Workshop: Discrimination as a Social Determinant of Mental Health Disparities

Transcript

EVENT PRODUCER: Okay. It is now 10:00 a.m. eastern time. Welcome, everybody, to today's webinar, Discrimination as a Social Determinant of Mental Health Disparities, presented by the National Institute of Mental Health.

Just a few housekeeping notes and reminders for all participants today. Participants have entered into listen‑only mode, cameras off, and mics are muted.

Please submit your questions via the Q&A box at any time during the webinar. Questions will be answered during the discussion sessions of the workshop.

If you have any technical difficulties hearing or viewing the webinar, please note these in the Q&A box and our technicians will work to fix the problem.

You can also send an email to nimhevents@nimh@mn‑e.com. Please also note we do have ASL interpretation today for this event and also closed captioning. If you do require the captions, make sure to enable them at the bottom of your Zoom screen.

And with that, I will now pass it on to Dr. Christina Borba.

WORKSHOP OVERVIEW AND WELCOME

CHRISTINA BORBA: Good morning, everyone. My name is Christina Borba, and I'm the NIMH Director for the Office for Disparities Research and Workforce Diversity.

It is such a pleasure having you all attend today the Discrimination as a Social Determinant of Mental Health Disparities workshop. We will spend the day together highlighting how discrimination plays a key role in contributing to mental health disparities.

It is clear how important this topic is for the field, as we reached our capacity for 5,000 registrations for this event.

Today's workshop will cover three key points: One, NIH's investment in this area to date; two, understand how discrimination serves as a social determinant of mental health disparities; and three, the current state of intervention research to address discrimination as a social determinant of health.

We hope you will stay with us for the breakout sessions where everyone will have the opportunity to interactively join the discussion about research gaps and opportunities in the topic that you've selected.

It gives me great pleasure now to introduce Dr. Juliette McClendon, to provide an introduction to the workshop and an overview of what NIMH has been doing in the area of discrimination and mental health.

Dr. Juliette McClendon is the program director for the Social Determinants of Mental Health Disparities Research Program in our Office for Disparities Research and Workforce Diversity. Thank you again for joining us.

And Dr. Juliette McClendon, I will now pass it to you.

DEFINITIONS AND PRIORITIES

JULIETTE McCLENDON: Thank you. Good morning, everyone. Thank you so much for being here and welcome.

As Dr. Borba mentioned, I am Juliette McClendon. I'm the program director for Social Determinants of Mental Health Disparities in the Office for Disparities Research and Workforce Diversity here at the National Institute of Mental Health.

I just want to first thank Drs. Mary Rooney, Mary Acri, Christina Borba and Lauren Hill for their work preparing for this workshop, and I also want to thank our breakout moderators as well, who you'll be meeting later on in the program.

So, the agenda for today, or at least from my portion of the day, is that I'll go over some definitions which will help us come to the same page. Also, our first two speakers will also be talking about definitions.

I'll talk about some of our NIMH relevant priorities in this area, NIMH relevant activities in this area as well as just a quick overview of today's schedule.

So, the objectives for today's workshop are, one, to provide definitions of terms to establish a shared dictionary. It's really important that we all understand what we're talking about and have common definitions. So, we'll do that.

We'll also highlight current NIH strategic priorities relevant to health disparities. And then we'll have a number of speakers present evidence that experiencing discrimination and other forms of systemic oppression are potent social determinants of mental health disparities.

We'll present cutting‑edge research from investigators who are investigating the impact of systemic discrimination on mental health disparities, as well as promising interventions; and we will also have the opportunity to discuss and identify gaps and opportunities to generate new innovative and impactful research in this area to improve health outcomes in populations that experience disparities.

So that is what we're going for today. So, let's get into some definitions. What are social determinants of health? This is a key point here.

So, the NIH recently released a conceptualization of social determinants of health which is based on a number of other conceptualizations that are existing, and defined social determinants of health as “the conditions in which people are born, grow, learn, work, play, live and age, and the wider set of structural factors shaping these conditions of daily life.”

And there are a number of different structural factors that we call out in particular, such as social, economic, and legal force systems and policies that determine opportunities and access to high‑quality jobs, education, housing, transportation, the built environment, information and communication infrastructure like broadband access, food and healthcare.

And you can see here on the right just an example of what some of the social determinants of health that are often discussed in the literature and in this work, including economic stability, education access and quality, social, community context, et cetera.

So, this is what we're talking about when we're talking about social determinants of health today. And what is discrimination? Well, discrimination is the unfair or prejudicial treatment of people and groups based on characteristics such as race, gender, age or sexual orientation, as well as things like disability status.

Structural racism and discrimination is a form of discrimination that is more sort of macro level. So, things like residential segregation, institutional policies that limit opportunities, relative power and well‑being of individuals and populations based on primarily marginalized demographic statuses.

The National Institute of Minority Health and Health Disparities has a research framework, and you can see here under sociocultural environment is where this framework includes discrimination and it includes discrimination at multiple levels of analysis, including the individual level, the interpersonal level, the community level and the societal level.

And this is important to see that because discrimination occurs on multiple levels on these more individual levels, these higher levels, that it's going to be important for us to think about multilevel interventions when we think about intervening our discrimination and its impact on mental health.

Now, moving to NIMH's priorities in this area. So, in NIMH's strategic plan, which was recently actually reissued, NIMH describes discrimination specifically as a social determinant of health.

The strategic plan prioritizes research on mechanisms of mental health disparities and interventions to reduce them. So, for example, one priority is research that identifies mechanisms contributing to the persistence of mental health disparities and tests interventions aimed at reducing disparities. Of course, this would likely include interventions that focus on discrimination.

The strategic plan also describes community engagement as contributing to the validity of research evidence. So, the strategic plan really focuses on valuing and fostering partnerships between study participants, communities and researchers from all backgrounds and describes community engagement as being extremely important to improving the validity and the reach and the relevance of research.

The NIMH strategic plan has four goals. And in each of those goals, there's also a description of how each of these goals addresses social determinants of health. So, in Goal 1, define the brain mechanisms underlying complex behavior. Even within this which focuses on primarily understanding the brain and brain mechanisms and how that influences mental health, there is a call‑out within this goal that not only genomic, epigenomic and other factors should be studied, but also environment and experience and how those interact with brain mechanisms to influence mental health and mental health disparities.

Goal 2 is to examine mental illness trajectories across the lifespan. And this goal calls out at the level of contextual factors, focusing on examining how social determinants and environmental factors impact risk and resilience to mental illness as well as mental illness trajectories.

Goal 3 strives for prevention and cures and calls out the socioecological levels beyond the individual level that plays a large role in risk factors. So again, if we go back here, looking at the sociocultural environment, this goal is calling out these higher levels, around the community and the social levels, for examining social determinants of health.

And Goal 4 is about advancing mental health services to strengthen public health. And again, this goal again calls out social determinants of health as very important factors that affect the usability and transportability of interventions and services.

So, within the NIMH strategic plan, there is a strong focus on social determinants of health and there is also calling out of discrimination and health equity.

Now, to turn to some of what NIMH's doing in this area right now. So, NIMH has a number of notices of funding opportunities as well as additional notices that focus on the area of racism and discrimination.

One is PAR‑23‑112 which is “Addressing The Impact Of Structural Racism And Discrimination On Minority Health And Health Disparities.” This particular Notice of Funding Opportunity expires January 8th, 2026. So, it's still active. And I'll talk about one study that's been funded by NOFO.

There's a new NOFO out, Understanding the Intersection of Social Inequities to Optimize Health and Reduce Health Disparities, or The Axes Initiative. This was put out by the National Institute of Nursing Research and NIMH is participating, and the goal of this is to understand and examine pathways and mechanisms through which social determinants of health and related biological, psychological and behavioral factors impact health and health disparities at intersections of privileged or oppressed social statuses. This first due date is July 5th of this year, and it expires March 11th, 2025.

Another notice that has come out recently is “Intersectional Stigma and Discrimination or Other Social and Structural Determinants of Health in HIV Prevention and Treatment.” This notice really calls for research to understand and address the impact of HIV‑related intersectional discrimination and stigma on HIV prevention and treatment.

These are some active notices of funding opportunities and other notices that NIMH is participating in currently and some grant highlights.

As part of the first RFA I talked about, “Understanding and Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities,” one funded grant currently is entitled Structural Racism in Black American Mental Health: Neurophysiologic Mechanisms and Sociocultural Processes Promoting Resilience During the Transition to Adulthood. This study is looking at the interaction between both the neurophysiologic mechanisms and social mechanisms such as discrimination and other social determinants of health to understand what promotes resilience in particular, so not just focused on risk, but focused on protective factors during this transition, this sort of young adult transition.

The PIs here are, Luke W. Hyde, Colter Mitchell, Christopher Monk and Enrique Neblett, all at the University of Michigan.

Another grant highlight which was funded by a parent R01 is Discrimination and Racial Socialization on Asian American Parent and Youth Mental Health.

And this study is looking at a number of factors that, in particular, how racial socialization may protect against the impacts, the negative impacts of discrimination, specifically among Asian American parents and youth.

And from this study we have a publication highlight where the authors studied the effects of vicarious discrimination on race‑based stress symptoms among Asian American young adults during the COVID‑19 pandemic, and they were interested in the impact of vicarious or secondhand discrimination.

For example, witnessing racism targeted at one's own racial group, which is not well understood. And what they found was vicarious ‑‑ I'm sorry, vicarious discrimination does have a negative impact on the mental health of Asian American young adults.

So that is what NIMH is doing in this space right now. It's obviously not totally comprehensive. We're currently in the process of doing a landscape analysis to better understand exactly what we've been funding in this area and what sort of areas it's focused on, what levels of analysis those studies have focused on and where we need to go from there.

So, from there, turning over to the agenda for today, we're going to start first with a brief Q&A with me, and then at 10:25 we'll start Session 1. We'll have three speakers. This is focused on definitions and the state of science.

Once Session 1 is over, we'll have an hour‑long break. We'll come back at 1:45 to the same room where we'll go over Session 2, which focuses on interventions addressing the impact of discrimination on mental health.

Then you'll have a short 10‑minute break, and then you'll all click on the second link you were sent in your calendar invite for breakout sessions. That will be an interactive opportunity to have a discussion about the topic that you chose for the breakout session and then we'll come back to that third link that you have to the closing room where we will have a brief report‑back about what was discussed in those breakout rooms, and we'll close. All of that will take us until 5:00 p.m. this evening.

With that, I want to, again, thank you all for being here. Now I'll introduce Dr. Mary Rooney, who will get us started for our first session.

INTRODUCTION OF KEYNOTE: MEASUREMENT OF DISCRIMINATION AND RACE‑BASED TRAUMATIC STRESS 
Speaker: Robert T. Carter.

MARY ROONEY: All right, wonderful. Thank you, Juliette. I'm thrilled to be kicking off our first series of presentations today which will be focused on describing the current state of the science, as well as some challenges associated with the measurement of discrimination, the association between discrimination and mental illness and the impact of discriminatory policy on mental health.

We'll have time for Q&A at the end of these three presentations, and you can submit questions at any time to the Q&A box. I'll be moderating the Q&A session, and we'll be sharing your questions with the speakers at that time.

So now I'll hand things over to our keynote speaker and a true leader in the field, Dr. Robert Carter, who will be presenting on the measurement of discrimination. Take it away, Dr. Carter.

ROBERT CARTER: Good morning. And welcome to the workshop. And thank you for coming and joining us today. So, in my presentation, I'm going to focus on how and in what ways ‑‑ one second. Let me just get this view up right. There we go.

I'll be focusing on how discrimination is a social determinant of mental health and how we decided as a research group to measure its effects.

In my talk, because the word "measurement" is involved in it, I try very hard to stay away from the nuts and bolts of statistical procedures and technical issues and try to convey as best as I can what I'm calling decision points and processes we employ.

And the body of work that I am involved in and have been for some time we concentrated on understanding the effects of racial discrimination, which we contend is a manifestation of racism.

More specifically, we decided to determine whether experiences of racism were associated with race‑related stress and trauma.

As such, I'm going to focus my talk on how we went about trying to assess the presence of racial trauma and how we developed and used the Race‑Based Traumatic Scale Symptom Scale and related instruments.

A lot of what I'm going to share with you today is contained in two books that were recently published. One called "Confronting Racism: Integrating Mental Health Research into Legal Strategies and Reforms." And the other is called "Measuring the Effects of Racism: Guidelines for the Assessment and Treatment of Race‑based Traumatic Stress Injury." And these two volumes are supplemented by decades of journal publications.

So to measure or to capture something in an empirical way that occurs among humans, the first thing that's necessary is having some understanding of what it is that you want to measure and preferably that's some sort of conceptual framework or theory and that that theory or conceptual framework will help guide what it is that you want to set out to measure and set its parameters. As sort of like the definitions that were presented earlier, it's sort of a way to define the phenomenon that you're trying to measure. And secondly, what is necessary is having some plan for how you're going to go about measuring the experience or phenomenon. So, you can choose to measure it with a survey. You could choose to measure it with an interview. You can choose to do behavioral observations and things of that nature. So, there's some plan of how you're going to go about that is important.

Alongside that, there's a third step, is determining the format and the length of the measurement procedure you're going to employ, and along with that you should have some sense of who your participants should be. That is, you want to select participants to test your instruments or measures or procedures, who capture or represent the population of people in which you expect the phenomenon to occur.

And fourth, you want to subject the information that you collected or the data you collected in your part of statistical analysis to determine whether the concepts or experience in question were captured effectively and appropriately by the measure and/or procedures that you developed.

So, our step one process, in terms of generating and understanding of race‑based traumatic stress or racial trauma assessment began from my research on race and racial identity. In the mid‑1990s, I published a book called "Race and Racial Identity and Psychotherapy" and have engaged in research involving those constructs, and racial identity is basically the way in which people understand themselves as racial beings.

The other element that contributed to the development of these measures that I'm going to share with you today is race‑related legal cases. It was in this context that I came into contact with the question about whether or not mental health and/or legal professionals understood how targets of racism are impacted.

And it did seem at the time, in my early involvement in racial cases ‑‑ which was about 25 or 30 years ago ‑‑ that there were not good mechanisms available to redress experiences of racial discrimination, and I'll touch on that a little bit as we go forward.

So, I was left setting up at least two related objectives or goals for research or questions that guided the measurement process. One was, are there psychological emotional effects of racism and racial discrimination? And the other is, if so, what's the path for legal redress that mental health effects can be documented from racial discrimination?

Said another way, someone who experiences racial discrimination has three options: They can accept what happened; they can seek mental health guidance or support to address the effects of that experience; or they can file a lawsuit and take action, or see a mental health professional and file a lawsuit. But the law and mental health begin to intersect in this situation.

But before I go on, I need to do what was done earlier, which was define some terms. So, for me, a race is defined as a social construct which ranks groups based on their skin color, physical features and language.

And racism is an aspect of race, but it is really the application of racial prejudice with the use of power directed against those who are deemed inferior by individuals, institutional members, and leaders with the intentional and unintentional support and participation of the entire dominant racial‑cultural group. All of those components need to be present for racism to exist. And lastly, racial discrimination is the behavioral manifestation of racism.

So, in the early phases of beginning to try to put together our conceptual framework or model to help us figure out what it is that we wanted to measure, we went to the social science and health and mental health literature to help us identify what was that social scientists understood were discriminatory practices and what settings and other domains. And we discovered that they documented, with empirical evidence, that there were mental health effects as a consequence of discrimination.

It's also true, as we discovered, that based upon legal and organizational practices and procedures, that racial discrimination and racial harassment are combined and capture racism. While, oddly enough, sexual discrimination and harassment have been separated with distinct procedures and remedies.

Now, both were legislated as legally impermissible by the 1964 Civil Rights Act. So that they are treated differently in practice is something that we found curious.

So, we asked ourselves, does racism or racial harassment and discrimination have separate elements rather than are they actually combined in the way that sexual harassment/sexual discrimination have been.

What I ask you to consider, even in your organization, organizations that you may be familiar with, you ask yourself whether or not there are clearly defined procedures and definitions for impermissible racial discrimination or racial harassment.

And I think what you'll find is the answer is no. There's a generic statement that discrimination is prohibited, but they're not really clearly defined. You will find something different with respect to sexual harassment. You'll find that there are distinct procedures, definitions and remedies for those in the majority of organizations and institutions you're associated with.

So, in 2002, Carter and Helms argued that we could treat racial discrimination as a form of avoidant racism, in which it's designed, when applied to distance, dominant and nondominant racial groups. While racial harassment, on the other hand, was designed and operates as a form of racial, hostile racism that is designed specifically to communicate to targets their inferior status.

And so, what we were contending is that these are actually classes of racism, and that the classes of racism that we were proposing were different than legal, organizational, mental health definitions, and we contend further that they are needed to seek legal redress or relief.

We argued that, more importantly, by using classes of racism, it is possible to establish a direct link between a person's racial encounter and their psychological and emotional reactions.

Let me try to explain this in more detail, or at least be a little more clear.

If we consider systemic or macroracism, what that usually refers to is a broad set of circumstances or racial disparities; and while evidence does document that systemic racism or racial disparities harms people, but it does so as group members.

A macro approach, on the other hand, is person‑specific and can be therefore linked to one's specific reactions. Let me say it another way. One is able to identify what happened to them beyond simply describing it as racism or discrimination.

We argued that it's easier to describe a race‑based encounter as avoidant racism when you are told that there are no jobs when you applied for positions, or that the apartment you applied for was rented when you discovered that it was not. Or it's easier to identify hostile racism or what happened to you as hostile racism when you're followed around at a store or stopped by police.

Or, after gaining access to education or work, and you are subjected to avoidant, not being told about important meetings or being left out of important decisions or as hostility when you receive low performance ratings or are given negative feedback about your participation in the organization.

These race‑based acts, we contend, are more appropriately described as aversive hostile racism because we can take one or multiple classes of racism and connect that class or that type of race‑based encounter to a person's reactions. So, by using classes of racism, we are able to connect more directly to the event that occurred and the person's psychological and emotional reactions.

So back to the legal context and concepts. You may or may not know that more laws and legislative acts have been passed to advance racial justice in the United States. There have been three constitutional amendments in 1865 and beyond and seven Civil Rights acts. So, there's been more legal and social progress, however, has occurred with respect to sexual discrimination and harassment as evidenced by the large legal and social science literature and the fact that explicit laws, definitions and procedures exist in many organizations.

So, if a person experiences a sexually unwelcome environment, which is considered a form of sexual harassment, it doesn't have to also involve sexual discrimination because these are separated in most instances.

But if you look for similar policies and procedures that involve race, racial discrimination or racism, you're unlikely to find them. At least we could not find them.

At the same time, there are very few ways to understand or seek redress. Research evidence has documented that racial encounters produce stress and mental distress; and yet, when we looked at the literature at that time, there was no connection to any form of trauma. And the primary mechanism for assessing trauma was through the Diagnostic and Statistical Manual of Mental Disorders, or the DSM, and its criteria for posttraumatic stress disorder because that was the primary and most salient form of stress.

However, the criterion for PTSD is threat of death or serious injury. And we find that racism usually does not today, or in this century, did not involve threats to life anymore. There was a time when it did but that's receded. We thought a more specific model of racial trauma was needed to understand and measure the effects of racism, since we could not find any mental health definition that led to an assessment how someone was affected by a particular racial encounter or series of encounters, and that the law had racial discrimination/racial harassment intertwined and so was it impossible to separate them.

So, we thought that if we could establish that there were emotional effects from racism that could be assessed and documented, that that would assist in legal redress.

So, in a 2007 paper, I argued that traumatic stress could be used to understand the effects of racism. And the distinction between traumatic stress and PTSD is that the core criteria for traumatic stress is emotional pain does not threaten life, which separates it from PTSD.

Other elements of the experience for race‑based traumatic stress to be present are that the event should be experienced as sudden and out of the person's control, in addition to the emotional pain that the person experienced, and we found, from the generic literature, that racial incidents were, in fact, associated with symptoms of mental distress, emotional disturbance such as depression, anxiety, hyperarousal, physical reactions, et cetera, for all Americans.

Some of you may know, if you've ever tried to present a claim in court or on an organization for racial discrimination, this is hard to advance. We contend that it's given the lack of definitions and procedures that makes it exceedingly more difficult for a person to succeed in claims of racial discrimination.

Unless the form of discrimination is highly ‑‑ it represents old fashioned, forms of racial discrimination that are fairly blatant and long‑standing, it was only these types of claims of racial discrimination that tended to succeed in courts. The majority of claims, when I looked at the legal literature, is that most, 80% of claims of racial discrimination fail.

So, race‑based traumatic stress is a way to break the blocked avenues of redress and relief for contemporary forms of racial injustice. And, therefore, the conceptual models that we're employing or we set out to frame our measurement strategies were Carter and Helms' notion of classes of racism and Carter's notion of race‑based traumatic stress. So, there were two conceptual frameworks.

One was classes of racism experiences as avoidant, hostile and avoidant hostile and race‑based traumatic stress injury not disorder. And I can explain what I mean by that if anyone wants to know.

So now we've moved to step two: The measurement of racial discrimination and racial trauma. So, we've defined two conceptual phenomena that we might need to measure: Does racial discrimination or do racial discrimination experiences, can they be captured in the classes of racism that I just described? Is that possible? And can that be done with a valid or can a measure be generated that reflects those classes?

And racism's effects ‑‑ does racism produce race‑based traumatic stress. That's our question that framed our measurement strategy.

So, again, as good and thoughtful researchers, we looked to the existing literature at the time, and we looked at life event stress research. We looked at posttraumatic stress disorder research or trauma‑related research, studies in discrimination and race‑related stress studies.

And these bodies of literature were our starting points. We believe that this would give us tremendous information and strategies for how we go about trying to determine whether classes of racism can be established and whether there's such a thing as race‑based traumatic stress injury.

What we learned from this literature, these literatures, is that they don't overlap, and hardly any of the studies investigated any connection between racial events and a person's psychological or emotional reactions.

When race‑related stress was studied, trauma was not. When stressful life researchers used racially diverse samples, they never looked at racism or racial discrimination as a factor in stressful life events. Trauma researchers did not ever consider racism as a factor in PTSD, with the exception of one researcher.

Even though the majority of these studies that included participants of color found that people of color had unexplained high levels of PTSD and they would often speculate that this had something to do with race and racism or their marginal status in society but, again, they never integrated that into their research studies.

So, these areas of research do offer evidence that racial encounters seem to be related to some form of traumatic stress, but they do not offer any information that they're related to traumatic stress, but they did show that psychological distress and race‑related stress did occur.

So, it was the case that there were over 30 instruments that assessed racism and discrimination at the time. And these instruments had various limits or limitations. Some of these limits and limitations made it more difficult to use to understand the phenomena that we were trying to capture. So, for instance, many studies used community experiences, not experiences of individuals.

They focused on work and educational settings more than they did anywhere else. They often employed college student samples which were not representative of the folks that needed to be sampled.

And more to the point, only a few used thoery of any kind. And when theory was used, one of the most prominent theoretical models was Folkman and Lazarus' stress and coping model. If you know anything about stress and coping, it has nothing to do with race. So how you can't understand racial encounters if you don't have a conceptual model that has something to do with race.

So, then there's the unfair treatment strategy in understanding discrimination where you identify unfair treatment and after the fact you identify the cause of that treatment. We didn't think this would help us connect a person's specific racial experience to psychological emotional reactions to that specific or racial experience if they're identifying generic unfair treatment.

And many studies that we encountered, racism was measured with a single item or with many events over a lifetime, a year or so on, and many of the researchers involved in this type of work did not provide psychometric information about the instruments that they were employing. But lastly, there was little information about the link between the experience of discrimination directly and a specific person's reactions or psychological emotional reactions to that event.

Step three, who should be included in the studies if you launch investigations? We found that racial discrimination is not exclusive to people of color. However, they do have higher exposure rates.

A national survey of discrimination in mental health found that one‑third of Black and white participants had one major experience and more than half, 60%, reported day‑to‑day experiences of discrimination. So, this data, among others, indicated that any measure designed to assess the impact of discrimination would need or should be tested in the sample that is racially heterogeneous.

So, we needed to include whites and a range of people of color and not focus on any particular racial group. So, believe it or not, we've moved through our steps and are now at step four, which is scale development and pilot studies.

And what I'm going to do here is talk in generic and broad strokes and can address more of the detail, perhaps, in the Q&A at the end of our session one.

So, one concept that had to do with classes of racism really involve frequency and stress of discrimination experiences, how often was a person, their personal experience of racial discrimination and, secondly, did they find that experience at all stressful. The second involving race‑based stress had to do with whether racial discrimination experiences cause a person, a particular person, lasting symptoms or effects.

Again, these line up with the two conceptual frameworks. So, to construct the approach for assessing classes of racism, it took us some six to seven years as well as the race‑based traumatic stress scales, and that timeframe includes constructing the measures, deciding on their design and formats and collecting data.

So, for classes of racism, we utilized 70 racial discrimination experiences, and for each we asked about the frequency of the experience, did it happen once every few years, once a year, once every few months, et cetera, up to daily or several times a day, and was it stressful.

So, for the classes of racism instrument, we borrowed items or utilized items, modified items or existing instruments and wrote our own because we found some experiences didn't capture all the types of things we wanted to include.

And the measure we asked how often the racial discrimination experience occurred in the past year: Not at all to several times a day. And with regard to stressfulness, we asked a similar range of from zero to four: Did it not happen at all? Were you slightly annoyed by the racial discrimination experience? Or did it cause you trouble functioning? Which is a high degree of stress.

For each of these experiences, participants separately indicated the frequency of the event and if the event was stressful. For race‑based traumatic stress symptom scale, we generated 147 items because here we were trying to capture a range of symptoms, about 10 different areas of symptoms that might emerge from an event that was experienced as stressful or traumatic. And again, we generated our own items and we also outlined items from other measures.

In the preparation for collecting data, we determined reading levels and reduced item duplication and were comfortable that the measure had face validity. We decided on using an open‑ended format in which we allowed participants to describe three memorable events of racism in their lives: Persistence from one of those three; they selected the most memorable. With the most memorable, we asked them to complete the symptom section of the measure.

And here we say using that memorable racial experience, indicate yes or no if the event was, A, one, emotionally painful, beyond your control and sudden. Then participants used that same event to complete the symptom section, and again the instructions for the symptoms section were below a list of feelings that people sometimes have after an upsetting event. Followed by reading each carefully and circle the number that best describes your feelings.

The reaction item then we asked them, as a consequence of the memorable encounter I had with racism, I felt sad, or I experienced tiredness and lack of energy and so on.

For each potential symptom or reaction there were three things that a person had to report. One was after the event, within a month, did you have this reaction? And they could say it was not my reaction and it happened infrequently or frequently or would not go away.

Then we ask, do you have this reaction now, or recently? Have you had it recently? And lastly, we asked for that reaction, did anyone notice a change in your behavior, yes or no.

So, when we subjected the 147 items to a statistical analysis, we found that there were seven scales, 52 items comprised seven scales, and we were able to determine that the scales captured depression, anger, physical reactions, avoidance, intrusion, arousal, and low self‑esteem, which basically supported the conceptual framework for race‑based traumatic stress.

There were two questions that we had to answer in a subsequent paper or analysis. We needed to establish that the 52 items in seven scales pertained to after‑the‑event responses only. So, we had to establish whether or not the after event and the recent responses for participants were related to one another. And we had to document the importance, did anyone notice a change in your behavior.

In a subsequent analysis, we were able to demonstrate empirically the recent and after responses were statistically related to one another and we were able to show that people who had higher race‑based traumatic stress symptom scores, reported that others noticed a change in their behavior. This was in a Carter paper published in 2015.

So back to classes of racism, in a paper that was published in 2016, we reported on three studies involving classes of racism in which we conducted analysis of the 70 racial experiences. In these analyses we had to separate frequency and stress, and we had to conduct study one and study two. Study one was frequency. And study two was analysis of the stressfulness.

I'll get to study three in a moment. In study one and study two, we conducted exploratory analysis to determine if classes of racism could be found with discrimination experiences.

But we had to take a second step after we established that it's possible, we had to then use the EFA results and we had to demonstrate that they can be replicated and confirmed on a different sample, which is a procedure known as confirmatory factor analysis.

So, we conducted exploratory, confirmatory factor analysis for both frequency and stressfulness, and then we conducted study three which tested the notion that classes of racism would predict race‑based traumatic stress symptoms as measured by the race‑based traumatic stress symptom scale.

So, what did we find? For frequency of classes of racism, we found three scales that were a total of 18 items in which hostile had seven; avoidant, five; aversive-hostile racism, six items. Study two found classes of racism for stressfulness was made up of 22 items and 11 for hostile racism, five for avoidant and seven for aversive-hostile.

Again, using these classes of racism in study three, frequency, stressfulness separately, we predicted or tried to predict race‑based traumatic stress symptoms. What we found is that the classes of racism did predict race‑based traumatic symptoms both for frequency and stressfulness, and overall, we found that stress was related to 13 symptoms and frequency to seven.

And for stress, hostile and avoidant were more strongly related to race‑based traumatic stress than aversive-hostile racism.

So, I need to go back to how we score the race‑based traumatic stress symptom scale. Remember, there are seven scales with a total of 52 items. So, the number of items per scale ranged from 10 to four. But we needed a scoring procedure that let us see stress and trauma ‑‑ and/or trauma. And in this way what we needed to see -- or to facilitate interpretation -- is that we needed to show that the symptoms were elevated or were beyond the norm or beyond the average, so to speak.

So, to accomplish this, we recommended that scores, the raw scores be converted first to a standardized format for each scale and person and then we changed the standardization from one that's a little trickier to interpret to one that's easier to interpret.

So, our procedure is to take some scores, change them to Z scores, where Z scores have a mean of 0 and a standard deviation of plus or minus 1. So, the standard deviation is how much scores differ from one another and within what we call the normal curve.

If you then take a standard score and convert it to a T score, you change the meaning from 0 to 50, and you change the standard deviation from plus or minus 1 to just 10. So, you leave out the plus minus issue.

An example of this conversion is we're going to assume we have a depression scale score. Depression is made up of 10 items with a maximum of 40. And let's say we have a scale score of 16, that's just a raw score adding up all the responses for the person's depression items. And we calculate the mean for this person as coming to 4.66 to standard deviation of 6.46. Sorry about the numbers, but they're necessary.

If we have a Z of 16, we subtract the mean which is 4.66 and divide that number by 6.46. What we got is a Z‑score of 1.76. Then if we convert that Z‑score to T, we simply multiply 1.76 by 10 and add 50. What we get is a score of 68.

In all of you, scores above 55, which is half a standard deviation above the mean, are elevated.

But we tend to try to stay with elevations that are one standard deviation above the mean.

And you can see ‑‑ I'm sorry. You can see that 68 is almost two standard deviations above the mean. I think it's fair to say that that person exhibited high levels of depression by the score.

So, some thoughts about the decisions about format and response options in the way we went about doing this.

You'll notice we treated frequency and stress responses differently from an individual's reactions to a memorable racial incident.

So how come we did that? Well, one thing is we can't really determine across a range of experiences that someone might have reported that may have occurred frequently for them and also may have been stressful. We cannot determine if a person, whether any of those particular events caused any form of stress or trauma because the assessment is of a series or group of events.

So, it's not really possible in that situation to discern if a person had a particular set of racial encounters. They were harassed in a store; they were subjected to racial discriminatory practices in their work setting or at school.

We cannot determine for that person whether that experience that happened within X amount of time produced any kind of stress or traumatic reaction. It is not feasible to use frequency or stressfulness generically to assess an individual's reaction to a racial incident.

Instead, we can establish that the general experiences capture classes of racism. Now, with the classes, we can contend that if the type of experience the person had been avoidant or hostile, we can now ask whether or not that hostile racism or avoidant racism experience or experiences are related to a specific set of reactions or symptoms for that person.

And that information can determine whether or not the person had found that experience stressful and/or traumatic, whether they experienced racial trauma.

If you take the memorable experiences and the reactions to those memorable experiences, now we can determine how that racial encounter, series of racial encounters of discrimination impacted that person. We can determine if it was stressful or not or we can determine if it was traumatic or not, because we can report and document specific symptoms. And we can also determine that whenever this happened, they had reactions at that time, and that they may still manifest some of the reactions in the present.

If it's involving a litigation process, it may have occurred several years in the past, but they still may have reactions in the present when they're reminded of this.

We can also document and confirm the impact of the reaction that others may have observed in that person. Again, it helps us corroborate the person's report that they had the reaction and others noticed it. But there's more.

This strategy I'm talking about allows us to assess whether discrimination is related to stress or trauma. Again, the experience has to meet multiple sets of criteria. It has to be emotionally painful. It had to have happened out of their control and suddenly; they had to have reported symptoms or a set of symptoms that contribute to impairment in identity and interpersonal relationships and in social function.

It's not enough to say that something stressed the person, it's also important to show that the stress and/or trauma that was experienced contributed to what we call functional impairment; that it interfered with a person's ability to function, and therefore they were injured as a result of that racial encounter.

And the distinction that I'm making between being injured versus having a mental disorder, which is why I reject the notion of post-traumatic stress disorder reaction is that there's no legal recourse or legal claim that you can file for someone making you crazy or driving you crazy. That's not, in my knowledgeable, actionable. If it is, I'm not sure that that's ‑‑ I'm not aware of whether that's happened or not. I doubt it.

However, if someone injures you, by definition you have a right to legal redress.

It’s necessary in that context to document the discrimination, the claim of racial discrimination and to demonstrate that it’s caused some form of injury that impaired you or disrupted your life and your functioning.

This form of measurement of discrimination is applicable and can be presented in a court of law or to a helping professional for that person to address the symptom reduction that's necessary.

But you'll notice that this objective of having legal redress in documenting the encounter's impact on an individual person is often not the goal of other discrimination measures developed to assess racial discrimination or racial trauma.

Thank you for your attention today. And I'm not sure ‑‑ I think we have a few minutes. I'm not sure how the organizers want to handle ‑‑ thank you ‑‑ the next portion, the remaining time that I have. I think I still have a few more minutes.

EVENT PRODUCER: Thank you, Dr. Carter. We do have a few more minutes. I think we'll handle all the Q&A at the end of the sessions but we'll add some time to the Q&A so that we can take some additional questions related to your presentation, but we just want to make sure everybody has enough time to get to those questions, but that was an outstanding presentation, a great one to kick off our sessions today and really highlights the kind of foundational work that's been done in this area, that's really allowed us to even conduct the high‑quality research that needs to be done in this area connecting the experiences of racial discrimination and harassment to mental health impacts.

We have next ‑‑ I believe, we have Jessica next, if she's on yet. Jessica LoPresti, are you here?

JESSICA LoPRESTI: I'm here.

EVENT PRODUCER: We'll go ahead and get started a few minutes early so we have some extra time for that extra Q&A at the end. So, I'll be presenting Dr. LoPresti, who will be discussing the association between discrimination and mental illness, and I'm sure has built off of Dr. Carter's work and her work as well. Thank you.

Jessica LoPresti: Wonderful. To clarify, I should stick around for the Q&A that's at 12:30?

EVENT PRODUCER: Yes, please.

DISCRIMINATION AND MENTAL ILLNESS 
Speaker: Jessica LoPresti

JESSICA LoPRESTI: Sounds great. I'm going to attempt to share my screen. All right. That worked. Okay. All right. Well, I just wanted to first start by thanking you all for joining this presentation today.

A tough act to follow with Dr. Carter, but I'll do my very best to present some work that we've been doing and thinking a lot about as it relates to discrimination as a social determinant of health.

And so, I'm Jessica LoPresti, associate professor at Suffolk, and do some consulting work around this stuff as well. I look forward to the Q&A as well a little bit later.

I always like to start this conversation by talking about the current context, the context in which we're living. The population of people of Color is growing exponentially year over year in the United States and around the world.

In the U.S., in particular, we're experiencing an influx of migrants, and with that influx the accompanying xenophobia and trauma that these micro populations are experiencing without access to support.

Of course, we had sort of what our country likes to call the racial reckoning in 2020. I think for many people who were minortized, it wasn't such a reckoning as it was sort of our reality, but for many in the U.S. and around the world there was sort of an unveiling of the pervasive nature of discrimination or oppression in our society.

We're living in the midst of turmoil and genocide across the world and trying to manage how to deal with that on an individual and group level.

And, of course, all of this is happening in the history and current context of exploitation of people who are minortized, particularly people of Color, and mistreatment in our healthcare systems. And under that umbrella, we certainly experience a lack of providers of color, a lack of providers of intersecting minoritized identities, and a lack of providers who are trained in culturally responsive evidence‑based treatment.

This is sort of a brief overview of the context that we're dealing with, and I want to start by talking a little bit about what I mean when I say oppression or when I say racism.

I know probably you've talked about this a lot, but I always like to sort of contextualize it in the way I'm thinking about racism and racial oppression.

Of course, racism is a system of oppression based on race, and it's really important that we describe it as such. I think many of us are really sort of used to this description of sort of the attitudes and beliefs that individuals carry about inferiority based on racial categorization. And that's a part of it.

And the system of racism leads to an inequitable allocation of goods, of resources and of services. And this inequitable allocation of goods, of resources and services experienced by people of color and other minortized identities limits our access to full participation in society.

It limits our ability to engage, to thrive, to feel safe, and so racial oppression is that system that doesn't give us access to the things that we need to be well, and in some ways that's what we're talking about here.

So, when we talk about those goods, those resources and those services, this is really what we're describing, the social determinants of health.

Economic stability, our physical environment, our education, our social context, having access to nourishing food and clean water. And, of course, having access to quality and effective healthcare.

All of these things contribute to life expectancy and mortality and our wellness in general, our ability to function, to thrive, to work, to do really all the things that we need to do in society and, by and large, racial oppression leads to the sort of inequitable access to the very things you see on the screen and the very things that we need to survive and thrive.

And this really creates a context of illness for our communities. I think COVID‑19 is a perfect example of the ways in which it's often internalized or placed on our community that, you know, we are unwell because we aren't healthier because we don't work hard enough or because of any sort of individualized suggestion and really the reason why sometimes we experience sort of, you know, challenging mental and physical health circumstances is because of our inequitable access to the very things we need to thrive and survive.

So, again, a really significant environmental issue and much less, if at all, an issue that sort of should have been placed within the individual. We'll talk about this a lot through the presentation, but I always love to couch this conversation within the of social determinants of health because that is the environment or lack thereof that we're living with as people in communities of Color.

And so, within this conversation, it's always a conversation about meritocracy. I think it is an American ideal. I use the word "ideal" because it's true. This idea that we live in a meritocratic society where we are rewarded for hard work, where we pull ourselves up by the bootstraps, that there is sort of an abundance of opportunity if we can only sort of grab that opportunity.

And it is, in fact, a lovely ideal. You know, as a human living in this world, as a person living in this country, like, I would love it if we did, in fact, live in a meritocratic society. And actually, that is not where we are. That's not what we live in, it's a myth, and it's a myth that is really harmful to the communities who are experiencing disparate access to the resources that they need.

I always like to talk about this myth of meritocracy in the context of a baseball diamond. I think in sports terms all the time, so I apologize for this.

But if the goal is home plate, the idea of meritocracy is that we're all starting at that. When in reality, some people are starting at bat. Some people are starting on third base. Some people are on the bench and can't even make it to the pitcher's mound. Some people are in the parking lot. Some people are at home and can't even make it to the field.

And we're suggesting as a society that those people who are at home and can't even make it to the field experience the same opportunity as those folks who are starting on third base. Sorry even starting at bat.

So, ironically, what we do as a society is we sort of say, if you weren't successful, it's on you. Right? And yet we are going to give some people more access to the things they need to thrive and we're going to take away access or not give access to other people based on their need to thrive.

And so, this idea of meritocracy, some people sort of see it as this beautiful thing, but within our communities, I think what we see it as is a way to sort of keep a thumb or keep a boot on our neck, if that makes sense.

I want to always sort of burst this bubble of us living in a meritocratic society because it creates such significant strain for people who are minoritized and it also creates a false reality for those folks starting on third base.

So, when talking about racism, I like to use James Jones' '96 model to describe racism. I think it's just incredibly comprehensive and clear. And so, I'll do my best to do this model justice. I want to describe it and then I want to provide an example.

So, when we think about cultural racism at the bottom of this pyramid, cultural racism is sort of the centering of the dominant culture, the centering of values, traditions and practices of dominant white culture.

And inherent in that centering of those sort of values and practices and traditions and ways to dress, ways to behave, all those things are the decentering of anything else, particularly those values and traditions and practices of minoritized people and communities. Cultural racism is also the widespread acceptance of negative stereotypes about nondominant group members.

And so, honestly, when we talk about cultural racism, it's that tacit acceptance of the negative messages that we're getting through all venues, social media, media ‑‑ we'll talk more about it ‑‑ about nondominant group members.

And this cultural racism really sets the stage for the institutional and systemic policies and practices and procedures and regulations that happen at federal levels and state levels, happen within our institutions, within our educational institutions, our healthcare institutions, these practices that disproportionately target minoritized individuals and that disproportionately provide us inequitable access to the things that we need.

And, of course, this institutional experience of racism and systemic experience of racism sets the stage for individuals to sort of see themselves as superior/inferior based on the access that they have to the things they need.

So, you can see how this system builds upon itself to create those sorts of interpersonal experiences of racism that we're so used to talking about, that those interpersonal experiences don't happen within a vacuum; they happen sort of on the shoulders of the institutional and systemic racism which happens on the shoulders of cultural racism.

So, I want to provide an example. So, there is sort of widespread and tacit acceptance of the negative stereotypes that are pervasive in our society about Black and LatinX men. We're inundated with messages all over the place, media, social media, television, film, literature, history, fictional history.

We're inundated with these messages that Black and LatinX men are dangerous; that they're violent; that we should be afraid of them; that they're criminals. These messages are so pervasive. As a society, we tacitly accept these images and these messages.

And this level of cultural racism sets the stage for our communities to be disproportionately targeted by police presence. It sets the stage for the disproportional existence of our Black and LatinX men in our for‑profit prison system.

It sets the stage for the targeting of Black and LatinX men with policies like Stop and Frisk, where less than 20% of those stops resulted in indictments or charges. And then of course it sets the stage for individual experiences that Black and LatinX men have on a spectrum where someone might clutch their purse on an elevator with a Black or LatinX man because of these messages or someone might have their family cross the street when a Black or LatinX man is walking down the street, all the way to when a police officer pulls a gun and shoots an unarmed Black or LatinX man because they are afraid, because they are trained and socialized to be fearful of Black and LatinX men.

And this inherently leads to sort of the dehumanization of Black and LatinX men, and it leads to sort of the adultification of Black and LatinX men, which leads to deleterious mental health consequences.

So, I wanted to provide this example so you can see how the systems sort of work in tandem, and there are many more examples I could provide, but I want to move on. But I'm happy to sort of field questions about this model as best I can in the Q&A.

All of this is happening in the context of power and privilege. I know we use these words a ton these days, but I think it's really important to contextualize the conversation because we're experiencing sort of, in our society, like, a burgeoning attack on the idea of power and privilege. And it's suggested that we should not attend to these constructs.

When we talk about power, it's access to resources that enhances our chances of getting what we need, to live comfortably, to be productive, to thrive, to live safely. Power is not only having access to these resources, it's the ability to decide who has access to those resources.

If I were to scroll back to the social determinants of health, what we're talking about is having the power, having the access to those resources and being able to decide who gets access.

And that leads to this inequitable distribution of resources. And privilege being, of course, these unearned benefits and advantages are given to individuals based on their dominant group status.

But privilege is also being sort of given and provided things and it's suggested that you've worked for them. Like, having quality and effective healthcare. That shouldn't be a privilege. That shouldn't be sort of given to some groups and not to others. Right?

Access to nourishing food and clean water. That's not a privilege that should be given to someone and not to others. These are sort of human rights issues, like human dignity issues, and not having access to these things in our sort of capitalistic society has been suggested that it's because we don't work hard or it's because we're not healthy enough, it's because we don't do things as individuals that we should do, when in reality what's happening is there's a distribution of resources and we're sort of rarely on that distribution list.

So, when we see these attacks on diversity, equity, inclusion and justice initiatives sort of across our institutions, across our country, when we see these things happening, what we're seeing is an attack on our livelihood.

I always sort of suggest and talk to my students and colleagues and really whoever will listen that for us politics are synonymous with livelihood. We have to be involved in policy because that policy sort of protects us from not having access to the things that we need and our children and the people we care about.

So, I wanted to sort of contextualize this conversation, and for the rest of the time today sort of ask you all to think about the resources that you have access to as mental health professionals and also as human beings.

So, in the context of power and privilege, I always like to use Pamela Hays' Addressing Framework. I think there are a lot of examples of this, many in counseling and psychology and social work that we can attend to.

And the idea is that we as clinicians, as researchers, as professionals in this field, need to be thinking about the human beings who sit in front of us or the participants in our studies as complex individuals with complex identities.

Like, I am a Black African American cisgender woman. I need to sort of seen with all of those complexities. You can't sort of tease those identities apart to see me. You have to see me as a whole. I think we need to do that both for ourselves and our clients.

This is an important aspect of how we think about our clients and ourselves, how we think about collecting demographic information and how those demographics affect the psychological mechanisms and outcomes that we're looking at in our research.

I always get a lot of pushbacks on our demographic questionnaires because people say this is too intensive, like people aren’t gonna fill this out. I get that, participant burden is important, and we really do need to understand the complexity of our participants so we can inform the field appropriately. Like, this is a validity issue in our research that we need to continue to think about deeply.

I'll get off my soapbox, but that's my plug for sort of thinking about humans complexly in this context.

I want just to talk a bit about the consequences of oppression. This is like the first time I've given a 30‑minute talk. And so, I'm trying to move very quickly and will be here to field any questions.

I want to talk about the context of therapy, and I also want to talk about some mental health models that have arisen in the context of racial oppression in our field.

So, the first thing that we always like to talk about are the ways in which therapy is cultured. It's culture‑bound and its class‑bound, like the values inherent in how we see mental health challenges, how we intervene as it relates to mental health challenges is wrapped up in this culture and class‑bound context.

We expect folks to come to therapy in person or to sign on to a computer and do it weekly, have time in their day to engage in this, have the money to pay for this, have the emotional capacity to set aside time to engage in‑between session activities.

And like, as a therapist, I obviously subscribe to evidence‑based practice, and I have seen it really falter in this culture‑bound/class‑bound situation.

We sort of need to think about the inherent, like Eurocentric idea of individual therapy, the ways in which we expect people to come to therapy and be vulnerable and the context of folks who represent a system that has historically harmed us.

It's not necessarily enough to acknowledge that system. We need to really think about what we're doing to disrupt that system. I think since 2020 we've had a lot of acknowledgment of the inherent challenges and issues with our system, and we've also seen a lot of folk sorts of shy away from the work associated with that acknowledgment.

So, like this is my call for myself and my colleagues and for you in this room to think about, like, how we recommit to disrupting these systems that affect access to quality and effective mental healthcare.

The other thing I want to talk about are sort of the values inherent in cognitive behavioral therapy. Again, I was raised in traditional CBT, and mindfulness and acceptance‑based practices. So, this isn't me preaching against these practices, I just think there's an awareness that we need to have as we engage in evidence‑based treatment as it relates to CBT. And at the core of CBT are the ideas that there is something inherently wrong within the individual.

Like, I've even said it myself in therapy, like what we're doing is we're working on you in this context. I can't do anything about the environment, but I want to work with you to change things about you. Like not in those words, but that's sort of like what we do from a CBT perspective. We place the challenge inside the individual.

If you think back to all the things I've said in the last 10 minutes, you can imagine how challenging it is to be in a toxic relationship that is causing trauma, causing pain, causing violence, causing all of these things and tell the person in that relationship if only they would be different, if only they would change a little bit and shift things about themselves and think differently and behave differently and do things differently, then things would be better.

And I think as mental health professionals, we really need to think a lot about how we position our psychoeducation and CBT for folks who are minoritized and living in this toxic relationship with the country in which they live, right? That you wouldn't tell somebody who's in a traumatic relationship to sort of stay and be different.

And so we need to think a lot more about sort of piece that is inherent in CBT of placing the problem within the individual and not within the environment.

And I also think, as a field and as individuals, we need to think more about how we are disrupting that environment. And hopefully I'll have a little bit of time to talk about critical consciousness in that way towards the end.

So, let's talk a little bit about some mental health models as it relates to racism.

So racial trauma is real. This has been sort of a decade or maybe several decades in the making. Really, Carter was doing this work in 2007, talking about racial trauma.

And Monica Williams, who is a prolific researcher in this field, developed a model that sort of describes the context of racial trauma that I want to do my best to do justice to.

In this model, she talks a little bit about historical trauma, the ways in which we are ‑‑ we are in the midst of or experience this historical trauma through intergenerational messages that our ancestors and our aunts and uncles and grandparents sort of passed down the messages of their experiences of racism.

And also, there's evidence of enzymatic transformation in our DNA intergenerationally based on these traumatic experiences dating all the way back to slavery.

And so not everyone who experiences racism develops trauma symptoms. And folks who experience this level of historical trauma are very vulnerable to the development of racial trauma. So, when we have that bed that we're sitting in that is sort of the inter‑generational trauma, the enzymatic transformations in our DNA, all of our experiences of racism sort of sits on top of that, that we have the cultural racism and the institutional and systemic racism and the interpersonal racism that are sort of all sitting on top of that bed of historical trauma. Even as a young girl, I can remember sitting in my grandparents' living room and hearing their stories, you know, from the early 1900s.

And so, like, it's really important for us to sort of think about that, you know, any one experience or any decade of racism is always sitting on top of the bed of this historical centuries‑long battle.

And then, of course, we have like a traumatizing racist event in the moment, and that's sitting on top of the many experiences that we've had. And the historical trauma can create sort of these trauma‑related symptoms like shock and fear and re‑experiencing the event and physiological arousal, all the things that I've seen so starkly and so clearly from those folks who have experienced a criterion A trauma.

And I should say that racially traumatic events don't have to be Criterion A. Many of them are and can be. And, like, there is so much literature that racial microaggressions, the interpersonal experiences of racism, that systemic and institutional experiences of racism also lead to these sort of trauma responses.

And so, there's a sort of conversation in the field going on whether we should battle to have racism as a Criterion A trauma. And that's, like, a whole other talk I can't get into right now. I would be happy to answer questions about my thoughts around that.

And I think what we need to focus on are the ways in which racism, at all levels, are creating PTSD‑like responses. And like what does that mean for our field and our interventions.

And then, of course, when people have these experiences, there is invalidation everywhere. Invalidation interpersonally, invalidation within our systems. There's invalidation coming from our government. There's invalidation coming from our health professionals. Right? We experience this invalidation in primary care settings, in therapy settings, at the dentist, in our schools. Like, it is everywhere. And that invalidation is sort of like pouring gasoline on the fire of these symptoms.

So, we're having these symptoms, and they're pervasive. And then society is, like, pouring the canister of gasoline, and the flames are growing and growing. And then we get to a point where we want to seek care and it's not there. Like, it's not good enough. I don't know any other way to say it. It's just not good enough. There aren't enough providers of color. There aren't enough providers with intersecting minoritized identities.

And that says a lot about our training system, how we train therapists, how we make our programs, our mental health programs for graduate students, inclusive and equitable and a place where people who are minoritized can thrive. And, again, that's another talk. Right? But we don't have enough providers of color, and we also don't have enough providers who are sort of committed to the ongoing nature of providing culturally responsive care.

And so all of ‑‑ this whole constellation, this whole model, leads to racial trauma. So, I just wanted to give the context that it's not just one event or it's not just a few events or it's not just seeing an event on television; it's the culmination of centuries of oppression.

And so, I hear a lot of people say, well, slavery was, you know, a million years ago. Like, why are we still talking about it? Like, this is why. Because we're still sort of living with, you know, the aftermath of that to this day. Okay? And so, I also want to talk about our CBT ‑‑ traditional CBT models that relate to racism.

These types of models have been, again, coming out since forever, certainly since Carter in 2010, and have been sort of built upon by Monica Williams and so many other people. But the idea, like, from a traditional CBT perspective, an event happens, we perceive that event, an emotion arises because of that perception, and then we behave. Right.

And when we think about racism, it's very similar. Right? We have a race‑based encounter, and in our minds, we're appraising that event and frequently appraising it negatively. And what we're looking for are those sort of core thoughts related to safety, related to belongingness, related to work and value, because, like, those are the perceptions that are sort of eating at mental health and wellness: I'm not safe. I don't belong. I'm not of value to anyone. I'm not worthwhile.

We know from, like, all of the anxiety literature, all of the mood disorders literature, the trauma literature, that, like, those types of thoughts lead to these negative emotions like anxiety and anger and sadness and hopelessness and helplessness.

And, like, I've seen it so often in my therapy space, in research, like, with my students, right, that this cascade of race‑based encounters and appraisal and negative emotions lead to avoiding the things that are most meaningful like avoiding school, avoiding work, not being able to engage in those contexts, not being able to engage in social support, not being able to engage in healthcare, not being able to engage in any of the contexts that sort of feed our wellness.

And so, you know, I wish I could talk more about intervention here, but we only have 30 minutes. But I want to present this model as something that's not so divergent from what we know. Like, this really fits squarely into how we understand CBT models and what we want to think about as where we intervene. Right? The intervention is a bit different, right, because of that culture‑bound, class‑bound situation that I talked about a bit earlier.

So how am I doing on time? I think I maybe have like 10 minutes. Okay. So, this model that I'm showing you here is a model that my colleague Tahira Abdullah‑Swain and I have developed over time, and it's the idea that racial oppression leads to these sorts of underlying psychological mechanisms that then lead to anxiety and negative mental health outcomes.

So, from this perspective, racism sort of leads to a lack of perception of control over our environments. And we know that perception of control is linked to anxiety and other sort of mental health consequences; that when we experience oppression, it leads us to sort of believe that we don't have control over our physical or emotional safety and that we also don't have control over the physical or emotional safety of the people we care most about.

And this idea, perception of control or agency, is really core to mental health outcomes. And what makes it worse is that when we talk about people who are minoritized across intersecting minoritized identities, it doesn't even matter, like, who you are or how you behave. It doesn't matter how wealthy you are. It doesn't matter how hard you try to live within sort of society's rules or society's boundaries. Like you'll talk to people who are minoritized and they'll say things like "I've been doing all the right things. I pay my taxes. I go to work every day. I'm 
kind, I'm" ‑‑ whatever it is ‑‑ "I do all the things to live in line with society's expectations, and yet every day I have these experiences."

And so that contributes to this perception of, like, what is it that I can do to make other people or systems or cultures see me as a human being.

Like, what is it that I can do to make sure that my Black son is seen as a human, is valued as a human like everyone else's son, right? Like we teach our kids to do all the right things and they do all those right things, and they are gunned down in the street by police officers, or they are sent home from school for a minor infraction, or they are, you know, ostracized in other ways.

And so, this lack of perception of control that is sort of maintained by consistent experiences of oppression leads to mental health consequences. And, of course, the internalization of these messages. As we talked about earlier in this talk, we are inundated with negative messages about who we are, like, everyone who is minoritized has this experience that we are inundated with these messages.

And we know that critical beliefs about oneself and one's worth lead to anxiety, leads tomood disorders, and leads to other sort of challenging mental health issues.

And when ‑‑ you know, I often say to my clients of color, like, I would be shocked if you weren't internalizing this. Like, any human being would fall prey to internalization of oppression because we're living in a society that so pervasively espouses these negative messages about who we are and our worth and value. And so, like, it is actually a human reaction to internalize messages in this consequence, and so ‑‑ in this context.

And so, I don't want to place ‑‑ I think oftentimes when we talk about internalization, we're sort of teetering on the line of placing the blame within the person, and I want to be careful about that.

I think there are lots of interventions we have that sort of help folks manage this, and I also want us to focus as a field on how we are talking to our clients about this. And the last piece that is so near and dear to me ‑‑ everyone I know hates how much I talk about values, but it's my favorite intervention, it's my favorite thing to talk about, because I think it is so linked to wellness; that when we experience pervasive oppression, it often leads us to avoid the things that are most meaningful to us, which exacerbate our mental health challenges.

And so, like I said, I've had students email me and say, "I can't come to class; I just saw something on the news" or "I experienced racism on my way to class and I had to go home." Racism is getting in the way of them doing the things that they want to be doing; engaging with people, doing the things that they need to be doing.

This happens to my clients all time, like "When I am at work, I can't function. I'm not able to engage there the way I want to be engaging. I'm not able to be thoughtful and participate in meetings and do all these things."

So, oppression leads to us avoiding, often, the things that are most important to us because we're just trying to survive. It is a survival instinct to sort of turn inwards and create a shell to protect ourselves. And that shell is in some ways keeping things out, not allowing things to harm us, but it's also not allowing us to experience the world in the ways that we want to and need to be experiencing the world. Right?

Like I said, this inequitable allocation of goods, of resources and services, limits our access to full participation in society. And that is really what we're talking about here.

Okay. So, the last couple things I want to quickly touch upon is, you know, we've been talking on our research team and, with my colleague Tahira Abdullah‑Swain, too, about the role of critical consciousness in our interventions and how it starts really with our therapists, the people who are intervening and the people who are doing the research.

How are we consistently and consciously developing an awareness of our sociopolitical and historical structural contexts that facilitate oppression? What are we doing to educate ourselves about this? And how confident are we in our ability to spark change.

I talk to my graduate students about this all the time, that it's, like, rough out there in the world. We try to teach them to be social justice oriented within the softness of our program, and then they go to their clinics, or they go to their practicum sites and their internships or post‑docs and beyond and experience sort of this, really, challenge in their confidence to spark change within these antiquated, embedded oppressive systems.

And so, what are we doing to cultivate that confidence in ourselves, to cultivate a community that can enact change and to cultivate that in the folks that we're working with and that commitment to engaging in anti‑oppressive actions always.

We're not always going to get it right. Like, I don't always get it right. In fact, I make a lot of mistakes. And I'm committed to continuing to engage in anti‑oppressive actions within my systems that I'm working within, within my education systems. It's not easy. And we have to be committed to this if we're going to provide culturally responsive care, if that makes sense.

And in that context, if we are sort of engaging in that level of critical consciousness as mental health professionals, we can then engage in fostering self‑advocacy and empowerment with our clients who are minoritized, talking with them about sort of who they want to be, what's meaningful to them, knowing themselves, knowing their needs, knowing how to get what they need, empowerment and sparking change in their environments.

And so, you can see the synergy here. If we're not doing the work, we're not going to be able to support our clients in doing the work. But if we are, then we can sort of make change both on our systemic level and help them make change in their systemic level. And so, this is sort of the journey as it relates ‑‑ part of the journey as it relates to culturally responsive care is that fostering of critical consciousness and then that fostering of self‑advocacy and empowerment.

All right. I am going to stop there. I don't know how much time is left but thank you all for spending 30 minutes with me. I know you're very busy, so I appreciate it.

MARY ROONEY: Thank you so much, Dr. LoPresti. I know we have a lot of questions for you during the Q&A, and I saw a lot of comments just about how much they appreciated your presentation as it was happening. So, thank you.

And our last presenter in this first series of presentations this morning is Dr. Devin English, who will be discussing the impact of discriminatory policy on mental health.

So, Dr. English, I'll hand it over to you.

THE IMPACT OF DISCRIMINATORY POLICY ON THE MENTAL HEALTH OF BLACK AND LGBTQ+ PEOPLE

Speaker: Devin English

DEVIN ENGLISH: Thank you so much. It really is an honor to follow up Drs. Carter and LoPresti.

This presentation will really represent an application of much of what they have talked about and is a study that is titled "Systemic White Supremacy: U.S. State Policy, Policing, Discrimination, and Suicidality Across Race and Sexual Identity."

This is a study that was recently published in the Journal of Psychopathology and Clinical Science, formerly known as Abnormal Psychology, and it was with my co‑authors Dr. Linda Oshin, Felix Gabriel Lopez, Justin Smith, Dr. Danielle Busby and Michael Anestis.

So many of you will know about the emerging research on suicide inequities among Black communities and Black LGBQ communities, and many of you will be familiar with the facts and research showing that Black U.S. American youth are dying from suicide at faster rates than any other U.S. racial ethnic youth group. It was recently highlighted and addressed in the Emergency Task Force on Black Youth Suicide and Mental Health through the Congressional Black Caucus.

Now, these trends are not just happening with youth. Recent research has shown that from 2000 to 2020, suicide rates increased among Black adults and decreased among White adults. And these trends appear to be inequitably pronounced among sexually minoritized communities.

In a recent study from our team, which included the New York City Department of Health and Mental Hygiene and researchers in the New York City area, we focused on YRBS data from New York City from 2009 to 2019. And what we found was a replication of past studies that have found that heterosexual youth and adults have lower rates of suicidal ideations and suicide attempts.

And you can see those here at the bottom with the dotted lines. The solid lines up here are the trends that we saw with lesbian, gay, and bisexual youth. And although there were inequities by sexual identity, when we disaggregated by racial identity, we found that the only group ‑‑ the only lesbian, gay, and bisexual group for which suicidal ideation and suicide attempt were increasing and increasing at increasing rates from 2009 to 2019 were Black sexual minority youth, LGB youth.

And so why is this? Why are we seeing these trends happen? Well, I think Drs. Carter and LoPresti highlighted many of those reasons. And I think the application of much of their work and ‑‑ is rooted in and helps to inform what we understand to be a critical health equity approach.

This is highlighted by Dr. Lisa Bowleg in her 2017 Health Education and Behavior article which challenged us as public health professionals to understand that population‑level inequities, population‑level health inequities, are not rooted within individuals.

In line with critical theories like queer, Black feminist, and critical race theory, the intersectionality framework, we should be focusing on how these population‑level inequities are rooted in structural inequities, are rooted in structural causes.

What is shared by these critical approaches is a focus on identifying those structural causes and taking action to address them. So, we're going to talk a little about that.

Now, if we were in class, my class right now, to my students I would say, "So we see these trends happening over the last decade, increases in suicidality among Black queer communities. What has changed? What are the structural causes that we might point to?" And you likely might be thinking, well, there's the anti‑LGBTQ policies that have proliferated in state legislatures.

In 2023 alone, we saw everything from the criminalization of drug shows to sports restrictions. 75 anti‑LGBTQ bills became law in 2023 alone. And that were just a few ‑‑ represent just a few of the overall anti‑LGBTQ bills that were introduced and then ultimately reintroduced, or some new bills were introduced. Over 300. Over 300 in January 2024 alone.

And so, this is an example of some of the potential structural causes. We have seen a similar approach with anti‑Black policies. And just to note that these are not mutually exclusive. Consistent with an intersectionality framework, we see that the application of these and the way in which these are formed are often formed in ways to target Black LGBQ communities and privileged White heterosexual communities. And we'll talk a little bit about that.

A few examples of what we've seen for anti‑Black policies are anti‑CRT measures that have been adopted by over 28 states, attacks on DEI in colleges, industries, and government which are targeted at reducing the representation, reducing the inclusion, reducing racial equity within those areas.

And we see states and cities re‑embracing tough‑on‑crime laws. Right? We know that the application of these policies, including tough‑on‑crime laws, increase the policing of Black and LGBQ communities, that increases the policing and increases incarceration.

And because of the presence of these policies, we see that from 2011 to 2018, U.S. police were 43% more likely to stop Black drivers than White drivers. State prisons continue to incarcerate Black Americans at 4.8 times the rate of White Americans. And we have emerging evidence, though we continue to need research in this area, but what we have suggests that sexually minoritized people are disproportionately targeted by law enforcement.

Here in New York City, Black LGBQ communities are more likely to be stopped and frisked than their White LGBQ peers. Police misconduct tends to be disproportionately focused on Black LGBQ New Yorkers compared to White LGBQ New Yorkers.

And so how do we understand these trends? We're seeing a decades‑long trend with increases in suicidal ideation, behavior, and completion among Black LGBQ communities. We see decreases among White and heterosexual communities. Well, as I mentioned, critical frameworks situate the source of those inequities in structural sources of oppression, some of those which I've just reviewed.

However, what we see with suicide research is it tends to be hyper‑focused on the individual‑level predictors of suicidal ideation and behavior. I think Dr. LoPresti highlighted that so well, where we tend to focus on helping individuals cope, right, understanding the individual‑level predictors rather than zooming out and understanding the structural‑level drivers.

And we know there's now quite a bit of research that shows discrimination is a strong predictor of suicidal ideation behavior. But what are those upstream predictors of discrimination and suicide inequities? What is driving inequities in discrimination and suicide.

Well, in this study, this application of the work that you've already heard, we sought to measure whether state‑level indicators of anti‑Black and heterosexist criminal legal policies predicted policing and, in turn, discrimination, suicidal ideation, and behavior across racial and sexual identity.   

This sample was an adult sample, and it came from three states: New Jersey, Minnesota, and Mississippi. All participants were recruited in 2021 for this cross‑sectional study, and they were recruited via Qualtrics Panels using quota sampling to match participants to 2010 state‑level census data.

Now, for our subsamples we focused on White heterosexual participants, for which we had 3739, Black heterosexual participants, for which we had 802 participants, White lesbian, gay, bisexual and queer participants, for which we had 377, and then Black lesbian, gay, and bisexual participants, for which we had 146.

Now, you will notice that ‑‑ just a quick look at those numbers ‑‑ we are much more likely to find statistical significance with some of those larger groups than some of the smaller groups, and so I just want to preface that.

I also want to preface the fact that only 19 of our participants included in the sample identified as transgender or gender expansive. That's important because those policies, those anti‑LGBTQ policies that I just mentioned, those target trans and gender‑expansive communities, trans youth in particular, at much higher rates. And so, unfortunately, we weren't able to look at that in this study, but it's something that's really important for future research to understand and for us to advocate against.

Now, we ran all our study models as path analysis with an Mplus 8.4, and I will walk you through those models.

Now, in terms of our measures, how did we measure this? This is an area of further development, something that I'll talk about in a moment. But for the criminal legal policies, the anti‑LGBQ criminal policies, we used the Movement Advancement Project's state criminal justice and laws measure from 2021.

For those of you who don't know, Movement Advancement Project, it's an organization that's doing incredible work in identifying and documenting all of the anti‑LGBTQ laws that are at the state level and helping to code those and understand those. And we’re now having the ability to apply them more to research.

So, these criminal legal policies measure was a composite score across three different policies. One, whether or not states had a hate crime law which made it ‑‑ makes it a hate crime to target LGBQ individuals because of their identities, coded whether there was a ban on gay panic defenses. For those of you who don't know, a gay panic defense is when an individual justifies violence based on a panic that is associated with learning someone's sexual identity. It sounds ridiculous as I'm saying it, and that's my reaction. It continues to be applied today.

HIV criminalization laws. For those of you who don't know, HIV was criminalized in dozens of states in the U.S. That makes it a criminal offense to pass along HIV. And so, we had a composite score based on those three measures.

For anti‑Black laws, we use the incarceration rate gap from Mesic and colleagues from 2018 which provided a score based on Black/White race ‑‑ sorry ‑‑ incarceration inequities from 2000 to 2015.

Many of you will know that many anti‑Black policies are simply baked into states. Right? And so, it is ‑‑ although we have voter suppression laws in many of those I mentioned, one of the good distal indicators of racist state policies is whether or not there are incarceration inequities based on race. And so that is the measure that we used. For police stops, we have a single dichotomous measure, and that asked about, in the past year, have you been stopped by a police officer when you were in a car, on a motorcycle, on a bike, or out walking? And so that was a single dichotomous measure. And so potentially very simple and potentially may have missed many of the experiences of our participants, which, importantly, given better measurement, we might expect the effects that I'm about to show you to be even larger.

For discrimination, we used the Everyday Discrimination Scale. We did not use attribution in this case. Attribution, although critical in many studies, it's not necessary, and there's been recent research that attribution is often difficult for our participants to engage in and is not necessarily consistent with intersectionality, the idea of being able to separate, “was this based on my race, was this based on my sexual identity,” et cetera. And then for suicidal ideation and behavior, we used the Self‑Injurious Thoughts and Behaviors Interview.

So just for a couple of descriptives really quickly we found, consistent with past research, sexual identity inequities in suicidal ideation and behavior, and we did not find there to be racial inequities among the LGBQ participants in this case.

So just to review the model, we looked at whether state policies that I just highlighted were associated with past‑year police stops as an indicator of institutional oppression, whether those were associated with everyday discrimination in the form of interpersonal oppression, and then past‑year suicidality that included past‑year suicidal ideation and suicidal behavior.

And we looked at this separately for Black LGBQ participants, Black heterosexual participants, White LGBQ participants, and White heterosexual participants.

Now, I'm going to highlight the right side of this model really quickly. What we found was that for Black LGBQ participants, past‑year police stops were possibly associated with everyday discrimination, indicating that police stops are part of the constellation of everyday discrimination that our participants were experiencing. Consistent past research, we found that everyday discrimination was associated with greater likelihood of past‑year suicidal ideation and suicidal behavior. Now, we've found a consistent pattern across all participants in this regard, that past‑year police stops were stressful, a form of everyday discrimination that was associated with suicidal ideation and behavior. So that included among Black heterosexual participants, White LGBQ participants, and White heterosexual participants.

Now, what's the difference here? The difference is, is that White heterosexual participants were substantially ‑‑ had a substantially lower likelihood of being stopped by police. Why was that?

Well, what we found was that state structural racism and state structural heterosexism scores were associated with higher likelihood of past‑year police stops for Black LGBQ participants. Potentially unsurprisingly, for Black heterosexual participants we saw a significant association with state structural racism but not state structural heterosexism, which you might expect.

Now, for White LGBQ participants, we did not find significant associations between state structural racism and state structural heterosexism.

Now, what did we find with the White heterosexual participants who had lower levels of police stops?

We found that in states higher on structural racism and higher on structural heterosexism, that White heterosexual people were less likely to be stopped by police in those states, which was associated with everyday discrimination, past‑year suicidal ideation and past‑year suicide attempt. This was a significant indirect effect suggesting that upstream, these state policies were benefiting our White heterosexual participants. In the language of Dr. LoPresti, it was empowering and privileging these White heterosexual participants.

And so, I think there's many important take‑homes from this. I think that this is a new collection of applications of the research in terms of focusing on the interconnection between state policies, institutional, interpersonal drivers of suicidal ideation and suicidal behavior.

I really want to stress, though, that one of the things that's coming up in this study ‑‑ and we're finding this in other studies where we're applying Movement Advancement Projects’ state and local metrics ‑‑ is that it's not just that Black LGBQ communities are being harmed, but White heterosexual people are being protected. Right? They benefit from racist and heterosexist state policies.

And so, I think it's really important that when we're thinking about ‑‑ and we're going to talk about, briefly, federal, state, and local actions ‑‑ for those well‑meaning White heterosexual people who don't want to live in an inequitable society, it is incumbent upon those communities to take action against those policies that are not just harming your neighbors but are benefitting you.

And so, these results really support the need for policy‑level structural intervention to reduce suicide inequities at the intersection of racism and heterosexism.

So future directions. I talked about critical theories, and so I'm going to talk about action, because critical theories are based in social action, in applying evidence to advocacy.

And so, at a federal level, the passage and robust enforcement of the Federal Equality Act may be particularly beneficial for Black LGBQ communities.

For those of you who don't know, The Equality Act prohibits hate crimes and LGBTQ discrimination in employment, housing, and public accommodations, which dozens of states have not passed. And so federal action would prevent and protect against negligent or discriminatory state‑level policies.

Now, there's been action taken through several legislative sessions to advance The Equality Act. It will not advance now. And so, there's little hope that The Equality Act will be passed at a federal level in the current state.

And so, what can we look at? What action can we take at the state level.

Well, I highlighted HIV criminalization laws as a part of our anti‑LGBTQ stigma measure. HIV criminalization laws are on the books for dozens of states. And that included New Jersey, home state of my university, Rutgers University, and we just overrode it. We just repealed HIV criminalization in 2022.

So, it's quite a bit of work that can be done at the state level to address laws that are being tracked by Movement Advancement Project, that are being tracked by ‑‑ in other areas, particularly among state legislatures that are amenable to this that might just not know about these laws being on the books. And so, advocacy at the state level would be really important.

However, I think the most important is local action. Why do I think that is the most important? Well, as highlighted by Drs. Bassett and Galea and many others, reparations as a form of public health intervention to confront intergenerational and intersectional oppression has incredible promise. And we see local action being taken in municipalities like in Evanston, Illinois. And it is incumbent upon us as public health researchers to understand and track the potential benefits of the passage of reparations on a local level where it often is the most politically viable.

And so in terms of ‑‑ for future research, I think addressing some of the issues that I highlighted with this study, which is really kind of, you know, we hope to replicate and move forward, and we hope to do that, I think, by examining the intersection of policies, not just assuming that racism and heterosexism are in separate boxes, and understanding longitudinal effects on suicidality with robust and community‑defined measures.

And I am so proud to say that our research team recently received an R01 to do just this. We have a team of community advocates and community leaders, policy experts, care providers and researchers who are working to find ‑‑ to define the structural oppression, to identify areas to understand how structural oppression is playing out and understand its potential negative impacts.

And so, I am so excited to work on that project with our amazing research team, and I'm really excited to talk about this work with you during the Q&A.

And thank you so much. Thank you to the participants, to the coauthors, of course, the funders and the mentors, including the 2008 University of Maryland Assertive Community Treatment Research Action Team, without whom I would not be here today.

Q&A

MARY ROONEY: Wonderful. Thank you so much, Dr. English.

And thank you to all of the presenters this morning for these wonderful thought‑provoking, insightful presentations.

And now we have some time for Q&A.

So, Dr. LoPresti and Dr. Carter, if you could both come back on camera so we can all see you and hear from you. And Juliette will also be joining us at NIMH.

And we've received many, many questions in the Q&A box. We won't be able to get to all of them today, but hopefully we can get to quite a few of them.

And I'm going to start with a question that I would address to all three of our presenters today because I think it really applies to all of your respective areas of research. And this question is asking ‑‑ it says that in the research, all the research that's been presented today, really, we speak about groups of individuals as either minoritized or not. Kind of this dichotomous categorization. And I think this happens throughout the research literature in this area and just generally, broadly, or even more broadly speaking.

But as this attendee points out, the groups that are in the minority can change depending on the communities that you're in. So, for example, in Atlanta, White people are the minority. However, with how we've learned to talk about groups, we would still classify that group as the majority.

So, I think there's two questions related to this. Can you ‑‑ the attendee would like to know if you could speak to how this sort of thinking can perpetuate racism in communities, and, relatedly, with the focus that we have today on research, how can we account for this phenomenon in our research and our interpretation of results so that we can have the most accurate and nuanced findings possible.

JESSICA LoPRESTI: I can start.

MODERATOR: Sure.

JESSICA LoPRESTI: Is that okay? Okay. I'm sure my colleagues have a lot to say here, too, so I'll be very brief.

I think when we talk about being marginalized and minoritized, what we're talking about is power, that folks who are sort of marginalized or minoritized, it's not about necessarily about sort of numbers but it's about power that those folks hold.

And so when you have access to the resources that I talked about and when you have access to the social determinants of health and when you have the power to decide who has access to those resources and social determinants of health, that is related to whether or not you fall into sort of these minoritized or non‑minoritized sort of categories, if that makes sense.

So, we're not always or necessarily talking about numbers; we're talking about numbers in the context of power.

This is why you hear often that people of Color can't be racist. And there's a lot of backlashe around sort of that assertion. And I think what people are saying when they say people of Color can't be racist is that we don't have the power to be racist, like we don't have access to those social determinants of health, we don't have access to those resources in order to deny others access to those resources.

And so that is sort of part of the delineation between being minoritized and not or being marginalized and not.

I have a friend who's a White man who lives in Hawaii, and while he is certainly in the minority in his community, he experiences significant power and privilege as it relates to his experiences as a White man in that context. And so, again, he was of very few White men in his context but held most of the power.

So, I'll stop talking. But I just wanted to contextualize that as best I could.

MARY ROONEY: That's great. And Dr. Carter and Dr. English, do you have anything you want to piggyback on off of that.

DEVIN ENGLISH: Yeah, I will just add to that that in a ‑‑ if we're talking about a local context, right, that local context is still within a greater context of policies, of a macro system, and of a chrono system that makes it so, although if I am in Newark, I'm at Rutgers School of Public Health in Newark, as a White man, if I'm walking down the street, I'm still less likely to be stopped by the police. That's what we've found in the study.

And so that ‑‑ although on a local context, there may be ‑‑ you may be in the minority, quote, unquote, you still are surrounded by institutions and structures that are designed and ‑‑ are designed to protect and support you. And that's exactly what we've found in our study.

MARY ROONEY: Excellent. Very helpful. And I'm just sort of ‑‑ I guess this is somewhat related in that ‑‑ and we had a few questions in this vein around kind of any updates ‑‑ this was directed to Dr. Carter specifically, although I think any of you could really answer ‑‑ any updates to racial trauma studies kind of more currently with research on multidimensional or intersectional factors.

And I think this question specifically gave an example, in this case, of a Black trans woman who might be targeted for discrimination and harassment and is experiencing racism as well as transphobia, for example.

So studies like that where you are taking an intersectional lens or a kind of more nuanced lens around the kinds of discrimination that may be occurring and the impact that may have on psychological symptoms and also how we measure this and ‑‑ both on the individual level, and then even in larger studies where we're using sort of these large national datasets, are there weaknesses or gaps in the measurement of these constructs that are making it harder to do high‑quality research that can inform policy or inform intervention that we really need to address at a foundational level.

Dr. Carter, I'll give you a chance to answer that one first since it was directed at you.

But since it's so broadly applicable, Dr. English and Dr. LoPresti, if you want to jump in, that would be great.

ROBERT CARTER: Thank you. So, I'm not aware of all the studies that have been produced more currently. The studies that I'm involved in are still looking at establishing the validity across various groups, and we're still trying to do that with respect to the usual racial groups in the U.S. So, we have not begun to look at the intersectional issues or how to address those.

I want to remind the participants that one of the purposes of the Race‑Based Traumatic Stress Symptom Scale was to seek legal redress. And what you don't ‑‑ may or may not understand is the fragmentation and nuance of laws and the application of laws and how these things have been built into our systems.

To overcome that takes a little more laser focus. It's really more difficult to contend that there are multiple aspects of an individual that have been harmed by some racial encounter or racist act. That's not easy to establish because when you do that, you allow the other side to make arguments about the validity of any of those elements.

So, I think it's a little more daunting to try to use this application in a legal context. And so there have been ‑‑ for those of you who may or may not have been following the news, there have been lots of news reports about legal proceedings about the trials and the appeals and the arguments and things of that nature, and it can get pretty detailed and specific and sometimes very outlandish in how judges ‑‑ and remember all the structural things that the other presenters have pointed out ‑‑ operate really in that legal context in a way that is really difficult to overcome and/or understand.

So, if you think about the effort to hold law enforcement accountable, laws have been structured in such a way to give them free rein, and there's been no real pushback or effort to alter that.

And even in the racial reckoning era where people tried to bring that out, that got stopped and pushed back. So, all of the racial reckoning went away after a year or two of effort. And now we're in an era of backlash where whatever progress had been made is being stripped away.

So ‑‑ and this cycle of racial reckoning and backlash is characterized ‑‑ it's evident in our history as a society and as a country, this has happened repeatedly. So, taking on race, if we can take on race as a separate single category and make headway there, then I think we can make headway with respect to other areas of identity and difference.

What I have not talked about are the research studies that we did after the publication of the Race‑Based Traumatic Stress Symptoms Scale in 2013. There were a series of validity studies that were published and other investigations looking at the connection between race‑based traumatic stress and PTSD and other forms of PTSD‑related trauma and emotional reactions.

And so there have been a series of additional studies that I didn't touch on that basically fall within the context of validity.

So that's ‑‑ I don't want to keep going on and on and on, so I'll just defer to my colleagues.

MARY ROONEY: It's very helpful. I think thinking about the purpose of that measure in particular and validating it with different populations and having that ‑‑ there's this kind of foundational measurement work. The scale you're talking about is one of them.

I think out in the field there's a lot of this foundational work that's starting to get done, but it's essential, really, to doing the high‑quality work we want that will be able to impact policy and impact people's lives.

ROBERT CARTER: Can I make another comment ‑‑

MARY ROONEY: Sure.

ROBERT CARTER: ‑‑ about the national probability studies.

MARY ROONEY: Uh‑huh.

ROBERT CARTER: These studies generally are designed in such a way as to not be able ‑‑ so that the researchers cannot employ or measure, like Race‑Based Traumatic Stress Symptom Scale that has like 50 items, that's contrary to the kind of data packets that researchers have to put together to get funding. So, it's uncommon for those kinds of studies to employ multiple‑item measures.

Even my 22‑item short form on the Race‑Based Trauma Stress Symptom Scale probably couldn't make it into those studies because it's too long and interferes with the efficacy, I guess, of the way that people who fund these studies think it should operate. So, I have not, and I do not participate. I've tried, but I've not been successful in participating in the funding world. So, I tip my hat to those of you who are and have been more successful there. Congratulations. I've not been able to crack that nut because I've been more partial to multiple‑measure instruments that capture more of the nuance of people's experiences than is typically accepted in those kinds of studies. I'll stop.

MARY ROONEY: Dr. English and Dr. LoPresti, any thoughts on that, on how that influences the quality of results we're able to get when we're looking at some of these large datasets, and in cases where there's a low base rate, relatively speaking, to other disorders or instances, like in the case of suicide, where you really need a very large dataset to detect effects? Any thoughts on this and how it might impact on our ability to have interpretable results.

JESSICA LoPRESTI: I'll try to go very quickly. I just want to, as an aside note, that somebody as prolific as Dr. Carter just said that he has had trouble getting funding, that is like ‑‑ that's just like an unbelievable thing. He's like a giant in this field, and I just wanted to note that. It's truly unbelievable to hear that from someone who is such a giant.

But as an aside ‑‑ sorry I had to note that ‑‑ I think one of our other challenges around measurement is trust in our systems. It's really hard for us to get the participants that we need from these intersecting minoritized identities. It's really hard to get trans women of color to participate in studies because we are not trustworthy as a system ‑‑ or we're not trusted as a system, I'm sorry, I should say.

And so, I think we need to do a better job of ensuring that our samples are diverse so that we can sort of approach the validity situation of our measures, both our mental health outcome measures and our measures specific to oppression. And so, I think that's really a significant part of the work that we need to do is figure out how to get more inclusive populations so that we can really see what we're dealing with.

Because we know from the Gallup polls and all these nationally representative polls that, for instance, trans women of color experience the most oppression and the most violence. I'm not a fan of the oppression Olympics, but if we were to play them, trans women of color would be at the very top here in terms of what they experience related to oppression.

So, I'll stop there.

DEVIN ENGLISH: I'll just add really briefly, to the funding, I was similarly floored by Dr. Carter's comment. And, I mean, it speaks to one of the easy go‑to critiques on study sections, right? Are you going to be collecting a convenient sample or a nationally representative sample? Right?

And when we're talking about multiply minoritized communities, the data isn't there. And in some ways, it's good that it's not there. Right? In the wrong hands, that data can be harmful. If we could identify, at a federal level, all of the trans communities, all of the LGBQ communities, that is a risk. And so having that be a valid critique at study sections, in manuscript reviews, is ‑‑ is part of the problem.

MARY ROONEY: Interesting, yeah. And I think in terms of kind of, I guess, engaging communities in research, right, and kind of ‑‑ we're going to talk more about that this afternoon ‑‑ but when you're generating these samples for ‑‑ in Dr. Carter's case you're validating a measure in a different population or you're having colleagues who are doing that, how important has it been really to engage at the local level with communities to foster that trust, to have people feel confident and open in participating in the research and that it's going to be used in a way that will truly benefit their community? I don't know if anyone has any thoughts on that, but ‑‑ the role that plays in their ability to get the work done.

ROBERT CARTER: So, in my effort to validate the Race‑Based Traumatic Stress Symptom Scale, we made a concerted effort to collect community samples. And to do that, we had to partner with health and behavioral health and community agencies to work with us, to encourage the clients that they served to participate.

And so, the strategy that I employed was to share with those agency members what this was all about and engage them prior to asking any of their clients or participants to participate.

I did not try to recruit the participants directly, but I worked through the agencies, and the frontline service providers were the ones who engaged in the recruitment.

And so, to me, that model ‑‑ and there was an incentive for the participants, for people to participate. So those elements, I think, helped us get folks from the community to complete the measures, which were critical, because the sampling needed to be everyday people. It needed to be outside of the university setting, which was usually where I typically have to collect data. So that was important to do.

MARY ROONEY: Yes. Excellent. Wonderful. And like I said, we'll be talking more about that this afternoon in terms of community‐based research and community engagement, and we'll have some talks on that, and also there's a breakout group around that as well.

And just looking here ‑‑ I'm looking through some of the other Q&A questions that might be most relevant.

I think, Dr. LoPresti, you talked about how in some of the treatment models, therapy models that we have using CBT as an example, how kind of Euro‑centric those models are, the evidence based is, how can we modify it to be more sensitive to the realities that we're living in today and the experiences of people who are showing up, people of Color who are showing up for treatment. I'm wondering what you see as advances that we need to see in the field, both in research and in practice, to really, I guess, change the mindset of providers or educate providers on how to not be so invalidating in session and really consider people's whole experiences and not kind of, as somebody in the Q&A sort of said, treat someone who's talking about race‑based oppression as being just delusional or kind of having this perception that maybe they're just feeling persecuted unnecessarily, sort of, and how invalidating that may be in therapy and how we can sort of move the needle on this in a way that's meaningful in all areas of the country, not just areas where people may be in a hotbed of thinking around this and more progressive.

JESSICA LoPRESTI: Wow, this is, like, a whole other talk, fortunately and unfortunately, but I'll do my best to highlight a few things.

The first thing is that we need to provide a context or container for mental health professionals to engage in this ongoing work in community.

My colleague and I, Tahira, do training like this, an hour, half hour, eight hours, several days, and it's never enough. People always leave wanting more, needing more support.

And so, Tahira and I are really thinking about how we can create a space for providers to come together and be in community and do this learning and engage in this learning in an ongoing way as opposed to these one‑off trainings or CE credits. Like how do we commit to this and be in community? So, we're developing an app that relates to that ongoing training.

The other thing that I think is a real challenge here is our lack of providers who are minoritized and marginalized and how we create space for providers in our training programs and support them through our training programs.

The models that we have in terms of our doctoral programs, in terms of our master’s programs, they don't work. They particularly don't work for our communities because of the significant financial burden, the significant oppression that they experience in the context of our programs.

And so, we need to figure out how we make education a little bit more accessible to folks of Color and folks who are minoritized who want to do this work. Because, frankly, I'm not sure that I would tell my daughter or my son that this is the path ‑‑ career path that they should take given what I'm seeing of my students of Color.

And so, I really want us to focus as a field on how we make these programs and public health and social work and psychology more accessible. Those are two spaces that I think we really need to change. As it relates to the specific CBT and integration of multiculturalism and evidence‑based practice, I think we need to think deeply about how we engage in those skills, like cognitive restructuring, how we engage in psychoeducation. We need to ensure that we're not questioning the validity or veracity of these experiences of oppression but getting to the core thoughts about self, like what does oppression do to me, how does oppression make me feel about myself, my worth, my value, my safety? Those are really places to intervene and bolster, and not focusing on the validity or veracity of these experiences or what oppression is like. We need to move past the "does racism exist" or "does heterosexism exist."

There is, like, eons and eons of literature that suggests that oppression affects mental health, but we need to move on to what are we going to do about it and not having researchers continue to have to start their talks with, “this exists."

And so, I think that is a great challenge that we need to sort of identify there.

So, I'll stop there. Those are just a few of my thoughts.

MARY ROONEY: That's great. Does anyone else have anything they want to piggyback off of that.

ROBERT CARTER: I was going to add a few thoughts.

So having been trying to promote or bring in more people of Color into the profession, when I was sitting in the tower, I can tell you that bringing in more people of Color sounds great; but I think, given my experience, I would argue for building a greater psychological foundation in how people understand themselves as racial-cultural beings.

So, I'm thinking about the pyramid that you showed, cultural, institutional, individual racism, and the structural elements that were just indicated with respect to policing and power. So, we really can't make any changes until we start to chip away at those structures, both at the cultural level and the institutional level and at the individual level.

And I would rather promote the building psychological awareness of yourself as a racial being as our strategy, which does not focus on any particular racial group. It's inclusive in that it includes everybody. Because everybody in our society is a racial being, and they have some cultural connection, and making that conscious and helping them understand how that influences what they see, how they interact, how they engage people, how it influences their perceptions I think gives us more currency and will give us more ‑‑ the potential for more inroads than saying we need to bring in more people of color.

Because those people who we bring in could be psychologically identified with the structures that we all just pointed out. So, if they're not identified strongly and culturally with the group in which we presume them to be a member, then we just have someone who has skin color that we assume to represent one thing, but in their minds and in their actions, they represent something totally different.

So, to me, that's the emphasis, where I would place the emphasis, not so much on the group memberships.

Secondly, I'll say I turn down opportunities to talk to people about interventions or training your staff if they only want a day, because I contend that this is a process. If you're not willing to support the process, then you're really not serious about bringing people around or helping them understand these issues. So, I tend not to be hired to do those things because I just ‑‑ I don't want to waste my time speaking to people in a day about something that's going to take years for them to get some grasp of.

So, when I was doing training at Teachers College, we made it a point to make racial cultural understanding of the individual student a key element of their movement through the program. That's something they were required and evaluated on for them to be able to move through the program, for them to be able to get through my classes, et cetera.

Now, I will tell you that that caused so much controversy and pushback that it was ‑‑ while there was some perception that the program was multiculturally oriented, they were not happy at all about making that a requirement. And so, to me, this is where the structural issues come into play. And I think they're harder to unearth and disrupt, but if we shift the focus to individual psychological awareness, then it might be ‑‑ we might make more inroads. And if we include a wider range of people in that process, we might make more inroads. Okay.

MARY ROONEY: Well, thank you all. I think that's the ideal place to wrap up this Q&A. And I think it just touches on everything that we talked about this morning. And I can't thank you all enough for your presentations, your thoughtful responses to some challenging questions. I'm really looking forward to this afternoon's sessions.

And I'm just going to hand it over to Juliette for a minute to talk about how long our break is and when we'll be coming back.

Again, thank you all very much. We appreciate it.

JULIETTE McCLENDON: Hi, everyone. I'll actually turn it over to our event producer to give a little bit of instruction for the next session.

EVENT PRODUCER: Thank you very much, Juliette. We'll now go to our break time, and we will all return back at 1:45 p.m. Eastern Time.

Enjoy your break, everybody. Thank you.

JULIETTE McCLENDON: And you can click on the same link you clicked to get to this webinar when you come back.  

(Luncheon Break)

AFTERNOON SESSION

EVENT PRODUCER: Ok everybody, we're back from break. Hopefully you enjoyed a nice, long lunch break.

I will now turn it over to Dr. Mary Acri to introduce the next panel.

SESSION II: INTERVENTIONS ADDRESSING THE IMPACT OF DISCRIMINATION ON MENTAL HEALTH.

MARY ACRI: Good afternoon. My name is Mary Acri. I'm Chief of the Child and Adolescent Research Program within the Division of Services and Intervention Research at NIMH.

I have the pleasure of introducing the next set of speakers who will present on individual and community‑level interventions that address the impact of discrimination on mental health with an emphasis upon youth and perinatal populations.

Dr. Sylvanna Vargas, who is an Assistant Professor of Psychology at San Diego State University, will present on Modifiable Risk and Protective Factors for the Impact of Discrimination on Mental Health and the Future of Interventions Research.

Next, Dr. Colleen Halliday, Assistant Professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina, will present on Multilevel Interventions to Address the Impact of Discrimination on Violence Specific to Youth. Finally, Dr. Natalie Hernandez, Executive Director of the Centers for Mental Health Equity, will discuss Community Interventions for Maternal Mental Health Disparities.

We will start with Dr. Vargas.

MODIFIABLE RISK AND PROTECTIVE FACTORS FOR THE IMPACTS OF DISCRIMINATION ON MENTAL HEALTH AND THE FUTURE OF INTERVENTION RESEARCH

Speaker: Sylvanna M. Vargas

SYLVANNA VARGAS: Okay. Hopefully you can see my screen. Okay. All right.

Well, thank you so much for having me. It's really an honor to be here among such phenomenal presenters.

I'm really excited to be presenting today on a topic that I've been working on for several years now with support from research teams who are committed to helping us understand the relationship between intersectional discrimination, depression, and suicide risk.

Okay. So, I probably don't have to tell everyone or anyone in this audience attending a NIMH workshop that we're currently living through a mental health crisis. And this is one of the major public health problems of our time in the U.S.

Particularly alarming to scholars like me who are focused on mental health equity are the historical and recent increases in disparities in mental health outcomes, especially in depression and suicide.

I won't have a chance to go into detail about what these disparity rates look like, but just to give you a sense, for example, we know that American Indian, Black, LatinX and sexual minority youth exhibit elevated rates of past‑year suicide attempts.

You can see in this figure here data from the Youth Risk Behavior Survey, data from 2021. There are similar trends in adults, and we also see elevations in depressive symptoms among sexual minority populations, and we know depression is a major risk factor for suicide.

So increasingly as a field, we're understanding the role of stigmas as social determinants that contribute to these disparities. There are many kinds of stigmas, like we've talked about today, and these tend to be linked to minoritized identities. I focus on stigma that's related to race and sexual orientation or racism and heterosexism.

And so, when we talk about racism and heterosexism, like we were talking about earlier, these really are best understood as systems, meaning that they exist and affect multiple levels of society both currently and historically with the goal of maintaining power structures that in this case prioritize White and heterosexual communities. So, stigma systems ultimately help to oppress and minoritize non‑White and non‑heterosexual communities.

There's a lot of different visuals out there that explain what stigma systems are like. We've talked about a couple of them today, but I like this one because it's pretty simple. It talks about stigma existing at three levels.

Structural stigma, which refers to things like policies; interpersonal stigma, which refers to experiences that exist in a social context; and individual stigma, which refers to a way in which a person is internally affected by a stigma system.

And, of course, all of these occur within the background of cultural norms and standards or what's called societal stigma. Even though this is a one‑dimensional image, of course we know this is a dynamic system which shapes and reshapes itself at these different levels over time.

We also know that discrimination can occur at any of these levels, and my work specifically is focused on discrimination that occurs in an interpersonal context.

So, at this point, like we said earlier, it's really very clear, based on multiple reviews of hundreds and hundreds of studies, that when a person experiences discrimination in a social context, whether this be due to their race or their sexual orientation, their sex or their gender, this is associated with worse mental health, whether that be depression, anxiety, PTSD, et cetera. These studies are primarily cross‑sectional, although increasingly there have been longitudinal studies that show that when people experience discrimination, this is linked with worse mental health over time.

So, some work that I and many others have been doing has been calling attention to really what's an insufficient focus on how multiple facets of identity can come together in understanding the impact of discrimination experiences given that we know that identity is not unidimensional, and neither is discrimination. So, for example, in a cross‑sectional study that I did with Stan Huey and his team, we looked at the relationship between discrimination, gender, and suicide risk in LatinX youth.

And what we found was that gender moderated the relationship between discrimination and suicide risk such that the relationship was significant both for girls and for boys, but the effect was greater for girls.

So, you can see here I'm using a binary definition of gender, and this is a really important limitation. But the implication here is that there's something about being a Latino girl experiencing discrimination that is probably important for us to think about. And one of the things that might be happening is that we know that Latina girls hold two minoritized identities. They're both LatinX and girls. And so that might suggest that we need to pay attention to how things like racism and sexism ultimately impact suicide risk.

More broadly, the implication here is that we might want to think about how different subgroups are affected by discrimination.

And like I said, we know that stigma exists in association with multiple identities. We also know that people can experience discrimination for a variety of different reasons. And this idea is reflected in what we've all been talking about through the chat and in discussions and presentations, this idea of intersectionality.

So intersectional frameworks have been getting a lot more attention in the mainstream lately, but, of course, these ideas are not new. They're actually rooted in Black feminist theory. And Kimberlé Crenshaw is a scholar who's really helped us advance our understanding of this area.

And so, broadly, what this framework talks about is what we've been saying. It's really important to look at subgroups and pay attention to the intersection of identities given that these identities all come with different histories of advantage and oppression. So, to be able to talk about intersectionality, we really need to attend to those power systems at play.

So, I was interested in seeing what the state of the evidence was in regard to intersectional discrimination. And along with Stan Huey and Jeannie Miranda, we did a systemic review to look at the landscape of the field in 2020.

And so, we looked at all the studies that measured intersectional discrimination with a mental health outcome. And before I tell you what we found, I just want to take a moment to acknowledge, there is a lot of controversy in the field about how to measure, analyze, and even conceptualize intersectional discrimination.

At this point it's pretty clear that intersectional discrimination is not additive, meaning it's not a sum of two kinds of discrimination or more than two kinds, but there's a lot of debate about how we can best capture these compounding impacts.

So for the purposes of this review, we took a pretty broad interpretation of intersectional discrimination, and we looked at all of the studies that ‑‑ so there were some studies that had really specific measures that tried to capture experiences like racist sexism really specifically, and there were other studies that did things like asked people about their experiences with racism and then, separately, their experiences with heterosexism and then did some kind of fancy stats to try to merge those experiences.

So generally, what we found in this review was that when people experience intersectional discrimination, this was associated with greater odds of depression. And a couple of studies also did this thing where they compared people who experienced intersectional discrimination with a single kind of discrimination or unidimensional discrimination, and here they also found that when you experience intersectional discrimination, you exhibit higher odds of depression in comparison to that single discrimination group.

We tried to see if there was anything we could say about suicide risk, and at the time of this review there was really insufficient evidence to say anything conclusively.

But this review ultimately generated a lot of questions about methodology and about other areas, some of which I tried to tackle in the work that I'll be talking about today.

So, for my studies, I'm focused on racism and heterosexism, like I mentioned. I'm going to be using the term "intersectional discrimination" just for simplicity to refer to these experiences. Of course, intersectional discrimination can refer to a lot of different kinds of discrimination.

So, one of the questions that we have as a field is trying to understand why intersectional discrimination would be associated with worse mental health outcomes to begin with. And our initial work has been implicating the stress-health pathway in helping us understand this relationship. This is similar to existing knowledge that we have about discrimination more broadly, suggesting that discrimination is a stressor, and we know stress is bad for your health. But we didn't know much about this relationship in terms of intersectional discrimination specifically.

So, we did a small study where we recruited predominantly cisgender men in their forties, about half of whom were Hispanic and identified as gay. And we recruited them during the ‑‑ as part of follow‑up to a year‑long depression trial. So, at the end of the trial, we recruited them, and we developed a community partner ‑‑ we used a community partner participatory research model to develop a protocol that was sensitive and would be acceptable by our participants because ultimately what we were asking them was to provide us a hair sample.

So, we were interested in a hair sample because hair actually stores information about how stressed you've been because it stores cortisol, which is the hormone that's released when you're stressed out. And so, the most recent one centimeter, the centimeter closest to your scalp, tells you how stressed you've been in the last month. And we wanted to see how this was related to intersectional discrimination.

And so, what we found was that participants who reported intersectional racism and heterosexism had higher amounts of cortisol in their hair than participants who reported only racism or only heterosexism.

And so, this initial study is pointing us to the particularly deleterious effects of intersectional discrimination on biological stress. We obviously need more research to replicate this finding and examine this same question with different samples using different methodologies, but one possibility is that this work is suggesting that intersectional racism and heterosexism generates additional stress for people who belong to populations that were similar to our sample.

So that led us to wonder, okay, at this point we know really clearly discrimination is bad for you. It causes excess stress. What can you do about it in terms of your mental health and well‑being.

So, some options that have been discussed in the literature, and we talked about today, are you can confront the person, you could report it, you can accept discrimination as a fact of life, you can act like it doesn't bother you. But these things all come with unintended negative consequences. So, like, for example, confronting can actually be really dangerous, and acting like it doesn't bother you can make you more depressed.

And so, one option might be related to thinking about social support. In my work, and the field increasingly, we've been focusing on trying to understand where social support and social context can fit into these options and whether this might be an area for intervention.

There's actually some theoretical and empirical work that has talked about the possibility and pointed to social support as a potential buffer, meaning that it reduces the negative impacts that discrimination has on mental health.

So, for example, Ilan Meyer developed the Minority Stress Theory to help explain health disparities in the LGBTQ community, and part of this theory talks about social supports such as through LGBTQ community support as a coping strategy that could ultimately buffer or attenuate the negative impact of minority stressors like discrimination on health outcomes.

There has been empirical support for this part of the theory focused on sexual minority and gender minority samples, but there have also actually been studies that have found something similar with racial and ethnically diverse samples. However, there really has been less work in this area taking an intersectional approach with a focus on racism and heterosexism, for example.

And when you think about it, actually, it's likely that social support is really important for sexual minority people of Color because of potentials for identity conflict due to experiencing discrimination within minoritized communities.

And so, my work is one example of how you can explore these ideas about the role of social context in intersectional discriminatory experiences.

One way that we've thought of the field about social support is looking at the context of where you live, because we know that this could have implications for your experience of discrimination.

So, we know from prior studies that neighborhood composition can actually protect you from experiencing racism. That's reflected in what's called the Ethnic Density Theory.

So, there have been a handful of studies that have shown that among Black and LatinX adults and youth, when you live in a neighborhood of higher co‑ethnic density, meaning more people of your same ethnicity, this protects you from experiencing racism. And, inversely, there have been studies that have shown that when you live in a neighborhood with a higher proportion of White individuals, this exposes you to racism.

So that led us to wonder if a co‑ethnic neighborhood can protect you from racism, what happens when you experience intersectional racism and heterosexism? Is that neighborhood still protective? So, to answer this question, we ran a study with 90 participants who all sexual minority people of Color who were based in L.A. and in New Orleans, and we calculated a measure of their co‑ethnic density by connecting their residential address to U.S. census data.

Our sample were predominantly cisgender men in their forties who identify as gay, primarily Hispanic. A large majority are HIV positive. And this was a very, very low‑income sample.

So, like I mentioned, there's a lot of ongoing debate about how you can best capture and understand intersectional discrimination. And so, I'll just walk us through one way that this can be measured.

And it's using the Everyday Discrimination Scale, which was developed by David Williams and his team. And, broadly, this is what's called a two‑stage measure, so meaning you start off by asking people about their experiences with daily discrimination. So, these are how often are you treated with less courtesy or respect than other people? How often do people act like you're not smart? Or are you threatened or harassed.

And then once they've answered those questions, you ask, why do you think that this happened? What are the attributions that you give to this experience.

And you can see that participants are given a really long list of options, and they include things like ancestry, your race, your religion, your sexual orientation, and you can also specify something else.

So, because we were interested in power structures related to racism and heterosexism, we created this coding category that you see here where we wanted to capture different categories, one where it was people who experienced discrimination due to a different reason, people who reported only racism, only heterosexism, or that intersectional racist heterosexism.

And so, I'll say there's a lot of pros and cons of this approach, particularly relying on a measure of these broad, unfair treatment questions.

One downside is that we're not using the measure that was designed specifically to try and measure a particular kind of discrimination or intersectional discrimination. So, for example, we know that something that happens for men of Color in LGBTQ communities is they are often eroticized because of their race, so a measure like this wouldn't capture that.

But an upside is that essentially what we're doing is we're allowing the participant to decide. They are telling us what their attribution is for their experience rather than this being constricted by the measurement.

And so, what you can see here at the right‑hand side is a breakdown of the percentage of our participants who reported and fell into these different categories, and you can see that actually very few people in our sample reported only heterosexism. This could be due to our coding scheme. Like you can see that there's one option that loads into the heterosexism, whereas there are several more options for the racism category.

And this is ‑‑ we followed sort of examples from prior studies, and it sort of loads on the social constructs of race and how we define it.

But I will also say that another possibility is we know racism is really common. And I'll talk about this in a couple of slides. But in our sample, one thing that we learned was that often our participants, due to concerns about danger and safety, were not out or they were out, as most people are, sort of contextually or in a gradient. And so, this may partly be accounting for this lower amount of "heterosexism only" endorsed.

So, what we've found in terms of the relationship with co‑ethnic density was that participants who lived in neighborhoods with higher co‑ethnic density were more likely to experience intersectional rather than a single kind of discrimination.

So here you can see a table showing the results based on odds ratio. We set intersectional discrimination as the reference group, and so what this ultimately showed us was that for every 10% increase in co‑ethnic density, our participants were 67% as likely to experience heterosexism rather than intersectional discrimination and 83% as likely to experience racism only rather than intersectional discrimination.

So ultimately what this would suggest is that we're not seeing that protective effect of a co‑ethnic context for sexual minority people of Color.

It's really hard to say why. There's a lot of things that we don't know from our sample, like we don't know where people spend their time, and we also don't know much about their experiences with discrimination. But one thing that we do know from prior literature is that support from your corresponding community around a minoritized identity can be really protective and helpful.

And there is some prior literature, mostly qualitative, that has shown that sexual minority people of color will experience heterosexism in co‑ethnic spaces where they're looking for support around their racially minoritized identity and then experience racism in predominantly White LGBTQ spaces.

So possibly part of what we're seeing ‑‑ part of this result is seeing some of that play out here. So, like one possibility, although, again, this is sort of speculation, is that maybe our participants who are sexual minority people of color were living in ethnic enclaves and may leave that area due to heterosexism and then get hit by additional amounts of racism in other settings. Of course, this leaves open a lot of questions because we know that heterosexism exists in all communities, we know, like I said, that racism is really pervasive, and we didn't do a comparison of neighborhoods. So, it's speculative, and we do need more research that goes into these questions.

One last thing that I'll say about the interpretation is we got some really interesting feedback from our partners, and they sort of talked about, like I said earlier, that the communities from which we were sampling our participants were places where often people were not fully out. And so that outness factor might be complicating the story given that we know that outness has implications for experiences of discrimination. And so, we really need more research to be able to better understand this relationship.

I would say, then, that the takeaway probably primarily is that we're that seeing that social context likely can directly contribute to experiencing intersectional discrimination, and this would have important implications for intervention, which I'll talk about later.

So, since we saw that social context can directly contribute in this way, this led us to wonder whether intersectional discrimination might wear down social connections and be related to suicide outcomes given that we know that low social connection is a risk factor for suicide, and prior literature has shown that minority stressors like discrimination can wear on social connection.

So that led us to wonder whether social connection might impact the negative effects of intersectional discrimination on suicide risk, now in a sample focused on youth.

And so, I had the really fortunate opportunity to work with a dataset ‑‑ a pretty cool dataset that was collected as part of an R01 awarded to Jeremy Goldbach and Sheree Schrager, and this was a dataset that's nationally representative of only sexual minority adolescents, and it follows the youth for seven years.

And so, I focused on the youth of Color in this sample. And we looked at their experiences with intersectional stress. So, to give you a sense of what those items look like, it's saying things like, you know, you feel like your racial or ethnic community judge you for being LGBTQ or feeling like a minority within a minority. And we also looked at youth’s experiences with suicidal thinking and behavior, and we also looked at a broad measure of social support.

So, as you can see here in our sample breakdown, we had a fairly large sample of sexual minority youth of Color. Our youth had a good diversity and mix in terms of race and ethnicity. They were overwhelmingly urban; a good split of female, male assigned at birth, and about 50% identified as bisexual.

So, we ended up running a mixed‑effect model with random intercepts to account for repeated measures within participants. So, this essentially helped us see whether experiencing intersectional stress, on the left, predicted a suicide outcome six months later and whether social support buffered this relationship or reduced the negative impact of intersectional stress.

You can see that this model has suicide attempt as the outcome, but we ran the same kind of models with all sorts of suicide outcomes. I'm just showing it, for simplicity, with suicide attempts, but the findings were similar across the board.   

So, what we found was, first, when we looked only to see if intersectional stress predicted suicide, we did find a really small but significant relationship in our univariate analyses, but then when we ran the whole model, we actually didn't see that intersectional stress predicted suicide attempts, and we didn't see that social support buffered this relationship.

What we did see was that social support was really protective against suicidal behaviors.

And so here you can see a table showing relative risk ratios. The middle column, basically if the number is less than 1 and significant, it means that this is a protective factor. You can see social support is the only thing that's significant here. And so essentially what this suggests is that social support seems to really lessen the risk of suicide attempts among sexual minorities of color, but not because they have anything to do with intersectional stress. And social support was actually associated with a 42% lower likelihood of experiencing suicidal risk in our sample.

So back to our broader question. In our study, we're not seeing any evidence of social support as a buffer, but we are seeing that social support is an important protective factor. And part of the reason why we got this finding actually might be due to methodological issues.

So, like, for example, you might remember we asked about intersectional stress, which seems to be more about identify conflict, whereas the literature that we've been talking about really has been focused on discrimination, which is more of a discrete stressor. So maybe these two things are related but not exactly the same, and that's part of why we're not finding what we thought we would.

We also used a pretty broad measure of social support. And I will say that some work focused on the LGBTQ youth has suggested that families in particular are the most protective kind of supports even in comparison to peers. And one study that has focused on an intersectionally minoritized sample, like African‑American women, has shown that it's really about tailored support, so support that's really tailored around racism, that that's what actually buffers and reduces those negative effects.

Not all the studies have found this, even with similar populations, but it's possible that we need to think more specifically about what kind of support we're measuring.

So, overall, I would say that since other studies that have focused on intersectionally minoritized samples have shown that social support is a buffer, we need to keep thinking about this as a possibility for intervention. And, of course, we need more research to see how this all plays out, with a specific focus on intersectional racism and heterosexism.

Now, sort of bringing it all together, we went through a lot of different studies. So, I would say, big picture, the takeaways are probably a bit loose because we do need more follow‑up research. But just as a reminder of what we've found so far in that review paper, we found that intersectional discrimination is associated with an increased risk for depression.

In that cortisol study we showed that intersectional racism and heterosexism is associated with greater stress. In the co‑ethnic enclave study, this showed us that social context can potentially expose people to intersectional discrimination. And in the final study, we showed that social support is very protective.

And so, I want to wrap up just sort of thinking creatively, and suggestions, since I haven't before, for what might be implications for interventions.

In terms of the depression and stress findings, we might think about implementing and adapting interventions that work for depression, for suicide and for stress. We have interventions that work. And what we need to think about is how do we, like we were talking about earlier today, implement these interventions with a really explicit focus and attention on labeling intersectional stressors and intersectional discrimination.

So, for example, John Pachankis has a CBT trial that he's done for depression that really puts at the center minority stress for LGBTQ communities, and he's found really promising effects with that intervention.

And I'll just say, you know, part of the rationale for why I say this is that I think it's important for us to acknowledge these intersectionally oppressive power structures, and one way we can do that is by labeling these experiences and putting these power structures on the table, acknowledging them, because we know from the literature that discrimination experiences often can be ambiguous, and it's very costly if an individual internalizes fault for these experiences.

So, for example, if something happened, you experience a discriminatory event and then you spend time thinking, did I do something wrong? What was my role in this? This causes a lot of cost and stress to the system. And so labeling things as racist and heterosexist, in the literature we talk about, this is very helpful strategy. And so, I think this same kind of thinking can apply to interventions.   

In terms of thinking about social support, I would say that we want to think about how to develop interventions both that help people find and receive social support but also that bolster existing social support systems.

So, in terms of youth, like I said, we know that LGBTQ youth in particular benefit from families and parents that are non‑rejecting and are supportive. This is a really important protective system if we think about it in that way. And there have been studies that have shown that schools also can be helpful for sexual and gender minority youth, especially when they can reach families.

And so, in the couple minutes I have, I just want to wrap up actually sort of illustrating through a potential case example. So, I'm a practicing clinical psychologist. I've seen many of these teens and adults in my clinical practice, and so I sort of blended together a couple of cases just to highlight how these stressors can come to light.

So, if we think about a 13‑year‑old Latina who identifies as bisexual and a cisgender girl, experiences frequent depression and suicidal ideation, gets easily overwhelmed, enjoys school, but in school experiences racism, insensitive comments and assumptions from her predominantly White classmates and her teacher. And the good thing is that she feels she can talk to her parents and her extended family about these issues.

But she recently came out to her parents, and their response was that they thought she was too young to think about her sexuality and she doesn't know, and they seem really uncomfortable talking about this topic. So now she's stuck and she doesn't know who to turn to because her parents don't seem to get her anymore.

So, for cases like this that I've seen, I'll just say anecdotally, things that we've seen seem to benefit our clients are, first, in thinking ‑‑ a combination of things. I'll just kind of throw them out there. First thinking about individual intervention with the youth.

So, we talked about CBT, dialectical behavior therapy, for depression and suicide risk. These strategies include things like relaxation techniques and mindfulness that can help manage stress. Earlier one of the speakers was talking about really focusing on the way in which oppressive systems impact your sense of self. Again, that sort of fits with this, like, labeling and really explicitly putting on the table that these oppressive systems are out there. So really an explicit focus in these interventions on discrimination and marginalization.

In terms of social support interventions, actually a couple of cases that I've seen, what we've done is we've sent parents to ‑‑ when I worked at UCLA ‑‑ an LGBTQ specialty mental health clinic called Empower. And so, they've actually been developing a group for parents of sexual and gender minority youth to support each other.

In this group, parents are able to speak openly about their worries about their youth's identity, they receive a lot of psychoeducation, and they can find ways to support their youth. So, this actually might be ‑‑ things like this might be especially important for youth of Color given that co‑ethnic support systems might be fractured when you add rejection and prejudice around another critical stigmatized component of identity.

And finally, something that we've done with youth is also encouraging them to think about where they can find community. Some of the kids that I've seen have really benefitted from meeting peers in safe settings online.

So, I'll just wrap up by acknowledging that to do any of this large‑scale work, you have to work with generous funders and with teams, and I've been really lucky to work with amazing mentors, collaborators, team members and study participants.

MARY ACRI: Thank you very much.

Now we'll hear from Dr. Halliday.

MULTILEVEL INTERVENTIONS FOR ADDRESSING THE IMPACT OF DISCRIMINATION ON VIOLENCE AMONG YOUTH

Speaker: Colleen Halliday

COLLEEN HALLIDAY: Hello. Can you see my screen? Let's see. Let me figure out how to make it big. All right.

Thank you so much for the opportunity to speak today, and I'm very honored to be among such a group of distinguished speakers and researchers.

I'm excited to talk about my work focused on schools and addressing racial and ethnic discrimination that occurs in schools to improve youth mental health outcomes.

And so why school? So, schools are a really important context for youth. They spend more time awake there than in any other setting. There are also opportunities for intervening to address mental health, and youth experience various forms of racial and ethnic discrimination in schools at multiple levels, and we'll be talking about all of those levels today.

So, when we think about schools as sources of racial and ethnic discrimination, often what comes to mind at first is teachers. Students spend a lot of time with teachers. Particularly in elementary schools, they're with the same teacher for almost all of the day. And there's a large body of research demonstrating that teachers' expectations and behaviors towards students is linked to outcomes.

Now, the vast majority of that research is on academic and educational outcomes, but, theoretically, we expect that this will also be linked to their mental health and behavioral outcomes.

We also know that teachers' expectations and behaviors towards racial and ethnic minority students is different from those from White students. So, they evidence, for example, poorer interpersonal behavior, poorer expectations towards African‑American students relative to other students. So, it stands to reason that their behaviors might be a big source of disparities in students' outcomes.

And so, you know, educators, they often ‑‑ they engage in this profession, we believe, because they care about students. And so, the idea that they are sources of discrimination and that they might be just racist teachers is something that some people might have some issue with. And we actually believe that there are teachers who value and oppose bias but are somehow, nevertheless, vulnerable to engaging in bias on an unconscious level.

So, a lot of the focus in our work is looking at educators' unconscious racial bias and how that links to the outcomes.

So, there's a very small body of literature looking at links between educator unconscious racial bias and student outcomes. Again, the focus is on academic outcomes, but, conceptually, the belief is that these are also linked to mental health and behavioral outcomes.

One of these studies focuses on links to discipline. So unconscious racial biases among administrators is linked to increases in discipline among African‑American students. And discipline outcomes ‑‑ so including out‑of‑school suspensions or being referred to the office from the classroom ‑‑ are linked long term to both adverse mental health and other developmental outcomes. So, discipline is a critical outcome when we're talking about school contexts.

So, with regard to discipline, there's tremendous disparities in discipline practices. Black and African‑American students experience disproportionate discipline, and some of our work demonstrates that this disproportionately widens with age.

The picture is more nuanced for Hispanic and LatinX students. Some groups ‑‑ excuse me, I'm sorry ‑‑ some subgroups experienced disproportionality, but others experienced what might be characterized as a reverse disparity.

And it's important to note that these discrepancies are not accounted for by students' behavior, academic achievement or social economic status. It's really about differences in administrative decisions for how comparable behavior is addressed.

Another form of racial and ethnic discrimination that occurs in school is discrimination from peers. So, there's a small body of literature that demonstrates racial and ethnic discrimination from peers is linked to mental health, even in elementary school, students show both explicit and unconscious racial bias.

In some of our work, we found that about 60 percent of both African American and LatinX youth in elementary school experienced racial and ethnic bullying victimization in school. This is fourth and fifth graders.

In this sample, we also found that their experiences with racial and ethnic bullying victimization were linked to their self‑reported conduct problems. So, this is consistent with the other broader literature suggesting that peer and ethnic and racial discrimination is related to mental health outcomes.

Now I'm going to talk about what we might be able to do to address some of these things that are going on. First, I'm going to talk about school policies and practices and a completed research study.

Before I do that, I'm going to just provide a backdrop about school mental health to help provide a context for some of the work that I'm going to be talking about.

School mental health is a public health model in which treatments are provided to the students on a school day with not out‑of‑pocket costs to them and their families.

As a public health model, it includes both identification of mental health problems as well as treatment, and so it includes the continuum of from promotion all the way to treatment for mental health.

School mental health addresses a lot of the barriers to accessing mental health care and barriers that disproportionally affect racial and ethnic minority youth. So perhaps, not surprisingly, because of that, students from underserved backgrounds are more likely to receive their mental health services in schools and in other settings.

The first study I'll talk about is an NIJ funded trial that's completed. This is an RCT involving 24 elementary schools. The schools are randomly assigned to one of three intervention conditions.

The first is positive behavior intervention supports, or PBIS. And for simplicity, I'm going to describe it, it's an educator‑focused framework, focused on addressing behavior by setting clear expectations and rewarding positive behavior. It has demonstrated to improve behavior and reduce adverse discipline outcomes in numerous studies.

The second intervention conditions involve that same framework, PBIS, plus mental health in schools. So, we added mental health clinicians to the schools as part of the grant, but did not provide any instruction about how to operate.

The third condition is called the Interconnected Systems Framework, and that is the integration of school mental health and PBIS.

One thing I forgot to mention about PBIS is it's multitiered. It involves universal prevention as well as targeted intervention, in theory at least.

So, with the Interconnected Systems Framework, integrating mental health at three tiers in the schools. When we collected data from all kinds of sources, followed students all the way into middle school for those who transitioned into middle school by third year. For this focus today, I'm just going to be talking about some of the discipline outcomes.

Some key features of the Interconnected Systems Framework are that there are multidisciplinary school teams who make intervention decisions.

So, these are teams of representatives from various aspects of the school and community, and they include a mental health clinician, and they make decisions about interventions at multiple tiers, including something that might be needed on a school‑wide level.

They use data to make decisions, and this data includes the universal mental health screening data. So, schools implement universal mental health screening in which teachers complete questionnaires about students; and in some cases, students’ complete questionnaires about themselves, to identify students who might be at risk for mental health or have a mental health need. And there's also a systematic process for selecting and implementing evidence‑based practices and for monitoring their implementation and fidelity.

So, what we found in this study was that students who were in ISF condition, there were dramatically greater reductions in out‑of‑school suspensions for Black males in upper elementary grades relative to all other students.

So, the idea is that youth who are in this condition in which there's a systematic approach to identifying needs for mental health and connecting them to mental health services resulted in improvements particularly for Black males in upper elementary grades.

One of the things I mentioned earlier is that as students get older, the disproportionalities gets greater. So, the opportunity to receive improvement is more important and greater at those older levels, and particularly for Black males who might be perceived as more threatening as they age and look more like adults, that we think this is partly why we think it might be going on here.

We saw a similar pattern for all Black students in upper elementary grades with regards to office disciplinary referrals. So, again, those who were in the Interconnected Systems Framework condition evidence a greater reduction in that outcome relative to youth, other youth, Black youth and other conditions and other youth.

That was the completed trial. Now I’m gonna talk about some active projects in which ‑‑ one of the things actually that I want to mention about this study is that we did not make any efforts specifically to target race and ethnicity.

So, these are findings that we have observed by using systems and practices at the school level that systemize some of the processes.

We know that there's opportunities for improvement. We did not eliminate disparities in that study. And as we mentioned, discrimination operates on multiple levels. So, there's other areas where we can improve.

So, the first study I'm going to talk about focuses on teachers. And this study is funded by the William T. Grant Foundation. Patricia Devine is the co‑PI.

This study is to examine the effects of training teachers in unconscious racial bias and looking at the impact on African American students' outcomes.

It's an RCT involving 18 elementary schools. So, teachers in those schools are randomly assigned to receive unconscious racial bias training or to be on wait list control.

The unconscious racial bias training is Patricia Devine's Prejudice Habit‑breaking Intervention. We're collecting data from numerous sources in this study.

The next study that I will talk about addresses all three of these levels. This study was funded by NIMHD, and we have collaborators from all across the country. Yet again, with these large projects, we need multiple collaborators.

The purpose of this study is to examine the effects of integrating multilevel racial and ethnic discrimination intervention into school‑based violence prevention.

It's an RCT in which we randomly assign middle schools to one of two intervention conditions. One is violence prevention. And the violence prevention approach we use is essentially the Interconnected Systems Framework model that I described for the NIJ trial, and the other condition is having the multilevel discrimination intervention integrated into the Interconnected Systems Framework approach.

We collect data from multiple sources for students who transition into middle school by year three. We follow them into that year and get student and teacher and archival data reports for them in high school.

You will notice that this happened during COVID. So, we've got some unique challenges with understanding and analyzing data while it was collected during school shutdown. So, the discrimination interventions include the unconscious racial bias training for school personnel.

We used the Train the Trainer model in which Patricia Devine trained key opinion leaders, people who were nominated by their peers -- school personnel nominated by their peers as having a good focus on equity. And they were trained to deliver the intervention alongside research personnel to the school personnel in their building.

We had also adapted Patricia Devine's intervention for students. So, this intervention was delivered by research personnel, and we also added some activities for hands‑on involvement that were delivered by social studies teachers after the initial visit by our team.

An additional component is teacher stress management. Teaching is one of the most stressful professions, and evidence suggests that people evidence their biases more so when they are stressed. And so, we hypothesized that by training teachers to reduce their stress that we might see a reduction in the biases that they evidence towards their students.

The third component is database decision‑making in which data are disaggregated by race and ethnicity. So, I mentioned that school teams make decisions based on data. So, for example, with regard to discipline, they look at discipline data and identify if it's, for example, if there's lots of problems going on in the cafeteria that maybe something needs to happen to reduce the amount of discipline that's going on in the cafeteria.

What we are training teams to do in this part is to disaggregate the data based on race and ethnicity to identify disparities in the discipline and problem solve those disparities and identify and implement a plan to address those disparities.

Okay. So, the next study that I'm going to talk about focuses on school policies and practices. This study is funded by PCORI. I co-lead this project with Janis Platt. We have a large team with people across the country.

The purpose of this study is to examine the effects of an equity‑centered approach to universal mental health screening data use for school intervention teams.

And looking at the impacts on African American students' unmet mental health needs and disciplinary experiences, we know that unmet mental health needs for African American students is one and a half to two times greater than it is for other students. And as mentioned, they have disproportionate discipline outcomes. So, this is an RCT in which 20 elementary schools are randomly assigned to one of two intervention conditions.

The first is universal mental health screening. So, as I mentioned earlier, universal mental health screening involves teachers completing questionnaires about each student in their classroom, and for older students, we also have them complete questionnaires on themselves. So, these are validated mental health screeners.

The second intervention condition involves some equity enhancements which I'll talk about shortly. We have data from a variety of sources, including transcripts from the school intervention team meetings. So, we get to see what's actually being said as these teams are making their decisions about students.

So, the equity enhancements are training and coaching provided to the school team members. They include mental health literacy training with a focus on the idea that behavior that is presented might have an underlying mental health need. So, to consider that.

Unconscious racial bias training for these school team members and then database decision‑making that's using data that's disaggregated. I talked about disaggregating data in the discipline context. Here we're focused on disaggregating mental health intervention receipt data.

So, looking at what intervention students are receiving and disaggregating those by race and ethnicity and identifying gaps and disparities there and problem solving those.

So, as we move forward, we have a lot of opportunities as well as challenges in this work. One particularly prominent then one now is backlash against racial equity work in schools. Another one is partnering with communities.

So traditionally we come up with this research idea, a research intervention, and we go to a community and ask if they're willing to engage with it. And increasingly there's a move toward working with the community earlier in the process.

And the PCORI study I described, for those may be interested, the PC in PCORI stands for patient‑centered. And they explicitly require partnering with members of the community, stakeholders and patients in the design and implementation of a research study. I think particularly when we're talking about work that's trying to address disparities, work that's focused on racial discrimination, I think it's critically to have community voices. I think it's a funding challenge because there's often no funding to be able to form the partnerships that are needed to carry out this work but that's an area that I hope will improve in the future.

Another area is engaging families. So racial and ethnic minority youth and families encounter, they are disproportionately affected by barriers to engaging them in school mental health. There may be policies and practices, for example, in the schools that make it more difficult for some individuals to be able to participate.

There's also stigma that might be particularly relevant within certain communities, and as well as team member -- intervention team members' biases with regard to engaging families. So, we need some work to address that.

Also, a strength focus, a lot of times we have a deficit lens when we're focused on mental health and focused on racial and ethnic discrimination but recognizing that youth and their families and the schools all have strengths that can leveraged for change.

A project that I'm collaborating with Stan Que that I hope to be funded is to examine the effects of training students who have had disciplinary histories to be peer coaches. So, leveraging some of the strengths that they have, even despite their problem behavior, to improve their outcomes.

And then another challenge is the nuance in the diversity of the heterogeneous categories for race and ethnicity. I mentioned earlier that there were some LatinX subgroups for whom there are disproportionalities and others for whom there might be a reverse disparity when we're talking about discipline.

One of the challenges is just the way racial and ethnic groups are categorized in school data. Hispanic might just be a checkbox without all of the diversity that we know is important for these outcomes. So that's something to think about going forward as well. So, thank you.

MARY ACRI: I'm muted. Thank you very much. We're going to round out now the presentations with Dr. Hernandez.

13:25

COMMUNITY INTERVENTIONS FOR MATERNAL MENTAL HEALTH DISPARITIES

Speaker: Natalie D. Hernandez

NATALIE HERNANDEZ: Thank you so much. Hi, everyone. Let me bring up my slides. Make sure you see them. Do you all see my slides, my notes, is everything good?

MARY ACRI: Yes.

NATALIE HERNANDEZ: Great. Good morning, good afternoon, depending on where you're at. I'm Natalie Hernandez‑Green, associate professor in obstetrics and gynecology at Morehouse School of Medicine, and the founding director of our center for maternal health equity, which was founded in 2019, to really address inequities in maternal health outcomes that we were seeing in the state of Georgia, which happens to have the worst outcomes in the country.

The talk that I'm doing today is around maternal mental health, and this is a picture of me with my two beautiful children, because besides being a faculty member and being a researcher, I'm a mother first.

And here you see a big smile, but a lot of people don't know that I was actually dying inside, that these were not just the happiest but the most difficult times of my life because I was a two‑time survivor of postpartum depression.

This was my second bout of dealing with a maternal mental health challenge and really catapulted me into wanting to do a lot more of this work.

So, a little bit about maternal mental health conditions just in case some of you are not familiar, because I know people are in different pockets of research. Maternal mental health conditions are the most common complication of pregnancy and birth affecting about 800,000 families each year in the United States. And suicide and overdose are the leading cause of death for women in this first year.

And there are a lot of economic impacts as we see here. The cost of untreated maternal mental health conditions is about $14 billion each year in the United States.

But furthermore, maternal mental health conditions disproportionately affect Black women and birthing people. Although it disproportionately affects them ‑‑ and I say Black women, I myself identify as a Black Latina woman and are part of these statistics, we're still mostly under screened, undiagnosed and untreated.

So, there are various contributors to what we see in terms of maternal mental health disparities, first being structural and social determinants. So systemic racism unemployment, exposure to violence, gaps in medical insurance, adverse childhood experiences, lack of access to high‑quality medical and mental health care, and lack of representation of people that look like us in the medical systems, and also the fact that Black women have higher risk of pregnancy and childbirth complications.

As some of you know, Black women are two to three times more likely to die from pregnancy‑related complications.

In addition to that, there are other factors such as weathering, where Black women experience physical weathering, meaning their bodies age faster than white women due to exposure to chronic stress linked to a lot of socioeconomic disadvantage and just discrimination over your life course.

And weathering can make pregnancy riskier for Black women at an earlier age and can also lead to Black women experiencing more chronic health conditions such as diabetes and obesity.

Then you have what's framed as the Super Woman Schema, the strong Black woman. And the Super Woman Schema is a conceptual framework that states that certain socio cultural and historical perspectives in the United States have impacted how Black women experience and handle stress with Black women taking on the following coping characteristics. So, applications to manifest strength, suppress emotions and help others, even to the detriment of personal health. And there's this resistance to being vulnerable or dependent and a determination to succeed despite limited resources.

And that's exactly what I was going through when I was having my own bout with postpartum depression, not seeking help and thinking that I can power through it and not understanding that I could have gotten the help that I needed.

The other thing is that maternal mental health conditions look different in Black women. Black women experiencing depression are likely to report irritability, self‑criticism. So, a lot of the self‑blaming and somatic symptoms such as fatigue, insomnia and decreased libido, rather than the stereotypical depressive symptoms such as feelings of hopelessness or depressed mood.

And lastly, the screening tools that currently exist don't accurately assess symptoms in Black women. Screening tools were historically created and informed by white research participants, and there has been increased discussion as to whether maternal depression tools such as the Patient Health Questionnaire or some you know as the PHQ9, and the Edinburgh Post Natal Depression Scale are valid and sensitive to the cultural nuances of non‑white women and specifically Black women.

So, until more validated screening tools are developed to specifically address the maternal mental health screening needs of Black women and other people of Color, it's been recommended that a lower screening score cutoff be used for Black women.

So, all of this background information is really what informed community intervention that I'm going to talk about and the research that informed a lot of these interventions.

So, a while back, my CBPR community‑based participatory partnership and I were funded through the Detroit Community‑Academic Urban Research Center through their CBPR Academy to really examine maternal mental health. This is a topic that's been brewing in the state of Georgia. We were continuously seeing things happening in the maternal mortality review committee, again, around maternal mental health. And a lot of the community members who serve Black women were saying this is something that's happening that's not being addressed. And so, this was our priority topic that we wanted to address.

The other thing is the power of community and research is how do we meet people where they're at. Because what we were hearing is all the women were suffering from these conditions and self‑reporting this. They were not accessing the services that they need because they felt that they weren't there, or that they would be criminalized if they were seeking care. And so how do we meet people where they're at?

So, we wanted to figure out some priorities from community‑based members to see how we integrate perinatal mental health services in community‑based settings. We used a mixed‑methods approach, a collective impact framework, and, again, as I mentioned the topic was identified as a priority.

And the reason why a CBPR approach in mental health was important because at the time we were conducting this research mental health services or research has typically left out community voice resulting in delays of translation of research into practice with communities. And it wasn't until 2003 with the president's New Freedom Commission on Mental Health report that recommended that mental health care be consumer and family driven through their direct involvement of communities.

And so that's why we decided to take this approach. We wanted to make sure if services were going to be created for the community that they were created with the community.

So just a little bit of context of the community that I'm talking about. The research partner community in Georgia that we worked with was in Atlanta. It's an area located in South Atlanta, which the majority of the population, about 88 percent, are African American. The average household income in this community is only $23,000 a year.

There's a 21 percent unemployment rate, a 38 percent poverty rate. And it's ranked the lowest on a constellation of neighborhood health and quality of life factors compared to other parts of Atlanta. People who live in this community have a 12‑year difference in life expectancy compared with others who live in North Atlanta.

The purpose of our study was to assess the mental and emotional health challenges of underserved women in Atlanta, specifically Black women, and then to examine local priorities and sources of care that we can integrate into community‑based settings.

As I mentioned before, our CBPR partnership was Our Atlanta Healthy Start, which most Healthy Starts have Community Action Networks, and CAN partners, for short, work collaboratively to develop community solution strategies to address issues related to maternal health. And as I mentioned, this CBPR partnership prioritized mental health as an issue they wanted to have addressed.

The framework that CAN used is a collective impact framework, which is hoping to achieve sustainable change. Our CAN was diverse. We had state governments, school districts, community‑based organizations, universities, healthcare agencies. I mean, you name it, we had it as a part of this CBPR partnership. And it included about 200 members more globally, but then really active and representing a lot of those agencies, about 20 member organizations.

Knowing and working in community‑based participatory research approaches, the community and our CAN were really instrumental in co‑designing and assisting with data collection or even in some instances some of that data collection.

So, we had to make sure we went all the way back and trained our community partners on how to do that. So, we collaboratively came up with a research orientation. It was an extensive training that provided information about the research process, how to work with Black women in their communities, a whole section on perinatal mood and anxiety disorders as well as depression and how to conduct research with pregnant women and cues on how to read an individual's body language and facial expressions as they're conducting interviews or collecting surveys. The training employed a multiple intelligences approach, which consisted of didactics, media, we have music, hypothetical scenarios, role playing and the teach‑back method.

And research partners decided on this process because of the existing distrust of academic partners to ensure integrity and fidelity in the research process, the stigmatization of mental health ‑‑ and so we knew it was something that's stigmatized, particularly in the Black community ‑‑ and concerns related to research with pregnant women.

As I mentioned before, it was a mixed methods study. Our first method was using face‑to‑face in‑depth interviews. And we started this project and as soon as we started the project, the whole world shut down for COVID‑19. We didn't have as many interviews as we would have liked. But they did provide really rich data. And we thought about three different stakeholder groups which were Black women themselves, healthcare professionals, and those that serve the communities, which were our community outreach workers.

Our interview guide was informed by our survey -- by different surveys -- and the peer reviewed literature. And this was co‑created in different design sessions we had with our community partners based on women's lived experiences, and it was also piloted with the community.

Our analysis took on very much a thematic analysis. Again, we wanted to keep it a simple analysis since we were analyzing with our community partners, and we did train our community partners on how to use different qualitative software. And in this instance, they felt more comfortable with NVivo software.

The interviews were mostly conducted in coffee shops or private meeting rooms. We left it up to the community members or those that were being interviewed to choose the safe space that they wanted to have an interview in. We made sure we were in constant communication with people we were interviewing. They were called, texted or emailed a day prior to remind them of the interview. And the interviews only began, because we know this was such a sensitive topic, after the participants felt comfortable and ready.

And prior to the start of the interview, we discussed what would happen. And we also had a mental health provider on standby just in case anyone required that.

These are a few of some of the infographics and instruments we developed, again, in working with the population of interest, particularly if you know that area, you know documents have to be at a sixth‑grade reading level and sometimes even less.

We wanted to ensure people really understood. And, again, our community partners wanted to ensure we created our standardized documents you use in research, but documents that are also easy for the community to understand. And so, again, I think this was before Canva existed, where I think we made a lot of these documents in Word.

With the interview, we did have demographic info sheets, not necessarily for the woman because, again, since it's such a sensitive topic, we didn't want to collect too much. But when we interviewed with our healthcare providers, they were mostly females, median age of 40, all Black and then all service something around mental health support.

With our perinatal population, the median age was 24. And then with our community outreach workers, very similar demographics ‑‑ Black, female, median age 40. And they represented not only community health records, but in a lot of different Healthy Starts sites they do have what we call family support workers.

So, the theme related to our three different stakeholder groups. With our family support workers. They really expressed the lack of resources to be able to serve women who have mental health conditions, that there's a lack of a supportive system within their institutions and a lack of infrastructure to be able to provide some of those services. But they felt like they still had to do it anyway because they're providing a lot of case management to Healthy Start participants or to their clients.

Another big challenge was this was an impoverished population. Even if you wanted to refer them out, how would they be able to afford seeking counseling from mental health providers.

There was also a lot of stigmata related to either talking about mental health with their clients or referring their clients out to a mental health provider.

And even from them, rather than speaking about their own experiences, they kept going back to their clients and saying there was such a distrust and fear of judgment and that a lot of women wouldn't participate in mental health services or getting access to services because they're often criminalized. There's a fear of their child being removed from their homes.

So, these are some quotes from our family support workers, that “they don't trust very well in the people they're receiving services from because they don't look like them. They feel like they're going to be judged and maybe by the questions being asked, they may not like where it is being held. It's not familiar grounds. It's just not a safe space.”

Again, you have to understand when you're displaced and lack of education, it really takes a toll on your mental capacity.

For the women, when they were being interviewed, these were the big themes that came on. A lot of the women felt nobody cared about their mental health challenges. They were continuously depressed; they didn’t even know how to begin to seek out services. A lot of what contributed to their maternal mental health conditions is the insecurities of being a mom. They didn't know, for a lot of them, you saw they were young. They were first‑time moms. They don’t know exactly what to do. They had a lot of structural and social determinants of health impacting them. They felt like even if they spoke to their providers, no one was really listening to them.

They also were, again, that distrust in speaking with someone that didn't have that racial concordance with them and that no one generally asked about their own mental health even when they saw a provider ‑‑ and this goes with the background literature ‑‑ no one really screened or asked them about their mental health conditions.

So, this is one quote, and I don't change the quotes, so this is in their true voice. "Because they don't care to me. They don't care so it's just like, why do you waste your breath if you don't do anything about it? I kept telling them it hurts. It felt like I was being torn apart. After they got her out, I felt everything afterwards."

This was how one woman who was having mental health challenges, just couldn't go through with stuff. Did a C section. She kept complaining that she was actually feeling them cutting her up and they told her to be quiet and they just took out the baby and completely ignored her concerns.

And that's what led to her trauma and postpartum depression that she experienced. And she had suicidality after that experience and, again, never wanted to talk to anybody about it.

And then the healthcare providers, again, this data is a little old. But what they mentioned was that a lot of their patients, there's no postpartum care after the six‑week checkup. So, Georgia just got postpartum Medicaid extension. So, we know that we're hoping that more women are accessing the services in the postpartum period. Some significant challenges for women seeking mental health services was the lack of insurance. A lot of what led to the mental health challenges in the postpartum care during pregnancy is that a lot of the women they see had prior mental health issues. Again, the environment and household trauma, and they also mentioned that there weren't a lot of screening tools tailored to Black women.

One provider said, “I want to get better. I want them to be better moms. They're resilient in that. They just don't know how to do it and how to make them feel better.”

Overall, the major theme was there's a lack of support for people who are seeking or who have mental health conditions, maternal mental health. The social determinants of health create the mental health conditions that a lot of the women are experiencing, but then also create conditions in which they're not able to access the care that they need.

There's a serious concern that the issues need to be addressed right away because they're not. People are living with challenging mental health conditions for a long time without any treatment, and the screening tools that currently exist are not really capturing their experiences. And the biggest one from all three groups was the repercussions if they did disclose that they were having a maternal mental health condition.

We did do a survey that was really important for the community to be able to work alongside and conduct. And we used a lot of validated measures. And as the researcher, when I first worked with them, I wanted ‑‑ the survey was about 30 pages. They said, no, Dr. H, we need to reduce this. No one is going to take the time to do the survey so let's make it five pages.

So, it's not as extensive as we would have liked and when you think about research, what you want. But, again, this was a community‑based participatory approach. We worked with our CAN partners. A lot of recruitment was done through the CAN but mostly word of mouth. People were fearful that there were some survey flyers or whatever, that it would sort of "out" them and their condition.

We worked with five primary community‑based organizations to serve as recruitment sites. And, again, this was really telling too. You know, they wanted paper surveys. They felt more people would feel more comfortable with that. We did paper surveys. Those were completed between August 2019 and October '19. We actually had recruited about 400 women during that time. The power of community and working with community. But our final sample was of 302 women and that was what was completed surveys because we had a lot of missing data. And we performed binomial logistic regression to look at predictors of symptoms of perinatal mood and anxiety disorders.

These are pictures of some of the community events we did so we can administer the survey. We utilize a lot of community baby showers. We were in libraries recruiting women during different reading times. Again, being really innovative and creative how we would be administering some of the surveys.

So, with our sample of 302 women, the most women were single and had an education, a high school education. An equal number of women were with and without employment. So about 50 and 50%, which was in line with what we sort of expected knowing the demographics of the community. The majority were insured but the caveat to that is they're insured because they're pregnant and a lot of women have Medicaid during pregnancy. And 77 percent had a regular healthcare provider. And what was disconcerting to us was that most women had an annual household income of less than $10,000 a year.

One of the things that the community said they were interested in was adverse childhood experiences. This was one of our predictors, and what we found was that emotional abuse as a child was the most frequently reported adverse childhood experience with 49 percent followed by living with a household member or adult who used illicit drugs or was a problem drinker and then by physical abuse.

Nearly one‑fourth of participants reported sexual abuse and having lived with a household member or adult who had a mental health illness as well. And the mean self‑esteem score, because we also used the Rosenburg Self‑Esteem Score, was 32.99, and one‑third of women reported experiencing symptoms of depression or anxiety before pregnancy.

What was really shocking to us ‑‑ and again this is self‑report ‑‑ but of our sample of 302 women, 56 percent self‑reported having some type of perinatal mood and anxiety disorder. And when we were looking at that compared to women without symptoms of PMADs, a higher proportion reported ‑‑ again this is aligning it, looking at it as a predictor with adverse childhood experiences ‑‑ a lot of physical abuse and sexual abuse. Furthermore, a higher proportion of women with symptoms of PMADs experienced symptoms of depression and anxiety before pregnancy. And then women without symptoms of PMADs had higher levels of self‑esteem. So, the two groups of women with symptoms and women without symptoms did not differ in other sociodemographic characteristics.

So, what do we do with this information? And I love this quote through Dawes Gay, "How are we then using that research to inform policy?" Because again oftentimes communities complain and say you're doing research, but how is it getting back to the community and how are we really informing systems change?

We worked with large national organizations as well as local organizations within Georgia to really ‑‑ to share these results and talk about the dire need for maternal mental health services in our community. And as a result of that, there was a huge interest in our local legislature in those years around Black maternal mental health.

So, there's been chatter about mental health and mental health parity, but finally really thinking about Black maternal health within itself we were able to use this data to get a proclamation for a Maternal Mental Health Day.

The data also informed investments at our state in the maternal mental health hotline, or the PEACE for MOMS, which connects Georgia's healthcare professionals with psychiatrists who specialize in perinatal and mental health.

We were able to institutionalize maternal mental health peer support groups for pregnant and postpartum women in two community-based organizations. One the Center for Black Women's Wellness and the other's for Healthy Mothers Healthy Babies Coalition of Georgia.

And then we were recently recognized by Postpartum Support International Georgia chapter as being Innovators of the Movement Award, acknowledging the work that we've done to be able to tackle maternal mental health and specifically Black maternal mental health within the state of Georgia.

Other outcomes again with CBPR approaches are being able to co‑present. So, every single presentation we do is with our community partner. In two years, we were able to present at 10 different conferences. Some are featured here. We have about three publications that we've done again that are coauthored with the majority of our community members.

In addition to that, a lot of this work we were able to use in the future and we are one of the Centers of Excellence in Maternal Health Research through NICHD where our focus is on maternal behavioral health conditions, and we're really grateful to that pilot funding mechanism and other things we've conducted with community to really inform that work.

We also received an R01 looking at integrating community‑based perinatal patient navigators in clinical settings, and through that, a big focus of what our community‑based perinatal‑based patient navigators do is not only provide doula and social support and screen around social determinants of health, but they help identify women with mental health conditions.

We have integrated maternal mental health trainings for our navigators, and they're the ones that deliver a lot of the health education around perinatal mood and anxiety disorders and connect Black birthing people to maternal mental health services.

I just want to say thank you to Black women that we work with in our communities. This is a picture of another sort of survey administration activity we did. We couldn't do this work without each and every one of you. You know the goal of the work that we do is really based in Black feminist thought, which is to center and amplify and recognize that Black women's voices are legitimate sources of data, and we're unapologetic about how we do our work and why we do our work.

And I hope that through this presentation you were able to get some inklings into the situation, which, again, this data is from a couple of years ago and none of it has really changed. I think it's changed at the Georgia State level, but we're hoping to replicate this in other settings. And so, thank you so much for your time.

Here is my contact information. And I'm grateful to have the opportunity to present our research. Thank you.

Q&A 
MARY ACRI: Thank you so much. I believe now we're moving into Q&A. First question: How does deciding in a race‑dense area protect against racism when racism is happening all over the place outside where you live and the probability that you live in these areas are a direct result of structural racism?

SYLVANNA VARGAS: I can go first. Looks like my camera is freaking out. That's a great question. And probably more a reflection of, like, the lack of precise term I used in talking about racism rather than racial discrimination as an event, specifically.

It's totally true that people experience racism everywhere. And so there are several studies, though, that have shown that when you live in neighborhoods where you're surrounded with more people of your same ethnicity that you tend to experience racism less often or racial discrimination less often.

Of course, I think that brings up the question, how much time are you spending in those neighborhoods or where else are you spending your time. But it's a great point. It doesn't erase the oppressive systems that we live in.

MARY ACRI: Another question: What conclusions do we derive regarding your findings regarding community protective measures? Does this mean we can't really integrate groups and that we're compelled to stay in our groupings in order for people to thrive?

SYLVANNA VARGAS: I'm guessing that's a question for me, too. Yeah, you know, I really struggled with exactly that question when we found our findings.

I think ‑‑ I try to be as sort of, like, careful in terms of the way that I frame those results as possible. You know, I definitely don't think that the direction we should go toward is segregation.

Although I do think there is something to be said about thinking about how you develop safe spaces, and to me that would be the main implication of those results. I don't know if the other speakers ‑‑ I feel like your topics also touch on safe spaces. So, if you have anything, any perspective on that too.

MARY ACRI: That's okay. We'll have questions for you as well.

Again, for Dr. Vargas, could you provide the level of social support the individuals were experiencing or receiving?

SYLVANNA VARGAS: So, for the social support study, we asked pretty broad questions about their perception of available social support in their life based on different people in their lives. So, there are, like, questions about family, about friendships.

Yeah, so there are studies that have looked at specific kinds of social support, and those sometimes have different findings, but we just use a pretty general measure since it was a pretty widely used one.

MARY ACRI: Thank you. For Dr. Hernandez‑Green, who was the convener of the CAN?

NATALIE HERNANDEZ: That's a great question. That was our local Healthy Start. They served as the backbone support organization for the CAN. And we wanted for them to be the convener so that there was ownership from the community side rather than from the academic institution.

MARY ACRI: Another question for you, do you work with Black Mamas Matter Alliance?

NATALIE HERNANDEZ: Absolutely. They're one of our major partners, and the executive director is a graduate of Morehouse School of Medicine's Master of Public Health program and currently we have three projects together, including some of their alliance members.

MARY ACRI: Dr. Vargas, how do you see your work in intersectional identities applying to folks with liminal identities such as biracial/bisexual?

SYLVANNA VARGAS: That's a really great question. I really appreciate the person who raised that. I think it's just an example of how we really want to think about different subgroups even within the sort of broad categories that I was working with.

Like, certainly we know that among even the LGBTQ community, if we look at the outcomes and the experiences of discrimination that bisexual individuals experience, typically we see greater amounts of discrimination, and there are a lot of questions about the amount of support that bisexual individuals can access in the LGBTQ community because there's this sort of idea of, I guess, like, colloquially what I hear is sort of this you need to be picking a side, you're not really part of our community.

It creates this tricky situation where you're getting hit by heterosexism from a straight community and then you're also not able to access social support from your sexual minority community in the way that gay and lesbian individuals can.

So, I think it's really important to pay attention to all these different subgroups. I will say, though, that the issue we often run into, which I think the last Q&A sort of is touching on, is the more you look at different ‑‑ the more you split your data, the more you look at these different subgroups, the harder it is to recruit your sample and the harder it is to be able to have sufficient samples to say anything conclusively about the questions you have. As you could see in many of our studies, our samples tended to be pretty small. It's a balance, I think. But I think it's important to pay attention to those other identities.

MARY ACRI: Dr. Hernandez‑Green, what screening tools were used to gather the data for perinatal mood disorders?

NATALIE HERNANDEZ: I'm trying to look at my paper and see, because I know at the time it was so hard to find any type of measure that wasn't really long.

And so, I think it was ‑‑ it was adapted from the Royal College of Obstetrics and Gynecologists Maternal Mental Health Survey. This was the only survey at the time that we found that had questions related to women's experiences with mental health challenges, women's experiences with engaging healthcare providers and referrals and experiences of maternal mental health. That also included anxiety disorders and not just primarily focused on depression.

And I can put a link to the paper in the chat if people were interested in looking at the methodology.

MARY ACRI: Wonderful. Thank you.

Dr. Halliday, how can we aid young LatinX girls in the double minorities stacked against them?

COLLEEN HALLIDAY: Can you repeat the question, please?

MARY ACRI: How can we aid young LatinX girls in the double minorities stacked against them?

COLLEEN HALLIDAY: Yeah, so I think that ‑‑ honestly, so I think I'd say we're not quite sure yet. So based on the literature and our research, there's lots that we don't know.

We don't have enough information about the nuances of that particular group or category. But I think that, more broadly, my work really focuses on trying to change aspects of school systems that might improve the outcomes for various racial and ethnic minority youth.

And so, while I can't speak specifically to Latinas, I would say that the extent to which we're able to reduce disproportionate practices and reduce biases that might be occurring amongst school personnel, then I think that we are likely able to improve the outcomes of our Latina girls.

MARY ACRI: Dr. Hernandez‑Green, I like the term you used "birthing people" and "birthing persons." I'm curious as to the reactions you've had, especially in Black communities. And if you could speak on how you came up with that term. And thank you for your work.

NATALIE HERNANDEZ: No problem. First, I did not come up with the term. I think it's a term that's inclusive. And one thing that I want to point out is that I do use "Black woman" and "birthing individuals."

And I see Dr. Fleda Mask Jackson is on ‑‑ because Black women fought so hard to be considered a woman. So, I did not want to erase that history.

So, to be inclusive, we do use the terminology "Black woman" and "birthing people." Now being in the southeast, in Georgia, where different populations aren't as open, that term can cause some friction, not just within the Black community, but with our policymakers and those that we're trying to get points across, but it does seem to be embraced by our communities, particularly younger generations who are open to diverse terminology and terms that are more inclusive of different genders.

MARY ACRI: Thank you. Drs. Halliday and Hernandez‑Green, how do you approach schools and medical facilities with your findings and training opportunities?

NATALIE HERNANDEZ: Do you want to go first, Dr. Halliday?

COLLEEN HALLIDAY: Sure. That's fine. I can go first. So, the first thing we do is we don't cold call anyone. So, we typically will have a warm introduction. Sometimes it takes a long time to develop relationships to be able to leverage so that we can be trusted.

There are long histories of people coming into communities, including schools, to provide sources for data but not coming back to provide information to help with their data. And schools are incredibly complex organizations with lots of moving parts and lots of priorities that don't necessarily align with the work that we're doing directly or not in the way that they can see, so it's really important to have a warm introduction.

NATALIE HERNANDEZ: I concur. With medical facilities or hospital systems, it's always a little bit more challenging as well, but I think it's working with ‑‑ I think one of the beauties of myself being out of medical school is that I do work with a lot of these different facilities and have built that trust with them but then also doing what we do, our community conversations. We present data. We go to resident meetings. We go to huddles. We make sure that we're meeting people where they're at and then getting buy‑in from the leadership at these different institutions and hospital systems.

And so, working with the American Hospital Association, the Georgia Hospital Association, the Georgia OB/GYN Society, ACOG. Again, just knowing who your audience is and how you can share that data in meaningful ways and the "what's in it for them," right? Because everyone wants to know, okay, the data is great, but what am I supposed to do with it?

And so, you dream up what they can do with it, and then they can see that vision and then make them think that they came up with it themselves.

MARY ACRI: ACOG is, for folks who might not know?

NATALIE HERNANDEZ: The American College of Obstetricians and Gynecologists.

MARY ACRI: Thank you.

NIH would like to answer the question about birthing people.

JULIETTE McCLENDON: No.

MARY ACRI: That's wrong. No, my bad.

How do you empower communities to have coping mechanisms in the community in the era of George Floyd? That's for all of you.

NATALIE HERNANDEZ: I don't believe that we empower communities. Communities already have power. We just provide the tools necessary to activate the power that communities already have.

And so, I think, being an HBCU, the George Floyd era, really, I think that's what made the project so resounding because as he was dying, he was calling out for his mom. I think it really created a movement and we just continued to be a part of that movement, and it was just really important for us to make sure that people had the correct information and tools again so that they can activate the power that they have. But I will stop there.

MARY ACRI: While you're on the hot seat, Dr. Hernandez‑Green. Are there are differences with respect to maternal morbidity and mortality? I do see that you work with BMMA. This individual answered ‑‑ emailed you but also it would be helpful.

NATALIE HERNANDEZ: Yes, absolutely. There are. We see older populations. And so, the magic number is always 35, which is considered advanced maternal age, and that's where you see more severe maternal morbidity and maternal health complications. And so, it is after 35.

Younger populations tend to have better maternal health outcomes. But if you're really interested in all of that data, the maternal mortality review committees and the CDC, Centers for Disease Control, has maternal mortality review committee data reported by age differences.

MARY ACRI: Beautiful.

Dr. Vargas, can you talk about whether your study covered chosen families of LGBTQ+ people, friends as families for social support? And thank you for all that you do.

SYLVANNA VARGAS: That's a great question. I've gotten that a couple times before. Because our measure was pretty broad, it's not totally clear.

Like, the questions tend to be things around, do you have someone who is available ‑‑ I don't remember the items ‑‑ but something, an example like, do you go to someone when you're upset, kind of thing.

And so, it's not a measure that's specific to chosen family. I think that's a really important direction to go in as a next step and try to have a better understanding of different sources of social support that people have.

MARY ACRI: In terms of intersectionality discrimination, have there been any studies focusing on Black people and the effects of financial hardship on their mental health? Specifically breaking down the difference of effects between genders.

SYLVANNA VARGAS: From what I know, there definitely are a lot of studies looking at social economic status and race for Black individuals, and one of the things that I think one of the earlier speakers was alluding to this that we find is I guess it depends on how you look at it, but a U shape.

So sometimes people think, oh, you're protected from racism if you have access to more financial resources such as what happens when you have higher socioeconomic status, but actually you don't tend to see that for Black communities. You tend to see that often in people in higher SES settings, they experience more racism. In terms of the question about gender, I'm guessing there might be a study out there. I'm just not familiar with that. I don't know if the other speakers are more informed on that.

MARY ACRI: Dr. Halliday, how does a parent address their school‑aged Black son to navigate an image of being disruptive or inept?

COLLEEN HALLIDAY: That's a really big question because we're talking about ‑‑ so the images that other people hold about us, which are based on stereotypes.

And so, I think that the best thing that I would recommend is to individualize the student. So, there's an assumption that school personnel might be making about the student based on the student's category as a Black male. But your Black male child has individual characteristics that they might not recognize.

So, I think really humanizing the individual, they're not just a member of this category; they have strengths and interests, and highlighting those things to them is what I would recommend.

MARY ACRI: Another question, Dr. Halliday. How do you think clinical psychology research can influence reform of hyper surveillance practices in educational systems above and beyond individual school‑based interventions?

COLLEEN HALLIDAY: About hyper surveillance, I'm assuming we're talking about in the area of discipline. So, I would say, honestly, I think that clinical psychology, the way it's conventionally been trained, is not the best discipline.

I'm a clinical psychologist by training. But I collaborate with people who work with systems and have more systems focus, and I think that, really, if we're trying to move away from surveillance, we really think about beyond individual level interventions, we need expertise from people who are not focused on individual level interventions and focused on systems.

So, I will say interdisciplinary collaboration.

MARY ACRI: Dr. Vargas, what is your next step in terms of the burning question you plan to address in the areas of your research interest?

SYLVANNA VARGAS: That's a great question. Some of the work that I've been doing the last couple of years has been focused, I guess shifting more to systems and thinking about settings where we can enhance naturalistic social support and settings that overwhelmingly serve youth from underserved backgrounds.

So, I've been collaborating with Anna Lau, school‑based study, actually, where we're implementing an evidence‑based intervention in schools that tend to work with students from families of Color.

And I'm now developing a line focused on mental health help lines that reach youth from underserved backgrounds, and the idea is that this is an opportunity to kind of catch youth and think about bolstering social support, potentially.

MARY ACRI: We can certainly fault systemic homophobia, transphobia, sexism and racism for the lack of minoritized people availability and unwillingness, distrust for research studies. Refraining from blaming the victim for keeping these populations out of the studies and rather focusing on deconstructing the causes of there not being enough subgroups to have robust studies. Can someone comment on this and any thoughts on the pace of change via Dr. King's quote on the arc of social change?

SYLVANNA VARGAS: I'll take a stab. I think what I'm understanding sort of implied about this study is kind of questioning the way that we even conduct science or why we're so focused on things like power, like statistical power and quantitative methods.

And I'll say, like, I completely agree. I do a lot of mixed methods like the two other speakers often rely on qualitative studies, and I think those are really important approaches to be able to bring light to different people's experiences and not be so concerned about this number/power thing.

That's at least I think what I would comment on that.

MARY ACRI: Wonderful. We have to wrap up the Q&A. Throughout the comments, it's very clear that the work you're doing is meaningful and important and impactful.

So, we will now transition to the breakout rooms. 

BREAKOUT GROUPS REPORT BACK/CLOSING     

JULIETTE McCLENDON: Okay. Let's get started.

So, for this portion of the workshop, we have about 25 minutes. We may not need all of that time, so we may end a little early. We will see. 

But we'll have the moderators from each of the breakout rooms just come back and give us a sense of some of the themes that emerged from the conversations and so we can all sort of hear what everyone else was talking about.

So, we can go ahead and get started. I will just go in the ‑‑ I'll go sort of by theme. 

So, we'll start with methods and measurement.

Mauricio, if you could go first, that would be great.

MAURICIO RANGEL-GOMEZ: Yeah, yeah, by all means. So we were, Brittany and I, in a group of about 30 people, and we barely managed to get to the third question because people were really actively participating, which is fantastic. I see that as a win.

And one of the themes that came to the group is that ‑‑ and this is actually across all the questions ‑‑ has to do with the fact that we are actually measuring social determinants of health and designing the measurements and the methods in a specific population, but we are not careful enough when we move to different populations. And that is not only populations that are different in identities across those populations but also in age within a single population, that we don't really understand how to measure the impact of social determinants of health or even those social determinants of health, how they are being characterized in those populations.

And came the theme of intersectionality and how intersectionality has an important role in how we are measuring and how we are identifying the impacts of social determinants of health.

Importantly, there was the idea of how we are thinking about researching social determinants of health and that we need to go beyond what is happening and understand why that is happening. And for doing that, certainly we need to move away, potentially, from the traditional approaches in social determinants of health research and then try to understand ‑‑ try to potentially combine different approaches, combine disciplines, make a clear connection between the public health specialists and the basic researchers and see how those can inform each other, the epidemiology that combines with public health and brings those elements of characterizing the population but also understanding why, specifically, something is happening in the population; following populations longitudinally but also trying to see in these populations how, for example, different interventions may be able to address the impact of social determinants of health on mental health disparities or not. That's basically what I wrote down.

But, Brittany, do you have anything else that you remember from our group? 

BRITTANY HAYNES: Yeah, absolutely. You summarized most of it. The only thing that I wanted to make sure that I brought up, because it was a really rich discussion, was around community‑based organizations and how do we make it more feasible for them to apply for grants independently, how do we help them with capacity building or even capacity support, particularly when some of those organizations find that capacity‑building grants are just not always enough. They don't even have the resources, the expertise, to be competitive for those types of grants. And so that was something that came up and really stuck with me that I wanted to make sure I shared here. 

JULIETTE McCLENDON: Thank you. Lauren.

LAUREN HILL: Great. So, this is community‑engaged research ‑‑

JULIETTE McCLENDON: I'm sorry, no.

Next, Dawn.

LAUREN HILL: Oh, sorry.

JULIETTE McCLENDON: Excuse me.

DAWN MORALES: Hi. I'm the other methods and measure moderator.

Thank you, Mauricio, for going first.

In our methods and measurement breakout room, we had another lively discussion. I believe we had in the range of about 30 people who attended.

The conversation began with the idea that there's a bit of a tension around the use of qualitative and mixed‑methods strategies in research when it comes to the larger scientific community, especially when it comes to, for example, getting research funding from someplace like the National Institutes of Health.

So ‑‑ and we spoke about this at length, the idea that it was a bit generational in terms of how old the scientist it was another thing that got brought up.

From that we sort of segued into a companion topic, which is this idea that something like discrimination could benefit from a converging measures philosophy where there are different strategies used for measuring discrimination. And the bias that is inherent in the different approaches is sort of characterized so that when you try to sum up the general, you know, Gestalt, of your understanding of what it is that you're measuring, you can get a sort of a rich, full understanding of the size and nature of the problem by using multiple measures, including qualitative and quantitative.

And then, last ‑‑ well, another thing that came up several times was this idea that there's a tremendous international need for the ability to measure discrimination.

So, it's not just a ‑‑ it's been sort of a United‑States‑focused discussion mostly today, and several people mentioned that they're working elsewhere and need good measures there as well.

And the last question we weren't really able to explore was this question of are their community‑engaged research approaches used in the development of diagnostic measures of mental health or mental illness.

So ‑‑ and with that, that was ‑‑ that's the summary of our conversation. Christina, would you like to add anything.

CHRISTINA BORBA: That was wonderful, Dawn. Thank you very much.

DAWN MORALES: There you go. That's us.

JULIETTE McCLENDON: Thank you. Okay. Wonderful.

Next, we'll go to interventions.

So, Mary Rooney.

MARY ROONEY: Great. Thank you. I'll try to be brief.

But we had some really rich discussions around, you know, community‑engaged research and then also barriers to just ‑‑ to conducting interventions research that's focused on discrimination as a social determinants of mental health.

And I think throughout the discussion around the community partnerships, you know, there was an emphasis on authentic engagement and being able to hear what communities really need and open us to revise and rethink and restructure your research, really, research questions, research aims, your approach based on what you're hearing and feedback.

And I think one of the key points that was made was that this process around building these community relationships and partnerships needs to start early, like well in advance of when to plan to submit a grant application, possibly a few years in advance. But you really need to be able ‑‑ in order to be open and flexible, you need the time to be able to revise your approach. And you can't do that if you're doing it too close to when you need to get things submitted. And the idea that in academia, we should really figure ‑‑ need to figure out ways to value community relationship building as an activity that is rewarded much in the way that publication productivity is rewarded.

And one of our participants mentioned that there was a Pew report that came out recently around some work that a group of universities are doing to explore ways to better reward faculty. And so, I'm just putting a link to that report in the chat in case anyone wants to see it, although I somehow accidentally direct message Josh on that.

Sorry, Josh.

So, I'm just going to send it to the whole group in a minute when I'm done talking.

Although, Josh, I think it's relevant to you.

So that was a key point, I think, that I just wanted to hit home on. And then I think another key point was just around the challenges of conducting research on interventions that are trying to intervene on structural‑level factors, right, and how do we do that, and a real barrier that comes up with intervening in states where DEIA focus grants are prohibited from being submitted ‑‑ so Texas came up as an example ‑‑ and the real limitation that that poses. So, I think we can't ignore that factor as we talk about this research.

But, you know, what was brought up is the idea of maybe we start by testing interventions and intervening at a very local level, and so looking at what those interventions look like, testing them at the local level, and then using that as kind of a demonstration part of your case study that you can then use to foster the additional testing and intervening at other larger scales and in other communities as well.

And I'll stop there.

JULIETTE McCLENDON: Thank you.

I'll go next. So, in our group, talking about interventions, some of the main themes that came out are that communities are very unique, that, you know, every community may be ‑‑ may have different needs in some way when it comes to thinking about interventions for discrimination's impact on mental health, and communities often don't trust researchers and the medical establishment.

And so that brought us to discussing the importance of community‑engaged and, actually, community‑led research and the importance of communities really being a central component, if not the leader, of the work that's being done to create interventions to address discrimination.

And, you know, we also brought up the component of funding and time being potential barriers to being able to do that kind of work, as well as what are seen as sort of the right people to be doing research and the leading research.

We also talked about the importance ‑‑ or that individual‑level interventions likely are not enough to really move the needle on the impact of discrimination on mental health, and that we need multi‑level intervention, systemic interventions, as well as broad training and education in a variety of systems, including healthcare systems and schools, et cetera, in training programs, so that people understand what discrimination is, what racism is, how it impacts people, how it impacts people's health, and how we can create culturally responsive community‑engaged interventions.

There was also a discussion around taking a critical lens on the mental health field in general and how we train and how we supervise people, you know. There's ‑‑ especially ‑‑ I come from a clinical psychology background. You know, I didn't learn a lot in school about ‑‑ in my training program about discrimination, how it impacts mental health, what are interventions that can be used to address discrimination, what does intervening on a systemic level look like. Those were things that we didn't learn. And so, changing the whole paradigm of how we train mental health researchers and practitioners to think about these things is really important as well.

And, yeah, so I'll leave it there and we'll move on to dissemination and implementation. Awesome. Yeah.

MARY ACRI: There were several themes that ‑‑ from your discussion that carried over with ours.

So, we spoke a little bit about, in reference to what are some of the best practices for communicating research findings to community members, that there's a tension that a lot of the language that is used in research is very academic. So, there's a need to really couch it in more lay terms so that it's easily understandable across the board, using infomatics and then using different vehicles in which you can transmit this information, so radio, newspapers, so forth, although acknowledging that by making the language plainer, you also run the risk of it losing its rigor, so to speak. So, understanding there's a tension there.

The second point we talked about is what resources are needed to implement effective social determinants of mental health interventions within systems and communities. And we talked about how there needs to be an intrinsic will, desire, effort to actually make changes, and to implement and de‑institutionalize practices that are racist and/or discriminatory.

But in addition to that, we need some tangible things, education, funding, time, really looking at power, doing a power analysis and who has the power and, pivotally, looking at those who hold the power, that they need to affect the change in order for it to really take hold.

The last point we talked about is what are some of the gaps in dissemination and implementation research in the area of social determinants of mental health disparities, and where do we go from here.

And I think the group was pretty unified in thinking that there's a huge gap. We're not at the point where we're actively addressing social determinants of health and disseminating effective practices to address them.

There was discussion about how we need to empower communities to be part of this change, and that having the right people at the table is critical in order to have authentic and transparent conversations.

We also need to start looking at how we, as medical professionals, mental health professionals, how we're educated, and is there an implicit agenda that is not addressing social determinants of health? maybe in the absence of, they're not discussing it, and that is an agenda. So, we really need to affect change at the point of training and education in order to really start addressing social determinants of health and then thinking about adoption and scale‑up.

JULIETTE McCLENDON: Thank you very much.

And who else was on dissemination and implementation.

Stacia. Thank you.

Stacia Friedman‑Hill: So, our room had a very heterogeneous group of people. And we had researchers, we had a lot of students in our room; we also had people working in different settings, state institutions, insurance companies, community organizations. And so, this actually led to us sometimes flipping the questions on our head.

So, we talked, for the first question, talking about how to disseminate findings. First, we heard from some researchers about their strategies for holding meetings with schools or community organizations, and we asked: So when do you do that?

There was a lot of community‑based participatory research. So, the question was, do you disseminate your findings after you've already published them, while you're presenting at scientific conferences? And what we heard was, you know, a real commitment to, you know, it's an ongoing process, but sharing findings while the research study is ongoing allows researchers to also get input on how to interpret their findings.

And then we flipped it on its head, and we asked other members of our group how they got information, what kinds of sources of information, and what they see as some of the barriers.

So, access to information can be difficult, being able to access journals, definitely things that are jargony. There was a ‑‑ information should come in a way that's very consumable and also adjusted to different levels.

And then we talked about ‑‑ for our second question we talked about resources for implementing intervention in different systems. We identified different sources of barriers. Some of them come from the culture of systems ‑‑ for example, in psychiatry, thinking that the patient should come to you; you should not go to the patients ‑‑ and also talked about stigma. Sometimes walking into, for example, an LGBTQ center could be outing yourself. There could be stigma. So, again, bringing those programs out of the center into the community was really important.

And so those are just some of the things we talked about.

JULIETTE McCLENDON: Thank you so much.

And then, finally, our community‑engaged research.

So, Jenn, why don't you go ahead.

Jennifer Villatte: Thanks.

Our group all agreed that community engagement and, particularly, community‑based and participatory approaches result in research that is more relevant, innovative, rigorous, and impactful. But it takes more money, time and skills than non‑community engaged research. And these are not often acknowledged or valued by research sponsors or review panels. So, researchers partnering with communities are often disadvantaged when trying to fund their science. So, we need community‑engaged research‑focused funding and training opportunities, dedicated funds, and resources for building community partnerships, community participation, and research planning and for returning results to ‑‑ research results to the community.

I think our take‑home was, you know, center the community and aim for mutual benefit.

So, sponsors, ask yourself ‑‑ ask ourselves how we can build mutual benefit into our research priorities, our selection criteria, our funding announcements and pay plans. And, researchers, we encourage you to ask yourselves how will this community will be better off for participating in this research, how can I partner with versus consult or exploit this community, and what am I leaving behind when this study is over?

JULIETTE McCLENDON: Thank you so much. And Lauren.

LAUREN HILL: I heard a lot of similar themes that Jenn did, so let me just try to be brief in terms of how community‐engaged research and science, succinctly, is going to make it better.

It's going to help us to ask the right questions. It's going to help us to engage more participants from impacted communities, particularly that represent the diversity within those communities, not those who are just most comfortable interacting with the research community. It's going to make the research relevant to the actual problems.

We talked a lot about upstream versus the individual. It's going ‑‑ so it won't miss the mark. It's going to help interpret the results better.

And what's missing when we don't include the community and those who are actually working closely with the communities, right, their advocates, et cetera, is the nuance and the context that investigators from outside miss.

So, the science is not as good. As Jenn said, it's not as rigorous, et cetera.

What else we're going to gain is, from the community side, the results are going to be more relevant and potentially even less harmful.

Some of the barriers that we discussed: Trust. Both the historical issues around trust that we're familiar with but also the more recent trust issues where there are still investigators who swoop in, they want data, and then they leave and do the one‑and‑dones, and that makes it harder for those who are sincere about doing research that's built on trusting and trustworthy relationships. And people are very sensitive to that. They get it.

The preconceived notions about what the community is going to be like, the arrogance of investigators who expect to be treated as experts instead of extending themselves to community members. You know, they expect community members to come to them and be like, oh, you're so cool, like, you know, take our data, please.

And then all sorts of bias that Jenn has already talked about that's baked into the funding system and what gets valued and what doesn't.

And one person talked about how the people who do this research do not do it for glory, they don't do it for tenure, they don't do it for funding; they do it because they're passionate about it. And, you know, it would be great if they could actually get rewarded within the system that we reward other investigators.

And the final word went to someone who implored us to include people with lived experience in these endeavors as well.

JULIETTE McCLENDON: Thank you. That's a great place to end.

As chair of this workshop, I just want to thank all the moderators so much for your work today. And thank you so much to all of our speakers as well as our ASL interpreters, our captioners, our producers, and technical people. Thank you so much for making this possible.

And with that, I will turn this over to Dr. Joshua Gordon who will close us out.

We can't hear you, Dr. Gordon.

JOSHUA GORDON: How about now? Can you hear me? Okay.

JULIETTE McCLENDON: Yes.

JOSHUA GORDON: Okay. Sorry. My computer seemed to have lost its connection in the middle of that session, so I had to switch over to my telephone. I hope you all can see me and hear me, okay.

I'm Joshua Gordon, Director of the National Institute of Mental Health, and it was my pleasure to join for this last concluding session and also to read through the wonderful agenda that was prepared today, and I look forward to learning more about the outcomes of your presentations and discussions.

Today I know that you heard from a number of scholars who've highlighted the important role that discrimination plays in shaping mental health disparities. And I think you heard and discussed that we really need to move beyond understanding that role and into interventions and implementation and dissemination measures that will mitigate this impact, whether it's through reducing discrimination, building resilience, and understanding the role that the healthcare system and other systems can play in reducing these impacts. As you leave today, I encourage you to think about what you learned today, to look for gaps in the field and the literature, and to bring those great ideas for filling those gaps to us.

We at NIMH have been really listening over the last several years, and I can personally attest to the dedication of the NIMH staff and many of you and others in the extramural research community who are committed to advancing policies and practices that reduce mental health disparities, promote equity, and address the needs of individuals and communities, especially those subject to discrimination.

Still, that commitment is just the beginning. The field has a long way to go, and I really appreciate your putting your heads together and thinking about how we might get there, loved the ideas that were discussed today, and looking forward to seeing all those advances to come in the future.

Thanks for having me here for these closing remarks. And, again, I look forward to seeing what you can do.

JULIETTE McCLENDON: Thank you so much.

All right. I will turn it over to our producers to close us out.

Thank you, everyone, for coming.

EVENT PRODUCER: Thank you very much, everybody. What a great webinar it has been today. Thank you very much. And we will see you at our next NIH event.