Senator Cindy Friedman Explains What It Takes To Fix A Broken Mental Health System

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one story at a time. Ti Hi, I'm Tony Mantur.
Welcome to Why Not May Embracing Autism and Mental Health Worldwide.
Welcome to our special event, crafting justice empowering autism and
mental health through legislation. Joining us today is Senator Cindy Friedman,
a dedicated public servant representing Massachusetts fourth Middlesex District. Elected
in twenty seventeen, Senator Freedman has emerged as a leading
voice in the Massachusetts Senate, especially in the fight to
address serious mental illness and improve mental health care access.
As co Chair of the Joint Committee on Healthcare Financing.
She has drafted and championed transformative legislation, including bills to
expand mental health parity, increase access to care, and address
systemic gaps and treatment for severe mental illness. Her commitment
to compassionate policy solutions is reshaping the Commonwealths approach to
mental health. She brings a wealth of knowledge and we're
thrilled to have a join us. Thanks for joinings today. Sure,
what was it that led you to get into advocacy
for those with serious mental illness?
Well, there are two parts of it. One is, we
in our family have had some experience with serious mental illness.
So I have experience with certain types of mental illness.
And it's really really hard. You can't change somebody. You can't.
You know, you individually can't make them better. This is
an illness, right, but it sometimes it helped me to
figure out, even if I couldn't help our family member,
is there something I could do to make the system better.
I remember when I started working for the senator whose
set I took because he passed away. I remember the
very beginning, I was looking at something and I went
into him and I said you know, mental health treatment
in this state sucks and we should do something about it.
And he said, okay, what do you want to do?
So we got involved in understanding the system and how
it was working and how it was not working, and
I think those two pieces led me to my interest.
In twenty twenty two, you did the Mental Health ABC
Act two point zero correct. Yeah, yeah, Since it's been
passed and now that it has been implemented, what are
some of the changes that you've seen come from it?
What I have seen change is access has changed, and
there appears to be a lot more use of mental
health services, and there's more of an awareness of mental
illness and mental health services, and those are the big changes.
I'm the share of healthcare financing so in the Senate,
and so we look at cost trends and you know,
what are the drivers of healthcare And if you look
at what's driving healthcare in Massachusetts, one of the pieces
is outpatient behavioral health. Those were making it a lot
more accessible.
Now that the bill has been an effect for some time,
you've observed it, You've seen how people are engaging with it.
What adjustments or improvements would you suggest to better support
those who might need the assistance that this bill addresses well.
I think reimbursement still is an issue, the rates of
reimbursement and the funny, weird ways that we reimburse So
there's supposedly parody, right, but there's still a really lack
of parody between medical services and well physical services and
behavioral services. There's still a parity difference. We still pay
much more for you know, specialty care in physical or
illnesses that you can treat with a pill or treat
with a procedure than there is with you know, treating
mental illness. So I see that, and then I all
also see that there's really problematic ways that we will
pay for things. Right, So we don't pay you know,
we pay for crisis interventions more than we did before.
We pay for inpatient but we don't pay as well
for ongoing care, which is what stops people from going
into crisis and needing intensive care. And I think the
other piece that I've seen, and this is more general,
and I just don't know exactly how to deal with this.
So much of what is driving the illnesses that we
see is trauma. I don't see really how we are
addressing trauma in a really efficient and meaningful way so
that people, over time don't get sicker and sicker.
Yeah, so what about AOT. Does Massachusetts have an AOT
law in place yet?
Outpatient assistant treatment? Yes, no, we don't. We're the only
what are we two left that don't?
So in your opinion, what do you think needs to
be done in order to get AOT in place in
your state?
I think there needs to be a reevaluation of the
lawsuits that are preventing it from happening, because the whole
understanding of mental illness and treatment for mental illness has
evolved over time. Certainly the understanding of mental illness has
evolved over time, and when there were court cases that
were think in the very early eighties that basically do
not allow other than a judge to determine whether somebody
can be treated against basically treated against their will. And
it's very very hard to do that in Massachusetts. So
you need a substitute judgment where the judge says, this
person is incompetent of deciding, so I will decide for them.
And then it's very limited around how much treatment and
how the kind the treatment that you can receive, and
they're you know, what we learn and know now is
that there are a very small set of people whose
illness prevents them from knowing that they're ill. And so
if you don't know that you're ill, and you continue
to have these horrible symptoms, you either end up in
jail or if you're lucky, you end up in an
emergency room, which then puts you into maybe treatment or
you know, maybe impatient setting for three days, whereupon you
can you know, check yourself out. And what we see
is that there are again a very small but important
set of people who can't be treated because of this
cycle of you know, or inability for somebody to say,
look at this person, please, before we have before we
put them in jail, please look at them and determine
whether they're able to take care of themselves.
Yeah, I've heard that the biggest hospital or the mentally
ill in the country is the La County Prison.
Yeah.
Yes, we definitely have to find a way for that
to change. How do you get your point across to
your fellow senators that if they can be treated, if
they can be diverted away from the judicial system, then
a very high percentage of those that go in front
of a judge and is diverted to a better facility
will not show up in front of that judge again.
By this happening, not only does it save the court
it's time, but it saves the taxpayers hundreds of thousands
of dollars, if not millions of dollars. How do we
get that point across to them that there is a
better way.
It's a hard sell for a number of reasons. People
who have this kind of illness do not present themselves
as poor. You know, it's not pretty. Sometimes it's amusing
to people, but often it's scary, right, and so we
quickly demonize them. So that's the first thing. You're not
dealing with puppies and kittens here, right, which people seem
to care more about than human beings. So I think
it's really and I understand very much the concern that
once you allow people to be treated against their will,
all of the pictures of all the women one hundred
years ago whose husband decided they didn't like them and
they stuck them in an insane asylum, right, I mean,
that's still really to a lot of people, that's really
or you know, a horrible you know, we closed all
of our mental health inpatient hospules because many of them
are horrible. So it's really getting through that. And I
think that if you look at the bill that we filed,
there's really nothing that happens to you as the person
who we are trying to get treatment. Nothing happens to
you ultimately if you don't follow the court, But it
gives everyone else an option to get you to a
place where you are where there's going to be more
treatment available. Right. So if I'm a parent and I
want to I want to get my very very psychotic
son assisted out patient treatment, I go to the court
and petition the court to require the least restrictive services
for this person, right, And if the court says yes,
what's great about it is the state then has to say, okay,
we have to provide these services. Right. But if the
patient in that case doesn't follow the treatment plan, all
that can happen is that people can bring them back
to court, but nothing is you know, we're not going
to put you in jail. But there's real evidence that
says a black robe effect is real for people when
they're in the middle of a psychosis. So that's kind
of what I think we have to start explaining to people. Look,
this is a tool, but ultimately you're not going to
be punished if you don't do this right.
I was speaking with a gentleman one time about his
son that was going through psychosis. He had been in
a situation where he had a conflict with the police
at one time, and he was very afraid of him.
Later on, he was in a situation where he was
walking down the street no clothes on, thinking he was
completely invisible, and he had another run in with the police.
Right.
It turns out the police that came to the complaint
was really good. They looked at him, asked him what
he was doing, and his response was, you can see me,
So they said yeah. Then they said, why don't you
get in the back of the car and we'll take
you to a place that can help you. And because
he has been handcuffed before, so he said, don't put
handcuff saw me, which they didn't. On the way to
the hospital, they asked him if he liked music. He
said yes, They turned on the radio. He got a
chance to listen to the music he liked, and they
finally got to the hospital. At that point in time,
the doctor looked at him and said, there's nothing I
can do. He's not a threat to himself, he's not
a threat to others. So the policeman said, okay, where
do you live? And the doctor asked him why he
asked that, he said, because I'm going to drop him
off and put him in your place, because evidently he's
not a problem. So the doctor actually took him in
and they were able to help him for a short
period of time. He was very fortunate. We don't usually
run across people that are like that. So number one,
how do we get more information out there to help
create that kind of atmosphere. And number two, we have
to get the doctors to realize that, yeah, he might
not be a threat to himself or others right now. Wow,
but that doesn't mean that five or ten minutes later
that he couldn't be. We need to find a way
to help them so that they don't become a problem.
Right Well, first of all, there are incredibly effective programs
here in Massachusetts and maybe another place, but we've developed
and sustained a corresponder model where if somebody is you know,
if the police get called about an incident and somebody
seems to be having a psychotic episode or something, a
police officer and a social worker will go out to
that place or that house, and so the police are
trained not only in protecting, but in de escalating. And
then you also have somebody there that really understands is
trained in dealing with people who are in the middle
of psychosis. And this I can't tell you how effective
this has been. Every year we have police chiefs, there
are these annual legislature days and they come in and
they tell what their priorities, and this past year, every
their number one priority was to keep the co responder
model because it really works for them and we can't
expect our police to be, you know, psychologists, and that's
not fair, right, Yeah, that's right. We can train them,
and you know, good training is really important, and de
escalation is the techniques are really important. But having that person,
having that team, those two makes such a difference. And
then the other piece is is that we're starting this
in Massachusetts, but other places have done it, like especially
Breer County, where they have these restoration centers where the
police or a EMT or any first responder or anybody
can bring somebody who's in the middle of a psychosis
to a place where they immediately get somebody is there,
and they can de escalate and they can figure out
what this person needs. And those are really really effective too,
right because the police get really frustrated because they take
this person who they know is sick to the emergency
room and then the doctor says, are you a threat
to yourself? Are you a threat to others?
No?
Goodbye, because it's the emergency room, you know. So having
a different way to get these people into a health
care system versus a criminal justice or judicial system is
really important.
Are you familiar with Sheriff Buckley down in Barnstable County?
Oh? Yeah, she's Brand News.
I had her on my podcast, And of course in
Barnstable County, the sheriff doesn't do patrol. They take care
of the jail system. She has implemented a system to
where she's helping the people that are incarcerated so that
once they get through their time, that they don't come back.
Oh that's true.
So in her area, it's kind of like we were
talking about the LA prison being the hospital. Well that's
what's happening here because of her success. How do we
build on that so that these people that do wind
up incarce rated can get help not just in one spot,
but all across your state.
So you should talk to well, there's two things. First
of all, you should absolutely talk to Peter Contusion, Okay,
because he's the sheriff of Middlesex and he's been doing
this longer than anybody. He has an amazing understanding and
commitment to treating people with mental illness. I mean, really,
he walks the walk and he's done it for a
very very long time. He's been involved in this. So
I think Middlesex sheriff Department in the Middlesex County, which
is Bill Aurica, is really a model. It's really through
the bully pulpit and encouragement because the way that our
sheriffs are set up in Massachusetts is they're really independent.
They get elected. So forcing people to do it is
kind of unless we change the structure of the relationship
of the county, corrections and the state is kind of hard.
But there are more and more people that are starting
to look at this because it is I think the
last time we saw it was like over seventy percent
of the people in the Middlesex County prison was they
had I think over seventy five percent of them had
an open mental health case.
Yeah, that is unfortunately a big number with all the
technology that's going on in the country. Massachusetts has a
lot of cities, yet they have a lot of rural
country area that leaves a lot of people underserved. So
how do you, as a senator find ways to legislate
not only for the cities like Boston, but for the
smaller areas that struggle with budget and because of that
have a hard time taking care of their people. How
do you handle that so that those that are underserved
can get help too.
Well, it's money, right, very true, down to money. Do
we have the money to implement and sustain and we don't.
It's very very hard, you know, to provide these kinds
of services, first of all because it's rural, and it's
hard when it's rural because people are so far apart.
Workforce is an issue. How do we get the workforce?
And then how do we sustain it with what money
do we use? Right? So, for better or worse, money
tends to go where the most people are. But I
think we can definitely do a better job because there
are definitely areas once you get west of Worcester that
you could put something in place and probably have enough
of a geographical service area that you could support it,
but it will be very expensive and we just don't
We don't spend their money on that.
Do you have funding opportunities available for telehealth or digital
health solutions focused on non physical digital methods of providing
healthcare support. It won't be the same as a one
on one meeting, but at least if there's an issue there,
hopefully something can be done so it doesn't go into
full blown psychosis.
Yeah, we do have behavioral health telehealth parity, which you know,
the insurers hate. They say it's supposed to quote cost
less telehealth. Well, it does cost less because that person
doesn't end up in the emergency room, so it does
cost less. So we push telehealth pretty hard. And then
we have set up these community behavioral health centers and
they are across the state and they have a front door,
you know, an open door policy where anybody can you know,
come in and get services or get evaluated if it's
an emergency. So we have started to set up a
more geographically disperse system.
Now you also serve as co chair of the Joint
Committee on Healthcare Financing. Correct, how does that intersect of
mental health care and pharmaceutical affordability in Massachusetts. Can you
expand on that sum as to how that works.
So we get we are responsible for all of the
legislation that is filed within the healthcare space. So there's
mental health and substance use recovery. That's a committee and
they hear bills and then ninety percent and ninety five
percent of the time those bills that they hear and
they vote favorably to move along, come to our committee, okay,
And same with pharma. We get all the pharma bills.
How do you see the role of pharmacies evolving to
ensure people can access and afford the medications they need
to manage their conditions, stabilize their health, and of course
improve their quality of life.
Well, again, we have mental health parity in this state
and we've got pretty strong laws. So if an insurer
has on their formulay something that is the equivalent of
a medication for another condition and then not supposed to
be available, right, the problem is you know, like you
you have high blood pressure, right, so you take lippiator
or you or you have high cholesterol, you take lipitur.
Right, Yes, that's right.
There's no such thing in behavioral or mental health. Maybe,
you know, maybe a drug will work, maybe it won't.
Maybe you need to take three drugs. Maybe it's a cocktail,
do you know what I mean? And the way you
figure that out is you try it and you see
if it works. Right. And so insurance companies don't like that.
Yeah, that's true.
You know, they don't like that. They want to know,
you know, will the clause are ill work? I don't know.
We have detroy it is lithium right for this? Do
they need lithium and depicoat like you know, maybe it's
just held on. I mean, they just you don't know,
and not from anybody's like malice or misuse. It's just
everyone's different. This is an illness where it's very very individual.
Yes, I get that. I have had the opportunity to
speak with several different people. They have been able to
find the correct medication. They've come out of it. They're
living a good life. It's just great. But they lost
ten years doing this right.
So, and we have not yet broken the code to
you know, to schizophrenia.
And you know, I've talked with several senators and legislators
across the country. Now, are you full time or are
you full time part time as a senator?
We're full time. Massachusetts is full time.
You're full time. Okay, Well that's great. So that said,
what does your constituency look like? What are you getting
for feedback from them on serious mental.
Illness in what way? Like? What what do you mean.
When they make appointments to come to talk to you
they are looking for change? Is they looking for help?
What's some of the things that they might be looking for,
things that you might have looked at or or other
things that you might say, hey, this is a good idea.
Is there anything that they bring to you in their
meetings that just may stand out from others?
Yeah, they're access, access and access and insurance, you know,
access and like especially for parent like parents, I can't
get my child here, my child is sitting in the
emergency room for forty days, or you know, my child
had an incident in their school and they want to
kick them out. Now, well, what's wrong with your child? Well,
they have you know, they're autistic, and they're seriously autistic.
And one of the things they do is they lash
out and they're not being bad, they're just suffering from
what's going on. So I hear a lot of that.
I get a lot of that, And for a very
long time, I just got lots and lots of cales
of like my child can't be placed, they can't find
a place, this person won't pay that person. So it's
really a lack of access to the right treatment and
to treatment. You know that. What I see is that
this treatment is not one and done. And as much
as you want it to be, and as much as
the insurers want to treat it that way, that's not
how it works. And that's really what I think is
so difficult.
Right, Yes, that's so true. Now I've heard of some
states that once diagnosed, they only have a certain time
that they can be in the hospital. Right then they
kick them out right then they go to another hospital
and it's like a bouncing ball. Do you have that
problem in Massachusetts?
Yeah, the insurers will pay for X amount of days,
up to seven days, up to sometimes up to a
week sometimes, you know, but yeah, no, they determined the
length of treatment.
Then I've heard once they got kicked out of one hospital,
they would go to another hospital, spend the seven days
or whatever the timeframe may be. With that one get released,
then that hospital would find that unknowing to them, the
other hospital was first, and then that second hospital didn't
get paid. Have you run into that scenario at all?
No, I haven't run into situations where that were because
they thought they were being still in another hospital.
No, they were in another hospital, but that hospital couldn't.
Keep them right.
They were released from that first hospital. Then they went
to the second hospital, and because of that, across those
fine lines and ultimately that second hospital did not get paid.
Oh no, I have not heard of that, but I
would believe it if somebody told me it was true.
Sounds like insurance, you.
Know, Yeah, unfortunately it does. Now in closing, what do
you think the listener needs to hear that you think
is very important on legislation that you're trying to do,
legislation that you have done that hopefully will make a
better scenario for those living with serious mental illness.
This is an illness, and we have to constantly remember
that this is not a choice. It's an illness. And
this illness affects your ability to think in a way
that is, you know, the common way of thinking right,
the way we look at reality. This is an illness.
That challenges that right and remembering that it's an illness,
you know, working about against the stigma, and then requiring
that it be treated like an illness, you know, that
it is treated like anything else, heart disease, diabetes, any
other illness that people have, that it be treated that way.
Yeah, yeah, that is good and so true. One last question,
any legislation or bills that you see coming up that
we might not have talked about that still can help
many many people. You know.
I think there's going to be a lot of pressure
on all of the strides that we've made in Massachusetts
because of what's happening at the federal level and how
much money we're losing with Medicaid and SAMSA and the
grants that have come from the federal government that have
been really really important to helping address mental illness. They're
all at risk, and that's what we're spending an inordinate
amount of our time trying to figure out.
Yeah, that's what I hear from a lot of people. Well,
this has been great, great information, great conversation. I really
appreciate you taking the time to join us today.
Sure, well, thanks for doing this.
Oh it's my pleasure. Thanks again. Thanks for taking time
out of your busy schedule to listen to our show today.
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