Good morning, excuse me, because I think we should value time since there is a not an infinite amount of it left for any of us. I'm gonna go ahead and get started and to honor all of you who were up early, got here, most of the eyes in the room are still open and I'm hoping that over the next hour or so they will remain that way. I won't bore you back to your little nap after having to get up this early. I'm Dr. Altha Stewart and I apologize for my voice. Yesterday I had a full voice and the activities of the day and evening robbed me of my voice and I will try not to make it too painful for you to listen to this crackling voice of mine. It's an honor to be here at the APA and to be able to deliver this talk on behalf of the allied organization of the APA that I represent, the American Association for Community Psychiatry. Can I just get by a show of hands how many of my members are in the audience? One, two, three, okay, all right. Not bad for what, Tuesday morning is it? Tuesday morning at 8 a.m. Thank you for being here and for all since most of you are not members I really thank you for being here because unless you're a community psychiatrist this may not have been as attractive a session as it I hope will be. I could have also titled this how I got into community psychiatry and why I think it's the best thing for every psychiatrist to do but that would just be the story of my life and this is more the story of an area of need that can be filled in the field of psychiatry by people with a certain mindset, a certain perspective and a certain passion for public service and serving in the public's good. There's no one scheduled to introduce me and since there may be a few people in the audience who might not know me I want to give you just a little background as to who I am and why I'm standing here and you can certainly read the bio that's in the in the APA I guess the app it's on the app so you can certainly read that brief bio there but I will tell you that I am a community psychiatrist it's all I've ever wanted to do it's all I've ever done and while I've worked in various settings practicing community psychiatry my heart is in the community. I'm a graduate of Temple University Medical School in case there are any owls in the audience. I did my residency at Drexel both of them in Philadelphia just blocks away from each other on Broad Street. I just had my 45th medical school reunion a couple of weeks ago and it was amazing to think how long I had been out of training. It was actually a little shocking how fast the time has flown. Since graduating from residency I have worked in a variety of jobs in the public sector primarily starting with a clinical approach as most of us do fresh out of training running inpatient units working as a staff psychiatrist or medical director in a community mental health center and my life's path career-wise took a real turn when I returned to my the hospital where I graduated the medical school where I graduated and joined the faculty and had a real abrupt relationship ending because my passion for working in the community was contrary to a practice in the department that we always did things a certain way and I'll tell you this story by way of introducing you to the kind of passion that I have for this work. The issue, the situation that led to my departure from the department had to do with a chronically mentally ill what we would call SMI patient who was diagnosed for bipolar but who was a pleasant very intellectually smart cognitively sharp individual young woman except when she went off of her medication and went into full-blown manic episode. Then she was very dramatic colorful makeup fashionable colorful clothes and the the usual presentation of a bipolar patient who you have all probably seen admitted through your crisis service or emergency room and was stabilized within 24 48 hours and but taken to mental health court because this was you know incident number 17 or something and her case manager was a young woman a young white woman fresh out of social work school who believed that everything she needed to know about working with patients was taught to her in social work school. I didn't argue with that until my patient was seen outside of the room where we held mental health court holding the woman up by her neck against the wall saying things that I'm certain had to do with what she planned to do with her with her other hand and I walked over and very quietly called her by name and she looked at me and said no she said something that was wrong and she won't apologize so I have to hurt her. There's a room here where the magistrate is about to begin the hearings and it's a glass wall so you can see and I quietly said to the young woman I said well I can understand why you'd be upset and I'm sure she will apologize hoping and praying to myself that the woman would follow my lead and she didn't and I said to the patient you know sometimes it takes people a while to come around to seeing your side and maybe just maybe if we talk about this outside of the view of the judge who could commit you for a much longer time than you probably need because this would be considered assault and I did all of that quiet tone soft-spoken eye contact engaging you know the the whole hold out your hand extended and people want to come to join you I used every trick in the psychiatric manual for de-escalation and finally she did release her slowly thank God because she would have dropped it I mean this was a big woman holding this little girl up she could have dropped her and she would have hit her head had a concussion I'd have had incident report to fill out hospital investigation all of that and the woman ran away the young woman ran away and I pulled the patient and said look I don't think the magistrate saw it we're just gonna hold on to this quietly for now she became very calm she went in she was not committed for I think maybe a couple of weeks she was made to remain in the hospital which was not unreasonable at that time to properly stabilize her what I did not realize was that the woman was so personally embarrassed in addition to being traumatized personally embarrassed that she immediately reported to her supervisor that I had embarrassed her I choose to think I saved her life but tomato tomato so I get a call from my chairman who starts out do you know who I am yes you're the chairman how can I help you I have a complaint about you you did something and it was very embarrassing and jeopardizes our partnership with the mental health center and we have to have better behavior from our attendings and blah blah blah and and I kept trying to say but you don't you know that I'm trying to tell you something boys and when I finally did get a chance to tell him that the truth of the matter was that I believe strongly that the woman was in grave danger and felt it was my obligation as the attending and director of the unit to save her life that was my position it's kind of one of those that's my story and I'm sticking to it and as a community psychiatrist though I understood the in within at that point for me within the academic setting community psychiatry was really low man on the totem pole there were the top clinical services there were the training aspects of the academic center there was the prestige of achieving tenure and doing certain things and being honored in certain ways and then there were the people who I considered doing the grunt work you know we were the front line we were the rapid response team and he persisted until he said this which was his undoing because I gave notice at that moment do you know how much I make and I thought no I don't I know how much I make and it's not enough to take this crap so you have officially received my two weeks notice I had no job I had no prospect of a job I hadn't even considered changing jobs but at that moment I knew that what I wanted to do I was not going to be able to do in that setting and I had to make that impulsive young person's decision to say screw you oh this is being recorded I'm sorry at least I didn't give names and so with no notice and no prospect of a job I spent two weeks ending my career as I thought and then I realized I'm a doctor I'm trained I got credentials I know stuff that is needed and I happened to get a call and how this ties into the topic for today I happened to get a call from someone who was new to the city and reestablishing within our public mental health office the Office of Mental Health was a step reestablishing a director a medical director role because his predecessor had no time for psychiatrists didn't believe we knew what we were doing didn't want us interfering with his his work and the man said to me I've just heard a great story about you and I understand that you left a job and may be interested in a job and I said well yeah I did leave a job and I guess I should look for a job and he said well I'm thinking of establishing this medical reestablishing this medical director role would you be interested I said well I'd be interested in talking he said the other thing you need to know that I know about you is that you were heard in the the district branch local association you were heard to say something to the effect if the idiots who ran the system had ever really treated a real patient they'd make better rules for us to follow so that we could treat patients better and I actually had said that I actually had said that he said so those two things make me believe that you're the person I want working with me and so thus began my career in community psychiatry before that I was a practicing community psychiatrist that established that incident and I thanked later after I calmed down a little bit like 10 years later I thank the man who was my chair at the time who coincidentally had married someone that I really liked so I forgave him and I moved on after a decade of harboring ill will but the role of community psychiatry in mental health systems of the future is what we're here to talk about not my past and again you can read my bio and the accomplishments and awards and stuff and if someone were here introducing me they would have read all of that the time that I just took to tell you that story they would have taken that time to introduce me that stuff is available and that's not what I want to talk about today yeah okay the requisite conflict of interest financial disclosure statement I have none and I have not I'm gonna provide this in the context of the organization of which I am now president the American Association for community psychiatry and I have this slide to give you a centering point a a level set if you will for how one organization within the field of psychiatry and professional organizations in psychiatry conceptually believes these are the the principles that we should operate from that our mission statement very clearly talks about promoting health recovery resilience in people we don't say in patients in people that families and communities have to be included and need to be inspired and supported by us as providers in the community of the psychiatric care and that ultimately we believe this approach will actually transform the mental health system that's a big big goal mission that we have established for ourselves and I'm here to tell you that I think we are and I'm certainly biased at this point we are the organization that believes in that that practices that that shares that philosophy with any and everyone who is interested in doing community psychiatry our vision statement indicates a level of activity dedicated to the mission advocating and partnering two critical things in transformation advocating for change and partnering with other like-minded individuals and in our case organizations who believe that the system the mental health system we have now is not just fragmented broken it is harmful to people it creates more problems for many of the people who go into it hoping for help we have regulations we have rules we have policies we have practices that just aren't consistent with the kind of stuff that we in AAC people leave ought to be the cornerstone the foundation the level-setting place for our mental health system we are big influence long influencers long before the influences on social media AACP was an influencer kind of like EF Hutton we did stuff and people listened and looked and tried to emulate and replicate and I'll talk a little bit about some of those some things that we have done and are doing that really are making a difference in how the system operates that kind of influence means that whether it's the age-old dilemma of how do we adequately balance medication and therapy how do we create the multidisciplinary team approach to working with people since there is no one-size-fits-all one problem for everybody thing in the life of a patient and how do we how do we use something like this whether it's a social justice issue whether it's a structural racism and psychiatry issue whether it's a dilemma in our workforce capacity and diversity issue how do we use our influence to push the needle on changing all of those things so part of our vision is to change and I'm a big believer in change someone once introduced me as a change agent who has spent her life transforming systems and then leaving them for other people to carry on I really don't have a big desire at this point in my life to stay on for 15 years anywhere I really do like meeting a challenge that I haven't had yet looking at ways to resolve it setting in motion the plan for that resolution transformation change whatever and then moving on to the next challenge there are people who say that is not a good career path and I don't encourage anyone to move around a lot but over 40 years I've worked in four states at high levels medical director executive director CEO of large public mental health systems and I think I've done pretty good in terms of the perception of me by the general public that I'm not an unstable employee and then finally the knowledge and skills development and dissemination is critical to system transformation so based on our mission and our vision in my mind community psychiatry equates to the American Association for community psychiatry which equates to the future of psychiatry so I could shorten it to say the ACP is the future of psychiatry but that would be limit rating limit limiting and might make some of our partners a little upset because I'm declaring that we're the best and the first and the greatest but we see ourselves as a community of psychiatrists for the community of psychiatrists we're really a very family oriented group that takes care of each other that supports each other that encourages self-care we look out we ask questions about people we start meetings by not just introducing ourselves and where we're from and what we do sometimes it's what good thing has happened in your life aside from whatever you're doing at work or who've you been in contact with recently that really made a difference in level setting you if you've kind of been going to one side or the other so we really are a community for the community of psychiatrists and I would encourage what this is not just a recruitment pitch but I would encourage you to check us out look at our website see what we do and really take a look at whether we may not be a group if you're not already in that kind of supportive organization a group that you'd want to take a look at at coming along for the ride of this family so we get this big vision and mission how do we accomplish all of that well somebody much wiser than me a while ago decided that there could be planks now when I first came into the organization and I wondered why why do we call these work groups that accomplish our mission and our vision planks someone looked at me and kind of smiled and said because boards have planks you know planks make up the boards and I thought whoa now that's a turn of a phrase if you will and and we still use the word planks but but it's an indication from my standpoint that we want to make sure that people understand there are clear and specific action operational parts of the organization that focus like a laser beam on certain things and so the first one I'll share with you has to do with policy and advocacy this is our monthly gathering and all are welcome it is listed on our website the dates and I have it here on the slide when the next one will be and and for me it existed before I became president last year but for me I saw it as an opportunity to to dial in and hear what people were saying and in fact I will share with you that it was on a call like that that I was trying to very quietly sit and listen to that something stirred inside of me in the conversation which led to the discussion about whether or not I would become president I was not then on the board of the ACP but I said I heard something during the conversation that piqued my interest I said something during the conversation to respond to what I heard and somebody who shall remain nameless but is in this room thought that was my indication of interest in joining the board and doing some of the fun things that ultimately led to me being named president and and it's not a bad gig I will say you know you you get lots of support people actually these are all volunteers they actually volunteer and do the work it's not just a committee in name and when something happens oh I don't have time I'm sorry I'm busy they actually do the work and it's it's as it says there are monthly form can take the the the the position of something topically interesting in the field that we'd like to have a discussion point on, some cutting-edge, urgent, time-sensitive issue. There's about to be a vote in Congress for something and we all need to advocate against or for something. There's going to be a change in a regulation and we need to weigh in as an organization because it's going to significantly impact our members. So the policy and advocacy plank does some active stuff, they do some research investigative stuff, and they do some rapid response stuff, depending on the issue and the time. And that's just one of the things that they, a few of the things that they do. And at this meeting, and during our board meeting, we actually set a few other things on their plate to begin working on. The next plank is what we call communication and collaboration. And this is a full bucket of ways that we work with other people to get things done and that we work within to coordinate our messaging to the outside world and also to our membership. I'm very proud to say that some of our young people, recently joined AACP members, have established a place in history for themselves. Within a couple of months of coming on board, they created a podcast, which is available on Apple or Spotify or wherever you listen to your podcast. And they're teaching me this whole technology digital language that I have no understanding of. But it's a wonderful place to hear both what we're doing and to hear from people who are doing things in the field about how they're doing and why they're doing those things. So, you know, find us and listen. I think there are three so far that have been completed. So you've got a whole folder to look at. Some of the other things that the communications and collaboration plank does is that we have a newsletter that's produced two to three times a year called Community Psychiatrist. We have a journal, the Community Mental Health Journal, peer reviewed, available as members available to you. And you can purchase a hard copy. Check us out on the website. That plank meets monthly. And the date of the next meeting, if you are a member and interested, is there on the slide as well. And some of the people in the room, by the way, are participants on these planks. So during the Q&A period, if you've got specific questions, I may call on them to answer some things. Here's a copy, a look at the Community Mental Health Journal. We have just, in preparation for this meeting, we now have a Spring 23 issue. It is available on our website, communitypsychiatry.org slash home. So you can find that there. We have a very talented crew of communications experts. Mira Bodick, who some of you may know from New York, is our newsletter editor and our website webmaster. Sandy Steingard. My voice is complicating this greatly, is the editor of the journal and is always looking for good material to include. So if you are of the mind that you have something that you'd like to say that fits within the guidelines and the rubric of what the Community Mental Health Journal is looking for, please look for it on our website with instructions for how you may submit. This is just one slide, and there are so many more partners that we could talk about to give you a sense of the perspective that we take for collaboration. The AACP is a wonderful organization. It's a small but mighty organization. I liken it to, we are David against the Goliaths of the big organizations in medicine and psychiatry. But like David, we've got secret weapons. We partner with some of the best groups to get the work done that we all agree is important. And this is just a small sampling of some of those groups. We're involved in climate change. Several of our members are leaders in that area. One of them is in the room. I'm not going to out him as a spokesperson, but he's really helped to raise the bar on our level of involvement. The whole criminalization of the mentally ill has led to a strong partnership with several justice-involved organizations that look to us for our mental health and psychiatric expertise, whether it's treatment in those settings or doing things to keep people with mental illness out of those settings. We are at the table in a meaningful way. Many of our members are very active, long-time members of the group for advancement of psychiatry. And so that more long-term, learned, analyzing everything for a period of years approach matched with our very action-oriented, timely, look at what we need to do now approach has proven quite helpful. And there are stories behind all of these that are meaningful, I think, in terms of how we are operating as an organization. Just want to check my time. Now, I want to talk a little bit about what we call our products and services plank. And that includes several actual items, work products, and other things that are adding value to the kind of work that we all do, but also adding the level of accountability and credibility that is required more and more often by the regulatory bodies that we all have to answer to. I included this quote from Wes Sowers, who is one of the developers of these tools. Has everyone heard about LOCUS? Do you all know what LOCUS is? Okay. Were there some? There were a couple of people who I think said they weren't. LOCUS is the tool that was developed by AACP, and there's now CalLOCUS, which is the child and adolescent version, which serve as our quality improvement tools. They allow us to help organizations, particularly organizations that value data and outcomes, to gauge how they plan to reimburse and what they will reimburse for. These are the tools that were developed by AACP to fill the gap that was clearly needed at a time when we struggled very hard with convincing people that what we did made a difference, whether it was in assigning levels of care, identifying lengths of stay, all of those things that some of us who are a little older than some of you in the audience remember as a real challenge to the system that we currently have, and for which the future system that we hope to create will benefit, because these now have been in the service of the system of care for long enough for there to be substantial data, for people to be comfortable, and for payers and people who do the reimbursement models, to trust as valid instruments and validated instruments to assign to their systems to use as the way to determine payment reimbursement and satisfaction with the service being provided. So these two alone stand to create the transformational bridge that is needed to move from the system we have to the system we are working to create. And I think this quote from Wes captures the spirit of how they came to be created and the reason we are continuing to work to upgrade and make them even better as we learn more about treatment and aspects of treatment that are important in making those kinds of patient care decisions and reimbursement and payment decisions. So this is just the beginning and this is one of our older products so that's why I listed it first. We also have a model curriculum for training in community psychiatry. It was developed by members of the AACP who volunteered their time to create something so that for young people entering the field or more seasoned practitioners who want to learn more of the specifics around what is community psychiatry, there's a curriculum in development, in final stages of development, that is already approved by ADPERT, which is a good test to pass, no pun intended, when we are looking to change the way we train individuals in community psychiatry. There's information available including outlines and references and other things available on our website or you can contact Frances Bell who is our administrative director at the email there. But you can go to our website and find out just about anything about community psychiatry and it will help you understand why I say the future of community psychiatry is the AACP. Okay, another product and service which is of certainly some importance to many people is the AACP developed community psychiatry certification exam. Now everybody has been through credentialing so you know that there are aspects of that that require you to demonstrate that you have achieved a certain level of competence and that evidence for that is by some exam or something. The community psychiatry certification exam, again, a product developed by members of the AACP who put lots and lots of effort into it, is available right now for anyone who wants to take it, who meets the criteria for sitting for that exam. Available information on our website. The important thing I think which we discuss a lot is that for individuals who consider themselves community psychiatrists and who want very much to be recognized and respected, that that is a specific level of skill and competence that not everyone has. This is a perfect example of the ways we believe that changing how we identify and measure skill and competence is one of those things that sets us apart as community psychiatrists. More information is available on our website. We're really proud today that this is also one of the products developed by our members. The SMART tool. SMART stands for self-assessment for modification of anti-racism. It was created, the development of it began in the aftermath of the murder of George Floyd. It was during that time in our recent past where we were locked in and everything changed. The world changed around us. We began to have to do things differently and AACP, like many organizations that work in the behavioral health, psychiatric psychological arenas, had a long, painful discussion about what our contribution to resolving some of the issues that came as a result of all of those things. The murder of George Floyd, the subsequent unrest, the challenges with increasing need for mental health, particularly in underserved communities, the focus on needing to really work hard to eliminate health disparities, to do the necessary work to eliminate structural racism in psychiatry, all of those things that were buzzwords at the time. The AACP took seriously and began work on this tool then. We now have an established product which is available for use. If you go on the website, you'll see things like, I want my organization to be an anti-racist organization. Will this help me with that? The answer is absolutely yes. We've got a team of members of the organization who serve as consultants to other organizations. In fact, at this meeting in San Francisco, we had a consultation with a local community organization that is struggling with how to adopt new practices and policies to address some of the needs of the patients they serve who are primarily racial and ethnic minorities, sexual minorities, people who are under-resourced and have lots and lots of issues around social determinants of health and mental health. We spent the evening with them. One little aside about that consultation that was not planned as part of the consultation is that if you notice, I'm wearing green. May is mental health month. Green is the color of mental health. In honor of some work that we do back home where I am in Tennessee, I brought this notion into the consultation that we have an obligation because the first week in May is Children's Mental Health Acceptance Month. We have an obligation to our children. All of the data, the Surgeon General's report, long time understanding of the challenges facing our children. It's a moral obligation that we pay attention and do something concrete and meaningful. Coming to this meeting when I went to get a manicure, I ran into a young woman in the salon who had this brilliant green nail polish. I've never worn a bright color on my nails. It's always neutral. Don't want to upset people. Don't want to stand out. Well, actually, that last part is not actually true. Because it was green and I thought it was just the kind of subtle statement that I could use as a conversation starter, I had my nails done green. When I held them up as I'm telling the story, one of my colleagues had agreed when I told the story at dinner the night before, had agreed it was a good idea. So when I opened up the floor to talk about it, he brought me a bottle of green nail polish from a local drug store. And I asked if anyone in the room wanted to get a nail painted green in solidarity and support for children's mental health. Over 40 people let me paint their pinky finger. They're in the room holding up their hands right now. And it's just one tangible way that we can use communication and collaboration to spread a message that was very subtle. I fully, and I had nail polish remover, so anybody that just wanted to do it for the picture and then take it off was free to do that. But there were guys in there who were a little hesitant at first to have green nail polish. There were young people who thought it was fascinating and they wanted all their nails to be that green color and everything in between. And I tell you that story because in the course of doing a consultation with a local organization that had a need for our expertise and perhaps the use of the smart tool, I was able to insert the communication process into the communication process that there are subtle things we can do to get the message out about the needs of the community. So if, and I do have the polish with me if anyone after this wants to get a green nail. I'm just saying. Another thing that we are very proud of and I love promoting this is that ACP started this dialogue about community psychiatry that was very much needed by publishing a handbook. And handbooks have their place, but handbooks aren't usually used as standardized textbooks that have all of the requisite information and scientific rigor of the research that led to the statements that are published. And usually we aren't able to get those as the textbook for a topic in training, like a residency training program. It's a good starter, but what we need is the textbook. You know, we got the textbook of psychiatry. We got the textbook of psychopharmacology. People won't teach without those things. At this point, people shouldn't teach community psychiatry without that textbook. So everyone in here is encouraged to purchase one for themselves and a friend. Have your department purchase them for the department. Have the residency program give them to every resident. Make it a nice gift at the end of the year. We're coming up on the end of the year. You know, transition, people coming in, make it their entry gift into your residency. A stand out medical student that you're going to give high honors to, add this to the list of things that you give them. We have recently investigated this. One of our members investigated this and it turns out that if your library has a deal with Springer, the publisher of this, that you can actually get a copy for $40 through your library. What? Yeah. And now, now you have a copy that you can get signed by one of the editors the next time you see her and you can buy copies and spread them around. And it was a nice way to be on the cutting edge of the understanding that a textbook is what we've needed all along. And it's a nice, you know, you can use it to hold the door open. It's a big book and the hardcover is a big book, but I encourage you really seriously. I'm president of the ACP, so I am biased. I admit that. I think it is a wonderful reference learning point for everyone. I also have co-authored a chapter there, so I'm very proud of the chapter on, I was going to say consolidation, collaboration and consultation because that's what I do most of the time. And my co-author here, Mary Kay Smith, raise your hand, is here and that's what she does. So buy the book, share the book, tell people where they can buy the book, make your libraries buy the book, make your department, any department chairs in here? Shoot, I was going to make my department chair pitch. That every faculty ought to have the original hardcover for their own personal use to spread the word about community psychiatry. Oh, I'm sorry. I repeated the picture of the journal here. What this was intended for was to share with you that we are also now a presence on various social media platforms. We've got Twitter, Instagram, Facebook, and we have a YouTube channel, which was a surprise to me until I started to look for all of our various social media places and found it. So you can find us everywhere, including that podcast that I told you about. Why am I going on and on and on about AACP? This is a lecture on the future of community psychiatry. Let me say again for those who didn't hear me the first four times, I believe the future of psychiatry is the AACP because we are focused like a laser beam on community psychiatry. I think we have many of the answers and gap fillers for what is not present in the field of psychiatry generally, but also in the area of community psychiatry. I think we are community psychiatry and the folks here who are members have heard me say this on many, many occasions. I'm a history buff, so after I tell you all the wonderful things that we do and why I think we're the best thing since sliced bread when it comes to community psychiatry, I want to take you back a minute into the early beginnings of what we now see as the field of community psychiatry. We all remember the stories of how inhumanely people were treated initially, if they were considered to be mentally defective or acted bizarrely or just weren't desired to be within society. Then there was a shift of that that created this much more concern and more humane treatment for people who we would currently call mentally ill. That lasted for a while and certainly the advent of folks like Dorothea Dix here in the US to encourage that, the proliferation of what were then called state asylums where they were on big plots of land and lots of green space and people did normal things in this confined environment but also weren't forced to face stigma and isolation and marginalization by being in the general community. So that was a nice period. Then we moved to this period that we loosely would call Freudian where the concept of things go on in our minds that have to be drawn out and analyzed to understand and explain our behaviors. Once we have that knowledge and understanding, we can be better people, we can act differently, we can do certain things. That was an interesting concept and it remains today one of the cornerstones of how we work with people to help them understand what's actually motivating behaviors in the psychotherapeutic arena, but also it was a glimpse into, at that time, the period of that era and the people of that era and was heavily influenced by the practices and principles and morals and other things of that era. I had several supervisors in my training, in my residency training, who focused a lot on that and taught us a lot about psychoanalytic psychotherapy as the basis for a lot of what we did in the community. But I'm proud to say that of the supervisors that I had who were analysts, to a person, all of them understood the community work, the community side of work, that there were people in the community who brought those intra-psychic challenges to the table, but they came with other baggage that had to be factored in. And some of my favorites were Paul Fink, a former president, a couple of legends in the Philadelphia area where I trained Spurgeon English, who was like the dean of psychiatry in Philadelphia for years, and several others whose names you might or might not recognize. And then we moved, after the war and everything, we moved into this new era that began with the return of doctors from the field after World War II. Some know them by the name Young Turks, the forming of GAP and everything. But there was this period between the late 40s and the mid-60s where there was a lot of activity and thought given to what we did with the mentally ill. There were questions about whether big state hospitals with large populations were really the way to go, were people getting what they needed, was it humane, was it legal? And so that culminated in the early mid-60s with the passing of the Community Mental Health Center Act by President Kennedy at the time. And I will point out that in each of the, what I call revolutions in mental health, there were particular things that triggered the beginning of thinking about these things and helped to frame and direct and shape how that played out. The particular one around the Community Mental Health Center Act was the personal understanding of what a mental disability at the time meant to the individual, to their family, and the desire on the part of one man to have the courage to say, we're not going to do it that way anymore. Now, it was clearly well-intentioned, but not well thought out. Because most of us were the recipients and beneficiaries of the system that remained after the community mental health system. It was supposed to transfer money from big state hospitals, cost centers into the community with a range, a continuum of services that went from handling emergencies to hospitalization as needed. But everything in between was going to be in the community. There were going to be established community mental health catchment areas. There were going to be staffed by people with an understanding of working in this. No one planned on how to train that workforce. No one planned on what happens when a state has all this money invested in a state hospital? Jobs, tax dollars, easy money to transfer to roads if you needed it, you know, because nobody's watching the state hospital budget. It didn't work the way he intended. And we have spent most of the time since the 60s trying to fix the system that was created to help that actually wound up doing harm, as I said earlier. So now we have entered what I consider that fourth wave. We're still trying to fix the broken system. But in addition, thanks to all of the things that have happened since the 60s, we've got to address the disparities that came about as a result of policies that were put in place as part of the negotiated settlement between North and South going back as far as the Civil War. When you're from Tennessee, everything has the Civil War as a reference point. So going back in time to how our nation was actually founded on haves and have-nots, differences based on race and sex or gender, these are the kinds of things that have been layered on now to make this fourth wave even more challenging for folks. And it has been made the work of community psychiatry. While it is not legislatively our responsibility, we are the default system for anybody who does not have the means and ability through employment to pay for getting the care that they need. So mental health disparities, the inequities in our system, addressing social determinants of health and mental health, and the social justice component that we have identified very recently, but really which has been there all along. We just have a new language for it now. And the other thing about this revolution is there was language attached to each of these waves. We talk about social justice. We talk about structural racism. We talk about structural competency. When I was training, we called it cultural competency, plain and simple, cross-cultural issues in psychiatry. And we didn't name racism by name as a problem within psychiatry and psychiatric treatment systems, but we certainly identified the way different groups were treated within the system. We didn't have the language that we now have to talk about these things. So what's the work in this fourth wave? I've identified a couple of the key areas that we need to work in. Part of the work of these areas is that those of us who are part of the community psychiatry family are also part of other families. And so working to align activities, goals, and objectives for change and other things with like-minded individuals. And this is just the slide that references a few of the groups that I'm a part of as an example. Clearly, AACP stands out on the top. I am a member of AWP, the Association of Women Psychiatrists, and a former president. So I have a certain allegiance to that, the black psychiatrist, because that's the racial ethnic group I identify with and which I know has had more than its share of problems getting good mental health care, getting mental health care that addresses their both mental health, physical, psychological need, as well as the underlying structure upon which mental health was founded, which critically puts them in a position to have racism as a part of what they have to deal with in their mental health, in their quest for mental health services and mental health treatments. The National Medical Association, which is the organization that was founded by black doctors who could not gain admittance into the American Medical Association at the time, and which now serves not just as an alternative, but a viable and consistent presence, speaking out specifically and initially just on behalf of black patients, but has now broadened its scope to talk about all underserved populations and to partner with other groups who represent those organizations. And then, of course, the APA there, and I will admit that there are people who say I have control issues because I've been president of four of the five of those. And that is probably right. But I didn't, I will say in my own defense, I did not set out to become president. I became president in some cases by default, but in all cases because of a passion for the work that the organization espoused to do and my commitment to community psychiatry. You all have things in your backgrounds where you can look at the organizations and see how well they align. And I encourage you to do that because you can split up the workload by remembering that if you're part of multiple groups, one thing that you do in one group may be transferable. So when they ask you to volunteer, you just volunteer to do the thing you're already doing. It's a nice way to minimize the overwhelming workload. I put this slide in. And I usually use this when I'm talking about structural racism in psychiatry. And I think it's important in community psychiatry especially that we remember that a part of our work, especially during this wave, is to work to eliminate racism, to do the work to eliminate racism. And I will tell you very honestly, people like me believe strongly that people who don't look like me have as big a role in this work as I do. And I am sometimes short-tempered with my colleagues who are not black, who insist that it's all in the past, it's history, let it go, and we have to move on together. Well, for people who are black, and I will specifically talk about people who are black, it is not all in the past. It is happening today, every day. Every time someone who is a person looking for services comes into a setting where they're treated with disrespect, disregard, told what they must do or else, asked to see someone who looks like them for that kind of cultural understanding and be told anybody can work with anybody. And if you don't want to see who we assign you to, well, then we can't help you. These are things that I think we have just got to continue to deal with. And I keep hearing people, this is just an aside, I keep hearing people say, these are very difficult conversations. They're really not difficult. They're very matter-of-fact conversations. Things were done that did not benefit one group and benefited another. We call that privilege. There are things that I'm required to do to achieve the same level of accomplishment as many of my colleagues who are not black. I understand that. When I talk to people, they understand it. So I'm not sure what the difficulty in the conversation is. I know it is challenging. I know it can be painful. I know people can feel, as the kids say, some kind of way because the takeaway for many people is you're calling me racist. And the reality is we've accepted kind of in a very matter-of-fact way that we are light years ahead of our partners, our allies, in understanding how this came to be, what it means in the life of every individual that we work with, that we treat, when we disregard this factor, and what we have to do to overcome both those feelings that someone saying you're racist because they ask you, would you treat this person this way if they were not black? It's for me, the comparable thing for me, here's an example, is I work with kids who are on the path to going into the juvenile justice system. And after about a year of doing this work, I realized that I was tired of hearing people call the kid, the child, the youth, the adolescent, the young adult, juvenile, on the news. Child is shot in a drive-by, juvenile shot in drive-by. Child is walking down the street and assaulted by someone, juvenile assaulted in their neighborhood. Just the mere use of that term implies, I know if it bleeds, it leads, but it implies that your involvement, whether you are the victim or the perpetrator, is equal because you are now equally identified as that image that gets conjured up of the criminal delinquent, stay away from them. As a young man said in a session yesterday, every black man in America knows very well the sound of the door locking as you walk past their car. It's like amplified on some kind of megaphone steroid or something. You know what the message is, you are not safe, I'm not safe if I'm around you, I need to lock my door and get out of here. Every black man has to tell the son in the family the rules, they have to have the talk. When we ask our white colleagues if they have the talk about if you are stopped by the police what you should and shouldn't do, or how you should or shouldn't behave, what talk? It's more prominent now that people understand what the talk is, but there was a time when people said, what talk, I don't know what you are talking about, why would I have to say that, put your hands at 10 and 2, look straight ahead, have your ID already out, don't make any sudden movements. These are things that indicate that we got a lot of work to do on erasing racism. So I added this just to have a moment to say a part of what we do in community mental health, especially when we are working with individuals whose position in society is reflective of how society perceives them, and the layering on of a mental illness as another determinant of their health and mental health, and accessing care for that is not a simple matter for many in our community, and we have to pay attention to that, acknowledge it, and address it. I've had residents that I've worked with ask me, how do I bring it up, what do I say, do I say, I know I'm white and you're not, and is that going to be a problem, and I think there's probably as many ways to introduce it in a therapeutic setting as there are therapists who want to have it a part of the therapy. It depends on your level of comfort with talking across racial issues, it depends on your level of defensiveness, because if you hear something that you don't like and your response is, but that's not me, I'm going to shut down, as a black person, I'm going to shut down, because I wasn't accusing you, I was making a statement of fact. In my experience, many white people find me to be threatening, intimidating, I feel like they don't want to be around me and that I'm not welcome. If I say that, and your response is, but I don't feel that way, I don't think you've heard me, and we know a very important thing in therapy is to be heard, to be seen and heard are the cornerstones of the work that we do. I'll stop talking about that. I love this cartoon, and I will tell you the title of this slide, the title of this slide has changed over each of the presentations I've done, whether it's violence in the community, the whole issue of the naming kids by juvenile, trauma and adverse childhood experiences. This slide, this cartoon is applicable to so many things that we do in community psychiatry. I just keep repeating the slide and changing the title. And really, I know this is obvious, but a lot of what begins to bring people to our attention is based on the things that you see here that create behaviors that get to our attention, generally through some system, whether it's law enforcement or the legal system, the schools, community groups that work with individuals. They don't really think about the mental illness. They see the behavior and want you to do something to make the behavior stop. It's only after we get them and can assess, evaluate what's going on that we can add the things that are codable. But generally speaking, this is what community sees, and part of our job as community psychiatrists is to begin to translate for the community the behavior is symptomatic of the illness. It's a manifestation of the illness in most cases. And so we have to work very hard to make that translation for them. Just a couple of things on health and equity, because that's a big deal in community psychiatry. We have the unfair, unjust, and avoidable definition. Three words really captures the spirit of the inequity problem, and it's where we can plant our flag of work, because if it's unfair, we know we can do things to advocate and create better policies and practices for the kind of equitable care that all people deserve. Health care is a right. Unjust because we know that the system can be tweaked to create the framework, as my patient, who was holding the lady up, had there not been a good intervention, she would have begun her life going through the criminal justice system, because that assault would have turned into something that may or may not have treated her in jail, and she would have come out mad and angry and feeling like she'd been treated unfairly and unjustly, and the cycle then would begin. And it is avoidable. There are things we can do in the areas of social determinants of health and mental health that serve as the underpinning for why some people have more challenges, whether we get them good help or not, they have more challenges with being able to respond appropriately and in a positive way to the kind of care that they've received. And then we've got this inequity that is triggered by a workforce issue, the capacity as well as the diversity. I left off capacity. It's that we have enough and that they are diversely representative of the kinds of things that people in the community need in terms of their health care treatment. I never can do one of these things on community psychiatry without talking about the difference in how women and men are treated and viewed as doctors. And there are several things more recent than this one, but there are several articles that continue to show that even when we are doing comparable work, they don't call us doctors. We are Miss Somebody. We had a very long conversation about this in another session yesterday and what we can do about it. And the primary response on the part of even the men in the room was that men have to be more active in identifying this as a problem and correcting it when it happens, whether they're the supervising, attending of a young female resident, the chair of the department who sits in the faculty meeting and hears Dr. So-and-so, the guy be called by that, but the woman be called by her first name. Or just, you know who you are. I'm very proud of this group and I love sharing this picture because I think when I talk about future of psychiatry, this is who I'm talking about. These are all young women who at the time this picture was taken, actually in San Francisco in 2018 in the Marriott Hotel, actually. This was a group of young training, individuals involved in training, training directors, assistant program directors, people who were responsible for the minds of the future in terms of how they learned. They wanted to meet as a group because they had only done these meetings online. And they couldn't get a room in any of the meeting space. This was at an annual meeting. They could not secure a room at no cost with all of the meeting space that we have at the annual meetings. They couldn't get a room. So I let them meet in my room. And I was president at the time, so I had a great room. You know, so I let them meet in my room. And we took this picture to make sure that we all remembered why it was so important that diversity of all types be represented. They went on after this to write the article that appeared in the American Journal of Psychiatry reflecting their individual experiences and issuing some recommendations for the future to overcome them. These are four principles that embody the work that I do in community psychiatry at the University of Tennessee in Memphis as we are developing a formal community psychiatry program. It's based on four pillars of transparency, intentionality, commitment, and accountability. That number two intentionality is based on a quote that I love about centering our decision making, how we guide our decision making from Toni Morrison. When I served on the board of directors of the APA, at the end of the term of one of our early career people, as we were saying goodbye to one group and beginning to welcome the next group in, the person made the statement that she hoped going forward that the board would begin to change the way that it made its decisions from a white supremacist centering manner of decision making to a more inclusive people feel that they belong kind of decision making process. And I thought that was very apt as an organization that had been in place for at that point 175 years that still had a fairly basic white male focus model of decision making. That it was a good thing for a young person to say to this group of mostly older mid-career to senior career people in that room. And so I went looking for something that would describe it and I found a quote by Toni Morrison which you can look up online about when you are a certain kind of person that you have to move away from the center that's been ascribed to you, the system, wherever you are and go to the edge and find a new centering spot. And I always botched the actual quote but it's worth reading because it now is a part of the way I do the work with kids who are at risk of going into the justice system because they're all stuck in a middle not of their making where you're a juvenile, you're a delinquent, you're a bad kid. So it works for me and maybe it'll be helpful for you. I'm gonna go on through this. I've already talked about the model that we use, which we did here in San Francisco at the program here. I wanna introduce, because community psychiatry was early to embrace the concepts of trauma and adverse child experiences as triggers and initiators of some of the mental health issues that we see in community. And I know everyone has heard of the ACES questionnaire, 10 questions. This was one representation that we use now more and more because many of our families are so used to checklists and yes, no, yes, no, and rating things that we thought if we could use this one, which is not something that I developed, we use it, this organization developed it. But we thought if we could do something to show them in pictures and very few words what it was we were trying to find out about what's going on in the home, what's working or not working to create problems for this child, this family, that it would be very useful. And so far the feedback is they like it better than that list of 10 questions. And it is readily available. Knowing that we as psychiatrists are often viewed as doctors who don't really touch patients, the implication and the importance of cross-collaboration and integrated models based on adverse childhood experiences and traumas is obvious in the lifelong consequences of these early childhood experiences. I wanna just introduce, there's not time to talk about it. There's a whole new definition of professionalism coming online that goes way beyond the things that we talked about in terms of being a good professional in medicine, that we now have incorporated these other things, whether your social media presence is acceptable to your specialty, challenges to people around how they dress, wear their hair, et cetera. And one of our early career psychiatrist board members is creating what she calls the Equity Traveler's Guide. I don't know when it's gonna be published, but I'm looking forward to reading it. And this lack of will, we have hit this point in health systems where people are, as long as it's working for them, it's okay. And there has to be some will regenerated in our leadership in psychiatry that says we're courageous enough to find a way to change the system, even when everyone is telling us to let it alone. The area of research is ripe for work in community psychiatry, and the notion that the only kind of research is the academically focused community-based participatory research is a thing of the past in my mind. Communities have ideas about research that they'd like to do, about things they'd like to learn about, about things they wanna test to see if it works because they believe it does, but they know in order to sustain it, they've gotta demonstrate to someone that it does. Every idea for research should not come from us into the community. Some of those ideas oughta grow organically up out of the community, and as people tell me all the time, long before UT came to help us, we were taking care of things. It may not have been up to your standard, but we were getting things done. And I think this presumption that we have all the answers will be our undoing. We have lots of science around inequities and disparities and the whole notion of where care should be provided, going back to actually before 1985, but I just highlighted a few of them. If this slide were extended beyond 2014, it would include the three recent reports from the current Surgeon General, a couple of things on children that came out as part of the work, all of the opioid and substance abuse issues. These would all be things that would be probably about five slides now. And much like Toni Morrison, one of my other favorite authors says something that I think in community psychiatry we should take to heart. Not everything that is faced can be changed, but nothing can be changed until it is faced. Baldwin was a man ahead of his time, clearly, and much more knowledgeable, I think, in mental health than we give him credit for. We talk about him being open about therapy and the help that he perceived it to be, but we don't talk about how his work often translates into good therapeutic stories, and I think we should. This is just a nod to my friend Carl who taught me this, risk factors are not predictive factors due to protective factors. And Carl was the guy on the left who received the first American Psychiatric Foundation Advancing Minority Mental Health Awards with the Empire State Building sticking out of his head. And he was also the guy who, at my presidential reception, leaned in, in his signature costume, leaned in and said, okay, yeah, I guess you did okay. I'm president of the American Psychiatric Association. That's okay, but that was Carl. But the lesson that he taught about not consigning people to a predictable outcome if you factor in the protective factors. We are all part of the protective factors for the people that we serve in community psychiatry. And again, these are the opportunities to say all of these people worked in community psychiatry. They were also, they also happened to be role models, mentors, supporters, and sponsors for me. And they were all dead. Oh, and let me go back because that is the actual Toni Morrison quote, I'm sorry. And I, this is on this slide because I saw them as the model for how I could be, go to the edge, create a new center. This is my final slide. Community psychiatry is the cat, in case you were wondering. There's a line of people that represents organized psychiatry that does not believe in community psychiatry. It represents the legislators and elected officials who don't think what we do is important until a family member has a problem. It represents all of the laws and regulations and compromises and restrictions that we live with. Community psychiatry is the cat. That is certainly a female cat first. The tail is hooked up. And she is walking with confidence and pride to her next location where she's gonna challenge some system to do better and be better. The dogs want to leap. They want to restrain her. They wanna tear her apart limb from limb. She's not even worried. We should not be worried as community psychiatrists that what we do is not valuable and that it will be valued. We should not worry that just like that cat, that what we do is so important that we have to have the courage to face down anybody who gets in our way. And we have to be like the cat because it's kind of nice to show your tail to the people who say it can't be done. It always seems impossible until it is done. Thank you. If I read my watch right, we've got about 12 minutes, 15 minutes for questions. So if you would, please go to the mic because this is being captured. The audio and the slide set, slide deck is captured for folks who could not be here and wanna know. So questions, comments, challenges, criticisms of the pictures on the slides. I did not put a picture of me on there. I thought that would be a little self-serving and immodest. Oh, I don't think so. Come on. Hi, I cannot say fantastic. Thank you so much. You're such a leader and you have always inspired many of us. I'm Milton Weinberg, I'm at Columbia and I started my work as community psychiatry because I did HIV psychiatry, and then went to go global mental health and I'm bringing global mental health back to local mental health because the resources here are so poor. One of the issues that you said is about how we stay still because it's working for me, so why do I care? And that's a challenge that we need to bring to our psychiatric association and other mental health organizations because we don't have enough providers and we're not gonna have enough providers for what we need. Even if we invest billions of dollars, which we will not because as you know, there's no investment. So the idea of creating a workforce that is not mental health specialists is I think crucial. And some of us are trying to do that, but of course we need to fight for reimbursement otherwise it's not gonna be sustainable. So I wanna hear your thoughts about that. Well, those are all good aspects of challenge. Not having enough or the right workforce, not having enough sustainable funding to do all of the things that we know need to be done, having to make tough decisions about what we can do or can't do. And then that category of people who believe, yeah, I'm kind of like in the community, but I don't wanna rock the boat. So I'm just gonna do what has worked for me and all of this innovative novel, be courageous stuff is fine for other people, but I can't do that. I'll start with them because while the picture of the cat and the line of German shepherds is funny, and I put a spin on it that says, if we're the cat, we have some hope of getting through without getting bruised and bitten and torn apart limb to limb. The reality is without the public sector, the funded public mental health sector, the rest of the system would come crashing down because we all know the experiences that we have when that person who has the access, who has the ability, who has the resources, when all of that is gone, they get dropped into the publicly funded mental health system. So whether we get them at the beginning or at the end, when they may be more seriously ill, when they may be less likely to be as responsive to some of the treatments, these are the challenges that face all of us. So just because it's not a problem for me today and I'm getting by okay, doesn't mean tomorrow the rule will change, the money will dry up, and I'll be forced to do things in a different way. My position is work with me now, wherever you are in the system to create a better system and we all benefit. That's a kind of optimistic outlook, but I don't think we have anything to lose by being optimistic at this point because pessimism certainly hasn't worked for us. Accepting the inevitable has not been a good thing either. Pushing for change, pushing for, even if it's incremental change, there's a window of opportunity right now. The eyes of the nation are focused on mental health because our children are affected, because the elderly are affected, because schools are being forced to fill in the gap, because there aren't enough places for these kids to go for services, because the mass shootings in schools are triggering all kinds of other psychological issues, and because people have gotten comfortable after the pandemic with not having to be out amongst other people for fear and safety and other things, but also because the change in how we knew we could operate was based on a critical issue, a health issue that we were slow to work on addressing, and that in the aftermath continues to be a problem for us so people aren't feeling psychologically healthy all the time. And it's not to say that everyone has a mental illness, a diagnosable lifelong mental illness, but it does suggest that if we can only do telehealth because people won't come back out in public, in person, if we can only do telehealth under certain restrictions, we've now limited even more the access to care and increased the disparities and inequities because the people who need the treatment most are the ones who are most likely not to have access to the ways they can access treatment now. So all of that to say, if we in community psychiatry, which I believe is the future of psychiatry, let me say that again. If we in community psychiatry can continue to create models of care and have those models of care be acknowledged, validated, accepted, and properly reimbursed and funded, the whole system benefits. Community psychiatry leads the way will be my other tagline. That's for next year. So I have hope, I remain optimistic, and I lobby every single day to convince a legislator, regulator, elected official, payer, that you are doing yourself, and for some in the private sector, your shareholders a disservice by not adopting the kinds of things that community psychiatry does so well. I don't know if that's helpful or just my bit of adding a little hope to the mix. Good, keep hope alive. Yes, sir. Good morning, Dr. Stewart. I'm also Dr. Stewart, no relation as far as I know. Oh, we're cousins, we're cousins. So Rod Stewart, I work in Southern California for Kaiser Permanente in outpatient psychiatry. I also, one of my roles is to lead the patient and family-centered care, the behavioral health arm of that, and so I work with the Patient Advisory Council. Anyhow, so my question is, I consider myself to be an ally. What do allies, what should allies be doing? What's the main role, if they want to be helpful to help with minoritized individuals and psychiatrists? Well, you know, that's a great question, Dr. Stewart. And I'll also say that the picture, the cat with the dogs there, I saw it differently, I think, because I see this very vulnerable, confident but vulnerable creature out there alone. No one's out there, right? And maybe it's going okay for now, but it seems like there should, I wanted to say there should be someone in authority like Cesar Millan come in there and say, this is, let's bring these dogs into dominance or whatever. But anyway, something like that. I like that. That's a different perspective than I've ever seen that because I always thought the person taking the picture had things under control, but that may just be my control stuff. But to your first question, what can or should allies do to be helpful to assure that minoritized populations get the kind of mental health care that really addresses their need comprehensively, culturally, psychologically, socially, and et cetera? That's an interesting question, primarily because the first response that people like me usually say is don't ask that question because in an effort to learn about what needs to be done, that's a part of the work of you and not me telling you what the work is and how to do it. But I've come to realize that when we say that answer that way, it's another, I just wanted to know and I don't know where to start. And there are a couple of things that I would encourage if you're interested in being a better ally in this arena. One is to really, in the same way that we read and learned and listened to get these medical degrees and to complete our medical training, this is a learning process. It's stuff that you don't know that you need to know that you have to acquire knowledge and skill and a level of competence in. And in the same way that we created the environment, not we create, but the system created an environment for teaching about medicine, about psychiatry, there are lots and lots and lots of places that teach both in person as well as online, that teach about culture and psychiatry, that teach about treating patients from various marginalized groups effectively, objectively and appropriately. And so immersing oneself in the learning about and then taking advantage of the people who are doing this, whether it's people of color or others who have become experts, then using them to help to verify, clarify, translate, all of that stuff, gets you into the mindset of how to do the work. Because the simple fact is, if we were to ask at a certain point in our medical school career, how do I treat appendicitis? The response would be, we had a lecture on that two weeks ago, go back to your notes, review that, and then when you're ready, come into the OR with me and I'll let you try one. It's the same model of learning, except it's about something that can be so threatening, intimidating, and actually scary. Because while there's a lot of work going on in the country today to neutralize history or to whitewash it or whatever word you wanna use to such a place so that people don't feel uncomfortable, we learn when we are in that place of discomfort. That cutting edge of, I'm not comfortable, but I wanna know, is where you really do your best learning, skills development, understanding how to be competent in what you're trying to learn. So I would encourage you to immerse yourself in the learning experience. There are many, many people both within the APA and within the AACP who are experts in this area. They do webinars. Get on the mailing list of the AACP and hear what's going on. Get on the mailing list of APA when they do their diversity series. Because they talk about everything from community engagement to psychopharmacology with marginalized populations. It's a learning thing as opposed to an inquiring, tell me how to do thing. And it's really important, I think, if you are not a person of color, that the first question that you ask should not be, what should I do? The first question you might wanna consider asking is, I've learned this stuff, how to approach. Is that really a good way? Because then you've given the sense that I've taken a moment to learn something and now I'm testing my theory. We really get off on that stuff. Really. I mean, if you came up to me and said, I read this book and I went to the lecture, the woman, Heather McGee. Is it Heather McGee? Who talked yesterday. The sum of us all. Her last name is McGee. I always get first names wrong. But her lecture on economics and its relationship to how a racial structure has placed a category of people in a consistently subordinate position so that there is, in their lifetime, perhaps no hope of regaining some level of wealth or justice or whatever scale you're measuring it on. That's an excellent starting place because it's about people and it's about the system that people live in, but it has things in there that are important in the understanding of health and mental health. So reading something that is not as tragically and intentionally provocative to you as a non-black person might be a good starting point to kind of loosen up the fear and let it wash away. Other things, the 1619 Project give you a good historical framework for understanding the real story of the starting of this country. Ibram Kendi's book on how to be an anti-racist and those kinds of things. Even Robin DiAngelo's White Fragility. Well, and I didn't start with that, but I mean, I've read, I have read those, you know? And so I feel like the movement, I don't know, I feel like I'm still, even I've read all those things, I'm sort of outside the movement, but I get the analogy to the appendicitis, it's like, okay, well, you jump into the work. That's what I'm hearing you say. Learn, okay, so I've done that. So jump into the work that's already being done. Yeah. Yeah, all right. But you're Dr. Stewart, so you'll get it. Thank you.

community psychiatry

Dr. Altha Stewart

American Association for Community Psychiatry

APA talk

policy advocacy

social justice

structural racism

workforce diversity

system transformation

SMART tool

anti-racism assessment

community-centric care

systemic change