Film & Media Workshop: Outpatient Commitment: The Pros, Cons and Realities of Leveraged Outpatient Care-Film & Media Workshop: Outpatient Commitment: The Pros, Cons and Realities of Leveraged Outpatient Care

Film & Media Workshop: Outpatient Commitment: The Pros, Cons and Realities of Leveraged Outpatient Care
Video Transcription
Welcome everyone to the evening. I am so excited and honored to be introducing our Film and Media Workshop, a real highlight of the program.  Actually, there were many highlights, but so happy to be here.  This panel came together, we have an incredible panel of speakers with various areas of expertise, and you will be seeing a portion of a film under development, currently by Ken Rosenberg, who has created this film.  We'll be watching the film and hearing from our panelists around the theme of allocation and commitment.  I was personally moved, and it was a very eye-opening experience as we pulled our speakers and our panelists together around this topic.  So I'm going to go right into introductions. I'm going to introduce our panelists, and then we'll watch a portion of the film, and hear from our panelists, and then have, hopefully, an interactive and lively discussion and Q&A.  So first, I will introduce Dr. Ken Rosenberg, who specializes in addiction psychiatry in New York City, with an emphasis on behavioral addictions, such as sexual compulsivity and substance use disorders.  He is the co-editor of a textbook on behavioral addictions, and authored a popular book called Infidelity, Why Men and Women Cheat.  Dr. Rosenberg is a producer and director of films about mental health issues for PBS HBO.  His first HBO film when he directed, Why Am I Gay? Stories of Coming Out in America, was on the Oscar Shortlist Top Ten Films of the Documentary Branch of the Academy of Motion Picture Arts and Sciences in 1995,  and his last PBS documentary, Bedlam, premiered at the Sundance Film Festival in 2019 and won a DuPont-Columbia Award in Journalism in 2021.  He was a recipient of the 2021 AAA Arts Advocacy Award, and again, he will be showing a portion of his documentary introduction titled Committed, which will be our spoon holder discussion.  I also have the bearer of some unfortunate news this evening. One of our panelists, David Sheff, author, is unable to attend. He fell ill yesterday and had his tool built to even participate virtually.  So I still would like to share some of the context in which we invited David Sheff to participate as a panelist, so that you can keep his perspective in mind, because you're going to be hearing about different perspectives around outpatient commitment and how this commitment impacts the patients that we care for.  So his perspective is apparent. He is the author of Beautiful Boy, A Father's Journey Through His Son's Addiction, a very powerful book. Also, Queen, The Blues by Matthew Rowe, and other books.  There was a feature film adaptation of Beautiful Boy, after some of you have seen it. It was based on Steve Carell and Timothy Chalamet. David Sheff has also received awards from multiple organizations, CPDB, ACMP, ASAM, and others, certainly, he was speaking about the Arts Advocacy Award.  We invited him to join because he had recently published, again, this important search, if you haven't seen it, the New York Times op-ed, titled, My Son Was Addicted and Refused Treatment. We Needed More Options.  In his absence today, and at his request, I think it made a lot of sense to do so, I'm going to read just a few, not the whole op-ed piece, but a few excerpts from the piece that highlights what he made as a parent around this issue.  Regarding his son, Nick, in the New York Times op-ed, once he was 18, on quite a course, he had to decide for himself, and yet, he was in no condition to do so. His son quoted, I was completely out of my mind, unable to make rational decisions, and he says now,  Most people who are seriously ill want to get better, and if given the opportunity, will choose to be treated. However, addiction can be applied to logic. Ideally, people with addiction would seek care, but waiting for a person to choose treatment for a disease that affects gradual thought can be catastrophic, now more than ever.  I would have wanted someone to intervene with my child on the street using potentially lethal drugs in an individual hospital. As unpopular as that decision may be, I would have supported it, even if I knew my son had been taken into care against his will.  There's a common view that people with addiction can't be helped unless they choose to go into treatment, but the data on voluntary versus coerced and court-mandated treatment is not so clear-cut. Some studies show people don't need to choose treatment for it to be effective, even though it may be more effective if they choose it willingly.  A sympathetic police officer gave him a choice between rehab or jail. He chose rehab. If he hadn't been held, he says, and I believe, he probably wouldn't be alive today. There was a time I didn't think he would make it to 21. He has turned 40 this year after being stoned for 11 years.  I will now introduce one of our panelists, Tawn Hall.  Tawn Hall lost her son, Miles, in 2019 and has since worked tirelessly with her husband, Scott, and daughter, Alexis, to not only promote awareness of the problems affecting care for those living with mental illness, but to identify where the leaders of change are.  She has since dedicated her work and effort to promote change to protect families from a system that failed her son, and we could do more about this from her perspective.  Since Miles' death, the Miles Small Foundation was created, and its mission is to support and protect families by educating communities about mental illness and by protecting those suffering with mental illness from excessive use of force by law enforcement.  Her work is supported by organization volunteers and supporters from all over the country.  Tawn Hall is an advocate and co-sponsor for the Miles Small Lifeline and Suicide Prevention Act, AB 988, which was signed into California legislation in September of 2022.  This legislation provides alternative cover to 9-1-1 that involves trained mental health professionals and a multi-crisis response team that doesn't involve police.  The Miles Hall Crisis Hub is now 24-7 as of December 1, 2023, and provides mental health service in Costa County and staff with licensed behavioral health clinicians and peers with work experience who will triage calls, de-escalate situations, and dispatch mobile crisis teams.  Tawn formed alliances with other families, organizations, and politicians across the country who are working for change.  She is a featured speaker and panelist on media and public and private events.  Last, I will introduce Dr. Aaron Meyer.  He is an assistant clinical professor at UCSD.  He earned his medical degree from St. Louis University in 2013, completed a UCSD combined family medicine and psychiatry residency in 2018.  He is the city of San Diego's first behavioral health officer.  His clinical interests include health care systems, care of patients with tri-morbidities, and legislative advocacy.  Dr. Meyer assisted with the development of SB 43.  You will hear more about this.  It was designed just this year by Dr. Newsom in California.  So with that, Dr. Rosenberg will take it away.  Thank you.  I'm going to go on that slide.  We're having technical challenges.  I can talk.  I usually don't show a film that's not completed.  This is the way it works.  I have a bunch of friends who want to show 15 minutes of the film, which will work.  I start editing in January.  It really looks at the problem, which I encountered because I was a psychiatrist in town.  My sister lived and died in a facility.  I didn't know where to turn.  So this whole idea of finding some place to get people help, even if they refuse help, is a very interesting idea.  I know it's very controversial.  That's exactly why I wanted to make a film.  As a psychiatrist, I would love for people to be interested.  As a journalist, I try to approach this from a different angle.  For three years plus, I've been wanting to impact people's lives, which I could really support.  I've been to restaurants.  I've been to a hotel.  I've been to quite a bit. The reason I've been to Akron is because it's a flagship for something called AARC.  That's what it is.  It's a film.  It's a barricade film.  It's about Akron, looking at the judges and the police in this very organized place.  We, in Addiction, know a little bit about Summit County.  What is Summit County famous for?  It's famous for tires.  It's famous for tires.  It was famous for tires.  But it's also famous as the birthplace of the AARC.  In Akron, you'll see a house, hospitals, and various hospitals.  I think that's important, too.  This is really a place that looks at a very serious issue. A very serious issue.  How can we help people who may not necessarily want to help?  Where are we at technically?  We're still talking.  We're still talking.  Is it the slide or is it the video?  Both.  Yes, that's good. That's good.  I can't even ask how obviously the jokes are.  I've run out of them already.  I think we should think about having Tom talk a little bit about her story.  I think it's very...  I'm going to talk about what was part of the funding.  Keep going.  Keep going.  I think it's a very serious issue.  I met Tom because we're funded by several foundations.  We're blessed to have a number of foundations.  We don't have to have a broadcaster to tell us what to do.  That's quite logical.  We're grateful for that.  One of the foundations that supports us, as we say,  a foundation, I went to a meeting in which Tom was interviewed.  I spoke with her.  At one point, I felt the loss of her son.  I don't know why she, as a family member, has come to look at the situation.  I'm very eager to have her talk about how we can persecute,  but also, we're persecuted on progressive treatment.  Because, as she'll tell you, it's very complicated when you get the police involved.  We're going to turn it over to you.  Hello, everybody.  I guess you guys are hopefully enjoying this conference. I feel very privileged to be able to be here, to be able to speak to you guys.  I feel like I speak to professionals like this.  You guys already understand the difficulties to get someone to care  who doesn't want care, who doesn't understand what you're saying.  Sometimes, I feel like we're preaching to the choir a little bit.  You guys haven't met me.  You haven't met my son, Miles.  My son, Miles, is 23 years old.  He was shot and killed by police in Walnut Creek, California.  A very beautiful, affluent area here in California, near Oakland.  Stuff like this doesn't happen.  People don't get killed by police in Walnut Creek.  That's where you want to raise your family.  It's the White Creek offense.  It's the beautiful houses.  It's the amazing community.  We're an African-American family.  There's not a whole lot of black people that live in the area. It's maybe 5%.  We moved there.  I met my husband in college.  We were living the American dream.  It was just very beautiful to be in Walnut Creek, to start raising our family.  I have Miles and my daughter, Alexis.  With Miles, we started seeing the challenges with mental health early on.  He had ADHD.  We know ADHD can eventually move into different disorders, like bipolar, schizophrenia.  Always in the back of my head, I always had the feeling he was more serious.  He also had some obsessive compulsive stuff that he would do.  When he was in high school, he was on the honor roll.  He was playing basketball.  He was an artist.  He learned how to make music. Of course, he's my son.  I wish I had some pictures to show you.  He's just a great kid.  He was someone who walked in the room, lit it up.  He was vibrant.  He was beautiful.  They called him Miles.  What happened is we started seeing really signs of serious mental illness with Miles  graduating from high school.  That was like he started doing all these disorganized texts and sending them to his family members  and friends. He started thinking he was Jesus.  We go to our neighborhood.  Of course, we live by the same plains.  We go on creeks.  It's a very cool area.  Concern for Miles as a black man in this community, even though a lot of our family people knew  who Miles was, still obviously concerned.  He started doing door knocking, thinking he was Jesus.  That was very alarming for me.  I was like, what do I do?  What do I do? We turned to NAMI, National Alliance of Mental Illness.  This is a resource for us, at least, to be able to know how do you handle someone who  has mental challenges.  Clearly, something was going on.  I have a bachelor's degree in psychology, so I understood.  I took classes.  I understood some of it.  It was the door knocking and just going to someone's house that was frightening.  NAMI said, local law enforcement should know about your son.  They should know that Miles is in the community.  Somebody did that.  I partnered with police, made a relationship with them.  Miles was, he would barely, literally, hurt a spider.  He was one of those kids.  He was so gentle and kind.  We made contact with police.  From that point on, it was like they were trying to help him.  He's 18 now.  We know you have to meet a certain criteria, danger to self, danger to others, or greed  or guilt.  He did not meet any criteria.  There was nothing they could do.  We were stuck.  We were trying to help someone who was ill.  Now he has a diagnosis of schizophrenia.  As I said, we partnered with police, trying to get him help.  We were successful.  About nine months before he was killed, getting Miles to 5150 upon a non-voluntary hospitalization.  As soon as we did that injection, he got injectable medicine.  It was like nine days.  He was ready to start a family.  He was like, I've got to find a girlfriend.  I've got to make friends.  It was amazing. My light switch went off.  It was like ding, ding, ding.  It was so amazing.  I was like, oh my gosh.  He's going to be able to live a life that we know he can have.  Unfortunately, about nine months later, Miles was doing the same thing.  The injectable wore off.  He's doing the doorknob thing.  Miles broke a window in our house.  911 was called.  We actually called 911. I had a relationship with an officer who was a mental health officer.  When I called, it was like, hey, we need help.  We need someone to come help Miles.  He's at a point right now where we can get him in a picture 150. As some people may know in California, there is Laura's Law, it's where you can get a  conservatorship, so those are kind of our thoughts, conservatorship, trying to get him help, trying to provide resources for him.  But unfortunately within 30 seconds of them arriving on scene, knowing even Mama's had a mental health challenge, he had a diagnosis of schizophrenia, let's say from a year ago,  a year before, they came within 30 seconds and shot Miles four times. And he was running when he had a, he had a crowbar, it wasn't a crowbar, sorry, it was  actually a guarding tool. So he was guarding with my mom, he was, you know, the neighbors loved Miles, one of my  neighbors gave it to Miles and was like, hey Miles, looks like I have one more time at that garden, let me help you out.  So they gave him a guarding tool, he thought it was a stack of God, he's running with it, he's not brandishing it, he's holding it like a stack of God.  And within like I said about 30 seconds Miles was being back and then two of the officers shot Miles.  So I knew from that point that when we went to the hospital, that as I explained we had an adult officer that we had a relationship with, she basically came and she called me  and she's like, get to the hospital, and within 15 minutes he was declared deceased. But I knew from that moment when I walked out of that room of like, well, this is my  life's work, this is what I'm supposed to do, this is not a calling that I asked for, but it's a calling that I knew that we had to address.  Because it's impossible, literally impossible to get someone help in California who doesn't understand their state unless they meet certain criteria, and unfortunately our family is  one of those families. Now we're in a group of families that, as I say, it's a club you don't want to be on, we want to.  And I've met so many other families like us who are struggling and need help. So as we now are in this new world of trying to find help and trying to get, like, I can't  bring Miles back, but I can make sure that this doesn't happen to another family. And that's kind of where the Miles Hall Foundation was started, we're a 501c3, and she explained  what our mission is, is to make sure police don't show up to mental health calls when they don't need to be there. So we wanted them to be here.  With the advocacy that we've had, we changed the county where there's now everywhere, well,  in Contra Costa County, that's near Oakland, California, I don't think anyone doesn't know where that is.  What it started off as a pilot program is now a, it's a 24-7 program now that in our county, if you call for help and you have someone in a mental health episode or need  help, you will get a mobile crisis unit that will come to your house. So that's really a big, because that could have helped us, that would have saved Miles  if we had something like that, that was nothing available. I think they had one mobile crisis unit for the whole county at one point.  So now it's 24-7, and actually they just got 24-7 on December 1st, so that's really exciting.  And then also, as many of you all know, about 8098, that's also Miles Hall, suicide prevention, and now all counties in California are mandated to have a mobile crisis unit.  So as the work we do in our foundation is just really to make sure this doesn't happen to other families, and yeah, so I appreciate the time.  Hopefully you guys have this movie rolling. Okay.  For those of you who walked in late, we're having technical difficulties playing the film. So we're switching the order again.  But if you would like to ask a couple of questions while we are focusing on the nerve of having that film connected. Actually, first of all, I have a couple of questions.  Is this on now? Okay. Well, first of all, again, thank you for joining us. It's, you know, we've told this story so many times. It's just heartbreaking. I've heard it many times.  It's just really awful. So thank you for sharing that and turning it into something that saves hundreds of thousands of lives. So thank you for that.  My question is, you know, we wanted to talk about, and I hope after the film we'll talk about, coercive treatments, what it means.  There's an idea that, you know, that will be helpful, and that certainly is a common experience. We've had CIT officers, crisis intervention training officers.  So one of the concerns about coercive treatment, just to get into it, is that especially people  of color, it's not a good thing to be involved with the judicial system, to be involved with the police.  On the other hand, people are so dependent on that to get the help that they need. So I wonder how you, you know, how you manage all of that. Yeah.  So, yeah, I mean, yeah, I think for us it's just the criminalization, right? Like, why do we have to go to police officers? Why is our system set up that way?  Right now the police, they do everything, right? So they can't be the ones who don't have the training that show up to mental health calls.  But especially for people of color, I mean, the disparities are enormous, right? Like 16, I think it's 16% of people, like 16 times higher being killed by police.  And I knew, I knew that for miles, that police, involving police could be deadly. But I involved them because we were trying to prevent this.  So I felt like when I was in my little community of Walnut Creek, somehow we were more safe than him going to his grandmother's house, you know, a couple counties over.  So it's also, for me, it's like you think, okay, well now they know he's not well, so they're going to come and protect him.  But I think your question now is, I don't know if I'm, okay. But I mean, how do you kind of process that?  Because on one hand, you know, what I hear a lot against coercion, which I think is... Can't hear you.  What I hear a lot against coercion, where are we at with our, we're still working? Almost. Almost. Great.  What I hear a lot is that, you know, that forced treatment, you know, in the situation of miles, mental illness, here we're also going to talk about substance abuse.  But forced treatment unfairly targets, you know, people of color, and they end up in worse traits because of that. And it often involves calling the police and that sort of thing.  So how do you... I mean, what's the reply to that, given your experience? I'm curious if you have one. Yeah, I mean, yeah. It's a hard situation. Because the fact that we...  It puts, for one, people of color in a position where there's decriminalization. We have to have, like, diversions and ways to be able to give alternatives, I think.  Great. Thank you. Okay, we're going to test this out. We have a picture we need sound. This is a good sign. Yeah, please.  But I did want to just, you know, just make sure you guys all do go to our website, milestofffoundation.org. We are on all social media. So we have Facebook. We are on Instagram.  So part of how we kind of thrive and do this work is by people liking us on these social media platforms, to follow us, the work we do.  So we're also doing really impactful work in the community as far as African American males. We just did a youth summit where we had some males.  And it was all about being black in America and the disparities. And also how to maneuver being black.  Because as black people, as black men, as we know, the criminalization is so much higher.  So we're also, you know, doing trying to impact these communities by educating about mental illness, though,  and also letting people know that there's possibilities in their own families, you know? Yeah, so I think it's working.  I'll also just put a plug in that it's a very important organization.  I keep on saying it. It's responsible for the 988 here in California, which is monumental. And also they have amazing sweatshirts.  I'm sorry I did not bring my Miles Hall sweatshirt. I think I like it too much to leave it in a hotel. But please go.  Yeah, if you can come to the mic.  Hi, my name is Gibson.  I'm a second-year resident at Bel Air College of Medicine in Houston. And, I mean, your story about your son is so touching that it just made me reflect a lot.  So in my county, which is Harris County, we have a crisis line that can be called by anybody. It's called MCOT.  And it's been very helpful because those are trained professionals who handle situations like that. And prior to residency, I also worked as a mental health technician.  So we got the training to handle patients without violence.  And one thing that we have done as residents in my program is we developed a program where we reach out to the police officers  and still train them, basically, on how to manage mental health crisis among people who have mental health issues.  Because we envision a situation whereby MCOT arrives to the site and the situation is too overwhelming for them. And then they have to call police.  And when the police arrives to them, mental health professionals have done their best. Now we have to do the police situation, which is sometimes with violence.  And I'm curious to know whether in your community, as much as you are trying to manage the situation by creating the crisis team,  whether there's any effort to teach the police officers and law enforcement officers on how to still handle crisis in the case that they are involved  when mental health, like the CIT team, is not able to manage the situation?  Yeah, thank you for asking that.  I know that the mobile crisis unit in Contra Costa County isn't doing any training to the police officers.  But I do know that some of the different cities within our county, they're trying to get more CIT-trained officers.  That's also an initiative with Miles' Foundation, too, is to also make sure that there's more resources for police officers as well.  But with that said, one of the officers was actually a CIT-trained professional. So you have to go back, and it's a lot of that implicit bias. Because you don't look like that kid.  They didn't not value Miles' life. Miles didn't have a gun. He wasn't running to them. He wasn't attacking them. He wasn't doing anything. So again, I think that whole part is...  Yeah, and one of the strategies we've implemented is to target the police, like when they're in training, to join the police force.  You cannot get them early enough, because the rookies, the older ones, it sometimes feels very hard to get through to them. It's more like, you can't teach me my job.  Kind of how they come off, right? So we focus on the newer people who are getting training.  And they are so gracious enough that they involve us, like give us a couple of hours to talk to the newer people, and kind of give them that training.  And again, I don't know, we've not had any... Because it's a residence initiative, we've not had any data to say, okay, this is the outcome.  But I mean, I assume that they will probably know better than their peers or senior officers who didn't have that training at all.  So I think that's something probably to consider in order to target the people who are in the training category. Yeah, no, absolutely.  I think, are we ready? So I just want to say one thing. There's a slide, but God forbid we're not going to leave this screen.  So let me tell you what the slide would say, had we seen it. Because this film is a verite film, it doesn't have any narration.  It's really how we like to do it, and eventually we'll have some explanation. But there's two ways of getting in front of a judge in Akron, and in most places.  There's the civil side, civil commitment is where you go for your wills, your states, or that sort of thing. And then there's the criminal side.  And you're going to see both courts, so let me try to explain it. If you are in a hospital in Summit County in Akron, and you're there over and over again,  eventually they will bring you to a magistrate, and your family might participate in this, and they'll say enough repeat hospitalizations.  We're going to force you into outpatient commitments, which can include residential treatment as well.  And you're going to appear in front of a judge every two weeks, and you're going to do whatever the judge says.  You're going to have to be sober, because of course a lot of people, as we know very well, have co-occurring disorders.  And if you fail, the judge can take you out in handcuffs, which I've seen once, or put you back in a hospital, which I've seen also. So that's the civil side.  The judge can't put you in jail, because you've never committed a crime. So there's no reason to put you in jail or prison. Does that make sense, the civil side?  And then there's the criminal side. So the criminal side is what we desperately need to do in America, because we are the incarceration nation.  As we all know, incarcerate more people than anywhere else in the world, per capita. It's quite insane. And a lot of those people, 25% of those people, have serious mental illness.  So the idea is to divert people who would go to prison, go to jail, and then go to prison, and divert them into treatment.  And there's another court that's called a mental health court. And there you need cooperation and collaboration of the district attorney, and the public defender,  and the therapeutic team, and sometimes even the victim. Because the victim has to sign off on this, sometimes. And say, it's okay that this person doesn't go to prison.  It's okay to let them be in treatment. And that's mental health court. If that doesn't work in the opinion of the judge, what happens to the person? They go to prison or jail.  And I've seen that happen as well. I've seen many people taken out of the mental health court in handcuffs. I don't think we'll see that in this clip, but that is just the context.  And also in Akron, they have CIT officers, and as you were just hearing, as good as that is, it's a very perfect system. They also, you know, unfortunately, kill people.  But here they have CIT officers. So those are kind of the three prongs of what you'll see. So fingers crossed, we'll play 15 minutes of Committed. Okay. Thank you.  Thank you.  We made it through the film. We're eager, wonderful, powerful film, pulling together a lot of what we've been talking about and bringing up new issues.  We're really eager to hear your reactions and questions. I also want to make sure we have time for Erin Meyer to present a few slides that also will add a different angle  to the discussion, and then we'll move to discussion and questions.  So thank you, everybody. I appreciate the time to talk here. And really, the reason why I was invited to give this talk or participate in it is because of the work  that I did to become the third most problematic psychiatrist in the country. Thank you.  Because I noticed, as an inpatient counsel liaison psychiatrist and emergency psychiatrist, the people that revolve through our system hundreds, sometimes thousands of times, are  people who are gravely disabled by severe substance use disorders, oftentimes with co-occurring cognitive disorders. There is no parity between mental health and substance  use disorders, and I saw too many people die. And so I started looking into, well, what was the reason in the system why this was like this?  And I'm assuming this is the same across the country, but in California, there are particular reasons. So in California, can you now involuntarily  commit someone to outpatient psychiatric care for substance use disorders without co-occurring serious mental illness based on the criteria of treatment  noncompliance and persistent illness? So persistent illness, no, with the exception of what California statute calls chronic alcoholism.  But the caveat there is that there are no treatment facilities for people who are conserved for chronic alcoholism. In fact, people with substance use disorders  are excluded from systems of care that are meant for people who are gravely disabled, who can't provide for their daily needs. So for treatment noncompliance, that  is a criteria if you're unable or unwilling. But again, if you're deemed gravely disabled by a severe substance use disorder, you're excluded.  And what that means is if you're a psychiatrist and you want to put somebody, if you want to apply for a temporary conservatorship,  you have somebody coming in from a county public conservators office spending about five minutes with a person who says that they want to go to rehab,  and that's enough to have a petition denied because the person is willing. But they're willing in the moment, and oftentimes we see that isn't durable.  The difference between assent and consent is never challenged, and so people slip through the cracks. So can you commit someone to outpatient commitment  for substance use disorders with serious mental illness based solely on noncompliance and persistent illness? Kind of. We have assisted outpatient treatment  in California, Laura's Law that was highlighted. But the issue is that Laura's Law is particularly only for people with serious mental illness,  and substance use disorder is excluded. You can say that the person might have co-occurring disorder, but oftentimes when you're looking to decrease the case numbers on your loan,  you'll say that their presentation is solely due to a substance use disorder, and so they are left with none.  And so what is new about the expansion of grave disability as a reason for outpatient commitment? So some of you, I'm assuming some of you are from California.  I know Dr. Marienfeld is here, and she's from California. So SB 43 is all over the news in California because a lot of counties are having  to admit, which won't surprise anybody in this room, that they don't have the treatment infrastructure. And so SB 43 expands the definition of grave disability  to include those with severe substance use disorder or those who have a co-occurring substance use disorder and a mental disorder. And this is important because so many people  are getting excluded because you have county public conservators and county behavioral health that are saying that their presentation is solely due to a substance use disorder.  Well, now that takes that argument off the table and brings them into treatment and gives a fuller continuum of care to somebody  who is gravely disabled from a substance use disorder. And I think it's going to cause counties to think about, well, what does it mean to be gravely disabled?  Because already we're having counties saying, well, we need to know what objective criteria somebody's using to identify somebody who's gravely  disabled from a severe substance use disorder. Well, I would say the same criteria that we have for somebody with a mental disorder  if they're unable to take care of their daily needs. But I think one of the issues is going to be how we train law enforcement to understand  what it means for the expanded criteria of SB 43, particularly what does it mean when somebody is unable to provide for their personal safety, which is a new criteria.  What does it mean when somebody is now unable to provide for their necessary medical care? I cannot tell you how many times my hospital has laid out  the red carpet for somebody with osteomyelitis, somebody with bacteremia, somebody with endocarditis, and they've not achieved the full course of their treatment  because we do such a poor job of treating addiction in the hospital setting. And how many people have died because of that? Well, now are we going as hospitals  to hold somebody against their will because we do a poor job of treating their illness and they're unable to manage their personal medical care?  I think these are going to be questions that California is going to be grappling with for the next decade.  So what recent changes in the California law permit outpatient commitment for substance use disorders? Well, besides the substance use disorder component,  it's the necessary medical care and personal safety. And I think necessary medical care is going to be particularly relevant for substance use disorders, especially potentially  in the transplant world. But we're not done. SB-33 was just one step. Because in California, if you want to hospitalize somebody for a severe substance use disorder  and they're gravely disabled, Medicaid excludes it. You have to have a substance use disorder with psychosis, with a mood disorder, with anxiety.  And if you don't have that, then you have nothing. And that's a problem. If you have a cognitive disorder, like I said, a co-occurring substance use disorder and cognitive disorder  is the real battle, I think, in getting people adequate care. And in order to be admitted to a geriatric psychiatry unit, you have to have a cognitive disorder with delusions  or suicidal ideation. And so what we need to do, and what we'll be working with the legislature on this year, is striking that language from our California code of regulation.  And for people who need to be in an IMP, which is a long-term rehabilitation unit for people with mental health diagnoses, they explicitly exclude.  They call it substance abuse disorders in our California code of regulation. And what we need to do is take that away. Because if you're gravely disabled  for either a substance use disorder or a mental disorder, you're deserving of treatment. You are worthy of treatment. And so we need to make those changes in California.  What we need to do, I think, also is to expand AOT eligibility to include substance use disorders. And we also need to have our health care services  to create new licensing categories similar to what's been done in Washington state with Ricky's Law to allow for people who know that they need  or are unable to demonstrate their awareness that they need a more secured setting than an open residential unit. So we need to expand the continuum of care,  just like we have for mental disorders. And we need better treatment from a system in California. And I'm happy to take questions. This is a topic that I think has the potential  to save thousands of lives. Thank you. Thank you so much, Aaron, for all the work you're doing to help reduce the siloing and stigmatization  of substance use disorders that many of us are working towards in our clinical and professional lives and personal lives. OK, eager to hear from the audience, your reactions,  questions for our panelists. Hi, my name's Ricky. I'm from Washington state. But it's not that Ricky. Actually, it's Richard. And I am from Washington state.  And we have a legislator in Washington, Lauren Davis, who understands all this stuff and was responsible for Ricky's Law. Now, of course, the same thing you run into  that you mentioned with the various counties around here saying, well, that's a great idea, but we don't have the facilities. Ricky's Law really has very limited facilities  in Washington state. So it's a good idea, but it's really not really working. I just looked it up. There's 1,800 acute care psychiatric facilities in the United States.  I work on three different levels of super inpatient psychiatry at Harborview, which is our downtown Seattle level one trauma center. And we love level one psych, too, if you will.  If we have 1,800 acute care psychiatric, and we have a lot of people that are very ill psychiatrically, and many of them are co-occurring,  when those people get admitted and committed, they not only get psych care, but they get medical care, a lot of medical care, because they have a lot of medical conditions.  The issue of our patients with severe addiction disorders. And by the way, we have about 50,000 people a year nationally who kill themselves from suicide.  And we have over 100,000 people a year who kill themselves with overdoses, which are accidental, semi-accidental, or on purpose.  So if you look at this, we've got the death rate here, and we've got this many psychiatric acute care facilities, if you will. How many acute care substance facilities  that would correspond with an acute care psychiatric facilities do we have nationwide? I don't know. I can't find any data on that. My guess is there's like 10, maybe.  So there's this huge disbalance. And certainly, I treat both of these kind of patients, super severe addiction, super severe mental health.  And you can just get just as ill with a bunch of fentanyl and methamphetamine, maybe iller than most people with pure schizophrenia. So there's a complete disbalance in all this.  The public's going crazy, because they're saying, what are we going to do with all these folks that are running around crazy on the streets, et cetera?  And we could have a lot better acute care system for them. We'd have to build all that. But the answer's sitting right in front of us, at least a partial answer, which is,  why don't we either use the same facilities or build a lot more? We don't have enough acute care psychiatric facilities either.  So this huge disbalance, as you were sort of invoking, is something I've been screaming about for years.  The ratio of 1,800 to 10, maybe? And the deaths rate is twice as many. And substance use is enormous. So that's what I have to say.  Hi. Is this on? Yep. OK. So I'm Andrea Weber. I am an addiction specialist that works in Iowa. And I trained in Iowa. And we've had both civil commitment law  around substance use disorder treatment as well as mental health treatment the entire time that I've been a physician. And I've worked in the community-based setting.  I've worked in academics. And unfortunately, I've become really disenfranchised, honestly, with civil commitment around substance use treatment for a few different reasons.  The reality is, in Iowa, it's really relatively, I think, easy to commit someone in the state of Iowa. That's been my experience. Most of the courts, barring a lot of differences,  are going to trust the opinion of the medical team when it comes to determining if someone meets criteria. If someone gets committed to substance use treatment,  assuming there is a facility that will take them, which that might mean three weeks in a hospital setting, and no hospital is going to do that, they get to a facility.  If they get there and they decide, I'm not going to participate, I'm going to cause problems, I'm going to leave, usually what the facility does is dismisses the commitment.  Because they say, this person's not going to benefit from treatment. We don't think that this is the right time. And so more and more, I feel like the commitment  has become this illusion of hope. And I actually think the people that suffer from it more are the families and the people who really want it. They're trying to use their tools.  But unfortunately, the system is not really there. And I think, ultimately, I think the call I have is, there just needs to be more creativity  around making treatment accessible and effective. Because I agree, I think most people who, they want to be better, they want to get better.  And I think the law provides some avenues for that, for substance use treatment. But my experience with it has been just, it doesn't deliver. And I think there's this illusion  that if we just force someone to stay in a separate building and do therapy all day for four weeks, that they're somehow going to get better. And that's all we need to do.  And it's just not the case. I think everyone knows this in the setting of that disease. But I liked what you said, Dr. Myers.  There's just a lot of stuff you guys are going to be grappling with now that maybe there's some avenues to help people get into treatment differently.  But just some perspectives from Iowa.  I just want to add, one of the things I've observed in doing this film for a couple of years and in looking at the literature, is the biggest problem with forced treatment  is not the forcing, it's the treatment. And it's really a lack of treatment. In Summit County, I think what works there is that there's great treatment.  Everyone you saw has an ACT team, Serve Community Treatment Team. In the mental health court, they don't call it ACT because the Medicare won't pay for an ACT team  in a forensic setting. But suffice to say, people have intensive treatment. And my reading of the literature, it's equivocal about AOT. It really is. I wish I could say it was not.  But the biggest study was done in the UK, which showed no difference between those people in AOT in terms of hospitalizations and acuity.  However, everyone agrees that when you have intensive treatment, it really works, and however people get there. So I think one of the things I've observed  is just what you were talking about, which is not necessarily the lack of... Forcing doesn't really get it done, but really having intensive treatment really does.  I'll just give you a little bit of follow-up. The guy you saw, Nick, we interviewed his parents just last week because Nick passed away a month after he graduated.  He did great while he was in treatment, but once he dropped out of the court and the intensive treatment, he did crystal and fentanyl and passed away.  And that's not an uncommon story.  Thank you. Great information.  I want to address first the issue of police killings of mentally ill people. Ms. Hall, I'm so sorry for your loss.  Long ago and far away, I was involved in an incident in which two police officers were responding to a case of a very large, very dark-skinned, distraught man with a knife.  It ended well. Everyone went home safely that way.  And trying to think what went right, what went right is partly that there were mental health workers, more than one of them, known to the patient, who were willing to sit right next to him with human contact while he was carrying that knife and threatening to arm himself with it.  They were willing to sit next to him, the mental health piece, which meant that the officers could be 20 to 25 feet away, where they didn't have to worry about anybody taking their weapons away.  They could just stand and watch. And one of the officers was so supportive, I was thinking, this officer could be part of our therapeutic team if they wanted to.  So I know things can work well. Another thing that worked well is I know the police chief of that jurisdiction, a very conservative person who very, very much wants everybody to go home safely and is willing to train and train and train in de-escalation so that that can happen.  Hopefully, even when the mental health workers aren't there, that people try to get mental health in on the scene, close to the patient, and trusted. And that allows police officers, with their special strengths and special vulnerabilities, to stay back where they can be the best help to the public safety.  So I wanted to let people know there are models by which this can work on the street. And thank you so much.  I had so many thoughts, but one thing that just stood out to me is how incredibly well put together this panel is. There are so many parts of it that touch in areas that I think we've all experienced as professionals in this field, and each part has been very touching and very thought-provoking for me.  One thought that has come up for me is how housing fits into the picture. So the video seemed to emphasize an element of a housing problem, and then when we're talking about mandated outpatient commitment, I'm just personally wondering how that's going to be effective without a housing component for so many people.  And is that going to work? And so I'm just curious your thoughts on that, and I really honestly don't know, so I so appreciate it.  Great question.  Thank you. That's the question I think that I grapple with all the time, because we live it in our inpatient psychiatric units. We have some people waiting years for a long-term placement.  And once they're at the long-term placement, there's another bottleneck, because where do they go from there?  And my, you know, what I hope from SB-43 is what Berkman, who's our behavioral health director in San Diego, said, is that now we have, now the county's incentivized to work with emergency departments and more closely integrate substance use disorder treatment into emergency department care.  We have lots of sober living homes in San Diego. We have lots of, well not a lot, but we probably have four times as many residential rehabs, but the linkages from the emergency department are very difficult.  We have one substance use navigator in two hospitals, and he's not able to, you know, and we probably need five to get people into treatment.  And what we really need is our county to take ownership and really lead on making sure that emergency departments are integrated with sober living homes, with a network to get people to the treatment that they need.  And we need to be able to get people to residential rehabilitation facilities without having to fill out a 17-page application and giving them a bus pass to show up and hopefully get a bed if they show up on that day.  We don't have treatment on demand, and we need an integrated system from the emergency department to link somebody to a treatment setting just like we do a skilled nursing facility, just like we do an inpatient psychiatric unit, and we don't have that.  Substance use disorder system is more siloed than our mental health system and certainly more than our medical system, so we need a lot more TLC on the substance use disorder front.  Thank you. I just want to say in Akron, they have a lot of residential treatment, and you'll see that in the film.  In the care courts, this is not my neighborhood, but to the best I understand it, one of the powers of California's care courts is that counties will be fined $1,000 up to $25,000 per incident if the county agency doesn't provide the care.  One of the things that I think AOT and mental health courts do, they really put the burden on the team, and now a judge is watching them, and they could get fined if they're in California.  I think housing is a very important component.  We know that the housing first model has its problems because people don't necessarily get well.  They don't necessarily stay sober, but without housing, you have nothing.  I'm so glad you brought up that point because when we make the film, I'm going to really make sure that we emphasize the residential treatment because housing is like food.  You need it.  Hi, Debra Barnett from Tampa, Florida.  I just want all of us to engage in this silly little thought experiment.  Let's say that we had this society where we actually had mobile crisis teams responding to psychiatric or substance, including substance abuse emergencies in the community.  Then somebody came along and said, hey, I've got an idea.  Instead of them, let's send law enforcement.  Now, what would the reactions be?  We would think that that was so ludicrous and absurd and catastrophic.  I think we need to take that perspective to think about how to fix this problem.  That's beautiful. You're making the point that mental illness crises, substance abuse crises are the only health crises where police are the first responders.  Hi, I'm Sara Zarki.  I'm an attending at Bellevue Hospital in New York City.  It's a public hospital.  I work in the psychiatric emergency room there.  Disclaimer, I'm very new to practice.  I only graduated residency pretty recently.  I would say more than 50%, probably 75% of the folks that we come in have some component of substance use impacting their presentation as EDPs, although we're not supposed to use that term anymore.  Something kind of dysregulated about their behavior that has brought them in.  I think there's oftentimes a really large gap between the behavior that's brought them in versus the behavior that would lead them to meet criteria for involuntary commitment or even anything along the lines of AOT or outpatient commitment.  A lot of times we talk with these folks and we do strongly encourage detox, rehab.  We do have resources for it. We have drivers who will come and pick them up from the emergency room, drive them to a rehab facility.  The number of times that that doesn't lead to fruition because it's like 5 a.m. and they would have to wait until like 6.30 a.m. for the driver to come and bring them to detox and that hour and a half just feels like too long for them to wait.  I just feel like the chasm between meeting criteria for outpatient commitment and wanting to really make that jump to commit themselves and let go of their autonomy, their freedom, the ability to come and go as they please, which you really do lose when you are involved in a program like that.  Where is there any kind of in-between to kind of meet people where they're at, not necessarily involuntarily committing them, but also kind of getting them to a point where they're ready to accept some treatment without necessarily losing all of their autonomy, which is such a big thing to kind of ask for.  This is such a big question. I'm not sure I have the big answer for that. I think it's a great point. Where do you draw the line between the need for civil commitment and taking away people's autonomy? At what point do you take away civil liberties? It's huge.  I think one of the problems that New York has, frankly, is that you don't have the collaboration. That's why I went to Akron, not New York, where it would be a whole lot easier. I live on the Upper West Side. I did my internship at Bellevue.  In New York, you don't have that. You don't have the infrastructure. You don't have the collaboration, which is kind of what you were sort of alluding to. The public defenders and the DA and the judge, they're all fighting with each other. I've been in the Queens Mental Health Court, and Manhattan is just, really, it's pretty tough.  A lot of fighting. I think that you need this kind of collaboration. You need the infrastructure. Maybe you have the big answer.  I don't know about the big answer. Ten people in San Diego had 3,400 ED visits. Their MOCA score, on average, was 13. I think cognition is a big missing factor in all this. It helps to distinguish between what is just systems that are not nimble, that can't really meet people where they're at, which I think is a big part of it.  But then, also, the independent of that is somebody's cognition, and then really insisting that occupational therapy come on board and really assess if someone can do their basic and instrumental activities of daily living.  In our hospital, it's not looked at well when you request an assessment of somebody's IADLs. If you can walk, you can discharge. I think cognition is a big missing factor with those ten folks, because they had co-occurring substance and cognitive disorders.  I think when I heard the question, I do agree that our systems need to be more nimble and need to be flexible and not just say, well, you failed this level of treatment, so it must be conservatorship next, in a kind of algorithmic, stiff approach.  I think we need to do a better job of assessing people's cognition. But, again, those systems are siloed.  Thanks for putting this together, Marianne Kuhl from Oklahoma.  One thing, or two things I want to mention is a real positive experience having been on the Opioid Overdose Review Board, where many different people were sitting at the same table.  This goes back to the collaboration, right? Where you had, like, fire department, police department, justice department, medical people, child protective services, and they were all looking, in a sense, at psychological and autopsies of identifying the gaps and then going to the state legislators, going to grants, going to all those kinds of things.  And having tiny projects, but many tiny projects to improve things. So I think, you know, that was a really good experience, and that could be the same for what you mentioned, that the systems need to be more flexible and there needs to be more, like, spontaneous but guided action to help those people.  The other part, though, is if I think about trainees and training, we see the horrible outcomes and we see, like, the failures of the so-called system, but then how do you learn to advocate, and I would just say, like, AAAP can give some guidance to some of those things, because, again, it's about the teamwork.  How do you sit together with people from the city? How do you sit together with people from the county? And how, as a humble community psychiatrist, do you actually take this next step into how you advocate for those things effectively and not just fight about the system?  So we do also try to have workshops where we make suggestions about how we, as clinicians, can become advocates and get more involved in this kind of work.  We are almost out of time, so let's take maybe, we'll see how much time we have, two more questions, and then certainly you can also come up at the end.  So my question is, what happened to voluntary admissions? That's my big question. I work in the Rochester, New York area, and when I talk to people, they don't even offer voluntary admissions.  I've done a lot of work, I feel, for my colleague at Bellevue, but I have a feeling of volunteers never even thought about.  In New York, we have several different levels, right? An informal admission, a volunteer admission, a 2PC, which is really a committee of people, and does a voluntary admission still exist in New York, and is it offered a lot?  That's my question for my New York, California, otherwise folks. Yes? Yes?  Yeah. Yeah, we have, I mean, we have voluntary admissions.  Okay. All right. Thank you. Sir?  I think it gets to the, the question, I think, gets to the birth of availability of facilities.  I mean, as I mentioned, we, you know, callously said, if you want to stay, you have to go, and if you want to go, you have to stay.  And, so I think that's part of it.  One final quick question. I just have a quick question. In all the research that you guys have done, who's, is there anyone out there that we can kind of model after?  Is there, who's doing it the best, which I guess is kind of a stretch, who's doing it the least wrong?  Well, I, I mean, that's why we went to Akron, you know, we looked at AOT quotes across the country.  There's more outside the U.S.  Oh, outside the, oh, outside the U.S., oh, that's, yeah, hmm.  It's, Portugal, yeah, I mean, the Scandinavian country.  Let's talk about that afterwards, yeah.  Hi, Kathleen Haney, Minneapolis, Minnesota, Hennepin County Medical Center.  I appreciate your comments so much, what you describe day in and day out.  I deal with this in the psychiatric emergency room.  But when you say, where is there a place that might do it a little bit right, I can just say my experience, this was years ago, but it was in a national health system, which I know has disintegrated pretty much, in Ireland, where they took a more paternalistic approach to the SMI population.  And if you wanted to live in a safe place and be taken to get vocational training and gardening and learn how to do laundry and have massage, you got your injection every month.  That was part of the deal.  That was a given.  You were safe, you got your medicines, you had activities and support.  That, and what a psychiatrist in Ireland said to me is, you know, you in North America, you got great research.  Boy, do you guys do great.  But you don't take care of the mentally ill like we do.  Yeah.  Very interesting. Thank you for your comments. And really, thank you all for your participation. Let's give a round of applause for our panel.
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