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It's entitled The Neuroethics of Involuntary Treatment for Serious Mental Illness.

And with us today, we're very fortunate to have Dr.

She's founder and principal consultant of Lario Forensics, and she is the chair of psychiatry at the Morehouse School of Medicine.

So we're very thrilled to have you, Sarah.

And Stephen Stahl, of course, is here, as always.

Steve, I know you've got a very long-term interest in this topic and have been very involved in the state of California.

Oh, I'm doing great and really pleased Sarah could be here.

I was going to say rising star, but I think it's already risen, but...

And rising further and knows a lot about this field.

I come to it from the perspective of the state hospitals in California where we have not only hospitalizations but decriminalization programs where we try to divert from the hospital and do competency restoration outside the hospital.

And we also have this new and somewhat controversial law that just passed called CARE Court, in which it is possible to get a judge to help patients by having housing and medication before they've committed a crime, but possibly even administering it involuntarily, wherein lies somewhat of the controversy.

So we want to pick Sarah's brain to see how best to do this, and also come to it from the perspective of seeing these systems work in other countries.

The idea of what, if you will, families are and communities are, or even an old-fashioned term paternalism or maternalism in which the communities take care of people and kind of move them towards treatment and housing, which is somewhat involuntary, but it's a little bit coerced at the same time.

So the United States has this civil liberties idea and disability rights idea that you can't even touch that.

And so we have looked at Ireland, we've looked at Austria, we've looked at Italy, and they do this much better than we do.

We put them in jail or throw them out and make them homeless.

And so it's a pretty brutal system in the United States.

So it'll be interesting to see what Sarah's vision is for the future to fix all this.

So we've got some here, we've got some stormy times, but we're moving ahead in California, and let's see what the right coast thinks of the left coast.

Well, Sarah, maybe you could tell us a little bit about the situation where you are and where you consult.

Yes, so and I would say that the perspective I have is informed by being a consultant and someone who has worked in correctional facilities and as someone who wrote a book about social justice and mental health.

And 1 of the things that I'll say comes up quite a bit is the, not tension, but the need to always address treatment in the traditional mental health sense with safety net services and psychosocial resources, concrete resources that people need like housing, community, things of that nature.

And 1 of the things that we're running across in Georgia, which is where I'm based, is this push to medicate people without a commitment to providing them with what they need as a whole person, rather than just as a patient in need of medications.

That is so well said, And I know, Steve, you've talked about the program in California.

We've actually worked with the Vatican on some of the neuroethics of this.

And so the three-piece stool is medication, housing, and the third leg, meaning.

So the issue is people get meaning in various different ways, but what is it like to be even stabilized, medicated, and housed with this kind of illness of schizophrenia or similar illnesses, and how can we have meaning in people's lives.

We found some of that meaning in overseas, in communities of 10 to 20 people living in private houses.

In fact, 1 place in Italy we went to, there were 20 people and 3 horses.

So they actually had horseback riding and other things.

And these were some very sick people, some of whom had done some fairly heinous crimes, but they just looked like ordinary people.

They couldn't leave and they had to take medication.

But part of the United States problem with that program is not only not so much community caring about your brother and sister as maybe they do in other cultures, but the answer to 2 questions, which we haven't done very well, I think, in my estimation in psychiatry.

Number 1, to actually show that schizophrenia is an illness, not a choice, not bad mothers.

And number 2, medications work, but you have to give them and they don't cure you and they have to be done in the context of being leveraged, like Sarah just said, with housing and other resources in order to, quote, work well.

But there's a myth out there that schizophrenia is not an illness and that the meds don't work at all, they just cause poisoning, and that their

you know, the right to refuse them is really part of the crux of all this matter.

When do you medicate, and do you have the right to do that, and do you have the right to

Well, Steve, you've brought up something very interesting.

Sarah, I'm going to cut to the heart of this a little bit.

Are an individual's personal rights compromised if they get involuntary treatment for their mental illness?

Yeah, and I think it's a really, it's a tough question, right?

Because with the brain and with mental illness, the decision-making organ is the 1 that's impacted by the illness, right?

So it's a different kind of conversation if you're talking about treating diabetes or high blood pressure or something like that.

And so at some point, you know, the harm that people face, the risk that they carry of being untreated raises different questions for mental illness.

And then especially when you start talking about people from marginalized communities, whether that is by race or by socioeconomic status, the reality is society's tolerance for perceived deviant behavior in those populations is different.

The risks of being untreated are different.

And so the risk-benefit ratio may change, right?

If you're having an honest appraisal of what it means to be untreated in a society where you're already at disproportionate risk of being targeted by the criminal legal system.

But I did also just raise some points about why it's not yes or no because you have that balance of letting people be harmed who may not be able to see what's happening versus overstepping, you know, your bounds.

My boss, you probably know her, or I'd like to hope that you guys could work together, Dr.

Katherine Warburton, Kate Warburton, she's the director of the state hospital systems here.

We're trying to put this together in a simple way, And the dilemma is life versus liberty.

And the idea is that in the United States, because of our past in psychiatry, we've lost the moral high ground to make moral pronouncements on what's ethical and what's not ethical.

So that's why we've reached outside psychiatry for advice on that.

You know, is it ethical to treat people when they've lost the capacity to make healthcare decisions?

If you're a psychiatrist, you would say yes, probably in most cases.

On the other hand, if you're civil libertarian, you think you have the right to refuse treatment, and liberty is more important, and we would say they would love people to be able to die with their rights on.

And so, you know, the question is, you know, those are the 2 extremes.

And right now, the disability rights people and the ACLU and people like that have the upper hand, because they are very opposed to any involuntary treatment.

They think everybody, even stark raving out of their ability to make rational decisions still can refuse medication, partly because of our ugly past where we did abusive things.

But it's gotten too far, the pendulum, we think, I don't know if Sarah agrees, has swung too far in that direction.

And now you're finding, it would be interesting to see, Sarah, whether you think that if you're in a marginalized community, do you have to get very sick before you get treated and then you go into the criminal justice system, you don't even have the possibility of getting treated before you commit a crime.

Well, I think part of Sarah's concern, and Sarah, please tell me, is that, no, it'll be overused, not underused here because of what...

Who's deciding here, who's competent and what the deviant behavior is, you know?

There's overpolicing, for instance, in minority communities and things like that.

How is Sarah, how is this different from years ago when people had tuberculosis, they were confined and treated for their tuberculosis?

Well, I think the stigma of mental illness and as Dr.

Stahl mentioned, just the fact that people still have a hard time wrapping their head around what it is and that it's real is part of the issue, right?

I remember in residency they said in order to get people to take medication or to go on the treatment, they have to believe that they're sick, that the treatment is going to help them, and then whatever the treatment is worth the side effects, right?

They don't think they're sick or they don't think this is something that's actually a medical issue, you're not gonna go any further after that.

And when it comes to marginalized communities, there's the both and.

So there's the increased risk of criminal justice system involvement, whether you've done something or not.

It could be a wrong place, wrong time, and you're just in an overpoliced community, but there's also the increased risk of you being perceived as more dangerous than you are.

You may be being given diagnoses that don't account for things like mood, a trauma by the mental health system as well.

Saul is talking about our history as it relates to human rights, there's a history we have in psychiatry as it relates to differential treatment of these marxist groups that can make engagement, you know, challenging as well by us.

There's a risk of under-treating and over-using this tool, if you will.

But I still see this as a public health issue to some degree.

It's certainly an issue for the individual, but also we know that if people are not medicated or not treated that we have a homeless problem.

We have violence Why is this not seen as the larger impact on all of us on society?

I think our society isn't very good at public health period Right.

It's not just you know public health as it pertains to mental health, you know, not to do anything or say anything too controversial, but we saw how he responded with COVID vaccination versus comparable nations, right?

Public health is not our strong suit in the United States.

Public health, like mental health, is vastly underfunded.

I think you're right and underappreciated.

And how does that impact people with severe mental illness?

So with competence to stand trial, what you're hoping is that someone who is at risk of losing their liberty or having a criminal record is able to assist their attorney as their attorney is trying to defend them against these charges.

So in order to do that, they have to have an understanding of what people are saying they did.

They have to be able to follow court procedure.

They have to be able to have a coherent conversation with their attorney.

And 99 times out of 100, they're actually not going to go to trial.

So they have to be able to kind of understand what's a good deal, what's not 1 and how do I figure that out?

And so for people who have severe mental illness, sometimes their symptoms are going to get in the way of them being able to do those things.

And if they are not able to do those things, it halts their criminal proceedings completely.

So you can have somebody who has a misdemeanor charge for loitering and they can be caught up in the criminal justice system for 2 or 3 years if it takes a long time to get into the state hospital to get found competent or to get found not be able to resort to competency.

So it's something that's meant to protect the people going through this system But what you can see is that sometimes it ends up resulting in really long delays.

So people as they're trying to get their cases taken care of and a lot of money and resources are spent on competency restoration, and then they're restored and returned right back to the community with very little to catch them or to keep them well.

Let me tell you some sobering statistics that we found looking at the IST, the incompetent to stand trial population in California.

The cause of this is not completely clear, but it probably is they're not getting treatment in the community, so they just wait around until they get arrested.

And so our IST population ballooned so that we had 2, 000 patients in jails all over California who were IST and couldn't get into the state hospitals because it's full, a little bit like Sarah said.

But they sued in federal court and won, basically for civil liberties or civil rights violations, which means they were incarcerated and they weren't getting treated.

And that's, you can't do that to somebody.

So we had to develop some jail-based competency programs, restorations in jail, not very ideal.

And then also to try to divert them to outpatients.

They had no evidence of having been in the Medicaid, Medi-Cal database or any sign of any treatment the prior 6 months, and they had a median of 14 prior arrests.

So when you're coming into the system, these are rotating, just as Sarah said.

You get in the system, get medicated, get restored.

Maybe you just go to trial at that point.

Maybe you just get released for time served.

But then you get released, you know, with a handshake, and chances are they don't have a home or medications.

The average length of stay in California in jail is about 6 months for these people.

And, you know, the Twin Towers is the biggest psychiatric hospital we think in the world.

There's 25, 000 people can be housed in the Twin Towers jail, the Men's Central and Women's Central Jail in Los Angeles, 6, 000 of whom have serious mental illness at 1 full.

So that's the problem, is that this cycle, and that's why the CARE Court has been conceptualized as well as diversion.

So get them out of jail, get them restored as outpatients.

If you are in the program, I think it's 36 months, you get your charges dropped, you're not even a criminal at that point.

If you haven't committed a felony, you can go to court and be given housing and treatment, but you have to accept it.

And in fact, there is the ability, which is controversial, of the judge to impose that.

Whether the judges will, it remains to be seen because the court's not really in full swing.

So these are some of our solutions to this problem.

Are we on the right track or going crazy?

So we know we have to do something different.

And I think that sounds like a great first start.

We only have so many dollars that we can invest in this population and continuing to invest it the way we have clearly is not yielding good results.

And so I think there's going to be a lot of trial and error as a lot of different municipalities and states are coming to the conclusion that this isn't working.

And like any other thing we do in medicine, we wanna be curious, we wanna be data-driven, and we want to watch and see how it plays out in terms of outcomes.

And 1 of the things that I think is going to be really important with these outcomes is making sure that we're paying attention to stratified data, right?

So we're not just looking at it as a whole, but we're looking at things like socioeconomic status and race and if people have ID or things like that, right?

And making sure that we are giving these opportunities for resources before they get caught up in the system in an equitable way.

So it's the only outcome, whether they get rearrested or not.

I mean, this is 1 of the problems with outcomes.

I mean we want to have somebody have more of an outcome than that.

The people we saw in these villas and in these places in Austria and these little homes in Ireland, I don't know how you measure that.

I mean these were just nice people sitting around, you know, kind of in a pseudo family and they were having meaningful things in life.

They weren't employed necessarily, but some of them were part-time.

So, you know, we don't have really good tools, do we?

I mean, Sarah, how do you measure an outcome?

And I think that the outcome that is measured in some respects is going to depend on your audience or the outcome that is emphasized.

So when you're talking to judges in a conservative state like Georgia, not being rearrested is the outcome they might care about the most, right?

And that's what you play up with that population.

When you're talking to community stakeholders or family organizations, right, they may be talking about engagement with their family and how much are they coming out of the room and have they picked up their hobbies again, right?

And so I think there are different outcomes, but I really appreciate that point.

It's not just about staying out of prison.

It's about what are you adding to their life that's giving them some sense of connection and some sense of purpose.

And as a child psychiatrist, I talk to parents a lot about, you know, managing behaviors in their children.

And 1 of the things we emphasize is you can't just tell somebody stop.

And so I think that's a really great point.

I do think that sometimes depending on people's orientation, their eyes might start glazing over if you start talking about meaning, but I think that's critical for the people who you're trying to get to engage with this and buy into what you're trying to offer them.

Well, Sarah, isn't it expensive the way we've been doing it now?

Doesn't it cost a lot of money to be putting these people in the criminal justice system?

Wouldn't we be better off putting some of this money into these community services we've been talking about?

You know, and part of the trick that you have to make sure to be mindful of is that once that process of trying to resolve criminal charges starts, you can't undo that.

And so in order to keep people from going off that track, you have to intervene before they're indicted and before they're charged.

And I think that for a lot of places, that has been a big challenge.

What does it take to to spend, to keep a person in the California Department of State Hospital for 1 year, 1 patient, 1 year,

What does it take to put somebody in the inpatient jail, in the prison system?

I mean, there are jail, prison, sort of pseudo-prisons inside the psychiatric disorders, so not the outpatients in prison.

The psychiatric hospital inside a prison is $250, 000 a year.

The jail in California is around $100, 000 to $150, 000 a year.

When you go to a diversion program, you get housing, medications, staffing, you're living in the community, what's that cost?

So, you know, part of the people of course that are infested like prison guards and others that don't want to lose their jobs, they want to keep the prisons full and of course people who've got other agendas that are more political, I suppose.

But the reality is, you know, the famous you probably know him, Steve Leifman from Miami.

There were 2 big jails in Miami until he got there.

Warburton didn't want to build another 1.

We need another hospital for 2000 people.

We already have 7, 000 people in these hospitals here.

The idea is to divert them away from criminal justice for most felonies.

And Sarah, you know this, you know, if somebody, a cop wants to really get somebody off the streets, he provokes them or she provokes them and they push the cop and now that's a terrorist threat or assault, it's a charge we call it, so they can get a nice felony on the record to put the person away.

So the upcharging in some ways is merciful and it gets them care, but it's horrible because it puts them in criminal justice for the rest of their life.

So the question is how do we divert from criminal justice without having some ability to put people involuntarily, I must say, into treatment.

Otherwise, they'll just keep on having bad behavior until they offend, and we can take their rights away from them.

So the question is, is that the way to run a system?

Steve just mentioned involuntary treatment again and I think maybe we want to define this a little more clearly.

What exactly does involuntary treatment include?

Is it medications against the patient's will?

So what are the various forms of involuntary treatment?

Yeah, both of those would certainly qualify.

And maybe it's not quite involuntary, but even in my juvenile clinic, sometimes I'll see families where they're told, if you don't take them, then he has to go to a juvenile justice facility or that sort of thing.

And so it can take the form of therapy that people may not want to engage in, but they're kind of facing an ultimatum, forced medication, hospitalization, any of those things could certainly qualify.

And then what changes in the criminal justice system are needed to improve recognition, treatment, diversion, as we've said, and hopefully rehabilitation of people with mental illness?

Well I think part of the problem, right, is that the criminal justice system is trying to step in where the mental health system has failed.

And so we own this in the mental health space, but we haven't owned it.

And you're giving cops the job of being triage nurses, and it's not going well, not surprisingly.

So there's a part that they can do, but there's a piece of this that is a direct indictment on our failure to reach these marginalized communities in an effective way on the front end.

Isn't it really, if you look at it historically, isn't this a failure of the deinstitutionalization process?

I mean, the idea was to, with these modern antipsychotic medicines, We could start closing down state hospitals, move people into the community.

Ideally, the dollars would follow them, but that's not what happened.

That's really where this all breaks down, as you've said.

If you look at this over centuries, though, it's been sort of a migration from 1 place to another.

So, families, even today in Italy and a place like India, they take care of weird Uncle Joe in the back room and make sure he gets his medicines and the family takes care of him, he goes to dinner with them and when he gets a little out of control, they see a doctor, but you know, families, these patients were in families.

Then the next thing is that they went to asylums and at first the asylums were great because they were not overcrowded and they were merciful and nice people started them and they got crowded and that abused him.

So then they went from the asylums to the streets because the dollars didn't follow them.

They went to the criminal justice system.

Our society in general fails to grasp that 1% or more of us, all of us, have this illness.

And if we do not have resources for, say, you know, out of 300 million people, 3 million people, they're going to go someplace.

And so we have basically under-resourced the mental health system and so pushed them.

I, when I had the chance to talk to the Pope actually about this, I was referred there, you know, because he was interested in migrants.

And I said, you know, with all due respect, sir, I think you were, he was worried about the Syrian migrants and the various people that at that time were coming into Europe because of not getting a good reception necessarily, and had all sorts of horrible things happening to them from the dislocation of war.

And I said, what about the eternal migrant?

And he looked at me funny and he said, what do you mean?

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NEI Podcast - E190 - (CME) The Neuroethics of Involuntary Treatment for Serious Mental Illness