Hi, my name is Tina Nadeu, and I am the Chief Justice of the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction psychiatry, and other judges. And we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. And in this module, you'll hear from Dr. Jordan about the cultural significance and cultural differences that we need to keep in mind when we're deciding how to impose sentences on people that come before us. Now, I don't know about you, but I think I say to myself every day, well, I'm sure I treat everybody equally and evenly at all times. And oftentimes we don't even know when we are using implicit bias to inform our decisions. It doesn't mean that we are racist. It doesn't mean that we are sexist. It just means that we have cultural upbringing that teaches us how to respond to people. So one study that I think is important to keep in mind, has to do with the rate at which black people are arrested for simple drug possession crimes. They are arrested at a rate double the rate of white people, even though federal statistics show that black people and white people use drugs at the same rate. So we know there are issues that we need to pay attention to as uncomfortable as they are. And in this module, you'll learn about how you can pay more attention and just be more conscious in your decision-making. Many of you have seen that slide where you see three people trying to look over a fence at a ballgame. And if we treated them all the same and gave them all the same step ladder, one person would be able to see the ball field, another person would barely be able to see the ball field, and an even smaller person or someone in a wheelchair wouldn't see it at all. So equity doesn't mean the same. It means how do we address each person's needs with understanding of their cultural backgrounds. So enjoy. My name is Ayana Jordan, Dr. Jordan. I am an assistant professor at Yale University School of Medicine an Addiction Psychiatrist, and also an attending physician, which means that I see patients and also teach doctors how to take care of people with substance use disorders. And my specialty is dealing with the most vulnerable populations, usually racial and ethnic minorities with substance use disorders. I'm very happy today to talk to you about cultural considerations for court-involved Individuals. I just wanna bring attention before we get started to that very deliberate choice of court-involved individuals as opposed to criminal system, or criminal legal system, or criminal justice system, because in an effort to de-stigmatize people with substance use disorder, we really want to be sure to take away the phrase of criminal and really think about court involved or legal system to decrease stigma. I have no conflicts of interest to disclose. And here, I'd like to introduce this concept of a liberated space. What do I mean by liberated space? A lot of judges might not be familiar with this term. And it really does push the concept of a safe space, which you may have heard of. When people refer to a safe space, they mean talking about issues that might be uncomfortable to others, and not wanting to hurt people's feelings, and saying things in a way that's appropriate, so that everyone feels safe. And although I understand the notion of a safe space, I just want to think about a liberated space, especially as we talk about cultural considerations of court-involved individuals, because we know that sometimes to grow and learn, we have to have some uncomfortableness, or sometimes we have to have some conflict. So if you go through this lecture and you have strong reactions, or you don't understand a particular point, I welcome questions to addiction specialists, colleagues, and friends to talk about these subjects, because even though it's uncomfortable, we are in a liberated space and it's important for our growth. So the objectives are threefold for this lecture. First, I'd like to describe the social and political factors that contribute to the over-representation of underrepresented minority communities involved in the court or legal system. And here, when I say underrepresented, I'm talking specifically about racial and ethnic underrepresented minority communities, namely black and Latinx community. Also to describe how the social determinants of health commonly known as SDOH, impact court-involved individuals or individuals involved in the legal system. And finally, to understand how concepts such as othering and implicit bias affect outcomes for court-involved individuals. So first, I think we should have an understanding of the overall racial and gender breakdown of State court judges versus those of the American people. And here, this slide is just showing you the disparity that exists. The American people are 51% women, and 38% of American people are people of color. However, if we look at the state court judicial system, we see that this is in a huge contrast to what we see in America where 70% of state court judges are men, compared to only 30% of women. And overwhelmingly, 80% of state court judges are white, compared to only 20% of people of color. So what we're dealing with here is that most people who make decisions for those involved in the legal system are white men, whereas those who are likely to engage in the system will be people of color. And that is really important to understand decisions that are made and why we see an over-representation of racial and ethnic minority in the judicial system. And if we look at who are those individuals that are most likely to be imprisoned in the US, this is from the Sentencing Project. And this is quite telling, what a graphic. You can see for all men in the United States, one in nine will be involved in the US Imprisonment System. For white men, that drops down significantly to one in 17. However, for black and Latinx men, there's a huge increase. Whereas one in three black men have a lifetime likelihood of being in prison and for Latinx men, one in every six Latinx men have a lifetime likelihood. Again, we're seeing an over-representation of black and Latinx men in the system. And that same pattern is reflected amongst women. So if we take all women together, one in 56 women will be involved in the imprisonment system in terms of their lifetime likelihood. For white women that drops down drastically to one in 111, whereas for a black woman is one 18, and for Latinx women, it's one in 45. So we're seeing the disparities in action where again, most of the state court judges are white males. However, those that have the lifetime likelihood of being in the imprisonment system in the US are black men and women, and Latinx men and women when compared to white men and white women. So the Surgeon General says here that there are racial and ethnic minorities that really bear a greater burden from unmet mental health and substance use disorder needs and thus suffer a greater loss to their overall health and productivity. And the reason why this is important is because a lot of what we're seeing in these numbers that I'm reflecting here, really are related to this undue or greater burden from unmet mental health and substance use disorder needs across this population. And this is often not discussed as why we might see an increased likelihood of racial and ethnic minorities in the system. They have less access to care in terms of getting their mental health and substance use disorder needs met. And if they do receive care, they're less likely to receive quality care when they do. And oftentimes people with unmet mental health needs and substance use disorder needs will get involved in crime, that unfortunately are final, not necessarily into treatment, but relate to involvement in the system. So what really needs to be a focus here is not necessarily people from these racial categories, but the systems themselves in terms of how can we tackle the cost of care, how can we tackle societal stigma and getting help for mental health and substance use disorders, and then how fragmented our system is so that even when people want to get help, it's extremely difficult, and oftentimes, the only time people can access help is when they are involved in the system. Also, it's important to note when we're looking at the over-representation of black and Latinx people with substance use disorders in the system, we know that there is a huge influence of racism which is just to say that it's a man-made system based on race where certain people who belong to the majority population, which tend to be white people, have preferential access to resources and opportunities and people who belong to other systems, like black and Latinx, do not have this same opportunity. And this relates to discrimination where they're not treated the same. And again, what we're seeing is even with the same diagnoses, one person from the majority system is allowed to access treatment while another person will be funneled into the system. So we have to take into all of these concepts when we're thinking about why is there over-representation of these races in the system. So what does this mean in terms of how does this impact minority populations? Well, if they have a greater burden from unmet mental health and substance use disorder needs, this relates with an overall loss in their overall health and productivity. So this means that there's an impediment in terms of academic progression. They're not able to finish high school, post graduate school, college at the same rate as majority population, which leads to diminished employment opportunities, which leads to increased risk for homelessness, frayed relationships, and limited resources. And you can see that these all come together to really lead to people having minimal options which often allow them to make poor choices or I say, they're not presented with alternatives, and so they have to make difficult decisions to survive, which often lead them to involvement in the system. Then if we look at the issue of less likely to access mental health and substance use disorder treatment. We know that there's a huge disparity in terms of Black and Latinx accessing treatment. Even if you control for access to insurance, like through the Affordable Care Act where people no matter what your race is will have access to care, well, black and Latinx people are less likely to receive quality care, even when they do interact with the system. So what does that lead to? That leads to them having more severe symptoms, meaning that when they present, they present much later in the disease state. They're more likely to have maladaptive coping mechanisms, meaning that if their healthcare providers do not trust them or not making the appropriate recommendations, they're more likely to engage in activities that help them feel better. And that can lead to substance use. And this is the whole theory about self-medication where people will take substances, oftentimes illicit to help them relieve their own symptoms. Another thing that's important to really understand is that a lot of people from these communities who enter the system are dealing with untreated, undiagnosed illnesses upon entering the judicial system. So it makes it even more difficult to treat their underlying substance use disorder 'cause they have co-morbid medical problems. So again, we're dealing with people who are already vulnerable, who are not treated equally by the medical system, and are more likely to be funneled to the court-involved system. And when they do, they have many, many problems. So this makes it very difficult to address this population. And we break down what I was talking about related to another huge barrier which is cost of care, societal stigma, and our fragmented mental health system. What are those potential implications? This makes it much more harder for populations to be able to follow up with the recommendations. So that's what we call nonadherence. And that relates to difficulty being able to take your medication, maybe you don't have the finances to access the co-pays that you need. Maybe you don't have the ability to arrange transportation. What if there are no providers that take the insurance that you have. Finally, if we think about, okay, we might have access to insurance, we might have transportation, we might have money to pay for the co-pays, but what if the institutions in which we live are not covering the services that we need? And this is not uncommon in many racial and ethnic minority communities where they have to travel far in order to get access to the services that are in more affluent areas. So then we get into this concept of double stigma. Not only do people have to deal with racism, so a system based on race that preferentially advantages or disadvantages groups, they also have to deal with the stigma of a mental health diagnosis and/or a substance use disorder. Then, it gets even more complicated if we think about the triple stigma. And what I mean by that is racism, plus the stigma of a mental health or substance use disorder, plus a legal history, which makes it even more difficult to integrate into society. So again, it's important as judges who really have a lot of power in the system to take into account how all of these factors must be addressed and really thinking about how people can have the best possible way of staying in recovery. It's not just about a medication, but it's dealing with access to continuing healthcare, but also dealing with bigger concepts such as racism, discrimination, and stigma. Other things that we have to take into account or what I call the secondary barriers. So those are things like lack of cultural awareness when people are accessing healthcare system, bias, that is inherently within the system, language, what is considered appropriate language or not? What do people understand? Sometimes people who are highly educated might not speak in a way that it's easily accessible to people who are not able to take advantage of higher educational system. So thinking about people not understanding their symptoms, or how if their symptoms are explained to them in a certain way, they might be missed or misinterpreted. A lot of times physicians may look at black and Latinx people with mental health and substance use disorder as being criminal, rather than having an actual illness that needs to be treated. Also, there's little faith that treatment will actually work, or that providers will help. And this is really based on historical atrocities that have happened in a lot of these communities where there is real data to support that they should have mistrust in the system because of lack of informed consent with care, or withholding life-saving treatments from these populations. So all of these reasons could contribute to why there might be a fear to engage with the systems in place. And those are things like the healthcare system, the housing system, immigration system, the Department of Family and Children and Services, because these particular institutions don't always necessarily have a cultural awareness of how these groups can interact with them. So this brings me to an important point about culture and structure. Both of these huge categories can really influence behavior. So if we think about how cultural and structural experiences shape our beliefs, values, and actions, then we can understand how this might have a huge impact in how people that have a mental illness can interact with the health continuum. Meaning that if there is no understanding of the important cultural and structural significance to these populations, it's really gonna be important to engage people in the health continuum. And there's not going to be a huge buy-in in terms of mental illness or substance use recovery if there's no consideration of these cultural and structural norms. For free localized education and training designed to meet your needs, contact the Opioid Response Network.

addiction

implicit biases

disproportionate arrest rates

cultural considerations

racial and ethnic minorities

societal stigma