the idea that this will help this individual patient. It can be a challenge in geographical reasons where there is not a lot of obvious diversity. So I think it's helpful to help people think about diversity across our spectrum of characteristics, as well as specifically talking about areas where there may not be as many of an identified population, but to talk about what sort of the issues would be and some of the challenges and figuring out a systematic way to work on the issue of many programs in many regions lack content experts, right? Is thinking about how you use the literature, how you can network with people who are not in your area, what should everyone know as a practitioner versus what should an expert know, as well as experts can be found in different fields. So for example, the clergy can be very helpful. So people in religious institutions, in schools, in other sort of institutions that are part of the community. And I think encouraging this as a part of routine care makes it seem less daunting. And also I think helps people be curious about this in a productive manner. It is also easier to implement, particularly if you're a program that doesn't have lots of resources either. For example, you don't have the ability to give people time off to go visit. You don't have the ability to send residents out to the community to visit homeless shelters for a significant part of their time. Or you don't have the ability to give them an administrative or an educational elective because you don't have the funding. This can be a way of implementing this across the board and the curriculum in a way that fits with what their other activities are and what your resources are. So I've listed a bunch of resources. I'm just gonna go to the end just to put in a plug for the community psychiatry model curriculum, which is very helpful. And then a number of the institutions and professional organizations and a number of academic institutions have resources as well. I appreciate everyone's interest and attention and I'm looking forward to the question and answer. And I'm always available if people have any questions and I'm pretty sure my email is somewhere, but it's adingle at unr.edu. Thank you very much. Thank you, Dr. Dingell for highlighting the importance of patient-centered care and the use of the clinical encounter as a teaching tool. Next, Dr. Jordan will share with us how to use advocacy and health equity to teach sociocultural psychiatry. Please join me in welcoming Dr. Jordan. Thank you. So I'm gonna talk about how social justice education can really lead to innovative mental health policy. But before I get started, I always like to take a moment of silence to really recognize the time that we're living in, right? We've all been dealing with some type of psychological strain at the very least and just emotional turmoil given the current state of the pandemic and global injustice. So as a black woman in academia, I am always affected by killings of unarmed black people. And I'd like to just lift up the Black Lives Matter movement not because other lives don't matter, but until this country starts to treat black people with the humanity that they deserve, I always try to have a moment of silence. So if you would be wherever you are to just pause for 30 seconds, I'd like to close my eyes. I wanna bring in the memory of George Floyd, Mubarak, Solomon, Danielle Prude, Breonna Taylor, Walter Wallace, and Ahmaud Arbery amongst many others. So 30 seconds of silence. Thank you all so much for being willing to hold space with me. These are my disclosures. I don't have any relevant financial relationships to disclose, and I'm not gonna be discussing any off-label use of medications. So when we're talking about social justice and health equity, it really comes down to the fact that we're all in this together. And so I'm gonna be talking a little bit about social justice and health equity. It really comes down to two foundational phrases, the first one being social justice, the second one being health equity. And as we first began to teach what we call SJHE, social justice and health equity at Yale, it's always important to ask the learners, what does that mean? And so at the beginning of each year, when the residents embark on the social justice and health equity curriculum, we have them fill out a word cloud through Qualtrics to allow us to have an understanding of where they're at. And I will tell you, I've been doing this for five years now, and I can see that there is a growing sophistication in terms of what learners understand as social justice and health equity. And I was really impressed by a lot of the terms that came up, thinking about distribution, thinking about resources, actions, societal resources, inequality, rights, these all encompass what we're trying to teach in social justice and health equity, and how can we make it relevant or sticky to our psychiatric learners? So what I like to review quickly with you today is a few points. One, I'm gonna describe the learning theories and frameworks that we utilize in the social justice and health equity curriculum or SJHEC at Yale. Then we'll go over the rationale for the different tracks. There are four tracks in SJHEC. We realized that we can't really teach in silos, but this allows the learners to have access to the theories that we are presenting. And finally, I'd like to make it very relevant about how our learners engage with the teaching of advocacy in the social justice and health equity curriculum and how that has translated to real mental health policy change. So it's important in the spirit of Sankofa, which really means to look back and understand before you go forward, that you all know that this has been a 10-year process in terms of getting to the current form of SJHEC. So it started out with being a Yale resident course that really focused on professional values and shaping one's own identity as a psychiatrist in order to combat implicit bias. But what we realized is that it wasn't enough to just stop at being a Yale resident and understanding bias, that our residents actually live and work in the city of New Haven, and there are structural forces that actually dictate health outcomes, irrespective of how much the provider knows about their own biases. So really being empowered by the work of Helena Hansen, hashtag site black woman, and I appreciate Dr. Castillo for having that slide, and Jonathan Metzl thinking about how can we teach residents the extra clinical structures that impact patients' lives and health, giving them tools to deliberate and think about meaningful change. So we expanded that first course to include experiential and transformative learning principles. We wanted to be sure that the social justice and health equity curriculum was indeed participatory, so residents are involved. We call them resident track leaders, and it's an iterative process, which means that if something is not taught well or it's not understood, we really do change so that it's relevant for the 21st century and indeed for the learners who we're trying to engage. So it's really important to understand that when we're talking about transformative learning, it pushes us, both learners and teachers, to really think about what are the conditions that are necessary for a transformative learning environment? First of all, we have to understand the context, and I think that it's already been discussed. What is the context in what you're trying to teach? The learners have to understand the history of New Haven. They have to understand how mental health care was provided before they came along in training. We also use varied mediums, so we think about TED Talks, we think about a flipped classroom where they have to do work outside of the classroom, and then you just come ready for discussion. We use journal articles, chapters, movie snippets as a way to engage in learning. We also are very deliberate to have critical reflection. So we've learned over the years in SJHEC to actually have time in the classroom to engage in critical discussion, but also figure out what does this mean in terms of understanding my worldview and challenging my socialization process to this point? How do we curate environments where there can be trusting relationships? We do that through dialogue, intentional dialogue, and then direct and active learning experiences. So this is really important in terms of the literature, understanding how the transformative learning process happens. And I'm not gonna take you through every single point, but I just wanna bring your attention to the top where it's like generalization of past experiences. And this happens a lot of times for many people when you're learning, is you think you already know something based on concepts that you are bringing in based on your own socialization. So we have to acknowledge that as automatic thoughts, right? And then try and introduce new life events, training, provide opportunity so that people can critically reflect on their past experience, face their fears, and see if they can develop new ideas, new belief systems that leads to new action. So what we're doing here is being very deliberate in breaking down our learning and our teaching in the social justice and health equity curriculum, SJGC, so that we are ushering the residents along this transformative learning process that's really based on principles in the literature. And I have the references here so that you all can look these up for your own further understanding. Another thing that's really important, and we teach these to the residents is how do you establish new guidelines to be able to engage in critical discussion and also reflection, right? So we teach them how to use language that actually respects difference, but doesn't automatically agree, right? So for example, if you want to grapple with challenging ideas and you're really striving for intellectual humility, we can say something like, I'm really scared or uncomfortable to say this, but I don't agree with what you said, or I'm afraid I may offend someone and please let me know if I do, however, and then put whatever you need to out in the atmosphere. And we call this space, a liberated space, understanding that everybody might not be safe, everybody might not be comfortable, and that's okay because a lot of times when you have guidelines where there can be tension and you can engage in this respectfully, a lot of times there's an ability to learn. So instead of safe spaces in social justice and health equity curriculum, we teach liberated spaces so that we can grow in the tension. As I move on to why are we spending so much time teaching social justice in medical schools, in residency curriculums, it really is because of this ACGME, Clinical Learning Environment Review report or the CLEAR report, right? Where it says eliminating healthcare disparities in the U.S. is of national concern. And I think we've seen that very up close and personal with the pandemic. Overall, the findings from this first set of CLEAR site visits suggest that there is currently a substantive deficiency and preparing residents and fellows to both identify and address disparities in healthcare outcomes as well as ways to minimize or eliminate them. So this was from 2016. So the problem is that residents and fellows are not able to identify the disparities, but then if they do identify, they have no way to address them. So that really is the basis of where we are now, the social justice and health equity curriculum. I'm no longer the director of SJTC and I'm glad for its continued development under the new director, but I do want you all to understand how deliberate we are to get to this point. And the four tracks are the history of psychiatry, right? Understanding resident, excuse me, encouraging residents to cultivate their knowledge of history so they can critically reflect on and change the systems in which they work. So that's the history of psychiatry. Then it's structural competency to develop an awareness of the patient's extra clinical structural vulnerabilities that impact access to care. Then the focus in the next few minutes will be really advocacy. So what we are teaching residents is to have the skills in order to enact solutions, which will reduce health disparities. What are ways that you can advocate in different contexts and different environments at the patient community and population health level? And then finally, the human experience to eliminate systems of power and oppressive social forces that impact the human experience, health and the doctor patient diet. So, like I said, we're gonna focus on advocacy. And what I love about SJHEC and many different social justice curriculums across the nation is that when a resident or learner comes in, they're really excited. They just want to do the best they can to take care of patients from all different backgrounds, varied backgrounds. But the thing is they don't necessarily see the barrier that exists in order to take best care of a diverse patient population. So through SJHEC, we're able to bring all of these things to the surface, right? So that the residents have an appreciation of all of the different elements they need to address in order to bring about healthy outcomes. And through advocacy, that's one tool that they can work on the patient, provider, community and population to do so. So I think it's really important to think about physician advocacy in the context of the social norms and public policy, right? So the social determinants are for the most part created by this unequal distribution of opportunity in society. And when we're thinking about opportunities, we're thinking about safety, stability, nurturing environments, and we understand that the unequal distribution of opportunity is underpinned by both public policies, right? Rules and legislation pertaining to all types of things, including health, but also is shaped by social norms. So when we're thinking about physician advocacy in particular, we need to teach our residents what public policies exist that are creating unequal distributions of opportunities, and what are the social norms that are preventing these opportunities to be more equitable. So we teach our residents that we educate the public. We educate them about present and future threats to the health of humanity, and how to advocate for social, economic, educational and political change. So we understand that not all advocacy has to be within the clinic, it can be outside the provision of medical care. It can be within the community level, and that physician advocacy is not necessarily just for the physician's personal expression, but it's for the greater good of producing equitable outcomes. So one of the things that I wanted to highlight is just that psychiatry residents make highly effective advocates. Why? Because they are really educated and these are some of our residents at the Capitol in Hartford. When they advocate, it's really rooted in evidence-based orientation, they're able to critically engage with policymakers, they distill the evidence down and interpret it in a way that makes sense. They already have professional attributes from being a physician and socialized in that system. And then they have firsthand experience because they are on the front line, taking care of patients. So, what are the SJHEC advocacy track tenets? We talked about equipping them with the skill set that advocacy interventions have to be framed within the context of history, structural competency and human experience tracks. And then we actually role model and mentor for them through the assistance of Kiki Kennedy, Esperanza Diaz, and Felicia Gilman, in terms of how indeed you actually become an advocate. I just want to kind of show you the spectrum, all the different levels of advocacy that they learn to really engage in. And then you can just see that this is a process that is built over time before their PGY-4 year where we really consider them psychiatric leaders. We talk about what it is to be an advocate through the activism workshop. We teach them advocacy skills through cultural and structural interviewing. Then the second year, they actually go to the Capitol, work on framing and messaging. Third year, they have to actually write an op-ed. Many of them have been published. And then the last year, they can actually testify. So, my last slide is just some examples of what we've been able to do in the last few years based on our social justice and health equity curriculum, particularly within the arena of advocacy. We're really proud of the State Bill 552, which has led to universal access to Narcan, which is a medicine that reverses overdoses from opioids. It used to be that there needed to be an individual physician prescription in order to get access to Narcan. But because of the advocacy of our residents going through the track, there's a standing order. This is from one of our attendings who was a faculty track leader in advocacy. This bill supports efforts to remove existing barriers to Narcan as a way to provide greater access to this lifesaving drug at a time when people are dying of opioid overdoses at an alarming rate. One way to achieve this is implementing standing orders. There were people who came out against this, but our residents were extremely efficient and masterful in getting this passed. Another thing that we were able to do is increase funding for the Safety Net Mental Health Center in New Haven, the Connecticut Mental Health Center, which we call CMHC. Our residents involved in the advocacy track of SJHCC have participated in direct testimony four years in a row. CMHC remains a critical community and state resource, a national model for clinical innovation and an engine for the Connecticut economy. Here our residents are showing you that having a well-funded mental health center not only just helps the patients on an individual level, but also helps the direct community of New Haven, but also the economy of Connecticut. Healthy minds, healthy people can participate in society. And then finally, a huge win that our residents participated in was network adequacy in Connecticut for access to psychiatrists. What does that mean? It means that a health plan has to deliver the benefits promised by that plan by providing reasonable access to a sufficient number of in-network specialty positions. We're having a huge problem with this. We're so grateful that our residents are pushed, really, for there to be network adequacy in Connecticut. So I'm really, really excited about the work that we've been doing. I can't wait to build on that. And I hope that you guys have taken away something that you can use in terms of integrating or establishing advocacy within your social justice curriculum at your university. Thank you. Thank you, Dr. Jordan, for that presentation. It is important to see how teaching our trainees and medical students about advocacy, social justice, and health equity can really have an impact not only in our local communities, but in the nation as a whole and in the larger scale by impacting policy changes. I would like to invite Dr. Castillo now to talk about another tool in teaching about sociocultural issues in psychiatry by focusing on our communities. Dr. Castillo? Hi, everyone. I'm Enrico Castillo. Thank you so much for that introduction, Dr. Padilla, and thanks so much for this opportunity. It really is an honor for me to be a part of this panel with Drs. Padilla, Jordan, and Dingell. These are my disclosures. And I don't have any financial or other conflicts of interest. You know, upfront, I just want to acknowledge that, you know, it's the leadership, the creativity of the residents of UCLA who make this work possible. And also I want to give a huge thanks to the faculty and the community partners who teach in our curriculum. So to start, when it comes to teaching about socio-political, socio-structural concepts in psychiatry, you know, I want to start with my key take home points. And so the first point is to make these concepts visceral by teaching experientially. The second point I want to make is to make it local by teaching about the city, the town that you're in. And the third point is to make it actionable by building partnerships. So I'm going to focus on each of these in turn by sharing with you some of the tools and the exercises that I use in my teaching that I hope you'll consider using as well. I oversee our curriculum at UCLA in community psychiatry, global mental health, and we use that curriculum as a vehicle to teach structural competency and health equity. So part of what I'm going to talk about, it expands on and summarizes these two articles here, which were written by colleagues at UCLA, Yale, and Howard. And the focus of this work is to figure out, you know, how can we train the next generation of psychiatrists to be actively engaged in eradicating health and social inequities faced by our patients, particularly Black, Latinx, Indigenous, and other minoritized populations. So this is a snapshot of our community global psychiatry curriculum. It's organized into five modules focused on local public health crises. So homelessness, criminal justice systems, and immigration. The curriculum is over 40 hours in total. It spans four years as part of the core curriculum so it's, it's given to all of our residents. Each module, it includes teachers from multiple disciplines, history, anthropology, public health, health policy and also health services research. But we also bring in community partners, community leaders as teachers, because on topics like these, I feel that it's, it's so important that we learn from our partners who do this for a living. You know, so for example, we're really fortunate to have the director of Frontline Wellness Network, and a leader in Black Lives Matter LA partner with us to teach a two hour class on alternatives to incarceration and local advocacy opportunities to reimagine criminal justice. So I can't go into detail on all of our curriculum but I want to highlight some things that might be helpful to you when you're teaching about social competency health equity and the social determinants of health. So the first thing is that, you know, it's important to me that we don't teach these topics theoretically. You know that makes these concepts feel a million miles away. You know for residents and other trainees know residents will say to me, how is this important today for me when I go back to clinic. You know, so I think it's really critical to make this material memorable, but also immediate. And so one way that we try to do that is to include experiential components in our curriculum. So during class time we physically bring the residents to the county jail, with a tour led by an alumna of our program, who's a psychiatrist that works in that setting. And that's how we start our personally involved populations and services module. And then as another example, to start our module on homelessness, we bring residents to skid row, which is the historical name for district in LA, with a large population of people experiencing unsheltered homelessness. And then when it's good road they visit with a nonprofit organization called Project 180, and there's a that tour is led by an addiction counselor with lived experience with both homelessness and also a car show involvement. So it's really important to do these kinds of experiential visits thoughtfully, not to be a tourist or to be for heuristic, but when it's done right, you know, I think they can really take this abstract concept like structural inequities, for example, and it can put a face and an image to that. So you know when they're when a residence. Next patient talks about being in jail, or being on skid row, you know, these are no longer abstract things for for our residents. You know our residents have been there. But it also helps our residents imagine what would it be like to work in these settings for living. And we've had residents graduate from our program and take on public service careers in these settings, in part because of these experiences. The same thing I want to try to do when teaching about social and structural determinants is I try to make it local. Homelessness aren't something that happens away over there, you know they're happening right down the street, or on our campus. And so I feel that residents should leave the program, knowing about local history, local challenges, local strengths and culture. So when I teach about homelessness, I use a local redlining map like this one. So you can see, I circled, a couple of neighborhoods where our residents live as an additional step, you know, instead of just showing them this map. And you can see Hollywood it's circled in yellow over here. And in 1939 and appraiser wrote, if not for a scattering of Japanese and Filipino residents, Hollywood would be entitled to a higher grade. So residents can see how racism was encoded into housing policy and mortgage assessments, and that that was done in a neighborhood that I and my residents know really well. And so if you're interested in doing something like this for, you know, the place where you train. This, this map is from an amazing resource from the University of Richmond. It shows actual scans of maps and appraisers notes from that time. But then we also try to connect that legacy that history of redlining to the local inequities that we all see during this pandemic so this graph here. It shows COVID-19 infection rates by LA region. And what you can see is double the infection rate in South LA and Central LA, which are predominantly Latinx and black communities, the redline communities, compared to South Bay and West Side, which are more highly resourced. And then also, these are articles from a series of classes and events that we've done that focus on troubling trends that we're seeing on the criminalization of homelessness. Now how LA is taking steps to lock up people in jail, or to cite them with misdemeanors as a way to control encampments rather than to offer them services. So this is an example, you know how in three slides, the last three slides that I've shown. We've talked about local structural determinants and history, you know redlining. We talked about contemporary local inequities during this pandemic, and also ongoing structural inequities via local politics and also municipal laws that affect our patients lives and their health. By making it local and current, it highlights that inequities are really all around us right now, and that there are opportunities for advocacy and reform. That takes us to the importance of making this actionable. My experience as a teacher, is that if I teach structural competency without action. There's this risk that learning about these topics can actually worsen residents moral injury and their hopelessness, because it can create this feeling that these problems are too big, and that there's nothing that can be done. So one thing that you can do is to give residents that experience of action. And so one small way that I tried to do that is with this exercise. I've also done something like this you know you give your patients, a bunch of referrals to local community resources to help them address their social needs. But what I try to ask my residents is, you know, what do you know about those organizations that you're referring them to, you know, will your patient be welcome there. Do they meet their eligibility criteria for their services or will they be rejected. So for example at a food pantry. What time should I show up, you know what days are they open do I need to bring an ID. So taking you through this exercise in LA, you know we have a website. It's called one degree. It's a site that compiles information about local social services and community based organizations. And you can search the website by social need. So what I do in classes I divide the residents into teams of two, and then I assign them a social need. So one team needs to find food resources, another team domestic violence resources, another housing and then another one legal assistance. And then I give the residents this website. I give them this hypothetical case here I asked them to use a real case of someone that they saw recently. And then I give them just 10 minutes, you know, during the class to call up a community based organization and to make a connection. And so you can see this exercise slide. This is what the slide looks like. I asked residents to try to put themselves in their patients shoes, and to think about the information that they'd want. If they were being referred there for social services. You know I asked them to envision, you know, from the moment that they entered the door to the moment they're receiving the help that they need. What does that process look like. And what can they expect. And I also asked President to consider what are these programs level of comfort, when it comes to mental illness, and they're all and their overall willingness to help. And just to comment on what the experience is like, you know, it's always a really fun experience because there's this level of hectic energy in the room, which I really love. You know we end the exercise by reflecting for about 15 minutes after. And what residents have told me is how nervous they were to call up these organizations. And the thing that I always respond to them as I say that if they felt nervous. Imagine how nervous their patients must feel, you know when they receive a pamphlet and have to show up to the organization or have to give them a call. And one of the things that happened during this exercise is that residents have found errors on pamphlets. You know wrong phone numbers or phone numbers that weren't in service. And then on the flip side you know residents have made these incredible connections to organizations so once an organization offered to meet with a resident and also the entire clinic to see how they could build a stronger partnership, moving forward. And then lastly, residents have commented to me that this exercise was empowering, because it gave them the confidence to go beyond a brochure and to call up an organization to see how they can build that personal connection, but also their own knowledge about local resources. And so again this is just one small exercise about building connections. And you'll see that throughout our curriculum, we try to build in community partnerships and non physician teachers to model for residents that when it comes to the social and the structural determinants of health. This has to be a team effort. You know we need the skills in building partnerships outside of medicine, and that that's just the beginning of structural action. And so to wrap up, please teach your residents about social structural issues. And when you do, I hope that you find ways to make it memorable to make it visceral local and actionable. And lastly, if you want to learn more about these topics I hope you'll check out these articles, and I've included names and also article titles here. Thank you very much. Thank you Dr Castillo for reminding us about the importance of thinking about our patients and communities, as the teachers and educators. I want to thank all of our presenters for their wonderful presentations I really enjoy listening to you and seeing how in addition to the traditional teaching tools of the classroom and curricula, we can really expand that to think about the clinical and the communities and other settings to learn about social cultural psychiatry and teach our trainees I think this can really have a big impact in our experience of psychiatry and that of our trainees as they start developing their professional identity. So thank you all again I look forward to the question and answer session. So please stay around. Thank you.

teaching

social cultural issues

psychiatry

clinical encounter

sociocultural issues

advocacy

health equity

community-based experiences

teaching strategies