Jhilam Biswas Reveals Paths to Mental Health Reform From Forensic Hospitals to Freedom

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Hi, I'm Tony Mantur.
Welcome to Why Not Me The World? Humanity of a Handcuffs,
the Silent Crisis special event. Today we're joined by doctor Jillum.
This was a Board certified adult and forensic psychiatrist. She
is the director of the Psychiatry Law and Society Program
at Brigham and Women's Hospital and co director of the
Harvard Mass General Brigham Forensic Psychiatry Fellowship. She chairs and
contributes to numerous psychiatric, forensic, and medical committees at both
state and national levels. Her research focuses on improving mental
health laws to better support patients and families while advancing
criminal justice reform. With her expertise in mental illness, risk assessment,
and more, We're thrilled to have her share for insights
with us today. Thanks for coming on.
Thank you. I think you're doing such a huge service.
Thanks for your kind words. I really appreciate you taking
the time to be with us today. It's truly inspiring
to see your impact as a mental health advocate and
your leadership across various boards. Can you share with us
your journey and how you reached this point in your career.
A lot of what I've done is research.
So I worked at Forensic Hospital for many years and
I realized that it was very hard to get the
courts to allow us to provide medications for psychotic illness
in time if somebody didn't have the insight into knowing
that they needed it. So what we ended up doing,
and I was the principal investigator in this research project,
is it took years to get all the agencies to
sign off on doing a research study in the car
Serole setting on mental illness. But what I did in
the Forensic hospital this is all those individuals you're talking
about with mental illness, but also a lot of my
patients did have an autism diagnosis, not all of them,
but certainly we do see a correlation of individuals with
autism who might have a comorbid serious mental illness like
bipolar disorder or schizophrenia or PTSD.
You know, because what.
Happens when you have autism and you're having difficulty with
social cues and having difficulty with reading social situations. It can't.
It just makes you more vulnerable to falling into difficult
situations meeting up with law enforcement. Law enforcement not necessarily
reading you right, but reading you well, and it resulting
in something that's much bigger or spiraling out of control.
And so a lot of times when I was working
at the forensic hospital in Massachusetts, these individuals would have
mental illness but also have this diagnosis of autism and
also a diagnosis of traumatic brain injury. That was another
really common thing that I would see in individuals. And
so we did a research study because one of the
biggest issues that I've found in forensic hospitals and working
and the incarcerated in a system with patients who are incarcerated,
is that it's very difficult to get standing doses of treatment.
For then, so, going over everything that you've done so far,
what was your next step to finding more information?
So we ran a study and we showed all of
these different adverse events that occur while we're waiting for
the courts to.
Allow us to give treatment, and those adverse events, you know,
we're like patient on patient assaults, patient on staff assaults,
climate incidences where you know, the individual is.
Either victimized by others or you know, throwing things or
breaking things in the unit and really just causing a
lot of disruption. And so what ends up happening with
these delays to treatment in carceral settings or forensic hospitals,
and actually in Massachusetts we see it even in our
acute care settings is it's not a healing environment necessarily
for people.
Can you expand on why that is?
Because the other people are so sick around them or
they themselves are so sick and there's this delayed care.
So anyway, all that to say, we did this research study.
We found that when we do provide treatment to individuals
and forensic hospitals, things improved dramatically and these adverse events
decrease dramatically. Actually, I'm going to be president of the
Massachusetts Psychiatric Society in April.
Wow, that's awesome.
Yeah, And I'm working with a group of other organizations
to really help change some of the laws in Massachusetts
to bring time it's called the Timely Treatment Bill, and
we're trying to bring better psychiatric care to people in
in patient settings and in forensic hospitals and in prison settings,
antipsychotic treatment when.
They have psychotic illness.
The other thing we're doing in an cochrane I know,
connected me to you for this is what my hope
is is rather than having people get care in these
locked settings, really bring that level of care.
To the community through assisted out patient treatment and wrap
around services. Individuals with autism definitely have a higher comorbidity
of serious mental illness, but also are in proximity to
others with serious mental illness due to living in group
homes or living in various institutions with people with serious
mental illness, and getting timely treatment.
To these individuals rather than these delays to care, I
think it's key to keeping individuals with serious mental illness
in the community and with family members and reducing sort
of the high burden that caregivers feel I think in
providing care for their loved ones who have serious mental
illness and coorbid autism.
When do you get involved with a patient that's been incarcerated,
do you step in before they enter the court system,
or only after they're already in it.
Yeah, So that's so when working in a forensic hospital,
they need charges, they need criminal charges actually to be
in the forensic system, and then the court will have
clinicians within the court determine, you know what, this person
needs a higher level of care, and they'll get diverted
into a forensic hospital.
And that's where.
We see them as forensic psychiatrists providing care in that setting. However,
now I don't work in a forensic hospital. I actually
work in a regular academic hospital in Boston, Pulprigham and
Women's Hospital, and I still see a lot of forensic
issues that come up in the hospital setting. You know,
people with criminal charges who are needing medical care but
then also have a psychiatric illness. We see it also
in our in patient psychiatric units. I also have a
private practice called psych Expertise, where I do evaluations for
the court, for attorneys, for organizations that.
May need a mental health evaluation for.
An employee, or a school may need in a mental
health evaluation for somebody who might have been suspended due
to some issue, and then turns out there's a mental
illness involved and we need to know that it's treated
in order for them to.
Come back to school. So end up in a lot.
Of different situations thinking about how did this person get
in trouble?
In which context did this person get in trouble?
Is it related to their mental illness or their autism diagnosis?
And how do I provide recommendations for them to return
safely into whatever institution that wants.
To have them back, and how do we do that well.
I also have done evaluations for people who are in
a forensic hospital or a jail and then are going back.
Into the community.
How do we keep that individual safe in the community
with services so that they don't end up in this
cycle of incarceration. So what ends up happening is basically
I just think of myself as getting mental health consultation
to various social systems, whatever they may be, because all
of our social systems are interacting with people with mental
health issues.
When someone comes to you tells you they need someone evaluated,
what is that evaluation process?
Great question?
The evaluation process I think by word to drill it down,
it's a psychiatric evaluation.
A psychiatrist is a medical doctor. We go through medical
school and we do.
A psychiatry residency, and then we have a sub specialty
in understanding how people with mental illness may interact with
the law.
And so I use a lot of my training and
experience to do an evaluation.
But a lot of what I'm doing is looking at
the psychological factors, biological factors, environmental factors.
And social factors social.
Determinants of health that may have resulted in the illness
that I'm seeing, and how do we intervene in all
of those various factors so that individual can be stabilized
from their crisis and then be maintained in a lower
level of care or in the community.
And the way that I do that.
Is I get a very deep social history, developmental history,
substance use history, mental illness history, medical history, legal you know,
like there's a lot of ways to get all this history.
And then we use all the components that we have
kind of sussed out in the examination to describe what
we're seeing.
Once you determine what you think is happening, what is
the next step after that?
So the next step after kind of thinking about what
is happening, you make a diagnosis if a diagnosis is available.
To make or or not you can make a diagnosis.
Sometimes it requires more testing, depending on what the issues
we're seeing. Sometimes it's a deep dive into the past,
medical history and legal history, or if it's a court case,
kind of going into the you know, the components of
the court case and making a clinical opinion on that diagnose.
So so saying there's this diagnosis, and in my clinical opinion, this.
Is what we need to do next.
And then in that clinic opinion we offer treatment recommendations.
Also, how long does it take from the initial meeting
with a patient to assessing their condition, making a diagnosis
and prescribing medications or other treatments they might need to
move forward.
So it happens on a case by case basis.
It really depends on the story, and it really depends
on the situations.
Some stories are really hard to figure out.
You know, somebody might be very high functioning and they're
living a very you know, functional life, but there's just
a missing link that results in a bad situation or
a bad outcome. It may take a deep dive into
the history, doing interviews with family members and friends and
institutions that they're part of, their caregivers, their treatment providers,
and so that can take some time. The other thing
I always say about a psychiatric diagnosis is it's hard
to make a diagnosis of psychiatric illness in one snapshot.
Really need multiple evaluations, and you need to see someone
over time, or you need to be able to retrospectively
or look backwards into their history and say, okay, this
is what they looked like at this point in time
and this point in time, and then through that pattern
you can really say what that diagnosis is. All psychiatric
diagnoses actually do need to occur over a period of
time and cannot really just happen.
For one day to get a diagnosis.
When you're involved with a legal system and the court
requests an evaluation of an individual, do they provide enough
time to conduct a thorough assessment. This would help explain
why the person acted as they did, allowing the court
to make an informed decision about their next steps or
the necessary actions that they may need to continue.
Yeah, I mean, I think that's a great question.
So I think different evaluations require different periods of time.
Depends on the decision that the court is making.
One decision the court will make is let's say somebody
comes off the street after an assault and battery. There's
just some obvious mental illness science that the court is seeing,
like the person is not making sense, they're confused, they're disheveled,
their hygiene is bad. You know, they're talking to themselves.
That's kind of a quick and dirty snapshot view that someone.
In Massachusetts, we call them court clinicians.
There are psychologists and social workers on every court that
will do a quick and dirty evaluation and say, look,
this person.
Needs a longer mental health evaluation versus you know what.
They can actually have their day in court, they can
get a rain, they can go to a jail setting
for a pre trial period. There is an evaluation that's
done within the day in that setting. Then if there
needs to be a longer evaluation by statue in Massachusetts
law and the Massachusetts General Laws, it's Chapter one twenty three.
We have lots of different statutes that discover how much
time you'll have to do a psychiatric, a forensic psychiatric,
or psychological evaluation.
And once someone ends up.
In a forensic hostital from the courts, you have twenty
days to do that evaluation and then make a determination
of whether they need to stay in the hospital or
if they can kind of go back into.
The jail setting. So that's what we see in the
forensic setting.
However, a lot of situations, the courts will allow the
person to go right back into the community and have
the evaluation done in the community. Now, as a private
forensic psychiatrist, I will do those evaluations out in the
community over longer periods of time, or if someone's been
able to pay bail, they will be out to have
those evaluations done out community.
So it just sort of depends where the person ends
up and what their history is. That determines how long
we have to do those evaluations.
When you conduct an evaluation and propose a hypothetical treatment plan,
but the individual is placed back in an environment where
they regress, how do you support them to regard stability.
If time constraints or unaddressed issues lead to new challenges surfacing,
how is that situation managed to help them get back
on track.
It's a big piece of detective work.
I think every puzzle is different and you have to
put the pieces of the puzzle together to figure.
Out what's going on. It depends on the kind of
mental illness we're seeing.
You know, if it's somebody with autism, sectrum disorder, they
may be able to articulate everything that's going on, they're
connected to their family members, we'll have direct contact with everybody,
they will have some insight into what their issues are,
and we'll be able to provide care and treatment more quickly.
What I often will see.
With people with serious mental illness, like a psychotic disorder,
whether it's resulting from schizophrenia spectrum disorder, or from bipolar disorder,
or for substances that then causes a psychotic disorder. Those
are often the three big pathways in which we see
a psychotic illness. So those individuals might not have a
lot of insight into what's going on and will be
you know, one of the symptoms of psychosis maybe that
they don't have insight, they're not engaging.
In care and treatment, and they don't want treatment. At
that point, we really do need to.
Get the courts involved to help us provide some psychiatric treatment,
which we call you know, there's various names for it,
but we call them antipsychotic medications. That every state has
laws around in order to provide that care in a
way where the individual doesn't have insight that they need
the care, and so it ends up being somewhat compulsatory, right,
but we need the court to mandate that, and in
those situations they can just take a lot longer because
there's so many procedural hurdles and we need to protect
the due process obviously of the patient themselves, especially if
they are refusing treatment and they do have insight and
you know, we're just missing something. Certainly, due process is important,
but the problem with due process currently is our court
systems take a really long time to hear the cases.
And so that's what my research showed.
In one of the forensic hostels in Massachusetts, it took
up to sixty one days to get medications to an
individual who had acute psychosis. Which is why I have
worked with multiple other organizations, the Massachusetts Behavioral Health Services Organization,
to bring a bill to the Massachusetts legislature called the
Timely Treatment Bill.
Can you expand on this bill that you brought to
the legislators and what it does.
More timely medications to people with psychotic illness, because right
now in Massachusetts, and I know in other states because
I talked to psychiatrists everywhere, this is a huge issue.
We cannot get care to individuals with serious mental illness,
who have an insight problem, who can't tell that they're ill,
and that's a very common problem among people with psychosis,
and that I do think result is a multifactorial, but
it is a factor that.
Results in this cycle of homelessness and incarceration.
Because if you're coming off your meds and you become
sick and no one is monitoring you, and you don't
have ties to care and you burn bridges with your caregivers,
you do end up in this cycle of losing your housing,
ending up on the streets, using substances, ending up with
head injuries, and then that is this downward spiral into
interactions with law enforcement and prime and then ending up
in the carceral system. One of my deep sadnesses is
the fact that some of our largest jails in the
country LA.
Chicago's Cook County and.
New York Writerers are some of the biggest psychiatric hospitals
in our country, and that shouldn't be the case. I
think that's a human rights violation to have our carceral
systems provide psychiatric care.
Yes, I've heard that the prisons are exactly that the
largest psychiatric hospitals in the country, and it's up to
them to take care of them, and they really don't
know how to take care of them, which ultimately create
more issues.
Exactly, And so it is important in those settings to
really get a forensic psychiatrist to do an evaluation and
provide recommendations. It's very sad that so many people with
mental illness do end up in the carceral system. But
just having that psychiatric evaluation that follows them, that people
can read and say, oh, this person has this diagnosis, Oh,
this is this person's history, these are the medications that
might be helpful, or here are some ways this individual
can cope with their mental illness. That is such an
important report to have for that individual, and to have
that level of psychiatric analysis done for that individual who's
in the carceral system.
I really think that that's so important.
Many prisons aren't equipped to handle inmates with mental illness
or medication needs. Guards often lack training to recognize these issues,
mistaken genuine distress for defiance. This can lead to inmates
being denied proper medical, escalating problems and ending up in
solitary confinement. How do we create a better system so
that some of these people don't fall through the cracks
and wind up in places they don't need to be
because it may just be a medication issue rather than
a personality issue. What do we need to do?
This's is such an important question.
It's one I personally struggle with every day and think
about every day because I think there are some.
Key things to educate society about when it comes to
mental illness and how people end up in the criminal
justice system.
One is substance use is like one of the biggest
issues that results in violent behavior and then results in
someone with mental illness or substance use disorder to be incarcerated.
This impulsive behavior that comes from substance use. Another is
traumatic brain injury.
Traumatic brain injury is a really big deal in the
United States.
People end up with concussions and a series of concussions
over the course of their life, through sports, through fights,
through lots of different car accidents.
This is an issue and it does actually.
Cause people to have personality changes, to become more impulsive,
to not necessarily pick up on all social cusers, to
self medicate with substances their symptoms that they're experiencing. So
that's another way where we see violent behavior and Lastly,
we see a violent behavior when someone has mental illness
that is untreated, untreated mental illness that results in a
lack of insight and self awareness that somebody is ill.
That is the third way. I think people do end
up in the car soil system due to having a
mental health issue.
And we know that as psychiatrist, when I'm doing that evaluation,
I know I see those factors and those are three
Those are three things we could divert back into the
community and prove intensive treatment for and help society understand.
Look that treatment might need to be.
Mandated for a short period of time until that person
develops insight.
That's going to be the way to keep people in
the community.
But there are a lot of little problems we end
up along the way in being able to provide that.
Level of care.
I think in the United States, and I think that
is resulting in a cursoral system problem of mental illness.
We need that medication, treatment and the therapy that goes
along with in housing that goes along with it, and
occupational therapy and physical therapy that goes along with it
to be in the community, and the community needs to
have a deeper understanding of what causes violence, impulsive violence,
and individuals not necessarily premeditated violence.
Now you said that you were involved in some type
of legislation. Yes, what type of legislation are you trying
to get changed or improved upon? That needs to be
under the microscope and you think is just really really important, Yes.
Very important.
So different states end up with different sets of issues
that result in the same problem, which is people with
mental illness end up incarcerated.
And in Massachusetts, I have to.
Say we have the lowest number of incarcerated individual rate
of incarcerated individuals in the country, So it not in
terms of numbers, but in terms of the rate of incarceration,
we had the lowest amount. However, those who are incarcerated
are more likely to be mentally ill in Massachusetts, and
our judges have done a great job of creating new
standards in Massachusetts that they recently updated in twenty twenty
four to really think about mental illness as one of
the things they consider when they're looking into a case.
And I was just involved in one of their annual
meetings and provided some mental health education at their annual
meeting because they're really.
Looking into this issue. But what I think is an
issue in Massachusetts?
Is that or a very rights driven state where treatment
is important. But to maintain someone's rights to refuse medication
is it takes precedence in Massachusetts. It's not the case
in all states, but a lot of states do follow
this same thought process. And while I think that's absolutely
important for people with disabilities to have all of their
rights intact, what sometimes happens is these individuals in maintaining
their rights to stay off medications and not get mandated treatment,
they end up in the carceral system because they end
up in a violent situation and then end up in
the carceral system with criminal charges.
And so in Massachusetts, two things we need to do.
We don't have any assisted out patient treatment laws, and
we do have one filed with the legislature right now
at the State House, call the Critical Community Services Bill
that we've just refiled in January, to help us bring
this level of intensive psychiatric treatment into the community rather
than just in locked psychiatric units.
That sounds like a great piece of legislation. What do
you see coming out of this?
The hope is we can provide antipsychotic medications to someone
with serious mental illness and a psychotic disorder in the
community monitored while getting them all the other services.
They need to stay in the community. And the other
thing that we are trying to do in Massachusetts.
We have this timely Treatment bill that's also in the
legislature that we just refiled in January to reduce that
time that it takes for the court hearing to happen
in order to get medications to an individual who has
a psychotic disorder, is lacking insight and is refusing careen
therefore has ended up in this cycle of needing multiple
hospitalizations or ending up homeless, or ending up with multiple
criminal charges and in the jail system.
Right now, we have no safety nets.
In either of those two spaces to provide medication treatment
for people with psychotic disorders in Massachusetts. So those are
the two bills that I'm really hoping we can push
during the time that I am president of the Massachusetts
Psychiatric Society.
So that's one of my goals. But what I will
say is this is a nationwide problem. In the nation.
Every state, whether they have those AOT.
Laws, assisted out patient treatment laws, or timely treatment laws
in the in patient settings, sometimes they have major staffing
shortages they don't have psychiatric care necessarily available very quickly,
or they don't have the psychiatric beds, or they don't
have the wrap around services needed in the community to
keep people off the street and in a shelter system
with psychotherapy, with other types of community services needed for
people with serious mental illness. So every state has solved
version of this problem.
It's aims that if you get this passed through, this
would be a good bill to take to the House
and try and make it national.
Yeah, I mean, I think.
I think what has happened is this issue has become
a state by state basis issue, and every state makes
their mental health laws and their determinations of how they're
going to manage people with mental illness. You know, the
hope is what the Supreme Court does is give the
bottom this is what you have to do, but states
can have a higher level of scrutiny than what the
Supreme Court deems to be needed.
I would love.
Some sort of way of keeping people out of the
criminal justice system and in the community at a national level.
That is an really important legislation to pass. I think
at a national level to really recognize this as an
issue that this cycle of homelessness, constant psychiatric hospitalizations, and
criminal justice interacts.
Actions is a result of individuals.
Of mental illness either remaining untreated or self medicating with substances,
also having these other morbidities like autism or traumatic brain
injury or other types of personality disorders.
They all play a role.
Yeah, I definitely agree. Now, what would you like to
tell the listeners that you think they really need to
know about what you're doing and of course what you're
trying to do with legislation.
It's a great question. Serious mental illness is treatable.
Symptoms of autism can be alleviated with really good therapy.
We do have treatments available. Serious mental illness is a
waxing and waning illness.
It can come back.
It's not necessarily curable, and so people need to stay
on medications to stay well. One of the issues we
see with serious mental illness, which is a biological illness.
It's a like any other disease that we see in
other organs in the body.
Needs maintenance and needs treatment. It doesn't just go away.
I mean it can for a period of time, but
it comes back, and when it comes back, it's unpredictable.
What I really want people to understand is when people
can get very sick from mental illness, they can lose
insight into their well being, into their self awareness, and
into reality in general.
And that experience a lot of times can be very distressing.
So even though if a person is telling you they
don't want treatment or they're not able to give you
a very clear decision of what they want, part of
that is.
The illness itself.
Part of that is the distress, the emotional distress that
they're experiencing from being in psychotic illness. And so even
though it feels sometimes really wrong to provide psychiatric care
to an individual when they're refusing it, you can actually
restore their well being and dignity much faster with medications.
And I think we really need to.
Understand that, and there's a lot of resistance to that
understanding of mental illness, I think in this country.
Yeah, well, this has been great conversation, great information. I
really appreciate you coming on.
Absolutely, I really appreciate you having me. Thank you, it's
been my pleasure.
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