Get Out, Right Now

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Welcome to M4 Medicine, mystery,
mayhem, and sometimes murder.

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I'm Andrea Marziano and RN with
35 years of experience across

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various fields.
From direct patient care in

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hospitals to home health,
geriatrics, and injury medicine,

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I face life, death, and
everything in between.

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And I'm Crystal Miller and RN
with 13 1/2 years of experience.

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My work spans home health,
Hospice, emergency care,

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geriatrics, and occupational
health.

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From the chaos of trauma based
quiet moments with patients,

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I've seen stories that defy
explanations.

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We've been friends for over 25
years and as nurses we've shared

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countless stories that have left
us and our families speechless.

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Now we're bringing those stories
and many more to you in

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medicine, mystery, mayhem, and
sometimes murder.

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Each week, we'll uncover cases
that challenge the boundaries of

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medicine, sharing the human
stories behind the science.

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From puzzling medical mysteries
to shocking real life crimes,

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we'll bring you stories that'll
leave you questioning everything

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you thought you knew while.
We're both experiencing treats,

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nurses.
We want to make it clear we're

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not here to give medical advice.
This podcast is about

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storytelling, education and
exploration, not diagnosing or

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treating medical conditions.
This is medicine, mystery,

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mayhem and sometimes murder.
Let's dive in.

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Hey Crystal, how are you doing?
I'm doing well.

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How are you?
I'm really well, Thank you.

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What's up?
Anything exciting?

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I had something interesting
happen.

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Do you remember the pop singer
Debbie Gibson?

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I do.
You really liked her?

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Yeah, she sang.
She wrote the song and performed

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the song Lost in Your Eyes.
You know, I get lost in younger

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eyes.
I'm no Debbie Gibson.

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But anyway, for those who don't
know who she is, she was famous

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pop singer in the 1980s.
She was considered one of the

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mall singers.
And that's because she and

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another artist, Tiffany and and
Belinda Carlisle, they would go

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and travel and perform in malls.
And at the time malls were huge.

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So this was like a big deal.
Anyway, I met her a few years

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ago.
She was helping out with our

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charity and our charity
fundraising event, the Prince,

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the Princess Festival, got to
know her, got to become friends

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with her and she recently wrote
an autobiography and she gave me

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a shout out in the
autobiography.

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So my name is in Debbie Gibson's
autobiography, which I think is

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really cool.
Yeah, you're nearly famous.

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Practically famous.
So anyway, it's always.

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Exciting when something like
that happens, even.

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Yeah, it's just the fact that
she thought of you these years

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later.
And maybe you were.

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And all of that that's.
Right, exactly because she was

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helping out with our charity.
She really could have just

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mentioned the charity and she
didn't.

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She, she named me.
She named the charity also, but

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she named me by name.
And that was really flattering

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and really kind of her, I think.
So anyway, everybody go pick up

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Debbie Gibson's autobiography
and see my name in it.

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Yeah, we'll Sturge and Sturge.
And she said it was in here.

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That's funny.
Well, cool, that's exciting.

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Will you still talk to me even
though you're super famous now?

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I suppose.
I guess we'll make an exception

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for this.
Well, good, since I Can't Sing,

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but I have been willing to hang
around with you for 25 plus

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years.
We actually we probably need to

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recount that because I think
we're flattering ourselves by

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saying it was only 25.
Now it's.

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Probably true.
Gosh.

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When I, when I look back at
things, I'm like, oh, that was

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about 20 years ago.
Oh my gosh, it was 30.

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Yeah, no kidding.
I never, I never thought I'd be

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old enough to think of remember
something.

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It was 30 even 50 years ago now.
Like, Oh my heavens.

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So I was talking about being 15
recently and realized that was

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35 years ago and I'm like,
aren't I only 35 years old?

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Yeah, When, when did this
happen?

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What?
What's going on here?

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I know.
It's so ridiculous.

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And just anyway, we're
listeners, we're having a

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moment.
Sorry.

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OK, So what do you have for us
today?

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Today I have another sad story,
which I don't know why I'm

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saying sad story laughing.
That's horrible.

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Yeah.
So today we're going to be

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talking about the
deinstitutionalization of

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psychiatric care, the waterfall
effect that that had.

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My sources are I have quite a
few sources, but primary sources

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are an article called American
Psychosis, How the Federal

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Government Destroyed the Mental
Illness Treatment System from

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the Oxford University Press, An
article called The Mad Among Us,

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A History of the care of
America's Mentally ill from the

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Free Press.
Another article, The Shame of

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the States by Harcourt, Brace
and the rest all put into the

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show notes 'cause there's quite
a few.

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So right.
So in 1955 the United States had

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558,000 people living inside
state psychiatric hospitals,

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585,000 people in beds under
roofs with staff, However

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inadequate, however cruel,
however broken the system around

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them, there were staff.
By the year 2000, that number

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had dropped to under 55,000.
So it had dropped more than

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500,000 in 45 years.
Not because mental illness got

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better, not because we invented
a cure, not because the need

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disappeared, but because we
closed the doors.

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Just that's it.
Goodbye.

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Good luck.
Yeah, exactly.

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Right when you find work.
Yeah, right.

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And we told ourselves a story
about why that was the right

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thing to do.
And in many ways, in many

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genuinely important ways, it
was.

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The old system was a horror.
I'm going to tell you exactly

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how much of A horror.
But we also told ourselves the

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second story.
We told ourselves that closing

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the hospitals was a beginning,
not an ending.

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That we would build something
better, That the communities we

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were returning people to would
be ready, that the funding would

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follow, that the care would be
there.

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And it wasn't.
And what filled the gap would

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absorb the 500,000 people who
are no longer in psychiatric

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beds is a different kind of
institution entirely, one with

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bars on the windows and
correctional officers instead of

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psychiatrists and philosophy
built not around treatment but

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around punishment.
Today, we're going to follow the

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long, tangled, heartbreaking
thread of psychiatric

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deinstitutionalization America.
We're going to talk about where

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it started, why it happened,
what we were promised, and what

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actually came to be.
We're going to talk about the

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jails and prisons that became,
as one psychiatrist famously put

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it, the new asylums.
We're going to talk about the

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sidewalks and encampments that
absorbed hundreds of thousands

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of people with serious mental
illness when they have nowhere

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else to go.
And we're going to talk about

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the families, the clinicians,
the advocates, and the

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incarcerated people who have
been screaming into the void

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about this for 50 years.
This is one of the most

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important public health failures
in American history, and almost

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nobody calls it calls it that.
So let's talk about it.

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Let's do, although it feels sad
already.

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It's it's, it is.
It's.

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So before we can talk about
deinstitutionalization, we have

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to understand what we were
deinstitutionalizing from.

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And I need to be careful here
because the history of the

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oldest silent system has been
weaponized in both directions.

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On one side, you have people who
look back at the old state

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hospitals as a lost solution.
Imperfect, sure, but at least it

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was something beds, containment,
a place to put people.

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Some critics of
deinstitutionalization have

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romanticized the institutional
era in ways that are genuinely

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dangerous, because what was
happening inside those buildings

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was in many cases barbaric.
On the other side, you have

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people who point to the horrors
of the old system as full

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justification for everything
that came after, as if

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acknowledging the failure of
institutionalization means you

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can't also acknowledge the
failure of what replaced it.

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And I want to do neither of
those things today.

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I want to be honest about what
the old system was and honest

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about what the new system
became.

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State psychiatric hospitals in
America have their roots in the

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reform movement of the 19th
century.

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Dorothea Dix is the name most
associated with this era.

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She was a Massachusetts school
school teacher and activist who

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in the 1840s began A crusade to
document the conditions in which

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mentally ill people were being
housed.

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What she found was genuinely
appalling.

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People with serious mental
illness are being kept in alms

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houses alongside the poor,
jailed for behaviors they

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couldn't control, chained in
unheated Cellars are simply

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turned out into the street.
In 1843, she presented a report

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to the Massachusetts Legislature
called the Memorial that

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described what she had
personally witnessed people

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living in cages, closets and
stalls, stripped of clothing in

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winter, beaten and whipped to
force compliance.

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Yeah, I've heard about stuff
like that.

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It's.
Horrifying.

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Dorothy has spent the next 40
years travelling across the

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country and lobbying state
legislatures to build hospitals,

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proper hospitals with trained
staff and medical oversight and

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therapeutic programming to treat
them mentally ill with dignity.

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She was enormously influential.
32 states opened or expanded

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psychiatric hospitals as a
direct result of her advocacy.

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The original vision was
genuinely humane, fresh air,

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structured routines, moral
treatment, which in the 19th

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century context meant treating
patients as human beings capable

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of improvement rather than as
animals to be warehoused.

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The the early reformers believed
that mental illness was

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treatable, that a well designed
environment could heal a

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disordered mind, and for a
while, in small institutions

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with adequate resources.
There is actually some evidence

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that moral treatment work
recovery rates from the early

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19th century for mild to
moderate cases were surprisingly

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good by the standards of the
era.

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But then something happened that
destroyed well-intentioned

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institutions over and over again
across history.

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The populations grew, and the
budgets didn't.

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By the early 20th century, state
psychiatric hospitals had

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transformed into something
almost unrecognizable from

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Dorothea Dix's vision.
Populations had exploded.

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Facilities built for 200
patients held 2000.

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Well, I was just thinking, did
this increase the number of

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people in beds in these
facilities, these changes, did

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we go from 500,000 to a bigger
number or a smaller number?

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I mean when but.
Went from zero to I don't know

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how many at this point.
Well, I just wondered if some of

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those who had been previously
basically incarcerated, I mean,

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not in prisons and stuff, but
really in lots of other ways,

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are the same people that came
off the streets?

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Or is this a long enough gap
that it didn't it didn't cover

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any of the same people?
You know what I mean?

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Yeah, I'm not really sure, but I
think that it was, it was

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probably a mix of both.
It was probably some passed away

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in these deplorable
circumstances in the alms houses

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and on the street and some were
put into these institutions, but

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it doesn't.
I didn't really come across that

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to be honest.
Right.

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Got you.
So just that just that the

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populations clearly the need was
more than people realized

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because like I said, the
facilities built for 200

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patients held 2000 patients and
the staff ratios were

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catastrophic.
There were no resources for

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individualized treatment and the
entire enterprise shifted from

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therapeutic institution to
custodial warehouse.

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And then there's the treatments
being used.

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And I want to be very clear
about this.

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They were not treatments in any
meaningful sense of the word.

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They were experiments in
subduing people.

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Horrified.
Hydrotherapy involved wrapping

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patients in cold, wet sheets for
hours at a time.

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Insulin coma therapy put
patients into repeated

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hypoglycemic comas, sometimes
dozens of them, over weeks, in

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the belief that inducing and
reversing coma could reset the

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brain.
There was no evidence this

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worked, and people died from it.
Lobotomy, the surgical severing

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00:12:17,680 --> 00:12:20,680
of connections to the prefrontal
cortex, was introduced to

232
00:12:20,680 --> 00:12:23,840
American medicine in the late
1930s and became, for a

233
00:12:23,840 --> 00:12:27,160
terrifying window of time, a
mainstream psychiatric

234
00:12:27,160 --> 00:12:29,160
intervention.
Walter Freeman, the most

235
00:12:29,160 --> 00:12:32,200
enthusiastic practitioner of
what he called the transorbital

236
00:12:32,200 --> 00:12:35,200
lobotomy, performed the
procedure by inserting an ice

237
00:12:35,200 --> 00:12:38,400
pick through the eye socket and
moving it around to sever brain

238
00:12:38,400 --> 00:12:40,240
tissue.
And I want to make it really

239
00:12:40,240 --> 00:12:44,000
clear what that means.
He literally, literally took an

240
00:12:44,000 --> 00:12:47,600
ice pick, stuck it into the
corner of the eye socket,

241
00:12:48,080 --> 00:12:53,280
hammered it in some depth and
then moved it around.

242
00:12:53,280 --> 00:12:57,280
Like if you've ever had like a,
a shake or a Slurpee that you

243
00:12:57,280 --> 00:13:00,920
want to kind of break up the ice
crystals like that, like swirled

244
00:13:00,920 --> 00:13:04,840
it around with, I know with kind
of the hope of that it would

245
00:13:05,040 --> 00:13:10,000
sever the correct brain tissue.
Yeah, and as you describe this,

246
00:13:10,000 --> 00:13:11,560
it's just just giving me the
chills.

247
00:13:11,560 --> 00:13:14,280
That is so awful.
Can you imagine?

248
00:13:14,480 --> 00:13:17,560
And he did this in his office,
and he did it without full

249
00:13:17,560 --> 00:13:21,040
anesthesia.
He performed it on children and

250
00:13:21,040 --> 00:13:24,640
he operated out of a van he
called the Lobotomobile, which

251
00:13:24,640 --> 00:13:28,120
is also horrifying like.
So many reasons it was and.

252
00:13:28,600 --> 00:13:30,720
He travelled the country
performing surgeries.

253
00:13:31,080 --> 00:13:35,880
He lobotomized an an estimated
3500 people.

254
00:13:36,640 --> 00:13:40,680
That is unbelievable.
And the people inside these

255
00:13:40,680 --> 00:13:42,640
hospitals had essentially no
rights.

256
00:13:43,040 --> 00:13:45,760
They could be committed
involuntarily by a family member

257
00:13:45,760 --> 00:13:47,960
or a physician with minimal
legal oversight.

258
00:13:48,080 --> 00:13:50,200
Once committed, they were
subject to whatever treatment

259
00:13:50,200 --> 00:13:53,600
the institution decided to use.
They could not easily leave.

260
00:13:53,960 --> 00:13:55,960
They had no meaningful access to
courts.

261
00:13:56,280 --> 00:13:57,880
Their mail was read and
censored.

262
00:13:57,880 --> 00:14:00,840
Their visitors were controlled.
Some people enter these

263
00:14:00,840 --> 00:14:03,960
institutions as teenagers and
did not come out until they were

264
00:14:03,960 --> 00:14:07,400
elderly.
The journalist Albert Deutsch

265
00:14:07,400 --> 00:14:11,080
published a book in 1948 called
The Shame of the States, and I

266
00:14:11,080 --> 00:14:12,440
said it was an article and it
was a book.

267
00:14:12,480 --> 00:14:15,480
My apologies.
The documented conditions in

268
00:14:15,480 --> 00:14:17,840
state psychiatric hospitals
across the country.

269
00:14:17,960 --> 00:14:20,840
He described patients lying on
the floor in their own excrement

270
00:14:21,280 --> 00:14:25,200
wards so overcrowded that
patients slept in hallways, nude

271
00:14:25,200 --> 00:14:28,680
patients in freezing unheated
buildings, staff so under

272
00:14:28,680 --> 00:14:31,440
trained and overworked that
abuse was constant and

273
00:14:31,440 --> 00:14:34,360
institutional.
It makes me think of 1 Flew Over

274
00:14:34,360 --> 00:14:37,840
the Cuckoo's Nest, you know, and
that's exactly what that book

275
00:14:37,840 --> 00:14:41,360
slash movie is about, is about
the the deplorable conditions

276
00:14:41,360 --> 00:14:45,080
that these psychiatric
institutions maintained.

277
00:14:45,400 --> 00:14:50,080
Life magazine wrote a photo, ran
a photo essay in 1946 called

278
00:14:50,080 --> 00:14:53,280
Bedlam 1946.
And I want to pause on that word

279
00:14:53,280 --> 00:14:57,600
Bedlam because it comes directly
from Bethlehem Royal Hospital in

280
00:14:57,600 --> 00:15:00,840
London, which was such a
notorious institution for so

281
00:15:00,840 --> 00:15:04,320
many centuries that its name
became a synonym for chaos and

282
00:15:04,320 --> 00:15:08,200
horror.
Photos showed emaciated men

283
00:15:08,200 --> 00:15:11,880
lying on bare floors,
overcrowded wards, patients

284
00:15:11,880 --> 00:15:15,240
restrained without 'cause it was
shocking at the time, and it's

285
00:15:15,240 --> 00:15:18,280
still shocked.
So imagine Bedlam being

286
00:15:18,400 --> 00:15:23,400
literally named for your
hospital, your institution.

287
00:15:24,360 --> 00:15:28,360
Like, yeah.
I mean, that's it's just so, so

288
00:15:28,360 --> 00:15:31,320
out of the realm of
understanding, I think really.

289
00:15:31,320 --> 00:15:33,640
It really is, and this is the
system that the

290
00:15:33,640 --> 00:15:37,000
institutionalization was a
response to, and I cannot stress

291
00:15:37,000 --> 00:15:40,480
this enough, The reform impulse
was real and it was justified.

292
00:15:40,680 --> 00:15:44,960
Something had to change.
Two things happened in the mid

293
00:15:44,960 --> 00:15:48,680
20th century that made that made
deinstitutionalization feel not

294
00:15:48,680 --> 00:15:53,080
just possible but inevitable. 1
was a pill, 1 was a president.

295
00:15:54,720 --> 00:15:59,680
In 1952, a French surgeon named
Henri Labourri was experimenting

296
00:15:59,680 --> 00:16:03,160
with antihistamines in surgical
patients when he noticed that a

297
00:16:03,160 --> 00:16:07,000
compound called chlorpromazine
seemed to produce a profound

298
00:16:07,000 --> 00:16:10,640
sense of calm without sedation.
The patients were conscious.

299
00:16:10,920 --> 00:16:13,640
They could respond to questions,
but they were utterly

300
00:16:13,640 --> 00:16:15,560
indifferent to what was
happening around them.

301
00:16:16,440 --> 00:16:19,920
Core Promising made it to
psychiatric wards within a year.

302
00:16:20,400 --> 00:16:22,640
The results were by the
standards of what had come

303
00:16:22,640 --> 00:16:26,320
before, extraordinary Patients
who had been in states of

304
00:16:26,320 --> 00:16:29,200
frantic agitation for years
became manageable.

305
00:16:29,840 --> 00:16:31,880
Patients who had been
experiencing Florida

306
00:16:31,880 --> 00:16:34,920
hallucinations and delusions
showed measurable improvement.

307
00:16:35,680 --> 00:16:38,280
Wards that had required physical
restraint to maintain order

308
00:16:38,280 --> 00:16:41,240
became, for the first time in
decades, something approaching

309
00:16:41,240 --> 00:16:44,920
quiet core.
Promazine, marketed in the US as

310
00:16:44,920 --> 00:16:47,440
Thorazine, was hailed as a
miracle.

311
00:16:48,000 --> 00:16:49,800
Time magazine called it a wonder
drug.

312
00:16:50,360 --> 00:16:53,280
Psychiatrist who had spent their
careers in hopeless custodial

313
00:16:53,280 --> 00:16:56,120
institutions suddenly believed
they were practicing medicine.

314
00:16:56,320 --> 00:16:58,240
And here's where the story
starts to fracture.

315
00:16:58,320 --> 00:17:01,560
Because the drug was real, and
its effects were real, but the

316
00:17:01,560 --> 00:17:05,119
conclusions drawn from it were
catastrophically overconfident,

317
00:17:05,560 --> 00:17:07,560
core promising.
And the antipsychotics that

318
00:17:07,560 --> 00:17:10,000
followed it did not cure
schizophrenia.

319
00:17:10,520 --> 00:17:14,520
They managed symptoms in they
managed them well enough to

320
00:17:14,520 --> 00:17:17,520
allow for a significantly
improved quality of life, but

321
00:17:17,520 --> 00:17:20,880
only with consistent access to
medication, consistent

322
00:17:20,880 --> 00:17:23,599
monitoring, consistent support
services.

323
00:17:24,040 --> 00:17:26,680
The medication was a tool, not a
solution.

324
00:17:27,040 --> 00:17:29,800
It required a scaffold of care
around it to work.

325
00:17:30,720 --> 00:17:34,320
That distinction got lost almost
immediately in the rush of

326
00:17:34,320 --> 00:17:38,040
optimism.
John F Kennedy had a personal

327
00:17:38,040 --> 00:17:40,760
connection to psychiatric
institutionalization that almost

328
00:17:40,760 --> 00:17:43,200
no one in his in his
administration talked about

329
00:17:43,200 --> 00:17:46,120
publicly.
His sister, Rosemary Kennedy,

330
00:17:46,120 --> 00:17:49,520
had been lobotomized in 1941 at
the direction of their father,

331
00:17:49,520 --> 00:17:51,760
Joseph Kennedy.
She was 23.

332
00:17:52,840 --> 00:17:55,520
The surgeon was intended to
address mood swings and the

333
00:17:55,520 --> 00:17:58,200
seizures associated with her
intellectual disability.

334
00:17:58,880 --> 00:18:01,080
It left her permanently
incapacitated and

335
00:18:01,080 --> 00:18:03,080
institutionalized for the rest
of her life.

336
00:18:03,680 --> 00:18:05,880
The family kept this secret for
decades.

337
00:18:06,400 --> 00:18:10,600
And, you know, it's, it's been a
secret for it's, it was a secret

338
00:18:10,600 --> 00:18:12,720
for a very long time.
It's only been recently that we

339
00:18:12,720 --> 00:18:16,200
were even, you know, made aware
that Rosemary Kennedy existed.

340
00:18:18,240 --> 00:18:20,840
And whether Kennedy's personal
history shaped his policy

341
00:18:20,840 --> 00:18:23,160
thinking is something historians
have debated.

342
00:18:23,160 --> 00:18:25,520
And I got to tell you, I'm not a
historian and I'm not in the

343
00:18:25,520 --> 00:18:28,960
debate, but I cannot imagine
that it did not shape his.

344
00:18:29,000 --> 00:18:32,160
No, it couldn't.
I mean, I've read some things

345
00:18:32,160 --> 00:18:36,120
about Rosemary Kennedy and from
what I understand she was

346
00:18:36,120 --> 00:18:40,440
beloved by I like I said, I
can't imagine that it didn't

347
00:18:40,440 --> 00:18:44,080
have a large impact on on what
he was thinking.

348
00:18:44,280 --> 00:18:47,680
What is in disputed is that in
1963 he delivered a special

349
00:18:47,680 --> 00:18:50,560
message to Congress on mental
illness and mental retardation,

350
00:18:50,680 --> 00:18:54,120
the first presidential message
ever devoted to the subject, and

351
00:18:54,120 --> 00:18:56,200
signed the Community Mental
Health Act into law.

352
00:18:56,640 --> 00:19:00,440
It was in many ways a visionary
piece of piece of legislation.

353
00:19:01,240 --> 00:19:04,880
The plan was elegant in concept.
The federal government would

354
00:19:04,880 --> 00:19:07,560
fund the construction of a
network of community mental

355
00:19:07,560 --> 00:19:11,720
health centers, 1500 of them
across the nation, one for every

356
00:19:11,720 --> 00:19:15,400
catchment area of 50,000 to
200,000 people across the

357
00:19:15,400 --> 00:19:17,720
country.
These centers would provide

358
00:19:17,720 --> 00:19:21,480
outpatient treatment, partial
hospitalization, inpatient

359
00:19:21,480 --> 00:19:25,560
services, emergency care, and
consultation of and education.

360
00:19:25,720 --> 00:19:28,760
The idea was that people who had
formerly required long term

361
00:19:28,760 --> 00:19:32,000
institutionalization would
instead receive intensive

362
00:19:32,000 --> 00:19:35,320
community based support.
They could live and be treated

363
00:19:35,320 --> 00:19:38,240
in their own neighborhoods, with
their own families, in their own

364
00:19:38,240 --> 00:19:40,320
lives.
That, on the face of it, looks

365
00:19:40,320 --> 00:19:41,440
really good.
I mean.

366
00:19:42,000 --> 00:19:44,920
Well, I want to say that in
researching this, like this,

367
00:19:45,880 --> 00:19:48,320
this broke my heart.
And you'll see why in a second.

368
00:19:48,400 --> 00:19:52,200
But this sounds beautiful and
perfect, right?

369
00:19:52,920 --> 00:19:56,160
And the state hospitals would
depopulate and the community

370
00:19:56,160 --> 00:19:59,440
centers would absorb the need.
It was a beautiful plan.

371
00:20:00,680 --> 00:20:02,680
And then Kennedy was
assassinated in November of

372
00:20:02,680 --> 00:20:06,680
1963, six weeks after signing
the Community Mental Health Act.

373
00:20:07,480 --> 00:20:10,240
And the community mental health
system he envisioned was never

374
00:20:10,240 --> 00:20:15,320
fully built.
So like it's a super, super

375
00:20:15,320 --> 00:20:17,720
bummer because it does, it was a
beautiful plan.

376
00:20:17,720 --> 00:20:21,880
It was, I feel, I feel like just
from my perspective, it would

377
00:20:21,880 --> 00:20:25,000
have worked and, and to have the
federal funding because that's

378
00:20:25,000 --> 00:20:29,920
really where a, a big part of
why we did deinstitutionalized

379
00:20:29,920 --> 00:20:31,800
was funding, right.
Yeah.

380
00:20:32,440 --> 00:20:37,240
So from 1955 to 1994, the census
of state psychiatric hospitals

381
00:20:37,240 --> 00:20:40,280
in the United States fell by
approximately 85%.

382
00:20:40,360 --> 00:20:42,760
Nearly half a million beds
disappeared.

383
00:20:43,480 --> 00:20:45,000
And this did not happen all at
once.

384
00:20:45,000 --> 00:20:47,640
It did not happen because of a
single policy decision.

385
00:20:47,760 --> 00:20:51,360
It happened through a confluence
of factors that each

386
00:20:51,360 --> 00:20:54,520
individually had responsible
justifications that that

387
00:20:54,520 --> 00:20:57,440
together produced a a
catastrophe.

388
00:20:58,880 --> 00:21:01,880
So here's something that almost
never gets said loudly enough in

389
00:21:01,880 --> 00:21:03,800
histories of
deinstitutionalization.

390
00:21:04,280 --> 00:21:07,360
The states saved an enormous
amount of money by closing

391
00:21:07,360 --> 00:21:11,120
psychiatric hospitals, and the
federal government created a

392
00:21:11,120 --> 00:21:15,440
financial incentive to do it.
In 1965, Medicaid was created,

393
00:21:15,920 --> 00:21:18,840
and buried in the Medicaid
statute was a provision called

394
00:21:18,840 --> 00:21:21,720
the Institution for Mental
Diseases Exclusion.

395
00:21:22,280 --> 00:21:25,960
The IMD exclusion, which
prohibited federal Medicaid

396
00:21:25,960 --> 00:21:28,880
funding from being used for
inpatient psychiatric care in

397
00:21:28,880 --> 00:21:32,440
facilities with more than 16
beds for patients between ages

398
00:21:32,440 --> 00:21:36,920
22 and 64.
So think, yeah, think about what

399
00:21:36,920 --> 00:21:39,520
that means.
State hospitals, which were by

400
00:21:39,520 --> 00:21:43,000
definition large institutions
with hundreds or thousands of

401
00:21:43,000 --> 00:21:46,400
beds, could not be funded by
Medicaid, but outpatient

402
00:21:46,400 --> 00:21:48,680
community care could be.
And once a patient was

403
00:21:48,680 --> 00:21:52,040
discharged in the into the
community and onto Medicaid, the

404
00:21:52,040 --> 00:21:55,000
cost of their care shifted from
the state budget to a shared

405
00:21:55,000 --> 00:21:59,200
state federal funding stream.
Governors and straight and state

406
00:21:59,200 --> 00:22:01,560
legislatures noticed this
immediately.

407
00:22:01,720 --> 00:22:04,800
Discharging patients was not
just ideological aligned with

408
00:22:04,800 --> 00:22:07,240
the community mental health
vision, it was fiscally

409
00:22:07,240 --> 00:22:10,320
profitable for states.
The financial incentive to empty

410
00:22:10,320 --> 00:22:13,960
the hospitals was enormous, and
it operated independently of

411
00:22:13,960 --> 00:22:16,120
whether the community
infrastructure to receive those

412
00:22:16,120 --> 00:22:19,240
patients existed.
The IMD exclusion is still in

413
00:22:19,240 --> 00:22:22,000
effect today, by the way.
It continues to distort the

414
00:22:22,000 --> 00:22:24,360
mental health system in ways
that advocates have been trying

415
00:22:24,360 --> 00:22:29,120
to fix for 60 years.
Then, in the 1960s and 70s, we

416
00:22:29,120 --> 00:22:32,200
saw a series of landmark court
decisions that reshaped the

417
00:22:32,200 --> 00:22:34,720
rights of people with mental
illness in ways that were both

418
00:22:34,720 --> 00:22:38,640
genuinely liberatory and, in
practice, deeply complicated.

419
00:22:38,720 --> 00:22:41,120
The core issue was involuntary
commitment.

420
00:22:41,600 --> 00:22:43,880
Before the reform era, a person
can be committed to a

421
00:22:43,880 --> 00:22:46,960
psychiatric hospital essentially
at the discretion of a physician

422
00:22:46,960 --> 00:22:49,280
and a family member, with
minimal legal review.

423
00:22:49,600 --> 00:22:52,320
Patients who had been committed
had almost no mechanism to

424
00:22:52,320 --> 00:22:53,920
challenge their commitment in
court.

425
00:22:54,120 --> 00:22:57,160
Advocates argued, correctly,
that this was a profound

426
00:22:57,160 --> 00:23:00,280
violation of civil liberties,
that people with mental illness

427
00:23:00,280 --> 00:23:02,880
were being deprived of their
freedom without due process,

428
00:23:03,040 --> 00:23:05,800
that the hospitals themselves
were often doing more harm than

429
00:23:05,800 --> 00:23:08,680
good, that the right to be free
from unwanted

430
00:23:08,680 --> 00:23:11,600
institutionalization was a
fundamental constitutional

431
00:23:11,600 --> 00:23:13,440
right.
Courts agreed.

432
00:23:14,080 --> 00:23:16,920
A series of decisions through
the 1970s established that

433
00:23:16,920 --> 00:23:19,920
involuntary psychiatric
commitment required meeting a

434
00:23:19,920 --> 00:23:21,600
standard similar to criminal
law.

435
00:23:21,800 --> 00:23:24,280
The person had to be
demonstrated to be an imminent

436
00:23:24,280 --> 00:23:27,880
danger to themselves or others
or gravely disabled, and they

437
00:23:27,880 --> 00:23:30,440
were entitled to legal
representation and judicial

438
00:23:30,440 --> 00:23:32,160
review.
The standard for what

439
00:23:32,160 --> 00:23:36,720
constituted gravely disabled was
interpreted narrowly in many

440
00:23:36,720 --> 00:23:39,960
jurisdictions.
That result in practice was that

441
00:23:39,960 --> 00:23:43,400
it became very difficult to
hospitalize someone who is

442
00:23:43,400 --> 00:23:46,600
experiencing serious mental
illness but was not actively

443
00:23:46,600 --> 00:23:49,680
threatening violence or
starvation, a person who was

444
00:23:49,680 --> 00:23:53,920
psychotic and decompensating but
who could articulate a refusal

445
00:23:53,920 --> 00:23:57,480
of treatment at legal standing
to walk out of an emergency

446
00:23:57,480 --> 00:24:00,520
room.
This is genuinely one of the

447
00:24:00,520 --> 00:24:02,760
hardest tensions in mental
health law.

448
00:24:03,400 --> 00:24:06,080
The civil libertarian case
against involuntary

449
00:24:06,080 --> 00:24:08,000
hospitalization is real and
important.

450
00:24:08,520 --> 00:24:11,440
The history of that system being
abused, being used to warehouse

451
00:24:11,440 --> 00:24:14,240
the poor, the inconvenient, the
politically dissenting, the non

452
00:24:14,240 --> 00:24:16,680
conforming is real.
The argument that forced

453
00:24:16,680 --> 00:24:19,480
treatment often doesn't work and
that it destroys the therapeutic

454
00:24:19,480 --> 00:24:22,440
relationship is real.
But there is another reality.

455
00:24:23,000 --> 00:24:25,600
There's a population of people
with serious mental illness,

456
00:24:25,880 --> 00:24:31,880
particularly those with nausea,
a neurological condition which

457
00:24:31,880 --> 00:24:34,960
the illness itself impairs the
ability to recognize that one is

458
00:24:34,960 --> 00:24:37,560
ill, for whom the ability to
refuse treatment means the

459
00:24:37,560 --> 00:24:41,120
ability to remain in a state of
untreated psychosis potentially

460
00:24:41,120 --> 00:24:44,600
for years or decades.
So basically it's a condition

461
00:24:44,600 --> 00:24:47,320
where you're mentally ill and
you can't see it for yourself,

462
00:24:47,320 --> 00:24:50,840
which I feel like I feel like is
prevalent in mental illness.

463
00:24:50,840 --> 00:24:56,480
I feel like it's more rare for
somebody to be, to be cognizant

464
00:24:56,480 --> 00:24:57,840
of the fact that they have
mental illness.

465
00:24:57,840 --> 00:25:00,040
And I'm talking in like severe
mental illness.

466
00:25:00,560 --> 00:25:06,200
I have a friend who is severely
mentally ill and he has paranoid

467
00:25:06,200 --> 00:25:10,520
schizophrenia, OCD.
He's got several diagnosis and I

468
00:25:10,520 --> 00:25:14,960
can't remember all of them, but
he has done things like he cut

469
00:25:14,960 --> 00:25:17,440
off his own finger because the
voices in his head just told him

470
00:25:17,440 --> 00:25:18,960
to.
Yeah.

471
00:25:18,960 --> 00:25:22,880
And he's he is 1 of what I
consider the rare that is fully

472
00:25:22,880 --> 00:25:26,400
aware of his mental illness.
And sometimes he bends to the

473
00:25:26,400 --> 00:25:29,880
whims of his mental illness and
sometimes he's able to resist.

474
00:25:29,880 --> 00:25:33,200
But, and I, I, it's anecdotal in
the sense of I haven't been in

475
00:25:33,200 --> 00:25:38,040
every single psychiatric
situation in the world, but I, I

476
00:25:38,040 --> 00:25:41,960
do find that it's for the psych
nursing that I've done.

477
00:25:41,960 --> 00:25:45,160
I do find that the majority that
I've experienced that have

478
00:25:45,160 --> 00:25:49,600
severe mental illness, they're
they're fully unaware of and in

479
00:25:49,600 --> 00:25:52,600
denial of the fact that they're
they have mental illness.

480
00:25:53,120 --> 00:25:55,680
And it and that piece that in
denial may be actually more

481
00:25:55,680 --> 00:25:57,800
accurate than unaware.
Yeah, true.

482
00:25:57,840 --> 00:26:00,280
That's true.
That's that's see, these are not

483
00:26:00,280 --> 00:26:02,520
people making an informed
autonomous choice.

484
00:26:02,520 --> 00:26:04,640
These are people whose illness
is preventing them from

485
00:26:04,640 --> 00:26:07,640
understanding that they are ill.
So you're right, I think denial

486
00:26:07,640 --> 00:26:11,080
may be more more accurate than
this.

487
00:26:11,480 --> 00:26:16,880
Anna's nausea, Anosanosia.
I don't know.

488
00:26:18,440 --> 00:26:20,880
The legal reforms did not
adequately grapple with this

489
00:26:20,880 --> 00:26:24,160
population, and that population
is a significant part of who

490
00:26:24,160 --> 00:26:28,000
ended up on the street.
Deinstitutionalization also had

491
00:26:28,000 --> 00:26:31,160
genuine intellectual champions,
and not all of them were wrong

492
00:26:31,160 --> 00:26:34,960
about everything.
The sociologist Irving Goffman

493
00:26:35,320 --> 00:26:40,960
published a hat a landmark study
in 1961 called Asylums, based on

494
00:26:41,000 --> 00:26:44,000
ethnographic field work he
conducted at Saint Elizabeth's

495
00:26:44,000 --> 00:26:48,520
Hospital in Washington, DC.
Goffman argued that psychiatric

496
00:26:48,520 --> 00:26:52,080
institutions did not treat
mental illness, they created it.

497
00:26:52,200 --> 00:26:55,200
That the dehumanizing conditions
of total institutions

498
00:26:55,200 --> 00:26:59,160
systematically stripped patients
of their identity, agency, and

499
00:26:59,160 --> 00:27:03,360
self concept in ways that were
themselves profoundly damaging.

500
00:27:03,520 --> 00:27:06,040
That what looks like the
symptoms of mental illness was

501
00:27:06,040 --> 00:27:08,640
often the product of
institutionalization itself.

502
00:27:08,640 --> 00:27:12,240
Thomas Czaz, a psychiatrist and
fierce critic of his own

503
00:27:12,240 --> 00:27:16,640
profession, published The Myth
of Mental Illness in 1961 and

504
00:27:16,640 --> 00:27:19,400
argued that but most of what
psychiatry called illness was

505
00:27:19,400 --> 00:27:23,000
actually deviance from social
norms, that the diagnostic

506
00:27:23,000 --> 00:27:26,200
categories were not medical
realities but moral judgements

507
00:27:26,200 --> 00:27:29,880
dressed in medical language, and
that involuntary commitment was

508
00:27:29,880 --> 00:27:32,560
a form of social control
masquerading his medicine.

509
00:27:33,480 --> 00:27:38,160
The Italian psychiatrist Franco
Basalia LED a movement that

510
00:27:38,160 --> 00:27:41,360
resulted resulted in Italy
literally abolishing its

511
00:27:41,360 --> 00:27:45,920
psychiatric hospital system in
1978 through a law called Lege.

512
00:27:46,040 --> 00:27:50,360
180 believed that the
institutions were the problem,

513
00:27:50,760 --> 00:27:53,640
that liberation from them was
self therapeutic and that

514
00:27:53,640 --> 00:27:56,800
society had an obligation to
create real community based

515
00:27:56,800 --> 00:28:00,080
alternatives.
These ideas had enormous

516
00:28:00,080 --> 00:28:04,000
influence on the policy
environment of the 1960s and 70s

517
00:28:04,080 --> 00:28:06,200
and again they contained real
truths.

518
00:28:06,600 --> 00:28:10,600
The institutions were harmful.
Institutionalization did have

519
00:28:11,040 --> 00:28:14,680
iatrogenic effects.
The civil commitment system had

520
00:28:14,680 --> 00:28:18,120
been abused, but the ideological
enthusiasm for a

521
00:28:18,120 --> 00:28:22,080
deinstitutionalization often
outran the evidence and, more

522
00:28:22,080 --> 00:28:24,640
importantly, outran the
infrastructure.

523
00:28:25,200 --> 00:28:27,880
The community mental health
centers were underfunded from

524
00:28:27,880 --> 00:28:29,920
the beginning, and many were
never built.

525
00:28:30,400 --> 00:28:33,000
The wrap around services that
were supposed to support people

526
00:28:33,000 --> 00:28:36,200
in the Community, Housing, case
management, medication

527
00:28:36,200 --> 00:28:39,600
management, crisis response
materialized only partially and

528
00:28:39,600 --> 00:28:42,720
inconsistently, and in many
regions, not at all.

529
00:28:43,040 --> 00:28:47,120
By the time Ronald Reagan took
office in 1981 and converted the

530
00:28:47,120 --> 00:28:50,120
federal community mental health
program into a block grant,

531
00:28:50,640 --> 00:28:52,960
slashing funding and removing
the requirement to build the

532
00:28:52,960 --> 00:28:55,600
Promise Centers, the system was
already failing.

533
00:28:55,680 --> 00:28:58,040
Reagan's cuts accelerated A
collapse that was already

534
00:28:58,040 --> 00:28:59,840
underway.
And I was thinking about this,

535
00:28:59,840 --> 00:29:05,120
and I'm not great at my
presidential trivia, so I don't

536
00:29:05,120 --> 00:29:09,840
know who came between Lyndon
Johnson and Ronald Reagan, but

537
00:29:09,840 --> 00:29:13,440
it makes me it didn't make me
curious what those presidents

538
00:29:13,640 --> 00:29:18,600
did in the interim before Ronald
Reagan did his really crappy

539
00:29:18,760 --> 00:29:22,040
funding slashing jerk face
moves.

540
00:29:22,040 --> 00:29:23,960
But how do you feel?
I mean really feel.

541
00:29:26,240 --> 00:29:28,840
So there was.
There was Nixon, Ford and

542
00:29:28,840 --> 00:29:30,600
Carter.
Thank you.

543
00:29:30,840 --> 00:29:33,600
Heartbreaking in my opinion.
Yeah, me too.

544
00:29:34,640 --> 00:29:40,040
So in 2016, the Treatment
Advocacy Advocacy Center, a

545
00:29:40,040 --> 00:29:43,480
nonprofit mental health policy
organization, published a report

546
00:29:43,480 --> 00:29:46,760
with a title that should have
stopped the country cold.

547
00:29:46,840 --> 00:29:49,880
Quote The treatment of persons
with mental illness in prisons

548
00:29:49,880 --> 00:29:53,240
and jails.
Estate survey close Quote The

549
00:29:53,240 --> 00:29:57,720
report found that in 4450 states
the largest single psychiatric

550
00:29:57,720 --> 00:30:01,120
inpatient facility was not a
hospital, it was a jail or

551
00:30:01,120 --> 00:30:04,560
prison.
The three largest de facto

552
00:30:04,560 --> 00:30:07,200
psychiatric facilities in the
United States were the Los

553
00:30:07,200 --> 00:30:11,080
Angeles County Jail, Rikers
Island in New York City, and the

554
00:30:11,080 --> 00:30:14,200
Cook County Jail in Chicago.
Let that land.

555
00:30:14,920 --> 00:30:19,480
The largest psychiatric facility
in Los Angeles County is a jail.

556
00:30:20,360 --> 00:30:24,520
Wow, we even not having ever
really been closely experiencing

557
00:30:24,520 --> 00:30:27,400
it, it's like that can't be
good.

558
00:30:27,840 --> 00:30:29,160
No.
That can't be good.

559
00:30:29,160 --> 00:30:32,040
Nothing about that.
Even if they are getting good

560
00:30:32,160 --> 00:30:35,720
mental health care, which I'm
dubious about because I've never

561
00:30:35,720 --> 00:30:38,880
known any kind of jail or prison
that was actually staffed

562
00:30:38,880 --> 00:30:42,480
appropriately and doesn't
necessarily draw the highest

563
00:30:42,480 --> 00:30:46,800
talent is Yeah, that's shocking.
So how did this happen?

564
00:30:47,360 --> 00:30:51,040
Let's look at the numbers.
In 2006, the Department of

565
00:30:51,040 --> 00:30:53,720
Justice published a special
report on mental health problems

566
00:30:53,720 --> 00:30:57,600
of prison and jail inmates.
It found that 56% of state

567
00:30:57,600 --> 00:31:03,280
prisoners, 45% of federal
prisoners, and 64% of local jail

568
00:31:03,280 --> 00:31:05,040
inmates had a mental health
problem.

569
00:31:05,240 --> 00:31:08,640
Even with the DO JS relatively
broad definition of, quote,

570
00:31:08,640 --> 00:31:11,640
mental health problems, those
numbers are staggering.

571
00:31:12,400 --> 00:31:19,600
Again, I'm going to repeat that
56% of state prisoners, 45% of

572
00:31:19,600 --> 00:31:25,000
federal prisoners and 64% of
local jail inmates had a mental

573
00:31:25,000 --> 00:31:29,360
health problem.
So that's more than half in

574
00:31:29,360 --> 00:31:33,880
state prisons and local jails
and nearly half in federal

575
00:31:33,880 --> 00:31:36,320
prisons.
And, you know, my thought goes

576
00:31:36,320 --> 00:31:40,080
to a lot of federal prisoners
are white collar criminals.

577
00:31:40,640 --> 00:31:44,320
And I suspect that they're
there's there's less mental

578
00:31:44,320 --> 00:31:48,080
health issues that are as
prominent, I would say, or as

579
00:31:48,080 --> 00:31:50,960
severe in those kinds of crime
criminals.

580
00:31:50,960 --> 00:31:54,080
That's just science by Crystal,
by Crystal's imagination.

581
00:31:54,080 --> 00:31:56,720
But you know, that's kind of
where my thought went to that

582
00:31:57,520 --> 00:32:02,400
with that just it.
Just and the problem is too many

583
00:32:02,400 --> 00:32:05,120
people become criminals because
they're trying to support their

584
00:32:05,120 --> 00:32:07,520
drug habits which they're trying
to medicate themselves for

585
00:32:07,520 --> 00:32:08,840
psychiatric.
They're self medicating,

586
00:32:08,840 --> 00:32:12,160
exactly.
So more recent estimates for

587
00:32:12,160 --> 00:32:14,920
serious mental illness,
specifically conditions like

588
00:32:14,920 --> 00:32:18,160
schizophrenia, bipolar disorder
with psychotic features, and

589
00:32:18,160 --> 00:32:22,000
major depressive disorder with
psychosis, find that between 15

590
00:32:22,000 --> 00:32:25,320
and 20% of the prison and jail
population has a serious mental

591
00:32:25,320 --> 00:32:27,960
illness.
Applied to the roughly 2 million

592
00:32:27,960 --> 00:32:31,240
people incarcerated in the
United States at any given time,

593
00:32:31,320 --> 00:32:34,960
that means that somewhere
between 300 and 400,000 people

594
00:32:34,960 --> 00:32:38,280
with serious mental illness are
behind bars on any given day.

595
00:32:38,360 --> 00:32:42,320
So again, that 15, that between
15 and 20% is specifically

596
00:32:42,320 --> 00:32:48,160
psychotic features between 300
and 400,000 people in our

597
00:32:48,160 --> 00:32:51,400
prisons are psychotic.
Yeah.

598
00:32:51,400 --> 00:32:54,640
So compare that to the
approximately 35,000 to 45,000

599
00:32:54,640 --> 00:32:57,000
people currently in state
psychiatric hospitals.

600
00:32:57,200 --> 00:33:00,760
The ratio is roughly 12:50.
For every person receiving

601
00:33:00,760 --> 00:33:03,840
inpatient psychiatric treatment
in a hospital, 10 people with

602
00:33:03,840 --> 00:33:06,080
comparable illness are in a
Correctional Facility.

603
00:33:07,600 --> 00:33:11,560
And it's interesting.
I, I, I'm in researching this,

604
00:33:11,560 --> 00:33:14,160
I'm curious to know what state
psychiatric hospitals still

605
00:33:14,160 --> 00:33:15,960
exist.
And I didn't look it up, but I'm

606
00:33:16,240 --> 00:33:19,320
old enough to remember the state
hospital in Provo, UT.

607
00:33:19,440 --> 00:33:23,800
It clearly was not shut down in
the 70s because I was born in

608
00:33:23,800 --> 00:33:26,040
the 70s.
And, you know, it may have been

609
00:33:26,040 --> 00:33:30,480
one that was shut down by 1994
because I would have been 18 in

610
00:33:30,480 --> 00:33:33,200
1994.
But I do very much remember the

611
00:33:33,200 --> 00:33:36,360
hospital on the Hill and I
remember it being shut down.

612
00:33:36,360 --> 00:33:39,520
And I Remember Remember my mom
particularly being really upset

613
00:33:39,520 --> 00:33:41,680
about it.
I also had a friend whose mom

614
00:33:41,680 --> 00:33:44,760
was employed there and she was
very upset about it with it

615
00:33:44,800 --> 00:33:46,960
because obviously she lost her
job, but that's not what she was

616
00:33:46,960 --> 00:33:48,360
upset about.
She was upset about the

617
00:33:48,360 --> 00:33:52,480
deinstitutionalization of these
patients who who needed the

618
00:33:52,480 --> 00:33:53,880
care, right.
And.

619
00:33:54,520 --> 00:33:57,000
And may have had nowhere to go
at all, right?

620
00:33:57,160 --> 00:33:58,720
Exactly.
Yeah.

621
00:33:59,040 --> 00:34:02,160
Well, and just just for your
information, I was just looking

622
00:34:02,160 --> 00:34:06,280
up state hospitals and it came
to Washington State because of

623
00:34:06,280 --> 00:34:10,840
course this is where I am and
Washington State has three main

624
00:34:11,320 --> 00:34:14,239
state-run psychiatric.
Institutions.

625
00:34:14,600 --> 00:34:18,520
Oh, that's interesting.
Yeah, that's that's wild, given

626
00:34:18,520 --> 00:34:22,920
that there are only enough to
house about 45,000 people.

627
00:34:22,920 --> 00:34:27,719
So the psychiatrist E Fuller
Tory, who has been one of the

628
00:34:27,719 --> 00:34:30,719
most prominent and sometimes
controversial voices on the

629
00:34:30,719 --> 00:34:34,239
issue for decades, has argued
that this represents a complete

630
00:34:34,239 --> 00:34:37,040
inversion of what mental health
system was supposed to be.

631
00:34:37,080 --> 00:34:39,480
We didn't end
institutionalization.

632
00:34:39,520 --> 00:34:42,920
We re institutionalized in the
worst possible settings.

633
00:34:44,360 --> 00:34:47,120
So how does this person with
serious mental illness end up in

634
00:34:47,120 --> 00:34:49,400
jail or prison?
The pathways are multiple,

635
00:34:49,639 --> 00:34:51,719
interrelated, and often
heartbreaking.

636
00:34:51,920 --> 00:34:54,960
The most common is what is
sometimes called criminalization

637
00:34:54,960 --> 00:34:58,000
and mental illness, the process
by which behaviors that are

638
00:34:58,000 --> 00:35:00,240
symptoms of illness become
criminal charges.

639
00:35:00,480 --> 00:35:03,000
A person experiencing A
psychotic episode may be

640
00:35:03,000 --> 00:35:05,440
disruptive, aggressive, or
threatening in ways that result

641
00:35:05,440 --> 00:35:08,040
in police contact.
A person with untreated bipolar

642
00:35:08,040 --> 00:35:11,520
disorder may engage in reckless
behavior, public intoxication,

643
00:35:11,800 --> 00:35:15,080
disorderly conduct, petty theft
that cycles them through the

644
00:35:15,080 --> 00:35:16,960
criminal justice system
repeatedly.

645
00:35:17,560 --> 00:35:20,200
A person with schizophrenia
lying on the sorry living on the

646
00:35:20,200 --> 00:35:23,520
street may be arrested for
trespassing, loitering, or

647
00:35:23,520 --> 00:35:26,640
urinating in public.
These are not crimes in the

648
00:35:26,640 --> 00:35:30,600
sense that the criminal justice
system was designed to address.

649
00:35:30,760 --> 00:35:33,280
They are symptoms.
But in the absence of a

650
00:35:33,280 --> 00:35:35,600
functioning mental health
system, the criminal justice

651
00:35:35,600 --> 00:35:38,400
system is where they land.
The officer on the street who

652
00:35:38,400 --> 00:35:40,960
encounters someone in
psychiatric crisis has limited

653
00:35:40,960 --> 00:35:43,080
options.
They can transport them to a

654
00:35:43,080 --> 00:35:46,160
hospital emergency room, where
they may be held briefly if they

655
00:35:46,160 --> 00:35:49,360
meet the narrow standard for
involuntary commitment, and then

656
00:35:49,360 --> 00:35:51,800
discharged back to the street
within hours or days.

657
00:35:51,880 --> 00:35:54,040
They can try to connect them
with the community mental health

658
00:35:54,040 --> 00:35:56,880
resource, if one exists and has
capacity, which often it

659
00:35:56,880 --> 00:35:58,840
doesn't.
Or they can arrest them, which

660
00:35:58,840 --> 00:36:01,560
at least gets them off the
street and into a system that

661
00:36:01,560 --> 00:36:04,840
will, however inadequately, feed
them and house them.

662
00:36:06,240 --> 00:36:08,400
Criticism of individual
officers.

663
00:36:08,640 --> 00:36:11,640
Many law enforcement officers
are deeply uncomfortable with

664
00:36:11,640 --> 00:36:14,800
being the default response to
psychiatric crisis Crisis

665
00:36:14,800 --> 00:36:17,840
Intervention Team training.
The model developed in Memphis

666
00:36:17,840 --> 00:36:20,880
in the 1980s specifically to
address police response to

667
00:36:20,880 --> 00:36:24,000
mental health emergencies, has
been adopted by many departments

668
00:36:24,000 --> 00:36:26,160
as an attempt to handle the
situation better.

669
00:36:26,320 --> 00:36:28,640
The CIT model is genuinely
helpful.

670
00:36:29,160 --> 00:36:31,800
It is not a substitute for a
functional mental health system.

671
00:36:31,880 --> 00:36:36,320
This reminds me of the story of
a that now this is not mental

672
00:36:36,320 --> 00:36:40,800
illness but of a kid that was
having that was on the autism

673
00:36:40,800 --> 00:36:46,040
spectrum and an outburst and cop
shot him to death.

674
00:36:46,040 --> 00:36:52,040
Dude, I will say that a lot of
police departments are working

675
00:36:52,080 --> 00:36:58,160
on partnering with mental health
crisis specialist and just to

676
00:36:59,000 --> 00:37:03,800
deescalate situations so that
they don't result in harm to

677
00:37:03,800 --> 00:37:06,360
others or arrest.
Unfortunately, it's not enough.

678
00:37:06,400 --> 00:37:07,760
It's not enough police
departments.

679
00:37:07,760 --> 00:37:10,920
I mean, and also it's not enough
of an intervention, but it's a,

680
00:37:11,240 --> 00:37:14,080
it's a huge step in a better
direction because there are

681
00:37:14,080 --> 00:37:18,200
mental health professionals that
are trained in a much more

682
00:37:18,240 --> 00:37:22,440
effective crisis intervention
than one would, would get from a

683
00:37:22,520 --> 00:37:24,880
police crisis intervention
training, right?

684
00:37:24,880 --> 00:37:29,040
And we do that's like, that's, I
think it should be the first

685
00:37:29,040 --> 00:37:34,000
step in all police departments
that we stop sending, we stop

686
00:37:34,000 --> 00:37:39,360
sending only cops to mental
health crises situations.

687
00:37:40,560 --> 00:37:43,560
And we, and we send in the
mental health experts.

688
00:37:43,680 --> 00:37:47,480
We, we hear a lot of times of,
you know, people with

689
00:37:47,480 --> 00:37:51,720
schizophrenia holding people
hostage or things like that.

690
00:37:51,720 --> 00:37:56,520
And it's just, it's just there's
so many things that can be de

691
00:37:56,520 --> 00:38:00,680
escalated if you have the tools
and not enough people have the

692
00:38:00,680 --> 00:38:04,120
tools right now.
Yeah, my biological father said

693
00:38:04,120 --> 00:38:07,800
help set up a program in
California that put teams

694
00:38:07,800 --> 00:38:11,080
together, go out with police in
in the Oakland area.

695
00:38:11,440 --> 00:38:14,120
And it was a pilot program and
it grew and grew because they

696
00:38:14,120 --> 00:38:15,640
were seeing the benefits from
it.

697
00:38:15,920 --> 00:38:18,280
And there were target times.
The way I understand it, there

698
00:38:18,280 --> 00:38:20,880
were target times that they sent
them out because I guess there

699
00:38:20,880 --> 00:38:24,480
were more, more times with
psychiatric issues than other

700
00:38:24,480 --> 00:38:27,640
times during the day.
I mean actually times it was

701
00:38:27,880 --> 00:38:29,560
said to have made a huge
difference.

702
00:38:29,760 --> 00:38:32,800
Yeah, it's that's what they're
finding in in these places to

703
00:38:32,800 --> 00:38:35,320
have these programs.
So good on your, good on Steve,

704
00:38:35,560 --> 00:38:37,080
I'll say.
Yeah.

705
00:38:38,640 --> 00:38:41,200
So what happens to people with
serious mental illness once they

706
00:38:41,200 --> 00:38:45,000
are inside jails and prisons is
in many cases, a story of

707
00:38:45,000 --> 00:38:48,000
compounding harm.
The jail environment is

708
00:38:48,000 --> 00:38:50,960
profoundly hostile to people
with psychiatric symptoms.

709
00:38:51,040 --> 00:38:54,360
The noise, the unpredictability,
the loss of control, the threat

710
00:38:54,360 --> 00:38:58,080
of violence, the inability to
access medication reliably, all

711
00:38:58,080 --> 00:39:00,800
of these things are acutely
destabilizing for people with

712
00:39:00,800 --> 00:39:03,440
conditions like schizophrenia
and bipolar disorder.

713
00:39:03,600 --> 00:39:05,680
Scales are not designed to treat
illness.

714
00:39:06,000 --> 00:39:09,200
They are designed to detain
people awaiting trial or serving

715
00:39:09,200 --> 00:39:12,200
short sentences.
The result is that people who

716
00:39:12,200 --> 00:39:15,960
arrive in jail in psychiatric
crisis often deteriorate

717
00:39:15,960 --> 00:39:19,800
rapidly, and the response in
many facilities in many

718
00:39:19,800 --> 00:39:22,640
jurisdictions is solitary
confinement.

719
00:39:23,360 --> 00:39:26,440
The logic is perverse but
operationally coherent.

720
00:39:26,840 --> 00:39:29,400
A person who is behaving
erratically and is difficult to

721
00:39:29,400 --> 00:39:32,760
manage gets removed from the
general population and placed in

722
00:39:32,760 --> 00:39:36,720
a small cell with 22 or 23 hours
of isolation per day.

723
00:39:36,920 --> 00:39:40,120
The research on solitary
confinement and mental illness

724
00:39:40,120 --> 00:39:44,040
is unambiguous.
Isolation causes psychiatric

725
00:39:44,040 --> 00:39:46,520
harm in people who are mentally
healthy to begin with.

726
00:39:46,640 --> 00:39:49,400
In people who are already
experiencing serious mental

727
00:39:49,400 --> 00:39:52,400
illness, it is catastrophic.
Studies have documented the

728
00:39:52,400 --> 00:39:56,160
emergence of hallucinations,
severe anxiety, paranoia, and

729
00:39:56,160 --> 00:39:59,520
self harm in people who had no
prior psychiatric history after

730
00:39:59,520 --> 00:40:02,480
periods of isolation.
For people with existing serious

731
00:40:02,480 --> 00:40:06,200
mental illness, it reliably
causes rapid deterioration.

732
00:40:06,520 --> 00:40:10,400
A 2014 study of suicides in New
York City jails found that

733
00:40:10,400 --> 00:40:12,080
roughly half occurred in
solitary.

734
00:40:12,200 --> 00:40:16,440
Confinement despite solitary
housing only about 77% of the

735
00:40:16,440 --> 00:40:20,000
jail population, the risk of
suicide in solitary is not

736
00:40:20,000 --> 00:40:23,720
modestly elevated.
It is orders of magnitude

737
00:40:23,720 --> 00:40:26,120
higher.
And yet solitary confinement

738
00:40:26,120 --> 00:40:28,880
continues to be used as a
management tool for people whose

739
00:40:28,880 --> 00:40:31,440
primary presenting issue is
psychiatric illness.

740
00:40:31,680 --> 00:40:33,360
Because the system has no other
tool.

741
00:40:33,480 --> 00:40:35,720
Because the mental health
resources inside jails and

742
00:40:35,720 --> 00:40:39,320
prisons, while they exist, while
there are dedicated correctional

743
00:40:39,320 --> 00:40:41,800
mental health workers who
genuinely do important and

744
00:40:41,800 --> 00:40:44,320
difficult people at work, are
nowhere near sufficient to

745
00:40:44,360 --> 00:40:46,840
address the need.
Perhaps the most pernicious

746
00:40:46,840 --> 00:40:49,200
feature of the criminalization
cycle is that it doesn't

747
00:40:49,200 --> 00:40:50,960
resolve.
It recycles.

748
00:40:51,240 --> 00:40:54,400
A person with untreated,
untreated schizophrenia is

749
00:40:54,400 --> 00:40:56,120
arrested.
They are held in jail.

750
00:40:56,440 --> 00:40:58,360
They may or may not receive
medication.

751
00:40:58,600 --> 00:41:01,960
They are released.
They have no housing, no

752
00:41:01,960 --> 00:41:04,520
medication prescription, no
connection to outpatient

753
00:41:04,520 --> 00:41:07,720
services, often no
identification, sometimes no

754
00:41:07,720 --> 00:41:09,240
clothing appropriate to the
weather.

755
00:41:09,560 --> 00:41:12,320
They decompensate.
They come to the attention of

756
00:41:12,320 --> 00:41:14,640
law enforcement again.
They are arrested.

757
00:41:14,960 --> 00:41:19,360
They cycle through studies of
high utilizers in urban jail

758
00:41:19,360 --> 00:41:22,040
systems, have documented
individuals with serious mental

759
00:41:22,040 --> 00:41:25,640
illness who have been arrested
dozens or even hundreds of

760
00:41:25,640 --> 00:41:28,280
times.
One analysis of Los Angeles

761
00:41:28,280 --> 00:41:32,160
County Jail found a cohort of 30
individuals who collectively

762
00:41:32,160 --> 00:41:36,240
accounted for more than 700 jail
stays and cost the county an

763
00:41:36,240 --> 00:41:39,000
estimated $19 million over a
decade.

764
00:41:39,600 --> 00:41:45,640
These 30 people, not 30,030.
The cost of incarceration for a

765
00:41:45,640 --> 00:41:48,000
person with serious mental
illness, accounting for the

766
00:41:48,000 --> 00:41:50,520
additional mental health
services, the medical care, the

767
00:41:50,520 --> 00:41:53,200
administrative overhead of
managing someone with complex

768
00:41:53,200 --> 00:41:57,280
needs in a custodial setting, is
estimated at two to three times

769
00:41:57,280 --> 00:42:00,400
the cost of incarceration for a
person without mental illness.

770
00:42:00,680 --> 00:42:03,520
We are spending an enormous
amount of money on a system that

771
00:42:03,520 --> 00:42:06,600
makes people worse and cycles
them back out into the same

772
00:42:06,600 --> 00:42:09,520
conditions that brought them in.
If not.

773
00:42:09,520 --> 00:42:13,240
Worse, if not worse, right?
So prisons and jails absorbed

774
00:42:13,240 --> 00:42:16,200
one population, the streets
absorbed another.

775
00:42:16,760 --> 00:42:19,520
The relationship between
deinstitutionalization and

776
00:42:19,520 --> 00:42:22,760
homelessness is real, important,
and significantly more

777
00:42:22,760 --> 00:42:25,760
complicated than either the
advocates who deny it or the

778
00:42:25,760 --> 00:42:28,360
commentators who treat it as the
whole story are willing to

779
00:42:28,360 --> 00:42:30,880
acknowledge.
The contemporary homelessness

780
00:42:30,880 --> 00:42:35,000
crisis in America began in the
early 1980's, the same period

781
00:42:35,000 --> 00:42:37,520
where community mental health
funding was being cut and the

782
00:42:37,520 --> 00:42:40,400
last wave of large scale
hospital closures was occurring.

783
00:42:40,400 --> 00:42:45,040
That timing is not coincidental.
Current estimates from Hud's

784
00:42:45,040 --> 00:42:48,640
annual Point in Time count, HUD
being the Housing and Urban

785
00:42:48,640 --> 00:42:53,000
Development arm of the federal
government, find somewhere

786
00:42:53,000 --> 00:42:58,000
between 550 to 600,000 people
experiencing homelessness on a

787
00:42:58,000 --> 00:43:00,000
single night in the United
States.

788
00:43:00,520 --> 00:43:04,360
Among those, roughly 30% are
estimated to have a serious

789
00:43:04,360 --> 00:43:08,040
mental illness.
That means somewhere between 165

790
00:43:08,040 --> 00:43:12,720
and 180,000 people with serious
mental illness sleeping outside

791
00:43:12,720 --> 00:43:14,600
or in shelters on any given
night.

792
00:43:15,240 --> 00:43:19,320
In some cities, particularly in
urban areas with large

793
00:43:19,320 --> 00:43:22,240
unsheltered populations, the
proportion is higher.

794
00:43:22,360 --> 00:43:25,600
Surveys of unsheltered
individuals, people sleeping on

795
00:43:25,600 --> 00:43:28,440
the street rather than in
shelters, consistently find

796
00:43:28,440 --> 00:43:32,480
serious mental illness rates at
35 to 45%.

797
00:43:34,160 --> 00:43:36,760
Does deinstitutionalization
explain all of this?

798
00:43:36,920 --> 00:43:39,800
No Homelessness is caused by
many things.

799
00:43:40,160 --> 00:43:43,840
The shortage of affordable
housing, poverty, substance use,

800
00:43:43,840 --> 00:43:46,960
substance use disorders,
domestic violence, economic

801
00:43:46,960 --> 00:43:49,640
dislocation.
Serious mental illness is a

802
00:43:49,640 --> 00:43:53,000
significant risk factor for
homelessness, but it is not the

803
00:43:53,040 --> 00:43:55,720
only one, and it's not operate
in isolation from these

804
00:43:55,720 --> 00:43:58,480
structural factors.
But is the connection real?

805
00:43:59,000 --> 00:44:01,200
Absolutely.
Studies tracking patients

806
00:44:01,200 --> 00:44:04,240
discharged from long term
psychiatric hospitalization have

807
00:44:04,240 --> 00:44:06,000
found that a significant
minority.

808
00:44:06,040 --> 00:44:09,320
Estimates range from 15 to 40%
depending on the study, the

809
00:44:09,320 --> 00:44:12,760
population and the availability
of community services, end up

810
00:44:12,800 --> 00:44:16,280
unhoused within a year.
Research on unhoused populations

811
00:44:16,280 --> 00:44:19,320
consistently find that a large
proportion of those with serious

812
00:44:19,320 --> 00:44:23,960
mental illness report the onset
of homelessness coincided with

813
00:44:23,960 --> 00:44:27,000
or followed the onset of their
illness, not the other way

814
00:44:27,000 --> 00:44:28,840
around.
OK.

815
00:44:29,440 --> 00:44:32,400
The experienced Ness of
homelessness is in itself

816
00:44:32,400 --> 00:44:35,520
psychiatrically devastating.
The chronic stress, the sleep

817
00:44:35,520 --> 00:44:39,120
deprivation, the constant threat
of violence, the loss of privacy

818
00:44:39,120 --> 00:44:41,720
and dignity, the exposure to
weather, the inability to

819
00:44:41,720 --> 00:44:44,560
maintain hygiene, the social,
social isolation.

820
00:44:44,560 --> 00:44:46,920
These are not neutral
conditions.

821
00:44:47,520 --> 00:44:50,360
There are conditions that will
worsen any psychiatric illness

822
00:44:50,360 --> 00:44:53,080
and will cause psychiatric
symptoms in people who had none.

823
00:44:53,360 --> 00:44:57,120
Maintaining medical adherence,
medication adherence, excuse me,

824
00:44:57,120 --> 00:44:59,520
while unhoused is
extraordinarily difficult.

825
00:44:59,640 --> 00:45:02,400
Psychiatric medications often
require refrigeration.

826
00:45:02,880 --> 00:45:04,520
They require a consistent
schedule.

827
00:45:04,880 --> 00:45:07,440
They require refills, which
require prescriptions, which

828
00:45:07,440 --> 00:45:10,080
require appointments, which
require a phone number and an

829
00:45:10,080 --> 00:45:13,480
address to receive appointment
notices, which unhoused people

830
00:45:13,480 --> 00:45:15,920
often don't have.
The practical barriers to

831
00:45:15,920 --> 00:45:19,320
medication access for unhoused
individuals with serious mental

832
00:45:19,320 --> 00:45:22,440
illness are immense.
The result is a population of

833
00:45:22,440 --> 00:45:27,160
people who are simultaneously
very ill, very visible, very

834
00:45:27,160 --> 00:45:30,640
vulnerable to harm, and very
difficult for the mental health

835
00:45:30,640 --> 00:45:34,080
system to engage.
Outreach workers who do St.

836
00:45:34,080 --> 00:45:36,640
based mental health work, and
this is some of the hardest,

837
00:45:36,640 --> 00:45:38,960
most important work in the
field, will tell you that

838
00:45:38,960 --> 00:45:42,120
building trust with a
chronically unhoused person with

839
00:45:42,120 --> 00:45:44,760
serious mental illness can take
months or years.

840
00:45:44,800 --> 00:45:48,080
And that trust can be shattered
instantly by a single coercive

841
00:45:48,080 --> 00:45:50,400
interaction.
That the involuntary commitment,

842
00:45:50,400 --> 00:45:52,880
however well-intentioned, that
results in a person being

843
00:45:52,880 --> 00:45:55,880
hospitalized for 72 hours and
then released back to the same

844
00:45:55,880 --> 00:45:58,760
sidewalk, having lost their
belongings in their camp while

845
00:45:58,760 --> 00:46:01,680
they were gone, makes that
person less likely to engage

846
00:46:01,680 --> 00:46:04,000
with services in the future, not
more.

847
00:46:04,920 --> 00:46:07,040
We have not figured out how to
do this well.

848
00:46:07,240 --> 00:46:09,520
There are programs and models
that work, and I'm going to talk

849
00:46:09,520 --> 00:46:12,880
about some of them, but they
require resources and patience

850
00:46:12,880 --> 00:46:17,120
and political will that have
been persistently lacking since

851
00:46:17,120 --> 00:46:20,080
the 1990s.
A model called Housing First has

852
00:46:20,080 --> 00:46:23,320
been gaining ground on as an
alternative to their traditional

853
00:46:23,320 --> 00:46:26,800
approach to homelessness among
people with mental illness.

854
00:46:27,280 --> 00:46:30,280
The traditional model, sometimes
called the Treatment First or

855
00:46:30,280 --> 00:46:33,160
staircase model, required people
to demonstrate sobriety and

856
00:46:33,160 --> 00:46:36,800
medication compliance as
prerequisites for accessing

857
00:46:36,800 --> 00:46:39,160
permanent housing.
The theory was that you need to

858
00:46:39,160 --> 00:46:41,520
address the underlying illness
before you could stabilize the

859
00:46:41,520 --> 00:46:43,800
housing.
Housing First flips this It

860
00:46:43,800 --> 00:46:46,840
provides permanent supportive
housing first immediately

861
00:46:46,840 --> 00:46:49,560
without preconditions, and then
offers voluntary treatment

862
00:46:49,560 --> 00:46:51,920
services in place.
The underlying theory is that

863
00:46:51,920 --> 00:46:54,880
housing is healthcare that you
cannot stabilize, is someone's

864
00:46:54,880 --> 00:46:57,120
mental illness while they are
sleeping outside, that the

865
00:46:57,120 --> 00:47:00,440
trauma and stress of practical
barriers of homelessness make

866
00:47:00,440 --> 00:47:03,240
treatment nearly impossible,
while the safety and stability

867
00:47:03,240 --> 00:47:05,240
of housing makes it far more
achievable.

868
00:47:05,280 --> 00:47:09,800
And I will say that Holly Sue,
my sister who is a economist,

869
00:47:10,440 --> 00:47:13,720
100% agrees with the housing
first model.

870
00:47:14,160 --> 00:47:18,960
And I actually, when I was in
nursing school, I did AI, did

871
00:47:18,960 --> 00:47:22,200
clinicals at a facility in Salt
Lake City that was a housing

872
00:47:22,200 --> 00:47:25,640
first model.
And I'll tell you, it was one of

873
00:47:25,640 --> 00:47:27,080
the most interesting places I
ever worked.

874
00:47:27,080 --> 00:47:30,000
I was, my clinicals were
actually in the in the head

875
00:47:30,000 --> 00:47:32,520
start classroom.
And there were some rough kids

876
00:47:32,520 --> 00:47:35,640
in that head start and there
were some rough parents coming

877
00:47:35,640 --> 00:47:38,440
to pick up those kids.
But I'll tell you what that we

878
00:47:38,440 --> 00:47:40,560
knew where the kids, you know,
they knew where their kids were

879
00:47:40,560 --> 00:47:42,720
all day and they knew their kids
were being taken care of and

880
00:47:42,720 --> 00:47:45,640
they were and they were able,
they were not only able to go

881
00:47:45,640 --> 00:47:47,680
and look for jobs, they were
doing it.

882
00:47:47,840 --> 00:47:50,800
And they may still, you don't
have a drug addiction, They may

883
00:47:50,800 --> 00:47:55,200
still have mental illness that
isn't necessarily fully treated,

884
00:47:55,200 --> 00:47:59,800
but they were definitely not on
the street.

885
00:48:00,040 --> 00:48:03,440
And even more and more likely
than being right, and even more

886
00:48:03,440 --> 00:48:05,240
and more likely to be lost in
the system.

887
00:48:05,960 --> 00:48:07,280
Exactly.
Yeah, exactly.

888
00:48:07,560 --> 00:48:10,680
The research on Housing First
is, relative to most things in

889
00:48:10,680 --> 00:48:12,680
mental health policy, unusually
positive.

890
00:48:12,840 --> 00:48:15,880
Multiple randomized controlled
trials have found that Housing

891
00:48:15,880 --> 00:48:18,560
First significantly outperforms
treatment first models in

892
00:48:18,560 --> 00:48:21,400
housing retention, and that it
does so without worse outcomes

893
00:48:21,400 --> 00:48:23,520
on substance use or psychiatric
systems.

894
00:48:23,640 --> 00:48:26,200
In many studies, Housing First
participants showed better

895
00:48:26,200 --> 00:48:28,480
outcomes on both.
The model has been implemented

896
00:48:28,480 --> 00:48:32,000
nationally in Canada, across
Scandinavia, and in various

897
00:48:32,000 --> 00:48:34,760
programs in the United States.
The sticking point, and it is

898
00:48:34,760 --> 00:48:37,760
always the same sticking point
point is cost and political

899
00:48:37,760 --> 00:48:39,600
will.
Providing permanent supportive

900
00:48:39,600 --> 00:48:42,120
housing to every person with
serious mental illness who is

901
00:48:42,120 --> 00:48:45,160
unhoused would require an
enormous investment in housing

902
00:48:45,160 --> 00:48:48,200
stock that this country has not
made housing first programs work

903
00:48:48,200 --> 00:48:49,440
for the people who get into
them.

904
00:48:49,600 --> 00:48:51,960
The challenge is scaling them to
meet the actual need.

905
00:48:51,960 --> 00:48:55,360
And I do want to say that today,
in today's climate, political

906
00:48:55,360 --> 00:48:59,040
will is a huge part of this.
I know that there are hundreds,

907
00:48:59,320 --> 00:49:06,200
thousands of empty housing units
that could be used to house the

908
00:49:06,200 --> 00:49:10,080
unhoused and to do this housing
First program, but the funding

909
00:49:10,080 --> 00:49:13,640
isn't there and the desire isn't
there, unfortunately and so.

910
00:49:13,640 --> 00:49:16,600
I think it's, yeah, I think the
desire is the part.

911
00:49:16,680 --> 00:49:18,800
I mean, because you there's
always 2 fold things and they

912
00:49:18,800 --> 00:49:22,520
can always blame funding.
But really, if it were a

913
00:49:22,520 --> 00:49:24,800
priority for people, it would be
available.

914
00:49:25,240 --> 00:49:27,960
And so, you know, where you do
see these programs in the United

915
00:49:27,960 --> 00:49:29,800
States, they're typically
private.

916
00:49:29,880 --> 00:49:32,680
They're privately funded.
I want to step back from the

917
00:49:32,680 --> 00:49:35,480
policy for a moment and talk
about what this looks like from

918
00:49:35,480 --> 00:49:38,800
the ground, because the story of
deinstitutionalization is not

919
00:49:38,800 --> 00:49:42,680
just a story about symptoms, It
is a story about families.

920
00:49:42,800 --> 00:49:45,480
When the state hospitals began
closing, the prevailing

921
00:49:45,480 --> 00:49:48,440
philosophy in the mental health
community was that families were

922
00:49:48,440 --> 00:49:51,240
resources, that discharging
patients to their families was a

923
00:49:51,240 --> 00:49:54,280
therapeutic good, that community
and family support was what

924
00:49:54,280 --> 00:49:56,280
people needed.
And what the old institutions

925
00:49:56,280 --> 00:49:58,000
had denied them.
And some families were

926
00:49:58,000 --> 00:50:00,560
resources.
Some families were themselves

927
00:50:00,640 --> 00:50:03,120
the source of harm and
dysfunction that had contributed

928
00:50:03,120 --> 00:50:05,200
to their families memory,
illness, their family members

929
00:50:05,200 --> 00:50:07,920
illness.
But many families, perhaps most

930
00:50:07,920 --> 00:50:12,000
families, were simply ordinary
people with ordinary resources

931
00:50:12,000 --> 00:50:14,560
who were being handed the
caregiving responsibilities for

932
00:50:14,560 --> 00:50:17,440
someone with a severe and
persistent mental illness,

933
00:50:17,520 --> 00:50:20,600
without training, without
respite care, without crisis

934
00:50:20,600 --> 00:50:23,520
support, without adequate mental
health resources in their

935
00:50:23,520 --> 00:50:26,400
community, and without any
honest accounting of what they

936
00:50:26,400 --> 00:50:29,480
were being asked to do.
The family advocacy movement,

937
00:50:29,600 --> 00:50:32,480
particularly the National
Alliance on Mental Illness, or

938
00:50:32,480 --> 00:50:36,280
NAMI, which was founded in 1979
largely by parents of adult

939
00:50:36,280 --> 00:50:39,040
children with schizophrenia,
emerged directly out of the this

940
00:50:39,040 --> 00:50:41,360
experience.
Nami's founders were not

941
00:50:41,360 --> 00:50:44,120
abstract policy advocates.
They were mothers and fathers

942
00:50:44,120 --> 00:50:47,160
and siblings who had spent years
trying to navigate a system that

943
00:50:47,160 --> 00:50:49,920
didn't exist, trying to get help
for family members who were

944
00:50:49,920 --> 00:50:54,080
acutely ill and often unable or
unwilling to seek treatment,

945
00:50:54,400 --> 00:50:56,720
watching their loved ones cycle
through emergency rooms and

946
00:50:56,720 --> 00:50:59,600
jails and shelters, and finding
that nobody in the official

947
00:50:59,600 --> 00:51:01,880
mental health system was
particularly interested in

948
00:51:01,880 --> 00:51:04,560
helping them.
The experience of having a

949
00:51:04,560 --> 00:51:07,520
family member with untreated,
serious mental illness is in

950
00:51:07,520 --> 00:51:11,120
many cases traumatic.
Not in the casual, modern usage

951
00:51:11,120 --> 00:51:13,240
of that word.
In the clinical sense.

952
00:51:13,600 --> 00:51:17,840
Families describe living in a
state of chronic crisis, calling

953
00:51:17,840 --> 00:51:20,040
police on their own children
because there is no other

954
00:51:20,040 --> 00:51:24,160
option, watching psychosis take
hold and being unable to compel

955
00:51:24,160 --> 00:51:27,400
treatment, burying family
members who died by suicide or

956
00:51:27,400 --> 00:51:30,000
on the street or in altercations
with law enforcement.

957
00:51:30,040 --> 00:51:32,920
One of the most painful features
of the current system is that

958
00:51:32,920 --> 00:51:36,400
sometimes is what is sometimes
called the compassion trap of

959
00:51:36,400 --> 00:51:39,600
confidentiality law.
Under HIPAA and most state

960
00:51:39,600 --> 00:51:42,800
mental health privacy statutes,
clinicians cannot share

961
00:51:42,800 --> 00:51:45,360
information about an adult
patient's treatment with family

962
00:51:45,360 --> 00:51:47,600
members without the patient's
consent.

963
00:51:48,280 --> 00:51:50,880
In principle, this is a
reasonable privacy protection.

964
00:51:51,400 --> 00:51:54,440
In practice for families trying
to coordinate care for a family

965
00:51:54,440 --> 00:51:57,520
member who lacks insight into
their illness and refuses to

966
00:51:57,520 --> 00:52:00,840
consent to information sharing,
it creates a situation where the

967
00:52:00,840 --> 00:52:04,080
people who know the patient best
and are most affected by their

968
00:52:04,080 --> 00:52:07,080
illness are systematically
excluded from the treatment

969
00:52:07,080 --> 00:52:10,600
relationship.
I know I can't imagine man

970
00:52:10,720 --> 00:52:13,600
families have fought for
modifications to confidentiality

971
00:52:13,600 --> 00:52:16,000
law for decades with limited
success.

972
00:52:16,160 --> 00:52:19,000
The privacy rights of patients
and the legitimate interests of

973
00:52:19,000 --> 00:52:21,800
families are genuinely in
tension, and I don't want to

974
00:52:21,800 --> 00:52:24,680
minimize that.
But the curtain system in many

975
00:52:24,680 --> 00:52:27,320
cases serves neither.
And I don't want to end this

976
00:52:27,320 --> 00:52:30,000
episode in despair.
That's not what this podcast is

977
00:52:30,000 --> 00:52:31,640
about.
We come here to understand

978
00:52:31,640 --> 00:52:34,840
things all the way the hard
parts and the hopeful parts

979
00:52:34,840 --> 00:52:36,480
both.
So let me tell you what we

980
00:52:36,480 --> 00:52:39,000
actually know works because we
know some things.

981
00:52:39,080 --> 00:52:42,880
In the early 1970s, a
psychiatrist named Arnold Marx

982
00:52:43,320 --> 00:52:46,480
and a team at Mendota Mental
Health Institute in Wisconsin

983
00:52:46,560 --> 00:52:49,360
were working with patients with
severe schizophrenia who kept

984
00:52:49,360 --> 00:52:51,200
cycling in and out of
hospitalization.

985
00:52:51,440 --> 00:52:54,880
They developed a model called
Assertive Community Treatment

986
00:52:55,120 --> 00:52:58,080
ACT, built on a simple but
radical premises.

987
00:52:58,240 --> 00:53:00,720
Instead of waiting for patients
to come to the clinic, the

988
00:53:00,720 --> 00:53:05,160
clinic comes to the patient ACT
teams are multidisciplinary

989
00:53:05,440 --> 00:53:08,120
psychiatrist, nurse, social
worker, substance abuse

990
00:53:08,120 --> 00:53:11,040
counselor, peer support
specialist and they carry small

991
00:53:11,040 --> 00:53:13,080
caseloads.
They meet clients wherever the

992
00:53:13,080 --> 00:53:16,240
clients are at home, on the
street, in shelters, at the jail

993
00:53:16,240 --> 00:53:17,800
exit.
They provide medication

994
00:53:17,800 --> 00:53:21,240
management, crisis support, help
with housing and benefits, and

995
00:53:21,240 --> 00:53:23,600
daily living skills and ongoing
relationship.

996
00:53:24,360 --> 00:53:27,400
They're available 24 hours a
day, seven days a week.

997
00:53:27,400 --> 00:53:30,280
The research base for ACT is one
of the strongest in all the

998
00:53:30,280 --> 00:53:32,720
psychiatry.
Multiple randomized controlled

999
00:53:32,720 --> 00:53:35,600
trials have found that ACT
significantly reduces

1000
00:53:35,600 --> 00:53:38,840
hospitalization, reduces
incarceration, reduces

1001
00:53:38,840 --> 00:53:41,440
homelessness, and improves
quality of life compared to

1002
00:53:41,440 --> 00:53:43,840
standard case management.
It works.

1003
00:53:44,120 --> 00:53:46,320
We've known it works for 50
years.

1004
00:53:46,320 --> 00:53:50,880
A/C TCACT teams now exist in
many states, but there are

1005
00:53:50,880 --> 00:53:52,720
nowhere near enough of them to
meet the need.

1006
00:53:52,960 --> 00:53:57,360
Assisted Outpatient treatment.
AOT, sometimes called Kendra's

1007
00:53:57,360 --> 00:54:00,480
Law in New York where it was
first enacted, is a court

1008
00:54:00,480 --> 00:54:03,120
ordered outpatient treatment
program for people with serious

1009
00:54:03,120 --> 00:54:05,640
mental illness who have a
demonstrated history of

1010
00:54:05,640 --> 00:54:08,200
treatment non adherence
resulting in hospitalizations,

1011
00:54:08,200 --> 00:54:10,480
incarcerations, or violent
incidents.

1012
00:54:10,560 --> 00:54:14,520
AOT is controversial.
Civil liberties advocates argue

1013
00:54:14,520 --> 00:54:16,760
that it represents coercive
treatment and that it

1014
00:54:16,760 --> 00:54:19,320
disproportionately effects Black
and brown patients.

1015
00:54:19,760 --> 00:54:23,200
These are legitimate concerns
that deserve serious engagement,

1016
00:54:23,920 --> 00:54:27,240
but the research on AOT
outcomes, particularly the New

1017
00:54:27,240 --> 00:54:29,840
York study, has generally found
that participants have

1018
00:54:29,840 --> 00:54:33,040
significantly reduced
hospitalization rates, reduced

1019
00:54:33,040 --> 00:54:36,280
arrest rates, reduced
homelessness, and improved

1020
00:54:36,280 --> 00:54:38,280
functioning compared to control
periods.

1021
00:54:38,480 --> 00:54:41,840
Crucially, studies of patient
experience have found that many

1022
00:54:41,840 --> 00:54:45,400
people who go through AOT
programs report in retrospect

1023
00:54:45,480 --> 00:54:47,800
that the intervention that the
intervention helped them.

1024
00:54:48,080 --> 00:54:51,040
The debate about AOT is
ultimately a debate about the

1025
00:54:51,040 --> 00:54:54,200
limits of autonomy when illness
impairs the capacity for

1026
00:54:54,200 --> 00:54:57,520
autonomous decision making.
That is a genuinely difficult

1027
00:54:57,520 --> 00:55:00,960
philosophical question, but I
think the evidence suggests that

1028
00:55:00,960 --> 00:55:05,320
well implemented AOT attached to
robust service provision

1029
00:55:05,400 --> 00:55:08,160
produces better outcomes than
the current default of cycling

1030
00:55:08,160 --> 00:55:09,880
through gels and ERS and
shelters.

1031
00:55:11,600 --> 00:55:14,240
Yeah.
One of the most promising recent

1032
00:55:14,240 --> 00:55:17,000
developments in mental health
policy is the growth of

1033
00:55:17,040 --> 00:55:18,880
alternative crisis response
models.

1034
00:55:18,880 --> 00:55:21,680
We were just talking about this
programs that dispatch mental

1035
00:55:21,680 --> 00:55:24,360
health clinicians rather than OR
alongside police officers to

1036
00:55:24,360 --> 00:55:27,440
psychiatric emergencies.
The CAHOOTS program in Eugene,

1037
00:55:27,440 --> 00:55:32,080
OR, which began in 1989, sends a
medic and a mental health worker

1038
00:55:32,080 --> 00:55:34,480
to certain 911 calls rather than
police.

1039
00:55:34,600 --> 00:55:38,960
It handles roughly 20% of the
city's 911 call volume and has

1040
00:55:38,960 --> 00:55:42,200
documented significant cost
savings and improve outcomes

1041
00:55:42,200 --> 00:55:44,320
compared to traditional police
response.

1042
00:55:44,880 --> 00:55:48,800
Star program, which launched in
2020, Similar similarly

1043
00:55:48,800 --> 00:55:51,960
dispatches mental health
clinicians and paramedics to low

1044
00:55:51,960 --> 00:55:54,480
acuity mental health and
substance use calls.

1045
00:55:54,560 --> 00:55:57,680
In its first six months, it
responded to over 700 calls

1046
00:55:57,920 --> 00:56:00,840
without police backup being
requested in any of them.

1047
00:56:01,960 --> 00:56:04,400
Yeah, these models are promising
and are expanding.

1048
00:56:04,640 --> 00:56:06,840
They do not solve the
fundamental problem, which is

1049
00:56:06,840 --> 00:56:09,760
the absence of a robust, A
robust continuum of mental

1050
00:56:09,760 --> 00:56:12,520
health care for people to be
connected to after the crisis,

1051
00:56:12,560 --> 00:56:14,240
crisis response to the front
door.

1052
00:56:14,520 --> 00:56:17,760
It needs rooms behind it.
Every evidence based

1053
00:56:17,760 --> 00:56:20,400
intervention in serious mental
illness comes with the same

1054
00:56:20,400 --> 00:56:23,400
footnote.
It is dramatically underfunded

1055
00:56:23,400 --> 00:56:26,040
relative to the need.
Mental health and substance use

1056
00:56:26,040 --> 00:56:29,120
disorders account for roughly
13% of the global burden of

1057
00:56:29,120 --> 00:56:32,240
disease, but receive
approximately 5% of health

1058
00:56:32,280 --> 00:56:34,640
expenditure in high income
countries.

1059
00:56:34,720 --> 00:56:36,840
In the United States, the gap
between the need and the

1060
00:56:36,840 --> 00:56:40,280
resources devoted to meeting it
is enormous and has been for

1061
00:56:40,280 --> 00:56:42,280
decades.
The argument that we cannot

1062
00:56:42,280 --> 00:56:44,720
afford to build a real mental
health system is worth

1063
00:56:44,720 --> 00:56:47,400
interrogating.
We are currently spending

1064
00:56:47,480 --> 00:56:52,000
conservatively 10s of billions
of dollars a year incarcerating

1065
00:56:52,000 --> 00:56:54,640
people with serious mental
illness in the most expensive

1066
00:56:54,640 --> 00:56:58,200
and least therapeutic
therapeutic setting imaginable.

1067
00:56:58,360 --> 00:57:01,600
We are spending billions on
emergency room visits and police

1068
00:57:01,600 --> 00:57:04,440
response and shelter beds.
We're paying for the failure of

1069
00:57:04,440 --> 00:57:07,160
the mental health system through
every other system it has

1070
00:57:07,160 --> 00:57:10,120
offloaded its burden on to.
The question is not whether we

1071
00:57:10,120 --> 00:57:12,920
can afford to build a real
community mental health system.

1072
00:57:13,040 --> 00:57:15,160
The question is whether we are
willing to organize the

1073
00:57:15,160 --> 00:57:19,360
political will to do it.
In 1963, John Kennedy stood

1074
00:57:19,360 --> 00:57:22,080
before Congress and told them
that mental illness and mental

1075
00:57:22,080 --> 00:57:25,120
retardation were among the most
critical health problems facing

1076
00:57:25,120 --> 00:57:27,240
the nation.
He said that the old custodial

1077
00:57:27,240 --> 00:57:29,000
institutions were no longer
adequate.

1078
00:57:29,360 --> 00:57:33,760
He said that a quote, bold new
approach was required.

1079
00:57:33,960 --> 00:57:37,440
He signed a law.
Six weeks later, he was dead and

1080
00:57:37,440 --> 00:57:39,880
the bold new approach was
quietly defunded.

1081
00:57:39,920 --> 00:57:43,160
De prioritized, cut block
granted, forgotten.

1082
00:57:43,360 --> 00:57:45,600
The people who left the
hospitals had nowhere to go.

1083
00:57:46,000 --> 00:57:49,200
Some went to families, some went
to nursing homes where they were

1084
00:57:49,200 --> 00:57:52,600
warehoused in slightly different
conditions, some went to rooming

1085
00:57:52,600 --> 00:57:54,640
houses and Sr.
OS that have since been

1086
00:57:54,640 --> 00:57:58,440
demolished and not replaced.
Some went to the street, some

1087
00:57:58,440 --> 00:58:00,920
cycled through emergency rooms
and jails for the rest of their

1088
00:58:00,920 --> 00:58:03,040
lives.
The story we told ourselves was

1089
00:58:03,040 --> 00:58:06,560
about freedom and dignity,
dignity and community, and those

1090
00:58:06,560 --> 00:58:09,280
are real values.
The old institutions really were

1091
00:58:09,280 --> 00:58:12,280
doing real harm.
The civil libertarian critique

1092
00:58:12,280 --> 00:58:15,440
of involuntary commitment really
does contain real truths.

1093
00:58:16,000 --> 00:58:20,240
But we use those true things as
permissions to do nothing, to

1094
00:58:20,240 --> 00:58:22,800
cut budgets and call it
liberation, to discharge

1095
00:58:22,800 --> 00:58:26,080
patients and call it progress,
to let the jails absorb what the

1096
00:58:26,080 --> 00:58:28,800
hospitals had held and tell
ourselves we've done something

1097
00:58:28,800 --> 00:58:31,480
humane.
The people in those jails are

1098
00:58:31,480 --> 00:58:33,600
not criminals who happen to be
mentally ill.

1099
00:58:33,600 --> 00:58:36,160
They are people who are ill who
are being processed through

1100
00:58:36,160 --> 00:58:39,640
system designed for criminals.
Because we dismantled the system

1101
00:58:39,640 --> 00:58:42,160
designed for illness and never
built what we promised to

1102
00:58:42,160 --> 00:58:45,120
replace it with, the people on
those sidewalks are not choosing

1103
00:58:45,120 --> 00:58:47,120
to be there.
They are the downstream

1104
00:58:47,120 --> 00:58:50,720
consequence of 50 years of
policy decisions made by people

1105
00:58:50,720 --> 00:58:52,760
who are never going to sleep on
the sidewalk.

1106
00:58:53,400 --> 00:58:55,920
We've known how to do this
better for a long time.

1107
00:58:56,120 --> 00:58:58,440
We have the models, we have the
research.

1108
00:58:58,560 --> 00:59:01,120
We have the evidence.
What we have not had is the

1109
00:59:01,120 --> 00:59:05,440
sustained political will to fund
and build and scale what works.

1110
00:59:05,520 --> 00:59:09,720
That choice, it's a choice we
make with every budget cycle, is

1111
00:59:09,720 --> 00:59:13,280
a choice reflected in every jail
bed we fund and every AC team

1112
00:59:13,280 --> 00:59:15,400
slot we don't.
It is a choice we can make

1113
00:59:15,400 --> 00:59:17,080
differently.
And I want to close with

1114
00:59:17,080 --> 00:59:18,560
something that's not a
statistic.

1115
00:59:18,880 --> 00:59:21,720
I want to close with something,
a forensic psychiatrist, names

1116
00:59:21,880 --> 00:59:25,520
named James Gilligan, wrote in
his book Violence, Our Deadly

1117
00:59:25,520 --> 00:59:28,840
Epidemic and Its Causes.
He spent years working inside

1118
00:59:28,840 --> 00:59:31,680
maximum security prisons.
He wrote about what he found

1119
00:59:31,680 --> 00:59:35,240
there, and what he found.
What he kept finding, was people

1120
00:59:35,240 --> 00:59:38,160
who had started their lives in
conditions of such profound

1121
00:59:38,160 --> 00:59:41,640
neglect and chaos and
unaddressed suffering that

1122
00:59:41,640 --> 00:59:45,160
violence and incarceration were
not aberrations, they were

1123
00:59:45,160 --> 00:59:48,160
logical conclusions.
He wrote that the most violent

1124
00:59:48,160 --> 00:59:51,520
people he had ever encountered
were, almost without exception,

1125
00:59:51,760 --> 00:59:54,680
the people who had been treated
with the most violence, the most

1126
00:59:54,680 --> 00:59:59,000
abandoned, the most neglected,
the most comprehensively failed.

1127
00:59:59,200 --> 01:00:02,000
The system we built when we.
Emptied the hospitals, the

1128
01:00:02,000 --> 01:00:04,840
jails, the streets, the cycling
the crisis and release the

1129
01:00:04,840 --> 01:00:09,000
crisis again.
It itself a form of violence.

1130
01:00:10,000 --> 01:00:13,240
It is not called that.
It is not seen that way by most

1131
01:00:13,240 --> 01:00:15,760
of the people who administer it
or fund it or vote on it.

1132
01:00:15,800 --> 01:00:18,640
But it is a way of treating a
group of vulnerable people with

1133
01:00:18,640 --> 01:00:22,000
profound neglect and then being
surprised when things go badly.

1134
01:00:22,720 --> 01:00:25,360
We do better.
We know we can do better.

1135
01:00:25,800 --> 01:00:27,800
The question is whether we
decide to.

1136
01:00:28,080 --> 01:00:29,680
I drop.
Mic drop.

1137
01:00:31,680 --> 01:00:34,640
Wow, wow.
And that's it's intense and I've

1138
01:00:34,640 --> 01:00:38,120
seen it in multiple times
throughout my career, both as a

1139
01:00:38,120 --> 01:00:41,600
nurse and early on when I was
police dispatcher, because a lot

1140
01:00:41,600 --> 01:00:43,960
of the things that we got in the
calls we got were just people

1141
01:00:43,960 --> 01:00:48,480
losing it for whatever reason.
And they were psychiatric based

1142
01:00:48,480 --> 01:00:51,600
complaints, many of them
exacerbated by alcohol and drug

1143
01:00:51,600 --> 01:00:55,720
use, as you had alluded to and
even mentioned in some of the

1144
01:00:55,720 --> 01:00:59,080
cases.
It's a conundrum because we

1145
01:00:59,080 --> 01:01:02,040
know, well, I don't even know if
conundrum's the right word, but

1146
01:01:02,040 --> 01:01:04,880
we know what to do, as you say,
but it's just not being done.

1147
01:01:05,520 --> 01:01:08,720
And I think a lot of the sort of
thing is, is significant to a

1148
01:01:08,720 --> 01:01:11,520
person if they've experienced it
within their own family or

1149
01:01:11,520 --> 01:01:14,240
friends more than it is to
people who don't.

1150
01:01:14,240 --> 01:01:17,400
Because for people who don't
understand mental illness or

1151
01:01:17,400 --> 01:01:20,280
have never experienced it, it's
just sort of an out there thing.

1152
01:01:20,600 --> 01:01:23,680
And some people even considered
an excuse for poor behavior.

1153
01:01:24,280 --> 01:01:30,920
But it's a real thing that needs
urgent care and consistent care.

1154
01:01:30,920 --> 01:01:33,800
When a person is not competent
to make the decisions on their

1155
01:01:33,800 --> 01:01:37,560
release after an emergency hold
and things like that, then that

1156
01:01:37,560 --> 01:01:40,160
gap is definitely huge.
And then people are surprised

1157
01:01:40,160 --> 01:01:44,240
when someone is hearing voices
and then kills their family and

1158
01:01:44,240 --> 01:01:45,960
they're.
Surprised, Right, Right.

1159
01:01:46,000 --> 01:01:48,120
Yeah.
Well, I think another thing to

1160
01:01:48,120 --> 01:01:51,440
consider is a lot of us grew up,
and I know that this is a

1161
01:01:51,440 --> 01:01:54,320
buzzword and that there's a lot
of, there's a lot of charge to

1162
01:01:54,320 --> 01:01:56,560
this word, but a lot of us grew
up with privilege.

1163
01:01:56,600 --> 01:02:01,960
And the reality is there are
households in this country where

1164
01:02:02,160 --> 01:02:06,040
children are introduced to
heroin at 8 years old by their

1165
01:02:06,040 --> 01:02:08,720
parents or crack or crack
cocaine.

1166
01:02:08,880 --> 01:02:10,080
Yeah.
I mean, I was listening to a

1167
01:02:10,080 --> 01:02:14,240
podcast and there was a guy who
dad was giving him heroin and

1168
01:02:14,320 --> 01:02:17,400
crack cocaine at 8 years old.
And like, that was his lifestyle

1169
01:02:17,400 --> 01:02:19,600
moving forward was just using
drugs.

1170
01:02:19,600 --> 01:02:22,520
And so he ended up killing
somebody.

1171
01:02:22,520 --> 01:02:24,720
And it was like, well, of course
he did.

1172
01:02:24,760 --> 01:02:27,920
And, you know, and I mean, I've
read several books because it's

1173
01:02:27,920 --> 01:02:32,240
an interest of mine where, yeah,
there's just the, the, the

1174
01:02:32,240 --> 01:02:37,680
neglect epidemic and the drug
epidemic is just absolutely

1175
01:02:38,040 --> 01:02:40,360
horrifying.
And it, it's what it's not even

1176
01:02:40,360 --> 01:02:45,120
what we don't believe in our, in
our privileged state, but we,

1177
01:02:45,200 --> 01:02:48,160
we're not even aware of it.
It's not something we see.

1178
01:02:48,160 --> 01:02:50,960
It's, it's outside of the realm
of our experience.

1179
01:02:50,960 --> 01:02:53,360
That's another thing we aren't
addressing.

1180
01:02:53,400 --> 01:02:55,840
There's a great, great
documentary if you're

1181
01:02:55,840 --> 01:02:57,360
interested.
It's on HBO Max.

1182
01:02:57,360 --> 01:03:00,200
And I will say it's very, it's
very raw.

1183
01:03:00,320 --> 01:03:03,680
It's called Life of Crime 1984
to 2020.

1184
01:03:04,440 --> 01:03:13,040
And it, it's, it follows 33
individuals who are drug addicts

1185
01:03:13,040 --> 01:03:15,680
and live a life of crime to
support their habits.

1186
01:03:16,360 --> 01:03:19,720
And it is just, it's very eye
opening.

1187
01:03:19,720 --> 01:03:23,480
So I would recommend it again,
it's, it's graphic, it's, it's

1188
01:03:23,480 --> 01:03:28,760
raw, but it is very eye opening.
Anyway, it, it really gives some

1189
01:03:28,760 --> 01:03:33,160
insight into what is going on in
these communities that you and I

1190
01:03:33,160 --> 01:03:35,480
aren't a part of and that
probably the majority of our

1191
01:03:35,480 --> 01:03:38,000
listeners aren't a part of.
And I would, I would close

1192
01:03:38,040 --> 01:03:40,680
honestly with just reminding our
listeners and reminding

1193
01:03:40,680 --> 01:03:45,240
ourselves, like it really is
important to have compassion and

1194
01:03:45,240 --> 01:03:48,000
to try to see things for the
perspectives.

1195
01:03:48,000 --> 01:03:51,640
If you're in a place where you
can volunteer for organizations

1196
01:03:51,640 --> 01:03:56,320
that promote mental health
support, you know, do it.

1197
01:03:56,440 --> 01:04:00,440
It's so important.
And like I said earlier, right

1198
01:04:00,440 --> 01:04:03,480
now, the desire is not
necessarily there from our

1199
01:04:03,640 --> 01:04:06,400
government.
And so we are currently having

1200
01:04:06,400 --> 01:04:09,640
to rely on private institutions
and private funding and

1201
01:04:09,640 --> 01:04:11,320
nonprofits and those sorts of
things.

1202
01:04:11,320 --> 01:04:14,280
We continue to prove the model.
Eventually there's got to be,

1203
01:04:14,880 --> 01:04:18,480
we've got to get to a point, I
believe, where we can get the

1204
01:04:18,480 --> 01:04:22,360
political will there, where
it's, you know, it's UN, it's

1205
01:04:22,360 --> 01:04:24,880
unavoidable.
I I think we got to start with

1206
01:04:24,880 --> 01:04:26,560
the grassroots, I think.
Yeah, we do.

1207
01:04:26,840 --> 01:04:29,200
Well, thanks for that.
Definitely, certainly

1208
01:04:29,200 --> 01:04:30,560
informative.
Thank you very much.

1209
01:04:30,840 --> 01:04:31,640
Yeah.
Thank you.

1210
01:04:31,920 --> 01:04:35,160
And we'll see you next week.
All right, if you've made it

1211
01:04:35,160 --> 01:04:37,760
this far, clearly you like a
little mayhem with your

1212
01:04:37,760 --> 01:04:39,840
medicine.
Or you just enjoy hearing us

1213
01:04:39,840 --> 01:04:41,680
ramble about weird medical
mysteries.

1214
01:04:42,000 --> 01:04:43,560
Either way, we'd love you for
it.

1215
01:04:43,800 --> 01:04:46,480
So hit that follow or subscribe
button wherever you're

1216
01:04:46,480 --> 01:04:48,400
listening.
And toss us a rating or review

1217
01:04:48,400 --> 01:04:51,440
while you're at it.
Helps other curious weirdos find

1218
01:04:51,440 --> 01:04:54,080
the show.
And we know there are a lot of

1219
01:04:54,080 --> 01:04:56,240
you out there.
Oh so many.

1220
01:04:56,480 --> 01:04:58,600
Come join the chaos.
Thanks for listening to

1221
01:04:58,600 --> 01:05:01,720
Medicine, Mystery, mayhem, and
sometimes Murder.

1222
01:05:02,280 --> 01:05:04,840
Do you have an idea for an
episode of this podcast?

1223
01:05:05,240 --> 01:05:08,120
Just want to say hi?
You can get in touch with us at

1224
01:05:08,200 --> 01:05:12,880
our M4 pod.
That's OURM

1225
01:05:12,960 --> 01:05:19,360
thenumberfourpod@gmail.com.
We read every e-mail, and

1226
01:05:19,360 --> 01:05:22,680
sometimes we even respond just
like real professionals.

1227
01:05:22,880 --> 01:05:27,280
Because we are.
Old friends with new twists and

1228
01:05:27,280 --> 01:05:29,120
lots of body bags.