Judge Milton Mack: A Man on a Mission to Reform Mental Health

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Welcome to Why Not Me? Embracing Autism and Mental Health Worldwide.
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Today with thrill to be joined by a truly remarkable
guest Judge Milton Mack. Judge Matt brings a wealth of
experience to the conversation, having served as the State Court
Administrator for the Michigan Supreme Court and as chair of
the Governor's Mental Health Diversion Council. He's also held the
role of Chief Judge of the Wayne County Probate Court
and worked as a consultant and advisor for numerous advocacy groups.
In twenty seventeen, his groundbreaking policy paper Decriminalization of Mental
Illness Fixing a Broken System played a pivotal role in
the creation of the National Justice Task Force to examine
state courts response to mental illness, where he served as
co chair from twenty nineteen to twenty twenty. With his
deep expertise and passion for reform, it's an absolute honor
to have Judge mac with us today. Thanks for coming on.
Well, I've spent a passion mine for some years now,
so we're making progress.
Yes, it's a great passion. Can you tell us why
it became a passion of yours?
Well, when I became a probate judge, That's why I
started hearing these mel health cases, and I had no
familiarity with them at all. But it didn't take me
long to say, I don't think this is working. I'm
seeing the same people over and over and over again.
This person's been hospitalized by every probate judge who's searched
nineteen seventy and with multiple hospitalizations and just seeing to
me the thing weren't working. We weren't accomplishing anything that
we were just in this revolving door. I started to
agitate for change. Might say this led to my being
appointed to the Governor's Mental Health Commission in two thousand
and four. When I was appointed, the point I wanted
to make where the mental health system was an inpatient
model in an outpatient world. It was focused on hospitalization
and preventing hospitalization, but not promoting that, not focused on
getting people well. So I advocated a number of changes,
which the Commission adopted, but I really got nowhere. But
I kept plug along and then one day chel seven
came in and wanted to film a mental health case.
Early in my career, I probably would not have done that,
but I thought, you know, the publisher see this. They
used to see what's going on, so on them televised
in mental health trial as Langely the invest piad of
reporter coming in and saying, you want to do a
series filming cases, talking to the family and members, talking
to persons of the metal illness and so forth, and
the series was called Waiting for the Disaster. I said,
the way the mental health system works is you just
imagine a train going down the tracks and then bridges out.
So we have two choices. We can dial up the
engineer and say the bridges out without the train, or
wing from parking ambulances at the bottom of the ravine
and picked up the dead wounded. Well, that's how the
mental health system was working. We wait for crisis and
then we intervene. Now, the two thousand and four Mental
Health Commission report said we live in the recovery era,
or mental illness is treatable, recovery as possible. People with
mental illness can lead productive, satisfile lives, ifficant or retreatment.
But the system was not designed to permit early treatment.
It was designed to wait till a magic moment just
before someone actually killed themselves or killed someone else or
we're just something terrible.
Yes, I've heard that from several people. What approach did
you take that you thought might work for change.
My effort has been has been trying to change the system. Ironically,
I had thought I'd run into a brick wall with Michigan.
I'd been appropriate judge for twenty five years and the
Chief Justice asked me to be state court administrator. So
I agreed to do it. And when I became a
stacred administrator, this made me a member of the Conference
of State Court Administrators. They do a paper overy here
on a topic of some sort, So I volunteer to
do a paper on the mental health system and how
we can change the system. So interviewed early reduce hospitalization
and incarceration, and you improve people's lives. They actually chose
the paper as the paper for that year, and I
led the creation of a national task force, and in the meantime,
all of a sudden, long jam broke roots and Lansing.
I was able to get a series of bills passed
in twenty sixteen. In twenty eighteen that changed the way
the process works in Michigan. We're seeing real temperances now.
Are there other things that you do as well?
One of the things I do is I do CICH
training for law enforcement, and I tell them about the
new Mental Health Code in Michigan. How it's now an
inpatience now an outpatient model in an outpatient world. And
when I say that, it's because over ninety percent of
all the mental illness is on an outpatient basis. So
the system should reflect that. We should find a way
to help people get help when they need it. I mean,
if you go back to nineteen sixty three the Community
Mental Health Act, that bill was designed to do two things,
significantly reduced number of people in hospital and provide an
outpage system of care as an alternative. The outpatient treatment
system didn't happen. So what happened. We got two million
people in America with serious metal illness in jail every year.
We had well over three hundred thousand in our state
prison system. But serious metal owns because you're left untreated,
and people think that guardianship is for adults. Now over
half of our guardianships harbor people with serious metal illness
who never got the treatment they needed when it would
have made a difference. So my objection has been to
treat a system or intervenially and avoid the use of
hospitals as well as jails and prisons. It's hospitals really
are not therapeutic environments. Number one. They're well, they're more
than jails in persons, but they're designed to stabilize someone,
not to get them into recovery, not to get them
well the table. So, just for example, in Wayne County,
which is where the twice located, we did a study.
Over a five year period, we had fifteen thousand petitions
for metal health treatment, or nine thousand individuals. Six hundred
of those nine thousand people accounted put thirty six percent
of all the petitions filed. There is less than one
percent of the population, but thirty six percent of the petitions,
and they are with all the firmly faces that rotate
in and out of the system capitulate. We looked at
the atop the users of the system. We had seventy
nine people who had at least ten petitions in the
previous five years. Those individuals in the prior fiscal year
we spent three point three million dollars on hospitalization, one
point six million dollars on incarceration, we're told with four
point nine million dollars. And for the four point nine
million dollars we got nothing. One individual had forty six
business to the er. So at what point in time
do we say this is not working, clearly not working.
Wow, that's amazing. So what was the next step to
make a change.
So we have changed the standard for intervention. We don't
wait till someone is dangerous to self, brothers. We want
to know do you have a mental illness, do you
understand your need for treatment? Are you faced with decompitization, cheriation,
and does this create a risk of harm? The harm
doesn't have to be immediate. So, for example, we had
a case in Michigan. At the trial, the mental health trial,
the doctor testified that the individual was not presently at
risk of harm. However, he had a history of stopping
taking his medicine, and the doctor testified that he could
be expected to stop taking his medicine in three to
six months and he would then be at risk of
harm arm in the form of drug abuse, suicide, increased
rest of dementia, and so forth. And the Court of
Appeal said, yeah, that's good enough. We're kind of looking
at the total circumstance which you get someone into treatment.
What we've done in Michigan is we actually have a
system of mediation or mental health cases, which I think
is kind of you need works the best for petitions
where we ask for out patient treatment only. We have
a system in Michigan now where you can file a
petition with the probate court. Don't go to the hospital,
don't go to the police department. The person may put
it this way when I'm hearing cases in probate court
and I act family members, But when did you stop
taking medication? And they say six months ago, eight months ago?
We all know where this is going. We're just waiting
for the magic moment. Well, no, we don't have to
wait anymore. Taking file the petition with the probate court
and get a hearing on whether to order out patient treatment.
And then as an extra tool instead of going to
full hearing, you can say, let's go to mediation. So
we have mediation centers of process date, we have about
one hundred mediators who are trained in mental health issues
to mediate these disputes. If you're going to mediate agreement
with someone who has a mental illness, you have engagement,
you have the good compliance. I have four bills pending
on life such right now they have passed the Senate
round and four of the House as we speak, I
might get attempt any minute now from the center of
the hotel. So I may have be got them all done.
The bills I had introduced expand mediation so that providers
of care will have a better option. The providers of
care don't like to petition their clients for treatment. They'll
certainly take advantage of mediation. They'll see if their client
is beginning to decompensate and before it gets too bad,
it's going to get mediation. We are trying to make
the process work better.
These all sound like they are great ideas that you've
been able to accomplish. Have you had any bumps in
the road in doing some of these things that you're
trying to do?
So we still have some blockages. For example, if I
want someone to get outpatient treatment only, I have to
have a psychiatrist testify I want them to be hospitalized.
A psychologist can testify to me. It would seem that
the higher ranking medical person ought to be talking about
hospitalization and a lower echelon person talking about outpatient treatment.
There's been tremendous resistant to these outpatient treatment orders. What
did you think what's going to happen when you empty
the hospitals? What are you going to do with individuals
who had to be hospitalized before you just give you
a comparison. In New York State is where Kinderslaw is adopted,
and that's where nineteen ninety nine they started the idea
of assistant out patient treatment. New York State right now
has about twenty five hundred people on AOT and the
population of twenty million. In Michigan, Gennessee County, but it
poperates to four hundred thousand has about eight hundred people
on AOT orders. So New York City or New York
State rather used AOT the way Jenesse County does. Here
in Michigan, they have twenty thousand people on AOT. It's
a preferred option to hospitalization when we go off the
hospitalization road. But that involves is the police go to
someone's home, parents and they go down and they effectively
arrest the parents sung and then take them out into
a squad car in from the neighbors and transport into
the hospital where he's held guests as well for a
few days befending a trial in front of a judgement
of black Road. Now, that experience is pretty traumatic.
Yes, that's what everyone says.
Why do we have to do it that way, and
we don't have to do it that way. We inflict
trauma and then the period of hospitalization is a few days.
In fact, we measure length to stay by hundreds of
a day, so we say, okay, the average length of
state of Wayne County is six point twenty five days.
What's length of the state is now, but it's typically less
than seven days.
I've talked with a few judges that are just like you.
They want to make change. How do we get this
across to other judges around the country. There's a couple
of things I think that are very important. One is,
of course you're helping people. Two along with helping them,
you're saving taxpayers millions of dollars by keeping them out
of the judicial system. What's our best pathway forward to
get this across the country.
Well, you know, judicial leadership really does matter. After your
front the Meyers breaks personality profile. Basically, I saw a
paper on this by judges, and judges tend to be
introverts and they tend to be reluctant to engage directly
with the legislature. So you have to find the judicial
leadership at each level. Now, when we formed the National
Task Force. One of the recommendations by the National Task
Force was every state administrative court at administrative level spreate
part level, every state should have a behavioral health administrator
at that level, and Michigan now has one, Illinois has one,
Pennsylvania has one, and this provides leadership at the state level.
Michigan and Wing County Judge Freddy Burton formed a behavioralhalk
Unit within the probate Court to monitor this process from
beginning to end, to treat accountability by the hospital, the
community treatment system, and so forth. And then the person
he hired to run it has now been hired by
the state to run behavior health Unit for the state
of Michigan, and part of her mission is to find
champions across the state. We don't need a lot of them,
but we need one for reasion for example. This can
be copied across the country by each state court administrative
office having someone who's charged with that responsibility to find
these individuals who are willing to do this. So I'm
seeing progress. I wasn't for the first twenty years. I
wasn't seeing much progress, but things really started to change
when the series came out. I had a clock from
the tenant governor's office went of howould help fix the statute.
I thought back to my space with the Mental Health
Commission in two thousand and four where we made seventy
some recommendations that got nothing. So that's not a while
goose Chase. I was sure it wasn't. So I went
up and did that, and things are improving. There is
a challenge though it Implementation is a big deal. So
in the fifties there was one shop shopping you. A
person was admitted to a facility and that facility provided
all the service of the person could possibly need. Well,
now that's not the case. Now you're in the community.
So now we have stakeholders that all have an interest.
Law enforcement is a stakeholder, the hospital, emergency department, the
community treatment system, the core families and other schools and
so forth, all the stakeholders, and so we have all
the makings of a mental health system. But the stakeholders
don't communicate with one another, they don't work together, they
don't have warm hand dots one place to the next,
and so it just doesn't hasn't been working. So in Michigan,
what we found was after these laws were adapted, a
lot of the hospitals weren't complying with the laws and
needed with the community treatment agencies and need to with
the courts. So we're changing the culture and that's huge
change the culture of an organization. It's hard to do.
So the culture has been we don't give people treatment
they don't want, even if they don't have the ability
to make that decision. So we're changing that. So the
idea is you've probably heard the term of anasegnosia.
Yes, I've heard that term many times in my travels
with this topic.
People who have a mental illness through the thought process
are compromised. They're not the ones exercising choice, but the
illness is exercising the choice. Well, we want to do
is free people so they can make their own choice,
free them from the effects of mental illness, get to
make recovery. Aside from me the economic sense, you know,
the avoiding jail, of avoiding incarceration, which is expensive, especially
to people with mental illness. We have to have extensive drugs,
We spend a ton of money providing mental health treatment,
and our jails and prisons and what are not through
future environments. If we can get people to kind of
care the need in the community. Not only can they
do well, but you can save a lot of money.
Under Jenessee County, they had a seventy percent reduction hospitalization
and in the individual surround. These outpatient treatment plans are
lying with treatment the level of ninety percent and the
satisfaction rates like ninety two percent. Now, when our serings
judge and I'd order some of the central hospital, I
don't think my satisfaction level was very high. The average
individual didn't appreciate me sending them to a hospital. But
back in Genesee County, what happens is when they ordered
outpatient treatment, a form is sent to the patient saying
team is going to guide your treatment and you're on
the treatment team. The only thing they can to engage
the individual to participate in the planning of their own
treatment plan. And individual's that situation to elect that being
listened to and they respond. So I think there's a
great opportunity to help people recover from mental illness, become
productive citizens, substantially reduce hospitalization or mercery room costs, and
substantially reducing incarceration.
Yeah, now, you were a part of the Mental Health
Diversion Council.
Correct by sharing the Mental Health Diversity Council in Michigan.
How does that approach some of these issues. I think
it goes in line to what you've been talking about.
Does it give a bigger audience to the issues that
we've been talking about.
Yes, definitely, because we have stakeholders. All the stakeholders are
in these meetings. We even had the hospital Michigan Hospital Association.
I suggested they be part of the Diversion Council. They're
kind of curious why they were there. They didn't think
they were part of the issue. I said, actually, you're
a big part of the issue is if your system
has been working, nothing's working. With the Diversion Council. We've
been developing these statutory changes in twenty sixteen and eighteen
and nineteen, so I've kind of expanded the notion of
what diversion is. So in my view of diversion is
a healthy mental health system that these people from involving
themselves in the criminal justice system at all. It's a
form of diversion, but it's rather expansive. I mean, the
Diversion Council in the beginning was focused on people who
are in jail and what would do with them. I
want to focus on people before they end up in jail.
You think about it. In Michigan, in an average year,
between one hundred and fifty thousand and two hundred thousand
people show up in hospital and mergery rooms. On the
other hand, no health courts we have in Michigan, which
you have a lot. We have over two hundred courts
that do the sort of work, but only about three
percent of the people who have a mental illness in
our jails are in a treatment corp. The treatment courts
are expensive and you can't scale them up. So if
you really want to make a difference, go upstream. Help
people stay well so they don't get in trouble with
the law.
Now, does the council work with the legal system like
lawyers DA's that type of people, so that they can
get more information about what needs to be done to
help these people. It's my understanding that once a person
gets in front of a judge, that's when the legal
system judges. The lawyers, das, even some defense don't understand
the mental health situation.
That's just true. But we're having one of our bills
to create a diversion process for those who are charge
of theft demeanors. So currently in Michigan and most states,
when you're charge of the crime the mental illness, they
send it to the forensics tire from evaluation and they
have to assure if you're combatist stand trial or not.
If you're not compet stand trial, they have to make
your combet stat trial so they can convict you now
or misdemeanors. Sending those individuals to the forensic center is
an enormous waste of time, talent, money, resources, because at
the end of the day, all you run to view
it is a conviction for this demeanor for an individual's
going to reoffend. So it'd be much smarter. So instead
of staying this person to the forensic center, you send
them into assessil out patient treatment and drop the criminal charges. Now,
when we put together that legislation, we have the support
of the Michigan Prosecutors Association as well as a defense buyer.
We have the support of the disability rights people, so
they all saw this is a better option because if
we can take someone who's mentally committing misdemeanors and get
them well, they were not going to have to deal
with them again in the criminal justice system. So let's
see if we go upstream and take care of people
before taking in trouble the penneral justice system, and you're
just going to significant reduce the that impacts with that level.
Have you had situations where you sit down with some people,
tell them what you're trying to do, yet they're just
still not getting behind you. While you're talking with them,
you think it's going to be an upward battle. They're
just not getting what you're trying to put across. Then
the more you get into it, the more you show
them the facts how they can save money, most importantly,
how they can make it a better system for everyone involved.
Oh yeah, it's been very enlightening. It's lightning for stakeholders
to find out how they are victims of a bad system. So,
for example, ask for emergency rooms, are trying for the
fact that their emergency rooms are crowded with people met
us when I point out, well, you know, if we
take care of that properly, they will becoming your emergency
rooms or law enforcement. Yeah, one third all of the
people in this country with the straightest mental illness their
pathway to care with through law enforcement, which is staggering.
So people in law enforcement are not a front line.
There's not a police officer around who won't tell you
that deal with people behavioral health issues is a big
partner job. If we can take care of that at
the treatment level, we help them out, and we even
help out community treatment because if you get people on
their into treatment and into recovery, it puts less pressure
on everybody all the way around. People eventually see it.
You are so correct there. The police officer is the
first one most times that they come in contact with
The unfortunate part is sometimes the officer has only seconds
to make a decision on what to do. The more
we can get them to understand, the better situations we
can have, so when they do come in contact with
someone that has a mental illness, they might be able
to have a better outcome.
Right. Well, you know, judge, I think that you spoke
with Judge Steve Wifeman. I believe already. Yes, and he's
a he's a master with that. He's uh, it's amazing
what he's done. Florida is not a Medicaid expansion state
and they don't have a good, uh civil system or
mental health issues like we do in Michigan. So to
that extent Michigan really is is in an advantageous position,
and theoretically we should be doing better than what Judge
Leicheman is doing. By Judge Laichman has a head start
on us, so we're still trying to catch up. We're
trying to We're moving into in lying a crisis centers
out of hospitals and you know, if you're right at
outpatient treatment price saturs and so forth, and hospital emergency
rooms are going a lot different. Yeah.
I think he's got up two hundred and eighteen thousand
square foot facility that he's opening up.
I've been down there and checked it out. It's quite
quite an operation.
Yeah, it's great. I think that's what we need is
more people like him yourself to show people that change
can be made. Not only does that change help lots
of people, it also saves tremendous amount of money and
time within the legal system that can be better put
to use for other things.
And it eliminates all kinds of risk as a ganger.
And I mean, you're still going to have situations, but
you can reduce a number. You can manage it better.
Absolutely. Now, what would you like to leave with our
listeners that you think is very important for them to
understand on what it is that you're trying to do
to help people.
Well, we need to intervene early. We don't wait to
treat someone. We wouldn't wait to treat someone cancer under
stage four. We do just as much damage by waiting
to treat mental illness. And it is no, you're not
depriving people of their freedom when you're freeing them from
the impact of mental illness, which is left untreated and
assistant of patient. Treatment is the most humane treatment possible.
It's better than being treated in the hospital, far better
than being treated in jail, and far better than homelessness.
And we should do this and it's good for everyone.
Absolutely well. I definitely appreciate you coming on, great information,
great conversation.
All right, thanks lot, I appreciate you doing this.
It's been my pleasure. Thanks again. Thanks for taking time
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