Hello and welcome. Thank you for joining the third national conference on advancing early psychosis care in the United States presented by SMI Advisor. I'm Susan Azrin at the National Institute of Mental Health. Next slide, please. I'll be moderating today's session, Cultural and Contextual Considerations in the Early Identification of Risk for Psychosis, with our speaker, Dr. Jason Schiffman. I'll remind you, Dr. Schiffman will be answering questions following his talk as time allows, so please put your questions in the Q&A box, which is next to the chat box, at any time. I am absolutely delighted to introduce you to the faculty for today's session, Dr. Jason Schiffman. Jason Schiffman, Ph.D., is Professor of Psychology and Director of Clinical Training at the University of Maryland, Baltimore County. Dr. Schiffman co-directs the Maryland Early Intervention Program's Strive for Wellness Clinic, a research training and services program designed to improve the lives of young people at risk for psychosis and their families, one of the first such clinics in the country. He's also about to begin a professorship at the University of California, Irvine. Jason has dedicated his career to refining the identification of and treatment strategies for young people at risk for psychosis, while addressing issues of racial inequity and health disparities. He's published over 135 scientific papers in this area and has received numerous research grants, including from the NIMH and SAMHSA. A passionate teacher, Dr. Schiffman has also mentored dozens of junior investigators in this field, and many have gone on to establish their own independent research careers in early psychosis care. As yet another example of his dedication, Jason is right now in the midst of driving cross country, but he's pulled over in Albuquerque and set up a Zoom studio in a days in just to give this talk with us. Next slide, please. Dr. Schiffman reports no financial relationships with commercial interests and no conflicts of interest. He does share his personal disclosures. Dr. Schiffman, you now have the floor. Thank you, Susan. I really appreciate it and I'm humbled and honored to be introduced by you. I don't know if everyone knows this, but Susan is sort of an architect of the early intervention and prevention movement in the United States and really is fundamental in the direction in which our field is going. She has been a source of support and guidance for me personally, and I know dozens of my colleagues as well. So it really is an honor not just to be introduced by you, but to know you and to be able to benefit from your wisdom and your leadership. So thank you. Thank you for all you do. I do what I am in Albuquerque and I am so excited for this talk because I think that this work needs to go in a direction that encompasses more cultural responsibility. I want to start by acknowledging my own identity in my disclosures. This talk is going to cover an array of topics related to discrimination, oppression, and societally influenced racial and ethnic identities. I want to acknowledge my own identity as a white, upper middle class, able-bodied, highly educated cisgendered man who has gone through life with tremendous privilege. As much as I strive to be an advocate, there are sizable limits to my understanding, and I continue to grow and learn from the literature and specifically from my colleagues of color, colleagues broadly defined. This includes academic collaborators as well as consumers. Lastly, I want to acknowledge that I perceive race and ethnicity as social constructs that are used to consolidate power, and therefore when I describe scientifically established correlates of race, implied in that link is that social, not biological, factors are driving the relation. In other words, I believe it's society's influence or the experiences associated with marginalized identities, not something inherent to that individual that account for associations I'll be describing. I want to briefly acknowledge my team, all of whom make this work possible. In particular, Pamela Rakshan Rukotar has co-authored with me on this presentation. Learning objectives include identifying signs of psychosis risk symptoms through exposure to risk assessment tools, demonstrating awareness of psychosis risk screening and assessment strategies, and recognize how attention to culture and contextual factors inform these strategies. Describe an action plan that can be taken to change the status quo with respect to potential biases and health disparities in the field. And as an overview, I want to start by talking about psychosis and schizophrenia very briefly, and then dig deeper into health disparities in psychosis, dive into strategies for early identification, including an overview of how we define risk in this field, and then identifying those at risk, and then looking at different differences in risk identification and strategies across different races and ethnicities. Finally, I'm going to end with some steps we can take to address disparities. The talk, it provides information we know about early identification of psychosis, but I also attempt to articulate that there's a history of racism and oppression embedded in this field, as this field is embedded in a larger societal context with a history of racism and oppression. Before I dive in, I just want to say I'm one of many people doing this type of work, and I want to highlight a few recent articles I find particularly relevant. My slides, including resources that I have at the end of the slides, are freely available and can be found here. All right, impact of psychotic disorders. In some ways, it's hard to overstate, but approximately 1 to 3 percent of the general population develop a psychotic disorder lifetime, and this is a worldwide phenomenon, but there are aspects of the population who are more at risk than others. This translates, this 1 to 3 percent, translates to about a hundred thousand adolescents and young adults developing a first episode of psychosis every year, a work that was put forth by Dr. Asrin. And the impact, well, a few things I want to highlight here that first is a reduced life expectancy by 20 years, and I find this to be a particularly appalling statistic. Now, there are many drivers towards this reduction of life, but one is an increased risk of suicide, which is very relevant and important for the kind of work that I think should be done in this field. Psychotic disorders also impact independent functioning and quality of life, and they're not just unique or reserved for the identified client, but family functioning is impaired as well, with degrees of distress and burden being reported by family members. The disorder is economically taxing as well, and despite some of these negative implications, there's a growing recognition that recovery should be the expectation and not the exception, and that many individuals who experience psychosis can lead full and successful lives, and they report positive changes as a result of their experiences. When we're thinking about identifying psychosis and psychosis screening, I'm sure this will be a review for many people, but we think about positive symptoms, not called positive because they're good, but because they represent behavioral excesses. These include the hallmark symptoms of psychosis, including hallucinations and delusions, and negative symptoms, which I'll talk about in a moment, but the positive symptoms, delusions, or ideas or beliefs that are held on too tenaciously, despite evidence to the contrary. Some examples of some delusions include, I think people are talking about me. Someone is following me. People are talking about me to plot against me. Aliens are sending me messages through the TV. I picked these four examples because I think they represent experiences on a continuum from a growing level of severity, and I think thinking about psychosis symptoms on a continuum helps connect people, irrespective of their status with respect to psychosis, and if a person doesn't have psychosis but doesn't have an understanding of psychosis, thinking about symptoms or experiences on a continuum can help bridge gaps and lead to more inclusive and less stigmatizing communities. In addition to positive delusions, there's hallucinations, which are perceptions in the absence of sensation, and auditory hallucinations or hearing voices are oftentimes the most commonly reported, and for many folks, the most distressing as well. I alluded to negative symptoms, and these include things like blunted affect or a lack of emotional expression, and to be clear, the research suggests that many people with psychosis have vivid and non-blunted internal experiences of emotion, but the expression can be muted, and this is relevant clinically, I think, as we work with folks with psychosis. Elosio, another negative symptom, this is a poverty of speech, asociality or social withdrawal, anhedonia, the inability to enjoy things or events, experiences, and people, and abolition or lack of will or motivation. One of the major motivators for early identification and working with folks prior even to developing psychosis is a concept referred to as the duration of untreated psychosis. If you imagine this arrow is a progression of time, and here is when psychosis onset begins, and here's maybe when treatment is initiated, the duration of time between these two points is referred to as the duration of untreated psychosis, and in the United States, the U.P. is lasting on average about two years. Now, NIMH under Dr. Aslan's leadership is trying to reduce this, but for now, I find this to be another particularly appalling statistic and one that needs continued attention. A related phenomenon is the duration of untreated illness, and so here is the time between when the risk state begins and when treatment is initiated, or DUI, and we think that if we can reduce duration of untreated illness or work with people when they're in the risk syndrome, we might be able to forestall the eventual development of psychosis for some people, mitigate the impact of psychosis for those who do develop psychosis, and maybe in some cases, potentially prevent psychosis from ever happening. Longer duration of untreated psychosis is associated with just about anything negative that you can think about or imagine. Worse long-term outcomes, more intensive needs for services, more negative symptoms, social impairment, occupational impairment, neuropsych deficit, psychological distress, and a likely increased cost and burdens to the system. So, to me, this brings out sort of a common-sense notion that a pound of prevention, or is it an ounce of prevention is worth a pound of cure, and in order to have this early intervention, it requires the right strategies, community involvement, and the tools supporting early identification, and I'm going to talk a lot about the tools today for early identification. In particular, implementation also requires recognition of biases, awareness of cultural and contextual factors and considerations, and an understanding of the history that's created a systematically marginalizing mental health care system. And to kick us off in that direction, I want to emphasize that I believe that social and societal factors matter for mental health. They matter for mental health writ large. They matter for psychosis as well, and I think sometimes schizophrenia and psychosis get lumped into being primarily biological disorders, and, of course, biology plays a large role in the development of all mental health conditions and psychosis and schizophrenia in particular, but societal and social factors are meaningful and should be discussed. I'll start by saying that marginalized racial and ethnic minority status is a reliable risk factor for psychosis. There may be a lot of reasons for this. Some of them come from historical roots. So, for instance, dreptomania, this is a term that was used for runaway slave syndrome. This term is a reflection of a lack of insight, understanding, and empathy of the white community and not seeing how black slaves would want to leave what they themselves experience to be wonderful, safe, nurturing environments, that runaway slaves must be pathological to, in fact, run away. It's also one specific instance of a broader strategy, a strategy that's used to assert white power to lend an air of credibility or morality within the veneer of science or medicine. After the age of slavery, things continue to be unequal and marginalizing. So, for instance, in the mid-20th century, there were asylums that were separate for whites and blacks, separate but not equal. There was over-diagnosis in black asylums. Folks that were relegated to black asylums were often labeled as aggressive. They received inappropriate treatments. They had poorer nutrition than their white counterparts, less medical care. They were more likely at risk for sexual violence as well as exploitation. And this is just the tip of the iceberg that was going on at that time. This continued into the 60s and 70s. And just an example that I want to highlight here is that the term schizophrenic was basically hijacked here to marginalize civil rights activists and to minimize black civil rights voice. Today, well, there's both over and misdiagnosis, which I think is particularly relevant for treatment of individuals with psychotic disorders. The literature suggests that black people are more often diagnosed with schizophrenia than their white counterparts who are diagnosed with schizoaffective or affective disorder alternatives. This finding holds true even in vignette studies where the only difference in the vignette is the race of the hypothetical client. At the same time, we know the contextual factors such as poverty, stress, trauma, and discrimination lead to an increased risk for psychosis. So these factors have to be considered in diagnostic evaluation. Regardless of where the error lies, the current state of affairs leads to mismatch in treatment, stress associated with that mismatch, and a negative feedback loop on mental health and functioning. Immigration status is one of the most reliable risk factors for psychosis. And the risk for immigrants holds not just for first generation immigrants, but also second generation as well. In fact, the greatest risk for the development of psychosis in immigrants is in second generation for folks that also immigrated from developing countries where the majority of the population is black. Now, why? Although the mechanisms haven't been entirely established, the fact that the finding holds as strongly, if not stronger, for the second generation immigrants suggests that it's not something inherent to the immigration process itself. But rather, it's about living in a marginalized society where, among other countless issues, resources and access to care are scarce, and folks might be considered strangers or othered in their own country of birth. That being said, there has been some evidence for protective effects of immigrating to communities with people of similar cultures and ethnicities. We also know that some issues relevant, well, always, but certainly catching some current headlines, that there's increased risk for psychosis among people that have been victimized by police or police victimization. We also know in clinical folks that are at clinical high risk for psychosis, a concept that I'm going to define momentarily, that they are more likely to experience They are more likely to experience trauma, bullying, and discrimination relative to people not at clinical high risk for psychosis. And discrimination in particular is linked to a further conversion from risk for psychosis to the development of psychosis. Here I want to mention that even well-intended public policy can lead to inadvertent marginalization. So this is a piece that I co-authored with some colleagues and friends, Jordan DeBatter and Vijay Mittal, where we note that the good intentions of restricting cannabis, which is a known risk factor for psychosis, in an effort to reduce psychosis, given the established link between cannabis and psychosis, can backfire. We reflect on how this could be a short-sighted policy in that criminalization will lead to further incarceration, particularly among Black youth. So if there were any gains in reduction of psychosis by criminalizing cannabis, they'll be more than lost by systemic criminal targeting of Black youth. I'm going to just go through what it means to be at risk for psychosis in terms of the definitions in the field. I'll start by saying that the clinical risk state is distressing and impairing in and of itself. So sometimes I talk about risk for psychosis leading to conversion to psychosis, and I think that's relevant and important. But other times I think about being in the clinical high-risk state as distressing in and of itself and as a disorder that's unique. It's also commonly comorbid with other difficulties. It's associated with impaired social and occupational functioning, and in many cases, by definition, warrants treatment. I want to mention that with respect to treatment, there is some hope that if we work with folks early that are in the clinical high-risk phase of illness, we may be able to forestall, at least, and maybe prevent, in some cases, psychosis. Now, this is a clip from a meta-analysis we published several years ago now, where we looked at the conversion rates of people at risk for psychosis who were a part of some randomized control trial that emphasized cognitive behavior therapy to reduce conversion to psychosis. What we found is, in summarizing the literature, after one year, so I don't know that these findings hold after one year, but after one year, what we found was almost half as like folks that were randomized into the CBT for CHR across these different studies, they were half as likely to convert to psychosis than folks that were either randomized to some weightless control or treatment as usual. So, some glimmer of hope that we might be able to forestall or prevent psychosis. In order to do this, and to get better than just a 50% reduction, we need to circle back to this idea of accurate identification. When thinking about how to recognize folks at high risk for psychosis, there's many things that we can look for. So, here's some broad stroke warning signs. Feeling something's not quite right. Jumbled thoughts and confusion. Trouble speaking clearly. Unnecessary fear. Declining interest in people, activities, and self-care. Comments from others. And deterioration in functioning. Of course, all of these are very non-specific concerns. So, we drill down a little deeper. We have to think about specific questions that if someone said yes to those questions, we might follow up and probe more specifically about psychosis risk. The most prominently used tool in North America is the Structured Interview for Psychosis Risk Syndromes, oftentimes called or referred to as the SIPs. And the SIPs, it helps us identify people with attenuated positive symptoms. And also, it distinguishes between low and high risk, as well as the development of psychosis itself. It does so by focusing primarily on five positive symptoms. These symptoms mirror some of the symptoms associated with psychosis. Unusual thought content. Suspiciousness. Grandiosity. Perceptual abnormalities and hallucinations. As well as disorganized communication. Here's some questions directly from the SIPs, just to give you a sense of unusual thought content, or P1. Have you had the feeling that something odd is going on that you can't explain? Have you ever been confused at times whether something you experience is real or imaginary? Do you ever feel like your thoughts are being said out loud so that other people can hear them? Or do you ever feel the radio or TV is communicating directly to you? We give you a vignette, a brief synopsis here of a person where unusual thought content might be something that we would think about. Candace reports a new and very intense interest in new age philosophies over the past few months that's really consumed her. Since opening her mind to this way of thinking, she's noticed increasingly more coincidences in signs. She frequently sees her lucky number eight, and takes this to be a sign that she's on the right path, moving in the right direction. Oftentimes, she'll change her schedule and follow where the number eight seems to be taking her. She also reports that over the past six months when she's meditating, she'll sometimes sense a presence, which she thinks could be her spirit guide, although she wonders about this as the presence can feel dark. Although these things have been on her mind a lot, she told you she's just not sure what's happening and wondered if it all might be in her head. There's a lot going on here, and it's somewhat ambiguous, right? It's not clear that Candace would be at risk for psychosis. So this SIPS guides us towards thinking about some of what our experiences might be like. So we see here that interest in new age philosophies, coincidences and signs, being on the right path with the lucky number eight, and the sensing of a presence. Those are the experiences of unusual thought content. SIPS also wants us to consider whether the experiences are intense, distressing, and or inspire behavior change. So here we see very intense, really consumed her. She's changing her schedule and following the number eight, where it takes her. And the presence can feel dark, maybe an indication of some distress there. SIPS also wants us to think about novelty. Is this something that's new and deteriorating, or has this been longstanding? So here we see past few months, increasing past six months. The SIPS also, in this case, wants us to distinguish between risk for psychosis and full psychosis, and it relies heavily on doubt. So here she's saying, she's just not sure what's happening and wondered if it might all be in her head. The fact that she doubts it and is wondering that it might be in her head keeps this from crossing a threshold for psychosis and maintains it in the risk phase. Here's some questions about suspiciousness. Do you ever feel that people around you are thinking about you in a negative way? Have you ever found yourself feeling mistrustful or suspicious of other people? Do you ever feel that you have to pay close attention to what's going on around you in order to feel safe or feel singled out or watched? In this vignette, I have one about Michael. Michael often feels that strangers think negatively of him, and he's generally mistrustful. He describes being vigilant in public and worries about potential harm. He's not completely convinced, but he sometimes suspects that he's being targeted. He reports feeling like he's being watched, but he's not sure who would do this, why they would single him out. Although he says he's always been a little mistrustful, Michael noted that his feelings of being targeted have gotten worse over the past five months. And here you think, thinking negatively, distrustful, suspects that he's being targeted, feeling like he's been watched. Vigilant in public, worries about potential harm. This is his change of behavior and his distress. It's new, it's happened in the past five months. There's doubt here, not completely convinced, not sure who would do this or why. Keeping this in the risk range, if it's even risk. Which highlights what I wanna spend a good portion of the rest of the presentation talking about and thinking about, alternative explanations. Most folks who would say yes to those questions are not gonna be at risk for psychosis. And I think cultural and contextual factors might influence how a person responds. We need awareness. We need awareness within our field and beyond. And I'm gonna circle back to this theme as we push forward. I do wanna mention that the attenuated psychosis syndrome lines up with clinical high risk and the SIPs and it finds itself in DSM now. So it is a code at 298.8. It finds itself in sort of what used to be called not otherwise specified. If you're interested in more information about the SIPs, feel free to go to thesipstraining.com and you can reach out to either myself or Barbara Walsh, the world's leading SIPs expert and my SIPs mentor. Thinking about the SIPs, one of the things that's important to question is its accuracy. So how accurate is the SIPs? Well, about 25% of people that are deemed SIPs positive will convert to psychosis over the course of three years. Which is pretty good. Much better than the one to 3% we see in terms of just randomly picking somebody in the general population. And even better than the 12 to 14% that you would expect of risk for someone that has a parent or a first degree relative with schizophrenia. But there's still room for improvement. So we have to think, how can we improve prediction if our interest is in conversion to psychosis? Well, in order to do this, of course, we need the right tools and the SIPs is one of them. But the SIPs can be supplemented with other tools. In particular, risk screening tools. And this is something that me and my team have spent a lot of time thinking about and trying to bring forth to become nice compliments to the SIPs to increase accuracy and to get better at early identification. Screening for early psychosis can help find people not currently in services. Like, for instance, integrating them into schools. They can increase the efficiency and accuracy of assessments. That's one of the emphases of our team. Trying to get better tools to help the SIPs be more accurate. We can also monitor folks, though. And so in our clinic, our clinical high-risk clinic, we administer one of the screening tools which I'm gonna be sharing, telling you more about in a moment, to all of our clients weekly to monitor their clinical high-risk symptoms. And I also wanna mention that I believe there's a reasonable amount of evidence to suggest that just the act of assessment is healing and part of treatment itself. Clinical interviews, such as the SIPs, are the gold standard. So they include participants' input and give you the most rich sources of information, depth of information. But they're lengthy. They take a lot of time and they require a lot of training. So SIPs trainings, for instance, are two-day-long events. Nonetheless, they are comprehensive and, as I mentioned, gold standard. Self-report measures, on the other hand, they have the advantage of being very brief. And as I'll try to share in a moment, have pretty good validity. But they're unable to take culture and context into account. And there's more work that needs to be done to make sure that they work as intended across different settings and populations. Good first-line assessment. I'm gonna talk more about some of the work that needs to be done for self-report screenings. This is the SIPs book. All right, so if you're interested in the SIPs, this is a good resource. And this is a segue for a series of studies that I wanna talk about that look at the validity of the screening tools, in some cases, in relation to the gold standard SIPs. In this first study that I wanna mention, this is about convergent and discriminant validity. And this was spearheaded by, at the time, my student, Emily Klein, and now my friend and colleague, who, what Emily was interested in this study in doing was to see if the measures of risk screening that are self-report, brief measures of screening for, of risk for psychosis, if they converge with one another, and if they're different than other tools. And so what we did was we took the four most prominent risk screening tools and gave them to a lot of different people. And then we also gave those same people instruments or tools that measured other constructs like anxiety, depression, and even one about their preference towards exercise, which we hypothesized wouldn't be all that correlated. And what we found, and it might be hard to read on some of the slides, but I'll just briefly share that as anticipated, the screening tools of psychosis risk seem to correlate strongly with one another, and they correlated less so with other tools that were of constructs that were slightly less related to psychosis risk. So CHR screening tools correlated strongly with each other. They also correlated significantly with anxiety and depression, for instance, but less strongly than they did with one another. And they didn't significantly correlate at all with, for instance, preference for exercise. And this gave us some notion that these tools might have good convergent and discriminant validity. So a first step in our journey about validating these tools. In another study that was, I think Emily was also the primary author on this one, what we did here was simply look at the concordance between the self-report tools and the SIPs interviews. So we gave the self-report measures to our clients, and then we followed up with the gold standard SIPs interviews. And what we found was good accuracy between 69 and 80% accuracy of the screening tools and the SIPs interview. And we didn't notice any specific screening tool being better than any other, at least not significantly so, but they were all strong, giving us some indication of criterion validity. And Emily again took the initiative to write a review. And looking at this literature, we found that it was consistent with some of our own findings with good criterion validity. And we also found that measures such as the PQB, Podromal Questionnaire Brief, that incorporates distress was more accurate than without distress. So what's behind that notion is this idea that it's not just an experience that indicates risk for psychosis, but rather an experience that's problematic or becomes a symptom. In some of our work, we were in some of our community partnerships, we were trying to encourage our community to administer some of these screening tools. Now, we use the Prime Screen, which was created by the Prime Clinic at Yale, and we've added a distress scale with their permission. And this is a 12-item, we like this measure because it's only 12 items, pretty quick. But some of our partners were saying, you know, Jason, we like the screening tool and we believe in this, but 12 items is really just too long. Is there anything that you can do to make it briefer? So in partnership with a recent intern who's now a postdoc at the University of Maryland and also a friend, Peter Phelan, we took a large sample of people that had filled out our self-report questionnaires and subjected their responses to item response theory. We found two items that seemed to work very well as like a pre-screen for psychosis risk. And so this is, I believe that these items are worth thinking about. And maybe, you know, if there's anything you get from this presentation, this might be one thing that I think is useful clinically. These two items, do you ever hear the voice of someone talking that other people cannot hear? And have you ever felt that someone was playing with your mind? So these are good questions to begin a conversation. If someone says yes to one of these questions, then I would recommend following up with another screener. And if they say yes to some of the items on that screening, then I would say maybe good to consider a SIPS evaluation. There's all sorts of different considerations that need to be taken into account when thinking about implementation of screening tools. And one of them that I wanna highlight is the population of interest. Because those two questions and the 12 questions that we look at, they may not work the same way for all groups of people and for all individuals. And I wanna emphasize that with my remaining time. Think about validity in context. If you think about this as like a pathway from symptoms of psychosis risk, it should be a clean path to an accurate diagnosis or an accurate label. But there's all sorts of other factors that kind of confuse this, what we would optimally want to be an error-free process. Like race, community, development, culture, and biases of the interviewer. We can think about these things as statistical confounds that create error in this link. However, I think if we apply a sensitive approach to assessment and we are aware of cultural and contextual and individual factors, we can begin to reduce some of that error and get more accurate labels and diagnoses. I'm gonna describe a series of studies, four really, pioneered by my students and who have gone on into awesome careers. All of them, all of these studies share overlapping sample. They were conducted in Baltimore. Help-seeking young adults and adolescents. It was a highly diverse sample. The first study, which was led by Zach Millman, who recently graduated, his research question was, are screening tools valid across culture, race, and ethnicity? And in particular, the specific question for this was, does the prime screen, our primary screening tool that we use in our clinic, does it perform equally well for black and white participants? And to cut to the chase, the answer here was no. Now, statistically speaking, the prime screen did, of course, predict overall to SIPS status. But if we look here at the simple effects, what we see is when predicting the prime screen to the gold standard SIPS evaluation, clinician-driven evaluation, the prime screen does not significantly predict SIPS status among our black participants. It does, however, seem to work for our white participants. So what might this mean? Well, the prime screen, at least in our sample, doesn't adequately assess black youth. Potentially, it lacks required context. It's just questions without us knowing why they're saying yes to these questions. And this leads us to suggest that screening alone, it may over-pathologize. So we have to be mindful and careful of that. Black youth, however, I wanna emphasize, should not be considered monolithically. It was the case that for some of our youth participants who were black, the prime screen worked just fine. Just like for some of our white participants, the prime screen didn't work well at all. So the individual has to be considered in all of these things. But this gives us some thoughts to think about. The next study was actually not about the prime screen at all, but just about the SIPS. And I mentioned the SIPS questions for suspiciousness, which led us to wonder, what does neighborhood crime impact responses to the SIPS? So as a reminder, those P2 suspiciousness from the SIPS, have you ever found yourself feeling mistrustful or suspicious of other people? Do you ever feel that you have to pay close attention to what's going on around you in order to feel safe? Do you ever feel like you're being singled out or watched? Again, people are gonna say yes to these questions for all sorts of things. And one of them might be because of the nature of their neighborhood. So in partnership with the Baltimore Neighborhood Alliance, we created a Neighborhood Crime Index. And this was under the leadership of Camille Wilson, who is now a professor in Ohio. And what she found from this study was that our crime index correlated significantly with P2 suspiciousness. And it was an independent effect from the other attenuated psychosis symptoms. So if you're predicting, well, in our sample, predicting suspiciousness, controlling for the other P symptoms of psychosis risk, while controlling for neighborhood crime, neighborhood crime continued to be a significant predictor. What might this tell us? Well, neighborhood has an effect beyond just psychosis. And we have to think about the importance of context in individual symptom reports. So what's surrounding our participants, our clients? This makes me think about the concept of healthy contextual mistrust versus psychopathology. Now, sometimes people refer to this as healthy cultural mistrust, but I actually, I don't know. I don't know that it's culture is the right word for this because to me, it's nobody's culture in particular to be suspicious or mistrustful. Rather, it's when a dominant culture is oppressive or marginalizing or treats people in ways in which they will react with suspicion. That is a healthy contextual mistrust, but not psychopathology. Now, I wanna emphasize for this study, it's important to note that the stress of being in a high crime neighborhood could also increase someone's risk for psychosis. We're unable, at least at this phase in our research, to be able to tease those things apart, but clinically, we wanna be on the lookout for all sorts of different factors. But I will just say that being in a high crime neighborhood seems to, as one might imagine, increase a person's likelihood to endure some of the suspiciousness items on the SIPs, and we need, as mental health clinicians, to be sensitive to that possibility. Third study. Actually, the third and fourth study are related, and these are led by my, well, my current intern, a senior graduate student and soon to be research professor at UMBC, Pamela Rakshan Rukhatar, and the research question here was really about the psychometrics of the prime screen, in particular, the factor structure, and the different items, and whether or not different items make a difference. And what she did was first, well, submit the prime screen to factor analysis, and she found two factors. Now, I think the two factors are somewhat interesting. The first one seems to be more in keeping with what people might think with respect to psychosis risk, odd or unusual things going on, my own thoughts being said out loud, feeling like I'm going crazy. The second factor maybe has some different connotations, predicting the future, superstitions, gifts and talents, a different flavor or flair to that. What Pamela did cleverly was correlate the sums of both of those scales independently with some important outcomes, such as global and social functioning. And what she found was factor one, the factor that was typified by going crazy, feeling like I was going crazy, that was correlated with worse global functioning and worse social functioning. Factor two, the one with superstitions. As a surprise to us, that was actually correlated in a positive direction with social functioning. In other words, the higher you were on factor two, maybe thinking you had some gifts and talents and superstitions, the better you were in your social functioning, the higher your social functioning was. And that study is related to this fourth study about the item level that Pamela here in this study looked at the mental well-being or correlated mental well-being with a measure that we used for both black and white participants with the prime screen items. And just briefly, what we found here was that some items showed significant correlations with well-being for white participants alone, and most of them didn't work for the black participants. There wasn't a relation between a lot of the SIPs, excuse me, the prime screen items and well-being. There was one item that worked for both groups pretty well, and that was the last item, feeling like one is going crazy. So that was significantly correlated with worse mental well-being for both participants. Now, summarizing all of this, I wanna just emphasize that, well, we found two factors. One may be about attenuated psychosis, and one we're not sure. Maybe it's not something so bad, depending on the culture and the context. Not all questions, though, as the take-home message from this line of work, indicate psychopathology. Particularly questions, particularly questionable for black participants, I wonder if people may be planning to hurt me, or even may be about to hurt me. And this harkens back to the study about the SIPs and the poor neighborhoods, excuse me, the neighborhoods with a lot of crime, not poor neighborhoods. The most predictive item, I have been concerned that I might be going crazy, and that seemed to work for most folks. So some take-home messages with all of this. I believe we need an understanding of the integration of culture and context. We can't just have blanket statements and blanket tools for all of our clients and participants. We need tools that avoid systemic biases and disparities. And we need to be mindful of race, neighborhood, things like development, which I didn't mention today, culture, trauma, the informant, and distress, as I mentioned. And there are risk calculators that are out there that are used to identify people at risk for psychosis. And I'd like to suggest that we think strongly about adding some of these contextual factors to those risk calculators. I wanna end by sharing 10 domains of action to challenge the status quo. These are the ideas that I think could be useful for our field. And the first is to think about cultural competence through examining our mindset. And is cultural competence enough? This is a definition of cultural competence, a set of attitudes, skills, behaviors, and policies enabling individuals and organizations to establish effective interpersonal working relationships that supersede cultural differences. I think this is a good start. And obviously a lot of work is built from this. But it seems to me that there's directions that we should be following that bring this to other levels, like intercultural competence, which could help us think about different intersecting identities. And culturally responsiveness, where we're thinking about things in responsive, active ways. Another term or concept that my good friend and colleague Melissa Smith has introduced and championed to me is cultural humility. And this one speaks very loudly to me. Committing to an ongoing relationship with patients, communities, and colleagues that requires humility as individuals continually engage in self-reflection and self-critique. So when we're examining our mindset to overcome, I just want to throw out a particular, a book that I think is really useful. It thinks about equity and systems. And I recommend it highly, How to Be an Antiracist by Ibram Kendi. But there's more out there. But intentions don't matter. We need to do more to think. We need to think about systems. All right, so the second point that I have about systemic racism, we need to locate the problem. Again, this one requires a mindset and an action to overcome. Talked about cultural competence. There's also cultural incompetence. And it turns out that many people who are the worst offenders in terms of lack of cultural competence, think that they're great. Think that they're the best. So people, they report being very culturally competent, but studies find otherwise. People are not necessarily, quote, practicing what they preach. And experience is necessary, but not sufficient. I think here, oops, we have to recognize that we have to address racism, subtle or overt, in a way that might be uncomfortable for some of our privileged colleagues or ourselves. We might need to make a choice between the feelings of our colleagues and perpetuating systemic marginalization. Sometimes we need to put people on the spot if they, quote, unquote, microaggress or sometimes are racist in their behaviors or are negligent in their journey towards cultural responsiveness. I think we should challenge existing professional cultures that condone silence. All right, leadership. All right, allow for systemic change in training. The field of early psychosis is very homogenous and we need to change that. Under the leadership of Vijay Mittal, one of the societies that I'm part of, Society for Research in Psychopathology, is trying to address this actively. So there's examples out there where we're increasing access and we're borrowing from other societies. So folks are mindful in this endeavor. Networking, mentorship. Some of my colleagues at the Maryland Psychiatric Research Center are working with me with the Meyerhoff Program at University of Maryland, Baltimore County to create mentorship opportunities for undergraduates to get research experience who are from traditionally underrepresented backgrounds in mental health fields. So there's good examples of work going on that can challenge this part of the status quo. All right, I say that I fully believe that we can all grow, that we need to educate ourselves. Reading books, trainings, movies, YouTubes, going beyond the headlines in current events and sticking with those stories even when they drop off the front page. These are things that we need to continue to be mindful of. Learning about microaggressions and how to respond is also important. And we have to understand that the systems have formed our profession. It's not necessarily about individuals but individuals within a system and a system that pushes us in different directions. Sometimes without us, many times without us even knowing, in my belief. Broken trust. All right, so many folks from marginalized communities, they're suspicious of mental health professionals. And I think that the best thing that we can do here is just allow the time to build that trust or rebuild that trust in some cases. This is a picture that I found online. It says, trust takes years to build, seconds to break. And it said forever to repair but I tried to cross out forever and I said time, time to repair. And that can be just as the beginnings of that step could be your first introduction to a client or a participant. And you spend a little extra time even if you can't bill for it or your time may run late. It's commitment to that part of the relationship that I think is required for us to move forward. I also think that working with your clients is important and I mean that in the most broad way where there's no hierarchy. Our clients are the best experts on themselves. Co-produce and participatory action research. And then I also think just being positive and showing that you care, that makes a difference. I think there's literature to support that as well. All right, next one, stereotypes and monoliths. So groups, they're made of individuals and this hearkens to this notion of intersectionality. So awareness of all sorts of intersecting identities including race and ethnicity but beyond. And also early psychosis and CHR. So if your client is at risk for psychosis that their mental health status is gonna be a part of their identity that intersects with other aspects of their identity. Number seven, more than just biology. Okay, I've mentioned this and tried to emphasize this towards the beginning of the talk but social and contextual factors, they matter. So I think that assessment training and retraining where folks are emphasizing the importance of contextual factors with respect to predicting and identifying people at risk for psychosis or an early psychosis, these matter. We need to understand that there's socially mediated stress that is a dynamic factor that leads to more risk for psychosis. Training and trauma is gonna be important and there's compelling statistics that suggest that over 85% of people at clinical high risk for psychosis have been exposed to at least one traumatic event and the more trauma that they experience the more likely they are to later develop psychosis. I've alluded to neighborhoods in this talk. We've talked about immigration and immigration status, discrimination and we have to think about the item level as well in some of those screening tools as well as the SIPs itself. As an example in partnership with Melissa Smith who I mentioned earlier, we, and actually this is a part of an R34 that Dr. Asrin supported and helped us with and is the program officer on. But we created a three hour long continuing education platform. It was primarily targeted towards social workers but anyone can take it and it is now available for free online at that web link below. In this study we reached over 1,400 social workers. This was done in conjunction with Melissa, also Dr. Bob Buchanan and Dr. Jordan Devalder, partners in this study. Jordan Devalder, partners in this. And we really tried to emphasize the importance of understanding contextual and cultural factors in identification of risk for psychosis. Much of what we have is broken. So sometimes we need to think about tearing stuff down, reimagining and maybe building better. It is the case that most of the work in this field is done on white people. And if it's not done on white people it's often done in relation to white people. We should think about that and expand. More research on the creation of racially unbiased and culturally sensitive psychosis risk assessment tools is required. And I feel like the work that I've presented here today is lacking and I need to do more with my team to push this field further. And I say here sustained longitudinal approach. And I don't just mean longitudinal research. I mean like within the study design. I mean that we as a community need to be committed to these things for the long haul. Over pathologizing and it's balanced with accurate identification. It's important to ensure a shared understanding of meaning. I sometimes find that I'll ask a question or my participant or client will fill something out on the self-report. And then it's not that they answered it wrong or incorrectly, it's just that they're answering it from a different perspective where we're not sharing the same sentiment or the same meaning for that particular question. So we need to ensure that some of that comes from talking, some of it comes from more clarity in the language we use for our questioning. Irrespective, the incorporation of culturally responsive explanatory models of psychosis risk and mental health concerns have to be family and client driven. There are some tools that we can use that have been shown to be effective in this population in particular. And this is about the DSM-5 Cultural Formulation Interview. It's a systematic process for resolving normative or diagnostic uncertainty with regard to psychosis. I should say that at the same time that we're being culturally sensitive, we can't let discomfort or lack of knowledge stop us from seeing and identifying a need. So we have to guard against the pendulum swinging too far, I think is what I'm trying to say here, with the conclusion that anyone with it from a different culture than me is free of mental health concerns. So for instance, there can be situations where a person draws on cultural content, but the level of their experience is still pathological relative to others in their culture. Regardless, this tool, the CFI, is really helpful and it's been shown to be effective in some minority groups, not necessarily, in some minority groups, in re-diagnosis. So in this one study, 49% of 70 participants were diagnosed with psychosis, were re-diagnosed after this tool was implemented. It's flexible, yet structured, and it makes it easier to probe topics that might be uncomfortable for some clinicians. Last point, number 10. Treatments designed for by white people, yet they can be adapted or created for other groups, but we might need to recreate as well. So the adaptation of existing or the creation of new intervention strategies that incorporates cultural values and are responsive to race, ethnicity, and identity. And also address some of the systemic mistrust that's endemic to our field. There's some good examples of treatment strategies on this slide as well that I think are worth checking out. I just like to think that there's so much stuff that I don't know, and I don't even know that I don't know it. And it's humbling, but it makes me optimistic about the future and what we can do and recreate or create de novo that could be really effective for folks. And I don't have all the answers. I have a lot more questions than I have answers, but I know that this stuff is important and that the federal government feels that way as well. These are just a couple of funding announcements, and there's a strong investment at the federal level to identify folks at risk for psychosis and to prevent psychosis from ever emerging, which I'm very excited about. And a lot of that is under the leadership of Dr. Asrin and also Dr. Bob Heinzen, a personal hero and mentor for me. And our own work, and some of this was inspired by Susan and Bob and Dr. Gary Blau, where we were funded for a SAMHSA-funded clinical high-risk treatments clinic. And we allowed our treatment model to be driven by a model that I created with my colleagues and was first authored by Elizabeth Thompson, who was a student then, now a friend and colleague at Brown. And it's modular treatments for those at risk for psychosis. I won't talk too much. Actually, I won't talk much about it at all, but I will say that at the heart of our modular treatment, and it's still growing and emerging and evolving, but at the heart is Bronfenbrenner's model of understanding people as only one part of an entire context that surrounds them. We've shared some of our work with our sister, who I like to consider my sister CHIRP program in Tennessee, and my picture is down, my team, some of my team is down here on the bottom right. And if you're interested in more about the clinical high-risk intervention projects, pilot projects, they can be found here. And I would just like to end by thanking my team, Pamela, as well as ending with this quote from Brandon Staglin, who is, I think, an inspirational person in my life. He said, enthusiasm and hope make the difference. Thank you very much for your time, and I think we have some time for questions. And if you're interested in my slides, I have lots of different resources here. Bravo, Jason. Thank you so much for your wonderfully provocative presentation and your call to action. That was a tour de force. So we have received many, many, many questions, so we'll jump right into them. The first one is multiple requests for that link to access your slides, which we put up early on. If you could put that up again, people would be most appreciative. So there's a question, how can I learn more about this clinical high-risk or CHR concept? All right, so a couple of great resources for the CHR concept. One would be the book that I showed. So I'm going to, when I send my slides, that, I can't actually remember the name of the book, but probably, like, if you just type in Google, I assume you're on Amazon, Clinical High-Risk for Psychosis, you should be able to find it there. But that would be one place to start. There is the, another place to start would be the SIPS website. It says, I think it's theSIPSTraining.com or something like that. Oh, I'm going to put this link for my slides in the chat box. All right, and then you can sign up for trainings and learn more about the clinical high-risk stage of illness. And then, let's see, it's, yeah, theSIPSTraining.com. I'm going to put that in there, too. Great, thank you for doing that. Yeah, of course. There's a question about how the processes of systemic marginalization play out in sexual and gender minority populations in the context of psychosis risk and identification. You know, this is a good question. And I believe that there's literature to suggest that folks who are marginalized for all sorts of different reasons, including being a part of the LGBTQ community are at greater risk for mental health concerns in general and also psychosis risk. And I would imagine, although there are some certainly unique differences, and I focus mostly on African-Americans or black people in the research and the work that I talked about, but some of the concepts, the higher-order concepts of marginalization and using isms to influence and oppress, to consolidate power from majority groups, you know, exacts its toll on all sorts of different folks that share different identities and intersectionality as well. So I can't think of, like, a meta-analysis or a view off the top of my head that I could refer you to, but I know that that literature is emerging and is likely out there, and that even if it's not, it's something that we as clinicians and researchers need to be mindful of. Excuse me. You... Let me just say we had a phenomenal response. So many questions here. Would you have a way people might be able to get in touch with you if their question does not get answered in our session? Yeah, so my email. You want me to put my email? Whenever you're comfortable doing. All right, so... And while you're doing that, can I ask you a multitask? I can lob another question at you that we've received. Let me just say, I probably won't be able to email you back right away because I am literally traveling across the country. I told you. But I will try, and sometimes I get buried behind email. So if you don't hear from me within, but you want to hear from me within 24 hours, email me again, but don't email me right now, unless you want to, but then email me again, and then I'll get back to you. But I don't mind multiple emails, so thank you. All right, sorry, go ahead. Okay, you said that the act of assessment is healing and treatment in itself. So can you say more about that, how assessment is therapeutic? Yeah, that's actually, I don't... I mean, that was something that I learned in grad school, and I actually don't have the references for that off the top of my head, but I know that, I believe fully that the act of assessment and evaluation is not just useful for the clinician and the client to maintain priorities and a shared understanding of what their goals are ongoing, but self-examination and self-reflection that comes with monitoring is part of the therapeutic process as well. Now, there may be evidence that refutes what I'm saying, but I think that there's compelling evidence to suggest that what I'm saying is true. So related to alternative explanations for experiences, there's a question, how does one kind of sift through early signs of psychosis versus particular religious experiences or beliefs somebody is having? I mean, that's a fantastic question because it gets at the root of what I'm encouraging in this, right? So, I mean, one tangible strategy that I can recommend is that cultural formulation interview that you can just, I think if you just type it in Google, you can get that. And it helps you sort of tease apart some of these things. I do think it's worth mentioning that sometimes, like people within a particular culture can also have psychopathology. So just being in a culture that's different than the interviewer doesn't mean that person doesn't have some things that they're challenged by or struggling with. But to your point, to get to the heart of that question, I think it requires awareness of our own biases, sensitivity to the context that surrounds our clients, and not just thinking about them as like sort of a locus of a problem, but all that kind of, you know, that makes them who they are, that influences them, the social aspects of their existence. These are the things that we need to be mindful of. And we need to have conversations with them. And we need to take time. We need to dedicate the time that's required to have a shared understanding of what's important to them. And if we follow their lead, I think that's how we can parse some of these things out. One other thing I'll say, that it's very important to think about distress and interference in these things. So, you know, an experience that's not distressing or interfering should just be considered just that. You know, it reminds me of my, I started my career at the University of Hawaii, and I learned so much from my clients and their family members there. One woman, the mom of a client that I owe a lot to, she was talking about the difference between psychopathology and hearing voices in sort of native Hawaiian culture, and it was versus hearing spirits and guides. And she gave me two tips. She said, you know, if the child is the only person that can hear it, then that's one thing that you wanna be mindful of. And then if it's negative or, you know, like gory in its nature, like death or, you know, bloody or whatever, then that's another sign that it's not just a culturally sort of typical experience. And she gave me some books and I read those books and I learned in my continual journey to be more responsive. Great. Well, we're out of time. We're gonna try to squeeze in one last question here. So it sounds like living in a high crime neighborhood is gonna increase someone's likelihood of endorsing suspiciousness questions on the screeners like the SIP. But does the research say anything about the stress of living in a dangerous high crime neighborhood actually increasing one's risk of developing psychosis? Yeah, I mean, that's such a critical nuance of this. So I believe that there, I mean, the immigration literature in particular, although it's different, it's not crime necessarily. I believe actually the driving mechanism in the immigration literature is being marginalized by the dominant culture. But I think the next step for the field is to be able to parse out some of those, you know, whether like being in that neighborhood, you know, what does that mean for that particular client? And, you know, we're trying to tease some of that apart. But for the time being, we have to hold both possibilities, both hypotheses in our hands at the same time, that it's, people are gonna say yes to these questions because of non-psychosis related experiences. And these experiences can lead to further risk for psychosis. It's sort of a both, sort of a two strike kind of, you know, thing. So great question, really at the heart of what we really need to think about for this line, that particular line of work. Well, I'd like to say thank you to our audience for all those excellent questions. And thank you, Dr. Shiffman, for such a thoughtful and timely presentation. We all wish you well as you continue your journey across the country. And folks, if you are claiming continuing education credits for psychology or social work, please be sure to complete the evaluation at the end of this session. And if you're claiming education, continuing medical education for physicians or a certificate of participation, you will be able to do so at the end of the entire conference. And thank you all for joining us and take care. Thank you.

Dr. Jason Schiffman

risk for psychosis

cultural competence

systemic racism

marginalization

racial and ethnic minority status

historical racism

oppression

psychosis risk symptoms

Structured Interview for Psychosis Risk Syndromes (SIPS)

cultural responsiveness