2019 Public Health Ethics Forum: Ethical Dilemmas in Child and Adolescent Health – Part 4 of 6

good afternoon everyone we're gonna get started for the concurrent session on facing substance use and mental health challenges with facts and moral courage we have two presenters for today miss Rosalyn holiday Moore who's the senior public health analyst in the Office of behavioral health equity substance abuse and mental health services administration and joining us at the table is dr. Marsha Gregg Riggs who was at the Jr's kind love professor of Christian ethics at the Columbia Theological Seminary they will both be presenting I'm Julio descent I'll appear in the office of minority health and health equity and I'll be keeping time as well as taking some minimal notes and then helping with facilitation facilitating the discussion after the presentations so we'll start with Miss Moore take it away thank you all for joining I'm looking forward to the conversation that we've planned I think it will be a little bit easier if we can be tighter but I don't like to ask people to move if you're settled in at the moment no I know I get and it's it's really a privilege to be able to engage as many people in a distance as we are with this afternoon's conversation so I know it's not just limited to those in the Roman glad about that so my my focus will be on substance use and mental health issues but I I'm going to start the conversation with a question that I'd like everyone to focus on for a moment and it's looking at the what if what if behavioral health equity was the starting point for decision making an innovation sometimes we get to the place of equity at the end but if we flip the switch and we have that as the driver of how we think I want to use that question in framing the way you look at the next set of slides that will give you a snapshot a snapshot of how we are understanding binge and heavy alcohol use among people aged 12 and older and as we look at the slide I'd like you to just pay attention to the tan bar for a moment but it's showing you a focus on binge drinking that creates a different vulnerability than regular alcohol misuse and I also want you to look at the age range starting at 12 so imagine if you would someone you know in that age category who might be vulnerable to binge drinking and at the same time still with that question around behavioral health equity in your mind thinking about the use of illicit drugs and as we look at the bars here we also see an alarming number of young people engaging in the use of illicit drugs and the tan bar showing a larger number of those 18 to 25 and so those in our virtual space as well as those in the room to to focus on this morning's panel to think about the brilliance that we heard and the age in which young people are more vulnerable to alcohol and substance misuse and as we know our national narrative on opioid misuse is rampant and growing again looking at the prevalence were those 12 to 17 as well as 18 to 25 and at this place the data not only shows illicit drug use ages 12 to 17 but it highlights something different those with major depressive episodes within a year and as you look at that and listening to this morning's discussion it underscores the need for better understanding how we can move in front of conditions that are rooted in mental health and substance use issues unaddressed mental health needs very often create pathways to alcohol misuse and illicit drug misuse that's what this slide is pointing to and earlier today I talked about with a group that was before this that these data slides very often are not the points that people want to focus on they're not interesting they're not trendy they're not colorful they're informative and they're important but this is too often what we see social media mainstream media our public leaders speaking to both the crises the needs but also solution but if you're in the average public domain it all starts to sound the see so for 17 seconds I'm using 17 intentionally I want you as an individual and for those in the virtual space you have the opportunity to share with us using the the chat feature or Twitter some of what you are seeing here and through the previous slides as most significant what is standing out for you that may not have been in the forefront of your mind at the beginning of this conversation and so there will be 17 minutes of science seconds thank you seconds you you thank you for taking time to reflect and while we're not going to take moments at this point to ask you what bubbled up I am going to ask you to save that thought because I want you to put it in a place of moving forward now thinking how what significant can be better aligned with what's actionable what are we doing how are we thinking about the cultural frames in which people are experiencing some of these conditions what are the cultural frames that are underpinning the occurrences that are reflected in the data and how do we understand culture as a pivotal point one of the pillars of how we move forward how do we think about culture as a strength and not always as a second thought as an aside what are the drivers here that allow us to break through points of isolation that help us identify new people to work with strategies for building awareness new ways of thinking about expression sometimes it's leveraging the way it used to be said sometimes it's the new way of doing it but culture is very often the driver that sets the stage for how we create partnerships and how we frame partnering so I decided that today would be a good opportunity for us to think about not just the partners but also the partner ring how do we take action how do we create those steps on the on the bridge that was mentioned in the opening remarks and so I've identified three different resources here that are all in the public domain but all reflecting new ways of partnering with different industries with federal agencies and with ways in which the voices of young people are rising to the top in addition to that you see through these se it's a way in which we combine health education material with interactive options so that there are live chats and so when we think about the infusion of social media in our everyday experiences is there a new way of thinking about the way we communicate with each other and that that communication can also be brought to the forefront of how we can think about prevention and in the effectiveness of prevention so from my home base the substance abuse and mental health services administration we also manage a network that I'd like to invite everyone to join it's a network established for communities who are prioritizing and focused upon the support of diverse populations and addressing mental health and substance use needs so here we have the national network to eliminate disparities in behavioral health we affectionately call it the NED but it's a way in which you in your community enjoy other partners around the nation and thinking forward about strategies some of them are emerging you directly from communities some of them are developed and designed implemented by young people others reflect partnerships that are new and innovative but all of them all of them are being focused on promoting health and equity across every community and we start with seeds there's a repository of best practices that we invite you to submit ideas around and today I heard a number of them that would be more than eligible to fit into this space it's also a way that you can connect with other partners in different parts of either your state or across States that may have similar challenges but you're looking for solutions and so here we have a way that not only can you provide a voice but you can hear what other people are sharing and while we have a number of resources I brought some to share with everyone here so on the back of the room there's a table with resources I encourage you to to take and to definitely use once you return home but I want to focus attention on the last resource that's on this slide which is national Prevention Week it's May 12th through the 18th of this year and you'll see here we are asking everyone to take action for prevention and so there's a wristband and the wristband has a number of tools and resources that you can use when you go home but also a brochure that can help guide some of the actions that you might want to initiate and for those of you who are in the virtual space these resources are available on SAMHSA's website they are downloadable and aside from the wristband but you can order them and everyone in your community can have access to these tools the idea here is that we are creating champions creating champions where they already exist and where they don't exist to establish new platforms for those voices to be heard and so with this I am asking everyone here not only to reflect but to move forward that we have a chance to think about equity versus equality that we have a chance to take action to promote equity and that as partners this will be our time to make the difference that everyone knows to be most important thank you very much and now we'll follow with dr. Riggs since the presenter this morning did such an excellent job of talking about ethics and ethical theory I decided I would shift my presentation a little because what I want to do is talk to you about what emphasis do and we have three tasks that we normally do one is descriptive one is analytical and the other is normative but what I think is most important is the way in which we describe the context in which we live in order to think about you know the the challenges of doing public health around substance abuse and mental health and one of the ways to describe our context is that there is the omnipresence of violence and so I want you to look at the diagram and take this as a visual representative of the way I want you to think about how the context looks so if you think about the context is one in which there's an omnipresence of violence and by that I don't simply mean episodic events of violence but that we live in a context in which harm is often done in a variety of ways to different groups of people and that is where I can begin to talk about describing the dynamics of the context of seeking to address substance abuse and mental health challenges if we think about for example the omnipresence of violence around drug and alcohol abuse in terms of the way that the media and pop culture for example represent that behavior as somewhat acceptable or even romanticize it such that youth and young adults may think that it's a way to be grown-up to engage in such behavior or if adolescents and youth live in communities where life is hard economically for example some adults they know may engage in substance abuse and alcohol abuse as means to survive to escape the harshness of the context in which they live so at that point adolescents and youth are kind of caught in a kind of tension between seeing behavior that has been told to them by some people is destructive but representative in the culture as acceptable or finding that the only way some of the adults in their lives can make it in there harsh context is to engage in substance and alcohol abuse likewise mental health disorders are constantly today used to explain or even demonize individuals who commit acts of mass violence well if that's the case why wouldn't an adolescent think wow I don't want to admit that I have a mental health issue because I might get demonized or in some of their racial ethnic communities and religious communities they hear that mental health disorders are not signs of illness that are treatable but instead they are described as perhaps lacking in character or faith so once again you have adolescents caught inattention between real physical mental and psychic distress that may result in substance abuse and or coincide with mental health struggles and they find themselves without parents or other adults with whom they can speak about the struggle so when we live in this context of the omnipresence of violence it becomes important to think about what are the tensions that drive us when we begin to think about making ethical choices are practicing our professions even in ethical ways well one of the way I do that is to ask people to think about living into tensions and living in to tensions means that you recognize that the context is filled with the omnipresence of violence but it's also a context where there's the omnipresence of justice and so in micro and micro context we're all living out our lives struggling between what are the values of a culture of deception and what are the values of a culture of moral courage and how do we live neither in neither one totally because we can't but how do we live in that overlap and begin constructing ethical ways of being and practicing that will allow us to find creative constructive ways to engage these issues so one of the ways that I would want you to think about it from a public health effects perspective is to think about you know perhaps there are principles that guide the way public health ethics operates and some of those might be non-maleficence or a principle about doing no harm beneficence a principle about how do we do good for individuals and collective good our health maximization you know how can interventions actually do the most good for the most people or how can we provide our services in ways that are efficient so a principle of efficiency how do we have respect for the autonomy of individuals at the same time we have to think about what's the public good how do we think about justice you know is it about discrimination against one group that has a historical basis which would mean we need to think both about reparation elack's as part of how we do public health at practice we might have to also think about how one moves to compensate within a policy for past bad acts and then you think about the future you know how are we going to redistribute that which has not been equally shared so we can get to what the first presenter said so we can get to equity so the tensions that we are seeking to live into and practice moral courage look something like this I think today there's a tension between how can what the interventions are how that can they can be effective in tension with cost benefits you know how can it be effective but also how can we pay for it secondly the tension of discerning what we owe each other you know that's what justice is really about what we owe each other and how what we owe each other may lead us into questions of how do we differently serve different groups in the society and it still be just we also are weighing individual freedom and which is autonomy the right to make choices with wider social goods and we want to think then about individual responsibilities as well as rights of people within the context and communities and therefore you know what's our social contract with each other and how do we maintain it so private goods but versus public interests so ultimately what I want to suggest to you is that an ethical frame for public health ethics practice and the way you think about it theoretically should be one that pushes us to think about how we live into the tensions of doing what I call countercultural and justice work because both of those have to happen when we do really really good Public Health work so how do we get so that we can live in that overlap and become creative partners in designing interventions and policies that actually live into the tensions don't resolve them necessarily but don't ignore them for sure and use them to creatively construct new responses we understand that we live in a context that's dynamic so the answers we may come up with the ethical responses for now may not be the same later on and we have to come back together be willing to come back to the table and grapple so fundamentally in a context where the omnipresence of violence is the pervasive way in which we live out our lives I think we have to ask ourselves can we are are we willing to be morally courageous in ways that are counter cultural and about the business of justice thank you [Applause] so now we have an opportunity to open up the microphones and to invite our online viewers for questions or comments just before we get started I want to summarize a little bit on what were the themes of the two presentations so the first presentation by Miss Moore really posited a a not a conundrum i would say but definitely a problem in terms of how public health and public health data is understood and digested she posited that we should consider looking at data in ways that help to provide an indication of a larger narrative that the data may not appropriately describe but that hints at right that the data is a reflection of a larger narrative of people that that data represents and dr. Riggs presented what for me is a major conceptual and in this issue of you know as public health practitioners how do we manage an environment of tension between you know understanding that we are surrounded by all of these different sources of violence in our lives regardless of who we are how old we are or what our position is and then what is our particular role within that environment of violence if we're committed to doing work social justice work and that as we figure that out it might require that we take a countercultural approach but the question here is countercultural to what I took that environment which permeates everything that we do in our lives when we when we watch TV when we play video games when we when we go to see a movie when we're interacting with people in the supermarket there are all kinds of macro and micro aggressions that we're managing or that we've grown accustomed to right so that you know how do we manage that and from a principle of ethics what do we do as agents of change in public health to really ensure that we're moving as agents of change in social justice some really interesting questions for us to consider one other thing that I want to point out again is that Miss Moore pointed out that there are a whole host of resources that given that she represents HHS and I'm a major agency within HHS Samsa that there are major sources of resources as Samsa has made available to support a National Partnership network of organizations and individuals who are committed to this kind of change in communities there are things that people can do this is not simply a theoretical exercise there are opportunities to engage and be engaged by other partners and so she gave resources that are at the table on on the corner by the microphone to everyone's right and so we encourage people to take the materials go online get connected because part of what prevents us from becoming agents of change is being isolated and there's no reason to be isolated and moving forward so now I'm gonna open up the microphones for any comments or questions for the two presenters and you also have the microphones at the table if you want to ask a question you can just press one of the mics on the table or you can come up to the mics in the room that's questions comments hi my name is crystal Muhammad getting my masters in clinical psychology right now oh you speak a little closer to mic I'm having a hard time here my name is Curtin Muhammad and I'm getting my masters in clinical psychology right now one of my concerns as a young adult right now what would be on your part there would be some resources that I could take to be more aware of the public health and mental health combination I want to start with congratulating you on your choice it's a great professional endeavor and I think there are a number of practical ways so in part by sharing resources that allow you to take action from wherever you are is so that you can start that practical application of the theory there are also a number of internships and fellowships that I would encourage you to take advantage of and we can offline definitely connect you to some of those directly but I do think applying theory as early as possible is one of the best ways to anchor the learning and making sure that we're able to take advantage of your educational experience good afternoon the so dr. Rigsby is this does this model presuppose own business model only to support a religious way of religious response a weight religious way of dealing with the culture of deception and conflict and so on well what's important about it is religious is not referring to particular doctrinal our denominational our traditional you know ways of being religious religious has to be understood here in this framework as whatever is used by an individual or group to define what is of ultimate concern to them that's what religious stands for here so what's religious for you or me maybe connected with some particular tradition but what's religious to someone else may not be defined by membership in some religious tradition or church or synagogue or whatever but instead has to do with what gives their lives ultimate meaning so someone grounding themselves in this dynamic is a resource for overcoming substance abuse is it also a resource for dealing with mental health issues someone grounded in this perspective and I was really thinking about the practitioners of Public Health someone grounded in this perspective is willing to grapple with individuals and communities about what substance abuse and mental health is first and the ways in which they respond to it in their communities and then begin to grapple together for answers in terms of what kinds of interventions would make sense what kinds of solutions might make sense for now it's it's really a framework than also I guess the other way I could have talked about describing our context it's to invite anybody who's willing to be countercultural in the sense of not buying into the kind of culture of absolutism and polarization that we live in today sorry can you define culture of absolutism of polarization for that well I'm defining absolutism is a culture in which people hold their positions as and their commitments as positions of certitude of absolute truth and therefore they don't see a need to engage someone who has a different position and consequently we end up with partisan polarization people standing on each side and maintaining that side at whatever cost people who are willing to work in this religious ethical frame are willing to say hey I can stand here and invite the polar polarities the people in their polarization to grapple for new meaning together rather than staying in a culture of absolutism and certitude where all we do is make claims and counterclaims against each other can I just add one piece to that cuz I think you raise an interesting point and having just had the opportunity to meet dr. Raikes it's been a real interesting alignment of experience in perspective but it reminds me also of one of the closing remarks from this morning that looked at principles of equity and health equity in particular where we were trying to address issues that are avoidable systemic and unfair and with that thinking and in the space that you've defined I imagine work that's related to policy and practice that's more inclusive in the dialogue then not inclusive and that where the paradigm can be more pliable and relevant and in that relevance I think we have opportunity for being accepted and effective in ways that we have yet to see yeah the posture of a person practicing religious ethical mediation and the policies you would come up with would be adaptive and responsive yeah Judy I thank you for um it's very interesting stuff I'm I'm feeling I'm feeling stuck in that bottles in appealing there's a lot of really fascinating theory here but I'm thinking about some of the discussions we have it's I Munsey see and I think a lot about how health department's can do things differently but I'm thinking about children versus adults and when we talk about people who are in the system substance abuse or people who use substances we often think about adults and yet children are in the in this environment and I wonder if if you take this model and and think about children who are exposed to to this kind of these kinds of situations the omnipresence of violence for sure would be a way a place where children are found how do we how can we think about this more practically I guess thinking about those kinds of age groups that makes sense yes I think so you can tell me if I don't know your class okay that will mean I didn't understand but one of the things that about this model is it invites folks to think about who are the partners to the conversation so if you're dealing with children your practices are not going to be conventional necessarily dialogue happens differently I mean art therapy is one of the things that folks use art with kids for example so you begin to think about what are the ways kids communicate you know the model does not preclude them as partners engaging in the dialogical kind of encounter that this is calling for it does require us to think outside our boxes does that make sense one of the things that comes to mind in this discussion our conversations that we often have in the office where when we talk about advancing health equity in practice we've talked about how we want to convey that often it doesn't mean that our actions in public health need to change so much as our understanding of why we're taking the action and both of you for me in your presentations spoke to that and how we look at data and what we think data is telling us and what may be missing in that data that we need to do further investigation around so that we're not blind sighted or coddled by our confidence in that data and then also how we're engaging our partners and and what do we think is feasible or actionable right if we're only staying within the lane or within the model there are a whole host of practices or techniques or methodologies that we're not going to even consider because they're they're not normative right and so we have to be creative and not necessarily having to construct new models or new strategies but taking the models that we reviews in other settings and in other context and using them in new ways or with new audiences so it's is a highly iterative and creative process and who said Public Health is boring I don't say public oh sorry I never say public all right but I want to take this time if there are to see if there are any questions online do we know if there are any questions that came online okay all right so at this time then I want to thank our two presenters and please give the our presenters a round of applause [Applause] and so I want to take the last few minutes to present the certificate of appreciation to our both of our presenters this is – Rosalyn Holiday more in recognition and appreciation for your participation in the CDC office of minority health and health equity 2019 public health ethics forum at CDC on April 26 2019 please come up and this certificate of appreciation is for Marcia Griggs in recognition and appreciation for your participation in our 2019 public health ethics forum thank you dr. Riggs so now this concludes this session thank you [Applause]

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