Takeiya Lynch M.D. is PGY 4 – Program Chief Resident and Adolf Meyer Chief Resident in Public Sector @UMassPsychiatry @umasschan
This presentation was made as part of our #grandrounds on February 8, 2024.
#mentalhealth #psychiatry #bestpractices
Hello everyone and thank you all for coming both in person and virtually um I’m going to try to do this without my glasses but we’ll see how this goes one of my favorite hobbies is cosplaying as a person who can see well so as long as no one asks me um how many
Fingers they’re holding up I think we’ll be okay um so transinstitutionalization an unintended consequence of good intentions I chose this title because there were many instances where people thought they were doing the right thing at the time but they were unable to account for the future consequences as
The saying goes those who do not learn from history are doomed to repeat it so I hope as we look into this topic we are able to learn from the past and then are able to avoid some of the same pitfalls I have nothing fun to disclose so the learning objectives are
Written in a question answer format because I try to think of what questions might come up with the a title of of this type of talk and how I might answer them so the first question I’m sure you’re all thinking is why should we talk about this so it’s to understand
Trans institutionalization and its effects on psychiatric hospitalizations in Massachusetts and then we’ll also talk about how did we get here we’ll talk about a series of relevant historical events that led us to our current state what is the current data we’ll learn about the current trends in psychiatric hospitalization who are these patients
We’ll learn more about the affected patient population how can we learn more about this we’ll discuss how to prepare residents to better manage these patients and lastly and arguably the most important what can we do about this we’ll discuss what may be some potential Solutions now that we have a road map
For where we’re going let’s start off with some definitions so so that we all on the same page with what we’ll be discussing today broadly these terms describe where people with mental illness receive treatment so for institutionalization it refers to patients um moving from being treated in the community to being treated in
Hospitals deinstitutionalization kind of refers to the the process of replacing long-standing psychiatric hospitals with um community supports trans institutionalization kind of talking about the migration of people from the community into the uh criminal justice system and forensic psychiatry a subp specialty in Psychiatry that focuses on the inter relationships between Psychiatry and the
Law then for our non-massachusetts friends um I wanted to include this uh slide just to kind of give some more background information so very briefly these are the state laws that will be referenced in this presentation the section three it uh facilitates the transfer of a patient from one psychiatric facility to another
Most often and in this context it’s um from an acute care to a higher level of care such as a state hospital section 15’s court order evaluations for competency to stand trial for an offense uh I I won’t go into all of the details of each of the
Section 15 16 18 um but this is just kind of like a general overview section 16 court order evaluation Andor commitment for uh people who are found incompetent to stand trial or um Not Guilty by reason of insanity or similar term in section 18 Co orded evaluations of an incarcerated individual determine
Whether or not they need a hospital level of care okay so why should we discuss this let’s start with a relevant scenario an acute care psychiatric hospital has two patients awaiting Section 3 transferred to a state hospital one has been waiting for close to two years and the other for about 13
Months due to their Acuity both patients require single rooms for a period of over a year the equivalent of four acute care beds are held in limbo while the medical floors and emergency rooms are overflowing with patients awaiting place to acute care hospitals so why I’m sure you could guess the answer
Limited resources um so limited resources both inpatient and outpatient um as well as in the community at large via the social determinance of health patients generally enter the state hospitals via two main Pathways civil through a section three transfer from acute care hospital and forensics through the through the courts via section
Yeah I’m looking now H more one I found the meeting um there section 18 well I’m glad he could join all the way from Hawaii um it’s so Massachusetts state hospitals were less than 50% forensic over a decade ago but this has increased to 60 to 80% in recent years these
Numbers are projected to approach 100% as Baby Boomers age and overwhelm the Health Care System how can we best allocate these limited resources in a way that is the most Equitable and assessible that’s the million-dollar question and adjusting for inflation probably the billion dollar question um
But we’re not going to answer that today but I think it’s important to keep in mind you may recognize the Clock Tower from wi Recovery Center realiz I kind of Point where’s the laser button sorry oh sorry here we go um I mean I know you
Have eyes but this um it just kind of showing the kind of long-standing History uh the clock tower was refurbished from the original Clock Tower and administration building of the second wer State Hospital built over 150 years ago so how did we get here I want to preface the next session with the
Warning about some of the language that is used in its historical context terms such as lunatic and insane were considered appropriate at the time even though we no longer use that language today in the early 18th century the insane were typically viewed as wild animals who had lost their reason they were not
Held morally responsible for their actions but were subject to scorn and ridicule by the public towns contracted with local individuals to provide care for those who were poor and without family a situation that often led to widespread abuses mentally ill persons were kept in appalling conditions often
In Chains and neglected for years or subject to torturous treatments including beatings blood letting starvation and isolation moral treatment developed in the context of the Enlightenment era and its focus on social welfare and individual rights awesome great intentions these ideas gained more traction in the 19th century when many
State mental heal Health hospitals were built uh dorothia Dick’s kind of our hometown hero here uh grew up in Western Massachusetts in the early 1800s she did work establishing schools and teaching children and she was said to have suffered from major depressive episodes and during one of these episodes she
Went to Europe for kind of a change of scenery while she was there she was inspired by Great Britain’s Reform movement for the care of the mentally ill known as lunacy reform while she was away her wealthy grandmother died and she inherited a substantial Fortune she
Returned to the US in the 18 40s and launched an investigation into the care of the mentally ill persons in the United States she found evidence of deplorable conditions and successfully lobbied State legislatures through her efforts she helped establish 32 psychiatric hospitals um so this part is the the fun
Part because I learned a lot here um so in 1829 so a little bit ahead of the the game the Massachusetts legislature ordered the formation of a committee to investigate the condition of its insane citizens across the state the investigation uncovered horrible scenes of lunatics dressed in rags kept in dark
Dungeons with no beds in 1830 the state legislature passed a resolution to erect a lunatic hospital with accommodations for 120 patients pictured here at the first Wester State Hospital built on Summer Street in the downtown area in the 1830s was considered a model institution built under the principle of moral treatment a
Holistic approach utilizing moderate labor the enjoyment of nature recreational activities wholesome eating and adequate rest however the 120 bed facility quickly doubled in capacity and fell into disrepair into deplorable conditions Doria dicks uh advocated for its expansion shown here in the 1840s following in an inspection 1855 it was determined that an
Additional hospital was needed which led to the creation of the Northampton State Hospital shown here which was completed in 1858 the first Wester State Hospital continued to operate for 20 additional years in its deteriorating State until the second Wester state hospital opened in the 1870s the second building and its
Grounds were a huge property spanning over 200 acres and included the land that will later become the UMass campus it was designed in the kirkbride style to adhere to the principles of moral treatment Dr kirkbride was a psychiatrist who influenced the design of many state hospitals and he believed
The hospital itself would function as a treatment for patients he emphasized sunlight and proper air circulation in large sprawling facilities of at least 100 acres where hospital staff also lived on the premises access to extensive Farmland Gardens and other outdoor space was also emphasized pictured here is the layout
Where you can see the multiple living quarters and areas including the the wood shop and the bakery so it’s very large building which is it’s really hard to conceptualize just how big it was circled here is a photo of Dr Adolf Meyer former APA president who developed a precursor to the biopsychosocial model
In the 1890s he was head of Psychiatry at wer state hospital and was the first Psychiatry Residency program director which originally developed at Worcester State before moving over to UMass the chief residency in public sector Psychiatry is named after him in 1955 the hospital’s population had ballooned to 3,000 patients and it
Operated until its close in 1992 after a series of fires the previous year the Kirk Breg style of building was very well-intentioned but such large buildings were expensive and difficult to maintain so it was eventually torn down there was one building remaining until the Wester Recovery Center and
Hospital uh with a staic capacity of 320 beds opened in 2012 and replaced it um and many of these photos are obtained from the Wester Historical Museum prior to the mid 20th century there were no anti psychotic anti depressant or mood stabiliz stabilizing medications the hospitals encouraged activities such as dancing sewing broom
And brush making weaving carpentry and farming as these activities were believed to be therapeutic pictured here are Wester State patients engaging in these activities and in an example of one of the seating areas um in the hospital so they really tried to kind of make it as homely as possible home uh
Here and then so you may recognize this gorgeous building um it is where the Department of Mental Health Central Area Office is located it initially served as a farmhouse in the late 1800s where farmers and and patients lived in the building intended the land and the animals um there are several dmh offices
Throughout the state that are in buildings that were originally part of Old State hospitals and I like this picture for scale of this is just the farmhouse like how big the entire facility was um another building you may recognize is the Hooper turret it Still Remains on the Wester Recovery Center
Grounds today the Hooper engaged turrets were circular Wards added to the wer State Hospital to house suicidal patients so that staff could monitor them initially made to house 24 patients with a day space and a separate sleeping area they were forced to accommodate 48 patients due to the need for more hospital
Beds there were not enough bathroom shower facilities for the numbers of of patients held there the hospital was a convenient place for inconvenient people this quot is attributed to a former patient at the Northampton state hospital I saw it written on a plaque pictured here as part of the Northampton State Hospital
Memorial Park and it really struck me these were the unintended consequences over time hospitals had become overrun with immigrants minorities deviant women political dissidents and people with physical disabilities particularly deafness hospitals were overcrowded understaffed and underfunded they were old and deteriorating rapidly there are numerous human rights violations such as Force labor and
Sterilizations as well as questionable experimental treatment including labotomy ice baths insulin shock therapy and electrical shock therapy without anesthesia many patients starve to death during tough Economic Times and were buried in unmarked Graves on Hospital grounds all the photos seen here are actual photos from the Wester state
Hospital um though one unexpected kind of bright spot to me was um despite the time period there was actually a lot of integration so you can see that there are um the the staff are different races and when I looked at other pictures of the patients dancing together like it was
All very integrated despite the time period so moving on to the 20th century in the 1940s during World War II those who refused to serve in the war were sent to work other areas that were underst staffed these areas included Mental Hospitals which led to more public knowledge about the awful
Conditions leading to increased funding for mental health treatment and the creation of the National Institute of me mental health the 1950s saw the beginnings of the Civil Rights Movement the first antis psychotic medication poor borazine um also known as thorine was discovered in revolutionized psychiatric treatment as patients now had a viable
Opportunity to be successfully treated in on and outpatient basis 1960s JFK had a special interest in mental health his elder sister Rosemary had seizures and violent mood swings so their father secretly had her lobotomize following this she was physically disabled with diminished mental capacity and she was hidden away
In a private psychiatric hospital for 20 years President Kennedy signed the Community Mental Health act which provided funding for Community facilities that served people with mental disabilities the plan was to construct 2000 Community Mental Health Centers through $150 million in federal subsidies these centers had to provide pral hospitalization programs in
Intensive Outpatient Care 24-hour emergency services and educational opportunities they hop to make State hospitals obsolete these were good intentioned actions at the time however less than a month after signing the new legislation JFK was assassinated and could not see the plan through the Community Mental Health Centers never received stable funding
And even 15 years later less than half of the promise centers were built that these were the unintended consequences despite this the closure of many psychiatric hospitals persisted as patients were increasingly cared for at home in halfway houses clinics General hospitals or many not at all the 1970s saw even more public
Support for deinstitutionalization with popular mov movies such as One Flew Over the Cuckoo’s Nest and the United States Supreme Court limited psychiatrist’s ability to hospitalize patients and raised the burden of proof for involuntary psychiatric treatment the 1980s saw an increase in homelessness which was thought to be related to deinstitutionalization studies from the
Late 1980s indicated that onethird to one half of unhoused people had severe psychiatric disorders often cooccurring with substance use in the 1990s the National Alliance on Mental Health eami lobbied for the passage of the mental health parity Act of 1996 achieving the mental health movement’s goal of equal insurance
Coverage for mental and physical health but through managed care insurance companies would now dictate how long patients could stay in hospitals so best word to now what is the current data so there were 340 psychiatric impatient care beds per 100,000 persons in the United States in 1955 this number dramatically decreased
To 17 um in 2005 since 2005 there has been a modest increase in beds the number of adults in patient or Residential Treatment beds in increased by 24% from 2010 to 2018 in 2018 the average population rate for beds in Mental Hospitals in the United States was 39 per 100,000 today
The most cited estimate of psychiatric bed need in the United States is 40 to 60 beds per 100,000 which translates to up to 66,000 beds that were short in meeting the needs of our population in terms of forensic patients in California the forensic population in their state hospitals has hovered around
90% for the past 20 years in Colorado there’s been a over 200% increase in forensic patients from 2005 to 2014 and Hawaii has seen a three-fold increase in their forensic patient population from 1997 to 2016 um for us the patient Continuous Care bed capacity for psychiatric patients has dramatically decreased
Since 1970 from approximately 12,000 beds to the current level of 693 as of 2019 the reduction of beds over the years raises concerns over bed availability this has led to our state hospitals once again functioning well over capacity and converting other rooms into beds that were not appropriate for this
Purpose um so I think that this is a great graphic kind of representation of this so the massive decrease in beds happened right in the first six years um by more than 200,000 beds um then continued to steadily decline after that way back in 1939 long before widespread deinstitutionalization a
British psychiatrist lenel pimrose hypothesized that the number of psychiatric hospital beds was inversely related to the size of the prison population and well we know that correlation does not equal causation and it is important to note that the War on Drugs also started around the time at at the same time of
Significant Hospital closures in the 1970s but the prison population exploded in 1980s when discussing Hospital closures it’s not just the patients currently occupying the psych beds that are affected it’s also all of those who would have occupied those beds Beyond them it has been thought that patients
Who lost their homes when the large hospitals shut down were unable to make the change to Independent Community Living and trans institutionalized into the criminal justice system jails and prisons are the largest providers of Mental Health Services in the country and you can see some of the statistics listed
Here in this presentation we will not get into the ethical quandry that is the concept of a four profit prison system in the 13th Amendment to the United States Constitution outlawing slavery except in the case of incarcerated individuals but I do find it to be ironic that one of the main goals of
Institutionalization initially was to move those with mental illness out of jails and prisons yet here we are today so who are these patients surprise they’re the same patients we treat every day a study in Colorado in 2019 which compared demographic data risk factors and negative life experiences between civil and forensic populations found
That they had much more in common than not they did find that forensic patients are more often black and or male but that also aligns with these populations being over represented in prison and jails anyway as they tend to have more interactions with police and bias towards being perceived as
Dangerous the majority of forensic patients have common psychiatric disorders are accused of committing minor non-violent offenses and often don’t need State Hospital level of care 2016 data from Hawaii showed that 80% of their forensic patients were charged with low-level felonies or misdemeanors and of those 80% fewer than
Half were for offenses against another meaning that fewer than half of the forensic patients um there was no victim of the crime unfortunately there’s a lot of stigma towards forensic patients both inside and outside of the field of Psychiatry likely due to biases about perceived difficulty or dangerousness a 2017 UK study showed
That the Civil patients uh had more frequent incidents of aggression problematic sexual behavior and fire setting whereas forensic patients had more frequent episodes of self harm um so I I created this diagram to kind of there as a recap and a visual representation of what we’ve discussed
So Far So at the bottom we see the interplay between mental illness social determinance of health and inability to access Outpatient Psychiatric Services then patients were institutionalized as conditions worsened and psychiatric medications were discovered deinstitutionalization started some patients went back into the hospitals again and others were trans institutionalized into the prison system
So on the left side we see that a patient reaches a level of perceived dangerousness they get sent to an acute psych Hospital transferred to a state hospital hospital um beds Clos or the patient just happens to get discharged prematurely they get sent back into the community then they get put back into
The cycle at the bottom and some patients go back into the cycle on the left but others go to the right trans iniz so a patient commits a minor crime is arrested and sent to a correctional facility a judge or legal counsel feels that mental illness is a
Major factor the court orders the patient to go to the state hospital either before during or after a trial due to competency concerns or they’re found not guilty by reason of insanity or similar many of the crimes are committed are because of social determinance of Health there are things like loitering
Often while trying to get money food trespassing while trying to get warm or find a place to sleep and disorderly conduct from being ill and plagued by Voices or having a manic episode the fact that a very high percentage of admissions to psychiatric hospitals are dangerousness based exacerbates the
Problem we have to keep people in the community until they are dangerous to self or others and then of course by that point if they’re dangerous they might commit a crime and then they trans institutionalized instead of being primarily psychiatrically hospitalized how can we learn more about
This do you need to be a forensic do you need a forensic Fellowship to treat forensic patients no of course additional training is always helpful but in reality General psychiatrists routinely use utilize forensic skills in clinical practice including during patient safety evaluation informed consent processes and disability assessments psychiatrists already must
Understand the legal regulation of mental health practice within their state and appreciate the role of psychiatrist in court uh sometimes we get called upon to testify in civil commitment or guardianship proceedings further with the trend toward caring for forensic patients in the community as well as limited supply of forensic
Psychiatrist to care for the special population Journal psychiatrists are increasingly likely to work with Justice and involved individuals but remember these patients have a lot of the same mental health diagnosis and treatment requirements as other patients so do what you already know how to do I found this cool article um it it’s
A great article that has a lot of resources of things that General Psychiatry residency programs can do to introduce residents to forensic psychiatry work and generate interest in the field the um Psychiatry program does a lot of these through the Wester Recovery Center forensic group ation participation in mock trials which we
Just had one didactics opportunities to observe forensic evaluations and and attend H Hort hearings so for my fellow residents this is a Shameless plug for my public sector Chief role so far this year I’ve had opportunities to meet and learn from various leadership in the Department of
Mental Health as well as the medical directors of State hospitals I’ve gained a lot of invaluable experience into how systems function and how policy decisions are made so looking at you pg3s um and for our more seasoned psychiatrists our pgy 8s and above the American Academy of Psychiatry and the
Law also has additional resources and guidelines available for treating forensic patients and we need more studies a lot of the data about forensic patients that I’ve cited has come from other states and even outside of the United States in order to better represent what is currently the situation in Massachusetts
It would be helpful to have more relevant research that pertains to our patient population so the fun part what can we do about this the bip partisan safer Community Act of June uh 2022 also known as the gun act as it included many other items related to firearm sales was passed in
Response to mass shootings it established funding for Community Mental Health Services um community behavioral health centers also known as cbc’s establish the 988 suicide and crisis Lifeline establish funding for integrated care between primary care and Psychiatry and there are many additional funding areas included that I could include here
Because the ACT is like 200 pages so the addressing barrier to care for mental health Act was passed in August 2022 it included requirements of tracking Adult Ed boarding data insurance reimbursement for patients awaiting impatient bed psych beds one free annual mental health wellness exam an increased
Pay parody with primary care for the same work many more additional items were included such as changes to mental health care in schools uh professional lure and scope of practice as well as the psychiatric collaborative care Model A so so it’s a lot of information um that is available about that and so
Cbc’s uh there are roughly 30 across the state and they aim to serve as a One-Stop shop and offer an array of services they can help with ED diversion and bridge the gap when patients are in between providers patients can reach them by phone call text or webbased chat
24/7 they just celebrated a year of these in place um right now it seems like it’s a little bit easier to get services for patients who have mass health most commercial insurers are only reimbursing for crisis interventions at this time but as part of the law I just
Discussed um Mass health is able to kind of track this data to get have more recommendations going forward now now to discuss ongoing legislative efforts so the Massachusetts Nurse Association Bill the ACT providing appropriate care for certain populations Bill introduced in late 2023 will require that chapter 123 sections 15 16
18 to include language here forensic Unit A physically separate unit from other units these units shall have in place restrictions consistent with those present when an individual is incarcerated these units shall include appropriate Staffing levels to address the needs of the patient population and who have undergone specialized training
To work effectively with this patient population the physical environment of the unit shall be conducive to meeting the needs of the patient population this bill aims to require forensic patients to be admitted to specialized forensic units at dmh facilities for treatment prior to being transitioned to Continuing Care
Units while is presented with good intentions an unintended consequence of this bill would be to further stigmatize forensic patients the language I highlighted here is also ambiguous does this mean use of handcuffs prison cells it’s unclear Bridgewater State Hospital still exists for patients requiring a more secure environment the evidence listed for this
Bill is that forensic patients should not be mixed with other patient populations and that this proposed change would address workplace violence however as we have discussed earlier there’s no actual data suggesting that forensic patients are any more dangerous than their non-forensic counterparts I agree that the rise in workplace violence especially directed
Towards those of us in health care is alarming but this measure is unlikely to make any substantial difference State hospitals are already struggling to accommodate these patients and implementing additional restrictions seem unrealistic lastly this bill does not address the underlying issue of trans institutionalization itself I want to be
Clear that this is not an attack on the m&a but there are evidence-based alternative strategies that the state of Massachusetts could employ instead such as community-based competency restoration So community- based competency restoration is a promising practice that allows some defendants who may not require a hospital level of care to
Receive competency restoration services while living in the community instead of in in an Institutional setting like a jail or hospital this model has been shown to be less expensive than traditional competency restoration services and has favorable restoration rates more importantly it allows some defendants to remain in the community
Where where they can continue to receive support from friends and family and connect with Community Mental Health Services to support long-term recovery by allowing those who do not require a hospital level of care to stay in their Community these programs also help to reserve institutional based care for people with the most significant
Needs these strategies include to enact legislation permitting outpatient competency to stand trial restoration and currently only 16 states allow this create jail-based uh competency restoration treatment programs statutorily reduce the length of time allowed for um CST restoration services for minor crimes or eliminate that all together for minor crimes and
Lastly Implement jail diversion programs as far as I saw massachus does not currently use any of the above which is interesting because of the state’s history of being the first to implement moral treatment principles and to advocate for patients rights interestingly Florida is ahead of the game with the jail diversion program um
I’m I’m from Miami with family and law enforcement and I had no idea about this until doing research for this talk the so-called Miami model uh the the criminal mental health project located in Miami day County was established 24 years ago to divert individuals with serious illness away from the criminal
Justice system and into comprehensive Community Based treatment and support services the program operates two primary components pre-booking jail diversion consisting of Crisis Intervention teams uh training for law enforcement officers and post booking jail diversion serving individuals booked into the county jail and awaiting adjudication between 2006 and 2016 they
Were able to divert over 4,000 individuals away from the criminal justice system the same study also found that in a 5year span 97 individuals with serious mental illness in Miami day County accounted for nearly 2,200 arrests 27,000 days in jail 13,000 days in emergency rooms crisis centers and state hospitals and approximately $16
Million in cost of Florida taxpayers um so we could make a change um and so some of the advocacy efforts um through the masss society our prisons and jails have become a deao treatment deao treatment centers but this is hardly the setting of The for the healing growth and
Connection that is necessary in achieving mental health A fitting quote for this presentation comes from the nps’s testimony in support of State Legislative bills titled an act to create Equitable approaches to Public Health some of the objectives in the ACT include to develop and study alternative non-p police Mental Health crisis
Response team models to reform how law enforcement interacts with patients in mental health crises train dispatchers mobile mental health professionals and peer supports and have law enforcement back up when needed fund care centers that triage and facilitate referrals to appropriate Services NPS is also sponsoring bills to end prior
Authorizations bills to update section 12 language and uh improve mental health parity so so this is my call to action I encourage you all to attend on March 21st uh Lisa Seminary who lobbies on behalf of MPS will join the public sector committee to discuss legislation
And advocacy um they also had a meeting last night with I was part of um and learning kind of more about also more ongoing efforts so things are still happening and they’re always kind of looking for more suggestions and I think it’s important to have as many voices
And ideas um to help us all can think outside of the box so our take home points why should we discuss this topic we need better allocation of our limited resources how did we get here psychiatric institutionalization leading to deinstitutionalization it’s a lack of Community Resources then leading to trans institutionalization and
Reinstitutionalization so it’s been kind of one big cycle what is the current data our state hospitals are overcrowded and becoming majority forensic who are these patients they’re our patients and how can we learn more about this through General Psychiatry residency training education the American Academy of Psychiatry and the
Law uh andic fellowships what can we do about this engage with ongoing policy actions and advocacy efforts to increase access to outpatient services participation in the mass psych Society Mass Medical Society American Psychiatric ass Association and similar but overall I want to end this presentation with a
Message do not go where the path may lead go instead where there is no path and leave a trail I think we’ve learned today that psychiatric hospitals are not the only answer in neither are community- based resources we need both aspects in order to adequately care for
The wide range of patients that need us complex problems require Creative Solutions so let’s be brave and make change so I’d like to thank you all for listening to me um I’d also like to especially thank Dr Daly Dr McGary and Dr Stone for all of your help and input
And allowing me to ask a ton of very complicated questions about this topic um I’d also like to thank my mother and grandmother for being great examples and instilling in me the values of humility kindness and service to others I’m happy to take any questions or comments and
Here are some of my references and links to additional resources here questions from the audience you know your talk is very timely um this month is the 70th anniversary of uh Hines Layman’s paper on chlorpromazine for treating psychosis and that along with you know what was going on in the field I think
It was a little bit of an overpromise of psychopharmacology as to what the these medicines were going to do for people hi thanks teia for a great talk um I one thought that came up for me was things like um mental health courts or drug courts I didn’t know if you came
Across that and if that seemed to have any impact on outcomes for some people um I hadn’t come across that but I could see how that could be helpful I think that anything that has the ability to divert people away from being arrested and being kind of put in jails and kind
Of helping them find more resources that help them avoid that would be ideal um I kind of focused just on the um Community Based competency restoration but there’s so many different ideas and things that are working in different states so I think we could try everything that there
Just wasn’t a time to talk about it all the options I than you for your question hi tea great talk um I wanted to point out one thing actually we do have some pilot jail diversion programs going on right now um so we are uh at least in kind of
Central Massachusetts we have a few that are doing mobile crisis evaluations with non-p police folks and and social workers in the community and those reports are coming into our EMH before they get here um which has been really helpful and so it’s it’s a pilot program
Right now but it might be useful for you to kind of see how they can translate that to other parts of the state as well um the question I have is I’m I’m I’m only speculating but I’m wondering about the uh the m& kind of uh policy because
We’ve also seen I I think and there’s clearly a bias of of people uh incarcerated or coming in through the forensic system for all kinds of reasons but we’re also seeing a lot of dangerous situations in state hospitals and some of those are probably people that are inappropriately targeted to to mental
Health treatment centers and and it’s tough to find that line in between and how do we protect some of the patients who you know may need that additional support when 90% of our folks are forensic now granted 50% of those forensic people may be inappropriately labeled but we’re also seeing a blend in
The other way and creating some dangerous situations in state hospitals and I’m wondering if you can speak to that at all um yeah I think that it it definitely is a complicated situation and when I’m talking about these patients I’m talking less so about patients with like antisocial traits or
Like people who are minging who are there for the wrong reasons um I I do think that um it’s like it’s it’s hard to say because there are when we’re thinking about how some people end up in state hospitals it is kind of this dangerousness they’re unsafe to be in
The community and from kind of brief time at wer Recovery Center listening about the patients a lot of the ones that were more getting restrained weren’t the forensic patients so I think we have to treat them all the same like we can’t we have to kind of Judge Things
Based on our own clinical judgment and it’s hard to kind of paint any any of them with a broad brush I think um on the zoom there’s a discussion going on but I figure I’ve been just just check with you to make sure they’re it’s about children and
Adolescence so um is one of the uh child psycholog says there is no forensic adolescent unit um but for forensic adolescence ages 13 to 18 generally go to the adolis and continuing care units at Wester Recovery Center is that yes accurate okay other questions you know having lived in my earlier in
My career through the sort of the beginnings of this and and it was well underway but it continued I mean you know during my career Metropolitan State Hospital closed Medfield state hospital closed so I mean I think it it you know everyone knows that the funding for the
Community Mental Health Centers was not sufficient for what was going on with closing of the state hospitals and nobody ever still to this day has done anything about it now I I do have a question um I mean because I’m hearing in meetings that you might have said
Yourself that in short order was the recovery center maybe close to 100% patients who are considered forensic is that Zarah yeah it’s an increased so what is that going to do to all the sort of non-forensic psychiatric patients who suffer from say treatment resistant schizophrenia who get hospitalized at um
8 East or Newton Welsley or something and and you know not that long ago we would send patients like that for longer term treatment at at was the recovery center I mean what what is going to happen to those patients yeah so that’s what’s happening that’s kind of the the
Scenario I started with and when I first came here and what I saw on ads that that there were patients that were waiting for a really long time and so that kind of sparked that idea of like why is this happening and so it is an ongoing situation that is is is
Happening and it’s unfortunate um but part of what I I think could be um A Change Is the state hospitals can’t turn away court ordered people and the section three transfers are kind of up to clinical discretion and so they end up falling to the back of the line
Because the court appointed people just kind of get kind of skip the line essentially and so with kind of having these outpatient competency restoration services and things like that I think that that would help offload the burden from the state hospitals and allow for more non-forensic patients to come and
Or people who actually need State Hospital level of care thanks for a great talk to Kia and it’s been um very nice being with you in some of the public sector meetings of the masss society so um um you know one of the other things we were talking about in the meeting last
Night was assisted Outpatient Treatment um for people with mental illness who are who are out of treatment or one of only two states that doesn’t have assisted Outpatient Treatment there are lots of controversies about you know human rights and the right to refuse treatment there’s been a lot about it in
The press for ages really so there is one program in Boston called the boat program um that is a court diversion um you know assisted Outpatient Treatment that has actually had some good results my understanding um and um I don’t know if you know you
Know what per if we did have aot in Massachusetts um how much of an impact would that have on helping to decrease our current problems could you elaborate a little bit more on yeah I mean just that you know I I’m wondering what percentage of
Folks end up and and I I should know the answer to this too but but what percentage of folks who are out of treatment um you know not taking medication and then recurrently get into legal trouble and so they get you know they get arrested they end up in the
Criminal justice system then they get sent to Worcester State then they get sent from the forensic unit you know into continuing care but then may go back out into the community and and we’re sort of back to square one again um um and so sorry like the assistant
Outpatient Bill like what exactly did that part last night yeah so you know in Most states for people that have serious and persistent mental illness and are not competent and would in our state have a Rogers guardianship but there’s another Step Beyond that which is um um basically Court mandated to stay
In treatment and to stay on medication um and uh and so what the proponents of this are saying is that if we had this law in Massachusetts we would not have so many forensic admissions we would not have our state hospitals being as overcrowded as they
Are um and that that people might have better quality of life you know in in the community on the other hand um there are many advocacy organizations that say that this is an infringement on personal Liberty and people should not be forced to take medication against their will under any circumstances so it
It and and it can be done better and worse in in different ways um Massachusetts has been steadfastly opposed for decades um but there is some as we talked about in the meeting last night actually there seems to be a bit of a change of heart maybe at the state level about this
So maybe I’m just sort of wondering if that may be something that will help to impact this down the road right yeah thank you for the explanation um so I I definitely think that it could be helpful um it does kind of bring up those kind of ethical questions and I
Know that like with 8bs and things like courts do order for people to um receive medications against their their will or even with a Rogers guardianship but then usually like people need to be in a institution or in some sort of like higher level of care so I I I don’t know
I see the both sides of how if they are able to remain in the community on their own like how can you force them to take medication I yeah know it’s comp it’s it’s complicated for sure thank you so much for your question thank you well thank you very much was a very
Very interesting talk thank you worri