A Matter of Life and Death: Responding to Increasing Rates of Suicidality in Asian, Black and Latine Youth

Transcript

• 00:00So hello everyone, My name
• 00:02is Amanda Calhoun and I'm going
• 00:04to be talking about how anti
• 00:06black racism is fueling the
• 00:08youth mental health crisis.
• 00:09But before I start,
• 00:12I want to say
• 00:13that I have no disclosures. But I do
• 00:15enjoy pictures of very cute children,
• 00:20and anytime I'm going to
• 00:21talk about difficult topics,
• 00:23I always have a trigger warning.
• 00:26Obviously, as mental health
• 00:28clinicians and psychiatrists,
• 00:29we know that it's important to name the
• 00:32fact that a lot of the statistics that
• 00:34we're talking about are real people.
• 00:36They're affecting real
• 00:37people right now every day.
• 00:39And because of the lack of empathy
• 00:42that I have seen and that I think has
• 00:45been a part of American culture since
• 00:47its inception towards black children,
• 00:49I'm especially conscious before I
• 00:52start talking about very damaging
• 00:54statistics about black children
• 00:55to name the fact that for those
• 00:57of us who are impacted by it,
• 00:59for those of us who take care
• 01:00of black children,
• 01:01this material is very upsetting.
• 01:03The Biden Herest Administration
• 01:05recently announced that they
• 01:06would invest over 200 million in
• 01:08the youth mental health crisis.
• 01:10Since youth mental health
• 01:11was declared an emergency,
• 01:12multiple experts have weighed in
• 01:14citing multiple factors including
• 01:16things like social media.
• 01:19But what has not
• 01:20been talked about is how anti black racism
• 01:23is fueling the youth mental health crisis.
• 01:26Anti black racism has a crucial impact
• 01:29on the mental health of black youth,
• 01:31but the current mental health system
• 01:33was not designed to address it.
• 01:37Black children and adolescents are
• 01:39suffering at unprecedented rates
• 01:40and have been for over 20 years.
• 01:43Black youth suicide rates are increasing
• 01:45faster than any other racial ethnic group.
• 01:49The suicide rates of other ethnic groups,
• 01:51except for Latin X and native youth,
• 01:53have remained virtually the same or declined.
• 01:55Even black children as young as
• 01:57five are twice as likely to complete
• 01:59suicide compared to their white peers.
• 02:02Now medical literature often cites
• 02:04poverty or lack of access to care or
• 02:07treatment stigma as reasons why the mental
• 02:09health of black youth are suffering.
• 02:11But the elephant in the room,
• 02:12what has largely been dismissed
• 02:14or silenced are the effects of
• 02:16anti black racism on black youth.
• 02:18Amounting number of studies document
• 02:20the mental health effects of anti
• 02:22black racism throughout the lifespan
• 02:24of black Americans even before birth.
• 02:26The stress of racism experienced by
• 02:28black mothers, also known as weathering,
• 02:30is linked to low birth weight babies,
• 02:32putting them at greater risk for
• 02:34developing depression and other
• 02:35child mental health issues.
• 02:37And this is just one example.
• 02:39By preschool black children have
• 02:41their own experiences of anti
• 02:43black racism distinct from those
• 02:45of their mothers and families.
• 02:47Racist beliefs emerge in
• 02:48early childhood and by age 4.
• 02:50Some experts even say 3 children.
• 02:53In particular,
• 02:54white children can have more
• 02:56negative attitudes towards black
• 02:58peers and prefer white playmates.
• 03:00Black children experience racism from
• 03:02adults as well and are disciplined more
• 03:05harshly in schools from an early age.
• 03:07The anti black school to prison
• 03:09pipeline continues throughout
• 03:10childhood and adolescence and has
• 03:11been found to be linked to higher
• 03:13rates of depression in black males.
• 03:15But black girls are not spared and receive
• 03:17harsher punishment than white girls.
• 03:19Beginning in preschool,
• 03:20this criminalization of black students leads
• 03:22to poor grades and school performances,
• 03:25which is linked to low self esteem,
• 03:26depressive symptoms,
• 03:27even suicidality.
• 03:28The cruel punishment of black
• 03:30children is intertwined with the
• 03:33racist phenomenon of adultification,
• 03:34the perception that black children
• 03:36are older and more mature than
• 03:38white children of the same age.
• 03:39It is rooted in anti blackness and
• 03:42enslavement and can also cause suicidality
• 03:44as black children age into adolescents.
• 03:46Like all children,
• 03:47their increased social and cognitive
• 03:49abilities like abstract reasoning could
• 03:51allow them to become increasingly
• 03:53attuned to their experiences of racism.
• 03:55But even children in the pre adolescent
• 03:57range report more frequent experiences
• 03:59of racism than non black youth.
• 04:01A recent survey showed the black
• 04:03adolescents reported in an average of five
• 04:06anti black racist encounters every day.
• 04:08A systematic review examining
• 04:09racism and mental health found a
• 04:12significant association between
• 04:13depressive symptoms and experiences
• 04:15of anti black racism and black youth.
• 04:18As a child psychiatry fellow,
• 04:19I have witnessed the depressive,
• 04:21even suicidal effects of anti black racism.
• 04:24The kindergarten who came home hating
• 04:26her beautiful coiled hair because of
• 04:28dehumanizing comments made by white peers.
• 04:30The third grader who became began to
• 04:32self harm after a white peer called
• 04:34her the N word with no repercussions.
• 04:36The high schooler who attempted suicide
• 04:38because of peer exclusion and excessive
• 04:40punishment at a predominantly white school.
• 04:43Yet each time I was the only mental
• 04:45health clinician who documented
• 04:46the crucial contribution of anti
• 04:48black racism in their assessment.
• 04:50And sometimes I was met with anger
• 04:52and resistance from supervisors
• 04:53for mentioning racism at all.
• 04:55So for that reason I don't talk
• 04:58about the crucial impact of racism
• 05:00with certain supervisors anymore.
• 05:02Now, to be sure, the racist,
• 05:03multi generational wealth gap between
• 05:05black and white families rooted in
• 05:07white supremacy plays an undeniable role
• 05:09in the mental health of black youth
• 05:11and is tied to suicidality as well.
• 05:13But poverty is not the whole story.
• 05:15In fact,
• 05:16higher socio economic status can
• 05:18sometimes be associated with
• 05:20greater depressive symptoms.
• 05:21For white youth,
• 05:22greater maternal education was associated
• 05:24with lower depression skill ratings,
• 05:26but in black youth the opposite was true.
• 05:29Black youth with highly educated
• 05:31parents had higher depression and
• 05:33reported a higher frequency of
• 05:35anti black racism experiences.
• 05:36These findings suggest the racist
• 05:38interactions outweigh the protective
• 05:40effects of parental education.
• 05:42Anti black racism is a driver of
• 05:44black youth suicide crisis separate
• 05:46from socio economic status but
• 05:47it is often unacknowledged,
• 05:49dismissed or even minimize Solutions
• 05:51are urgently needed to tailor the
• 05:53mental health treatment of black youth.
• 05:55I see the solution as three pronged research,
• 05:58medical education, and accountability.
• 05:59There is a dearth of research
• 06:02focusing on the distinct impact
• 06:04of anti black racism experiences
• 06:06on the mental health of children.
• 06:08We really need more funding
• 06:10that prioritizes this research,
• 06:11especially for very, very young children.
• 06:14And standardized medical education
• 06:16does not teach us how anti black
• 06:19racism can trigger or exacerbate
• 06:21psychiatric illness in children.
• 06:23So traditionally trained psychiatrists
• 06:24are actually ill prepared to
• 06:27navigate these harmful complexities
• 06:29and that really needs to change.
• 06:31Mental health clinicians cannot
• 06:33provide racism vigilant clinical
• 06:35care though if they are engaging
• 06:38in racist behaviours themselves.
• 06:39Black child patients have confided
• 06:41in me personally more times than I
• 06:43can count that they stopped going
• 06:45to therapy because of dehumanizing
• 06:47and condescending behaviour from
• 06:49mental health providers.
• 06:50Another elephant in the room is
• 06:52that racism is a big part of many
• 06:55people's therapy experiences.
• 06:56That also needs to change.
• 06:59Black children are more
• 07:00likely to be diagnosed, still with stigma
• 07:03laden disruptive mood disorders than
• 07:05white children with comparable symptoms.
• 07:07They are the most likely to be physically
• 07:09restrained in emergency departments.
• 07:10So it is crucial that our leaders implement
• 07:13anti racist hiring practices and reporting
• 07:15systems to recruit and retain staff who
• 07:18are truly fit to care for black children.
• 07:20And when racist behaviors do happen,
• 07:22leaders must hold mental health staff
• 07:25accountable, even if it means penalizing
• 07:27their prized colleague or close friend.
• 07:29The youth mental health crisis
• 07:30will not end into the mental
• 07:32health of all children stabilizes.
• 07:33And I refuse to let black children
• 07:36be left behind.
• 07:37Thank you.
• 07:45And as a quick plug,
• 07:46I will be hosting a Black Youth Mental
• 07:49Health Clinical Case Conference
• 07:50series here at the Yale Child
• 07:52Study Center starting in January.
• 07:54They will be held monthly
• 07:55from January to June.
• 07:56A formal announcement will be forthcoming.
• 08:04Yeah.
• 08:13So, Anna, you should be all set.
• 08:20Thank you. Hi, everyone.
• 08:24So when I was thinking of contributing
• 08:27factors flattening suicidality,
• 08:28I wanted to share some statistics
• 08:30with you all that I came across
• 08:32in preparation for today.
• 08:34So according to the APA,
• 08:35suicide is the second leading
• 08:37cause of death for people aged
• 08:3910 to 34 in the United States.
• 08:42Each year, an estimated 243,000 Latina
• 08:45folk attempt to end their own lives.
• 08:48The CDC reports that suicide is the second
• 08:52leading cause of death for Latina youth.
• 08:55Latina populations are
• 08:56disproportionately affected by economic,
• 08:59social and health consequences
• 09:01due to racial discrimination,
• 09:03lack of available resources,
• 09:05documentation status,
• 09:06and lack of culturally tailored services
• 09:09and culturally informed service providers.
• 09:12A recent study done by the US Department
• 09:15of Health and Human Services,
• 09:16the Office of Minority Health,
• 09:18found that statistics for Latinx
• 09:21youth are especially concerning.
• 09:24Adolescents report disproportionate
• 09:25rates of suicidal ideation attempt
• 09:28with higher self reported rates
• 09:31among female Hispanic Latina girls,
• 09:34Suicide attempts for Latina girls
• 09:36grades nine through 12 were 30%
• 09:38higher than for non Hispanic
• 09:40white girls in the same age group.
• 09:43Even more concerning,
• 09:44Latin X folk were 50% less likely
• 09:47to receive mental health treatment
• 09:49as compared to non Hispanic whites.
• 09:52Documentation status is also
• 09:53something that I feel like we really
• 09:56need to keep in mind when thinking
• 09:58of at risk Latinx families.
• 09:59Sometimes entire families
• 10:01might be undocumented.
• 10:03Often times parents are
• 10:04undocumented and their children
• 10:06are second generation born here.
• 10:08This presents a unique situation in
• 10:10which the youth is stuck between cultures
• 10:13at home and out in the community.
• 10:15These parents who are undocumented
• 10:18face many challenges.
• 10:19Two that I wanted to highlight
• 10:20today is that they are at risk
• 10:22of deportation and they're also
• 10:24limited to stable employment.
• 10:26This can contribute to the youth
• 10:27feeling an increase in isolation,
• 10:29anxiety and a cultural difficulties,
• 10:32acculturation difficulties.
• 10:33This in combination with the
• 10:35lack of treatment,
• 10:36can substantially increase risk.
• 10:40So when thinking of specifically
• 10:42culturally and racially informed
• 10:44assessment and treatment considerations,
• 10:46I wanted to talk a little bit about
• 10:48the assessment tools we utilize.
• 10:49So I have been trained mainly
• 10:51to use the Columbia scale.
• 10:54For those that you don't who
• 10:55don't know the Columbia scale,
• 10:56it measures suicide severity.
• 10:58Most clinics that I've worked at,
• 11:00including the clinic here,
• 11:01that's what we utilize.
• 11:03However,
• 11:03the Columbia scale does not ask any
• 11:06questions about cultural variations.
• 11:08There is one scale that I've come
• 11:10across in my career and that I came
• 11:12across in research and preparation for today,
• 11:14which does keep this in
• 11:15consideration and that is the cars.
• 11:17For those of you that don't
• 11:19know the cars is the cultural
• 11:21assessment for risk of suicide.
• 11:23So when we are thinking of
• 11:25culturally informed assessments,
• 11:26we might might want to consider training,
• 11:28utilizing tools that have awareness of
• 11:31the impact culture has on the lived
• 11:34experience of the families we serve.
• 11:36Another consideration I wanted
• 11:37to highlight is our EHR.
• 11:39So as most of you know in EPIC we have
• 11:41open notes. Epic does not currently
• 11:43provide documentation in Spanish
• 11:45for our Spanish speaking families.
• 11:47Treatment plans and evaluations and
• 11:49safety plans are all in English.
• 11:52So as clinicians when we are creating
• 11:55sorry Spanish speaking clinicians
• 11:56when we are creating a safety plan,
• 11:59we need to ensure that we are providing
• 12:01a safety plan to the parents in Spanish
• 12:03and potentially to the child in English.
• 12:05That means we have to create
• 12:07two safety plans.
• 12:08Another consideration I wanted
• 12:10to highlight is religion.
• 12:12So religion is also something I've
• 12:14kept in mind when doing assessments.
• 12:17In the Latin X culture.
• 12:18Faith is often times seen as a primary
• 12:21coping skill which also means that
• 12:24having self injurious thoughts or having
• 12:26thoughts wanting to take your own
• 12:28life can be seen to a parent as a sin.
• 12:30This can create a larger divide
• 12:32between the youth and the parent.
• 12:34While the parent means well by
• 12:36labeling these these thoughts
• 12:38as a sin and a spite to God,
• 12:40added stressors,
• 12:41guilt and shame can be put on the youth.
• 12:44This is something important to keep in mind
• 12:46when considering comfort level of disclosure.
• 12:49A youth who is raised with these ideals that
• 12:52not being grateful for their life as a sin,
• 12:54will likely present with more
• 12:56reluctancy to disclose and share if
• 12:58they're having suicidal thoughts.
• 13:00Asking about a family's religious views
• 13:02or if they use spirituality as a tool
• 13:04can be a good way to gauge if this is
• 13:06a contributing factor in disclosure,
• 13:08disclosure or added feelings of guilt.
• 13:11On the other hand,
• 13:12it might also be used as a tool
• 13:15of resiliency in a protective
• 13:16factor in a safety plan.
• 13:18And lastly,
• 13:19when thinking of some strategies that
• 13:21might be helpful to rebuild trust.
• 13:23I don't have all the solutions by any means,
• 13:26but I can give some of my thoughts based
• 13:28of my lived and clinical experience.
• 13:30The first strategy I want to
• 13:32know is systemically,
• 13:33efforts should be made to assure that
• 13:36there is representation within faculty.
• 13:38The percentage of racially and
• 13:40linguistically diverse individuals,
• 13:41at the very least,
• 13:42should reflect the diversity
• 13:44in the population.
• 13:45We need to take it a step further.
• 13:47Providing these clinicians with
• 13:49culturally informed supervision
• 13:51and support while they hold these
• 13:53families is key in meeting the
• 13:55needs of a diverse community.
• 13:57On a smaller day-to-day scale.
• 13:58I think some other strategies we can
• 14:01implement are as easy as taking the time
• 14:03to ask a client how their name is pronounced.
• 14:05If you don't know,
• 14:07just ask.
• 14:08Understand that interpretation
• 14:09services are not always accurate.
• 14:12There are many considerations
• 14:13here that I could speak about,
• 14:14but to keep it brief,
• 14:15there's a high likelihood that the
• 14:17interpreter you are using speaks a
• 14:19different dialect and is from a different
• 14:21country than the family you're seeing.
• 14:23If you are working with
• 14:25an undocumented family,
• 14:26when there is a need for EMS
• 14:28transport due to safety concerns,
• 14:30remind them that they are
• 14:31safe and provide them with
• 14:32education around their documentation.
• 14:33Status that it at no point needs to be
• 14:36disclosed if there is a concern for this.
• 14:38And lastly, understand that it took a
• 14:41lot of courage for them to seek help.
• 14:44Continuing to attempt to meet
• 14:45clients where they are can begin
• 14:47with approaching their beliefs,
• 14:48religion, language,
• 14:49and experience with curiosity and openness.
• 14:51Thank you.
• 15:09OK. Thank you so much for having me coming
• 15:12back here feels like coming home today.
• 15:15I am talking about culturally
• 15:17responsive care for AAPI,
• 15:18mental health and suicide.
• 15:21When I think about this topic
• 15:23AAPI mental health and suicide,
• 15:24I think of the symbolic image 1000
• 15:27Guangyin with a child trapped inside
• 15:30Guangyin is actually my grandmother
• 15:32believe this Asian godless holding
• 15:34the multi hand seemingly perfectly,
• 15:37functionally keeping the peace and
• 15:41maintaining harmony across the world.
• 15:43I see that in AAPI youth seemingly on the
• 15:46surface like they look highly functioning,
• 15:49matriving amazingly.
• 15:50But deep down no one would figure
• 15:53out they are struggling silently.
• 15:55A city trapped invisible child crying
• 15:57lonely and sad being inside trapped inside
• 16:00this guanine invisible loneliness really
• 16:04capture aapi mental health and suicide.
• 16:08Do you know suicide is the first leading
• 16:10cause of death for Asian American,
• 16:12especially girl between age 15 to 24.
• 16:15But not that many people
• 16:16are talking about it.
• 16:18Every year NIH only has less than
• 16:210.5% of funding for dedicated for
• 16:24AAPI mental health and suicide study.
• 16:28I think as clinician we should
• 16:30really embrace ourselves knowing
• 16:32how to practice cultural humility.
• 16:35How do we really empathize and
• 16:36mentalize into our patient and family?
• 16:38Where are these unique challenges?
• 16:40They are struggling.
• 16:41For example,
• 16:42the concept of individualism
• 16:44and collectivism really speak
• 16:46loudly to this population.
• 16:48Collectivism meaning the health illness,
• 16:51it really is not only an individual issue,
• 16:54it expands to family,
• 16:55extend the family community.
• 16:58You can imagine how much shame,
• 17:00guilt,
• 17:01losing faith can amplify throughout the
• 17:04community that become a precipitating
• 17:07factor leading to suicide behaviour.
• 17:10Not to mention very concerning.
• 17:12Asian Americans are three time less
• 17:14likely to reach to mental health
• 17:16services than other Americans.
• 17:18We as clinicians, sometimes we stereotype.
• 17:20We think AAPI is only one
• 17:22box fit all we think.
• 17:24Maybe they are highly achieving,
• 17:26highly functioning,
• 17:27and they're highly resourceful.
• 17:28But there's also another spectrum
• 17:30of AAPI individual and family.
• 17:32They struggle with trauma,
• 17:34war and poverty, intergenerational trauma,
• 17:36but never have space to
• 17:38talk about these people.
• 17:40They also struggle with basic
• 17:42needs and in their eyes they see
• 17:44meaningless about mental health.
• 17:46They would not even come across
• 17:47the mind to reach or knock
• 17:49at our door to reach help.
• 17:50They would
• 17:50rather talk to the friends and family. How
• 17:53do we do a better job for this family?
• 17:56I also see invisible loneliness
• 17:59happen in AAPI family.
• 18:01This cross cultural cross generational
• 18:03conflict happened in family.
• 18:06In AAPI family,
• 18:07parents and grandparents generation,
• 18:09they could be immigrant themselves.
• 18:11They sacrifice big time to come to
• 18:13this country for the best interest for
• 18:16the family and especially for child.
• 18:19Often times they may not have the
• 18:21level of reflective functioning
• 18:22to mentalize into the child.
• 18:24Something may blow out from the mouth.
• 18:26Why are you feeling sad?
• 18:28Why are you killing yourself?
• 18:29Why are you feeling so selfish?
• 18:31They have no work to mentalize the child.
• 18:35On the other hand,
• 18:36the child trying 10,000 time meeting
• 18:38expectation of the children.
• 18:40In the concept of filial piety,
• 18:42we have the concept we want to look up,
• 18:44honor, respect our parents.
• 18:46You can see why I see AAPI children.
• 18:50It's like a multi functioning Guan Yin
• 18:52with a child trapped inside feeling lonely,
• 18:55sad and invisible.
• 18:58I also see the invisible loneliness
• 19:01happen in a systemic community level.
• 19:04In the context of racial identity.
• 19:06These two pictures would be
• 19:07pretty familiar to people after
• 19:09Pandemic AAPA youth and adolescent.
• 19:11They live under the shadow of model minority.
• 19:15We may see them successful book,
• 19:17smart be, you know, good at math,
• 19:19science, become doctor, medicine,
• 19:21engineering.
• 19:22But when they grow up they
• 19:23never be the leadership position in the field
• 19:25or they can also perceive for the
• 19:27picture on the right hand side where
• 19:29back in late 1800 AAPI youth and
• 19:32adolescent they they were perceived
• 19:34as I'll disease bringing bring not
• 19:37welcome in the US and that what
• 19:39happened many years ago and not re
• 19:42and also recently during the pandemic.
• 19:45We as a clinician can how can we imagine
• 19:48and teens and adolescent build up the
• 19:51racial identity under the societal
• 19:53inferences how can we do a better job.
• 19:57So accounting for what I do,
• 19:59why I do I have this deep reflection about?
• 20:02I also experience acculturate of stress,
• 20:04acculturate of gap.
• 20:05Once Upon a time I also at
• 20:07the age of my teenager,
• 20:09patient like I fly all the way.
• 20:11I was a Parasites Kid coming from Hong Kong,
• 20:14flying across the Pacific Ocean Lander
• 20:16in the US with my family 1000 miles away.
• 20:20I was Once Upon a time,
• 20:21the Guan Yin,
• 20:23multi functioning but deep inside
• 20:25feeling lonely and sad.
• 20:26Many years later I'm a mother of two
• 20:29Asian American boys and a witness.
• 20:31They also struggle with similar challenges.
• 20:34They think they are white,
• 20:35we live in a small town,
• 20:36and they they they somehow reject
• 20:39the Asian identity.
• 20:40This is the calling of why we
• 20:42need that's so much what we need
• 20:45to do for this population.
• 20:46Several years back when I was
• 20:48still a fellow in Child Study,
• 20:49I founded this group called Yale
• 20:52Chat Together Compassionate Home
• 20:54Action Together specifically geared
• 20:56toward working for AAPI family.
• 20:59In the context of this talk Chat
• 21:01Together we have a mission to call out
• 21:03the SAT child being trapped in the Guangyi.
• 21:06We want to call out the SAT and
• 21:08burnout parents being trapped in
• 21:10the Guangyi so they can see eye
• 21:12to eye again and they talk to
• 21:14each other despite barriers.
• 21:17These are the six component of what we
• 21:19do in chat together without getting
• 21:21detail what we do but like explain
• 21:24why we do for for the concept level.
• 21:27As I mentioned AAPA,
• 21:28mental youth and suicide.
• 21:29There's so much stigma around that.
• 21:31How do we create a medium that people
• 21:34feel safe enough under the skin to
• 21:36talk about this con conversional topic.
• 21:39So therefore we we try to get a less
• 21:42stigmatizing medium such as theatre
• 21:43such as graphic novel illustration
• 21:45for people can talk about things.
• 21:48Another big focus here.
• 21:50We also have a lot of community outreach.
• 21:53If they don't come to us,
• 21:55we go to meet them at the community level.
• 21:57We reach out to them at local churches,
• 22:00Community Center school.
• 22:01And recently I found a group in New
• 22:05York City how we work with AAPI artists
• 22:07to have a local art exhibition while
• 22:10we do theater workshop with a family.
• 22:12So a family can have a fun day talking
• 22:14about mental health without realizing
• 22:16they're talking about mental health.
• 22:20And lastly, this is the acknowledgement
• 22:23that like I want to conceptualize this,
• 22:25we create a community.
• 22:28How do we are really inspired by the
• 22:30two a cap presidential initiative by
• 22:32Doctor Warren and how do we capture
• 22:35the belonging creating a community
• 22:37people feel safe enough to talk
• 22:39about mental health and also Doctor
• 22:42Tammy Benton about that that the
• 22:44new a cap Presidential initiative,
• 22:46How do we bring the village for the
• 22:49children and family and together
• 22:50we can be
• 22:51together for better future generation
• 22:53of children and families. And
• 22:56lastly this other resources that I
• 22:59want to share with all that including
• 23:01like that could be a good resource
• 23:03for your library including all the
• 23:05referral for Asian therapists across
• 23:07different 50 states in the US,
• 23:09anti Asian racism teaching material
• 23:12for children, parents,
• 23:13Clinician by standard intervention,
• 23:15Stop AAPI Hate Report and also
• 23:17National Suicide Prevention
• 23:19Hotline with the Russian languages.
• 23:21Thank you for having me.
• 23:46Thank you all for your thoughtful
• 23:50presentations and I think in in
• 23:53the three presentations Amanda was
• 23:57really citing the history and the
• 24:00the impact of anti black racism on
• 24:04the mental health of black youth.
• 24:06And I also like I was thinking about
• 24:09this in terms of the two communities
• 24:11that you all were were talking about,
• 24:14the Latin a community and the API community.
• 24:17Especially thinking about immigrants
• 24:19who are coming,
• 24:21who are coming from countries
• 24:22where most people look like them,
• 24:24if not everyone.
• 24:25And so then they come to this country
• 24:27where there's a whole lot of racism,
• 24:30equal opportunity racism for lots of people.
• 24:34And so I wondered about what you
• 24:37thought or how you thought that
• 24:39impacts the their experience of
• 24:41both isolation and their mental
• 24:43health when they arrive in a man.
• 24:44If you have others to add about
• 24:46anti black racism,
• 24:46please do.
• 24:50Yeah I mean I think you know there are
• 24:53many black immigrants as well and so that
• 24:57you know you see an actual kind
• 24:58of similarity. And one statistic
• 25:00that I didn't show is that actually
• 25:02when we look at sort of
• 25:04negative birth outcomes,
• 25:05foreign born black women have
• 25:07better birth outcomes when they
• 25:08first come to this country.
• 25:09And after one generation
• 25:11of anti black racism that positive
• 25:13effect actually of being in
• 25:14a country with mostly other
• 25:16black people goes away. So I
• 25:19think it's important to understand
• 25:21the difference from people.
• 25:22You know, I talk a lot with, you know,
• 25:25my friends and colleagues who are,
• 25:27you know, from African countries or
• 25:28from different places in the Caribbean.
• 25:30And they don't understand
• 25:31the racism here in America.
• 25:32Because I just think, you know,
• 25:36from my time in Nigeria that I spent there,
• 25:39you're valued by your education.
• 25:41And if you work hard,
• 25:42you know, you will succeed.
• 25:44And then, you know,
• 25:45you get to America and you're a black person.
• 25:47And whether you're educated or not,
• 25:48people look at you all the time
• 25:50and assume that you're nothing,
• 25:52You're nobody.
• 25:53You have no education and
• 25:55nothing to give to this world.
• 25:56And I think that is a very difficult thing
• 25:58to deal with coming to this country.
• 26:01So I just think the racism here in
• 26:05America is very devastating and different
• 26:07and it's difficult to understand it.
• 26:10But I think one way to understand it
• 26:11is to understand the relationship
• 26:13between black and white people
• 26:15because blackness was created to
• 26:16be at the bottom and whiteness was
• 26:18created to be at the top and then
• 26:19everyone else kind of fell in between.
• 26:21And so it's sort of a,
• 26:24you know we have a lot of these these
• 26:26talks amongst ourselves but we're
• 26:27all harmed being non white people.
• 26:32I guess I can comment about like in
• 26:34terms of the immigrant and how that
• 26:36it could the experience could affect
• 26:38them the the mental health like
• 26:40from live experience and also like
• 26:42working with this immigrant family.
• 26:44It feels like that interesting like
• 26:46for people who just immigrant from
• 26:48the home country to the US like
• 26:50it is a process of acculturation.
• 26:52They want to adapt as much and as quickly
• 26:55as possible to the to the US for example.
• 26:59But often time they forget about
• 27:01their own pride of their own culture.
• 27:04I I see that in myself.
• 27:05I see that in many of the family
• 27:08and in the AAPI community.
• 27:09Recently I was asked to talk about
• 27:12have a talk for Asian parents group in
• 27:15the context of the affirmation act.
• 27:17Not to get into political,
• 27:19but like really to trying to
• 27:21understand these Asian parents
• 27:22really terrified about the the the
• 27:24children getting into college.
• 27:25I was shocked to see like how this
• 27:29student and parents they terrified about
• 27:31like checking the box of being Asian.
• 27:34How do we be like less Asian or
• 27:37doing things like extracurriculum,
• 27:39being less Asian,
• 27:40not do math or science so that
• 27:42they could be perceived as more
• 27:44you know more superior being
• 27:46selected for for the college.
• 27:49So I I just like was shocked by that
• 27:52like like how we can preserve on one
• 27:54hand we want to assimilate into the
• 27:57the white society but at the same
• 27:59time we want to preserve some of this
• 28:00cultural pride to have a cultural
• 28:02sense of stuff that we can proud of.
• 28:04I think that is very important a very
• 28:06it took a long time to realize it,
• 28:11so to speak a little bit about Latin
• 28:13immigration and and mental health.
• 28:15I think a big part of it is community.
• 28:17So a lot of people who immigrate from other,
• 28:19from any LATAM countries,
• 28:23they don't readily go see a therapist, right.
• 28:26They use their community.
• 28:26They use their family, their Fias,
• 28:28their, you know, their Elitas.
• 28:30And then they come here and
• 28:32they don't have that community.
• 28:34And it's kind of like, OK,
• 28:35we'll go to a clinic and figure it out.
• 28:37Most parents are not going to say, yes,
• 28:39let me bring my child to a clinic to
• 28:40talk to this stranger that we don't
• 28:42know that looks nothing like us, right?
• 28:43We want to talk to our families.
• 28:45We want to talk to our neighbors.
• 28:46So I think that's a big challenge
• 28:47in in mental health services
• 28:49specifically with that,
• 28:50you know, immigrants
• 28:53and just you, you made me remember
• 28:55something, which is when I,
• 28:57both of my parents are Puerto Rican.
• 28:59My dad was born and raised in Puerto Rico.
• 29:01And when I told them what I
• 29:03wanted to be when I grew up,
• 29:05his answer to me was why would you do that?
• 29:08Why do you want to get trained to sit
• 29:10and listen to white people's problems?
• 29:13Because that was the perception of
• 29:15who Mental Health Services was for.
• 29:17It was not something readily known.
• 29:19And you sort of keep your dirty laundry,
• 29:22if you will,
• 29:23to yourself and within the family.
• 29:24And so he now very much
• 29:27better understands what I do.
• 29:30But that was part of the thinking.
• 29:31And in the 20 years that I've been in,
• 29:33in, in, in working in this field,
• 29:35I've seen an evolution to more
• 29:38acceptance and more access,
• 29:41which is encouraging,
• 29:42but certainly not where it needs to be.
• 29:46So I'm curious to Amanda,
• 29:51you talked a lot about some of the
• 29:54things that you've seen yourself
• 29:56as a fellow and in your work.
• 29:58And I'm curious about how is caring
• 30:01for black children amid the youth
• 30:03mental health crisis impacted
• 30:04you as a physician and a person?
• 30:08So I move mine in a lot of hospitals,
• 30:10and I think I really like that,
• 30:12'cause I get a chance to see
• 30:13a lot of different hospital
• 30:14systems around New England.
• 30:16But what has been consistent
• 30:18is the poor treatment that
• 30:20I witness of black children.
• 30:22And I think it's very difficult
• 30:24for me and any of those actually
• 30:26who are working with me who
• 30:27have empathy for black children.
• 30:29And I know I've said this twice,
• 30:30but it's a whole nother conversation
• 30:32about how I think that the messaging
• 30:35in this country has led to a lack
• 30:38of empathy towards black children.
• 30:40Happy to have that as like a
• 30:41separate conversation with Y'all,
• 30:42but I've just worked with
• 30:44many people who I see
• 30:47just a real lack of empathy
• 30:49towards black children and the
• 30:50things that they're doing to
• 30:51them. For me personally it's it's
• 30:54very difficult to see that happen.
• 30:57You know, because these are
• 30:59children and it's very difficult to
• 31:00walk the line between, you know,
• 31:02you want to be part of your team,
• 31:04you're part of the mental health team.
• 31:06We want to, you know have
• 31:08this teamwork mentality.
• 31:09But I also not one to allow that
• 31:11type of behavior if I don't
• 31:13think it's the standard of care
• 31:15that we would give to any child.
• 31:17So if I feel a child is not is
• 31:19being restrained and we wouldn't
• 31:21do that for a white child,
• 31:23I'm going to say something about that.
• 31:24And I think that's all part of
• 31:26the process of how do we navigate
• 31:29difficult conversations as
• 31:30team members and mental health.
• 31:32And I think that's what's what
• 31:33Yale is training us to do.
• 31:35They're training us to be leaders.
• 31:36They're not training us to be followers.
• 31:38But you can be a leader and learn
• 31:40how to cooperate with the team and
• 31:42learn how to cooperate in a system.
• 31:44And you could also stand your ground too.
• 31:45But I think it can be really difficult.
• 31:47Thank you.
• 31:52You have so many questions and I want to
• 31:53make sure you all have an opportunity
• 31:55to ask them questions as well.
• 31:59And I I'm thinking to Eunice,
• 32:02you talked about sort of you
• 32:08mentioned cultural humility.
• 32:09And so I I wonder if you can speak
• 32:11a little bit more about how you use
• 32:14cultural humility and how you think
• 32:16it's helpful in approaching assessing
• 32:19and treating Asian youth. Yeah,
• 32:23great. And I'm sure everyone here we will
• 32:26train and learn about cultural humility.
• 32:29But sometime how we can put that into
• 32:31a cultural context when we practice it
• 32:34in our daily clinical practice it it
• 32:36it's a lifelong learning for everyone.
• 32:38I think we really should.
• 32:40Cultural humility really is like
• 32:42have us to I acknowledge that we
• 32:45don't know each other racial,
• 32:46ethnic background and core belief
• 32:48in family tradition and and I found
• 32:50that it is incredibly important to
• 32:52create a narrative and learning,
• 32:54being curious about learning the narrative
• 32:57from our patient and family and from
• 33:00the time I worked with AAPI family,
• 33:03I found that it is important also to
• 33:06utilize a family centre approach as well.
• 33:09How do we treat the family as
• 33:12one unit system?
• 33:13One of the slides show the invisible
• 33:16loneliness happened in AAPI family.
• 33:18Often time we can emphasize the the
• 33:20teens or the child better but it is
• 33:23hard to align with the parents per SE.
• 33:25If we don't have cultural humility,
• 33:28we may be like cross our mind
• 33:29like should I call DCF?
• 33:31Like how come that parents?
• 33:32I think so verbally abusive thing.
• 33:34But like maybe deep down like that
• 33:36parents need to be emphasized and
• 33:38understood in a cultural lens as well.
• 33:41How can we as a clinician also
• 33:43be a model to help the parents,
• 33:45to help the parents, to help the teens.
• 33:47So seeing that as one unit system,
• 33:50sometimes the patient could be the
• 33:52family in addition to the child.
• 33:54So I want to say about that and
• 33:56emphasize that we should all have
• 33:58a lifelong learning goal to be
• 34:00a culturally informed clinician.
• 34:05Anna Maria, you spoke,
• 34:08you brought religion in and some
• 34:11of the considerations that you've
• 34:14had to navigate with families.
• 34:15Given this, when when religion is an
• 34:20important lens of support and in the
• 34:22way that a family exists in the world,
• 34:24can you talk a little bit into
• 34:25how this could be helpful,
• 34:27but also how it can be challenging
• 34:29to navigate with the families
• 34:30that you work with?
• 34:32Sure, I think so.
• 34:33A lot of the times in, in my experience,
• 34:36it's normally the parents who are
• 34:38very religious and have this belief.
• 34:40You know, just pray you're feeling sad.
• 34:43You know, I pray to the,
• 34:45you know, the virgin.
• 34:48And while that skill might have
• 34:50really worked for that parent,
• 34:51for whatever reason their life
• 34:53experience was and their ability to be
• 34:55resourced and have people to talk to,
• 34:58that doesn't mean that it's
• 34:58going to work for the youth.
• 34:59So there's a layer there of providing
• 35:01psychoeducation to the parent,
• 35:03that the youth is growing up in a different
• 35:05type of environment than they're growing up.
• 35:07They're exposed to different things.
• 35:08So I I think there's a lot of psychoeducation
• 35:11that needs to be provided to the parent.
• 35:13I also have seen religion be
• 35:15used in a positive way, right?
• 35:17Sometimes we don't know if the youth is
• 35:20actually in agreement with the parents.
• 35:22Sometimes they're like purposely
• 35:23trying to be a little oppositional
• 35:25against the parent for whatever reason.
• 35:27But if you have a separate conversation
• 35:28with the youth about religion,
• 35:29they actually do have similar views.
• 35:32So I think it's just exploring
• 35:34and being curious with for both
• 35:35both the youth and the parent.
• 35:38Yeah. And if I can add,
• 35:40I think one of the things
• 35:42that comes from that is,
• 35:44is shame that you talked a little
• 35:46bit about that in your in your talk.
• 35:49And because of that shame,
• 35:50I know one of the questions that I
• 35:53always ask Latina youth and youth
• 35:55for whom religion is a big part of
• 35:58their their family is if they've
• 36:00ever had any secret attempts.
• 36:02Because that that answer is often
• 36:04different than when I just asked about
• 36:07have you thought about suicide because
• 36:09of the amount of shame that they hold?
• 36:11It's sort of coded in a different way.
• 36:14And so I'm always thoughtful of
• 36:17asking that question because of that.
• 36:20And I think there's also the piece of
• 36:22helping the family find the parent,
• 36:24the caregiver,
• 36:25find strength in their religion,
• 36:26but also maybe reminding them
• 36:27about where they might have been
• 36:29when they were an adolescent.
• 36:30And if religion was their main
• 36:32lens at that point to create some
• 36:34space so the family can find,
• 36:35strengthen what they need,
• 36:37but also make some room for
• 36:39the child to not have the same
• 36:41belief system at this point.
• 36:43So I'm going to ask a question
• 36:44that I'd like all of you to answer.
• 36:48What are some of the ways that you
• 36:52think the Yale Child Study Center can
• 36:54be involved in improving mental health
• 36:56care for the different populations
• 36:58that you have represented today?
• 37:02Sure. So just I'll get started.
• 37:05I I want to go back to community.
• 37:07So I really believe and Tara,
• 37:09you and I have talked about this before.
• 37:11Before coming here,
• 37:12I have never had a Spanish speaking or
• 37:15bicultural supervisor or supervision.
• 37:17So being here and having that community
• 37:19and supervision has been really helpful.
• 37:22Also having a space in our different
• 37:24kinds of consultations to talk
• 37:26about cultural considerations,
• 37:28potential adaptations to
• 37:29Evps is also very helpful.
• 37:32I know in some,
• 37:34some places if you have a supervisor
• 37:36who maybe doesn't understand
• 37:37and you bring up a concern,
• 37:39they kind of invalidate it.
• 37:40You know, no, just keep doing the model,
• 37:42it'll it'll be fine.
• 37:43That's not necessarily true.
• 37:45So having somebody that in leadership that
• 37:47is able to kind of speak your language,
• 37:50understand your lived experience,
• 37:51I I think it's helpful in talking that
• 37:53through and it's helpful for our,
• 37:54our clients.
• 37:58So I think that, you know,
• 38:01it's that's a really good question.
• 38:04I think the Ill Child Study Center
• 38:06has already started to make those
• 38:07steps when it comes to black children.
• 38:09And I say that because the number
• 38:11one thing that I always recommend
• 38:13is bringing in experts who are
• 38:15trained in navigating these issues.
• 38:17Because what I said was, you know,
• 38:19in standardized medical education,
• 38:20we get no training and you know,
• 38:22how do you make sure that you're not engaging
• 38:24in anti black racism in the clinical space?
• 38:26How do you actually navigate it?
• 38:28So you might grow some comfort
• 38:29in asking kids about it,
• 38:30but then what do you do?
• 38:31How do you do it in a nuanced way?
• 38:33And so you need, we need clinicians
• 38:35who are actually experts in this area.
• 38:38And so one of the things that you
• 38:40know that you can do to do that
• 38:42is actually having what you know
• 38:43has been supported by Doctor Mays,
• 38:45which I'm super excited about,
• 38:46another plug the clinical case
• 38:48conference series that is going
• 38:50to start January through June.
• 38:51But that's actually huge because
• 38:53I'm going to be bringing in expert
• 38:56discussants who are are trained in this
• 38:58and actually having trainees bring up
• 39:00cases from all over the country by the way.
• 39:02So if this is not a Yale problem,
• 39:04this is a country problem and
• 39:06we're going to talk about that,
• 39:08how do you,
• 39:09how do you handle that?
• 39:10And so I think that is really important
• 39:13to do and then like I said more
• 39:15money into research funding where
• 39:16you know my research is actually
• 39:19looking at this you know how do you,
• 39:21what are the mental health
• 39:22effects of anti black racism.
• 39:23And that's I mean that the Yale
• 39:24Child Study Center funded.
• 39:25So I would say
• 39:27continue doing that more funding
• 39:29and support to actually train
• 39:32clinicians and how do we hold other
• 39:35clinicians accountable and how do we
• 39:37do the best for our black children.
• 39:41I would echo all of the
• 39:42above and then like I think
• 39:45for conversation like this like myself
• 39:47learns so much from everyone we that's like
• 39:50how do we have a like what I said how a
• 39:53lifelong learning goal as a organization
• 39:55as like a diversity of our trainee of
• 39:59a diversity of the interprofessional.
• 40:00We are all come creating the community to
• 40:04capture this belonging and a sense of safety.
• 40:07To talk about this conversation
• 40:09is really substantial.
• 40:10It's really critical and how we can
• 40:13translate that into our work and.
• 40:15Training and for the next generation of
• 40:17clinician working for our family and patient.
• 40:21And I just want to add,
• 40:21sorry one more thing,
• 40:22but we don't have to be
• 40:23the best clinician for everybody, right.
• 40:25So it's like I, I echo what
• 40:28again what what Eunice is saying.
• 40:30But, you know I want to learn and
• 40:31I have learned so much from Eunice.
• 40:33But, you know, if I if, if thank you.
• 40:35But if I get a child who you know,
• 40:38let's say is a Chinese immigrant or
• 40:39their parents or Chinese immigrants,
• 40:41I'm going to talk to Eunice if I
• 40:43have any questions about it and
• 40:44possibly refer that child to Eunice.
• 40:46Does it mean that I'm not going to
• 40:47do my best to educate myself in it?
• 40:49No. But it also means that that
• 40:51child might do best with Eunice,
• 40:53and that's OK, You know,
• 40:55that child might do best with.
• 41:01And that's OK. And I think we need
• 41:03to understand that we may not be the
• 41:05best for that child and that family,
• 41:07and we need to understand
• 41:08how to pull on each other's strengths
• 41:10and use each other's strengths.
• 41:14I wondered, were there any
• 41:15questions in the audience?
• 41:20Anna Maria, I really like some
• 41:22of the very concrete suggestions
• 41:23you had in your talk about how we
• 41:26can dismantle structural racism.
• 41:28It's hard to say that word
• 41:30in our own institution.
• 41:32The practical ideas that
• 41:33seem so self-evident.
• 41:35Like why is my chart not bilingual?
• 41:39Why are safety plans not available
• 41:41in every possible language
• 41:43for the children we serve?
• 41:45Where are our role models at the assistant,
• 41:48associate and professor levels that
• 41:50represent the diversity that we all are?
• 41:53And so I'm wondering from
• 41:54all three panelists,
• 41:56are there some other very concrete
• 41:58examples of ways that at the Child
• 42:02Study Center we can really institute
• 42:05an anti racist approach as you
• 42:09started us off in in your PowerPoint.
• 42:14So I'll just suggest
• 42:16one quickly. So I went to,
• 42:17I recently went to a like a meeting
• 42:20conference in La Kinique Espana and I was
• 42:23actually talking about this with Carolina.
• 42:25All the signs in in the clinic are
• 42:27in Spanish and in English and the
• 42:28whole time I was like walking through
• 42:30I got lost myself even with signs.
• 42:32But I I thought it was amazing
• 42:35that everything was also in
• 42:36Spanish and just so helpful.
• 42:38So I think that's something small that
• 42:40even we can implement in in our clinic
• 42:41just to just to help the family kind
• 42:43of better navigate logistically even.
• 42:48I really think that reporting
• 42:51systems are important. And when
• 42:53I say reporting systems,
• 42:54not just like a system where you can
• 42:57report if you think a racist event
• 42:59has happened or you think that a child
• 43:01is not being treated adequately,
• 43:03but also an actual team that
• 43:05will look at those reports.
• 43:07Because you can have that and
• 43:10that exists actually Y and HH.
• 43:12But then the problem is who's reading that?
• 43:14And are they actually trained in
• 43:16being able to help you navigate it,
• 43:18help the people involved,
• 43:19come to a better place, do better,
• 43:21know better. And so I think we need both.
• 43:24And when I think of reporting,
• 43:25I think about that in a very positive way.
• 43:27Like I if I were the leader of something,
• 43:30I want people to report things.
• 43:32But we know that things are under reported,
• 43:34conflicts are under reported.
• 43:35So then things hit the fan and we're
• 43:38trying to put out fires, right?
• 43:40And so I want to know what those things are.
• 43:42I want to know if there was an like
• 43:44a trainee that was concerned about
• 43:45the way a child was treated or felt
• 43:47like that could have been handled
• 43:48better or felt like that should
• 43:50have been in another language.
• 43:51Those should all be things
• 43:52that go to reporting system.
• 43:53And then we have a group of people
• 43:56who are trained and representative of
• 43:58the population and who can actually
• 44:01follow those and do something about it.
• 44:03And so I I think that that would be
• 44:05something that the old child study
• 44:07Center could do that would be actually
• 44:09phenomenal and probably would be
• 44:10followed by a lot of other departments.
• 44:14My immediate thought was the training
• 44:17and education and also supportive space.
• 44:20Often time in I heard I heard that
• 44:23from trainee from junior faculty.
• 44:25We experience like micro aggression
• 44:27racism happen right at where we work
• 44:31and often time there's this happen so
• 44:33subtly and and all that nuances that
• 44:36happen and I kind of plug in one of
• 44:39my work effort here I'm starting a
• 44:41multi site training with other several
• 44:43site with Stanford Georgetown and
• 44:46tough where you we're using a theatre
• 44:48approach doing improv exercise that's
• 44:50creating a little play playground
• 44:52pretend space and simulate some of
• 44:55those scenario and having trainee and
• 44:57and interprofessional trainee to learn
• 44:59about what could scenario like that
• 45:02and what could be a supportive space.
• 45:04Do we wait poor do we speak of something
• 45:06do we call a friend like kind of
• 45:08training we need a lot of education
• 45:10and skill that we need to learn
• 45:12and as a lifelong learning process.
• 45:14So I think that could be really important
• 45:17in our training education system.
• 45:23And Anna Maria, you had also mentioned that
• 45:26in the assessments that you've seen and used,
• 45:29there aren't, there's nothing
• 45:30that refers to culture at all,
• 45:33you know and the the same is, well,
• 45:35I shouldn't say the same but when we were
• 45:37thinking about also what we typically use,
• 45:39which is the cultural formulation interview,
• 45:42there's also no talk about one's
• 45:44experience of race and racism.
• 45:46And so like one of the things that one
• 45:49of the efforts the Child Study Center
• 45:51is doing is trying to develop a tool.
• 45:53Actually not trying.
• 45:54We have developed a tool called the racially
• 45:57racially informed cultural formulation.
• 45:59And so that is something
• 46:01that Doctor Cecilia Fermetta,
• 46:02myself, Lori Cardona,
• 46:04David Reese and now Michael Block,
• 46:07Angie and Victor and Katie have
• 46:10been working on.
• 46:11And so hoping to fill those gaps because
• 46:14we are here to be leaders in this as well.
• 46:22You all are terrific. Thank you very much.
• 46:26All of you were very inspirational and
• 46:29really brought those key issues to the fore.
• 46:35I think the cultural formulation,
• 46:36all of those are really wonderful.
• 46:41I do wonder we don't quite get
• 46:43enough feedback from our patients
• 46:46and the families about their
• 46:48experience of coming into our spaces.
• 46:51And I wonder if in some ways we could
• 46:54do either more community engagement,
• 46:57have some families on a board
• 47:00that is working with
• 47:01us, but also
• 47:02regularly ask patients and
• 47:04families if they feel welcome.
• 47:06Do they feel understood?
• 47:09They feel that, you know,
• 47:12their identity was taken
• 47:15into account and respected.
• 47:17So I guess that might be
• 47:19another way to keep data and
• 47:21see if we're making progress.
• 47:22One thing to
• 47:30know, I don't know if people can hear me,
• 47:33but is that we're hoping we are
• 47:37taking efforts to fill that gap
• 47:38at least in outpatient clinical
• 47:41services where there were a pilot of
• 47:44questions sent out to our families
• 47:47asking them those exact questions.
• 47:49And if they're feeling that their
• 47:53clinician was responsive that they felt
• 47:56safe that they felt that their culture
• 47:58and identity were considered as in and
• 48:00respected as part of the treatment process.
• 48:03So it's it is another important piece of
• 48:06information to add to ensuring that we
• 48:09have the best possible care and outcomes.
• 48:12So we are at the end of our time.
• 48:14Thank you everyone.
• 48:15Thank you to the panelists,
• 48:17and thank you for being here.