NSSC: Voices of Change Part 1: Serious Mental Illness, Missed Care, and the Criminal Justice Gap

Welcome to Why Not Me? Embracing Autism and Mental Health Worldwide?
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Welcome to Why Not Me? Embracing Autism and Mental Health Worldwide.
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need to hear these conversations. Thanks for being here today.
We bring together a group of seven voices, each with
their own experiences, perspectives, and stories. We will talk about
something that affects far more people than we often realize,
serious mental illness in the spirit of Mental Health Awareness Month.
This is not just a discussion, it's an opportunity, an
opportunity to listen, to understand, and to bring light to
conversations that are too often left in the dark. Joining
us today is Crystal Fox, David Hagar, Laura Crasian, Linda Mimes,
Judge Milton Mack, Rachel Streithe, and Anne Cochrane. This topic matters.
It touches families, friends, and entire communities. This is the
first of a three part series that we'll focus on
serious mental illness. Today. We are creating a space where
honesty is welcome, where stories can be shared, and where
understanding can begin or deepen for all of us listening.
I'm grateful to everyone that's joined us today.
Thank you for having us.
It's my pleasure. I think one of the first things
we need to discuss is some of the things that
might need to be changed. Let's start off with you,
Judge mac mean.
I think I said for a long time that our
mental health codes are how to sync with science, that
they are in patient models in an outpatient world, meaning
that the focus is on inpatient hospitalization. On ninety five
percent of the care is provided outpatient we need to
convert this system from an intatient model to an outpatient model,
and we're slowly moving that way now. Michigan has made
some strides or assisted our patient treatment as a standard order. Now,
if you end up in winkin a probate court on
a petition for hospitalization, you're also going to get at
So problem is our standard or intervention permits you to
file a petition or someone who's not sick enough for hospitalization,
but they are second enough for our patient treatment. The
problem is, in order to use it, I could hospitalize
first because the system is still backwards. So we have
legislation pending which has passed the House and Senate, which
would allow for easier intervention early before someone is so
sick hospitalized, and then that should be our goal.
I believe that's a step up. AOT is what you're
talking about, am I correcting that?
I'm not sure about that. The way it would work
with a family member could file a petition of the
probate court saying my son as a mental illness he
needs treatment on an our patient basis, and then we'd
have someone testified on that, and that's the judge health
that he required it he could order our patient freedment.
Yeah, I mean that you've just defined something called step
up AOT. So we have court ordered treatment in Arizona,
and that's our version of AOT. But in our case
you have to go into the hospital first. There's not
an option to have outpatient initiated order for outpatient treatment,
so that's called step up AOT, and I think that's
exactly what you've described.
We will permit a psychiatric nurse practitioner testify, or a
position assistant with a psychiatric background could testify, or a
psychologist not just a psychiatrist at the airing, so it'll
be easier to prevent presents the testimony you need. And
the court being a position to an order for AOT,
if it was found to be required, may be sent
to the CMH. May'd be bound to pair the treatment
plan within thirty days and get it back to the
probate cross. You're going to make sure they're actually doing
their job, and we're often running.
Yeah, in Arizona, at least in some of our counties,
we have some problems with AOT. We don't exactly do
it quite right. The court order treatment doesn't at least
in Maricopa County doesn't involve the judge and it only
requires like a report to be submitted to the judge,
But it doesn't put anybody in front of the judge
and it doesn't create any accountability for our clinics.
And what you need is to judge involved from beginning
to end when the petitions filed. So we measure now
when we get someone who comes in or a pickup
order to have their loved line transport to the hospital
for evaluation, we measure how many petitions we get after
that we're running around twenty five percent. So what happens
to the other seventy five percent? We don't have the
answer to that yet. But so where at the front
end we make sure that the deferment process is followed.
So what happens is if someone is hospitalized, there's a
deferment conference with CMH and the individual and a lawyer.
If they work on a treatment plan, that becomes the
plan and there's a deferment. But what has happened historically
is the hospital devestment invites to the table patients signs
of deferral and it's to deferral to nowhere. So we're
trying to tighten up the ship all the way through
the end, and we're measuring things. For example, we measure
how many people we put on an AOT order are
getting treatment within thirty days, and we know that number,
and we know what provider is hitting the target right now,
the best provider seventy five percent or sun Song great
but better than zero.
One of the biggest challenges families and caregivers talk about
is you finally get someone the help they need, You
get them hospitalized, you get them stabilized, and then sometimes
far too quickly, they're released. There are time limits, there
are policies, there are system constraints, and before long they're
right back out, often without the support that they truly
need to stay well. So my question, how do we
break that cycle?
We get around that well. In California, our AOT program
is completely voluntary. It's not the gold standard of care
that Treatment Advocacy Center puts out and is promoting, which
when done right, is wonderful. We have fifty eight counties
in California. These programs are all voluntary, and guess what
the sickest people that they are targeted towards. If you
have schizophrenia, you have fifty seven to ninety eight percent
chance of having anasygnosia, which renders the frontal law of
your brain dysfunctioning, and you are unable to be aware
that you are ill. So you're not going to ever
volunteer for services. Why should you? You're not sick. So
we have this running horrible dichotomy in our state. And
then we have the disabilities rights people and ACLU fighting
for people's rights to die with their rights on in
the street. But you cannot exercise your freedom and your
rights if you are trapped in your mind, not seeing
the world rationally. You cannot. Then it's a form of
imprisonment in your own brain. So I admire Michigan and
Judge Mack because you guys are trying to do it
the right way. We almost all of our programs here
in this state are voluntary.
I've been hearing this same challenge from people all across
the country and even globally. Because of this podcast, I
get to talk with families, caregibbers and professors everywhere. No
matter where they are, there seems to be a common
frustration with how systems like AOT are applied. One example,
I was talking with one father whose son was in
a clear mental health crisis, walking down the street with
no clothes on, completely disconnected from reality. Thankfully, the officers
that responded to it handled it with compassion, no handcuffs,
They kept him calm, even played his favorite music on
the way to the hospital. But when they got there,
the hospital initially refused to admit him because he wasn't
considered in immediate danger to himself or others. Oh my goodness,
because he had a good first responder, everything did ultimately
work out. They did help him. So how do we
begin to shift this perception so that people in obvious
crisis aren't turned away simply because they don't meet a
strict immediate threshold. And what changes, whether in policy, training,
or awareness, need to happen so getting help actually leads
to meaningful care.
That's because our culture doesn't look at these illnesses as treatable,
no fault brain diseases. They're just like any other organ
based disease in our body. Yet they are discriminated against.
And most of that discrimination comes from old, ancient legislation
that was drawn back like sixty years ago in our state,
that did not recognize these conditions as medical because at
that time they didn't have the scientific evidence we do now,
there's no excuse. Yet they are still being block. Barriers
to care are so high to get somebody into care,
and it's just it's not right. And the only thing
I can see that we can do is we can
get doctors involved, because family advocates are not listened to
a lot of the time, believe me. But doctors have
an MD by their name and they are listened to.
And that's one thing that I don't understand is why
doctors have not come out and fought for their own
patients to in this arena that you're talking about, Because
I don't see anything really happening of consequence until we
get it through our heads in our culture that these
are treatable diseases that are being discriminated against. No other
disease is discriminated against like this. In our society. We
would never say, oh, you're having a stroke, you can't talk,
the doctor will not treat you till we get a
lawyer here. No, but if you have a brain attack,
forget it. Well.
The Michigan Metal Health Commission back in two thousand and
four came the conclusion of metal unless as streatable recovery
as possible provides you intervened early, and early intervention was
the key and now whitty for crisis. So Michigan has
rewritten the Metal Health Code as it relates to when
you can hospitalize someone, it's no longer danger to selve
for others. You won't find that in our What you'll
find is risk of harm. That's the question. So for
recent case in Michigan, this individual had a law history
of mental illness. He'd be treated, be hospitalized to get out,
wouldn't take his medicine. He comes into court and the
doctor who is testifying on behalf of the county says, well,
he is currently not at risk of harm. However, within
three to six months we can expect he'll stop taking
his medicine again, and then he'll be at risk of
harm due to possible suicide, drug abuse, increased risk of
dementia and other things. Court of Appeal said that works.
So by intervening earlier, that helps. But then the second
part is when the court inners in order for treatment.
If you've been hospitalized for mental illness, you've got to
even temporarily. That's pretty serious. Does anybody really believe you
can be discharged the next day with nothing. I don't
think so. So what we do in Michigan, the standard
order is, if we come to court on a petition
and you're in the hospital, we will enter a combined
treatment order of one hundred and eighty days of assistant
pacing treatment and up to sixty days of hospitalization to
be used during that period of time. And just kind
of evidence of why this works. I saw I studied
recently regarding those persons who are found not gut through
reasonable sanity, and they measured with the likelihood of them
being arrested again over the next five years. For those
people who were treated at the forensic center and discharged
without community treatment, they were arrested forty four percent of
the time. For those who were discharged on the supervision
of a treatment plan, they were arrested eight percent.
Yeah, I just want to say states are so very
different in their criteria for involuntary treatment. So the problem
that Linda just described, we don't really have it. In
the Arizona. We have persistent and acutely disabled statutes, not
just gravely disabled or danger to sell for others. And
so for example, that description of someone walking out naked
in the street as not being considered harmful. In Arizona,
I'm legal guardian of a woman who ended up easily
getting hospitalized for exactly that she was disrobing walking outside
of her group home, and she pretty quickly was qualified
for a partition for involuntary hospitalization. She actually was in
an er for a while. They even had to use
restraints to keep her from continuing that behavior walking out naked,
and we were able to get her into a hospital
under court ordered treatment and a safe discharge plan, which
I was required to authorize the discharge plan as her guardian,
and so I was able to make sure she got
into safe placement once her treatment was right. And you know,
it was a successful pathway towards compassionate if you will,
involuntary or I like to say, life saving medical orders,
and so we have good laws in Arizona. I actually
think they're probably model for the country. Were able to
get someone a court ordered evaluation and treatment if they
have even just signs of psychosis and they're refusing treatment.
The problem we have in Arizona is that we don't
have enough hospital beds and we haven't funded the system
at all. So the average we have the fewest state
hospital beds per capita of any state in the country,
and Maricopa County has almost none. So we don't have
the ability to hospitalize people for more than about twenty
two days. That is the average if you're lucky, if
you get into an involuntary court ordered civil hospital. So
we're releasing people on court ordered outpatient treatment, but they're
not stable. They have nowhere to go. They're going home
to families. Family parents are getting killed. There was a
very you know, nationally visible case last Monday, two parents
died after their son killed them because of poor treatment
after discharging from a hospitpital. So we have to have
a funded system. It's like the opposite of California. You
guys have money, but you don't have laws. In Arizona,
we have laws, but we don't have the money. And
I'm fighting legislation right now, and I'm having to beg
for five million dollars or a program, and I'm probably
not going to get it because our state budgets. Our
state legislature doesn't like funding things.
So we've been talking about funding and clearly resources matter.
They shape what services are available, how long someone can stay,
and what kind of follow up care even exists. Now,
I'd like to shift this for a moment, because even
beyond the dollars, there's something deeper going on in how
the system itself actually works. David, you've had a unique
vantage point on this. You've spent decades working in jails, prisons,
and psychiatric hospitals. So from your experience, how would you
describe the difference between how the criminal justice system handles
serious mental illness versus how the civil system handles it today?
Well, I'm a psychiatrist who's been doing this for over
three decades, worked in jails and prisons, currently working again
at a forensic psychospital, this time on the maximum security unit.
And you know, it's so sad that at this point
the criminal justice system has the laws and policies that
they have sufficient accountability, the ability to follow through, the
ability to actually do things better than the civil system does.
Because the laws and the civil side had been anemic
and they just let people go. They don't realize, they
don't recognize the reality, the neurological reality of the illnesses themselves,
and so the criminal justice system picks up the slat
And you know, I don't think a lot of people
are aware of that because you know, nobody goes to
visit a prison to see all the mentally ill people there,
and nobody goes to the forensic psyche hospital up here
on the hill to know what that is like or
what kinds of people lined up there. Now there's in Texas,
we're building a whole slew of new hospital beds because
the balloon phenomenon, you you close down the civil hospital beds,
and of course it doesn't do way with a need.
And then what we owned up with was this enormous
backlog of people who were incompedent stand trial, and that
put the pressure on to do something. And part of
the doing something is building the state hospital beds, a
lot of them all over the state, and overall, when
all is said and done, about sixty percent of those
are going to be forensic beds. And that's just how
the rules are written, how the structure is and until
the civil side can do something different, something more realistic,
it's just it's going to have to be that way.
You know.
My experience is that the two major factors that result
in people being rehospitalized or medication on it here and
that with the neurological illness of schizophrenia is directly attributable
to the anazagnosia. You know, I keep talking about neurological illness.
I consider her schizophrenia to be a neurological illness. As
neurological symptoms, anasygnosia is one of them, delusions, hallucinations, neuropsychological decline, thought, disorganization.
Calling it a mental illness makes it too fuzzy and
it conflates it with all of the diagnoses in DSM
that are a dubious validity. There's a lot of debate
around the validity of that body, that billing code book
that we call DSM in any event, So anazygnosia is
one of the major drivers or hospital admission or readmission
or getting picked up on the street by the police.
And nowadays unfortunately we think, oh, if they're lucky, a
felony filed and something will actually happen. The other is
substance use. So the two major factors are substance use
and as ignosia. I look at how the system flows,
and you know, if a person
can't see that he has a mental illness. Now sometimes
it gets better with treatment, not consistently, and it tends
to be a pretty persistent symptom in people of schizophrenia.
You know, the anazagnosia doesn't go away because you discharge
them to an outpatient setting, and the general strong tendency
unless there are pretty robust services in places for the
medication to be stopped or substances to be used. And
then the wheels fall back off the bus and again
find ourselves are wondering or hoping that the police get
involved in charge of felony so the person is safe
and the family is safe. But I notice there is
this terrible reluctance to consider compelled medication in an outpatient setting.
And if that was an.
Option, that would materially impact the need for psychiatric hospitalizations
if people have to stay on their medication. Of course,
it'd be careful review process, you know, there'd be a
lot of a lot of process and with representation, so
for then the ability at some point to get out
of that kind of an order. But you know, right now,
the only place medication can be compelled is in the hospital,
and then they walk out the door and it's no
longer compelled. Even with AOT. AOT is a nice model
but nobody compels medication in AOT. It's just not written
that way right now, So it's just it's one of
my frustrations. It's also interesting the variability and how the
involuntary detention laws are written on the civil side. And
I was thinking of the original Lessarde v. Schmidt in
out of Wisconsin, where the imminent dangerousness verbiage originated, and
it's ironic that Wisconsin actually wound up blocking that back.
They found it didn't work too well, so they came
up with a fifth standard in the mid nineteen nineties
as a way out of that overly restrictive language. And
I think or states are figuring out ways of doing
that as well. It sounds like Arizona. It's an example
of that.
A big part of this comes down to perception. People
don't truly understand this unless they've lived it. Yet. We
also just heard that even when the need is recognized,
the system is understaffed. So let's address that. How do
we change it? How do we attract, train, and retain
the kind of people who are willing and prepared to
do this work and actually help those who need help
the most.
I attended a conference recently and I had the opportunity
to sit with a number of psychiatry residents and I
asked this whole table, why did you choose psychiatry? And
everyone said exactly the same thing. They said they didn't
they had planned to do something else entirely, but they
went into their psychiatry rotation. They fell in love with
psychiat and when they told their parents that was their choice,
one even said it was worse than coming out as gay.
We don't have.
Any kids saying I want to be a psychiatrist when
I grow up. We need to build esteem back to
that profession, and we need to build up the value
and the importance of our good psychiatrists that are treating
the most serious mental illnesses. I want to be a
psychiatrist when I grow up. We have to start attracting
people into the field.
Yeah.
Yes, And I think that a big part of that
is because I have talked to a lot of psychiatrists
in our county and one thing I will say is
many do not want to take the hardest cases. Many
of the psychiatrists and clinicians in our county don't even
understand and asygnosia that these are the people that are
taking care of our loved ones who are ill. That
is really a terrible thing. I mean, the education is
lacking and it has not caught up to the scientific
and medical protocols, and we don't have a standard of
care protocol for across our nation, which would be so
helpful if we had. You know, Okay, this person needs
to be evaluated. Here's what we're looking for, here's what
we need to do to evaluate them. I know at
Meneger Clinic in Texas they always test for other diseases
that could cause psychosis. Well, that's the logical thing to
do first before you diagnose somebody with a serious brain
disease or neurological disease. And that's pretty scary right there.
So I'd say I agree with you, Rachel, but I
also really don't like what I'm seeing in my little,
well not so little state of the people that are
treating our folks and their lack of knowledge and their
lack of respect for the families. You know, the majority
of care givers for people with schizophrenia and other really
serious illness are the families. And like you like to say,
the families are the new asylums. Yet we get no
help from disabilities, We get no money to have an
in home caregiver like autism and other spectrum illnesses, and
that isn't fair. Many of us have had to give
up our jobs. It's a full time job to take
care of somebody who is ill and in psychosis, and
we have no training for that. We learn on the
job the hard way.
Yeah, and that's a very difficult position to be put into. So, David,
from a clinical standpoint, are their key factors, maybe even
neurological ones that you feel. The feel still isn't fully
recognizing or incorporating into how we diagnose and treat serious
mental illness.
Right, just briefly following up on what Linda is saying,
and that is my feshion has its own anazygnosia. About anasygnosia,
it's not even one of the criteria for schizophrenia. I
know doctor Ammador has tried it. I mean he used
to be involved in it with the researchers who developed
DSM three and DSM three are and he's spoken with
people about anazygnosia being a diagnostic criterion for schizophrenia, and
for some reason, it's just not there. Our profession doesn't
even consider it, and yet it's the major reason for rehospitalization.
So taking that into account, families that are listening across
the country right now, the system can feel completely different
depending on where you live. So in essence, we're dealing
with a nationwide problem with fifty different systems trying to
solve it. So how do we move beyond the patchwork
of state by state approaches and start building something more coordinated,
something that makes access to care more consistent and effective
across the country.
You know it might be helpful is in Michigan, the
governor appointed a Mental Health Diversion Council about fourteen years ago,
and that council has takeholders across the system and we've
recently added to the Michigan Hospital Association to it. And
so this group has been able to craft the legislation
to get it through the legislature because they represent all sides.
We have disability rights online, we've got prosecutors, We've got
the hospitals. We tell them what their interests are. Their
emergency rooms are crammed, they they can't handle the population,
and they know that there's a better way to treat
them instead of in the hospital. So the batch of
legislation that we're working hand now has passed the House
and the Senate and will really make the intigment changees
in how we handle mental health cases in Michigan. And
we had a unanimous vote in the Senate. Kind of
a weird yes vote in the House, but that's an
internal plorical problem. But there's an are you saying? And
we're seeing more local politicians talk about this, So it's
just a matter of finding way to spread the word.
I guess yes, that makes perfect sense. Hopefully we can
keep spreading that message to everyone. This has been a
powerful conversation and honestly, we're just getting into some of
the most important parts of it. I'm going to pause
things right here for today, but this is not the
end of the conversation, not even close. We'll be back
in just two days with Part two, where we go
deeper into solutions, real world challenges and what this all
means for families and communities. And then we're not stopping there.
We've got a Part three coming as well, where we
bring it all together and talk about where we go
from here. So stay with us. This conversation matters, and
we're just getting started. If today's conversation helped you see
the world a little differently. Then we're doing exactly what
we hope to do. Until next time, Keep believe, keep learning,
and most importantly, keep asking yourself why not Me? Thanks
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