Hi, all. Thank you for attending. We have a fantastic talk lined up, which is Understanding the Impact of Racism on Psychosis for Black Americans, and it will be presented by Bishan Davis. Next slide, please, Bishan. So a couple of ground keeping or housekeeping. This series, which is an excellent series, if you haven't been able to attend any of the other ones, some of them are actually available online for you to attend, but it is funded by SAMHSA, and it is a Strive for Excellence series with a partnership between Morehouse and SAMHSA. Next slide, please. For those that don't know, you're able to receive credit through one AMA PAR Category 1 credit, which you will be able to claim at the end of this presentation. Like other presentations, it is available on demand, and you're able to kind of view that recording and claim credits that way, too. Next slide. There is a handout for this presentation, and so if you kind of follow these instructions, you're able to kind of download the slides and follow at your own pace, which is fantastic. So thank you, Bishan. Next slide. If you have any questions, we will get to questions and have a little bit of a discussion at the end, and so there's a question box on the right-hand side of the presentation where you can kind of type in a question, and we'll get to them at the end, so please feel free to ask questions along the way. Next slide. There are no financial disclosures. Next slide. Okay, so Bishan Davis is a clinical psychologist, and he is an assistant professor at the University of Maryland School of Medicine in the Department of Psychiatry. His research focuses on eludicating the barriers to implementing evidence-based practices for early psychosis with an emphasis on how these barriers affect the pathways to care, access, engagement, and outcomes for individuals of color. Dr. Davis works centers on experiences of consumers, and he uses a participatory methods approach throughout all of the work that he does. To that end, he is currently investigating the impact of cultural factors such as skepticism of medical institutions and cultural beliefs about psychosis on engagement in care. The work that Dr. Davis does is really thoughtful in how he approaches his research questions and how he engages with his clients and even participants of studies, and so it is a pleasure that he is able to kind of give us a talk today, which I am super excited about, so without further ado, here's Dr. Davis. Thank you for the kind introduction, and good afternoon or good morning, everyone, depending on where you are. I'm really excited to give this webinar on sort of the impact of racism on psychosis for Black Americans, and before I even get into some of the sort of more specifics of how racism can sort of affect diagnosis, pathways to care, treatment, et cetera, I figured it was probably good for us to sort of start by kind of defining some terms to make sure we're all on the same page about what we're talking about. First, let's start with a little bit of a background, so first, when I say psychosis, the first thing I want to sort of emphasize is that psychosis itself is not a diagnosis. It's actually a sort of set of symptoms that people experience, right?, and so as you can see here on the slide, I have a sort of brief definition of psychosis that you can refer back to later, but at its core, psychosis refers to sort of a loss of contact with our sort of shared reality, right?, and this sort of difficulty discerning what's real and what's not, so people experience psychosis not exclusively in disorders such as schizophrenia, but across a variety of different conditions, so people might experience psychosis if they are severely intoxicated on things like stimulants or marijuana, other things with more sort of medical issues such as like seizures or sleep deprivation or sort of neurological disorders, as well as some of the more commonly associated disorders with psychosis such as bipolar disorder, schizophrenia, and in some cases, depression, so psychosis is actually a lot more common than we think, and people experience it to varying degrees, so when we talk about psychosis, it's important to think about different types of symptoms that people experience. There's typically, when people talk about psychosis, people typically, well, people are most typically aware of, we don't work with people with psychosis, or what we call the positive symptoms, and what I mean by positive symptoms in this case is not that they're necessarily a good thing, but more so that they're things that are added, things that weren't there before, so in this case, these are things like delusions or what we also call inflexible false beliefs, paranoia, hearing voices, seeing things like shadows or visions, and also things like disorganization, or jumbled words or thoughts, or behaving in an erratic manner. On the other side of the coin, we have what we call our negative symptoms, and again, as I emphasize with positive symptoms, it's not necessarily about whether it's a good or a bad thing, it's more about things that are added or taken away, so in the case of negative symptoms, it's things that are taken away from people, and so the most common negative symptoms that we'll typically talk about are things like difficulties expressing emotion, so people sometimes have what we call a flat affect, where their faces are not as expressive. Other things that are associated with negative symptoms are things like difficulties with social interactions, so this asociality, this loss of interest in social engagements, as well as poverty of speech, not really speaking that much, and having trouble forming or talking for long periods of time, like I'm doing right now, so other things that are associated with negative symptoms are things like low motivation, so a lack of goal-driven behavior, declines in self-care and functioning, and then troubles with memory and attention, and so I think when people hear negative symptoms, especially these last few, sometimes people really think about things like depression, right, and so sometimes thinking about people with depression and psychosis, sometimes it is a little tricky to disentangle where the negative symptoms begin and the depression ends, and things like that, so it's just an interesting thing to note, so like I mentioned before, psychosis is a continuum of experiences, right, and so we can, I think what we can think about with psychosis is that there are lots of times where we all experience things that might not be part of the shared reality that everyone else experiences, right, a really salient example of this is the experience of jealousy, right, I used to use this example all the time when teaching undergrads, where people talk about this idea that like if you have this belief that your partner is cheating on you, regardless of if it's true or not, you might start sort of gathering evidence to make the case that that's correct, right, you might start thinking about is their behavior different than it used to be, or you might look through someone's cell phone or something, not the best behavior, but some people might do it, and so that experience of jealousy or paranoia in the context of relationships is a very sort of normal experience, right, but I think what we talk about when things sort of veer into more severe levels of psychosis is that it becomes less sort of typical, right, so instead of focusing on like whether a loved one is cheating on you, you might have a more fixed false belief about that, it might be something like, you know, my loved one is having an affair with Ariana Grande, right, and you might start thinking, oh, Ariana Grande is communicating with my loved one through this song, and the song means that Ariana is like trying to seduce my partner, et cetera, et cetera, and so that's when we start veering into this sort of more distressing sort of area, right, and so the whole idea of the continuum that I have on this slide is that, you know, these beliefs that people have can start with sort of things that are like, you know, might not really be based on anything, but aren't that distressing, but over time, when things veer into the more severe levels of psychosis, these beliefs do become more sort of distressing and impairing in most cases for folks who go on to experience a psychotic disorder, so that's, I just wanted to sort of emphasize that and also sort of normalize the experience of sort of psychosis or the sort of beliefs that might not be grounded in reality, because I think we all sort of have these experiences, but I think the difference between sort of when it's distressing or sort of pathological is really our ability to sort of self-regulate and say, okay, you know, this might not be true, essentially. All right, so I'm going to step away from psychosis for a moment, because, you know, as the title of the talk stated, we were going to sort of focus on the factors, sort of types of racism and how they influence sort of the presentation and sort of treatment of Black Americans with psychosis, but I think it's also important to have the same language about racism, right, and so when it comes to racism, this might be your view for many people, but I think a lot of people don't often think about this, but there are different levels of racism, and they all interact with one another to influence not just sort of mental health care, but just all sort of levels of sort of going through your day in society, right, and so we can start at the sort of most sort of basic level, which is here at the bottom with sort of internalized racism, right, and so this is when someone has internalized sort of negative beliefs about their race that have been sort of conveyed by society, and then it might take the form of sort of being sort of self-deprecating or sort of like avoiding affiliating with others of their own racial background or things of that nature. Next we can take a step further and go to sort of interpersonal racism, which is the type of racism that I think most people think of when they hear the term, right, where you're interacting with another person, and they're treating you differently because on the basis of race, and if we take a step further, we can get to sort of institutional racism, which then goes beyond our interpersonal interactions and goes into policies of institutions, right, and so this is where we start to think about like the institutions that we all are a part of and how policies might be, might disproportionately affect one group more so than another, right, and in the context of psychosis, one thing we can talk about is like sort of like policies related to risk, policies related to diagnosis, policies related to treatment, and how even if someone doesn't identify or may not have high levels of interpersonal racism, the policies of the institution might lead them to make decisions that are ultimately disadvantage one group more than another, and then lastly, the largest sort of macro level is this idea of systemic racism, which are these sort of ongoing racial inequities sort of maintained or perpetuated by society, and so there's examples sort of of sort of how each of these levels of racism sort of interact listed in the sort of circle around the figure, right, so you can see things like housing, you know, like talk about redlining historically or currently and things like that, as well as like criminal justice, public health, education, banking, and the whole idea is that all these levels sort of intersect and affect the experiences of people of color, specifically in this case, Black people sort of living their everyday lives and also seeking mental health care, which is the focus of this talk, so I just wanted to sort of give that context before we moved on. All right, so now we're getting more specifically into psychosis, now that we all are on the same page about psychosis and racism, we can talk a little bit more about sort of the historical context, which kind of brings us to today, and sort of how racism affects the experiences of Black Americans with psychosis today, so I'm always someone who likes to, I'm always reading a book, as you can see behind me at my bookshelf, I'm always, and as I'm always recommending books for people to read, and a good example of a book related to the intersection between race and psychosis is this book called The Protest Psychosis, written by Jonathan Metzl out of Vanderbilt, and this book is really interesting, and there's a variety of really interesting gems that we could talk about, but I'm just going to sort of focus on this one sort of factor that he details in this book, which the context for this book is that Jonathan Metzl really essentially reviewed the sort of trends in diagnosis of psychosis, or schizophrenia specifically in this case, in a state hospital, I believe in upstate New York, over time, and what he found was that there was a shift over time, particularly around the 60s and 70s with the rise of the civil rights movement, wherein prior to that period, schizophrenia was primarily diagnosed in sort of, it skewed towards white women who kind of weren't really sort of meeting traditional gender roles at that time, right, and I think if you think about that time, you can think about sort of how Valium was a commonly prescribed drug to sort of like women who were staying at home, and how like lots of times women sort of did not meet criteria, meet with the society's prescribed roles, how they often were diagnosed and labeled with things like psychosis or depression or bipolar disorder, etc. What he noted though was that there was a shift around the civil rights era where diagnosis of schizophrenia were shifting from sort of women who were not meeting society's gender roles to men, I mean sort of to black people, particularly black men, with a change in the sort of criteria in the DSM, and so what he noticed was that, you know, the criteria in the DSM shifted from DSM into DSM-2, including things like hostility and aggression, and that became the basis for a sort of over-diagnosis pattern of schizophrenia in black people, for example, and so what's really interesting about this is, you know, I talk about this as if it was a historic sort of error that occurred, but there's still an over-diagnosis for black people psychosis to this day, and, you know, one thing I want to sort of know about this historical period when this book chronicles is that even the pharmaceutical companies were involved in this process, right, and I think that we can talk about sort of how we can talk about pharmaceutical companies for a long time and how like the sort of marketing that's done to prescribers as well as to sort of clients affects diagnosis and the patterns of like what people seek out, but I just want to show you a quick example of an ad that was around this time, and so what you can see here is an ad for a common anti-psychotic at the time, Haldol, a first generation anti-psychotic, and what you can see here is like, it's obviously very problematic the moment you look at it, right, so you can see that the sort of image that's sort of portrayed is of a sort of black man in like sort of 60s slash 70s sort of garb, and even the language here, right, like assaultive and belligerent, right, that's a very, it's a very sort of aggressive sort of language to describe a certain type of person, and then, you know, what you see here over on the right is that cooperation often begins with Haldol, right, so this whole idea here is that, you know, we can reduce how like hostile or aggressive these sort of black consumers are with prescribing the strut, right, and so you can see how like on one hand these changes to the DSM, which is like something that we can control as practitioners to a certain extent, as well as sort of societal pressures sort of intersected to lead to this sort of over-diagnosis and over-medication of black people with schizophrenia at the time, and that's how you can see these sort of intersecting levels of racism and how they play out historically and also currently. So like I said before, I love to read books, there's always sort of interesting sort of kernels in sort of like non-fiction books, and so one thing that I wanted to sort of note as well is that something that I didn't know until I read this book by two of the founders of the Black Lives Matter movement is that one of the founders, Patrisse Conkleur, actually became involved in sort of her work towards, you know, reducing to sort of bettering the interaction between black people and policing systems and criminal justice systems, etc., because of her experience with her brother who actually had a psychotic disorder, and so what I'm going to actually, I think what I like to do is center the words of people who actually have lived experience in this area because I think it's actually more salient than anything else that I could say, but what you'll notice in this clip is that she's going to talk about her the experience of her brother having his first psychotic episode and how challenging that was for her and her family in particular, so what I'll do now is we'll play a clip for a moment and then I'll kind of highlight some of the key points there. All right, so I'm going to go back to sharing my screen really quickly, but I think what's really interesting to note about, sorry, one second, I think I restarted my slides, what's really interesting to note about her experience, I mean, there are several sort of key points that sort of emerged for me, but I mean, starting from the beginning, right, so when her brother's released from prison, right, so we can talk about, like I mentioned before, we're talking about intersecting levels of sort of racism. Her brother is already experiencing psychosis in prison clearly, right? It's not that this just emerged the moment he was released, so he's released from prison without some sort of, any sort of discharge plan to connect with services. It's not clear what services he was or was not receiving in prison, right, so that's already a huge gap that you can kind of see. Another thing you can kind of hear from that is this sort of lack of really formal awareness about psychosis, which is common amongst all communities, right, but I think in particular, I think it can be harmful for the Black community because I think it puts us at risk for not really being able to navigate these systems well or knowing who to call in a situation, and so fortunately for Patrice and her family, she was able to sort of, she had a friend that she could call who could give her sort of insight into what was going on with her brother and what the next step should be, but even then, having a sort of advocate or sort of a connection to the system, there was not really a clear way to get her brother into care aside from involving the police in this case because of his status as someone who has a criminal background of being convicted, and so that's really concerning because again, if we think about who is incarcerated the most and sort of the mass incarceration issue, that already puts people who are already experiencing extreme stress in terms of the experiences of being in prison and jail in a situation where the people who put you there are now the people who are supposed to connect you with care in some cases, and I'd like to say that there are many instances where there are crisis teams and experiments with crisis teams around the country, but that's not necessarily the norm in every location, right, And oftentimes these crisis teams are overburdened. So it's a really aspirational goal to have these crisis teams, but the reality is that the police are involved in mental health care more often than not, and that puts sort of communities of color at a disadvantage with connecting to care. And so, you know, once, you know, and obviously she talks about her experience with the police saying that they would tase her brother if he was not able to sort of be calm, calmly escorted to the hospital, and that would obviously be a very negative experience for him and would potentially be escalated, right? There's no guarantee that they would just tase him with experiences that we see all the time on the news. So this whole, this combination of these sort of levels of racism really makes it hard for people of color, particularly specifically Black people, to engage in services in a meaningful way at the sort of start, right? And I think that like the way that we start engaging with services influences how we engage with them for the rest of our lives. And, you know, one thing we can talk about with psychosis, specifically schizophrenia, is that it's a lifelong illness for many people, right? And so if you're already sort of predisposed to having a negative early experience and already coming into mental health care, not trusting the system because of how you entered it and sort of the relationships you have with providers, we haven't even talked about the systems that people are entering into, it makes it really hard to actually engage meaningfully in services and get the care that you need to be able to live the life that you want to live. And so I say all of that to say that like some of the research that we'll talk about next really sort of emphasizes some of the points that I'm illustrating in the video, but I think it's so much more salient when you can hear it from someone's personal account. And yeah, so I'll go ahead and move on from there. So the next thing we can talk about when it comes to psychosis is that there are sort of three sort of focus areas we could talk about. We could actually probably subdivide these into many more focus areas, but for the sake of this talk, we'll focus on, we can talk about three focus areas, which are the pathways to care, how you get there, which we just talked about a little bit with the video clip, early intervention services, which are sort of our best approach for sort of reducing the impact of psychosis on someone's long-term functioning, and then sort of more long-term outcomes with sort of standard care. We're going to focus for now on pathways to care and early intervention services, because like I mentioned before, how you start really affects sort of how you engage long-term. So let's talk about some of these factors that sort of influence early engagement or pathways to care. So the first thing we can talk about based on the research is that, you know, this isn't just, I think, talking about sort of first-person accounts is important, but also the data suggests that, you know, Black communities are disproportionately impacted by psychosis at a rate that is much higher than other communities, particularly white communities within the United States, so this affects things like diagnosis, including sort of earlier first episode psychosis, as well as other things like pathways to care, attendance and engagement in care, and treatment outcomes, and so we're going to talk about each of these in a little bit more detail, but I think it's just important to note that, like, I think some people will say, oh, you know, race only affects one aspect of care, but race really, racism rather than race, or having a racialized identity can is, it affects multiple sort of aspects of care and how people ultimately will engage and recover. So next, what I want to talk about is a systematic review of the literature of pathways to care in the United States for Black individuals with early psychosis, and this is a paper that I was fortunate enough to be a co-author on with Dr. Oluwole, who introduced me earlier, who's our moderator for this webinar, and so basically, in the systematic review, what the sort of three key areas sort of emerged into sort of like what, how pathways to care sort of are different or specific for Black Americans. The first thing was sort of experiences pre-prodrome, and when I say prodrome here, I mean the sort of period sort of just before someone experiences a full first episode of psychosis, so these are, and so this, in this period, this is like the key period for earlier intervention that we sort of try to identify, because, you know, getting people engaged in care sooner is better and is actually associated with better outcomes. Next, the next area that emerged was sort of barriers to accessing care once psychos, once people were in the sort of prodrome phase, so these, this is a time where people, like I mentioned, I could tell you earlier, people are starting experiencing, starting, starting to experience some symptoms that are concerning and distressing but haven't quite crossed the threshold of psychosis, and then this last section was sort of an extended period of a duration of untreated psychosis and treatment delay, so at this point, people have already developed a full-blown sort of psychotic disorder and aren't really sure what to do about it, and that leads to treatment delays, which are associated with sort of worse outcomes over time, so let's talk a little bit more about each of those sort of sections very quickly. This is a really cool figure that kind of, that Dr. Oluwole made, Oluwole made that kind of shows all these sort of different phases and different factors that are, influence pathways to care. We're going to talk about these in more specifics, but I just wanted to sort of highlight this figure because I think if you take nothing else from this talk or you look at the handout later on, I would say look to look at this handout, this figure on the handout, because it really kind of breaks it down in perfect detail, but let's talk about each of the phases more verbally, so the first sort of phase is, like I mentioned before, these experiences pre-prodrome and the sort of, sort of prior to the onset of psychosis, and so there are a variety of factors that sort of influenced sort of the folks' experiences of gains and services later on, so these are things like household or environmental experiences, such as things like residential instability, sort of having a family member be incarcerated, substance use in the home or in the individual, as well as the sort of differences, like a lack of help-seeking experiences and support from primary care doctors, and so these factors, again, already sort of start to, are actually also associated with sort of worse psychosis down the line in some ways, and so it's important to sort of note that, you know, even before the psychosis begins, there are things that we could potentially intervene on that would hopefully reduce the impact of psychosis later on. Once we get into the sort of onset of psychosis and help-seeking experiences, people across a variety of studies reported a variety of sort of experiences, sort of like particularly family members, of noticing changes in their loved one but not knowing what to do about them, right, so loved ones might notice a change, might notice that their loved one is behaving oddly or, you know, that something's going on, but because of this lack of awareness about psychosis, don't know what to do or who to call, right, and so, for example, in some of the qualitative studies that were reviewed in this paper, family members were reporting thinking that psychosis was something else, right, misattributing psychosis to other things like substance use or sort of just acting out or other things like depression or things like that, and so because of this misattribution, people are experiencing psychosis but not getting the sort of appropriate care, and so the psychosis continues to worsen, right. Other things that were sort of noted were sort of interactions with law enforcement as sort of a catalyst for engaging in care but also a catalyst for worse experiences, and then also people noted sort of differences in initiation of care with like sort of formal supports with our sort of medical systems and emergency departments, informal supports like religious leaders, law enforcement again, and then the most important driving force for people were family members, but if you can think about sort of how I think it involves a level of involvement for parents that might not always be present, right, especially for the sort of intersection, we talked about sort of like income inequalities across race as well, and if someone is working, you know, multiple jobs to support their family, and then is, you know, how will they have time to notice what's going on with their loved one, and then how will they be able to take their loved one to appointments if they still have to work all these work jobs to support them, their family, things like that, so there's, family is a really important driving factor, but it's also, it's compounded by sort of all these other sort of levels of sort of racism that influence or inequity that influence one's ability to meaningfully engage their loved one in care. I kind of got ahead of the slides already, but I mentioned sort of delays in seeking treatment because of misattribution of symptoms, and then also what's really important is this whole idea of navigating services, right, and so once you sort of, once folks are connecting with services, what they're noting is that, you know, some people are noting that they're having their family, their loved ones with psychosis, having these lengthy stays in inpatient facilities, and, you know, having this sort of like almost revolving door experience of hospitalization after hospitalization, and not really being connected with the right services early on. Also, people note sort of these discriminatory experiences, such a lack of respect or lack of integration of services with their cultural or spiritual beliefs, and so if you think about all these sort of negative experiences that are happening both before the onset of psychosis and sort of when psychosis is happening and sort of like, like I said before, it's this perfect storm of factors that can lead to poor engagement in services and really worse long-term outcome. So let's shift over for a moment to talk about first episode psychosis, and so like I mentioned before, with psychosis, typically there's a continuum of experiences. People have a sort of prodromal period where they experience some symptoms, but they're still able to sort of function, but then there might, once the decline starts happening and functioning and an increase in severity of symptoms, someone is thought to have their first episode of psychosis. In this case, when someone has their first episode of psychosis, the best intervention that we have is called coordinated specialty care, which is this sort of wraparound service with a team, a team-based approach with like a small staff-to-client ratio, where we sort of help people to sort of navigate the illness early to reduce the sort of negative impact of psychosis on one's recovery and long-term functioning, and so this is an NIMH, sort of the, excuse me, coordinated specialty care was sort of initially funded by NIMH through some early trials called the RAISE trials, which demonstrated the benefits of this approach over like sort of standard community care, and now there's this proliferation of sort of early psychosis services across the country. In fact, it's pretty standard now, you know, and the good part about this is that we have this really great tool to sort of reduce the impact of psychosis on young adults functioning. However, there have been some recent analyses of this initial trial data that really call into question the benefits of this approach for folks that are not white and as well are lower SES, lower socioeconomic status, so there's a lot of text, but I'm going to walk everyone through this, walk everyone through this, and so one thing that's been done is that there was, with initial RAISE trials, what they found was that, you know, the coordinated specialty care was better than treatment as usual at improving long-term outcomes like quality of life and things like that for folks experiencing schizophrenia, but a secondary analysis, which used a sort of, what they did was that they made a composite of socioeconomic status that included factors such as race, parental occupation, parental involvement, income, reanalyzed this data and found that using this composite, only the top 25% of folks with this SES composite were benefiting from coordinated specialty care, and the remaining 75% saw little to no benefit, so that's an interesting sort of finding from this initial data or these initial data that we had from the trial. Another sort of key point that emerged from that initial data with work done by Dr. Oluwole was that this, the data suggested that Black and Latino clients were less likely to receive family interventions within coordinated specialty care, and that was, that's a really, as we mentioned before, family is really important for engaging people in services, and then lastly, there's a couple of studies like longitudinal studies using insurance claims data as well as tracking people longitudinally in early intervention services or early psychosis, and so what the sort of insurance claim data found is that it kind of found that Black and Latino clients were less likely to be engaged in both individual and family therapy than White clients, and then the sort of longitudinal study of sort of folks with FTP found that Black clients with early psychosis were to improve, were found to improve less from services, so they were in terms of overall functioning, mood symptoms, disorganization, negative symptoms, and also sort of odd or bizarre behaviors, and so this takeaway, what this really means is that, you know, we have this really great tool that helps people above treat, use sort of community care, which is great, but our current intervention approach seems to have significant barriers in engaging Black and Latino clients and their families, and these differences aren't simply attributed to SES, and so as some people sort of state that it's sort of like an issue primarily related to income inequality, so all this suggests that our early intervention services, while they are great, might have some gaps in engaging people of color, and so one thing that we can talk about here in terms of engagement is that, you know, we can talk about the differences in attendance versus engagement in care, right, and so when you, when we think about services, we like to say that people are really engaged in services, like they're coming to appointments, and, you know, if I see that someone's coming to most of their appointments, I might say, oh, that's really great, they're engaged, but engagement is different for different people, right, for a variety of reasons, right? Some people might, you know, come to appointments but not really talk much or might not tell their providers key information because of, like, lack of trust, and some might come to appointment, maybe come to one appointment a month, but it might be a really productive session. What we, what some of the literature on sort of early intervention services suggests is that Black young adults have less attendance at individual and family sessions than White people, so what this means is that, you know, even regardless of the sort of engagement, Black people are engaged or sort of attending appointments less than White people, and I think that this might link to some of these sort of differences in outcome. Next, in terms of coordinated specialty care, there are some key services that are thought to really be sort of like the sort of mechanism for change for improving symptoms for people. These are things like family psychoeducation, where you teach family members about schizophrenia and psychosis and sort of how they can sort of help their loved ones, as well as medication management appointments and things of that nature. What we see for things like medication management and family sessions, as I mentioned before, is that Black consumers are coming to sort of family sessions and medication management sessions less than White consumers, and again, that kind of highlights this whole idea that we are not engaging folks in the way that we need to to actually live the lives that they want to live, and right now, based off the literature, there's not a lot known about sort of why sort of folks aren't engaging, particularly medication management sessions, and when it comes to family sessions, as I mentioned before, Dr. Olowoye is an expert in this area, and some of the work there suggests things like inflexible appointment times, the location of clinics, and sort of getting for folks to sort of get to appointments and things like that, and also sort of the lack of sort of like outreach efforts to families of color, and so that's a real, I think our services right now require a more flexible approach to really meet the needs of Black consumers, and so the next thing you might be asking is how can we more successfully engage clients of color in our early intervention services, and so things that some of the literature suggests, there's a lot of preliminary work in this area from sort of like lessons learned sort of papers where folks are sort of talking about things that they've noticed have improved care, and so things that have been noted are things like developing long-term relationships with multiple stakeholders in the community, right, and so this really calls for a sort of outreach and engagement approach that really centers the experiences or really meets with sort of Black consumers in the community to understand ways to raise awareness about psychosis, right, like I mentioned before in that systematic review that many people aren't really aware what psychosis is, so the moment it comes up, it's just like what is this, what is this, right, and so people don't know who to call, what to do, other things are sort of becoming more engaged in communities even before that, before these crises happen, right, so people say, oh, I know, you know, I know Jane at that clinic, and I know that she's someone who can help with this, right, and that you become a trusted resource rather than just this new person who's like here to put a label on someone's loved one, right, because there's a lot of fear of labels in terms of diagnosis and things like that. Other things that people can do are really working on addressing these structural barriers, right, so I mentioned that there's this proliferation of early psychosis clinics across the country, but at the same time, many of these clinics are located in places that make it hard for people to engage in care. For example, I'm located in Maryland, and we currently have about For example, I'm located in Maryland, and we currently have about four first episode programs across the state within the Baltimore D.C. area, but they're located primarily as it stands within Baltimore, and there's a whole other parts of Maryland that aren't within the Baltimore D.C. corridor, right, so if people want to get engaged in care, they have to drive sometimes 45 minutes to an hour to go to an appointment, right, and so if you're, like I mentioned before, if you have other competing demands, it's really hard to engage in services. Other states might have more services, but I think putting clinics in the communities that need them is a good first step to sort of getting people to be engaged in the services that are beneficial to them. Other things that are really important are things like the use of cultural formulation tools, such as the cultural formulation interview that's used in the DSM-5 to sort of help understand the sort of cultural context that someone is experiencing psychosis with them. And that's a really important first step because a lot of the services that we developed aren't really developed with a cultural sensitivity in mind. And the next is a point that I sort of circle back to often, and it's this idea of workforce diversification. And so we can talk about how there are not a lot of black psychiatrists and psychologists and social workers and master-level clinicians of varying sorts in general, but within the psychosis community, there aren't any, that problem is sort of amplified. There have not been a lot of sort of formal workforce studies about sort of the demographics of the psychosis workforce specifically, but in general, it tends to be primarily white folks. And so if you are a person of color trying to navigate these systems and you don't see anyone who looks like you, it can be very hard to sort of form that initial trust to sort of like be comfortable sharing your experiences. And anecdotally, I've had this experience on both ends. As a psychosis researcher and clinician, I've worked in first episode clinics and clinics for folks with more prolonged psychosis. And often I'm the first person of color in general, the clients that I'm working with have seen. On the first episode, and it's been really beneficial and really rewarding to work with young adults who are experiencing psychosis who are like, oh, I really wanna work with you as my therapist. And then there's a cultural understanding very early on. Adding to that, or sort of on the other end of that with folks with more prolonged psychosis, I have done placements in community mental health centers where someone says, you're the first person that I've seen who looks like me, who I can just talk and be myself with, right? And then if you think about the experience of someone who's been navigating psychosis for 20, 30 years, and they're telling me that in their 40s or 50s, it's really helpful, it's really great. They're telling me that, and they're really able to sort of open up to me, but at the same time, what would have happened if they would have had a provider that they felt more comfortable with earlier on, right? And so I really, I can't stress this enough that there needs to be more of a pipeline of clinicians of color, particularly black folks. And I think that that's a really important, I think that there need to be more efforts to recruit sort of people of color to work in these sort of psychosis focused programs. The last thing I'll just say is sort of working with people and meeting in the community is really important. I think that like we are very trained to sort of meet with people within the confines of our offices for a variety of reasons, but I think what's really important, and I think to some extent what the pandemic has shown is that there needs to be a flexibility about where to meet people and sort of how to sort of connect with them. And so, if you think about other models of care for people with psychosis, there's this really popular model called a sort of community treatment where it's having people come to the clinic that the clinic is essentially the community and it would meet with people at a McDonald's or meet with people in their home or things like that. And that's actually associated with much better outcomes for people with more prolonged psychosis. So I think that same model could be applied to early psychosis and just treatment approaches in general. Okay, so I'm gonna pause here, perhaps to see if there are any questions from folks in the chat, because I've been talking a lot and we're about 15 minutes from the top of the hour and I realized that I'm just sort of talking at everyone. So I'm wondering if there are any questions from the chat or any things that people, come up for people as we're talking about this. Oh, Sean, I don't see any questions in the chat, but I have questions. Oh, I would love that, yeah. Okay, awesome. So I'm glad that you stopped on this slide. I was wondering if you can provide any suggestions for tools that you have used, especially like cultural formulation tools that you have used that you could possibly suggest for other people to use. Certainly, yeah. I mean, so I've used the cultural formulation interview in the DSM, which I think is kind of like the best sort of tool that we have currently, as well as I think what's really useful, obviously I'm like immersed in the research world to a certain extent, so I love collecting data, but sort of measures of sort of racial centrality or racial identity, I think are really helpful just because I think it helps you to understand is, I mean, the cultural formulation interview gets at that specifically, but like how sort of the context in which people are experiencing their symptoms, right? Because I think the whole idea of any treatment for any sort of disorder, not just psychosis is sort of having, treating the whole person, right? And understanding the context. So I think understanding the impact of culture for people experiencing psychosis is very important. So I really can't stress using that measure enough. I don't know, are there any others that you would recommend, Dr. Olowoye? No, that is the one that I would recommend. I am a big advocate for the CFI, especially because it's super flexible and it provides different options for it to be used. And in the work that we do here, we have adapted the CFI slightly so we can use it with families and not just as an informant type, but actually use it with families to inform the type of care it is that we're providing to family members and support persons. So no, I was just wondering, but I agree with you, CFI. All the way. My second question, because I, you mentioned a lot of barriers and areas for improvement and places where we can kind of think about maybe we need more strategies or interventions to target specific barriers that we kind of have noticed have come up repeatedly through research that has been done over the years, even though it has been limited research. So can you, and I know I'm a little bit familiar with the work it is that you're doing now, but can you speak about more about the work it is that you're doing that kind of addresses some of these barriers? Yeah, certainly. Researchers love to talk about their work, so I'm really excited to talk about some of mine. So for me, what I'm really interested in is intervening at the individual level, primarily because of my background as like an individual sort of therapist, right? So I think I understand individual therapy really well when it comes to working with individuals and groups and things like that. And so the work that I'm doing now is really focused on understanding the sort of decision-making points that folks have about when and how to engage in services, particularly for black folks. And so I think what's really important is that at any given point, engaging with services for black people, or in general, but for black people specifically, really it's like a cost benefit analysis in a way, right? Like if I'm already having these sort of negative experiences, particularly with being hospitalized more often, or having the police called on me, or being criminalized for my mental illness, I'm gonna make really strategic decisions about what to tell people and when to tell them those things, right? And so the work that I'm doing now is focused on interviewing clients, or individuals with psychosis, black individuals with psychosis, as well as their family members, about how they decide to engage in treatment and the factors that influence whether, the factors that help engaging in services with providers, and the facts that sort of hinder that, right? So what I'm focused on now is sort of interviewing people about those experiences as sort of key entry points into services, key sort of points of rupture, or building distrust with services and providers in ways that we can improve the relationships that family members and individuals with psychosis have with providers through either sort of targeted intervention or changing the sort of intervention services themselves. Currently, what I'm thinking a lot about is sort of like a sort of, almost like a prevention-based approach, right? So before someone even has the experience, the negative experiences that might lead them to disengage, intervening earlier on to sort of say, okay, here's what the services are, here's how I can help you navigate them, right? And so I think there are a lot of, or here's how you can navigate them and sort of providing sort of supports around that. Because I think for black families and clients, it's really hard to, that initial navigation period is challenging, right? Like, I think it's like being in like, you're having to learn all of these new things at once and then also support your loved one or support yourself, and there's just so much going on. So I wanna sort of develop interventions around sort of helping folks to navigate services to sort of opt to sort of engage with services better. And I think that like, in some ways there's been this movement broadly outside of psychosis for black folks to engage in mental health services more often, but there's still a cultural stigma around mental health broadly and then with psychosis specifically, right? So I think finding ways to sort of normalize the experience of engaging with services and also to sort of reduce the stigma that psychosis has for folks is really important, right? Because I think oftentimes that fear of a label for their loved one is something that like, stops people from engaging with services and also sometimes has people, half engaging with services. I have clients who I see now who, for example, one client that I see now is like, she's a young African-American woman and her mom says, the one thing that you actually need to do to actually get better is just to be a raw vegan, you don't need to engage, you don't need to take that medication. If you started eating better, if you started eating more naturally, like eating more sort of certain foods, your symptoms would go away, right? And so that's like, and that's her specific family's culture and how that gets in the way of her engaging with services and her even connecting with her mom. So I think it's just really important to understand those factors and then also to investigate sort of more individual sort of factors because again, black people aren't like a monolith, so there's gonna be varying level, very different experiences for people that are sometimes more salient and sometimes not. So understanding how identified with their racial group, with one's racial group one is, is really important. Sorry, I just rambled a lot about that, I hope that answered the question. It was a good ramble. It was a good ramble because you touched on multiple different things where especially thinking about how individuals and their families navigate through services and that as providers, we always just like, well, no, it's gonna be a positive experience if they come upon me. But those experiences are often shaped by providers that they engage with that are not beneficial, that lead to disengagement in addition to the multiple different systems that people have to navigate through. And so I really appreciated the video that you had us played or had us watch because I think it kind of highlights the multiple different factors and the different systems and the different types of formal engagement in terms of police officers and providers and things like that that people engage with because it's never a direct link to boom, onset of psychosis and they are connected with a mental health provider that understands their experiences. And so the second point to that is also meet in families where they're at, right? So I have heard quite often that symptoms are associated with like diet and what people eat. And I don't know if it's our role to convince them otherwise or it's our role to meet them where they are and integrate that into the treatment plan and how we engage with individuals because we could still address diet and healthy eating while still educating them about psychosis. And so I think that that is equally important because I think oftentimes just not even thinking about healthy eating, a lot of family members concerns and even service users concerns are ultimately dismissed because it doesn't align with what we consider to be the norm. But what is the norm? Everyone's norm is different. And so I appreciate you saying all of those different things. And I think a lot of it goes back to the CFI. The CFI is great because it asks us questions that are related to one's cultural beliefs and things that have worked for them and things that have not worked for them and kind of incorporate in that into care. Are there any other questions from the audience? If you do have questions, please throw them in the question box. We have about five minutes remaining. I don't know if you have an extra slide, Sean, that you want to kind of touch on. I do, yeah. And I think one thing that I thought about really quickly, while people, if people have questions, they can put them in. But one thing I thought about just noting is that thinking about the audience here, since we're at the American Psychiatric Association, is thinking about prescribing practices, right? And one thing that I haven't talked about specifically that I think is noted in the next slide that I'll show is that there are differences in the prescription patterns for black people with psychosis as well, right? And so I think thinking through prescription decisions and really just like relying on sort of best practices, because there are sort of evidence-based sort of prescription methods that exist. But I think, so let me, so I guess maybe I should take a step back and really know what these prescription sort of disparities are. There is this sort of trend in the literature for black folks to be prescribed first-generation antipsychotics more so than second-generation antipsychotics, right? And given this audience, I mean, I would just pretty briefly describe that first-generation antipsychotics are associated with more sort of profound negative side effects, including sort of the extra pyramidal symptoms, such as like the hand tremors and tardive dyskinesia, weight gain, and all those things, and the second generations, which also have association with weight gain, but less so with the movement-associated features and things like that. And so thinking about prescribing patterns and being really mindful about those is a really simple way to really, for psychiatrists in particular, or prescribers in particular, is to think about the impact that they're having on sort of the black folks that they work with psychosis. I just wanted to note that really quickly before we moved on to the next slide, but that's something I just wanted to make sure I emphasize. And so the last thing I'll sort of note before we wrap up is this sort of a sort of table that I made in collaboration with Dr. Oluwole, thinking about levels of intervention to reduce to better outcomes for folks with psychosis, early psychosis in particular. And so we've talked about each of these sort of factors in some detail, right, with this talk already, but other things that we can think about are like sort of the levels of intervention, right? So right now we're talking to each of you, and I'm not sure what level of intervention you can sort of act on right now, but you can definitely interact on the individual level, right, which are things sort of like adapting a sort of trauma-informed approach to care, right? So if you're working with someone with early psychosis, particularly a black person with early psychosis, you don't necessarily assume that they've had a subversive pathway to care, but I think taking this sort of broad trauma-informed approach can help people to engage in services earlier and better because you're understanding that the process might not have been easy and simple for them to get there. Other things, other factors that are really important are things like cultural racism and mental health care, which applies not only to people with psychosis. We could talk about this broadly. I mean, this series probably, this series of webinars probably talks about all sorts of different areas where racism impacts mental health care, but we can think about things like examination of individual biases leading to attributions of affective symptoms of psychosis, and what I mean by that is that oftentimes when it comes to psychosis, I mentioned that there are a variety of different disorders that folks can be diagnosed with, from schizophrenia to bipolar disorder with psychotic features, depression with psychotic features, et cetera. What's the symptom, the people, the diagnoses that are associated with quote unquote better outcomes are the ones that are mood disorders with psychotic features. But what we see in the literature is that black folks are diagnosed with mood disorders with psychotic feature much less often than white folks. And what you can think about there is perhaps the way that we are trained is not making us sensitive to the sort of expression of mood symptoms in black Americans. And that might lead us to say, oh no, this is just pure schizophrenia and we're missing a bunch of other things. There might be a mood component that we're not thinking about. And so other things to really think about in terms of that are like, clinician trainings to minimize diagnostic bias and things of that nature. And then lastly, with coordinated special care specifically, thinking about more flexible approaches to improve engagement and services such as increased telephone or telemedicine appointments, scheduling flexibility or meeting in the community. And so those are the things that I'll focus on just for the sake of this talk, just because I think at the organizational systems level, and this slide will be there for if you wanna review it, but I think it's harder to enact at the systems and organizational level if you don't necessarily have that power to do so. So I like to focus on sort of micro interventions at the individual level that each of us can do and take into our practice. And then with that, we are actually at the top of the hour. I appreciate everyone attending and listening to me talk about this for an hour. It's been really passionate about, and I hope it was helpful. And if there are any questions, you can feel free to reach out to me via email and I will put my email in the chat. But with that, I don't know, Dr. Oluwole, is there anything else that you would add to it as a closing thought? No, I don't have anything to add, but I wanna thank you for sharing your expertise with us and for the wonderful slides and having them available for anybody to kind of look at at their own time. And so we don't do round of applause, but it's a silent one. And so just imagine that you're getting one. And so with that, I hope that everybody has a fantastic day and just remember that this recording will be on demand. And so you kind of look at it at your own pace afterward. And so thank you, Sean. All righty, thank you, everyone. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay.

racism

psychosis

Black Americans

accessing care

disproportionate impact

engagement in care

structural barriers

workforce diversification

trauma-informed care