2021 Annual Meeting: President-Elect Address

Good morning. Thank you for the kind introduction. I’m so glad to be with you today, as I become President of the American Psychiatric Association.

I begin my presidency amid multiple ongoing crises that have been exposed by a global pandemic—namely social, economic, environmental, and political—these are critical issues that must be addressed.

But this moment of crisis also holds the possibility of opportunity. If current trends continue, we will eventually emerge from this pandemic. Every vaccine dose represents another ray of hope. I fervently wish that the very best comes of all these efforts, including the dramatic rise in attention to mental health we have seen over the past year. However, with the slowing of the pandemic, and increasing talk of “getting back to normal,” there is another danger lurking—that we lose the perspective and vision that this pandemic has afforded us.

This pandemic has revealed that previous ideas of normal were unacceptable for many people in this country. In too many places, what was considered normal fell far short of decent or adequate.

How do we understand our current reality? Each of us must ask ourselves, “Who are we as psychiatrists”? The pandemic has given us time to reflect. As psychiatrists, we care for patients, each one as a whole patient. We try to relieve their suffering and improve their ability to function. In 15 or 45 minutes, psychiatrists try to understand their patients’ lived experience. We ask them to tell us their story, their narrative. The stories of their past are in their unconscious, but it informs their present and their future.

We ask our patients to speak openly and honestly. Psychiatry also has to speak the truth. Psychiatrists must address the systemic disparities so that meaningful empathy and treatment are possible.

In the United States, we are dealing with an extreme political divide. Hate is on the rise, again. And so is fear. Many people are facing economic hardship and an ever-widening divide between the wealthy and everyone else. We’re seeing the destructive impact of historical discrimination and racism in our society. We have yet to address how this country was “discovered.” It is estimated that one hundred million indigenous people were murdered in order for the explorers to claim the Americas for their own. Our civilization, like others, is built on colonization and extermination. A significant part of our culture, what we accept as our “norm,” is based on destruction of culture, separation of families, and forceful conversion. Raoul Peck calls it “the disturbing confidence of ignorance.” He asks, Why do we think we can own another human being? America, as on other continents, was born as a colonial power, and that story continues today.

Whoever frames the story has the power. When a psychiatrist tries to fit a patient’s narrative into a purely standardized format, understanding and knowing the whole person are lost. Psychiatry must treat the whole person, and, frequently, those people around the patient, but also realizing that a patient’s whole life is at stake. As a psychoanalyst in private practice, I have had the great honor to assist my patients in learning about themselves—especially why they feel, think, and act—so that they can make informed life decisions.

But you may be asking, What can we do about issues that go beyond the individual, some that are of massive proportions? Psychiatrists are not economists, not politicians, nor Wall Street power brokers. But we do have collective experience and knowledge—as an organization of psychiatric physicians, we are experts in mental health and mental illness. And so we have the ability to focus our efforts where we can have the greatest impact—on population health and systems of care. Those efforts, in the form of Dr. Jeffrey Geller’s Presidential Task Force to Address Structural Racism Throughout Psychiatry, was an excellent accomplishment.

When we speak of 2020 as a year of reckoning, we have to consider how we build on what was done last year and how we can go forward to reach a more just society. But our social problems are deeply rooted. While last year the APA focused on its own structural racism, we began to acknowledge that racism lurks in every corner of our society. The different forms that racism takes can overlap. Implicit, unconscious bias can be an internalization of cultural, systemic racism. Let me be clear—we are all affected by racism, just as we are all affected by other forms of discrimination, such as misogyny and the stigma of mental illness.

As your President, I plan to address root causes of these problems with a Presidential Task Force on the Social Determinants of Mental Health. This approach comes from population studies that have identified that the social determinants of health are those social, economic, environmental, and political conditions that contribute to differences in health outcomes.

As we’ll examine it at the APA, there are four main areas. If that sounds methodical, it’s because it is a system that many scholars have used to break down the exact ways that inequities and other factors impact peoples’ lives.

So, if you will indulge me as I walk you through this, it’s a powerful model that will show you where lives could be improved and where we can have an impact. This model shows us simple truths and gives us a chance to make positive changes.

Let’s review these four areas of determinants.

The first area encompasses the social problems that impact mental health.

• Adverse child experiences, or “ACEs.”

• Racism.

• Lack of access to health care.

• Exposure to violence and to the criminal justice system.

Every one of these has an overwhelmingly negative impact on mental health. Success is difficult for a person if they’ve had an abusive childhood, been part of the juvenile justice system, or have been oppressed because of their race or ethnicity. In our roles as psychiatrists and mental health experts, we know that there are culturally informed programs and interventions that are available. We have to advocate for solutions that are funded, implemented, and accessible.

The second area encompasses the economic factors that impact mental health.

When we talk about helping people boost their economic status, the gateways are tight: a lot of people struggle with the burden of poor economic circumstances, lack of opportunity, and wage disparity. According to a 2019 Federal Reserve report (and this was before the pandemic), a third of the families in the United States would be thrown into debt by a $400 surprise. A medical bill, a car wreck, a layoff, any of these things: $400. Think about it—looking at economic status and its impact on mental health outcomes is the second area that psychiatry can advocate for solutions. Nobel laureate economist Amartya Sen said that poverty results in a failure to achieve minimum capabilities. Poverty is not relative; it is absolute in the way that it affects a person’s entire existence. Sen and his colleague Martha Nussbaum have proposed social choice theories and allocation of resources to mitigate the effects of poverty. This is applicable to understanding and advocating for psychiatric patients.

The third area addresses the fact that our physical environment impacts our mental health.

It matters where you were born and where you live. Is there a grocery store nearby or only fast food—known to be factors contributing to obesity? Does your child have a safe playground to enjoy, or are you next to a highway or a polluting factory? Are you dealing with frequent storms or fires because of climate change? On the other hand, is there green space around you, with trees, clean water, parks, and playgrounds? This makes a difference in stress levels and all the physiological consequences of increased stress hormones. This is our third area to study and address.

The fourth area encompasses political determinants.

There are systemic policies, laws, and enforcement that sometimes serve to maintain social choices. These are the policies that effectively institutionalize forms of discrimination and produce deep disparities. These policies represent barriers to mental health care. I believe the APA can make a difference by alerting legislators and the wider public to the deeply harmful effects of these policies on mental health.

The truth is, many psychiatrists can come out of this pandemic having had vaccines and going back to a comfortable place where loved ones can be hugged, eat in restaurants, and do all the things that have been missed.

But without intentionally addressing some of the problems that have impacted so many for so long, many will continue to face poor mental health outcomes. Or we can take this moment and say: “We are executing a massive public health effort to stop the spread of a dreaded virus. Now, what are we going to do about these other systemic problems?”

In addition to the task force, and focus on health care in the U.S., there are also global mental health concerns.

While working with the UN over the past 20 years, I had the opportunity to learn methods of diplomacy and negotiation that countries use to work toward global cooperation, peace, and stability. Since 2014, the APA has been an NGO of the UN with Special Consultative Status. During my presidency, I hope to increase the APA UN partnership to continue learning from each other.

I believe changing wide-ranging policies so that our patients have better outcomes and healthier lives is something that will give us a sense of purpose this year. Nevertheless, you may be sitting at home on your computer wondering why me? Why APA? What drives this? Why do I think we can make a change? And what can we do?

Well, I believe a lot.

Why do I believe APA is the organization that will make the change? APA has a mission to ensure that people with mental illness and substance use disorders are able to access effective psychiatric treatment. We can educate, and we can advocate for policy initiatives that are needed to improve outcomes for our patients. That is the basis for social determinants of mental health. Realistically, I understand that we don’t directly write the laws, but through education and advocacy, our APA voice is powerful.

Those of you who know my background will know that I have been involved in efforts fighting human trafficking for many years. In New York, I worked with several organizations and held a conference a few years back at Weill Cornell Medical School to train health care professionals to identify and treat a victim of human trafficking. About 88% of victims while in captivity see a health care professional, but most often the opportunity to intervene was missed. However, through that wide-reaching conference and other efforts for advocacy and education, there is now a law in New York State that went into effect in 2020 that requires every health care facility to train its workers to recognize the signs of human trafficking. A long-range goal is to prevent the largest risk factor for trafficking: adverse childhood experiences, designated as a social determinant of mental health.

So, as the task force begins its work on social, economic, environmental, and political determinants of mental health, we will be studying, educating, and advocating for the solutions we think will make a difference. We’re planning on consulting some of the best experts in psychiatry, sociology, economics, health policy, ethics, and other disciplines to look at how these problems impact people’s mental health. Our goal is to provide education and advocacy for psychiatrists, private sector, and the government to implement.

If you’re interested in this work, and you feel like it is time to make a change, I would encourage you to get involved. It only takes a few people who really believe in something to make a difference. When you feel passionate about an issue, you can make your voice heard, and you can make an impact.

At APA, one of the great ways to get involved is in your district branch. You can usually join a committee, show up, and speak up. You can join a caucus of the Assembly. You don’t have to be appointed to those. The caucuses give APA members tremendous ways to share information, to network with colleagues, and advocate for ideas you feel strongly about. Go to the meetings, take the notes, run for office. Let your passion for psychiatry, diversity, equity, inclusion, justice, or social determinants of health, whatever the cause, let it drive you.

Our next steps together have so much power and possibility. I believe that psychiatry has a profound value to society. We are in the right place at the right time. More than anything, I know right now is the time.

I know APA is the organization.

And for all that I have said today, it is really you, the members, who have the knowledge and power to work toward these changes and that you are the people who make this work.

I look forward to taking on these challenges together this year. Thank you.