When we think about cultural structural norms, the broader umbrella that these belong to, is what we call the social determinants of health, or SDOH. And these are elements of the social environment outside of the direct clinical care or the court system that can cause positive or negative health outcomes. So, if we think beyond the court system, beyond the patient-doctor interaction, what are all of the things in the social environment that can relate to if someone has a positive or negative health outcome? And these are powerful correlates in terms of mental health and substance use disorder recovery that are visible on a population level rather than an individual level. So these are things like: access to housing, access to fresh air, access to education, access to unlimited finances. It doesn't matter how strong an alliance someone has with their doctor, or if they are following all the rules that the court has set out. If they have vulnerabilities in these social determinants of health, meaning they are experiencing homelessness, financial constraints, don't have access to education, this is going to lead to a more negative health outcome, as opposed to people who have stronger areas within the social determinants of health. And I think that that's really important, especially as what we're seeing now with the pandemic and COVID 19, where there is an over representation of black and Latinx people that are being hit by the virus because they have vulnerabilities in the social determinants of health. So, an important concept for us to understand as we're considering the social determinants of health, is this concept of othering. And what do I mean by othering? What I mean is that people who are relegated to a certain group, mostly black and Latinx folks are considered different than, or less than the majority population which tend to be white people in this country. So, they are treated differently and they're thought of differently. And I think are really good example of othering is seen with the opioid epidemic. So white people with an opiate use disorder are seen as needing care or being worthy of treatment. Where black and Latinx people with an opioid use disorder are seen as needing to be involved in the legal system as opposed to necessitating medical treatment. And that really becomes a problem because that can lead to records and people not being able to access major institutions like housing and jobs, which again can lead to poor outcome. So when we're thinking about how do we deal with this huge iceberg that we see in front of us and this concept of othering? Now, one of the ways to do that, is really through a tool of structural competency. And this was introduced by two physicians and researchers, Dr. Helena Hansen and Dr. Jonathan Metzl. And they said that this new term, structure, needs to shift focus above the level of the individual. So above the level of judge, above the level of doctor, to really institutions; like clinical, educational, correctional, legal systems, so that we can focus on total communities and policies that determine health. So that's what we mean by structure. And in terms of competency, this is to indicate an expanded scope of a clinical intervention and responsibility. So meaning that practitioners can bring a symbolic, social and cultural capital to bear and partnership with other folks in the community in order to deal with these structural issues. So really thinking as structural competency being a tool to deal with the social determines of health so that we can improve outcomes for people with substance use disorders. So again, shifting from the level of the individual to the broader institutions and thinking about policies which determine health. Now, I think another part of this conversation that we have to really cover, is the experience-based perspective of officers of the court that are very different from the experiences based of other served by the court. So what does this mean? Just this means that there's not an agreement on which how people who interact with the court system think about those who are part of the court system. And this is important because it helps us to understand how our own biases can influence our recommendations and how we might not necessarily consider the views of those being treated by the legal system. So here, this is when we get into the understanding of bias. Which is an assumption made on how one person will act or what their intentions will be, that's not based on facts. And there's two different types of biases. There's explicit bias and implicit bias. And explicit just means that, people are conscious of this judgment. Their attitudes and stereotypes are consciously accessible through introspection and is endorsed as appropriate. And people can choose if they wanna really express their bias or conceale their explicit bias. Now, this is very different than implicit bias. And I want us to realize that all of us have biases that are both explicit and implicit. But the thing about implicit bias is that if not consciously accessible through introspection. And it impacts behavior. So we don't know that we have implicit bias, unless we take a test or there's a tool to bring our implicit bias from the not conscious to the conscious. And it's important for us to talk about bias because we know that it impacts behavior. And so as judges, I really want you to think about taking the implicit association test, www.iat.edu, because that allows you to understand what are your implicit biases, what are those unconscious attitudes or judgements that you might know about that are indeed affecting the way you interact with people who come into the courtroom that are different from you, that may be a part of these vulnerable populations, and how you might be treating them differently. So if we look at court involved individuals and people with mental health and substance use disorders, we can see some of those biases in action. So what does that mean? That means that people involved in the legal system that are black, are 44% less likely to be referred for a mental health or substance use evaluation than people who are white. So we know that there has to be a level of implicit bias involved, if people who look or belong to a certain group are treated differently. And that goes back to that othering point I was making in terms of Black people with opiate use disorder being treated very differently than white people with opiate use disorder. Further, people of color are more likely to receive misdiagnoses, not be diagnosed at all, or not even be referred for a mental health evaluation, despite exhibiting behavior that's consistent with a mental health disorder or substance use disorder. So again, this is showing that bias is not just within the legal system, but also within our healthcare system. Because the people who are interacting with the people of color, are seeing them as not being worthy of having a mental health diagnosis or substance use disorder, despite exhibiting symptoms that support this. So again, we have to be extremely diligent in understanding how our own implicit biases can affect how we're interacting with people that are different than ourselves. Again, there's more data to support how people involved in the legal system and who have mental health or substance use disorders are treated differently. For instance, Black people are significantly less likely to receive psychiatric medication and counseling while they're in prison when compared to their non-black counterparts. And then, if they are hospitalized, they're more likely to be involuntarily hospitalized. So that means hospitalized against their will as opposed to having collaboration around their hospitalization. So why is this the case? Again, one of the major reasons why we know this to be in the literature is based on implicit bias, those unconscious interpretations or judgments, just based on a group of people and how they look or what particular racial classification they belong to. And then if we go even further within correctional settings in particular, without a prior history of a mental health diagnoses, Black people are significantly less likely than non-black people to receive treatment. So I think you guys are getting the pattern here, that there is really discrimination that is taking place because of biasing within the system. So, then we're hearing all of the problems. We've heard about social determinants of health, we heard about othering, we heard about implicit bias. And so now I wanna spend the next part of this lecture really thinking about what can we do to improve our behavior, both as judges and as mental health providers. And one of the things that we can do is de-bias ourselves. So these are efforts to reduce our implicit bias, which we know shape behavior. Examples of this are stereotype behavior replacement. So, what that means, fancy way of saying, just recognizing when a response is based on a stereotype, label that response as stereotypical, reflect on why that response occurred, and consider how this bias response could be avoided in the future. And then, you can replace this bias response with one that is more consistent with your values. So for instance, if you see a Latinx man enter the courtroom, a biased response might be, oh, here comes another person who just stole in order to support their habit. Really labeling that response as, that is the stereotypical response. Reflect, why did this response occur? Is it based on media portrayals? Is it based on a specific group that I see only in my courtroom and not necessarily taking into account the whole heterogeneity within this group of people? And consider how this bias response could be avoided in the future. Do you have to make sure that you're treating your Latinx people the same as you would someone from our majority race? We have to be extremely vigilant in making these unconscious behaviors more explicit. Another way that we can de-bias ourselves, is really think about individuation. What do I mean by this? Is really treating a person based on their own personal experiences, as opposed to attributing their behavior to a group based action. For instance, gathering specific information about the individual themselves, rather than making stereotypic inferences. This strategy really does help people evaluate individuals based on their personal characteristics and attribution, as opposed to group based dynamics. Perspective taking is a really good one. And this is one that has been shown in the literature, especially with doctors to work well. In terms of imagining oneself to be a member of a stereotype group, in this situation a black or Latinx group, this helps to increase empathy towards the group and reduces automatic group based evaluations. So really a fancy way of saying, put yourself in this other person's shoes. What is it like to have to deal with the mental health or substance use disorder? To have to deal with vulnerabilities in the social determinants of health? To have to deal with daily discrimination? How does this affect the way that they have to live life, the choices they make? So really thinking about, if you were in that person's shoes, how would you react? And this helps to increase empathy. Another example for de-biasing behavior is opportunity for contact. This is huge, especially when we look at the huge over representation of white men in the state court system, how can we seek opportunities to encounter and engage in positive interactions with people that are different from ourselves? Contact with people different from you, decreases bias by altering mental representations of the group and improving evaluations of the group. This allows one to not only engage in meaningful relationship with others, but also to increase empathy towards other identity groups, which increases and changes behavior for the good. So finally, I always say, it's not okay to treat everyone the same. It just isn't fair. And in reality, that rarely ever happens. So people always ask, well, "Dr. Jordan, isn't it enough to just treat everyone as equal?" And I always say, "No, because the differences in which people face in life, there are different considerations, environments, cultures and views. And if we treated everyone the same, it doesn't necessarily equate to a fair outcome." And I think this illustration really sums it up best. We can see that these are three different people, three different stations in life, but they were all given the same box, but that same box is not enough for these three individuals to see the game that's happening on the field. In fact, for one individual, they don't need a box at all. For another individual, they need two boxes to be able to see the game. And then for another individual, a box just won't do, because they need more assistance in order to see the game. And this is what I want you to take into account when you're treating vulnerable populations, especially underrepresented minority populations with substance use disorders. Sometimes because of the vulnerabilities that they face, they need two or three boxes, or perhaps a ramp in order for them to engage in recovery. Thank you so much for your time and attention, I hope you were able to take away some key concepts from this lecture. For free localized education and training designed to meet your needs, contact the Opioid Response Network.

Social determinants of health

SDOH

health outcomes

mental health

substance abuse recovery