Good morning here in California, or good afternoon for those of you that are further east. I'm Dr. George Woods, President of the International Academy of Law and Mental Health. And we are here today for what's going to be a spectacular presentation by Dr. Dionne Hart. The presentation is Shades of Justice, Blue, Black, Brown, Gray, and Green. And this presentation is being presented by the African American Behavioral Health Center of Excellence, as well as the American Psychiatric Association. It is funded by SAMHSA, and I might note that the whole series is being funded by SAMHSA. The content, however, goes beyond the office and do not necessarily represent the official views of nor an endorsement by SAMHSA or the U.S. government. One thing to keep in mind at the end of the presentation, physicians who claim only the credit commensurate with the extent of their participation, it is to designate this particular event for a maximum of one category, one credit. So get your credits. We all need them. So take your time and get your credits and participate. In terms of downloading handouts, the handout here, you can see that in your control panel. And also to join, you can see you click the page symbol to display the handouts area. So if you're on a desktop, use the handouts area of the attendee control panel. If you're in your page symbol to display the handouts area. And you're really sure this PowerPoint is really spectacular. Questions. We really want you to ask questions. And I think that Dr. Clark is going to present some very powerful information that will bring up that you haven't perhaps thought about whether you are involved in forensics or correctional psychiatry. Use the questions. If you're on the desktop, use the questions area of the attendee control panel. If you're on an instant join of the webinar, click the question symbol to display the questions area. And we'll be monitoring the questions. Dr. Hart has no commercial supports to disclose. Now I get the opportunity and real honor to present Dr. Deon Hart. Dr. Deon Hart is board certified in psychiatry and addiction medicine practicing in Illinois and Minnesota. She's an adjunct assistant professor of psychiatry at the Mayo Clinic. In 2014, Dr. Hart was named Minnesota Psychiatrist of the Year. And in 2017, she received the National Alliance on Mental Illness Exemplary Psychiatrist Award. I might add, I've had an opportunity to speak with Dr. Hart for like five minutes, and she's heard all this before, I tell you. But Dr. Hart holds local, state, and national positions as well in organized medicine. She was the inaugural chair of the AMA's Minority Peer Section of the American Psychiatric Association, delegate to the AMA House of Delegates, and president of the Minnesota Association of African American Physicians, regional board chair of the National Medical Association, and the AMA liaison to the National Commission on Correctional Healthcare Board of Representatives. In 2020, Minnesota Physician Journal named her one of the most 100 most influential healthcare leaders in Minnesota. And that's just a start. From the short time that I've talked with her, she has presented immediately as well as caring, thoughtful, and a physician that understands the role of care as well as treatment. Dr. Hart, it's a pleasure moderating this. Thank you, Dr. Woods, for the introduction, and thank you to our sponsors for hosting this webinar and inviting me to talk about my passion, my clinical work, and my advocacy work. So let's get started. The views expressed in this presentation are my own and do not necessarily reflect the policy or opinions of the Federal Bureau of Prisons or the United States Department of Justice or any medical organization. This presentation will explore the laws and societal movements that led to America's status as the world's number one jailer. I will share information about the U.S. correction system, including demographics that demonstrate the over-representation of people of color and those living with mental health disorders. I will describe some of the barriers to delivering high-quality health services within correctional facilities. And finally, I will discuss a few policies and practices that work to further stigmatize and burden those involved with the criminal justice system. Over the next few minutes, I will share basic information for those who are less familiar with the U.S. correction system and a refresher for those who are more familiar. Local jails hold inmates sentenced to less than one year, people who violate parole or probation, those awaiting trial, sentencing, or transfer to a prison. State and federal prisons house inmates sentenced to more than one year of incarceration. Ninety-five percent of individuals in custody re-enter the community. The U.S. releases over seven million people from jail and more than 600,000 people from prison each year. Within three years of their release, two out of three people are re-arrested and more than 50 percent are incarcerated again. Probationers and parolees represent the largest proportion of the criminal justice-involved population. Inmates have the right to make informed decisions regarding health care. Inmates with capacity have a right to refuse health care. Inmates must have an access to meet their serious and chronic health needs. This is the fundamental principle established by the U.S. Supreme Court in the 1976 landmark case Estelle v. Gamble. The responsible health authority, the correctional institution, must identify and eliminate any unreasonable barriers, intentional or non-intentional, to inmates receiving health care. Now this graph shows the growth of the jail and prison population in my lifetime, beginning in 1970. The graphic also includes a timeline of movements and major laws that influenced the population growth. From 1970 to 2009, the prison population grew 700 percent. With the population greater than 300 million, the U.S. has just 5 percent of the world's population, yet incarcerates 25 percent of the world's prisoners. At any given time, roughly 2 million Americans are incarcerated and 4.7 million others are under judicial control through probation and parole systems. Since the start of the COVID-19 pandemic, the prison population has declined as a result of advocacy efforts that led to multiple policy changes allowing many individuals to qualify for early release or home confinement. Now let's get into why we're here. Who are the individuals at high risk for being involved in the criminal justice system? I'm going to highlight a few. Being male, being a person of color, individuals lacking a high school diploma or GED, individuals living in communities with high rates of poverty and unemployment, children of incarcerated parents, there are five times more likely to enter the criminal justice system compared to children of non-incarcerated parents. Black Americans are imprisoned at a rate that is approximately 4.8 of white Americans. Latinx individuals are incarcerated 1.3 to 1 of white Americans. One in 81 black adults per 100,000 people in the United States is serving time in a state prison. In 12 years, more than half of the prison population is black. According to the U.S. Sentencing Project, my neighboring state, Wisconsin, has the highest rate of black inmates. One in every 36 Wisconsinites is in prison. Although men are more likely to be incarcerated, women incarcerated are more likely to have disease burdens from infectious diseases such as HIV, AIDS, HPV, and other STIs. Women are more likely to have experienced trauma, physical, and mental illness. Women are more likely to have experienced trauma, physical, and sexual abuse. Nearly one in six transgender Americans and one in two black transgender people have been to prison. Black transgender people have higher rates of experiences of incarceration in general, 47% compared to 12% of white transgender people. How did we get here? The 1994 Violent Crime Control Federal Bill is often cited as the reason. We not only have mass incarceration today, but the racial disparities that exist. However, the rates of incarceration were already rising in the 1990s and have been since the 1970s, when President Nixon declared a war on drugs by declaring drug abuse public enemy number one. What the 1994 bill did was it created more punitive sentencing guidelines and incentivized states to build more prisons and pass truth in sentencing laws that require serving at least 85% of a sentence. It mandated life sentences for individuals convicted of a violent felony after two or more convictions, including drug crimes. That mandated life sentence was known as the three strikes provision. It is also important to highlight the disparities in sentencing based cocaine versus powder cocaine, and the lack of recognition by the public and the medical community of the biological basis of addiction. That led to campaigns like Just Say No. The mindset was drug abuse, even in its most severe form, was a choice. As a result, the population in jails and prisons accelerated, and the population is growing older. I always smile when I see this picture. I found it on Google Images, and it looks very pristine. Truly, there is no prison that is that pristine. It's very interesting how we always try to whitewash to make ourselves feel better, so we don't really think so much about what's happening inside. Geriatric prisoners are defined as individuals who are 50 years of age or older in the federal system, and 50 to 62, depending upon the state. Geriatric prisoners compromise the fastest-growing demographic in the U.S. prison system. Geriatric prisoners are 50 to 62, depending upon the state. Sixteen percent of the state and federal prison population, and again, that is growing rapidly. People who are incarcerated age at a faster rate than their peers. They acquire multiple comorbid conditions and die earlier. A person's physiological age may exceed his or her chronological age by 10 to 15 years, a concept known as accelerated aging. Inmates older than 55 have an average of three chronic conditions, and as many as 20 percent have a mental illness. Why would the APA host a webinar focused on the U.S. correctional system? Fifteen years ago, I began my career as a correctional psychiatrist as a service fulfillment for the National Health Service Corps. At the time, I was unaware of the unique aspects of practicing medicine within a correctional facility. I had heard over the years comments about deinstitutionalization, the criminalization of mental illness, and the social determinants of mental health, but I was not completely prepared to be a first-hand witness. The image on the left is the Rochester State Hospital. In its prime, it was the second largest mental health facility in Minnesota. The image on the right is the Curran Grounds. It is now the home of a federal correctional facility, one of six medical centers within the federal correctional system. Most people do not work in a place where there's such a concrete change in the mental health system, but many are familiar with the metaphorical change in the U.S. mental health treatment system. The new psychiatric hospital is a jail or a prison. This change occurred due to multiple factors, including deinstitutionalization, inadequate community mental health resources, and a failed war on drugs. Correctional facilities were designed to house young, able-bodied men. They were not designed or intended to be healthcare facilities. As we learned with COVID, the buildings are older, often in the South, lack air conditioning, have older ventilation systems. These facts are concerning, not just when there's a pandemic, but also when we consider patients with schizophrenia often have difficulty regulating their temperature, and psychotropic medications may also make it difficult for them to regulate their temperature. When a person has a mental health crisis in the U.S., it is almost always law enforcement who responds to the emergency. In other words, police are default first responders, and those with untreated severe mental illness generate no less than one in 10 calls for police service. Those with untreated severe mental illness occupy at least one in five of America's prison and jail beds. In fact, the likelihood of incarceration versus hospitalization is four to one. Laws meant to protect the civil rights of those living with mental illness may make it difficult to hospitalize people involuntarily when they're experiencing a mental health crisis, but it's easy to arrest. I will also note that one quarter of fatal police shootings involve a person with mental illness. About two-thirds of federal inmates with a serious mental illness were incarcerated with four types of offenses. Drug offenses, 23 percent, sex offenses, 18 percent, weapons and explosive offenses, 17 percent, and robbery, 8 percent. Deinstitutionalization. We've all heard the term. It's a theory posed by a British psychiatrist, Dr. Lionel Penrose. What it means is that when the large psychiatric facilities began to close in the 1950s, and at the peak there were about 500,000 individuals living in those facilities, people discharged. They didn't have resources, and they committed crimes to survive. It's a theory that we've often embraced. It's a very simple explanation, and I'm sure there's some truth to it, but that's not the only reason why community treatment began to take off in the 50s. Thorazine, or promozine, was developed in 1950, and it was the first antipsychotic. Its introduction was labeled one of the greatest advances in the history of psychiatry. In the 60s, President John F. Kennedy signed the Mental Retardation Facilities and Community Health Service Construction Act. Under the 1963 law, the large psychiatric hospitals and institutions would be replaced by community mental health centers. Incidentally, it was the last law he signed before his death. In 1965, Medicaid legislation stipulated that the federal government would not pay for inpatient care in psychiatric hospitals, so states were now incentivized to have patients treated in the community. All of these factors led to increase in community treatment, a closure of large psychiatric hospitals, and unfortunately, what we have today. Correctional facilities are the largest mental health providers in the U.S., but does that mean that correctional facilities also employ the largest number of psychiatrists? And who provides the mental health care services there? The National Commission on Correctional Health Care has its origins dating back to the early 1970s, when an American Medical Association study of jails found inadequate, disorganized health services and a lack of national standards. In collaboration with other organizations, the AMA established a program that in 1983 became the NCCHC, an independent, not-for-profit organization whose early mission was to evaluate and develop policy and programs for a field clearly in need of assistance. The National Commission on Correctional Health Care requires health care staff to have the same credentials as the community. Here we have two examples of job descriptions for medical staff. One is the Cook County Jail in Chicago, one of the largest mental health providers in the nation. And the second is the Federal Bureau of Prisons. Both are consistent with community standards. Historically, it is difficult to recruit physicians into correctional facilities. They are severely underserved, partially due to stigma related to a previously more common practice and now present in just a few areas of the country, the practice of issuing institutional licenses to physicians who are unable to practice independently in any other settings. The community standards are the same. So a typical clinical day within a correctional facility is very similar to most physicians in inpatient settings, rounds, charting, medication approvals, treatment team meetings, therapy, consultation with other staff, and medical education. So what's different? When you enter a correctional facility, you are searched and your belongings are scanned similar to when you travel by air. Each day, I voluntarily disconnect from the world, leaving behind my cell phone and access to my personal life. My communication on the compound is a pager, and for others, it's a radio. On top of my scrubs, I wear a staff-proof vest and a duty belt that holds my keys and a can of pepper spray. Pepper spray is controversial. Employee physicians at a federal prison have a dual role as a member, a sworn member of the federal law enforcement. Pepper spray, excuse me, is controversial because it conflicts with the APA's position statement on weapons use in hospitals and patient safety, but it's considered a public safety tool for law enforcement staff and hospitals, and in our case, federal physicians are both. I respond to all emergencies, including behavioral disturbances unrelated to a physical or mental health condition. We do not carry malpractice insurance. Our medical coverage is the federal government, so discussions about qualified immunity for law enforcement impact federally employed physicians. Patients seen in these settings may be in restraints or shackles. Non-healthcare staff, such as correctional officers, may be present for the encounter. Physicians are evaluated in non-traditional areas, like solitary confinement or secure housing. We have a dual agency, so physicians may be obligated to report institutional policy violations, such as theft or other abuse, not just threats of harm to themselves or others as in the community. Psychiatry risks are lower than working in a busy emergency room or some inpatient hospital settings, contrary to belief. What are some benefits? Well, U.S. psychiatry residency programs are located just an average distance of four miles from the nearest correctional facility, so there are opportunities to teach and mentor. No insurance company or preauthorization issues. There are opportunities to treat patients with some of the most severe needs, opportunity to enhance their access to evidence-based treatment, and provide high-quality mental health care. In 24 hours a day, seven days a week, 365 days a year, staff monitor patients so they can provide important information about daily function to assist with treatment planning. Before we began, I was talking to Dr. Woods about another benefit. Because my patients live where my office is, I often can just walk down, if they don't show up for an appointment, and say, hey, let's talk. Let's get out of bed. Let's go for a walk. Don't have to have a traditional sitting-in-an-office-across-from-each-other appointment. Some patients do not respond in that and take them for a walk. Some patients, I just sit beside them while they watch TV and we talk. For others, it's playing uno and distracting them from the fact that it's a clinical encounter and not just a conversation, and we can bring up their medications and their treatment. It's unconventional, but that's the best part. You can just be with patients, and it doesn't have to fit into a certain 15-minute or 30-minute clinical encounter. You can just be whatever they need at that moment. One study found that 70% of all correctional facilities have trouble recruiting and retaining mental health staff. Stigma plays a role. My position is viewed as less respectable subspecialty. Patients are perceived as less deserving, and the work environment as more dangerous. They're vulnerable to creative solutions for workforce shortages, such as a proposed pilot to authorize non-medically trained professionals to prescribe psychotropic medications. Many aspects of healthcare are the same as community hospitals, but unlike hospitals where physicians, nurses, or individuals with health administration credentials, the senior officers, excuse me, senior officials responsible for overseeing healthcare and safety in all federal correctional facilities and at the highest levels are not required to have hands-on healthcare experience or credentials and have final authorization for many aspects of healthcare. You recall, 95% of inmates were released to the community, and within three years of their release, two out of three are rearrested. So what goes wrong? What are the barriers to successful reentry? Individuals with less education are more likely to have jobs that are physically demanding and include exposures to toxins. Individuals with less education have fewer employment choices, which may force them into positions with low levels of control, job insecurity, low wages, and poor benefits, if any. Obtaining a GED while in prison reduces the chance of those over 21 years of age from returning to prison by 5%. The BOCS. The BOCS asks if applicants have a criminal record. Incarceration is a barrier to employment. 27% at least are unemployed. The average earnings someone loses over their lifetime by being incarcerated is $500,000. Thanks to advocacy efforts, the BOCS is now banned in some states and cities on pre-employment applications, giving applicants an opportunity to pass a screening application, interview, and have an opportunity to, more than they had before, to be a good candidate for a position. Even for those individuals fortunate to secure employment, they continue to face stigma as they attempt to rebuild their lives. Formerly incarcerated individuals often have difficulties securing employment and housing because of their criminal history. Additionally, those with certain convictions may lose state and federal benefits, including access to education assistance, public housing, food stamps, and their driver's license. People with felony convictions are banned from voting, decreasing their ability to advocate for lasting change. The trauma experienced in the lives of those living within the fence does not remain there. It directly and indirectly impacts the community. The stigma, isolation, and trauma associated with incarceration has direct impact across families and communities. One in every two formerly incarcerated persons and one in every two family members experience negative health impacts related to their own or loved one's incarcerations. Families report experiencing nightmares, hopelessness, depression, and anxiety. Three studies demonstrate that nearly two in three, or 65%, of families with an incarcerated member were unable to meet their family's basic needs. The other two show this 48 and 49% of families had difficulty meeting basic needs. Families struggled to meet these basic needs while managing the added burden of paying legal fees, financing prison services such as commissary items and phone calls and emails, and for fortunate visits. The annual pre-pandemic cost to families for prison phone calls and commissary purchases was $2.9 billion. Luckily, because of the pandemic, I know for the federal system, phone calls and emails are free. That's a big deal, particularly if you earn like 13 cents an hour. As mentioned, individuals with a parent incarcerated have an increased risk of being incarcerated themselves, particularly black children, who are 7.5 times more likely than white children to have a parent in prison. Luckily, there are increasingly more resources for children with parents who are incarcerated. In 2013, Sesame Street introduced Muppet Alex, who copes with his father being in jail. It's a great resource. The health effects of a correctional setting do not just impact the inmates, they also impact the staff. Here is a list of health effects associated with living, excuse me, with working in a correctional facility. I will focus on just a couple. Correctional staff have higher rates of depression and substance use. They have an inability to relax. Why? Well, if you work in a place where there's risk of physical harm, then you're hypervigilant in your environment. That adaptation does not easily turn off when you walk outside the fence. People seek external ways to relax and not all are healthy, and they can have a negative impact on relationships and marriages. 34% of correctional officers suffer from post-traumatic stress disorder, compared to 14% of military veterans. The average age of staff suicides in 2020 in the federal system was 42 and all by firearms. Correctional officers are 41% more likely to die by suicide than persons in other occupations. The suicide rate of correctional staff is twice as high as that of police officers in the general population. The average life expectancy of a correctional officer is 59 years compared to the national average of 75. And we just explored the barriers to successful reentry and the direct and indirect costs to families and communities, but what about the costs to taxpayers? Prison is an industry. The U.S. government spends an annual amount of more than $80 billion on prisons and jails. Below 8% of the market, private prisons are influential. The CoreCivic and CEO Group constitute half of the market share of private prisons, and they have a combined revenue of $3.5 billion in 2015. The government pays the private company an agreed-upon yearly cost per prisoner. Many private prisons mandate a state government to ensure it is built at a certain occupancy rate. That's only 90%. In Arizona, three private prisons operate under a 100% occupancy guarantee. A Washington State University found that privately owned prisons, on average, lead to an increase in the patient population and they're sentenced late for non-violent crimes. These private prisons have begun to diversify their services. At the same time, the community is pushing for people not to be incarcerated, but to be diverted to other means like home confinement, treatment centers. They are now expanding. In recent years, they spent $2.2 billion to acquire smaller companies to branch out to industries beyond incarceration, such as ankle monitoring, reentry, rehabilitation, food and health services, ankle bracelets, and transportation services. I like to end every presentation with a call to action. If you are directly involved in correctional health care or not, there are opportunities to advocate for individuals. As mentioned, U.S. psychiatry residency programs are located in an average distance of four miles from the nearest correctional facilities. If you work in corrections, implement clerkships for physicians and training in those facilities. All of us can be educational resources for law enforcement agencies, legislators, and judges. Early intervention is key. Advocate for social workers and mental health treatment within schools. Vote for increased public funding to support music and the arts and sports. Participate in organized medicine locally, statewide, AMA, within your APA district branch and the APA. And join the APA's Congressional Advocacy Network to reach out to your legislators. Now, this slide features an article I read in Essence magazine a few years ago. It was about a five-year-old black girl who was placed in handcuffs and taken into custody after breaking an item in a classroom during a temper tantrum. I read this article not intending to think about work, just trying to read a magazine about beauty and hair products, I thought. But when I read that article, I was outraged. I immediately began to write a resolution. That resolution became an AMA policy related to juvenile justice system. Did it spark change? I'll never know. But it is a tool that the AMA uses as a way to advocate for change, to bring an end to the juvenile school-to-jail pipeline. If you recall, in 1994, when Congress passed the Federal Crime Act, people, particularly those most impacted by the bill, did not anticipate the downstream issues, such as the overrepresentation of minorities in correctional facilities. It is important for all of us in the future to read these laws carefully and anticipate issues. For example, one area of the First Step Act that concerns me is the requirement for the Federal Bureau of Prisons to house inmates in facilities as close to their primary residence as possible and to the extinct practical within 500 driving miles. That's a great thing, right? But how is that going to be accomplished? If you look at a map of the Federal Bureau of Prisons, there is not a federal prison within 500 miles of every American. Some states have none. So how is this going to be accomplished? This law, intending to improve criminal justice outcomes, includes this provision. It looks great, but how is it accomplished? Are we going to build more prisons? Private contract facilities, are they going to increase? I don't know, but the point is we have to scrutinize. We have to ask questions. We can't just look at the surface and be excited because now loved ones would be within 500 miles, but we have to ask the question of how this is going to be accomplished. We have to ask the hard questions, not just of ourselves, but of our legislators, the people who make these policies, so that in another few years, we're not asking, how do we change another crisis? How do we address another crisis? These are my major references. I'm looking forward to answering your questions and continuing this dialogue right now, but I want to first thank you for your attention. I hope you acquired some knowledge and also feel inspired to advocate for those involved with the criminal justice system. I want to thank the APA staff, particularly Ebony Harris, for the invitation to present and her guidance during this presentation. I want to thank our moderator, Dr. Woods, and again, thank you for your attention and for your questions. Thank you very much, Dr. Hart. A profound and thought-provoking presentation, a startling presentation, and I think even a presentation that requires us to look at our deepest institutional relationships, whether our institutions, our medical institutions, training, when you use words that are so interesting, Micah, unconventional, but we'll get to those questions. I don't see any questions in the question box, but I thought I'd like to ask you like the three pages of questions that I have. Sounds good. Okay. I think the first one, and you answered this to some degree, but what can physicians that don't work in corrections, what can they do in fostering the kinds of issues that you brought forth? Thank you. Yes, I did try to touch it, but I really like the idea of being able to expand upon it. So I think we all know, as Americans, we have very short attention spans. So we see a headline, we hear about a crime, we see somebody go into custody, and we forget all about it. But for some people, that is when our work starts. So when somebody is in custody, that's when my work starts. When I think about that person and how I can help them to not only not repeat what happened, but to address their mental and medical disorders. I have a rule. I do not look at a person's criminal record before I look at their medical record and talk to them so I can put it all in a context. And I think people outside the fence have to remember that when somebody is having that moment when you see like the perp walk, that is likely one of the worst days of their life and also their family. There was some tragedy that happened. There are multiple victims on both sides. And we need to start thinking about when somebody comes into our office, if they have a loved one, or if they have been incarcerated, screening for trauma. How is that impacting that person? How is that impacting their loved ones? How is it impacting their community? Asking questions. And also just allowing them to talk about it, even if they haven't experienced trauma, allowing them to talk about it so they don't feel stigmatized. They don't feel like it's this taboo subject that they cannot bring up. I also think it's very important if you're not working directly, that you encourage and support people who are working in those fields. The stigma that existed where people had no other place to go and that's why they worked in those settings is for the large part over. The people who work there now choose to do so because we are working with the most vulnerable, sometimes the people who have the most burden of disease. And it is rewarding. But like we've talked about, check on your strong friends. Check on people who are working in these settings too because they are stressful. And it is important for us to not only support our patients, but support each other. So it's a complicated, long answer, but I think that there are multiple issues where people who are not involved in the correctional system can also support the people working there and support the people who are involved with the criminal justice system. Thank you, Dr. Hart. Let me ask you another question. One of the things we talked about before we went live was the cost. You know, the cost and access, the cost of care in this setting. And even though that was the initial question, I wanted to add to that question. Okay. You know, on the one hand, we talk about the cost of incarceration, and yet we rarely talk about the cost of keeping people's potential out of our society, given we've given everything that we need. We need every person to be at their best. Can you talk about both sides of that for a moment? I think it's a very important point. I think as psychiatrists in general, when we have patients who are diagnosed with long-term illnesses like chronic disorders like schizophrenia, they often, in their late teens, early 20s, they're people who have a lot of dreams, and their families are sharing those dreams. And you give them a chronic disorder, and that changes their lives. So now, when you add the criminal justice piece, you are taking somebody out of the community at their prime, somebody who can be contributing not only to their family, but to their community at large. And unfortunately, in some communities, it has been normalized. So that it's not even like a rare thing, obviously, because people of color are overrepresented. But it is normalized to the point where in the popular press and in some music and cultures, it is like it's a positive thing. When I walk on the compound, I hear the inmates talking about, oh, I know him from that place or that place or that. The way we talk about it, I know somebody from college, or I saw them at that meeting. It is normalized. So I certainly think we need to address the stigma. But at the same time, we also have to address the fact that there's a part of society that has accepted that this is part of our fate. So yes, if you're in Wisconsin and one in 36 people of color have been involved in criminal justice system, that's common. It doesn't make it normal. And I think we really should talk about the fact that this is not normal. It is not normal for people of color to be arrested at higher numbers, to be incarcerated at higher numbers, particularly when we think about children who are brought into the system for doing things that are developmentally appropriate. Kids make mistakes, but they are overrepresented in the juvenile justice system. They are over-suspended, even as far as getting punishment within the school system. We really have to do a better job of thinking about the cost, not only to society, but the cost to our long-term community goals. How is America going to sustain itself as the greatest nation on earth if this continues to be our practice? We can't. We really have to talk about our value system and how it is reflected in the fact that we are the world's number one prisoner and have frank conversations about what it means that Black men and women and children are overrepresented in the system. People like to say it's because, oh, well, they commit more crimes. Of course they're going to be, but it's not true. If you think about, if you start looking at the actual data, it is not true. They're just overrepresented in the system, but they're not committing more crimes. I think we just really have to have frank conversations about what it means to pull young people out of the community and to burden them with felony labels, the stigma, not being able to vote, not being able to access educational experiences, not being able to get the best jobs. Right now, healthcare is tied to employment. All of those things impact that person's health and impacts their family's health and impacts the community's health. Even if you don't know somebody incarcerated, you are negatively impacted by the fact that we have so many people involved with the criminal justice system. So numbers mean something. When we say that we incarcerate 25% of the people in the world that are incarcerated in spite of the fact that we are only 5% as a country, only 5% of the population, that's a warning bell. That's something that we should be looking at rather than just a statistic, but it has implications for who we are as a culture. Exactly. Let me ask you this. You've been working about 15 years, is that correct? Exactly. Okay. And here we are, 15 years later, working with this population on a daily basis. And this is where you are today. You are a scientifically rigorous, thoughtful advocate. Why hasn't working with this population made you more cynical? If anything, I hear you being even stronger in your understanding of their needs. I actually am a lot more cynical than I was. I grew up in a, in some ways, very protected family. My dad was born in 1920, so he witnessed segregation. He lived segregation. So he tried to build this very protective, supportive, but in some ways, not realistic environment for me. So I did not realize how much racism still existed because I was in this protected bubble. I never had the talk. I never knew until I was an adult and experiencing life, how much racism was involved in my everyday life. I didn't know what I didn't know, if that makes sense. So walking into this environment, I was naive about a lot of things. And I have learned that speaking up, which is not my, was not in within my comfort zone when I first started working in that environment. And I have learned to do that. And I've sometimes paid a price for it, because you can imagine in some of these circles, being a patient advocate does not make you popular. But who, if I don't speak up, then who will? Part of the reason why I stayed after my four years is that I was the only professional person of color. And I thought it was important that I be represented on that compound, that the patients saw me. And that sometimes I could go to them and have difficult conversations. Like when I would hear them saying the N word back and forth. Like, why do you have to say that word? Well, we're taking it back, Dr. Hart. I don't think so. And it's like, well, tell me why. Like having those difficult conversations, who else can have them with them? So I think that I have grown to be a bit pessimistic. I have probably become more outspoken. I know, like, as I have gotten older, I probably could get the auntie label. Because at this point, I'm like, I'm going to speak up. Because there's no one left to speak up. And literally, right now, I'm the remaining psychiatrist where I work. So representation is important. And to me, many of these patients are there because they didn't get the resources when they need it. It's the most and when it would have prevented them from being in the correctional settings. But also, I think it's important that I'm there and that they understand that I see them. Being seen is so important for all of us. But especially for people who have, quote unquote, been locked away, behind bars, the unseen, sometimes the forgotten. So I have grown more pessimistic. I certainly see things for what they are. But I also feel a lot more empowered and a lot more emboldened to speak up. So both things have happened. I plan, with God's grace, to finish my career there. Five years from now, I will be mandated to retire. I hope I will have made a difference, not just within the facility where I work, but also having opportunities like this to talk about my work so that other people understand the importance of working in these settings. I think that you, whether you will be aware of it or not, I think you will make a difference where it's most important, and that is with the people that you work with. I can't imagine that they would ever forgive or forget what you have done for them. And it brings me to our last question, although I've still got a few pages left, but only two minutes. And the last question really goes back to what you said in your conversation. And that is, whatever they need at the moment. Isn't that what medicine is all about? Tell me what you mean by that. Well, because I don't have the restrictions of a patient coming in and they're there for an average of three days, I can really get to know patients. Because I'll have a patient who just really needs to sit with someone. They don't want to speak, but just being present and sitting on a bench outside and looking at the landscape makes a difference. But to others, they really just want a symptom checklist. And having the luxury of time to get to know them and not have the pressure constraints to get them in and out the door in the same way as in a community hospital, I appreciate because I can just be there whenever they need something. I can just go downstairs to wherever they are, and we can either talk about it. We can not talk about it and just walk it off. Sometimes it's just sitting beside somebody and watching TV. Sometimes as we talked before, it's just remembering their birthday and saying, happy birthday. I'm glad you're alive. It is the little things that add up. So that to me is how I get people to understand that they have an illness, to listen to me about treatment options. And hopefully when they leave, to continue to have those same conversations with the next doctor, planting the seeds that they matter. Well, I think we could go on forever, but our time is up, Dr. Hart. I want to, first of all, thank you from the American Psychiatric Association and the Center for Excellence for more than a presentation. What I saw was a real doctor. I saw someone that is a, really should be a model for what we should be and who we should be regardless of the patient population that we have. And it was an honor meeting you and talking with you. And then to have such a rigorous scientific presentation as well, couldn't have been better. And thank you very, very much for your time and continue your efforts. Thank you, Dr. Wilson. Thank you everyone who attended. Take care. Bye-bye.

Dr. Dionne Hart

U.S. correctional system

impact on individuals of color

mental health disorders

overrepresentation of people of color

high-quality healthcare

cycle of incarceration

early intervention

access to mental health treatment

advocacy