Yeah. All right. First of all, we want to say welcome and thank you for joining us today. Both, you know, the three of us, my colleagues and I are very excited to talk to you about addiction and the family court walking on the legal tightrope. So my name is Dr. Sonia Moten. I'm actually with the Pine Rest Christian Mental Health Services Michigan State University psychiatry residency and fellowship programs. I'm actually one of the addiction and adult staff psychiatrists on the outpatient setting. And I'll let you guys introduce yourselves as well. So I'm Andy Bath. I'm addiction psychiatrist and the chief of medical addiction services at Pine Rest as well. I am Talal Khan. I'm also an addiction psychiatrist. I'm the outpatient medical director over there and the fellowship director. So there are no actual or potential conflict of interest in relation to this program. None of us are making any money pretty much. So no worries there. So what are the learning objectives at the conclusion of this session? Participants should be able to recognize the different layers of the legal system, understanding the barriers and the complexities that a patient with substance use disorder faces in the legal system, and be able to describe some practical steps to help this struggling patient in the legal system. All right. So before we move on to the next slide, I just wanted to set up the how we got to this point. Sonia was a fellow last year with us and she had this project of wanting to find out what kind of biases people have in the judicial system, like the judges, did they have any kind of a bias and towards patients who are struggling with substance use disorders. And we see that a lot with mothers struggling with their kids in custody, if they've had a substance use stigma attached to their names, whether the judges can be completely unbiased towards their rulings and just stick to the facts. We wanted to get it started there, but what we realized was there was such a major information gap in what we know as physicians, how much we actually know about our legal system and how different it is. So that's how we kind of that focus from just bias interpretation moved on to let's get a little bit of an assessment of what we actually know and kind of give this, share this information. So it was more than a few Google searches, but I think we got into interviewing people and we got a lot of information from them, learned different perspectives on about the same thing that we're looking at, same picture, people are looking at it from different angles, completely different ballgame. So went on to that and now we thought that what better stage to bring it up and talk to our colleagues who may or may not know a little bit more than us or maybe like most of us try to avoid whenever something comes with a subpoena or comes from a lawyer, we try to look the other way and it wasn't like, you know, not always ready to do what may be needed. So with that I'll let Mandeep start. So this is where we're going to do some audience participation. You have to go closer to that. All right, so this slide we'll do some, just see what comes to our mind when we have a certain situation that arises, especially in the context of our presentation. So let's say when there is a mother or a patient of ours in the legal system with substance use disorder, what kind of thoughts or what kind of, you know, first words that come to our mind? So the concern of the legal system getting involved, CPS, and the potential of the patient or the mother losing custody of her child comes to our mind. The anxiety that patient might be feeling as well. So that comes to our mind. How about when the CPS calls us? So let's say you're in a clinic, you're seeing a patient, and then during your practice with that patient you get a call from the CPS worker that this is what's going on. So have you guys had any experience with that? Any, yeah? So your first words or what comes to your mind? So your willingness to help in that case comes to mind, right? There's also that overwhelming, sometimes, anxiety of the patient's care or what's going to happen with them. If you know about what's going on, that's always good, but sometimes there's things that are not fully discussed with the patient or the patient doesn't fully disclose what's going on, and then you right off the bat get a CPS worker calling you. So anxiety from that. Now there in the legal system you get a letter from the probation officer. Have you had any experience with that or any? So you've had experience with that? Yeah, come on, come up front. You're too far back. It's not many people, so we can all just scoot up. Yes, yes. And please, you know, we are not lawyers, so don't be too afraid of us. We're not judges. We're not going to judge you. This is a non-judgment, judgment-free zone. We are one of you. So if we make mistakes, I just want to, if we say something that is inaccurate and you know that, please let us know. We don't want to be part, you know, encouraging misinformation. But also just because there's only 20 of us, just raise your hand, interrupt us, and we'll be fine. So there was an experience? Yeah, so what was the probation officer? Like if you can... I can vote for all of them. Yeah, yeah. You get the consent from the patient. Yeah. So, but it is also... What is the first thought, though? What are you thinking of when someone says, oh, the probation officer wants, is on the phone. Doc, what are you going to do? Yeah, there's like your staff, your support staff said there's a probation officer on the phone call. So you want to get consent, first thing. Yeah, I'll ask him to send 10% with the vaccine number. Yeah. So there's a little bit of a nervousness about what information the patient really wants me to share, and there's that balance. There's another question, what does the probation officer want to know? Yeah, yeah. If you ask the question, what do you want? Exactly. I feel like the probation officer always wants to know more than I want to share. So there's that fear, right? Like what if I make the situation worse? Yeah. So I had experience with probation officers, good and bad. So some of them really advocated for the patient with substance abuse, and some totally not. So that kind of thoughts come to mind, how it's going to be perceived, or what's going to be the outcome. The last thing you want to do is make things worse for your patient, right? So there's that fear of what comes out of my mouth, maybe my feelings, is it fact? How is it going to be perceived at the other end? Yes? Unless things should be worse for you. Yes. And that's a tough balancing act, is what do I share, what's in the patient's best interest, and what's the right thing to do? But the patient, when it's DCS calling, and there's a child involved, and so there are more stakeholders in some of these instances where sometimes the patients shouldn't be reconnected with mom or dad. What is the right thing to do? You have to make that judgment call as well. And the last one, if you have a mother, obviously who's pregnant, and has UDS positive screen, so what kind of thoughts come to mind as a provider? I thought we represented providers for these, but then on the same time, if they're positive, we kind of work in our practice, at least we work with them and say, if your appearance tends to get negative over time, and at the time of childbirth, if you do not have a positive screen, you probably will have less consequences for child-pregnant illnesses, and that kind of motivates them. That's a multi-layered thing that happens, right? As a physician, you want what's best for the patient, but also then there's the legal piece involved that you want to protect. Your protection kind of comes into play. You want to protect this patient, so that I'll walk you to that point, and then it's up to you, right? And we'll cover the legalities of addiction, substance abuse, and motherhood as well, but for now, thanks for participating. Yeah, how much can you share? So it is protected information for you to see if it does protect you, but that's where the consent from the patient is the first thing that you want to get, because not, and withholding information, if the patient doesn't give consent, you have to explain that to them as well, that that can be perceived very negatively as well, and it may actually be considered a positive result on their end if you don't share. So you know, if you're only positive for cannabis, it might actually be okay, because otherwise they'll think that you're positive for opiates as well if you don't share this information. You have to have that conversation with the patient, and it gets them through. So we'll try to bring it back. All right. So we want to introduce you to patient Heather. So obviously Heather's not her real name for privacy reasons. Now patient Heather is our 45-year-old white female. She's a mother of two, and she has been married for 20 years in a very abusive relationship. Now being in this, you know, she's been in this cycle for a very long time now, and the one way both her and her husband deal with the situation is that they drink alcohol. Now she lives on edge every single day. She doesn't know, you know, she's walking on eggshells. She doesn't know what's going to happen that, you know, this particular evening when her husband comes back from work. Is this the day she's going to get another black eye, or is it going to be her 16-year-old son who ends up with a black eye, because he's trying to protect his mother? So this particular evening, her husband comes home, and they get into a very volatile argument. They both end up drinking, and husband ends up physically becoming, you know, escalates. So Heather does what she thought was best. She left the house, got in her car, and she drove off. Unfortunately for Heather, she ended up crashing the car into a tree. Police got, you know, onto the scene, and she, on her, on the breathalyzer, she blew just above the limit, which meant she got, and she ended up, you know, getting arrested. This is not, this is, this is, this is Heather's, she's never had a criminal record before. This is her first DUI. So, and, and she did spend a night in jail after she got arrested that night. Two weeks later, she gets into another argument with her husband. He's again threatening, physically threatening her, threatening to take the children away, and what she, what could she do? She ends up taking, she ends up going to the car that was parked outside, gets in, starts drinking, and the neighbors hear the commotion. They end up calling the police again. Now, in the state of Michigan, if you are drinking, and you are behind the wheel, irregardless of if you are actually driving it, you do, you can get arrested. And unfortunately, she got arrested for the second time. She spent the weekend in jail because she didn't have the bail money to get out, right, because it gets very expensive. So, when we met her, she came to detox for, for help, and we were, we were lucky enough to follow patient Heather, actually, through her outpatient stay with us as well. Now, you know, she did have, she did maintain a three-year sobriety prior to this particular relapse, where she was like, she said, I relapsed even harder. I was drinking to deal with my marriage that was on the rocks. Now, when she went to court, she was actually allowed to decide, do you want to spend 90 days in jail, or do you want to go to sobriety court? Now, in Michigan, she was actually part of the Ottawa County Sobriety Court. It is one of the toughest counties, and judges, and, and she, and she put it in a way that it put the fear of God in me. They put you in different phases of the program, and each phase goes by the color system, which I'll go into. So, during this time, patient reports her license was, you know, suspended. So, this is a problem for a lot of people that go through sobriety court, by the way, and basically, they've been told that the Secretary of State, it's not the court, it's the Secretary of State that controls her license, and it's recommended they go with an attorney, and they go in front of a panel of people on the Secretary of State, and they can pretty much ask you any question. They can ask you, what's step eight in AA, or 12, or what have you done, or what's the law, you know, or what's the legal limit of alcohol? I mean, they can ask you anything they want, and guess what? Getting an attorney to do that, I mean, that's just as expensive. She actually, I believe it came out like between three to five thousand dollars out of her pocket to be able to get that completed. So, the patient stated that she had a very hard time in the beginning of sobriety court, because someone had to drive her around everywhere. She actually said, I was so embarrassed, because my 16-year-old, who had a permit at the time, was the one driving me to work, or the one that had to take, I wanted to take them out for dinner, and he had to be the one driving. She felt it was, as a mother, it was very humiliating for her. At one point, where she didn't even have a car at all, or someone to drive her, she was walking in the middle of winter to get to work, because if you don't have work, you don't have money, and if you don't have money, you can't pay for some of this stuff. She also mentions this interesting device called Interlock. I actually learned, I asked her a lot of questions about it, and she said, you pay $120 per month for this particular device. Now, the court tells you, they actually tell you what time of day, whether it's in the morning, the afternoon, or evening, they will tell you, this is the time that you blow in the device, and if you miss that time slot, that counts as an X mark on you. I mean, that counts against you, and you can get in trouble, and here's the thing that I didn't know, was she said, it has a GPS system on it. I mean, they track you, so you better be going either to work, to school, or any appointments related to whatever medical or mental health appointments that you have. You can't go to a concert, so I mean, that's not going to happen. So, the different phases that they go through, right? So, phase one is about 15 weeks, very involved. It's like, you know, she mentions, it's like kind of like having a job. You cannot miss work. You just can't. I had to call every morning at 5 30 in the morning to find out if I had to drop for them based on what color was reported on the telephone prompt. So, if your color was blue, and blue was called for that day, you have until a certain time to give your sample, and if you miss that time slot, just like the interlock, it's considered a failed test, and there were a lot of drops, by the way, during phase one. She also mentioned that curfew was set between 10 p.m. and 5 a.m. You cannot leave the house during that time, so that means no, even if you have a third shift, you can't go to work during that time because of the curfew. You can't have sleepovers, nothing like that. Phase two, very much like phase one, but you might get calls a little less compared to phase one for a random drug screen, and again, curfew is set at between 11 and 5 a.m. Phase three, a little bit less restrictive. Again, curfew goes to midnight to 5 a.m., and again, the random calls get less and less, and then phase four and five, which are 20 weeks, again, curfew is a lot less restrictive, and you may get called for a random drug screen. So like I said earlier, in phase one and two, you cannot go anywhere overnight. Pretty much your freedom is screwed. You have to go in front of a judge at sobriety court every two weeks. They make you journal different reflective questions. For example, she mentioned, her last question was, what was it that led me to drinking and why? That was something that she just recently wrote in her journal, and she was also required to go to a court-appointed group therapy. So it wasn't like a group therapy that you just go like maybe a program in the area. I mean, this was court-appointed. They have their own therapist that's run by them as well. So phase one, you are required to do five activities during the week. So I asked her, what in the world are the five activities? So these activities could be IOP. These activities could be individual therapy. It could be AA meetings. It could be going to detox. It could be having a psychiatrist. It could be going to residential programming. So again, so phase one, you have five, and then it gets less and less as you graduate through each of the phases, right? So phase two, there's four, and then phase three, there's three activities, and so on and so forth. Now phase three and four, you have to go to sobriety court in front of the judge every month and group therapy once a month. So we were actually curious about you guys. Hearing Heather's story, hearing about what she went through, hearing about, hey, this cycle of abuse and abusing and drinking and what she's gone through and going through sobriety court and the expectations that they had her on. I'm curious to know how many of you think that justice is being served, the patient should follow the program expectations? You seem iffy. It's a lot. Yes. I'm thinking about this, and it's interesting that most people complain not. I can understand because of the abuse of the husband. However, I'm thinking about the days when people like this kept in jail for six months or a year because she couldn't endanger somebody's life or herself or whatever, and driving intoxicated is a serious issue. Also, even though she's had periods of recovery in the past, there's going to be a question of whether or not, because we live in an era of multidimensionalism. Everybody does. Everybody does multidimensional interviewing, which really tries to be empathic and all that. But I'm a little bit older than some people here, and I still believe that there are times where coercion is helpful, especially in the criminal justice system, and where if she goes through all this, she's going to take it more seriously because she's got to follow all of these things. By the way, some of which may seem harsh to you, but if you're using Silverlink for one of these devices, it's easy to cheat on these things if you don't have to do it at certain times, and if it's not set in a certain way. So I'm the devil here. Yeah, I'm surprised you're the only one who's making that counter-argument. I'm surprised there's only one person. Yeah, so I felt somewhere in between the two, but I figured I'd stay with one because the step-down treatment, the idea that she has to go to meetings, she's got to do something, to me that doesn't seem unreasonable because that's in line with most treatment recommendations. The first initial period of sobriety, you should be involved with things, and with someone like this, you don't know if she's going to do it unless you do it. The judge doesn't have a lot of... Now, the alternative to this is, in the old days, the judge would put people in jail. He would just put people in jail and not put people in jail. Now... You have these family courts and... Five years later, be grateful that the judge did this and got her sober rather than put her in jail. So yeah, you want to have an advocate, you want to have somebody really judging the individual situation, but this is not a crazy system. No. So before I get to you, I want to make a small comment on exactly what you said. Just saying that you all got taken aback by the severity of the system, because it's not within this particular county, it's much more than a lot of other places we've heard. Especially, like, 75 activities during the week, fine, completely agree. But making every day phone calls early in the morning and not knowing where you have to go to work, where you have to go there, and it looks like altogether it has to be, what, for three years? Yeah, two years. Yeah, so what is... And the reason why most of the audience sides with the patient is because we hear it. There's a name, and this is a person, and we visualize this person. If we just talk about is it right or wrong, then of course we'll probably fall in the middle where that is the case. What is tricky about this whole situation is that her day job, which is being a parent and getting food on the table and taking care of the kids, she doesn't get a leave from that, so she has to do that and in addition to all of this. But see, the counter argument is there's somebody else who doesn't have three kids or, you know, and has to take care of them, and why doesn't that person... So it's not prescribed to one person, and maybe these other... She may not have a... She may just qualify for a diagnosis, but maybe there is someone who is much worse than her, and the law is not for one individual. The laws are made for the population. So did you have a question? I think... Yes. Yeah, I've got a comment. So I don't disagree that much with where you're sitting. My biggest issue is the cost of it, because in my outpatient addiction medicine practice, I have very few patients who report that maybe three to five percent of them can afford several thousand dollars for an attorney. So aside from... I don't mind the rigors of what you're being asked to do. It's the financial cost. Poor people can't do that. The issue that I have with some of these ordered treatments is that the patients know where they're going to get better. So they have to do that, and on top of that, this other treatment that the court has may not be that therapeutic to this person, and they have to attend that, and where they have to stick with their psychiatrist who was taking care of them before this problem. So now they have to go to this court-appointed doc as well, along with their, you know, previous psychiatrist. So courts don't really easily switch to whether you were getting treatment or what was working for you in the past. So, yes. No, I mean, I definitely agree there should be consequences, because a lot of people die. But, I mean, I've seen situations where women have lost their day jobs because they can't meet the obligations of the day job and all the other obligations they have. And, you know, there are people out there who absolutely do not have any money to transport people, and they don't have a license. They don't have any money, they really don't, to these appointments. I think there's a middle ground. Yeah, you're right. You know, daycare costs, right? Who takes care of the kids if I have to go to work? And, I mean, she was a little lucky where her kids were a little older, 16 and 13 years old, right? I mean, if they were infant kids, I mean, that gets even tougher. Or Uber, yeah, that gets costly, yeah. Wow, that he relapsed. Who to trust, yeah. Because, you know, everything like the interlock, people have their kids breathe into it, and, you know, sometimes people, you know, there's stuff that people do which spoils it for the rest of them. I think we have to move on. Yes, go ahead. Yeah. Yeah. Well, whatever it was, you know, I'm glad she didn't drive, right? But, unfortunately, she was caught sitting in the car and ended up getting arrested. So, there were a lot of, and I've actually had more than one patient tell me that, too, because, like, I didn't know until someone told me, like, yeah, like in the state of Michigan, if you are, because a lot of people, you know, they drink, they can't drive, so they sleep in the back of the car, and guess what? You still get arrested. If you're on your driveway, the car doesn't even have to be on, you could. Yeah, yeah, it could be still. But, Rupa, you went out of the way for your patient, and I'll tell you, generally speaking, doctors don't show up out of their time, their own time, with, you know, show up to courts for your outpatient. People are just trying to, in their practice, try to get to the next patient available. So, this is, you really, you know, not everyone, some of us try to avoid even, like, filling out a form, because you don't know what that'll get you into, but, yeah, it was really, and that's kind of what some of the reason for doing this is, like, most of us are not aware of what we should be doing. So, why should we care about this topic? I mean, what's the point of this entire, right, thing that we're doing right now? So, you know, women and children, especially, like, they represent a special population with substance abuse treatment programs. Studies have shown that maternal use of drugs are associated with higher levels of parent-related stress, and children of substance users are considered to be at increased risk for physical abuse and neglect. The ACE scores, the adverse childhood experiences, are actually much higher for the child to, based on, for example, the trauma experience when entering the foster care system. Let's say they're, let's say CPS got involved with our patient, Heather, right, and the children got taken away, that would increase their ACE scores, the 16 and the 13-year-old. Having a parent with an addiction also is, would increase that score as well. Also, financially, I mean, there's economic constraints, right. There's a really good example from the Washington State Parent-Child Assistance Program. They actually compare, like, three years in the foster care versus putting someone in a substance use disorder treatment would save about two million dollars. That's a lot of money. I'm sure they could do a lot other things with two million dollars. Now, family-oriented treatment programs are less expensive, right. They improve child outcomes and many times also increases the chance of reunification. Let's say they were separated from the parent, they were in the foster care system, and they went through whatever was required of them, and so the chance of having them come back home again is much higher. Let's talk about the law. All right, so I have some states listed here, but basically prosecutors have been working for years. They're looking for laws to criminalize substance use disorders. There are two states, Alabama and South Carolina, where the Supreme Court has made it as a crime, a criminal offense to for mothers who are using substances while pregnant. Alabama has a Class A felony charge, which is mandatory 10 years or more life if a mother is found positive for a drug screen if they are pregnant. South Carolina considers a viable fetus as a person, and any endangering of that person is a criminal offense as well. Other states take a different stance. They have, they take a stance of taking the parental rights away rather than a criminal offense, and some states have mandatory treatment program referrals, so they can put the mother in a treatment program without her permission involuntarily. So Minnesota, Dakota, and South Dakota, and Wisconsin are one of those, and it's changing. The federal government recently changed a stance on availability of substance use disorder treatment to mothers, and target is also towards people from minority groups, African-American, Hispanics, and the goal is not just to provide substance abuse treatment. It's also to keep the kids with their mothers, so decrease the number of foster care placements, which harm not just the mother, also the kids upgrowing, and the cost, the financial cost of it also. So some states are taking stances towards that, and some states are still stuck in the old ways, like Nevada has different grants. New Mexico also has positive grants for the mothers. You know, they have grants you can open up to help the mothers go into treatment programs, get help, rather than criminalize them. Anybody have, from the state, any experiences or knowledge? It's, no, I have no idea, but yeah. I haven't read this, you know, this particular law, but I think, though, it does depend on how it's applied. Like, for instance, if I'm in practice, I'm going to get addictions, I'm a psychiatrist, and a patient comes to me who's pregnant, seeking help, that's between me and her, and that's it. You know, when I have my OBGYN colleagues, and they call, and they say, oh, so, you know, this person tested, and they actually don't call me. But, you know, when they do test positive, there is a certain point in pregnancy in which they have to report, but it gets reported to your CPS, whatever you're, you know, whatever different states call it. But I'm not sure that actually criminal action is taken against them. CPS gets involved, but unless there's something egregious, or to whomever the report is made wants to pursue it, you know, the charges are often are not pursued. So, there's a possibility of criminal charge, but other states don't have that possibility. It's more about civil litigation. There are 25 states and British Columbia who require physicians to report to CPS if there is suspected drug use. Eight states, they require physicians to test if they suspect drug use. So, there's a lot of different legalities which change statewide. It's always good to have knowledge about your state laws regarding this particular situation. There are some online searches, online resources available. There's one link is ProPublica. They have a map of the whole, like, United States, and you can click on your state and get the laws. There's one more which is more updated. It's called GUTmatcher, G-U-T-T-M-A-C-H-E-R dot O-R-G. So, that has more updated information on this one as well. Same legalities and different state laws. I think it makes sense for psychiatry to be very clear about women's health issues and especially around the idea of criminalizing women who use substances during pregnancy and not medicalizing it and punishing it and trying to allow for greater women's health. I know it's also there, but it's health programs and for minorities. They have to add the three to the two, which are important. But then again, there's the whole issue about parenthood and helping poor families not have kids when they have an addiction in the family and trying to provide knowledge and education for young women and also to provide good OBGYN care and all that at every step along the way and to offer people treatment because a certain percentage of these women will, when they know that they're the issues, will stop using or will cut down on the use significantly. And so, we have knowledge as a matter of applying it and policies out there. You're right. The legislation usually falls behind on what is practical and what is medical. Some of these laws are prehistoric and thankfully not all of them are acted on. So, we can be grateful for that. But these nuances, how are they different for each parent? Our story was about a mother and we want to focus on that and that kind of perspective. Not that men have it easy, but easier. I mean, if there is a father and the mother is using opiates during pregnancy, well, so is the father. Is there criminal action taken on him or sometimes they can know they're using outside. So, there's a lot more protection for the father. I don't know if that's fair either. So, maybe treatment is, in this case, both the husband and the wife were drinking, but the wife is the one who has to do this. So, yeah. So, the nuances are so many and the punchline is that you got to know your own state and you have to know somewhat of what laws are going to be enacted in your head. So, I'm going to try to do a quick crash course in what courts are because we throw around these terminologies of state court, federal court, family court and what is all of this? How does this all fall into the picture? And physicians, we don't have this as in part of our training in our residencies. There's no real lectures on your court. So, let me just quickly do a crash course on that. Basically, our court systems, and I think this is a little outdated, so there's 13 court of appeals over there. So, basic structure of a court system is three. So, there's a trial court, and then there's an appeal court, and then there is a Supreme Court. So, the final state where appeals are. All of these other confusing boxes are the same format only for exceptions. The main one to look at would be in the... So, there's two court systems. There's a federal court system and a state court system. The federal court system utilizes federal court laws and each state has their own laws. So, most of the work is done in state courts, and about 90% of the cases in state courts also get... they don't really go to trial. Most of them actually get solved before... they come to an agreement before there actually is action taken on them. So, like I said, there's two types of cases, criminal cases and civil cases. Most of us, we will be dealing with civil cases. Civil cases, there's like... you get... there's no punishment. There's like liable to... you're liable to a fine, and you have to do that, but you pay up fines, but if you are... the verdicts are guilty or not guilty in a criminal court. There is an overlap sometimes with our patients, and that follows the public law. So, if that's not confusing enough, I just wanted to give you like a perspective of the three courts, like the... in some states, there is... it's a little bit more complicated than this, but basically there is a trial court, an appeals court, and a Supreme Court. But the trial court can be divided into municipal court, district courts, probate court, domestic and family court, and juvenile court. And beyond these courts, there are some specialized courts, which do a little bit both of what we are actually... we were talking about what it... what needs to happen, like come across and work with the patient and coordinate care with the doctors, and those are called specialty courts. We... mental health court is confusing, but that's not exactly what you and I are dealing with. What... in a... in a case like this, that would fall under your district court and comes to the... so the family court is what... so did you say your patient was a drug court? Sobriety court. Sobriety court would be a drug court. So that's a specialty court. So this is something interesting. I had... this will be over there, so let me see if I can... how do I get out of this? Escape. Escape. Minimize. So we had some technical... so this I found as a really good idea of how to... so how do I send this up there? He's copying. Help. Help. So we had a technical difficulties. Our videos were not playing, and so... and the... there we go. So this website, which is... it should be in our presentation when you get it. So, this actually shows you the structure of your own state. So Illinois has like a pretty simple quote, like I explained, but Texas has a little bit more complicated version of this. And if you click on say, Tennessee, that looks like that. So there's no one rule that I can share here, which is going to apply to you and how your court should look. It's completely different each state. So my encouragement would be, know your own state. And how do I go to full screen? Did I get that right? Yes. Okay, good. So yeah, so that's the website. Please go to that and check your own state for how your court is, how your courts are aligned. And so drill down into the family court here. This is what family court will usually take care of. So marriage, civil cases, custody, civil protection, order protections, and the juvenile law. That's where family court will take care of. And you'll always hear the friend of the court used. So friend of the court actually helps the courts administer their rulings and help out with them. So a lot of the cases are settled outside of actual court and friend of the court will help you, your patient with that. Drug court, like I said, is a specialized court and it's got criminal defendants, so it's not a civil anymore. And the judges order treatment. So drug courts are ordered treatments that they have to, and if they don't follow, so this is what you were talking about, if in the past your judges would send them to jail, and this is a better alternative than that. So most of us will have to deal with drug court or family court. So identify where your patient is coming from. And this is like the specialty courts that I was talking about. They are multidisciplinary, they're a little bit more collaborative, and the treatment is a requirement and also the right treatment is recommended there. But not only is the whole legal system so confusing, but what is really critical is that there are different driving forces to whoever is part of this. So if you think about what their roles are, the court is geared towards the community safety and everyone, so that's their north. That's what the courts are thinking like that. Judges have laws to abide by. So these are the laws, this is the ruling from a previous case, and this is what we're going to base our judgment on. Not necessarily community safety, but the lawyers are trying to do what is best for their client. The CPS worker is focused on child safety, and not all of those things align. Probation officer wants to maintain the judge's order, the doctors are thinking of symptom resolution and self-efficacy and building up the patient and recovery, long-term recovery. And the guardian at litem, this is someone the court appoints, someone who's going to decide what is the best parenting plan for the patient, for the child, and that has nothing to do with how bad the parent was. The custody evaluator just comes and sees which of these two is the best choice as a parent. So very few of these things actually align. So when the intention is different and the actions might be different too. So that's the balance that we have to be aware of. Did you have a question? So in the process of trying to prepare for this, we try to get interviews from all these, some of these players. We didn't get everyone, but some of these players. So Terry Clark was part of a specialty court which does the treatment coordination. So we got a few snippets of their, we asked them questions and edited it to this. Supposed to play. One more click. Treatment and support courts are a type of problem-solving courts and they are national. I'm going to speak specifically today to the 17th Circuit Court, which is in Kent County, Michigan. What really makes this a great opportunity for individuals is that it is a court that takes individuals with some specialized needs out of regular court proceedings and instead works with them in a cross system network of people. So I'm hearing that it's a little bit of a wraparound service. So who are the players in this service? Our specialty court has a judge, a defense attorney, prosecutor, probation officer, a peer support, myself as a coordinator. And then we also have clinical liaisons who manage them while they're in the court, providing all kinds of support, but also connecting them and monitoring their treatment service provision. We always use a therapeutic response first before moving to sanctions. And the reason I mentioned that is that we work with individuals with very high needs and high risk. And the risk isn't necessarily to recidivate or to engage in more unlawful behavior, but it is who will not likely be successful on a traditional probation track. And the needs, obviously, in our court, which is a mental health co-occurring court, who has high mental health needs, who is functioning is so significantly impacted by their mental health that their participation in regular probation is very unlikely to be successful. The same for the substance use. So one of the cases that I think can illuminate how this court functions is a woman, and it is not her real name, Brenda, is a 36-year-old African-American woman. She has three children between the ages of 18 and eight. And when she came to us about four months ago, she did not have custody at that time. She was charged with second-degree child abuse and arson with the intent to burn down a dwelling. She reports that her behavior that resulted in these charges, the starting of this fire, was her attempt to commit suicide. And the children and the children's father happened to also be in the home. To back up just a little bit, Brenda has a pretty extensive history of mental health challenges. Initially, she did not necessarily know she wanted to participate. There was a lot of confusion for her. She thought that the charges would be dismissed. She'd had some prior legal engagement, quite a bit, actually, that she didn't report. But of course, we have on record. And some of those charges had been dismissed in the past. And she thought that that would likely be the case here. So she hesitantly engaged initially. That helped us to build a relationship with her. She recently has pled and is not on probation yet. But because of this team approach and the probation officer being on the team, they were already developing a relationship. And she understood that the team was on her team. She was part of it. And we wanted her to win. And she noted that clinically, probation, judicial, we all had one plan for her success. And that she was leading and directing that plan. And that we were going to pace her at the pace that she was willing to go. We prioritize. She had a lot of needs. But we had to ask her, what are you willing to work on? And really getting a priority for her was getting her children back. So I believe the relationship development, the weekly monitoring, which doesn't always sound positive, but it's in the form of a clinician, not the direct provider, but someone on our team being with them every week, the judge listening to them every week, the judge incentivizing all the things they were doing well, providing therapeutic opportunities when they stumbled. Instead of jail, we were doing writing assignments, or we would use community service. So it sounds like a lot of coordination of care from your end kept her on track. Absolutely. We do have rare exceptions where we have some psychiatrists who will work directly with the treatment and support court. Ideally, what we would love is that flow of information, any direction and recommendations that they feel would be beneficial to the participant in the court, any significant updates or new information that they may have that would be helpful towards their success. Consultation would be really key. If we had the opportunity to call them, we tend to observe a lot on a day-to-day basis and over this extended period of time. And we can often provide new and additional information that could eventually impact the course of treatment. The only thing I would say is that if you have a client who is engaged in the legal system, look locally for a problem-solving court. There are a variety of populations where courts have been designed. Veterans, juveniles, sobriety courts, drug courts, ours is a mental health co-occurring court. It really is a great opportunity for some folks to resolve their legal challenges and to leave them behind to kind of break that cycle of becoming to the attention of law enforcement. Excellent. Well, thank you so much. So our next expert that we spoke to, her name is Lindsey Meyer. She's actually a probation officer out of Allegan County in Michigan and she's been with that county for about 14 years. In her passion, she works mainly with females on a felony supervision. Now, you know, for the sake of time, I'm not going to read all of this out, but the biggest thing that really struck out to me was that a lot of judges held their pregnant females at a bit of a higher standard. They kept closer tabs on them. They tested them more often. So they just wanted to know what was going on with them more often than their other clients that were going through. Now, again, I spent a really long time talking to her, just enjoyed that conversation, got to ask her a lot of questions. But the biggest takeaway from this is that, you know what, she really hopes that as clinicians, she wants us to know like, hey, talk to your patient, give them that support. Because sometimes when they go to the inpatient, they get the help, they get the detox, they get the mental health, and then they go out, right? And then sometimes the ball just gets dropped. I mean, appointments right now, like, I mean, psychiatrists are booked out like, what, months away, right, for some outpatient clinics. For her, she was saying like about one to three weeks after they get out, that's a long time for them to get back right into that same old cycle again, getting back to the same environment they were stuck in. And sometimes, and that not sometimes, but she says it makes them very difficult for them to continue to put their sobriety and themselves as a priority because of those environmental stressors. Well, I, again, that kind of, well, it goes by county. My, most of my ladies can, I would say 75% successfully discharged from supervision. But of that 75%, I probably see 25% of them back in the system within three to four years, unfortunately. And it, a lot of it depends on, you know, their situation, their age. Their age has a lot to do with it, their maturity level, and their support system in the community. Like you had mentioned earlier, it's like a, like a cycle. There's a lot of social factors, too, that come into play as well. From your, you know, from the work that you've done, I mean, what barriers have you encountered, you know, with the legal system trying to work with the medical team? Well, the two biggest barriers that I have noticed between, you know, our system and the medical system is a lot of times the females are not willing to sign releases of information. So, a lot of times we don't even know if they're inpatient somewhere getting help for one reason or another. And another barrier that I've noticed is really the inaccessibility of a physician to directly communicate with the field agent. A lot of times if I call a facility, whether it be an inpatient program or even the general hospital to get information, I've, in 14 years, I've never spoken directly with the physician that is working with that mom. Sometimes I'll be lucky enough to have a conversation with a direct care staff or a nurse to give me basic information. But having that in-depth conversation to really understand that patient as a whole, that does not seem to happen. So, it sounds like it also answered my next question. It's like if there was any communication at all between your team and the physician and it sounds like there isn't any. It's very rare. Okay. Well, you know, with my last question, I mean, what would you like to see from the physician, you know, especially, for example, a psychiatrist, an addiction psychiatrist, like that would be helpful for you and a mother who is dealing with substance use disorders? You know, it would be amazing if the, you know, medical team and the other services such as probation and CPS and treatment providers would have a way of all communicating on the same platform, whether that be a family team meeting every, you know, three to six months. So, all of the pieces of the puzzle per se are getting addressed at the same time. So, there's no either overlap in services or miscommunication. You know, a lot of times these women are not overly forthcoming regarding, you know, their exact addiction history and, you know, how long ago they've used and sometimes they're getting medications that are either very addictive that it's probably not the best fit for them or that are interacting with substances that they're currently using, but they're telling their physician that they're not currently using, so it, you know, just makes them not work. Just being on some kind of a team platform would be, I think, amazing. So, I just want to make one thing. When our patients are completing their program or like when they're just going to go off probation, that happens to be the riskiest time because sometimes that commitment or that reporting to that probation officer is what was keeping them sober and they think they've completed and they can go back right back to their use. So, I just wanted to highlight that. I found that to be a very critical time for most of our patients. So, the third person we were able to talk to is Michelle Vander Haag. So, she was in Michigan, moved to Alabama recently, and she brings a lot of experience with herself. She has 10 years of working in foster care and adoption and eight years as a CPS worker. I'm going to skip over the next slide. It's mostly about what she does, but let's listen to her side of the talk. You mentioned that when the kids get removed, so what's the success rate, let's say, for a mom? Let's say she's going through the programming and doing everything that the CPS is requiring of her. What is the success rate? Or have you seen from your work, you know, moms getting their children back? I don't have any direct numbers for that, but I have seen moms get them back. However, I do know it's difficult because it's a very short span. Most states want the children reunited, the parents have about a year to get their children back before they start looking at other options. And with substance use in particular, you know, a year isn't very long. We know that relapse is part of recovery. However, judges don't necessarily see that, and they like to see the parents have six to nine months sobriety before they return the children. So it's a very short timeframe. And do you find that there's any communication between yourself and, let's say, the physician directly that may be working with the mom in her sobriety? Physicians are typically very hard to get a hold of, but usually we can talk to the nurses or the social workers in that department. I know in Michigan, we work very closely with the methadone clinic, and those doctors were very helpful with working with us. What barriers have you encountered, let's say, between the legal system, like, you know, like, again, with CPS and then trying to work with the medical team, like you, you know, you mentioned, like, you know, it's very hard to get a hold of a physician as one of them. That's one is that it's very difficult to get a hold of them. And then, especially, I think a lot of it when starting with the doctors, with the methadone, with methadone, particularly in the, in the, you know, how they're reducing the levels and how quick, you know, can they tell us how quick that will happen? You know, social workers don't have that medical background. And judges also don't, a lot of judges don't believe in the methadone treatment, so that that's a barrier. And what would you like to see, let's say, from our, from a physician that would be helpful for you and a mom with, with substance use disorders? Just, you know, better communication. Like, again, it doesn't have to be from the doctors, but if they could, you know, send us notes or their, like, social worker or nurse working with us, if they would be able to testify in court, that would be extremely beneficial. I don't know if it was practical, but that would be very beneficial. And if there was one big takeaway for our audience today, what would that be? I just think, you know, services for moms, maybe some more rehab where they can go with the children would be great. And just giving them that time and understanding the process. So it sounds like better education for your folks, as well as being able to work with you all to better manage our moms with children and then also substance abuse. Correct. So for anyone who's curious about what happened to patient Heather, so she's currently nearing the end of phase four and hoping to start phase five. That means she gets to graduate from the program when she finishes phase five. Despite how tough the programming has been so far, she reports, I was lucky to have people like my probation officer who wanted to see me succeed. I made friends during some of the groups. One of them is my best friend now, who is also a mom like me, and we're always keeping each other in check. So the next couple of slides, we're going to just go over what are the barriers to treatment for the patient and for the providers. And for the patient, you know, one is the provider's attitude. We just heard from three experts about one of the deficiencies is providers communicating with them or open communication between a psychiatrist or the treatment team with the legal team or the CPS workers. So the lack of availability, like I think most of the people said that there's no, the doctors are unavailable for this. That's definitely one. I heard that she said that some of the judges don't have, they don't believe in methadone at the treatment, so that judge's bias surely comes in the way of a barrier for treatment for that patient. So it's that lack of education, right? But there's a lack of education within the legal system as well. Like you said, like judges don't believe in the methadone clinic. But you know, what can we- In New Jersey, we used to have training sessions with judges. We have, you know, maybe a hundred judges come through every training session and talk about all this stuff. And of course, a couple of judges would get very angry. And then later I'd find out that they had alcohol and drug problems themselves. Did they come to treatment later on? Yeah. But I think that the, that this group has an important role in advocacy. Absolutely. We have to try to get lawyers and judges to try to give talks. And also, as you said, you know, make ourselves more available. I think that that is key, right? People will turn to you for a question if they think you're a friend. So if they have a question and you're not available, they're not going to ask that question anymore. Barriers that you guys have found for the patient? Yes. Oh, yes. So for anyone who didn't hear that, that's partners who are in domestic abuse, they were victims of domestic abuse, you said? Yeah. Right. Because they keep going, they get better and they go back and they start using again. So that happens a lot too. There's no treatment facility I know that will take spouses at the same time. And especially in our own, I think that those are, that is a critical piece. We get one at a time. And by the time we get one, the other is ready to come in. And when they go back, the spouse may not be sober anymore. So it's not always... The cycle continues. The cycle, yeah. Transportation. These families come in very grateful and they've been able to keep their kids and they've dealt with problems. And so, but someone here, I think Rupa mentioned the resources. And we had state resources that were supporting this program. And so... End of the day, it becomes about resources, right? And now there's all this money for the Purdue stuff. And it should be used for things like this. Practical. Rather than get put into general funds. So how do we advocate to get the states to use resources for things that are important? And speaking of funding, right? Like we said, that's one of our barriers. It's like, hey, there's no funding. I mean, there's a lack of transportation, there's no safe housing, there's no... I mean, the resources are so limited, especially for... It's like for poorer patients. So yeah. Another thing, in New York State, somebody was mentioning about sending people. In New York State, we have programs like Daytop, where regardless of cost, and whether you've been in jail or anything, as an alternative to going to jail, you can go to Daytop and get treatment. And it's not wonderful, but it's a lot better than jail. It's not Silver Hill Hospital. I ran a fancy hospital. It didn't have the amenities that we had, so it was cool, and stuff like that. But it was pretty helpful to many, many, many people. And it actually had a story in the past about the great volunteers here as a medical director. I think they usually have a booth normally. Every year they come here. So yeah, the barriers... And this is only... We had two cases today we talked about. Both of them had happy endings. Unfortunately, many of our patients that we deal with don't end up with happy endings there. So we can move on to the next slide, which is barriers for the physicians. So here we can open up and discuss what barriers we see. The reason why we did this was the top one, not understanding the legal language or the system or the various cogs in the whole legal machine. And when we're uncertain ourselves, we don't dive in either. So if you don't know enough, you probably say, I don't want to look dumb in front of the judge, so let me avoid it altogether. And time is another one that... I don't know how... The doc over here earlier said that I went to the court to support this guy and all. Out of what time? I don't know. I had barely enough time to make it home to my kids. In my usual day, I don't know out of what time you're going to do that. How about the next one? How about our own countertransference? Towards the patient or the judges or the lawyers? It can be towards many different things. But towards the patient and a mother who's using substances, I had providers say certain things which makes us uncomfortable. I think most of the audience over here will probably side with the patient. It wouldn't be hard for us to understand because we deal with this distress on a daily basis. But the primary care doctor or someone who may not be so open to substance use disorder treatment can be a barrier. And coordinating care through them... Because a lot of times we tell our patients to go to their primary care doctors and get some time off for treatment. And FMLA is better filled by your PCP. And they may not agree with you on certain things. So I think understanding where the patient is and kind of helping out as much as we can. I know there's a lot of responsibility on the psychiatrist in this. But making ourselves available for one, doing it for your patient. Other things that didn't make the cut? Anyone? Yes? I mean, I agree with all these things. I think one of the things that I see... I live in Kentucky, which is the most progressive state. So a lot of my patients, you know, they get involved with CPS. They get assigned a caseworker. The caseworkers are... They're young. A lot of them, they don't have much experience. They don't have any real good understanding of substance use. So much, you know, they don't understand the difference between substance use and substance use disorder. You know, there are things like, what really constitutes an endangerment? How do you really define that? How do you really define, because somebody is abusing, are they a not safe parent? I mean, to me, those are things that a clinician needs to be involved in. There's a lot of education, but I just see so much, so many decisions made based on things that are not scientific criteria. And I've had times when I did try to reach out to a CPS caseworker, and they never called me back. So I think what you said was the young learner in their field may not have the same patience as may be required for the patient, because a lot of it is really quick get to the, you know, understanding addiction for the chronic disease that it is, not just, oh, this one time, right? And they, now it's over. And there's still that disease and the behavioral model is still not gone yet. I know we're trying to remove the stigma from, people still believe in that. From the back of the room, anyone has comments and thoughts on barriers that there are patients who are? It becomes a balance, yeah, because the judges will often see you not only as an advocate, but also as an expert, right? So I work in a health professional program, and even though we're not talking about that right now, there's so many parallels to, you know, your talk here today is asking people to do a whole bunch of things. Yeah, out of our time. So, but I think, point being, I just feel like we're, as addiction psychiatrists, we're going to be asked to participate in these types of discussions and how we navigate that. Yeah, so let me just go back. Yeah, so basically kind of what we were getting to, what are the practical things that we can do? Number one, we can continue to provide our high quality care for your patient, advocating for them as well, providing equitable, individualized care, not only for the mother, but also for the father, whenever you get a parent doing what is right for all involved. But then education, I think that's a common theme that we have to do. I think that has the highest bang for the buck. Going in, making yourself available for that one patient at that one case may not be, may not give you the ongoing results that you want, but making yourself available to your area judge or your, in your system, the patients that are coming to you through, what legal system are they coming to you from? So, identifying like the friend of the court or like the family court that is in your area or circuit court that you can be available for, maybe like once in three months to deliver a talk on methadone or substance use or buprenorphine or explaining chronicity of substance use disorder. Just making yourself available as that expert that they want to see you as, not necessarily expert for that particular case, but expert of the field. So, making ourselves available for that. And finally, familiarizing yourself with the local court system because like I had mentioned earlier, each state law is different, each state structure is different. So, familiarizing yourself and from one of our speakers, he said something about identifying the problem solving or the specialty court in your area, which actually may avoid jail time and actually has that cohesive team approach for that patient, which we all know works in our field. I know we had like 90 minutes to this, but I know you've been sitting very patiently. And so, if there's a thing, things that we didn't say or things that you want to add, please. Just another way, this has been fabulous. You did an amazing job involving the audience. Just one last thought that came to mind, I'm kidding for the kids also. You've got to admit it, a lot of the time we're going to be family. Yes. One case that came to mind where I chose... Did you want the mic? No. One case that came to mind where... It was against New York State. I was there for a witness. And it was... A little girl who was eight years old was thrown against the steam by her mom who was cocaine addicted and had severe third degree burns. And the social worker did a very minimal evaluation of the mom who had not been clean for more than two weeks and was given back custody after several years. The mom had a problem with prevention. She should not have been given a kid back in such a safe place in a foster home. So, our job is not only to try to be sympathetic to the parents and try to get the kids together and be families together, which we should do, but we also have a very large obligation to the children. Yeah, one of our audience members in the first half, I think he may have gone to a more interesting talk, but he mentioned that it's not always the safest to expedite someone to get back to their... So, whatever is the best, we can only hope for it. We can't promise that. We can't guarantee. In our field, we can't guarantee anything. Results are not guaranteed. Effort is what we appreciate. So, if there's nothing else, I think we can... Yes, go ahead. So, what is happening in New York State right now is somewhat controversial. There is a debate among professionals about whether a pregnant woman who's delivering should be chemically tested or maybe verbally evaluated. Their rationale is that if they're chemically tested, if it's positive, then it gets reported. If they do verbal screening, then they might be positive, but it's not reported. And we have professionals on both sides of that issue. So, if you could comment, what's your opinion on chemical testing should it be mandatory and then if it's positive, should treatment be done in order to report? You're asking me as if I'm an expert in New York law. No, I'm not. But my initial thoughts on how you said it was if there was a verbal screening, to me, I'm hearing patient maybe... If the patient is saying, I could be positive for heroin, to me, that's a patient who may be ready to get help versus if they're saying, no, I'm not and their drug screen comes back positive. So, I'm always looking for that one thing that the patient is saying that helps me help them get to the other side, right? So, I think there's credibility to asking initially and then if you need to confirm something if the person is already ready for treatment, then definitely doing or confirmatory test afterward. But what is your take on that? What have you experienced? So, traditionally, chemical testing has been required as a standard in hospitals and that's changing very recently, in the recent couple of years. It's also changing at the American College of Obstetrics and Gynecology. They are reevaluating this and there's obstetricians I've spoken to who may not come from one side or the other and there are hospitals in New York State. Some of them, when you deliver, you've got to get chemically tested and others, no, you just get verbal. And how we as professionals view that now, my view is that the chemical testing is more accurate so that should be great, but that is not the very view, necessarily, of a model addiction treatment professionals. I tend to be more liberal-minded, but what comes to mind for me is if we don't do chemical testing in terms of neonatal withdrawal symptoms, we don't know what's going on. If you don't do the testing, you might miss out on treatment for the neonatal abstinence syndrome and things like that. Well, the rationale is if you miss out on picking up chemical test that's positive and the woman is still using it, it's the child's welfare, the issue. Yeah. So I'm a strong proponent of testing on admission before we even have a discussion about anything for anyone in emergency room or even in coming into treatment. And I've always told my patients, hey, if you've got nothing to hide, give us a drug screen, right? So I like the drug screen as a positive thing and we frame it in our clinics as something they need to be working towards and something to be proud of, like challenge you to get a drug screen that is negative, of all things, even cannabis. Yes. I'm not an expert on this, but I think that it makes sense to do testing at a lot of stages along the way. The question is how it's handled in terms of public policy, whether punitive for mothers or not. But the reason it makes sense to do the testing is that then you can try to intervene. And my guess is a third to a half the time you intervene, the mother's going to stop using wards or maybe it's not that hard. Maybe it's a third of the time. But for most cases, you've made a big difference in what's going to happen. And that makes it worth it as far as officers. The question of how the state handles it, whether they make a decision for that, whether they do something terrible, and certainly these states obviously are doing terrible things to their mothers. In different counties, it's handled differently. So in some counties, it gets reported and custody then goes to the court. And sometimes, in some counties in New York, it stays on their criminal record. Now, that's another whole other thing. But in other counties, it might not get reported or mandated treatment. But the argument now is, your view of addiction as a disease is the woman going to be a criminal on us? Yeah. If you don't want to do that, so if you don't have the kids, I would say in the optimal world, I want to be able to do testing and not have it, and use it for good. Absolutely. Yeah, so testing, I don't think you'll get an argument from anyone in this room saying that testing is not good. But reporting, we can probably all side with the fact where if it's dangerous, yes, then we should report. But the reporting is critical, yes. Not always accurate, yes. Thank you for sitting through. I wasn't sure if everybody would... Thank you so much.

Dr. Sonia Moten

addiction

family court system

sobriety court

Heather

phases of sobriety court

state laws

supportive approach

substance use disorders

legal system

barriers to treatment

collaboration