Yale Psychiatry Grand Rounds, November 15, 2019

November 19, 2019

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Gary Belkin, MD, PhD, MPH, Visiting Scientist, Center for Climate, Health, and the Global Environment, Harvard T.H. Chan School of Public Health; Founder, Billion Minds Institute

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00:01Good morning.
00:04Good morning.
00:06Thank you. Thank you so I'm taking the role of John usually does. He's out of town so before we start grand rounds just a moment of housekeeping, so really soul element. And that is to let you to remind everybody about a really exciting grammar oz next week in the Cohen Auditorium over in child psychiatry, which will be 8. Gregory from Duke, who will be talking about bystander intervention addressing harassment and bias at work.
00:36And I think a really nice element of this too. It's going to be in a town Hall format. I'm sure there's a lot of discussion. I think there's even some role playing involved which will be very interesting and so encourage people to attend there again, Cohen Auditorium, not here next week.
00:53So for today's grand rounds. I want to start off by thanking Kyle Peterson, who as is his one. I walked into my office, a little while ago and said here's something you should be interested in and as always, he was right. And so I think thank him for starting this process and so this grand rounds is part of the division of public psychiatry and one of our slots to invite people to discuss.
01:23An issue where issues that we think are important in public psychiatry.
01:27So take a moment just introduce you to our Speaker Doctor Belkin. He's currently visiting scientist at the Center for climate health in the global environment at the Harvard TH Chan School of Public Health.
01:39And his focuses on building mental health and climate as a clear field of learning awareness and action.
01:46And so I'll just briefly give a little bit of further background and tell you that he's also the former executive Deputy Commissioner in the New York City Department of Health and Mental Hygiene, where he led the division of Mental Hygiene and its development and implementation of the innovative NYC wide public mental health initiative thrive NYC before that used medical director behavioral health across New York City health and Hospitals Corp.
02:11And his director of the NYU program in global mental health. He's partnered took globally through partner globally to test and scale community LED models of mental health promotion and access and less resource countries. They are now widely used.
02:24He's advised at host of governments local and federal institutions and is the editor in chief in global mental health.
02:33Graduate of Brown both undergraduate medical schools and also completing his MPH and doctor. It insert joke here at Harvard and so with no further ado, I introduce you to Doctor Belkin. Thank you all.
02:56Hey my sister went to Yale. So so listen, thanks so much for having me uh for existing there aren't many robust islands of excellence, an firm belief in community psychiatry. And this is certainly one of them and so I'm glad that you're here and I am going to be short on slides and data. But big on message and hopefully conversation.
03:29I going to talk a bit about what I did in New York City and how that and the context of that, really strengthen my resolve to shift my career to work on climate change and how and take home. I think is that?
03:49All these things that many of us in the room have really, and places like this are really worried about what I'm calling the social climate.
03:57And the relevance of how mental health plays out in how well communities do.
04:04Vice a versa.
04:06Has to be the central paradigm of our profession or we won't be of much value to the future? Which is going to need that kind of strengthening.
04:18Of our social ties of our resilience, but really operationalizing that in deep weighs more than ever.
04:26So I can stop there.
04:30So I'm going to start telling you a little bit about uhm how I came to Unlearn.
04:37A lot of what I learned in psychiatry residency because I did not come to you. I was actually at Harvard at mass general.
04:49And so a couple of things and I'm sure many of you are familiar with parts of these but this look familiar with this.
04:56Image so this is summary data from the last the latest global burden of disease study which.
05:03Uh.
05:05Increasingly gets you know aims at capturing the burden of disease globally burden both in terms of mortality, but also more interesting Lee and, importantly in terms of disability? How did different disease groups contribute to impairment and disability in the population and using either measure daleys disability adjusted life years? Which is sort of a mixture of the degree disease group contributes to the population level of.
05:36Premature mortality or of years of life lived with disability. This is a summary chart of results in the last go round focusing on years of life lived with disability measures so that's significant impairment and social or economic role and you know each color is a different grouping of disease musculoskeletal diseases mental illness neurological cardiovascular, etc cancers.
06:07And the age of the population left to right so infectious diseases or large younger in life and contributing to this so as population ages, an the takeaway is the red or metal is mental illness.
06:21And so just as a visual we see in particularly if this is a.
06:315.
06:32Particularly in.
06:35Um.
06:38You know as I approached 65 is a different conversation, but in our younger age profile. The population mental illness dominates as a source of disability and so that translates into all sorts of things right whether kids graduate from schools families stay together. People say employed the social fabric of communities.
07:00Who gets recirculates through the kernel dresses system? Etc and but we don't act like that?
07:09Uh we don't act like this is the most.
07:12One of the most pressing public health challenges. I think of the 21st century, so we haven't built things to act that way.
07:19And our treatment system. This is National Corbetti Server Application Data Ron Kessler and.
07:28And their group at Harvard that it turned out this is about about 10 maybe a dozen years or so old, but there have been similar data sense that basically.
07:40Tells us not a very pretty picture about the region effectiveness of our treatment system in this case that about one in four one in five of people with major depression. Something we should have down by now, maybe 1, four one in 5 Americans have major depression get evidence based care for it.
07:58I was once in talking to a group of psychiatrists in Ethiopia when there were 7 or 8 of them.
08:05About how to you know how to ideas that I'm going to get to about how to redesign the whole system and.
08:13And so you know it's easy for you to say you've got when we have 30,000 psychiatrists 35,000 psychiatrists. We have 8 they now have I think close to 20 or more, but?
08:25And I said yes that's a good point but it's but yes. We have that, but we also have this and so it's not so much who you have. But how you're using them and and it was work in other countries like Ethiopia.
08:42Like Haiti this Porter Prince after the earthquake. I also got to work with something called the Millennium Villages Project, which is.
08:50But it doesn't country sub Saharan country effort led by the Economist Jeffrey Sachs, who developed something called the Millennium Development goals of that rings. Valdez were global measures for development that have been replaced by the sustainable development goals to try to benchmark where the world needs to go to lift up its population.
09:11But the Millennium Villages Project tried to show how those goals can be met in the poorest places in a big element of meeting those goals? Is is more access to health care so very community. Health worker and community LED approach is is the.
09:29The Community Committee of Health Committee of a village in Uganda's I'm sorry in Kenya Salary, Kenya.
09:41Which was approaching health as does partners in health who I worked with in Haiti?
09:48Uh in a very social way, so community health workers are the backbones decisions are made communale about what the priorities are what success looks like where the work happens.
10:02Etc and So what I did with these projects was release. My anger about these 2 facts, which is we have a well resource system. Even though it doesn't always feel that way to us. We have a well resourced system that isn't really designed to meet what the population needs an even what it does, mostly invest in isn't isn't working, so well.
10:28And so when I went to these other places.
10:33And you know, I'm learning what you learned what was emerging at the same time that I started that global work was research on something called task shifting art as sharing don't know is that a term that.
10:47Anyone is sort of.
10:49Yes, maybe couple nights so it's is this notion that and really started I think in HIV world.
10:57That a lot of tasks of evidence based care can be shared by other other people than providers. And I'm going to talk about that in a bit, but it was in these other places that I really got my.
11:15Education but also was really pressed by these folks to really engage in the in the project. I think about OK? What would mental health look like?
11:23If it was approached in this, this really community based way, and I don't mean putting a clinic in a community, I mean, having community members doing work Co, creating what it looked like identifying.
11:35Priorities etc.
11:38Because that also helped address.
11:41Another failure another thing we
11:44Should be angry about about our system, which is how it has not dented?
11:52Uh what are really in during place based disparities right so these are Maps in New York City?
11:59So psychiatric hospitalizations darker is the more likely are higher rates of psychiatric hospitalization darker higher rates of lifetime depression.
12:09Darker are lower life expectancy.
12:16Uh.
12:18I just
12:19I have a lot of kids I just had my one year old living in this in this white an also white area, which is you know mile from the lowest life expectancies in New York City. So this is these geographies driving these things and the last slide is rates of people on formally incarcerated.
12:44So.
12:45You know in all these Maps, obviously at the same where they were lighting up and you could put any other number of Maps single parent households poverty, obviously immortality.
12:58Uh and uh.
13:03This kind of structural distribution of risk and adversity.
13:09Obviously, if you continue to fuel on itself. But what I used to also show and I just was getting too crowded here, but I would add redlining Maps from the 1930s and they map on the same place is redlining Maps issued by the federal government in the 30s to identify neighborhoods that basically would not be back for federal mortgage.
13:32Lending.
13:33And so you had you know you maintain and they're all black neighborhoods and so you maintain these very deep structural differences.
13:45Uh they go deep they've last long. Those Maps were you know now getting on 200 years old, and we still see these patterns so.
13:55So how do we?
13:57Have a treatment system that is much more responsive and proactive in being upset by the fact that we're just reaching one in 5 effectively. How do we operationalize our work so that we're getting to that, red and how it is?
14:16Changing so many other places that we live in work and how do we?
14:20Organize our work so that we start undoing.
14:25These walls.
14:27So.
14:30An I found some answers in these really interesting work going on in these other places.
14:35And 3 key principles I came away with that went into the work.
14:42Uh that was mentioned was introduced in New York City. When I was deputy health commissioner called thrive NYC really took these.
14:52Um principles to heart and what we did.
14:56And that I'm going to walk through each one of them briefly so task sharing which I've.
15:01Mentioned briefly embedding the work really physically embedding the work in other places outside of the treatment system. An doing it all in a way that is.
15:12Set up 2 for self learning and I'll explain a little bit about what I mean, the second sub task sharing so test sharing our task shifting as I mentioned is this idea is that you can take any sort of clinical evidence based practice pathway and break it up into what are the actually the specific tasks that need to be done to carry that out and so we did that in Haiti after the earthquake.
15:37And I'm not sure I mean, obviously can't read anything but you get the idea. So this column here is we took The Who treatment guideline for depression and we just broke it out this way. So now we can give somebody a screening tool go over the screening tool give motivational engagement interviews and these are the really the tasks.
16:08And then we listed up here all the people we had this is in the central plateau of.
16:14Of Haiti and we had community health workers. We'd clergy. We'd teachers with some social workers if you nurses a couple of Physicians and a psychiatrist.
16:27And so we basically blocked out where a task could be done by what person.
16:33So everyone was able to do psychoeducation sounds good. And as you can see we got every box filled with who we had.
16:41And so In other words, the Tasks were shared literally. We really mapped out so we kind of built our organizational work.
16:51Based on
16:54The skills and activities that we needed to disperse not on the people that we had that people sort of lined up.
17:00Uh and arrange themselves around the tasks to be done.
17:05Ann.
17:07And since since we did this, There's really been a mushrooming research literature on.
17:14On task shifting that again mostly comes out of the global South.
17:19A very large, randomized trials of this against.
17:26I'm usual care in India and East Africa, Pakistan that really demonstrates that an effective way of doing things.
17:39There's a good summary. I don't have the citation here, but there's a woman. Daisy single ASINGLA is not. Miguel has done just recently published a really great meta review of all this stuff.
17:53And it's very compelling and very convincing. So we wrote up how we did this as the basis for a delivery system in Haiti or about to publish our 10 years out.
18:04Experience of doing that uh a nothing system to a system that now is 30,000 visits and it's all through attacks shifted kind of a pyramid of care. The Lancet Commission on global mental health really solidified scientific consensus around around this approach and so when I built this thing called thrive NYC this idea of task shifting.
18:31So let me step back.
18:34I am a little New York Centric I have to say, I have people heard of thriving YC.
18:41Little bit OK, so.
18:44So thrive NYC was an effort.
18:47That's still very much in its?
18:52Uh isn't it past tense thing. Yet it still very much under development but this was the result of really commitment by the mayor and his wife, who had spoken.
19:07Republic Lee about their daughters their parents their families mental health issues. They wanted to do something differently. and I was positioned where I was at the time and I start talking about these sorts of things well. We need to give people other than clinicians skills and partner clinicians with them. We need to get all city government involved in each you know stuff. I talked about in the shower and it resonated I think with their sense.
19:38Of social progress that they saw the bigness.
19:45That doing mental health really needs to be.
19:48That, it's not about just subsidizing the public hospital system to run clinics that is really about changing the way this issue was experienced an worked on across sectors across communities across people.
20:04And so they gave this supporting green light to a fairly ambitious effort that is now funded about two 250 million dollars a year.
20:15Of 54 initiatives.
20:18An A lot of those initiatives are about and I'll talk about one in depth in a bit really brings these lessons home, particularly around test sharing I would say most of them involve some degree.
20:29Uh actually I think all of them.
20:33For the most part.
20:34Involve putting the work outside of the traditional treatment system.
20:40But partnering that system differently with it to support it to coach it to mentor it to be a partner with.
20:47One example is this thing called friendship inches, which.
20:53I was developed in Harare, Zimbabwe, where grandmothers were trained in problem solving therapy and evidence based counseling method per mile to moderate depression outside of primary care practices and they published in JAMA. Randomized trial compared to treatment as usual, which was pretty good treatment an so we, we stole this full bore we had.
21:24Dixon shavonda psychiatrist who developed this in his team come trained our team, we use their manuals for friendship benches in New York City. We did a pop up version of it. So here's an and spear staffed so we train peers and problem solving therapy and problem solving skills and they sit outside some of our neighborhood.
21:47Health.
21:49Part of Health neighborhood clinics, but they also appear in neighborhoods, so if there's been which there was, it kind of cluster of suicides in public housing projects when there's a shooting in a neighborhood if there is a building on fire their neighbor. There's some something that has shaken a community. Display this friendship benches, there in hours and it becomes a obviously a low barrier.
22:20Resource just for information and services as well As for some initial counseling engagement. So it gives you a flavor of this idea of putting putting the workout there right and so test sharing is a key way to do that, but using test sharing to really get you embedded is the Magic. So here's a map of New York City. These are mental health.
22:49Professional shortage area neighborhoods and so we tried purposely to concentrate where these thrive initiatives actually did their thing.
22:57And so you can all see this, but uh I've color coded dots.
23:03To different populations that different drive initiatives were focused on so children youth new mothers victims of crime elder New Yorkers homeless individuals and so forth so.
23:18The important thing to thing is just to experience is this visual sense of of.
23:26Coverage are really a new realestate.
23:30For mental health so each one of these dots is is where one of these initiatives is doing is or is done, actual contacted work and engagement and so within each one of those dots. There's some for the most part, some flavor of test sharing going on.
23:49An none of these dots. I think are in a mental health clinical setting.
23:58So I mean, so they're in schools there on street corners and police precincts their primary care practices.
24:07And so it's really this idea of putting work elsewhere each one of these dots.
24:14However involves some partnering.
24:18With her mental health.
24:19Provider.
24:21And that to me is the real exciting future for us.
24:25To not be the source of care or the primary source of care, but to be the partner in community capacity building to do all sorts of.
24:34Of things and the other thing we did was not only put more of the workout.
24:39Side the usual places, but we brought all of government in so the 5th for initiatives they are distributed across.
24:48A dozen or 2 city agencies, some of which are represented here, so you've got this array of.
24:53Homeless services don't of Education Aging Youth and community development economic opportunity, etc. Now were Co. Owners of this realestate and before I left a city government recently. We're starting to see talking to commissioners of these agencies how mental health was.
25:19Being part was being absorbed in their mission, and there are strategic what they do is an agency OK. This initiative was great, but what? How do we keep we keep it part of? What we do now? Which is exactly the provocation. We were hoping to do to bring more folks of the table.
25:37Um.
25:39And within not as much as I would want to have done but within a lot of these initiatives. We were able to also partner or bring into the work people who had skills an implementation so in quality improvement methods. In particular, to coach the partners, particularly neighborhood groups doing the work about how to be good implementers.
26:08So they could do more of this.
26:12So one example of where all of that came together.
26:15A test sharing embedding and learning is one of the thriving issues called connections to care or C2C.
26:23Where we seed funded partnerships between behavior health providers an community based organizations by community based organizations I mean?
26:35Not providers of care of any sort but in our usual sense, but so domestic violence shelters job training programs daycare centers.
26:48Uh use drop in centers often run away.
26:55And those were the the the CBO zan they identified a behavioral provider that was incredible. To them that they wanted to work with in their neighborhood or they had some relationship with.
27:07And the role of the behavioral health provider was to get on a learning curve where there would become a coach and mentor to the CBO and learning and using?
27:18Uh some basic skills like motivational interviewing using mental health screening instruments and things like that.
27:26And so you see in this map here.
27:30The distribution so any shade of blue had one of these partnerships of the Denser had more of these partnerships, so they were in 26, Community District, which is about half of the community districts in.
27:45In New York City.
27:46And again, they were mostly traditionally under under served under resourced places.
27:54And this is old this is old data, I do so. I last update. This maybe 6 months ago. But in some of those those tax shared skills. This train 1500 CBO staff so 1500.
28:09You know take care workers job training counselors, etc and screened at that time I think it's closer 20,000. Now, New Yorkers and we're finding 30% rates of depression on the on the pH Q9 or PTSD screenings. An mostly people had not been in care before so it was, it was reaching more deeply into a tapping into an unmet need.
28:40An when it was felt if that person needed more formal care, we had kept rates of like eighty 7080%.
28:49So this reaching in is both operationally doable and seems to be proving the concept that starting here.
29:00Um finds more unmet need and is a critical point of entry for people to stick with care if that's what they get but we also paired with this was.
29:12A small team that worked with these partnerships and particularly the CEOs about how to be better implementers an and for those of you for example, familiar with quality improvement methods. So they would do rapid cycle of change testing and aim setting and really trying to learn how to adjust.
29:32This new capacity to its best use.
29:36Becaus each one of these partnerships is different in terms of who they're facing and the organizational maturity and readiness of the organization of the organizations in these partnerships to take on this work.
29:47And so we need to include in this recipe of this more out for outward dispersed approach to community mental health. We have to include in that recipe real supports to having these frontlines be really smart implementers and adapters and testers.
30:09So these this flavor of doing things putting more of the work in other peoples hands bring all of government to the table. We started getting inquiries from other cities, including New Haven, an so we said. Let's have a meeting so we had a meeting we called it cities thrive.
30:31And we had a lot of people come and so we are continuing at the 3rd such meeting is on Monday actually.
30:40Um we've got 200 mayors signed up as members of what is now the cities thrive coalition.
30:46We're expecting over 200 folks to come and it really is a place where we showcase what we see happening in other cities that are doing things this way or examples of doing things this way, and workshops to try to get people around OK? How to do how to do it this way. One of the challenges and the opportunities. Since then, and this was a pleasant surprise to me. I did not expect this and it was not our proselytizing, but drive has been big in Europe.
31:18Thrive London launched about a year and a half ago and actually static on the London Mayor is going to give a message at our meeting next week. We've got thrive. I can't read which one that is Dr Bristol Dr West Midlands, which includes Birmingham, which the 2nd largest city in the UK.
31:38Thrive stock home is in the works thrive Amsterdam launched drive Toronto is moving along.
31:48You know who knew and I think what's gratifying to me is that? What has stuck? What is the thread they're all different but what is a thread through all of them?
32:01Is this starting point of assumption that more of the work has to be outside of the system and all government has to has to come to the table with real participatory.
32:12Ground rules from the get go and that's just really exciting to see.
32:20So.
32:24So I left city government.
32:26Uh and I left all that, but I haven't left it because I as a parent and as a mental health professional was feeling like if I'm not if I'm not working on climate change.
32:39Then I'm wasting my time.
32:42And.
32:44You know, I think everyone is going to find their own way to that. I think many people have found it before I did, and many people.
32:50Have yet have yet to find that but I think.
32:54We're all going to find how that fits into our life because it will be impossible for it not to it's going to change every.
33:01Field every aspect of our lives and so the question is how is it going to change?
33:07Mental health or what's it going to.
33:09Challenge how's it going to challenge my health change. My health work to change and are we up to it? Are we going to be up to answering.
33:18That.
33:20That challenge.
33:22Um.
33:23So that's I'm in the basement of baseball cap over there, if you're wondering why I'm there. I'm getting arrested so this was over the summer. This was an action by group that you may have heard of which is getting some more awareness called extinction rebellion also start in the UK.
33:43An so when I was in jail after this is an interesting group there about 7:00 of us arrested.
33:52And we're in a big sell they separated by gender. So the men were in this about 40 bus and some people came prepared who done this before, and they had a set of questions. We went into breakout groups. You have no idea how long you're going to be there, so went to breakout groups and there was a list of questions to ask each other and and one of the questions was go round and small circle and you answer.
34:23What are you hopeful about?
34:26So just get the context here right like work.
34:29Or in jail, we think the world is going to end.
34:32And uhm what are you hopeful about SI heard myself say the following thing an?
34:40And as I was, I was, I was hearing myself say it in a way that was almost like observing.
34:46And I've since returned to it, and wonder do you really think that way is that we really thinking? Yeah, it is?
34:51This is what I really think.
34:53So I said, You know.
34:55I we are not going to mitigate we're just not on a path to really dent this thing.
35:01A large parts in York City will be underwater in New Haven, so forth. This is not going to go well.
35:09But what we can do now.
35:12Is try to build new models of? What excellent human community looks like?
35:20That may be at the other end.
35:23People will use.
35:25Better ways of Participatory Democracy, better ways of sustainable.
35:32Economy.
35:35And better ways of mental health is.
35:38I know something about so since then, I've been trying to
35:43Connect those dots.
35:45Um.
35:47And so this experience of.
35:51This long.
35:53Allegiance to cities and their mental health.
35:57And getting deeper and deeper into ways to operationalize this idea that cities can be places. How are cities places that are metal promoting?
36:07What do we really think Tangibly Operationally about this idea of community resilience and?
36:13And.
36:14Collective Efficacy and social ties, I mean, we know they all correlate with.
36:19Little Morbidity, but how do we actually act on those connections and invest in them and so those seem increasing to me really important. Parts of the equation of the survival of our cities in the next century's.
36:37An increasingly from the climate perspective from the climate science perspective climate policy perspective.
36:43Um.
36:44There's also been this real attention to cities. Obviously, the largest consumers of energy so how cities profile. Their energy sources will be the leverage to change how NRG markets work its purchasing power cities as governments. I mean, New York City as a purchaser.
37:05His employer or 300,000 people, which touches about one point 1,000,000 people and in terms of you include their families just huge purchaser. The ways that cities in city government could really shapes of the things that need to be shaped food markets electric markets, etc.
37:22Am I really crucial and they're also you know where.
37:26Most of the people are with the density that it's really possible.
37:31To try to capitalize and build on the power of social ties? what I call that I've increasingly calling the social climate.
37:41Uh.
37:43And there's a social climate crisis that's part of the environmental crisis climate crisis.
37:48Which is how are we going to?
37:55Maintain.
37:57If not deep in those things that ever mentioning our communal resilience our ability to act socially and lean on each other that way.
38:13And that social climate is probably our most important.
38:18Asset.
38:20Solar energies are pretty good asset, but our social climate is going to be one of our most important assets. And so we have to really take good care of it and I think mental health folks, particularly community. Mental health folks have a lot to say, and to do about about that.
38:37Uh.
38:38And one thing that's starting to happen.
38:41Um from and I think it can.
38:45I hope it can in terms of my wish that we can create.
38:50Better things that then become models or some future time.
38:54Is that by doing so we as a mental health community?
39:00To finally face up, too long needed change in some of our fundamental paradigms about our work.
39:08That we start taking social economic social ecological models.
39:14Mental illness in mental health much more seriously.
39:19Um.
39:20And I don't know the mix of this audience, but that we start to get real about the dead end path of this focus on the synapse.
39:31And really start getting more realistic.
39:35About what strengthens people and supports them.
39:39And how we know that.
39:41Um.
39:44Including all those factors that led to those Maps.
39:48So it's
39:51We have in our hands, the possibility not only to help the world, but to have an exciting.
39:58Renaissance of our work in profession.
40:03And so that's sort of starting to have been creeping into the literature things and this is a nature climate is work by Helen Berry, who's in I think based in Sydney, a mental health researcher who developed this. You can't read anything an it's a mess. But that's the point, which she tried to do is take a lot of these literatures, she took the use case I think of.
40:28I don't know if it was.
40:30Flooding or heat.
40:34May have been rising temperature scenario and just to see all the factors that that sets in motion. All the interacting factors that that sets in motion and the degree that they end up in this is Pression. Depressive symptoms or some other suicide how they end up into outcomes that we that we work on and each one of these has a parentheses in each one of these linkages has parentheses which.
41:04Indicates the number of studies that show that that link so this is somewhat of a you know, an effort to condemn to bring together what we've been studying in sort of isolation. These correlations between between certain social community factors and ultimately mental health outcomes.
41:28So this is a really this is this is new again anew realestate. I mean, this shows us very different places employment and financial constraints.
41:42Uh.
41:43Decrease community resources and support systems migration and separation of families and so these are.
41:50This is part of this remapping of the things that we, as a field work on, but what I was struck by it. While it's heading in the right direction. It's mostly looking at this direction, Watt.
42:05Features of climate ultimately might give us more work to do right they'll be more depression. They'll be more drama OK.
42:15I'm also interested in this direction.
42:18Um what can we do.
42:21By having a really tight effective safety net for mental illness really effective tool kit for my whole promotion an prevention and resilience building? How does that help us?
42:38Act collectively to get to get through this an and perhaps even bend, the curve.
42:45Uh this.
42:48And.
42:50What I left my job to try to work on is to actually get a little more complicated?
42:56And see mental health as forming new partnerships people, the way we design what we do, and who is doing. The work partner with people actually working on these things from different points of view.
43:12In civic action building and Collective Efficacy and so forth as a way to.
43:20To meet this challenge so.
43:24New partners have to include the people who have been at the front lines of this, who are the front lines. If we're going to, if the way we contribute to strengthening communities or through these thrive like approach is putting more of the work out there, etc.
43:43Uh.
43:44We should put the work out there to groups that are really working on these issues.
43:53Up Roses, one example that I'm getting to know better in New York City and Brooklyn my circle. Hurricane Sandy hit community. So this is an environmental justice group that is on its way if not already.
44:12Down the path of becoming an implementing organization.
44:15I think the entire environmental justice world is a huge.
44:20Human resource to do this kind of Community Slash Resilience building work, many of them.
44:28And there are probably thousands across the country that are doing out working on one specific thing or another whether it's the exposure of communities of color to excess air pollution and thus higher pediatric. ER visits whether it's the similar often racial distribution of exposure to fracking or to you know, whatever it is these environmental justice groups are becoming implementers. They're starting to broker the implementing of new.
44:59Solutions so up rose for example, did block by block analysis of where their opportunities for climate mitigation of organizing a neighborhood to get do an off grid off grid solar power purchasing and so forth.
45:17And we could pass the Green, New Deal tomorrow.
45:21We're not going to do it tomorrow, but we could pass it if we pass it tomorrow.
45:25Um.
45:27There is it will work when combined with this ground level block by block neighbor by neighborhood culture change economic transition food market adaptation. All that needs massive granular hand holding and brokering of interests and implementation and so this notion that came to thrive putting more of the skills more than people.
45:55And make them learners and testers and implementers is a parallel process that needs to happen to realize the sorts of change. We need to do the work.
46:07That the climate is pressing us to do.
46:10And what what I see as a future for community mental health work is to see that Civic Army's also a mental health army.
46:21As one of the key platforms for putting more of the work and more of the hands and as I talk to these groups.
46:29They're the ones saying that.
46:31You know, we're trying to mobilize our community to X, but we have you know this history of layered community trauma in our community substance abuse. It's hard for us to get off the dime. If we're not also bringing other things that are building our communities back.
46:49Uh.
46:50Marshall Gans and heard Marshall Gans one. One running back Marshall Gans community organizer. I think he was. He was very formative in organizing snek civil rights movement. The farm Workers Union, he's here with Cesar Chavez.
47:11He was his thinking about how you do social movements or was really the blueprint for the Obama campaign in 2008 and a lot of his students were the field.
47:24Captains of the Obama campaign and what the kernel of his idea about social movements is they have to be social they have to bring people around in a way that they feel like they're part of a shared social connectivity and narrative.
47:39That describes the way that they want to live and connect and that they were supported by that.
47:44I think this is fertile ground.
47:49There is a virtuous cycle that's possible between bringing civic muscle to work on climate and bring civic muscle to help communities heal themselves through a more thrive like approach to community.
48:03Give me your mental health.
48:05Um and similarly.
48:08To bring
48:10To that ground level work real proliferation of ways that neighborhoods become innovators and implementers whole field of social innovation and social innovation hubs. I mentioned quality improvement work. the Institute for health care improvement, which really brought quite a health care. They're not quite so much yet to Mel Healthcare, Unfortunately, but has really now started to use these same methods. Learning Collaboratives and so forth for other community projects, so they have one learning collaborative around poverty reduction.
48:45Of Seabios in um it's in Minnesota. We use that model learning clever model to bring community organizations in New York City to work on what they wanted to work on which is to reduce parental stress.
48:59So we use this QIPDS cycle learning collaborative method to help them identify and test solutions that their tacit knowledge and lived experience through some tools logic models and stuff like that brought them to want to try.
49:17So this combination of a renewed.
49:23Of making new friends with people who want to work on this stuff at ground level of bringing tools to bear to that and then bringing what we know about how this work is a fertile ground for better community mental health work is one of those potential.
49:40Better way of doing things that we can that we can leave behind for the future and perhaps make the present.
49:46More livable.
49:49It's going to mean?
49:51It could potentially mean a real revival in.
49:57I just like the title of this paper, the roll of community mental health care and it's also really good review article talking about how these strategies. I mentioned at the outset that really these tax sharing strategies that gave that kind of found their their footing in low and middle income countries are really changing the way that the global N is at least some people in global N are starting to think about the role of community and mental health.
50:26The realities of climate I think force us to think that way. If we want to be relevant to our communities.
50:32Uh and was also coming out of the sustainability and climate literature.
50:38Not specific to mental health, but generally how all the Sciences need to change.
50:46Is to take transformative transformative learning approaches that is really learned teaching and learning in ways that are far more pragmatic and experiential.
51:00An really have the aim to change things rather than a receptive and and sort of incorporating a body of knowledge. It's really learning that is beating up a body for college as the needed.
51:20Needed path for the future.
51:23And there are many reasons, I agree with that which I don't know. Maybe all time in questions to talk more about but I think mental health would benefit from being a more.
51:33Beating up experiential knowledge base, then what is very much a kind of?
51:41Incremental.
51:43Plotting.
51:46RCT worshipping model knowledge base.
51:50Um.
51:51So I uh started a nonprofit about a month or so ago, so I'm.
51:59Currently, unemployed called the billion minus Institute to really think about scale about the social climate and working on a bunch of things that I think are consistent with everything I just I just said trying to form a consortium of environmental justice groups that really see mental health is ascential in their community work in their community survival to try to create a toolkit for them to be able to do that.
52:29So a lot of ground ground level, substance building and Prototyping on the one hand and on the other hand, trying to bring leaderships to get their head around that mental health. The future needs to look this way, and the social climate is really important. If we all want to get through the next century, so for example, convening a meeting of leaderships of most of the mainstream national mental Health Organization, including both APS DC to try to start to have a discussion.
53:00What do we think?
53:03Climate drives us to have to think about and actually hasn't been a discussion that's happened collectively yet.
53:09For field so I'm looking forward to that here's some.
53:13Pieces and medium, I've just discovered medium. It's kind of cool if you want to learn more about what I'm up to and.
53:23And I'm happy to start a conversation thank you.