JEN WHITE: Good morning, everyone. I wanted to let everyone know that we have an ASL interpreter online. And if you could please make sure your video is off and your mics are muted so that the ASL interpreter can be seen by those folks needing that. Thank you so much.
Mr. Brown, when you're ready, we're ready for you.
ALEXANDER BROWN: Okay, why don't we get started? I'm Alexander Brown. Ordinarily in the old days, pre-pandemic, I wore a shirt and tie almost every single day. I'm pretty sure this is the third time that I have been wearing one in over a year. I'm wearing my blue dress shirt and maroon tie, and it feels good. It feels a little bit more normal. So I'm Executive Director of Friedman Place. We're an assisted living program in Chicago. We look an awful like assisted living, but don't have to quite follow all their regulations.
Illinois is a leader in this one area. We have a network of assisted living programs that are really intended to keep older adults, lower income adults out of nursing homes. We have residence from 22 and up, but mostly older adults. All of our residents are blind. Half are totally blind. Half have other impairments. Everyone lives in independent living houses. Our residents have six chronic health conditions unrelated to their eyes — heart disease, as ma, high blood pressure, things like that. And they're on average 12 prescription medications.
Our residents are with us at Friedman Place, because of their medical conditions. They choose us because they're blind. I have nearly 30 years’ experience with involuntary hospitalization. My first job after grad school was in the crisis intervention program at a hospital. So I did a lot of emergency room evaluations. I was trying to think today, probably around 1,500 total, and probably 1/3 of those were involuntary, where we admitted people to a psychiatric unit against their will.
I was thinking in all that time, not once was I ever challenged by anyone in authority. Certainly the patients frequently challenged it, families sometimes challenged it. Friends sometimes challenged it. But in all that time, not once did anyone in authority really question what was being done. I think that's common. In most emergency rooms, you have attending physicians in charge of everything, and it's infrequent or rare that someone goes into emergency medicine with a particular interest in psychiatry. They have an interest in emergency medicine.
So often times the physicians in charge in the emergency rooms don't have a lot of experience or interest in psychiatric patients so they tend to defer to whoever is responsible for that. And I think that's a problem.
So we're going to be talking about involuntary, not the more clear cut cases, the ones in the middle. We have a fairly large group so I won't be able to easily monitor the chat, but I will pause for questions and comments. Our ability to assess and predict suicide risk is not very good. After all these years, all these decades of research and work, we're just not very good at it. There's no blood test. There's no level, there's no scan you can do to assess for suicide risk. There's simply too many factors that vary in importance and relevance to each individual.
Research has shown this extensively. 37 separate studies where they look at multiple research studies that show that half of the suicides that had been deemed lower risk, and 95% considered high risk did not commit suicide. So the vast majority of people deemed high risk did not. And half the people low risk did and did not.
The association between suicidal ideation thinking and later suicide has often been found to be stronger in schizophrenia than mood disorders, but there are a fair number of studies that found weaker associations between suicidal ideations and suicide in these populations.
A study tracking 5,000 psychiatric patients showed no measures had strong correlations with suicide behavior of a particular person. I think this is really important. It raises a lot of questions about what we are doing hospitalizing people oftentimes when we really can't say with any degree of certainty or even confidence that this person is at risk, and it also explains the common approach, if you're not sure, put them in. So if you're not sure how safe or unsafe they are, admit them to the hospital, better safe than sorry.
So on either end of the scale, we're looking at the middle. Not the psychotic person who doesn't have clinical competency, walking in the middle of the street where they can get hit and not the person with mild anxiety or depression, we're looking at the middle.
For example, Tim, an 80 year old African American man who is seen by a social worker in his home. He has two past suicide attempts about 20 years ago. He had been more depressed since his wife died three months ago and wants all this sadness and pain to stop. I want to go to sleep and not wake up. He's vague when you ask him about suicidal thoughts or if he wants to harm himself. He lives alone and is barely take caring of himself. He refuses a caretaker.
He's lost quite a bit of weight in the last few months. He's not showering or changing clothes that much. He has significant quantities of powerful medications available, which he could overdose. The social worker has raised the possibility of going to the hospital and he's adamantly opposed.
Another example, Barbara. A 45 year old Caucasian woman who brought herself into the emergency room late at night. She's a police officer in a town about 25 miles from the hospital. She deliberately did not go to her local hospital and explained that she earlier in the evening had a bad argument with her wife and was so upset that she put her loaded revolver with the safety off up to her head and with her finger on the trigger shouted what do you want me to do, shoot myself?
She was so afraid by what she had just done, she immediately locked up the gun and drove to the hospital. She's been depressed for some time, drinks more alcohol than she should, acknowledges fleeting suicidal thoughts that have been getting stronger. She's never acted on them until tonight. She promises she's safe. She's very concerned if hospitalized, or even if work finds out about this event she could lose her job. She wants to go home. The staff are concerned but divided. Some feel she needs to be in the hospital against her will. Others feel like she should go home and we can follow up.
Mitchell is seen as therapy in a local mental health center and identifies as queer. He's been hospitalized several times following suicide attempts and has been diagnosed with schizophrenia. He is very upset after recent arguments with his queer identity. He hears voices that tell him he's garbage. He's convinced his parents have put listening devices in his apartment.
Frank has very poor blind skills and thus has much difficulty navigating. He's become increasingly agitated and angry with staff whom among other things he repeatedly accused of putting foul tasting things in his food and possibly trying to poison him. Yesterday he yelled at angry staff about the food and today, a small pocket knife fell out of his pocket. When asked, he said he was carrying it for quote, unquote, protection.
These are the kind of examples that happen all the time across the country and are in the middle area. They're not absolutely clear cut. This person needs to be admitted. This person does not. The question is, what are we going to do when that person is in front of us? Are we going to move towards involuntary hospitalization or not?
While civil commitment in the United States includes a range of activities and situations including indeterminate institutionalization of those seemed sexually dangerous after a criminal sentence, we're focusing on the act of civil involuntary psychiatric hospitalization with the stated goal of protecting the person of farm between self even others. The process and experience of civil commit varies with each individual and across the country, different states have different processes, but typically begins with the police detaining a person in the community or in their home in mental health clinic who is in their opinion or that of their friends, families or neighbors presenting as mentally ill and at risk of harm for self of others.
They may be acting oddly or saying things bizarre and threatening. In most cases, law enforcement has broad discretion, whether to bring the individual to an emergency room where they'll enter the mental healthcare system or the police station where they enter the criminal justice system. This initial decision often has significant and long term effects on the individual, whether they go to an emergency room or the police station.
Once the police or family bring the individual to an emergency room, an evaluation is conducted and if deep deemed prompt, they're admitted to a psychiatric unit against their will. A preliminary hearing is held in front of a judge and a week or two later, a lengthier hearing is conducted. The processes vary across states.
Involuntary commitment is one of the few examples I can think of where the government grants to people, in this case physician, psychologists, social workers, certain types of nurses, powers that otherwise almost exclusively are restricted to law enforcement and the judiciary. And that power includes the ability, for example, a social worker with as little as two years of experience out of grad school to order and require police, order them, to forcibly detain someone, take someone into custody in the community and bring that person to the emergency room, and then for that individual to be further evaluated or detained for days or even weeks without a formal proceeding in front of a judge.
While the qualifications vary from state to state, it most commonly includes physicians with or without psychiatric training or experience. The dermatologist has the same authority as the seasoned psychiatrist. Social workers, or mental health counselors, usually two- or three-years’ experience after their Master's degree, psychologists and psychiatric nurses who have additional training.
Through the late '60s and '70s, de-institutionalization was being implemented. Tens of thousands of people were leaving institutions and moving with varies degrees of success to the community. In the late '60s and '70s, they recognized to a greater degree that institutionalization was unconstitutional. Forced institutionalization on women by their husbands or people of color or marginalized social status. In the 1880s, there was the Journal article regarding the discovery of enslaved diseased African Americans. Attempting to escape slavery, that was considered a mental illness.
As part of this historic recognition, the courts strengthened the concept that holds the government has a legal obligation to protect its citizens when they're unable to protect or care for themselves, along with recognizing the government's role in protecting others in the community from that person should they pose a threat due to their mental illness.
This differs from criminal and civil actions, which nearly all cases require concrete and specific behavior to have already occurred, rather than assessment on risk and potential for actions that may occur. For example, to commit the crime of assault, a person must strike another person. But for civil commitment to be enacted, a person taken into custody and committed, they didn't have to have actually acted. They have to have simply thought that thing or presented that they might.
This is something that could be defined as a thought crime. The court acknowledged the mandates of protecting individuals from themselves, protecting the community. For example, a key 1972 U.S. Supreme Court decision included a quote from Justice Brandeis, who in 1928 in a Supreme Court decision wrote, experience should teach us to be most on guard to protect liberty when the government's purposes are beneficent. The greatest danger to liberty lurk in insidious encroachment of men by zeal. Well meaning but without understanding. The people the government thinks it's doing well, doing us a favor, but, in fact, is harming us by removing those liberties.
The challenge continues today, to create reasonable and just laws and procedures that adequately balance those competing goals of respecting an individual's right to be left alone with a community's right to be protected. The ethical and moral issues raised include the individual's right to be left alone, versus the government's obligation to protect that individual and others to be protected.
I'm going to pause there for a minute and take any questions, comments that you may have put in the chat. My friend Jen has agreed to read them. I don't know if there are any questions that have come up several times, Jen?
JEN WHITE: Thus far, they are no questions. If you have any, you can raise them now or type them in the chat.
ALEXANDER BROWN: It either means, no one is listening or I'm answering every possible question anyone could have. Anything, Jen?
JEN WHITE: No, no questions.
ALEXANDER BROWN: If you have questions or comments as we go along, please put them in the chat and I'll pause again. So the process of involuntary commitment, civil commitment varies somewhat from state to state, but the most common legal procedure requires, really strongly encourages a two step process before someone can be committed against their will.
And then within a fixed time period, a more formal review in court or in front of an administrative law judge. I can use Illinois for example. It uses fairly common practices across the country and it's the one I'm most familiar with. The first procedural step is called the petition for involuntary judicial commission or commonly known as the petition. It's a legal document summarizing the lead for psychiatric admission that can be completed by anyone, anyone at all. It has no legal binding powers. It can be, and often is presented by family or friends of the individual, and it makes the argument that this person should be taken into custody and maybe admitted. But it carries no formal legal weight. It's simply a request. It's a pretty please.
The second step is a certificate. This document can be completed only by select professionals, physicians, dermatologist, psychiatrist, licensed clinical social workers, a psychologist, and is a legally enforceable order that a person be remanded into custody for further evaluation and possible admission. It's a formal order to police, the social worker, the psychologist can enact. The police officer has no choice. They must follow it.
The petition, certificate include the indication that certain criteria are met, the presence of mental illness and most commonly, risk of harm for oneself and others. In practice, it often falls to a Master's prepared social worker or counselor and a physician in little or no training in psychiatry to determine if a patient meets those state required criteria and is going to be hospitalized against their will.
Most locales in the United States use some form of variation of the following criteria or standards in determining whether someone can be hospitalized, the dangerousness standard essentially indicates that the individual is in imminent, generally thought of in the next two to three days of significantly harming themselves or others. This individual with a mental illness is, we believe, a significant likelihood and significant risk of harming themselves or others in the next few days.
In Illinois, the statutory language is as following. It's similar across the country. Because of his or her mental illness is reasonably expected, unless treated on an in patient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being harmed.
This is often applied to the individual deemed acutely suicidal or homicidal due to their mental illness. The next category is gravely disabled. And the courts have helped form these. The individual is an imminent risk, generally thought of in the next two to three day of experiencing significant harm due to an inability to care or protect themselves due to their mental illness.
In Illinois, the language is because of his or her mental illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm. This standard is often applied to an individual who is so depressed or psychotic, they may inadvertently and without awareness dangerously expose themselves to the elements in winter outside or walk in front of a moving automobile due to their mental illness.
The third standard is the need for treatment. Need for treatment standard is the least often used, in part because it really is the fuzziest, and it has been most successfully challenged in courts. It essentially indicates due to a mental illness, the individual is unable to make competent and informed decisions regarding their medical care, including psychiatric care, and is imminent risk of deteriorating, such as to be likely to get to the point of meeting those other standards, dangerous or gravely disabled.
So that one really pushes it out to four to six days. And like I say, it's the one that's used least often. Although presently in the laws of most state, clinicians are reluctant to use this standard because it has so often been challenged successfully in the courts, it is still used.
The petition and certificate are both not required. The certificate is required but the petition strengthens the argument. So usually the process involves both of those documents to bolster the argument for the need, but not always. Jen, many, many questions and comments?
JEN WHITE: There are a couple of questions now. So Maya Goodell says you refer to studies about poor accuracy, what do you think of the work suggesting that involuntary treatment leads to worse rather than better outcomes?
ALEXANDER BROWN: That's an excellent question. If I understand it, the question has to do with the notion, the idea that sometimes putting someone on an in patient psychiatric unit can make their situation worse. And there's the example of the police officer that I gave that is sort of a concrete consequence. This person could lose their job in many states, and here in Illinois, a single psychiatric hospitalization means you lose your right to carry a gun for several years.
I think it's a fact that often times someone who's admitted to a psychiatric unit made worse is harmed by that process in part because of the incredible pressure to get them out, regardless of their insurance status, regardless of their payer status, there's pressure to have them discharged as quickly as possible. So it lets clinicians know, hey, this person is safe for the moment, and allows a longer evaluation, but if you are having acute episode of mental illness, whether it's depression, anxiety, panic attacks, bipolar disorder or psychosis, you are now taken against your will by the arms and admitted to the hospital against your will. All your possessions are searched. Many of them are going to be taken away from you your time being. You may be allowed your clothes. You're not going to be allowed your phone, and you're going to be brought on to a locked unit where you cannot leave where all these strangers are asking you all sorts of intrusive questions, and you want to leave and you don't know when that's going to happen.
I think it's a really great question, and it's one of the many, many problems with this whole process. In the old days, 30, 40 years ago, it was not uncommon for someone to remain on an in patient psychiatric unit for a month or two months, and there are problems with that as well. So the lack of pressure to move someone out is the flip side of that.
Again, with lower income folks, there's also the question of whether they're going. They're going back to the same environment, and unless they have access to proper mental healthcare, they're not going to get it. They're going to get an appointment with a psychiatrist three weeks from now, an appointment with a counselor who can see them for 45 minutes once every week or every other week.
JEN WHITE: While still working at an SRO, some coworkers and I had to develop an unwritten process to always have a staff stay with the client while the police officers are attending to the mental health crisis. That's what's written in the chat.
ALEXANDER BROWN: Okay. I'm not exactly sure what the question is.
YARA: Is there a reason the police are involved and instead not designate hospital staff to do this?
ALEXANDER BROWN: So the details really matter. It's a great question. The short answer is because in almost all locale, that's the body that's been identified, the police, that have that responsibility of taking someone from the community, from their home, from the mental health center, from the SRO to the hospital, because they have the powers to do that. It's going to vary. Some communities have wonderful crisis intervention teams who can go out into the community and intervene that way. They're often going to have the police behind them, just in case. This question of what do you do while you're waiting for the police? What do you do when they show up is difficult.
Because on the one hand, in many ways, your role is over. You've begun this process, you filled out a petition, perhaps a certificate, and now you want the next group of professionals that are going to be responsible for this person to take over.
I always struggle with the question, is it going to be easier with the patient or the client if I stay in the room? Or is it going to actually upset them even more, particularly if you're the one that started this process. It may actually make them more agitated that you did this to me. But it varies. The majority of place, the police have very little training in how to intervene with mental health issues. It may often be the fire department who often provides the transportation, but police is going to be there. They also tend not to have very much training in mental health issues. There are those communities that have trained mental health professionals that are going to come out.
You're always balancing the need to facilitate this person getting a proper evaluation and the risk. What if this person bolts? What do we do then? It's a great question. Hope I answered it. Any others?
JEN WHITE: No, it looks like that — yes. What sort of interventions you and others are making to disrupt medical incarceration? How are you working to disrupt the cycle?
ALEXANDER BROWN: I'm not exactly sure what you mean by medical incarceration. Putting someone on in patient psychiatric unit can be termed medical incarceration. What I associate it to is I'm in Chicago. The Cook County jail is five miles from where I am, and it's often said that that is the largest mental health provider certainly in the state, if not the country, because the number of people who are being held incarcerated at the jail, short term, long term who have a mental illness.
If you think about the stress, the strain on someone who already is in a fragile position when they're taken on to an in patient psychiatric unit, it's a hundred-fold when they're brought into a jail setting. It's almost tailor made to take someone who's in that fragile psychological position and make their symptoms so much worse.
Here in Illinois — to answer your question, that's not an area that I'm really involved with anymore, but for many years, I was involved in the John Howard association that does prison and jail reform, primarily here in Illinois. One of the rules that still exists is someone who's at Cook County jail, and they're on psychiatric medications, whatever that may be, someone can be at the jail for years before their trial is over and they're convicted and sent to the prison.
That person may be on psychiatric meds for weeks, months or year, but then they're being transferred from the jail to the state prison system. And the rule is, you can't bring any medications at all from the jail to the prison. Even the staff can't facilitate that. And when you get to the prison, there's going to be a period of weeks before you sit down with a psychiatrist again. So you have people on powerful medications, antidepressants, anti anxiety, anti psychotic meds that you're not supposed to stop cold. When you stop, you're supposed to taper them down slowly under medical supervision.
Those folks have been incarcerated for action an extended period of time. Then they sit down with a social worker at the prison who gently as they can explains, you're off those meds now. I'll try to get you to see a psychiatrist as quickly as possible, but the reality is it's probably going to take a few weeks unless you get really symptomatic and psychotic. So if you hurt enough, you can then get treatment. That's an extreme example, but the phenomena of our society treating the two ends of the poles, those folks who are most severely mentally will and most demonstrative of it. So they're in public, they're around people who are aware of their behaviors and are bothered by their behaviors.
There's better accessibility of treatment for them, and on the other end of the pole, the folks who have minor mental illnesses who have good insurance and want to see a therapist. It's the folks in the middle we do not treat well at all. Did I respond? Did I help? Did I ramble? Or both? Any other questions?
There is an established and growing movement across the country to require the police to have better mental health training and better teams across the country who can intervene, because again, a police officer is not the right person in almost all cases to be the one intervening with someone who is in an acute phase of their mental illness and particularly vulnerable and fragile. Okay.
The role of race and gender in healthcare. And you can think about these two poles that I just mentioned. Those folks with the most severe illness who are coming to the attention of the community, and those folks with the mildest forms of illness who are seeking out treatment on their own often times.
There's been little direct research conducted in recent years on the specific issue of the role of race and gender in the disparate treatment of those facing civil commitment. There is some, as well as extensive related evidence in physical and psychiatric healthcare. People of color, particularly those with low income status have greater incidence of infant mortality, cancer, HIV/AIDS, diabetes. While the singular causes can't be determined, it's wildly accepted historical structural racism is a factor related to overall health, accessing healthcare, employment status, education status, accessing proper nutrition, neighborhood violence, insurance status, the ability to pay for care, the ability to travel to care, intergenerational poverty and trauma, as well as the ways in which treatment providers misdiagnose, interact and treat people with color.
Mental health providers are often no better than the general population in carrying biases and prejudices from having grown up in the society that we live in. There are tests that happen periodically where they will have a video, a film presenting an individual person with mental illness and ask clinicians to evaluate both what is their diagnosis, what is their level of risk? And you would think that most clinicians should pretty much agree, and they don't.
They tend to misdiagnose and write the evaluation of risk of people of color, people from marginalized communities much more severely than the dominant population. Socioeconomic, racial, gender factors are strongly correlated to care and outcomes. People of color, women, others the non-dominant population, lore economic means have less access to healthcare and as a result poorer outcome. These groups have greater levels of morbidity, mortality, extent of sickness and death than average, and these problems continue from one generation to the next from one family into the next, and extend into the area of mental health disorders and treatment.
Problems result in variations in how clinicians diagnose women and people of non dominant races and ethnicities. Similarly, African Americans receiving mental health services are frequently overrepresented in emergency rooms and psychiatric units when compared to the dominant population, and are diagnosed with severe and persistent mental illnesses more frequently when the same symptoms are presented to clinicians.
Similarity, certain ethnic minority groups receive much more mental health, quote, unquote, treatment, through emergency rooms, and are disproportionately represented on in patient psychiatric units than the dominant population. They're overrepresented in institutional settings, and they're much more likely to enter via involuntary commitment.
Asian Americans are underrepresented in institutional settings, but when they are there, they stay longer. Latinos are overrepresented in public institutions, underrepresented in private. Racial minorities as a group have less access to mental health services, less likely to receive mental health and when in treatment are more likely to receive poorer mental health care. They're also underrepresented in research studies. That is changing in the biologic sciences, but not so much mental health. Predictably, these disparities enter the realm of behavioral and psychiatric disorders. They received less care, received poorer care than the rest.
They're a multitude of causes ranging from historic and bias, legal, bureaucratic, financial, and often culminate in the individual's clinical encounter, they experience when they're sitting face to face with a clinician, whether it's a therapist or someone evaluating them for diagnosis or risk, they're ostensibly a well meaning clinician, but all those things come and impact and influence that interaction, just like they do in other parts of our lives.
Many of those encounters result in the individual being over or under diagnosed, treated too much, treated improperly. Women generally, and those in the LGBTQ community, especially all ethnic backgrounds, they also experience healthcare disparities. Lower income status and race and ethnicities particularly correlates to treatment, the kind of treatment, access to treatment.
Involuntary commitment remains particularly controversial, especially among recovery oriented mental health stakeholders. In the '50s, '60s, early '70s, there was a worldwide movement called the anti psychiatry movement. And they posited that psychiatry is nothing more essentially than society's effort to control behavior and to pathologize people who are different. If you weren't of the mainstream, whatever the average criteria were, that was going to be diagnosed as mental illness.
That movement has morphed into the recovery movement. It's prevalent. But involuntary commitment is a hot button. Recovery oriented mental health stakeholders, advocacy groups, they put a high value on personal autonomy, self determination. Individuals with severe and persistent mental illness want a higher bar for involuntary commitment and more self determination. They want it to be more difficult for someone to pit them in the hospital against their will.
While their family and their family's advocates and providers want more access and ability to get their loved ones needed care. They want a lower bar. And this happens all the time where you have an individual and a family member in an emergency room, and the clinician comes out to the family and says, you know, your loved one should be in the hospital. They could benefit from it — whether they could or not, they'll believe that and see that — but they don't quite meet the criteria, I can't force them in, I can't put them in involuntarily, so they're going home.
The family member pleads and begs, please. Give them the help we know they need, why can't you do it? So there's a tension there between those two broad advocacy groups, some that want easier ability to involuntarily hospitalize someone, and others who want much, much less. The tension is almost always under the state law, which is ended to protect the person from harm, to secure for the person the treatment they need, avoid bringing harm to themselves or others. It just doesn't always play out that way.
All mainstream healthcare professions, social work, medicine, psychiatry, psychology, nursing, have adopted codes of ethics or guiding principles that embody ideas of helping and not harming. Respect for autonomy through requirements of fully informed consent. Respect for patients' self determination and fairness or justice. These core principles and values are challenged by involuntary commitment, which essentially pits the desire and obligation to help protect an individual's right to be left alone.
This is unique to the area of mental health. There's no vehicle for a competent adult to be forced to undergo medical treatment against their will. Even if the health care professionals and their family believe they should. The closest thing I can think of are requirements that college students and people working in particular jobs receive vaccinations. But even there, they have the right to decline, with the consequence of them not being allowed to attend the college or hold that job.
There's nothing else like that. Across the country, there are mental health courts, which are a great step forward. The question of incarceration and culpability. And they are specifically for people who have been accused of committing a crime, but they have a significant mental health illness. So they go to special courts where the judge, the attorneys have special training in how to work with mental health issues, and they take that into account. Not that it's going to absolve someone of all responsibility or culpability, but to take that into account.
So someone who has a severe and persistent mental illness, a period of psychosis hurts someone else, they're most likely going to be charged with a crime. The mental illness may or may not be taken into account. But compare that to the sad situations where someone is driving and has a heart attack or a stroke and crashes and hits someone, kills someone, no one would ever say, well, that person, once they get better, once they have treatment for their stroke or their heart attack, they should be charged with a crime. It could be ludicrous to even think that. Because clearly, it was caused by their illness. They shouldn't be blamed for that. But with mental health, it applies.
Two years ago, SAMHSA issued guidelines. Many are useful, although sometimes pretty difficult to apply in the field, especially in a busy emergency room at 3:00 in the morning, or out in the field with police and fire standing there saying let's go, let's go, let's go. What SAMHSA said, is those diagnosed with serious mental illness where there's treatment that's likely to be effective. The expert in this field representing the government is saying that civil commitment should only be done in case of serious mental illness for which there's available treatment that's likely to be effective. And putting someone on a unit for three or four or five days to give them new medications that's not an available treatment that's likely to be effective.
If the person is willing and available to engage with services voluntarily, they should not be committed. And this is challenging. It happens all the time in emergency rooms where the social worker, the psychiatrist says to the patient, you really need to be in the hospital today. I really believe you need to be in the hospital today. And you're going to be in the hospital today. And it can happen one of two ways. You can either voluntarily sign yourself in, which will make the process easier and make it probably easier for you to be discharged when you want to, or we're going to put you in involuntarily.
Now, the law says if someone is subject to involuntary commitment, they really shouldn't be allowed to make a decision otherwise, because you said the risk is so high. And there have been a number of lawsuit against the hospitals, against the staff for allowing someone to sign in voluntarily when they have just kind of threatened them and said you meet the criteria but we're going let you sign in voluntarily.
A person should not be subject to in patient commitment unless, without a hospital level of care, the person will be of significant risk in the foreseeable future of bringing harm to self and others. This gets to the question of the evaluation, how good or poor we are at assessing risk. If a less restrictive possibility is available, it should be used.
So this is a principle that exists, and often happens that emergency rooms, clinicians, will send the person home with family or friends rather than put them in the hospital, but it also happens regularly that in that conversation where the clinician says to the family, I'm sorry, Johnny should be in the hospital, but they don't quite meet the criteria and the family is upset, so the social worker says, now, if you were to tell me that Johnny threatened you, then I could give them the help they need. Sort of wink, wink, nudge, nudge.
It's a way of telling the family member to lie in order to access treatment. And it happens all the time. And you can understand, hopefully, the plight, the desperation of family members who are so afraid and so eager to get help for their family that they're willing to lie and work the system in that way.
There should be assignment of counsel, an opportunity to challenge commitment before a judge or other judicial authority. That is there in theory, but in practice it is not. Three to five days after being admitted to the psychiatric unit, there is a hearing. These days it's all going to be done remotely. The individual really isn't in a position to defend themselves in any meaningful way.
Commitment practices should respect the privacy and dignity of the individual. Every effort should be made to minimize trauma. If law enforcement agencies are responsible for transporting individuals, they should assign plain clothes officers in unmarked cars whenever possible. Shackles and other restraints should be used only when necessary, never has a matter of routine. I'm sure that happens sometimes. I've just never experienced it personally. I had the experience of the crisis team being able to approach team with that kind of respect and patience. I'm sure it happen, I've never seen it happen.
Unless already incarcerated for a criminal offense or facing criminal charges, no candidate for commitment should be detained in a jail or other correctional facility pending commitment. No person who is being committed should be placed in correctional facilitate for treatment or services. If you live in an urban setting, there's going to be a similar phenomenon in your community as well.
Civil commitment should never be used solely for preventive detention or community control. Treatment staff should have the authority to terminate commitment without the court's authorization as soon as the individual progresses to the point where they no longer meet the criteria. So that idea is Johnny met the criteria for hospitalization and was admitted on Monday night to an in patient unit. And by Tuesday night or Wednesday, the in patient unit stuff feel like — I understand why he's admitted but Johnny doesn't immediate to be here today.
So SAMHSA is saying, the hospital staff should have the authority to discharge, but most states they do not. They have to wait until they get the administrative judicial hearing. I'm going to stop here. Questions, comments? Thoughts? Random thoughts? Not so random thoughts?
The long term practical effects of someone being admitted to an in patient unit, and they can be significant. That absolutely is going to be part of their record. At times it's not going to matter, but at times it really is, when they are trying to access other kinds of health services, trying to get insurance. That's going to pop up, and it sometime is going to trigger very serious consequences. Whatever your positions on gun rights, again, in most states, being hospitalized on an in patient psychiatric unit is going to be result in the revocation of your FOIA card, your license to carry a gun for a set period of time. Or you're going to have to apply to have that restored and it's not easy and it's going to cost money.
So there are real practical implications. The police officer is sort of an extreme example. We admit Johnny on Monday night because we feel we need to. But he's supposed to be to work on Tuesday, Wednesday or Thursday. So then he has the problem of what to say to a boss. He says I was in the hospital, I was in a psychiatric unit. When Johnny has the note from the doctor saying he's okay to return to work, does the note say, the doctor is a psychiatrist? Some employers are going to be fine and understanding. Many are not. That kind of stigma and shame is a part of all of this.
JEN WHITE: We have a question from Monica. Have we seen civil liability consequences for clinicians who do things like encourage families to lie to get a commitment?
ALEXANDER BROWN: I'm sure it exists somewhere. I've never heard of it. And I think in part, it was part of my training, honestly, both in grad school and when I was working in a hospital that, like, this is a way to help people get treatment. If you look someone in the eye and say, if you lie, if Johnny threatens you, we can get help, it's done more subtly, ambiguously, in part out of fear of some kind of consequence or retribution.
It happens all the time. And who is going to complain? Certainly not the family member who is trying to get the help, and if Johnny finds out about it, he's probably got other things going on in his life related to being admitted and his mental health issues to hire a lawyer and go after the hospital for doing that. So I'm sure it happens. I've never heard of it, though.
JEN WHITE: Are there studies about factors psychiatrists use to decide someone is ready for discharge related to race? Ideas of about what's good for their patients that may be influences by their own biases.
ALEXANDER BROWN: So the theory and criteria is the same, if someone no longer meets the criteria for involuntarily hospitalization, that really acute level of risk of harm to self or others, they're supposed to be discharged if they want. That's supposed to happen. The study is not just with psychiatrists, it goes both ways. It goes both ways that some clinicians are going to misinterpret, particularly an African American man's symptoms and level of risk is much higher than it really is.
Someone who was Caucasian would be determined to have a risk at this level. But if they're African American, they're going to artificially get a higher level and there are going to be more consequences. On the other side, this happens as well and research has shown that some clinicians will disregard and wave off those symptoms among racial and ethnic minorities because, well, they're all like that. That's just how they are. That same kind of prejudice and bias that can work against someone on one side, being over diagnosed and assessed too high for a risk can work the other way as well. Someone who really is in pain needs help and they're going to be dismissed because of engrained, unconscious prejudice. Research has shown consistently those two poles.
JEN WHITE: Are there differences if the person has an intellectual disability?
ALEXANDER BROWN: Theoretically no, but in reality, there are. This is certainly an area that I'm much more less familiar with than mental health, but the criteria is supposed to be the same. The training of emergency room social workers, psychologists, counselors who do this work is going to be largely around mental health issues, which is seen much more often. So they're going to be a disadvantage there.
I see a question about people bringing ADA claims for involuntarily commitment practices, for example, arguments for providing treatment in the communities instead? So after Olmstead was determined, passed by the Supreme Court, some states got on that right away. Many did not. Illinois was one of the last states to do anything, and it took multiple consent decrees for them to do anything.
The claims tend to be broad. So there are class action suit against many, many people who are not briefly on in patient psychiatric units, but on longer term confinement, either in an institution, a nursing home, other kinds of government funded facilities.
There are ADA lawsuits across the country about the need to expand community services, and we've seen it here in Illinois. There were two significant consent decrees related to getting people with mental illness out of institutions into community, those consents decrees required the government to put significant resources into community supports from caseworkers who work with the individual as they're leaving the nursing home or assisted living or long term care program, as they move into the community on all sorts of areas.
If you have someone who's been in an institution for 10, 15, 20 years, they haven't done their laundry in that long, they haven't cooked a meal in that long. They're going to need a lot of support. So these consent decrees had those resources mandated, and they really just were not followed up on to the extent that folks needed.
Even those caseworkers assigned to work closely with individuals, after a certain fixed period of time, whether the individual is doing really well or not, they get cut off. And the devil is in the details. And where you live makes a big difference when it comes to services.
I'm criticizing Illinois a lot, and it's well deserved, but the supportive living program, this network 25 years ago, Illinois recognized that a lot of folks in nursing homes don't really need to be there, and it's really much more expensive to have them there. So they created this network. We're almost assisted live, not quite. We don't have all the onerous regs. We have other regs. And from the government's perspective, we exist, I think, for one reason and one reason only, to keep lore income folks on Medicaid out of nursing homes because it's so much more expensive.
The code that created supported living, it says in the code the percent of nursing homes rates that supportive living programs are supposed to be paid. We've never gotten that much. We are reimbursed fairly well, and at Friedman Place, if we fail to exist tomorrow, 75% would end up in nursing homes, and none of them need to be there.
I get calls periodically around the country asking, how do we start in this our state? And it's hard for me to understand why there aren't more of these kinds of networks, because it makes so much sense. From the state's perspective, they get people cared for and housed as a much, much lower cost, and from the individual's perspective, they have a degree of autonomy, independence, flexibility, privacy, choice, so much greater than if they were in a more traditional institution. It's hard for me to understand why that hasn't picked up across the country. Other questions, comments?
Well, if not, we're a little early, but I want to thank you. I wish we were all in person. Maybe next time. And if you do have other thoughts, you can find me, Alexander Brown, Friedman Place. You can get my email on the website and certainly reach out to me. Jen, anything else we need to do?
JEN WHITE: I don't see anybody with any questions or hands, so if you're done, I'm all right.
ALEXANDER BROWN: All right. Thank you all very, very much.
JEN WHITE: Have a great day.