Lessons Learned from a Resident-Driven Mental Health Policy Elective Experience

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As a psychiatry resident, it felt like I was all on my own while learning to develop into a mental health policy expert and to advocate for vulnerable psychiatric populations. Some residents shared some interests in psychiatry social justice in a broader sense, but most were just trying to make it through the day or had other academic priorities. There were a few faculty who were visible in their work in organized psychiatry; however, it felt like few were doing the work I wanted to do.

When applying for psychiatry residency, I chose my top-ranked programs by considering many of the traditional aspects—diversity of rotations, academic opportunities, workplace culture, and geographical location. However, I also hoped to match into a program that had close proximity to a state capital and had an active state psychiatric society, so that I could regularly participate in legislative advocacy on mental health policy. Fortunately, I matched to University of California, Davis in Sacramento, the state capital of California. But when I got here, only a few physicians in my program shared my passion for advocacy and policy work, and there was no formal mechanism to foster that interest or connect residents to these sorts of opportunities. This was surprising to me. Fortunately, my program was and remains open-minded to residents’ passions.

This article will describe a resident-driven initiative to create a mental health policy and advocacy elective during psychiatry residency. The lessons I learned led me to develop a proposal for our psychiatry residency program to adopt a formalized Mental Health Policy Track and elective rotation. Prior to this, our program had not offered elective rotations or formalized training in mental health policy or advocacy topics. I saw the potential to develop a robust curriculum in mental health policy and legislative advocacy. Through such a curriculum, we could take advantage of proximity to the legislature, lobbyists, and other think tanks.

My Background

Like many other medical students, I desired to become a socially conscious physician who used their power for good. Having grown up in a politically tumultuous time, I was able to see how directly legislation impacted patient care through laws like the Patient Protection and Affordable Care Act of 2010. I came into medical school intending to learn more about how laws were written, and to then use my education to influence policy in support of marginalized populations.

I completed medical school at the Morehouse School of Medicine (MSM) in Atlanta, GA, where the mission is to “lead the creation and advancement of health equity.” At MSM, I learned about health disparities and the social determinants of health. Impassioned by my education, I sought out opportunities to make a difference in the lives of patients. However, I did not understand the avenues I could take to make a difference.

When the American Medical Association (AMA) chapter at my school recruited new medical students, I saw a golden opportunity. I wanted to make a difference by going above and beyond in my patient care, but also by pushing for systemic changes that would help patients on a greater scale. I participated in many efforts to influence health policy at the AMA. I learned analytical skills and learned how to debate about health policy. I was elected to represent my medical school the Medical Student Section, the AMA’s medical student equivalent of the House of Delegates. I coauthored multiple resolutions in topics of LGBTQ+ health, which led to AMA-level policy changes. My colleagues and I passed a resolution opposing the discriminatory laws states were passing to ban transgender individuals from using bathrooms that were concordant with their gender identities; this ultimately led to a similar resolution being passed by the AMA House of Delegates.^1,2 Another resolution we passed called for education about culturally diverse populations during medical school, with a special emphasis on the LGBTQ+ community.³ I went on to be the medical student member on an LGBTQ+ health advisory board to the AMA Board of Trustees. Through that group, I coauthored issue briefs to educate state medical societies about the harms of “conversion therapy” and discriminatory bathroom bills.^4,5 The skills I developed through the AMA helped me develop into a socially conscious physician who hopes to dismantle poorly functioning systems, to promote health equity, and to advocate for vulnerable populations.

I hoped I would be able to continue to do the same during psychiatry residency. Individuals with mental illness experience many social injustices, and in the past, psychiatric diagnoses have been used to pathologize homosexual individuals or slaves who fled their oppression. I became concerned about the criminalization of mental illness and homelessness, and the inequitable treatment of patients with serious mental illness. I developed a passion for ensuring high quality psychiatric services throughout the spectrum of insurances and joined the decades-long struggle to achieve mental health parity in insurance coverage.

Identifying Opportunities to Develop Skills in Residency

Given my experiences in health policymaking and advocacy work through the AMA, the clearest pathway to develop these skills for psychiatric patients was through organized psychiatry. I joined the American Psychiatric Association (APA), my APA district branch (Central California Psychiatric Society, “CCPS”), and the statewide psychiatry society “California Psychiatric Association,” which has since been dismantled and replaced. I joined these organizations early in my psychiatry residency. I saw the first opportunity for me to interface with organized psychiatry, through attending the annual CCPS conference in Sacramento in March 2020.

As luck would have it, a life-changing pandemic disrupted everything. The 2020 CCPS conference, and every other event I planned on attending throughout the year, were cancelled or postponed. Shortly afterwards, our state association was dismantled, temporarily creating a void of statewide advocacy. This void would later be filled by other organizations, including the Psychiatric Physicians Alliance of California (PPAC), where I am now a member of the Board of Directors. After a few weeks of the COVID-19 pandemic passed and it was clear our lives would be disrupted for the foreseeable future, I gave up on pursuing this interest for at least a little while. I feared COVID-19 and retreated into my shell. I put my head down, did my work, and tried to safely enjoy my free time at home.

I was motivated to become engaged in policy efforts again after my experiences on rotating at Sacramento County’s inpatient psychiatric hospital and clinics. Working in these facilities, I noticed differences from my core rotations at our other academic home, the UC Davis Medical Center (UCDMC). While UCDMC is a safety net hospital, it lacks its own inpatient psychiatric unit, requiring transfer of any psychiatric patients to private hospitals or the Sacramento County Mental Health Treatment Center (SCMHTC). Trainees in my program appreciated training at SCMHTC due to its expertise in serving an especially underserved population, those with serious mental illness. I completed rotations at SCMHTC, in addition to the county jail and county clinics. During these rotations I witnessed how the amazingly dedicated and passionate employees working alongside me went above and beyond to help their patients—much like I hoped to do.

Unfortunately, our efforts were often hampered by ongoing resource limitations of county mental health and the deteriorating dearth of discharge destinations such as board and cares. These limitations were further exacerbated by the COVID-19 pandemic. Our facilities tried to adapt, but almost everything was harder. It was harder to admit or discharge patients from our facilities, and harder than ever to get patients linked to outpatient care that could support them with medications, therapy, housing, and other social services. We all were advocating for our patients in some way or another, especially at the patient level, but things were increasingly difficult. These experiences were very challenging but also rewarding—they reignited my passion to serve the underserved through health policy efforts.

I concluded that my advocacy efforts could not wait until after residency. The state of mental health in my community, like communities across the country and world, was dire. I wanted my voice to make a difference now, not in 10 years. I believed I needed to strategically develop these skills during residency, so that I could also be up and running after training.

Mental Health Policy and Advocacy Training During Residency

I believe in the importance of training in policy and advocacy skills during residency. This belief is well-supported in both the academic literature and guidelines from the Accreditation Council for Graduate Medical Education (ACGME). For more than 2 decades, ACGME has considered systems-based practice as a general competency expected of all residents. Authors Greysen et al at George Washington University, in a paper describing their own health policy elective, wrote that “many of the specific skills encompassed by this competency (systems-based practice), such as the ability to work effectively in various health care delivery systems, the incorporation of resource allocation considerations, and advocacy for quality patient care, require a broader knowledge of the health care system.”⁶ Current ACGME guidelines for general psychiatry training programs describe that as part of systems-based practice, residents “must demonstrate an awareness of responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care.”⁷ They describe important areas of advocacy training as including advocating for quality patient care systems, understanding health care finances and impact on patients’ health decisions, and to advocate for their patients within the health care system.⁷

Further, ACGME states that a resident who has achieved higher levels of competency in the Systems-Based Practice milestones would “(lead) innovations and (advocate) for populations and communities with health care inequities” and “(advocate) for or (lead) systems change that enhances high-value, efficient, and effective patient care,” “participate in advocacy activities for access to care in mental health and reimbursement” and “advocate for patient care needs including mobilizing community resources.”⁸ The ACGME recognizes the importance of advocacy in other specialties; for example, in the pediatrics specialty, the ACGME requires an aspect of community pediatrics and child advocacy as part of their clinical rotations.⁹ In short, the ACGME explicitly and implicitly believes this is an important skill for residents to develop.

The importance of developing these advocacy skills during residency training is further supported by the academic literature across multiple specialties. One of the earlier health policy electives offered in residency training programs was the George Washington University policy elective. Authors Greysen et al note that in their study, participants in the elective had an “increased likelihood to pursue some aspect of health policy after residency” and “increased perceived ability to teach peers or medical students about basic policy concepts.”⁶ In her paper describing legislative advocacy in forensic psychiatry training at the University of Washington, Piel notes that the AMA and APA have adopted a code of medical ethics which includes that “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient” and acknowledged that psychiatrists should “serve society by advising and consulting with the executive, legislative, and judiciary branches of the government.”¹⁰ Yet, Piel further notes that many physicians lack formal training or skills in advocacy; Piel argues that legislative advocacy can support training in psychiatry training programs.¹⁰

In a 2018 APA Resource Document describing Advocacy Teaching in Residency Training Programs, the authors note that “research suggests that advocacy skill and values, when acquired during residency, are likely to continue post-residency.”¹¹ This research is supported in literature across other medical specialties, such as the study by Minkovitz et al, which concluded that pediatric residents who received specialized advocacy training experienced “greater participation in community activities and greater related skills than their peers nationally.”¹²

While policy and legislative advocacy work are not explicitly required according to ACGME guidelines, they are included as elements of system-based practice milestones for residents.⁸ While interviewing for residency, I compared programs based on opportunities to pursue advocacy. Key elements in my decision were opportunities to train in public psychiatry, opportunities for mentorship in health advocacy, and a general openness to residents’ pursuit of scholarly interests. Fortunately, I matched to the UC Davis Psychiatry Residency program, which benefited from its location in the California state capital, where mental health reform and social inequities are among the top priorities of the government.

Experiences Within Organized Psychiatry

In pursuit of developing leadership experience in mental health policy and advocacy, I was awarded the APA Public Psychiatry fellowship. This fellowship was established to contribute to the professional development of future leaders within public psychiatry.¹³ As I became increasingly involved within organized psychiatry in California and the APA, I decided the best way to develop the advocacy and policymaking skills I desired was to develop an elective rotation to have dedicated time. Through this elective, my hope was to develop a more comprehensive understanding of the laws and policies governing mental health care, and to pave the way for other residents in my program who had shared interests. This became the primary project I worked on as an APA fellow.

Designing the Elective

While our residency did not offer a preformulated elective in health policy, our residency offered tremendous flexibility in the ways we designed our electives. I designed mine to have protected time for relevant readings, writing projects, meetings, and hands-on legislative advocacy. I had developed relationships with influential mentors at the national level through the APA, and at the state level through the Psychiatric Physicians Alliance of California (PPAC). I hoped to leverage these professional relationships to develop a robust experience.

At the initial stages, I found designing my elective to be very difficult. I first planned on designing a 4-week “block” experience during which I would have minimal clinical duties and be able to focus on readings and hands-on advocacy; I later added a longitudinal component to better facilitate my goal to develop this work as an ongoing endeavor. At this early stage, I was unable to find a model curriculum for such electives offered in psychiatry residency, or many specific details from programs that offered health policy training—perhaps because my initial searches were too specific in looking for 1-month elective experiences. Fortunately, I came across health policy electives offered by outside institutions George Washington University (GWU)⁶ and the Kaiser Permanente (KP) system¹⁴ for all residents; however, these were not designed specifically for psychiatry residency, and both required travel and applications to do external electives.

I ultimately chose to model my elective proposal off the electives offered through GWU and KP. Each of these curricula offered a didactic portion as well as an experiential portion. These models emphasized that experiential learning was key to apply the knowledge and increase the likelihood of long-term advocacy work.⁶ Some of the readings I chose to incorporate were from the KP elective curriculum, focused on foundational learning in the financing of health care, the history of various health care reforms, and legislation regarding the practice of medicine. To incorporate more information relevant to psychiatry, a mentor at UC Davis (Lorin Scher, MD) recommended that I supplement my proposal with the APA publication “A Psychiatrist’s Guide to Advocacy.” This book describes the importance of physician-advocates in psychiatry to serve several marginalized populations, and additionally describes the major systemic challenges in psychiatry such as access to quality, evidence-based care, psychiatric workforce shortage, mental health parity issues.¹⁵ Additionally, I made it a priority to read accounts from various news outlets in the state (eg, the Sacramento Bee, the LA Times, the nonprofit newsletter CalMatters) to learn more about issues I care about like serious mental illness, homelessness, and the ways they do and do not interact.

For the experiential component of my elective, I planned to primarily shadow Mr Randall Hagar, the lobbyist for the PPAC. Mr Hagar and I chose to schedule the elective in January 2023, to start with the beginning of the state’s legislative season to gain maximum exposure to new ideas being introduced as bills. The experience would focus on legislative advocacy, but we planned to also review relevant judicial cases, administrative policy including the implementation of statutory regulations, and more. My schedule was intentionally flexible to accommodate the unpredictable legislative calendar. Aside from my experiential learning through PPAC, my UC Davis faculty mentor Dr Scher helped to place me in a hospital committee aiming to improve health care for the patients who are homeless and treated by our system, to gain more experience in systems-based advocacy. My residency program supported my elective proposal in part because of the extensive experiential components.

A 4-Week Elective Becomes a Longitudinal Project

After further considering my goals for my elective, I also saw value in longitudinal experiences rather than limiting myself to 4 weeks. With a slight revision, I persuaded my residency program to allow 4 hours per week of protected time throughout my entire PGY-4 year, in addition to the 4 weeks “intensive” elective experience. This offered me the opportunity to be more ambitious with reading and writing projects throughout the year and allowed flexibility to attend various meetings which occurred during the typical workday. It was easier to incorporate information I was learning throughout the year rather than in such a compressed period. This schedule also allowed me to attend all sorts of meetings and other events that I could not have predicted (eg, press conferences and meetings on the design and implementation of California’s new civil CARE Court, public hearings for bills involving mental health, among others).

Lessons Learned From my Experience

Two thirds through my PGY-4 year as of March 2023, I have completed my “intensive” elective experience and have taken approximately 4 hours of protected time weekly throughout the academic year. It has been an incredibly rewarding experience that has contributed greatly to my professional development as a mental health policy advocate.

Throughout the year, I have been able to work closely with Mr Randall Hagar at PPAC. Some of my activities during my “intensive” elective experience included reviewing the state budget proposal including billions of dollars for mental health care and substance use treatment, and a host of bills to reform our state’s mental health system. I have reviewed numerous proposed bills on topics including creating a state right to mental health care, expansion of access to naloxone to combat the opioid epidemic, and improving the crisis care continuum. I had the opportunity to provide early feedback on a bill modernizing California’s grave disability standard for involuntary psychiatric hospitalization and conservatorship. Even more recently, I was able to speak on behalf of PPAC at a press conference advocating for that same bill.¹⁶

I additionally learned the importance of regulatory rulemaking, by reviewing State Senator Scott Wiener’s legislation (SB 855, 2020) which strengthens the California Parity Act, and by collaborating on public comments to ensure the regulations truly adhere to the intent of the legislature.¹⁷ I have studied various court cases, including Wit v UBH, a case with national implications regarding mental health parity and covered services, and state cases such as the lawsuit by Disability Rights California against CARE Court.^18,19

While it has sometimes been challenging to utilize the 4 hours of protected time due to on-service clinical demands as a senior resident, my supervisors have been flexible when I requested to use a different half day than normal (eg, Monday morning instead of Tuesday afternoon). This afforded me the opportunity to attend meetings that had great educational value and aligned with my values—for example, when the Steinberg Institute (a local mental health nonprofit) held a meeting with a diverse group of stakeholders to discuss expansions of mental health care access and a state “right” to mental health care. Throughout the period of my elective, I have met periodically with my faculty mentor Dr Scher to evaluate my elective and to discuss future projects to give me a greater diversity of experiences. Additionally, because my ongoing engagement was facilitated by my elective’s longitudinal design, I had the time to coauthor a piece for APA’s Psychiatric News about CARE Court and blogs about the implementation of the 988 Suicide and Crisis Lifeline.^20-23 These various experiences and writing projects were extremely helpful in solidifying the knowledge I had gained from reading about health policy.

Future Directions

As part of my elective proposal, my program leadership requested that if I were to have so much time dedicated to the elective, that I should have a “product” of sorts similar to other nonclinical electives offered at our residency. We agreed I should leave some sort of outline for how future trainees could go about such an elective and offer feedback on the parts that worked well and those that did not. I first approached this as a relatively modest syllabus that I would offer to the program leadership describing some helpful reading materials and pointing residents in the direction of organized psychiatry. However, after spending some time on this longitudinal experience, my faculty mentor and I agreed that in many ways throughout my residency, I had developed and completed a policy “track” of my own, rather than a time-limited elective experience.

This inspired the development of a proposal for a formal Mental Health Policy Track, which once finalized will be offered to future residents in my program. The goals of the track would be to offer a broad exposure to mental health policy topics and to offer significant dedicated time to a resident’s area of interest (eg, parity and access to care, substance use, or patients with mental illness in the criminal justice system). The residents in my proposed track would participate in writing and teaching projects, spend additional clinical time in public psychiatry settings, and attend dedicated didactics. This proposal benefited from my discovery of a helpful APA resource document which described advocacy teaching in seven psychiatry residencies¹¹; I had missed out on this resource document by searching too narrowly for “policy” rather than advocacy. I then discovered examples of a few other psychiatry programs who have introduced some sort of policy and advocacy training. When I developed my proposal, I considered how all these other programs were designed, how other elective tracks worked in various residencies (eg, research tracks, educator tracks, or other self-designed thematic resident tracks) and any practical advice in the literature on how such a program would be effectively implemented. I tied the proposal to several elements of our department’s strategic plan including advocacy work, developing better connections with our county mental health services, and to invest and partner with community-based organizations to increase access to mental health care and to meet our community’s needs.

Programs which are considering offering a mental health policy elective or implementing a track may consider referencing the APA resource document by Drs Kennedy and Vance, as well as other programs which may be offer “policy” or “advocacy” experiences in training. Trainees should have exposure to core didactic session and readings (such as the APA text “A Psychiatrist’s Guide to Advocacy”¹⁵) to the degree possible. But perhaps most importantly, the resident should develop their skills through experiential learning, be it through shadowing a lawmaker or lobbyist, advocating for a specific bill, sitting on a community board, or working in mental health administration. This experiential learning will be key to solidifying their knowledge. As part of my future work, I may endeavor to update this resource document, collaborate to develop a model curriculum for mental health advocacy training, and to advocate for more trainees to have policy and advocacy experiences.

Because I have been fortunate enough to have such experiences in residency, I am now pursuing a career in academic psychiatry! I had not previously considered an academic career because I narrowly defined it as focused on funded clinical trials or bench research. As described above, participation in these advocacy and policy experiences in training increases the likelihood that this will lead to long-term participation in such activities as scholarly work. I am no exception. I hope to return to my residency program after fellowship to implement these proposals and to continue to engage in this work as a faculty member, while teaching trainees who represent the future of psychiatry.

Dr Shumate is a psychiatry resident at the University of California, Davis.

Acknowledgements: I wish to acknowledge mentors of mine as well as people who helped edit this essay. Thank you to Dr Lorin Scher for being my mentor for the APA Fellowship, for providing me with numerous connections, and for providing feedback on both my elective and policy track design. Your mentorship has been crucial. Thank you to the Psychiatric Physicians Alliance of California, which has welcomed me into the Board of Directors. Thank you to PPAC board members Dr William Arroyo and Mr Randall Hagar, who have also mentored me on California mental health policy issues and included me within PPAC. Working closely with them helped me to develop skills in interpreting proposed bills and regulations, considering strategy while doing advocacy work, as well as the importance of long-term advocacy for important issues. Finally, thank you to Dr James Bourgeois for helping me to edit this essay.

References

1. Carland CM, Carpenter NJ, Morgan Z, Shumate CD. Protection of transgender individuals’ right to use public facilities in accordance with their gender identity. American Medical Association. 2017. Accessed March 17, 2023. https://www.ama-assn.org/system/files/mss-digest-policy-actions.pdf

2. Access to basic human services for transgender individuals. American Medical Association. 2017. Accessed March 17, 2023. https://policysearch.ama-assn.org/policyfinder/detail/%22Access%20to%20Basic%20Human%20Services%20for%20Transgender%20Individuals%20H-65.964%22?uri=%2FAMADoc%2FHOD.xml-H-65.964.xml

3. Shumate CD, Abaza RH, Uzor NA, Carney DB. Cultural competency training for medical school faculty, staff, and students concerning individuals who are lesbian, gay, bisexual, transgender, gender nonconforming, and/or born with differences of sexual development. American Medical Association. 2016. Accessed March 17, 2023. https://www.ama-assn.org/system/files/mss-digest-policy-actions.pdf

4. AMA LGBTQ Advisory Committee, GLMA. Sexual orientation and gender identity change efforts (so-called “conversion therapy”). American Medical Association. 2018 Accessed March 17, 2023. https://www.ama-assn.org/system/files/conversion-therapy-issue-brief.pdf

5. AMA LGBTQ Advisory Committee, GLMA. Transgender individuals’ access to public facilities. American Medical Association. Accessed March 17, 2023. https://www.ama-assn.org/system/files/2019-03/transgender-public-facilities-issue-brief.pdf

6. Greysen S, Wassermann T, Payne P, Mullan F. Teaching health policy to residents--three-year experience with a multi-specialty curriculum. J Gen Intern Med. 2009;24:1322-1326.

7. ACGME Program requirements for graduate medical education in psychiatry. Accreditation Council for Graduate Medical Education. 2022. Accessed March 17, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/400_psychiatry_2022v2.pdf

8. Psychiatry milestones: The Accreditation Council for Graduate Medical Education. Accreditation Council for Graduate Medical Education. 2022. Accessed March 17, 2023. https://www.acgme.org/globalassets/pdfs/milestones/psychiatrymilestones.pdf

9. ACGME program requirements for graduate medical education in pediatrics. Accreditation Council for Graduate Medical Education. 2022. Accessed March 17, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/320_pediatrics_2022.pdf

10. Piel J. Legislative advocacy and forensic psychiatry training. J Am Acad Psychiatry Law.2018;46(2):147-154.

11. Kennedy KG, Vance MC; Council on Advocacy and Government Relations. Resource document: advocacy teaching in psychiatry residency training programs. American Psychiatric Association. 2018. Accessed March 17, 2023. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/2018-Resource-Document-Advocacy-Teaching-in-Psychiatry-Residency-Training.pdf

12. Minkovitz CS, Goldshore M, Solomon BS, et al. Five-year follow-up of community pediatrics training initiative. Pediatrics. 2014;134(1):83-90.

13. Public psychiatry fellowship. American Psychiatric Association. Accessed March 17, 2023. https://www.psychiatry.org/residents-medical-students/residents/fellowships/available-apa-apaf-fellowships/public-psychiatry-fellowship

14. Residency Elective in Health Policy. Kaiser Permanente Undergraduate & Graduate Medical Education Northern California. Accessed March 17, 2023. https://residency-ncal.kaiserpermanente.org/current-residents/courses/health-policy-elective/

15. Vance MC, Kennedy KG, Wiechers I, Levin SM, eds. A Psychiatrist’s Guide to Advocacy. American Psychiatric Association Publishing; 2020:440.

16. Holden L. California lawmaker wants to reform conservatorships for those with severe mental illness. The Sacramento Bee. Updated March 1, 2023. Accessed March 17, 2023. https://www.sacbee.com/news/politics-government/capitol-alert/article272630321.html

17. Wiener S. SB-855 Health coverage: mental health or substance use disorders. September 25, 2020. Accessed March 17, 2023. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB855

18. Larson C. Appeals court rules against plaintiffs in Wit v. United Behavioral Health . Behavioral Health Business. January 27, 2023. Accessed March 17, 2023. https://bhbusiness.com/2023/01/27/appeals-court-rules-against-plaintiffs-in-wit-v-united-behavioral-health/

19. Angst M. Civil rights groups to Gavin Newsom: court-mandated mental health treatment is unconstitutional. The Sacramento Bee. January 27, 2023. Accessed March 17, 2023. https://www.sacbee.com/news/politics-government/capitol-alert/article271730897.html

20. Shumate C, Arroyo W. Calif. law creates new civil court for people with smi facing incarceration or homelessness. Psychiatric News. October 26, 2022. Accessed March 17, 2023. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2022.11.11.37

21. Shumate C. 9-8-8: what to expect. APA Foundation Blog. April 19, 2022. Accessed March 17, 2023. https://apafdn.org/news-events/blog/9-8-8-what-to-expect

22. Shumate C. 9-8-8: what is happening. APA Foundation Blog. June 16, 2022. Accessed March 17, 2023. https://apafdn.org:443/news-events/blog/9-8-8-what-is-happening

23. Shumate C. 988: state of the lifeline. APA Foundation Blog. August 23, 2022. Accessed March 17, 2023. https://apafdn.org/news-events/blog/9-8-8-state-of-the-lifeline