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Dr. Alex Raben: [00:00:19] Okay. Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners. We have a very interesting episode for you today, listeners. We are here to discuss racism and mental health, the interrelations between those two things, and specifically with a focus on anti-Black racism and mental health. I'm Alex Raben. I'll be your host today. I'm a new staff at CAMH, working on an assertive community team here, and I'm joined by my co-hosts, Anita.
Anita Corsini: [00:00:56] Thanks, Alex. So my name is Anita Corsini. I'm a social worker and I currently work in knowledge translation and exchange at the Centre for Addiction and Mental Health in Toronto. And previous to that, the majority of my frontline experience was working as a counsellor with youth and young adults.
Dr. Alex Raben: [00:01:15] Great. Thanks, Anita, and we're very pleased to be joined by Rebecca Marsh, who is a fourth year medical student.
Rebecca Marsh: [00:01:22] Hi everyone. Yeah, my name is Rebecca and I'm a fourth year medical student here at the University of Toronto.
Dr. Alex Raben: [00:01:28] Thanks, Rebecca. And we should also say that Randi was part of this episode as well, but she wasn't able to join us this morning. But we are joined by the esteemed Dr. Kwame McKenzie, who is the CEO of the Wellesley Institute and is an international expert on the social causes of mental illness, suicide, and the development of effective, equitable health systems. Dr. McKenzie is also the Director of Health Equity at the Centre for Addiction and Mental Health and a full professor in the Department of Psychiatry here at the University of Toronto. And I'll let Dr. McKenzie introduce himself as well to add to that. Welcome to the show.
Dr. Kwame McKenzie: [00:02:12] Well, thanks very much and congratulations, Alex, on your new position at the Centre for Addiction and Mental Health. You know, not that I'm biased, but I am biased. A wonderful, wonderful place to work. And, you know, I'm really glad to be here. As you know, I'm a psychiatrist, although my books have tended to be about the social determinants of health or about anxiety and depression. And most of my work at CAMH was in schizophrenia, running the schizophrenia department before doing other things, as in old age and children and dual diagnosis. But most of the work I did in the UK was also in serious mental health problems. So I've done loads of different things and I'm really glad to be here and love this idea of this podcast. Making myself sound old, right?
Dr. Alex Raben: [00:03:19] Well, we're so glad to have you. We really appreciate you coming on and bringing your wealth of expertise, both clinically and in the research world. Alright. Well, let's start with the learning objectives. So, by the end of today's episode, you should be able to understand the history and legacy of racism and mental health in the Black community in Canada. Number two, understand the current state of racism towards Black people and the impacts on their mental health. And number three, explore how health care workers can be anti-racist in providing mental health care and how the system can change to improve the mental health of Black people. To start out. We wanted to go from the basics because we don't want to take things for granted. So this may seem like a question that has an obvious answer, but I'll ask it anyways. What is racism? How do we define that? And outside of the abstract, what does that look like practically speaking for people who deal with it?
Dr. Kwame McKenzie: [00:04:41] I think that is a really great question because one of the things that always happens with this is everybody has their own ideas about what we're talking about. And racism, one way of thinking about it, is discrimination plus power. So it's not that you discriminate, just discriminate against people because of their race, but there's a power structure that is set up so that that discrimination actually means something and it changes the lives of those other people. And it's built on the idea that one race is superior to the other. And therefore there's a hierarchy of races, where there's a privileged race and there's a less privileged race, and it permeates all areas of society. It permeates how we think about other people, how we interact with other people, people's chances in life. So it's an idea, it's an abstract idea. It's not based on anything that could be considered in any way scientific, but it has very, very real consequences to the lives of people. And so I think it's a great question because there's loads of confusion about what we're talking about.
Dr. Kwame McKenzie: [00:06:05] And when we're talking about anti-Black racism, it's actually a Canadian phrase that was coined at Ryerson University. And the idea of anti-Black racism is it tries to explain how racism is actually different for Black populations, how the systemic nature of racism — not just what we see with regards to stereotypes in the media, not what we see with regards to the way the Children's Aid Society or the prison justice system works with people — but how it permeates every part of society to produce a toxic environment for Black people in Canada that's different than the racism that other groups in Canada feel. You know, obviously there's anti-Indigenous racism, which has a similarly toxic air. But, you know, when you're thinking about Black and Indigenous, the levels of racism and the impacts of racism are very different to other groups.
Dr. Alex Raben: [00:07:14] That makes a lot of sense to me. I guess, in terms of examples of racism, I think that it can be kind of easy to think about examples of an extreme case or a historical case where racism took on violent and overt forms. And not that I'm presuming that doesn't happen now, but I'm wondering what is the range of things that qualify as racist in terms of examples that we could talk about or we could bring alive for the listener?
Dr. Kwame McKenzie: [00:07:53] So, it's one of these things that when you have a complex society and you have social divisions and you have ideas that create social divisions, they get everywhere. So, no, the question isn't where IS racism — the question is where ISN'T racism. So, you know, when people talk about perceived racism, so I can see that I'm getting differential treatment or, you know, our interaction is different, or I've got racist abuse or attack, or microaggressions happen, right. And I'll talk about microaggressions second. So those are perceived racism. I can actually see it. Right. But then lots of racism is NOT perceived. You may not know why you didn't get an interview. You don't know what happened. It's just, you didn't get an interview, so you never see it. But actually, it changes your life. Then there are loads of other forms of structural racism. The way the police react to people, what happens in education, educational outcomes, children's services, the prison justice system, not just the police, whether you can get a loan or not. Then there are other forms of racism, again, which we're seeing during COVID. Where we can see that there are these huge disparities in risk of COVID for some groups compared to the others. And we do nothing about it.
Dr. Kwame McKenzie: [00:09:39] And that form of racism by neglect is some of the most pernicious types of racism in Canada, where people just don't do stuff. They see that there are incredibly high differences in colon cancer screening or cervical cancer screening for Black women, but they just don't do anything about it. And so at the Wellesley Institute, when we were thinking, how do you think of this sort of systemic racism? Is systemic racism an intent? So, I tend to treat people differently? Is it that I have no knowledge about, you know, what is it? You're a system, like the mental health system, and you can see big disparities in access, outcomes, deaths, and you do nothing about it... then, that is systemic racism. It's not that you cause the problem, it's that you're not part of the solution and you just allow it to happen. And there are all sorts of reasons why we convince ourselves that we shouldn't be part of the solution. But in a connected world, where you're a human being, when you see other people suffering, you are supposed to be part of the solution. And so it's complex. But the thing is, you look at the effects and you can see the differential effects.
Dr. Alex Raben: [00:11:15] Wow. Yeah. So it's, I mean, quite a range. As you say, it's almost the better question is, where ISN'T it? It's actually at so many different levels. It can be at so many different levels. It can be visible or relatively invisible. And even inaction can be a form of racism, as you point out. Now, I know, Anita, you had done some looking into in terms of the history of racism in Canada, or maybe I'm misclassifying that, but I know you had dug in a little bit into the history because I was hoping we could present the listeners, because we have an international audience, with a bit of the Canadian context. Now, I know, Kwame, you're from the UK originally, I believe.
Dr. Kwame McKenzie: [00:12:09] Yeah, that's right. I mean, you couldn't tell from my voice? From somewhere, not Canada!
Dr. Alex Raben: [00:12:22] Yes, our listeners were ahead of me on that, I think! But I guess what I'm saying is we often in Canada talk about racism in the US context. We don't as often talk about it in the Canadian context. And so I'm wondering, what are the differences there? Are they meaningful and what do they mean to people living in Canada? Maybe, Anita, I can hand it to you, because I know you had done some digging into that question.
Anita Corsini: [00:12:50] For me what stands out is, and it's something I've kind of been mindful of for a while, is just like the tendency, the Canadian tendency, to understand ourselves as good and benign. And I think that erases a lot of our history. And if we're talking about the experience of Black Canadians or Black people in Canada, we often think of, like you mentioned, Alex, like the histories of slavery in America, but we don't recall or talk about the history of slavery in Canada and all the ramifications of that in terms of systemic racism and oppression and the legacies of that and how that, sort of, is part of our institutions today. I think that it's kind of that if we're thinking about neglect, like the historical neglect of acknowledging those histories and the fact that there is intergenerational, I think, implications for that in terms of people who are living today, who, you know, their histories, their personal histories, sort of extend back to those experiences. But also just that the fact that those histories sort of shape our institutions today.
Dr. Kwame McKenzie: [00:14:21] Well, fabulous question. I mean, I think that one of the things we take for granted is our understanding of our history and our heritage. So every time we have an interaction with somebody who has a very similar heritage to us, we have a whole bunch of cultural assumptions that allow us to interact with people at a certain level. And that's the foundation of the way we interrelate as humans, and that's the foundation of the way we understand what's happening in our consultations and our interactions. So what if somebody has got a completely different heritage? What if that heritage is a heritage that could produce a certain different discourse in the interrelationship? What if, you know, and it's relatively easy for people to think about it when they're thinking about the proximity to residential schools and the way that, you know, that colonial aspect of residential schools and the trauma that has been wrought on the Indigenous population through that violence. And you can understand how there is a different relationship between some Indigenous populations in the interaction with White European settlers and colonists and Black European settlers and colonists like we are. I mean, and you know, there's a dialogue and a dialectic that you have to think about.
Dr. Kwame McKenzie: [00:16:11] But we discount the impact of racism, the impact of the transatlantic slave trade, and the impact of the legacy of the transatlantic slave trade, and also the impacts of the lies. And so Canada, like everybody else at at that time, was in North America, was part of the slave trade. There were fewer slaves in Canada. Canada didn't have big plantations, but it was part of that whole trade. And it was part of that whole trade, but made laws in the 1780s and 1790s, which were sort of earlier than other people with regards to. And first of all, I think it was Upper Canada, so it would have been Ontario, was one of the first places to outlaw the slave trade, though they didn't free slaves, but they outlawed the slave trade. And that was how the sort of the underground railway started. And I think Canada plays on that, sort of, 30 to 50 years when there was a difference between what was happening south of the border and what was happening north of the border. And we produce this narrative that slavery wasn't here and slavery was different in Canada. And it probably was, for about one eighth of the whole time, you know, between the 16th and 19th century, there's 350 years of slavery. There may be 30 to 50 years where it was a bit different. But apart from that, it was the same thing. And that sort of continual retelling of history is a bit problematic.
Dr. Kwame McKenzie: [00:18:20] And then, of course, we don't think about the fact that there were whole structures that were set up to keep slaves in their places. So, one parent families and things like that were organised in that way and people were moved around so that there wasn't tight family units that would be strong. And then there's been a reaction to all of those. There's been a reaction to all of that, which plays itself out in Black communities, but also in the reaction of White communities to Black communities. And so that interaction between Black patients and White staff is a sensitive interaction. And understanding, you know, understanding a bit of what might be going on at various levels, at deep psychological levels, as well as present day issues that are coming up with regards to disparities, is quite important. And it's difficult, because the easiest thing and what everybody wants is a cookbook. Tell me what I need to know in order to, you know, work with Black patients, you know, and that's not how things work, because in every other part of medicine, you have to take in information, you have to understand it, and then you have to be a humble human being that's trying to work out what's going on in that particular interaction, which can be anything from somebody for whom Blackness isn't a particular issue to somebody who it's a real issue.
Dr. Kwame McKenzie: [00:20:22] And you have to have that in the back of your mind. But it can't then become a dominant stereotype that produces inauthentic interaction with your patients, because that's like, you know, that would be a mess. It would be like me deciding that I'm going to be "down with the youth" and wear a baseball cap. And everybody would laugh at me. But back to your question. There is no excuse for me not knowing anything about Indigenous populations. I'm here, in Canada. There is no excuse for a doctor who works in Canada not to know about the history of different Canadian people. That is the basic, whether you're a doctor, whether a human being, you relate to other people, people are part of your community, so know about them. It's just respect, right?
Dr. Alex Raben: [00:21:25] Yeah. I like your last point there about just having it being an issue of basic respect, not even talking about medicine, but as a citizen of the country. But then, you know, as professionals, as clinicians, we're in the business of people. And just like we're expected as physicians to, you know, know how to take a blood pressure and know what the ranges are on that... what you're saying is that we should have a similar expectation to know something about the people we're treating and the histories there.
Dr. Kwame McKenzie: [00:22:04] And, like, oh, sorry, Alex. I'm doing exactly what I said I wouldn't do, I'm talking over you!
Dr. Alex Raben: [00:22:11] That's okay. Go ahead!
Dr. Kwame McKenzie: [00:22:12] So, you know, there are always tools and structures that help you with these sorts of things. And one of the things, you know, when you're looking in DSM-5, they've got the cultural formulation interview. And the cultural formulation interview basically says, let's start an interview by trying to work out what your location is with regards to how you think of an illness, how you know, what the culture is around the illness, who you think should be treating the illness, whether you think you'll get better, and whether you think I'm the right person who should be here. And the reason why people go into that sort of conversation isn't because you get these concrete answers that tell you everything you need to know, but it gives you a structure to start an interview from a different place, that starts saying, you know, I actually want to know who you are and how you think and what's important to you. And, you know, the cultural formulation, plus a good social history, gives you an idea of what's going on and how an interview can run and what the sensitivities are in the interview. You're not going to get, in the first interview, anywhere near somebody taking down their guide about racism. But it starts an interview in a way that allows for a better balance to a discussion, and more humility in the interview, which then allows you to get to different places. And you've got to open the door to be able to ever hear about people's trauma. Because everybody is going to protect themselves, right?
Dr. Alex Raben: [00:24:04] Yeah. I mean, I was going to save this point for a little bit later in the interview, but since you've brought it up, I'll bring it up now, because we're talking now a bit more about how, as individual practitioners, we can be with people in a way that's culturally sensitive, competent, safe — to use some of the the buzzwords that we use in terms of the language around that. And to your point about people letting their guard down. So, I've become more intentional, I think, as I've gotten more experienced about asking about racism directly, that's been my strategy recently. But I've noticed that actually, frequently I get fairly neutral answers to that question, or patients I'm speaking to want to move on from that topic. And I'm wondering, and I'm guessing now it's maybe because of this guard. Maybe, Kwame, you could speak more to that. What advice would you give me, in terms of, and for our listeners, in terms of broaching this topic? Because I guess in my mind, I see it as something we could be more proactive about, and that's why I was using that strategy.
Dr. Kwame McKenzie: [00:25:28] The question I would ask is, to what end? To what end are you asking that question? So, is it that you are trying to look at people's socioeconomic situation and you're trying to find ways of decreasing barriers? Is it that you're trying to work out where the traumas are? Is it that you're trying to develop a rapport? And it depends what you're trying to do, as to how you broach the subject. And that then gives you an indication about whether they're ever going to answer that question to you. Because most people do not let their guard down unless it's going to help them in some ways. You know, and if you're not the person who's actually going to help them, then what is the point of going through the trauma of having to explain X, Y, and Z to this person? You know, to what end am I doing this? Is this just, are they just curious? And they're just asking? Are they just going to put it down in a chart? To what end am I doing this? So I think it's like anything, it's like any other problem or trauma or whatever. If you're just collecting the information to be able to say, I've got the information, then I think you'd expect a relatively low yield of that question, right?
[00:27:10] If, say, for instance, you've got somebody who you, you know, you're going to send for CBT, and you're saying to them, listen, I'm going to send you to CBT, and we've got different sorts of therapists who specialise in different things, and we have some people who — if you have, and there are those people in Toronto, at least, and I know there are the same people in Nova Scotia and there are people in Quebec — who specialise in CBT, taking an anti-racism approach. You know, you might say, well listen, I'm trying to work out who I'm referring you to. You know, I know this is difficult, but is this an issue for you with regards to where you're being referred? And then you might get a whole bunch of stuff that comes out because there's actually some utility to that for somebody. Similarly, if you're going to have that question and you're asking about police interactions, the question is, what's the utility? And it may be that you're talking about trying to set up a safer community response that tries to keep the police out of the way. And, you know, if you know that somebody has got experience of bad interactions with the police, you'd have to think really twice about a community treatment order because, you know, you're setting them up to have interactions with the police because that's the whole point of it.
Dr. Kwame McKenzie: [00:28:49] So I think, if it's gratuitous and you're just asking the question because you want to know, then expect low yield. If there's actually a reason for knowing about this and you're saying, say, for instance, you're saying, well, you know, I really don't understand what's going on. I'm trying to make a diagnosis. I don't know whether this is depression, anxiety, or whether this is an adjustment reaction because there are specific traumas and there are traumas, like blah, blah, blah that are happening. You know, I'm trying to work out what's going on, because that's going to change how we treat you. Then I think you'll find that people will start talking. But if it's gratuitous...
Dr. Kwame McKenzie: [00:29:35] One of the things I used to, when I was in the emergency department and you're looking over the notes that people write, you know, they'd start off with a description of the, of the patient and the patient would say, you know, a middle aged Black man who looks younger than his age or whatever. And I'd say to them, why did you write that? And they say, well, we describe the patient. And I say, okay. So you think the fact that the person's middle aged is important? Yes, because that changes what we might decide with regards to diagnoses and risk and blah, blah, blah. Do you think the fact that he looks younger than his age is important? Well, that's sort of descriptive, and blah, blah, blah, and it's helpful. And, so you think the fact that the person is Black is important? And they say, what do you mean? I said, well, you put it there, so it must be a very important thing. And, surprisingly, most people don't could not answer why they wrote it, apart from the fact that it is written, and then it's part of the notes, and then it's always part of the notes. But what it also does is it gives a signal. And the question is, what signal is it trying to portray in psychiatry? Not saying that it shouldn't be there... but the question I ask people is, what is that communication? Now, is the fact that this person is Black really important in this situation, yes or no? I mean, and it was interesting, just having that discussion, actually starts people thinking, yeah, it was important that he was Black. And you say, why? And often, we couldn't answer it, apart from race is so important that when somebody is walking down the road towards you, the first thing you notice is, you know, psychologically, is whether they're a man or a woman. The second thing is their race. And the third thing is whether they're a child or not.
Dr. Kwame McKenzie: [00:31:59] And that's how important it is. But why? And actually, when you start asking yourself why, is when you get into some self discovery. And that self discovery, I think, is important for producing equitable care. And people always think that it's the dialectic that's important, or it's the race of the other person that's important. But, actually, it's our own biases that are incredibly important. Did you see the paper in, I think it was in the New England Journal this year? They did a simple paper on the survival of children in ICU, of high risk children. So ICU type children in born to Black women in the States. And they simply said, we're just looking at survival rates. And the survival rates varied. If the doctor looking after the child was Black, the survival rates were much higher than if they were white. Much higher. And when you look to the actual, it's not clear that the white doctors were not following the protocol. Look, it looks like they were following protocols, but somehow the care that they were getting from the Black doctors was better and the outcomes were better. And it was a it was life or death. And that is not that is about that extra thing that we all do when we identify with people and we think it's important and we go that extra mile to take a better history and to better tests and we're on top of things and blah, blah, blah.
Dr. Kwame McKenzie: [00:34:06] It's that extra bit on top of the protocol. Yes, there are places where you see that people are getting worse care because there's neglect, but often they're getting worse care because one of the worst things that can happen in an hospital. Is if everybody works only to their contract. If the whole of the hospital and I mean, you'll know this Anita is a social worker if you just did the hours you were given to do. The whole thing grinds to a halt as a resident. You know that. Alex And unfortunately, Rebecca, you'll see this more and more as you get out of med school, that if you just did the job you were supposed to be doing, the whole system stops working and the quality of care is hugely different if you you are dependent on that extra you give. So if you study after study in the states in emergency departments, mental health and emergency departments have looked at Black patients and white patients and emergency doctors spend more time with white patients and Black patients, the interviews are longer. There's more information. Outcomes are better. Protocols followed the same with both people. And that's about. Sort of what we care about and the internalised disparities, the internalised racism and that we have.
Dr. Alex Raben: [00:35:45] Right. And jumping off of that last point you make, it sounds like there are the discrepancies within the system. The health system can be rather subtle, right? The protocols can seem like they're being followed in an equal way, but there can still be quite a lot of room there for disparities that happen. Maybe more. Interpersonally and what have you. I'm wondering if maybe now's a good time to turn more towards the mental health question specifically and explore that landscape a bit more. What does the mental health of the Black population in Canada look like? What are the outcomes? What are the disparities there? And Rebecca, I know you had looked into this question, so maybe I'll hand it over to you.
Anita Corsini: [00:36:36] Yeah, I did. I did see in my reading some disparities, particularly in the prevalence of some mental illnesses such as schizophrenia, as well as the burden of disease for those who are Black compared to those who are white in terms of the chronicity, the severity response to treatment. And interestingly, these weren't necessarily reported in the countries of origin of these groups, but rather where where white people are the majority. So I think reading about this, I guess my question to you, Kwame, would be what's what's the relationship between racism and mental health?
Dr. Kwame McKenzie: [00:37:30] Last time I looked. And there were about. 500 peer reviewed good studies that were looking at the relationship between perceived racism. And health and mental health outcomes. And a lot of them were mental health outcomes. And they were split into mental health. So you're looking at stress and depression scores and the others, and then you're looking at mental illness and you're looking at diagnosed schizophrenia, diagnosed depression, diagnosed anxiety. And the groups have done various meta analyses. And the meta analyses are complex, but they essentially show that if that perceived racism increases your risk of mental health problems and also mental disorders and. Even the mental disorders that people have sort of talked about as being more biological. And increasingly, everybody realises that your biology is in an interaction with your environment and and therefore you can increase your risk of sort of a more biological illness from what happens in the social space. And racism increases the rates of physical, biological, as well as psychological problems. Think of if you were thinking just of the normal sort of thing of anxiety and allostatic load, you'd be thinking, well, okay, you don't get a job that makes you upset and increases your stress and therefore increases your risk of a number of different types of mental health problems. Because we know there are a lot of things that are linked to stress. Then if you think, okay, well, you've got that first stress, which is I didn't get the job.
Dr. Kwame McKenzie: [00:39:43] And then on top of that, you start thinking, hey, well, just a second, that was unfair. But we've got a model in our mind that fairness is really important and that unfairness increases the level of stress now. So you don't go and get the I didn't get the job. You then get more stress because I didn't get the job and this was unfair. And then if you can't do anything about it, you get higher stress still. So this is unfair. You know, I didn't get the job. It's unfair and I can't do anything about it. And that multiplier effect on stress is what makes sort of racism stress sort of so pernicious. But on top of that, in Canada and in a lot of high income countries, it happens on a backdrop of. An increased likelihood of socio economic issues such as financial insecurity, the Black population or the one of the most food insecure populations in Canada, 28%. Increased rates of children being in care, increased rates of of of precarious housing and then sort of poorer housing in sometimes more dangerous areas. And when people talk about dangerous areas, they always think about gun violence. They forget police violence and they forgot they forget racist violence. Right. So. All of these stresses are happening on top of existing sociodemographic issues and social stresses, which means that that racism stress.
Dr. Kwame McKenzie: [00:41:43] That multiplies even more. And the truth about the Black population and its mental health. These. If you just went with the numbers, there should be many more mental health problems than there are. But that history of having to deal with adversity has made the population much more resilient than other populations. But still, we've still got in Ontario 60% increase with regards to. With regards to psychosis, we have increased rates of depression. We have increased rates of anxiety both here and also in the in erm in the US for the Black population and a lot of trauma and chronic trauma, so complex PTSD. So we see this whole gamut of mental health problems that are happening in the Black populate Black populations. Not every Black person. Mental health problems are a minority issue, not a majority issue, but significant. But here's one thing that most people don't know. We have increased risk of illness, but in Ontario we spend 30% less per head of per head of population on mental health services for the Black population compared to the white population. And you know, what I was saying before is this idea of. When you see disparities and you do nothing about them. So this is so high risk, high risk, low service. And then we get surprised that we see a whole bunch of people end up in the prison justice system.
Dr. Alex Raben: [00:43:42] I was just going to say what I really liked about that answer is because we often talk about in psychiatry, education, formulating patients and the importance of the bio psycho social cultural model. And I think we touched on actually aspects of that of all of those things. You touched on it, Kwame, in your answer, because there is the biology, you know, the illnesses we think of as biological that aren't completely biological, of course, like schizophrenia being one of them that has a biological component. But then you also have the psychological impacts of racism in whatever form it's taking. And then the social piece, right. The social determinants of health, which we know on a population level that the Black population has more struggles with respect to that, more potential social determinants of health that impact on them. And then of course, that cultural is wrapped around all of that. But where am I going with this is the better question. I guess what I'm what?
Dr. Kwame McKenzie: [00:44:46] Alex One of the things that I just wanted to say from that, if find out where you're going with it, the we always forget. That the social and the biological are linked. So when we're talking about stress, stress has a psychological, social and biological substrate. So, yes, you can get high blood pressure. Yes. Your kidneys may not work as well. But, yes, on top of that, your immune system isn't going to work so well. Okay. So your immune system changes and there are t cell changes and various other changes that happen because of chronic stress. And they also are more likely because of chronic stress, because of socio socioeconomic issues. Right. So these things that happen in society can change our biology. And when we're looking at things like inflammation, neurogenesis, things that we think are important increasingly in the aetiology of disease, we can see how the social can end up being biological, how the biological can then inform the social, and that we can, unless we break the cycle and see what we can do socially, we can set populations up for disparities, that we can then turn back on them and say, well, it was just genetic. But most of the things we think of genetic are actually epigenetic and they are influenced by society and the response to them isn't genetic. The response is to go upstream and to be social.
Dr. Alex Raben: [00:46:42] Right. Right. And you actually, you've brought me back to where I was hoping to go with that piece there, which is I mean, first of all, I think that makes a lot of sense that we think about the biopsychosocial model often separately. I think for learners, it's helpful to make those arbitrary distinctions in terms of categories, but we need to be careful that actually they're all interrelated and something that's actually social can be mimic or seem biological, and we need to be aware and mindful of that. Speaking of the social, this is where I was hoping to go is where how do we tackle things upstream? What what work is left for us to do in Canada and in the mental health care system to start to close these gaps? These disparities have a more equitable system.
Dr. Kwame McKenzie: [00:47:36] So I think there are a few things that are say, let's just think about the mental health system and how you'd produce equity of care. So equity of care is partly and when I'm talking about equity, I'm talking about differences and disparities that can be changed. And if we're thinking and that's where we're going to inequity, some things, maybe you're not going to be able to change, but a lot a lot of things you can and some of them are down to the social determinants of health. And so, you know, it's housing, it's income disparities, it's education, it's a prison justice system. It's laws around racism and cultural safety. It's all of those things that you've got to think about. And those are things that if we want our treatments to work, we need to have a some thought about. So often mental health systems start thinking about supportive housing. They used to think about supportive jobs and income, and we all think about getting people on DSP, but we don't think about advocating so that our benefit systems are Rdsp is the the Ontario benefit, but it's the same. All you know, there are benefits for every province, but we don't advocate for that to actually be at a level where people can thrive. We actually just allow it to be for our most seriously ill people to live in poverty. And that's okay. Actually, there's a responsibility to be doing that, to be actually saying, well, actually we need to do something about the social determinants of health because you don't get recovery without dealing with that.
Dr. Kwame McKenzie: [00:49:28] And disproportionately. Black patients have negative social determinants of health. So the generally looking at social determinants of health and focusing on the social determinants of health for Black patients will increase our will improve our outcomes. But we have to do that. And that doesn't mean every doctor necessarily has to do that. But as a system, we need to use our lever as doctors to make sure that we give people the best opportunity for access to care and outcome. On the mental health system side. Usually when we're thinking about health equity for racialized populations and definitely for the Black population, we're talking about having culturally capable or culturally competent practitioners with culturally capable and equity in outcomes because of having interventions that work equitably for different populations and then nested within a system of care that allows equal access to care and supports people so that they have equal opportunities for recovery. And we tend not to do any of that. We might do something like this to try and upskill people, to be able to offer culturally appropriate, culturally capable care at an individual level. We tend not to culturally adapt our interventions to make sure they work equally for different populations. And we know things like CBT. If you culturally adapt them, you get better care.
Dr. Kwame McKenzie: [00:51:29] If you don't, then there are populations that don't do so well. But it's the same for child services. It's the same for it's the same for old age services. And we tend not to go to the next stage, even if we do those things is to say, how can we ensure that people have equity of access to services and how can we make sure that we do the work to make sure that the system supports them in recovery? It's all of that stuff. This idea of vertical equity and horizontal equity. Horizontal equity is people with the same problems and the same needs get the same treatment. We don't do that. And vertical equity is that people with different levels of need get different levels of treatment. We don't do that for the Black population. And so we've got to structure social determinants, improve and also improve psychiatry. We've got an equity issue with regards to identifying need and giving services to people most need, and we don't do it. And then we're surprised that we get differential outcomes. All of the information on how to do this is all available. There are Canadian studies. The Mental Health Commission have lots on its website, but the true problem we have is that as a profession, we choose not to do it. And that's why communities will turn around and say that as a profession we have a racist profession because they'll say the information there.
Dr. Kwame McKenzie: [00:53:14] But we choose not to do it. And that's that is increasingly with Black Lives Matter and with all of the other things that are happening in society, that's increasingly the problem. I'll tell you a joke. There is a joke that goes around policy circles, which is why did the Canadian policy adviser cross the road? And the answer is to get to the middle. Right. And the truth is, in the past, that was a really completely fine and decent, pretty Canadian outcome. Yeah. But we've now reached a position in society. Where if you sit in the middle. It's not good enough for a lot of people. So if you sit on the fence around me, too, you're part of the problem. If you sit on the fence about reconciliation, you are part of the problem. And if you sit on the fence around anti-Black racism, you are considered part of the problem. Your people are increasingly saying if you are not with us, you are definitely against us. And I think it's a pivotal moment for psychiatry to start thinking about these things because we will be viewed through that lens. And if we are not clearly thinking about anti-Black racism and what that means for changes and significant changes in psychiatry, we will be considered to be part of the problem and that we we can't cross the road to be in the middle anymore. It's not possible.
Dr. Alex Raben: [00:55:15] Right. And it goes back to, I think what we were talking about earlier, where racism can take the form of inaction or neglect. Especially when faced with the stark data that we've been discussing around the disparities. I wonder, can we come? Can you help us in our listeners understand that? In a concrete example, you've talked about adapting CBT for different cultures and that being an important step that practitioners can take. You also pointed out that it's not readily readily available, and I've actually had no experience with that in my training. So I'm wondering, can you help us understand what that looks like and can we take lessons from that and apply it to our other areas of clinical work?
Dr. Kwame McKenzie: [00:56:05] There are very few things in psychiatry that have such a evidence base and are just neglected. And so last time I looked and this was a few years ago, there are about 400,000 people who've been in studies of culturally adapted CBT places like the London School of Hygiene and Tropical Medicine in the UK have even produced manuals of how you culturally adapt CBT. About ten years ago, something like that may be a little less and it can produced manuals of culturally adapted CBT for the Caribbean origin population, for the African origin population, and for the Spanish speaking populations of Toronto and the Caribbean and Africa. African one was picked up by women's health in women's hands, and they have seen hundreds of people and women's health in women's hands as a community health centre, and they've seen hundreds of people. Not only have they seen hundreds of people if you were a resident. Working in the emergency department at the Centre for Addiction and Mental Health. You used to see lots of Black women coming in with trauma, history histories, anxiety and depression from the Women's Health and Women's Community Health Centre. Once they started training, everybody in culturally adapted CBT, they managed to get those numbers down to a trickle, literally a trickle and all culturally adapted.
Dr. Kwame McKenzie: [00:57:52] Cbt does, it says that spine of CBT of how we do treatment and how treatment works, that stays the same. You don't have to adapt that. You don't have to take away the fact that you are doing cognitive work and behavioural work and you don't have to take away the fact that you're going to do it over a certain number of sessions. That's straightforward. The question is, are there things about that that will make it more accessible? And the things that you tend to look at is the illness models that use the words that you use around the illness models. The examples are there Black people in the examples? Are you talking about somebody who who works in a bank or an office when most of the people you're going to come across are not going to do that? Are you going to start calling things home? Work in the Black communities that we work with in Toronto really hated the idea of it being called home work, journaling, Fine homework. No way. Right. And then are you when you're doing your CBT, going to ask people who you know Black and are hard pressed to do homework? Are you going to have to think about your model? The other thing was we for that culture that CBT for the Black population, there was an extra introductory meeting.
Dr. Kwame McKenzie: [00:59:30] And that meeting was about CBT. It was about worries about CBT. It was about trying to introduce yourself as a therapist and getting people on the right page and all of those other things rather than just expecting everybody to to, to know you and like sort of give everything to you. And it was going back to some of the things we said before, Alex, about what you're trying to do in the first interview and what that first interview was actually about making the space. And it was about making the space for people to be able to ask all of the questions and allaying the fears. And it was also about demonstrating that, you know, there was a level of humility. You understood where they were coming from and that you were open to doing things differently if need be. And so it's all of the stuff around therapy doing it during the day. They're doing it right. Is it individual? Is it group? What do people like? You know, and all of these things when you put them together? You can change your outcomes by ten 15%.
Dr. Alex Raben: [01:00:47] So many common themes throughout this this talk we're having, it's very helpful to hear how the CBT has adapted, that it's not necessarily changing the core therapeutic principles, but it's about making things more accessible, understanding the person in front of you, which are kind of hallmarks of psychiatry in general. And yet, as you point out, we're still not doing this stuff. There's still that gap. Things being hardwired in that aren't helpful, that aren't equitable. Those are just some of the things that popped up.
Dr. Kwame McKenzie: [01:01:25] Yeah, no, I agree. And I think part of the part of the issue you have with the commodification of therapy and CBT is an evidence based commodification of therapy. We get a structure, we keep people structure, and because we keep we have that structure, we can replicate it. And that is the model of the Industrial Revolution. That's how it works, right? You get it, you work out how it works. You produce something that is your package and that's your widget and you produce something that everybody else can use and that is the model. Okay, fine. The problem is that if you bake in rigidity to that model, you bake in differential outcomes for people. And so cultural adaptation is just about saying we can understand why we have this model and we can understand that that increases the opportunity for different people to do therapy and for it to reach more people and for it to be demystified and for people who are not psychiatrists to do it. But we do actually have to try and say that that industrial model needs to be changed if we actually want it to work for the population.
Dr. Alex Raben: [01:02:47] Well well, we did go into some theories there, but I you know, what I really took away from that was a call to action that there's so much we have left to do, both in terms of personal reflection and as reflect and reflecting as a profession as well and as a society. And and that inaction, as we've talked about, is not not acceptable, frankly. I'm just being mindful of the time. We want to respect your time. And so maybe we will end on that note. But we would really like to thank you again for being on the show and providing us with such a rich discussion and stretching our brains today. Site is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced by Anita Corsini, Randy Wang, Rebecca marsh and myself, Alex Rabin. This episode was hosted by Anita Corsini, Rebecca marsh and myself. The audio editing was done by Rebecca Marsh. Our theme song is Working Solution by All of Music. A special thanks to the incredible Dr. Kwame McKenzie for serving as our guest expert on this episode. As always, you can contact us at Psych podcast at gmail.com or visit us at Psych podcast. Org. Thanks so much for listening.