Never mind, we're going to go ahead and get started right now. So hello, everyone. Good morning. My name is Christopher Chunseely. I am the Program Director for School and Justice Initiatives for the APA Foundation, and it is my honor to welcome you to this session, Stopping the Revolving Door, How Psychiatrists Can Reclaim Individuals with Mental Illness from the Criminal Justice System. For those of you who have arrived early or are just walking in, make sure you stop by and see Joy Lloyd Montgomery. She has some flyers that are being passed out. The first 50 people will receive a free book to a guidebook that we'll be discussing later today. So really exciting. And special shout out to Joy for all of her support in making this session happen. Introductions. We've brought together the APA Foundation in this presidential session, have brought together an exciting panel of experts to discuss with you how psychiatrists can reclaim their patients from the criminal justice system. First we bring to you retired Justice Evelyn Stratton, who served for 23 years on the Supreme Court of Ohio to pursue criminal justice reforms, particularly as they relate to mental health, juveniles, and veterans. She is a pivotal, she is the leader of Stepping Up Ohio and is an APA Foundation board member. Thank you, Justice Stratton, for joining us here today. Dr. Michael Kelly is an adult, child, and adolescent and forensic psychiatrist from the San Francisco Bay Area. Dr. Kelly's clinical, scholarly, and forensic work has focused on community mental health, violence risk assessment, child abuse investigations, and graduate medical education. Dr. Kelly is currently a psychiatrist with one of the largest mental health drug treatment courts in the U.S., located in San Jose, California, is chief of forensics of Caligula State Hospital, and teaches forensic psychiatry and ethics for residents with San Mateo County Behavioral Health Recovery Services. Thank you, Dr. Kelly, for joining us here today as well. Next, we have Dr. Zach Lanay, received his MD and MPH degrees from Tulane University School of Medicine right here in New Orleans, where he was a case manager at a free re-entry clinic and formerly incarcerated partners involved in the creation of an ongoing peer support group focused on the emotional and practical challenges of re-entry in Louisiana. He currently serves as chief resident for the San Mateo County BHRS Psychiatry Residency and is a UCSF Public Psychiatry Fellow. He was awarded the inaugural APA-APAF Correctional Public Psychiatry Fellowship for 2020-2022. He sees patients within the San Mateo County Jail System and is evaluating... I can never say that word. See, I'm not a doctor. Thank you so much for joining us here today. And last, we bring to you Thad Tatum. Thad spent 28 and a half years in Louisiana State Penitentiary. After coming home, Thad earned degrees in psychology and substance abuse counseling from the Southern University at New Orleans. Having seen the psychological toll taken by incarceration, Thad dedicated his life to serve those coming home. Along with collaborators from the Tulane University School of Medicine and Voices of Experience, Thad co-founded the Formerly Incarcerated Peer Support Group. Developing a space to process the traumatic experiences of prison, since 2015, this group has been a network of over 150 formerly incarcerated people, researchers, clinicians, and volunteers. Thad and other formerly incarcerated people deliver a trauma-informed evidence-based curriculum. Thank you, Thad, so much for joining us here today as well. So today, we're going to start out with a panel discussion. We're going to ask a few questions to each of our panelists, but we do want to invite you as audience members to also ask questions after we're done with our preliminary questions. Once that is done, we're going to roll into a breakout session. So we're going to be talking to you for a little bit. You're going to be asking us questions, but then we're going to look to get some information from you today from this session as well. So you might be thinking that you're going to learn from us, but we're trying to learn from you as well. This is really going to be an exchange of information today, so we're really, really excited. So our first question is actually to Justice Stratton. Justice Stratton, what are some facts that a psychiatrist should know about the intersection of mental illness and the criminal justice system? Well, I think most of this audience knows that the criminal justice system is the largest mental health facility in the country, and that is the opposite of what it should be. When we closed all the state hospitals, we promised a robust system to treat them. A, we never created the system, and B, we never really gauged the effect of the inability to recognize you have a mental illness and seek treatment. And so many of those people actually ended up homeless and under the streets and in jails. So the Stepping Up Project that I headed as a national project is, the goal is to break that cycle of recidivism, and we do it through numerous programs, but mental health courts is something I started working on very hard, Ohio and nationally, and then veterans courts were an outbreak of that. And that goal is to treat the reasons they got there and get them back to what we call intercept zero, getting to them before they enter the criminal justice system. But we need the treatment community. That cannot be done by judges, it cannot be done by the court process, it has to be done by the treatment community getting involved, and so my goal on the APAF Foundation is to really push them to get much more involved in the criminal justice system, because that's the only way we're going to make the hospitals the main treatment center instead of jails and prisons. Zach, do you want to jump in, or Dr. Kelly? Yeah, I agree with that, and I think in general, academic institutions and larger hospitals, I think it would be well suited if they were more involved in the type of work that we're doing in community psychiatry. I think a lot of it, if it doesn't make money, it doesn't get done a lot of the time, and so that's a little bit discouraging. That said, the reason I'm here today is because I'm not so sure the system's ever going to save us, or save what's happening here, and we just need people with their hearts and minds in the right place who care about this type of work to just do it, and because the systems we work in, a lot of times they don't work, and they're unfair, and they lack transparency, and what we need is just people who just want to do the work, just do the work, and that's what I'm here to say today, that we need help. If things are on fire, folks can grab a bucket and start throwing some water on the fire. Yeah, I totally agree. I think, like the judge said, everybody knows that the largest three mental health facilities in the U.S. are Cook County Jail, L.A. County Jail, and Rikers, right? And it's just kind of like, we're psychiatrists, this is our field, why is this the case? And I think working in these facilities, like we talk a lot about meeting patients where they are, right? Unfortunately, they're in correctional facilities, which is terrible, but is the reality now. And like, I, you know, myself working in correctional facilities, like, you know, I think a lot of people who don't now, especially like community oriented psychiatrists, it's kind of like, correctly, or like, this is the wrong place for this to be taking place, like I don't want to work in this, and it can feel like, you know, you're lending credence to like, your credibility going to like an untrust kind of system. And, you know, that's something that I think about a lot, and also still kind of struggle with, but whenever I'm actually working in the jail, it's like, well, this is actually where these people are, and they actually need treatment right now. So, yeah. Yeah, to add to anything that's already been said, I think that the psychiatrist, you know, in order for you to actually understand the mental health and impact of incarceration, you know, on black people without understanding the psychiatric historical and cultural and slavery and white supremacists, you know, for a long time and for some time, you know, they've been used as a tool to, you know, to keep people into this kind of system. The carceral system, the jails and prisons should not be used for psychiatric patients and places like that. And I think that, you know, as a psychiatrist, you know, you should be mindful that, you know, the duty that you have, you know, should be able to impact the people, you know, to be able to serve the people that's impacted rather than, you know, become partnership with the judicial system and the justice system. Thank you so much, everybody, for your response to that question. Question number two, I'm going to pass to Dr. Kelly. What are the ways that the criminal justice system can benefit from psychiatric knowledge? Oh, boy. I think, you know, there's a number of ways. I think a lot of ways psychiatrists can work with the courts. We're often sort of the only docs that are working with the courts, and I think something that's really important for us is to help educate the courts on just the language of medicine, translate that medicine, and also just discuss the impact of trauma and its lasting, lasting effects on people's lives and help the courts understand just how impactful that is. For instance, like, you know, where I'm seeing people, I see people that I would never, ever They wouldn't even come through my door if they had the opportunity to, like, go get a regular, decent paying job and be able to afford to pay rent or buy a house. I guarantee you I wouldn't see half the people that I see, and the folks that I see are so resilient. I mean, so many of them do well, do much better than patients I see in other settings just because they've gotten some attention for the first time in their lives. Someone's actually sort of looked and said, look, something's going on here. You need help. You need to do something about this. And you find so many resilient people that are putting them on death's door, on the street, addicted, and, man, you see them a year or two later, and they're working, and they're counseling themselves. And so I think educating the courts on just the impact of trauma and also just on translating the language of medicine, but also, you know, acknowledging just people's resilience, because I think it's easy to sort of sometimes feel like folks are sort of hopeless or lost, but I see lots of people who are lost every day, and I see folks come back. If I must add to that, what are the ways that a judicial system or the criminal justice system can benefit from psychiatric knowledge? I don't think the psychiatrists should benefit or the judicial system should benefit from what the people that's impacted by it, because going into partnership is almost like agreeing with the things that causes the justice system to be what it is today. You know, the justice system is a place where, you know, and what it's intended for, you know, is to get free labor, the voting and restriction of voting, to have control of the community and awareness once the people are being released from prison. So it's a direct antagonistic to what a psychiatrist's job should be, you know, so to try to become partners with the judicial system, you should be mindful of skills. You should be mindful that, you know, your job is to treat the people that's impacted by it, you know, rather than the judicial system. Thank you. Justice Drayton, what information have you found to be extremely helpful in your role in the criminal justice system as you're 23 years on the bench? So I'm not one that likes to study issues. There's lots of studies. I'm very action-oriented. So some practical solutions to try and get those psychiatrists involved, some solutions are, I did an attorney general task force, co-chaired it with the former attorney general Mike DeWine, who's now our governor, and now, we've done it for eight years and now three years with Attorney General Yost. We have 500 members. We have 15 committees. We have several, I've asked several psychiatrists to head them. And because of those committees, we got a whole appropriation to the legislature to reimburse jails with psychotropic drugs, including long-term injectables. Then we realized the jails didn't really understand well enough how to use them, so we formed another committee that did jail training on using those drugs, recognizing mental health issues, connecting the jails with the medical community, the hospital system. We've done three trainings. We've got two more. Then we started a series of grand rounds. We did them at Ohio State University Psych School, one hour. The first one was on mental health courts. The second one was crisis intervention teams, police officer training. The third one was on the civil side, NGRI, et cetera. We sent those to all the psych schools, all the training programs, trying to get them when they're young and interested and vulnerable and want to save the world. And then we also do some education stigma, mental health 101, which we've taken into all our prisons and our jails. Now we're training the judges with mental health, first aid 101. I've pulled in psychiatrists to head those committees under the NG Task Force, and they bring the expertise, and they do the trainings. It's not a lot of time. It's an hour, and for that hour, we spread it all through the state of Ohio as a way to try to get more psychiatry involved in the system. So I'm very practical-oriented in trying to pull the psychiatric community, and I've been very involved with our Ohio Psychiatric Association for many, many years and very involved with our medical association as well. So those are the practical things that you might think about trying to do in your state to try to pull people into the system and get them involved. I'd just add, I think that psychiatrists can do a lot to advocate for more community-based alternatives to incarceration for people, diversion programs, like really robust re-entry programs. I mean, I think those are so important and can make such an enormous difference and have a really great evidence base, and I think that's something all of us can do, like literally just talking to the judge about it, because judges have a lot of power and access to resources to make this stuff happen. Well, and I think you are transitioning right to your question, Dr. Lene, about what services can be provided when a community member is incarcerated, and how can we provide those services sooner? Yeah, I mean, there's a lot. There's like the sequential intercept model, which people might be familiar with. I mean, kind of starting with while people are incarcerated, obviously you can work in a correctional facility, provide treatment, kind of what you can do varies very much by state and especially facility, like jails have shorter stays, it's more difficult to really start a treatment plan, people are getting released kind of unexpectedly, you can't predict it in the same way. But I would say for people who are incarcerated, one of the most important things, like 95% of people in the most infamous prisons in the United States are going to get released and they're going to be living in the community, and discharge planning and reentry planning should start as soon as people are incarcerated, so kind of starting to make a plan for what you're going to do with this person once they arrive, like assessing their needs when they're there, really interacting with and connecting with community partners, and especially things like warm handoffs, like in the jail I work in, they're starting to do virtual warm handoffs for people who have substance use disorders, and I have a particular interest in people with opioid use disorder and treating them with buprenorphine, so to go on a slight tangent, I'm sure as people know, there's an enormous risk of overdose and death within the first couple weeks of release from jail, prison, any correctional institute, or even hospital, when people lose their tolerance and are reentering society with a ton of barriers to meeting their social needs, like Dr. Kelly was talking about, and 75% of people relapse within three months of release because they've lost tolerance, they overdose, according to the seminal paper in Washington State, within the first two weeks of release, people are 129 times more likely to overdose, die from overdose, than other state residents, and buprenorphine is super effective, it decreases that actual mortality by like 60 to 70%, and it has a number needed to treat for retaining people in outpatient treatment of two, like it's wild how well it works, and it's really underutilized, in 2017, less than 0.5% of jails and prisons in the United States used it, so I think that's just really, it's not easy to do, but it's a really important thing to do, and so that's kind of one thing I think could be, and it is changing, a lot of places are expanding its use, California, the state prison system started using it more in the last two years, and there was recently released data showing for people while they're incarcerated, a reduction in overdose deaths by 58% over that time, so it's super effective, reduces reincarcerations, so I think that's one thing people can do for sure, and then once people are released, I think assertive community treatment, like for any SMI population, has just wonderful evidence, basically just intensive case management for people when they get out, there's specifically focused fact, forensic, assertive community treatment, kind of wraparound social services in addition to helping people deal with all the legal logistics and stuff like that they have to do, so there's a lot, of course it requires money, there's also a lot of systemic barriers to this stuff happening, like people's Medicaid getting suspended when they are incarcerated in jails or prisons, most states don't have an automated system for re-implementing people's Medicaid once they get released, which is obviously an enormous barrier to them getting services when they do get out, there's just a lot more, but I'll stop talking. I agree completely, especially with re-entry, that's like the biggest break-limiting step with folks that I see is just when they get out, they come to me and they don't really have a plan, they don't have a case manager, those sorts of things, that's our first few weeks, just figuring out who are we going to partner with, how are we going to get this done, because it's completely overwhelming, you don't have SSI, you don't have a place to live, your family was helping, now they're not, things change, and that alone, I think we'll stick under the waves just from that alone sometime, because there's just so much to deal with, just as much as we need mental health, psychiatrists, psychologists, we need case managers, we need case managers to help folks get through the day-to-day, especially when they're coming out. And peer support workers, I mean, that's like central, I mean, I think that can obviously talk more about that than I can, but just really good evidence for it, not just for the people, the peer mentees of the peer support worker, but the peer support worker themselves, we're talking about people not being able to have a job, providing a level of stability both for the mentees and the mentor, him or herself, peer support services have really robust evidence, and obviously for people who are very traumatized by a very traumatizing system that we're kind of have like a dual role in, like especially in the case where you're working within the facilities, there's going to understandably be a lot of mistrust, so we should really, with this population, always be working with peer support workers, I think. Like what Thomas said, I think that issue of trust, I think also just make it important to let the folks you work with know that you're there for them, you know, like everyone I work with, I let them know I'm your doctor, I'm here for you. The court has some stipulations, right, they may have you sign a lease so that I can talk to the judge, but I'm always going to give the least amount of information as possible just so that we can establish trust, and that sometimes takes weeks, sometimes it takes like a year, but, you know, with the folks we work with, if you're not who you say you are, they're going to know. And so really, I mean, you know, just being genuine and also being very straightforward and very clear about this is the frame you're in, setting that training frame is so important for the folks you work with, so they know who you are and what you do, and anything else I can say about that? Yes, and they were speaking about the people that's coming on to be re-entry, but I think if you really want to help, then you would bring these services into the communities, right, you would educate our community. You got to be mindful of one thing, African-American people are out of grave distrust of the psychiatric community, right? And you must ask, where does it come from? Where does distrust come from? Well, through history, we have shown that, you know, you know, the psychiatric people have played a major part, you know, in enslavement and mass incarceration and other things that, you know, was against what African-American people think that should have helped them. So my thing would be not only would the community would be, you know, suitable for people that's coming home with the re-entry programs and all these things, but we have to understand that the community need service for those that was left behind by the ones that was incarcerated. The collateral damage of the family, of the kids, and all these different things that, you know, once someone in the community get locked up, that'd be taken away from. So I think that you really wanna help, then you would, you know, go into this community and educate about the things that would be essential, the good and the bad, you know, that it really does help alleviate this fear that we as African-American have towards the psychiatric division. And just to straighten, I know as far as services and especially in stepping up Ohio, you've worked to really bring the barriers that could be perceived to getting to treatment to the table, you know, quarterly, monthly discussion. So I wonder if you can touch on that just briefly on bringing those services forward. So I'll start with how I started. I was born and raised in Thailand. I was a missionary kid. I never saw mental illness in the small villages I lived in in my boarding school. I didn't even see it in college, although I now know it's prevalent. I didn't see it until I was a trial judge. I was a trial judge for seven years, and man, I saw it in almost every one of my cases. And so I started writing letters and trying to do something, and I got elected to the Supreme Court, and I wanted to do something, but I didn't know what. So I called up 10 people to my meeting, some from mental health, some from the prison system, NAMI, and I looked at them, and I heard something called CIT, and I heard about something called mental health courts. And I had 10 people, I looked at them, I said, I have no budget, no background, no training, no money, I have no idea what I'm doing, but I have one important thing, I have a big title, and people come to my meetings. And so my message to you is pull your judges in every one of our mental health courts. We have 259 specialized dockets. Every one of those judges now is a community organizer. For every case they have, they bring the community in, they bring the treatment. And we tell our judges, you are not the treatment people, you're just the judge, you listen to your treatment people, but they bring that community, and they plan that reentry program, but nobody uses judges enough because, I mean, I've left the bench now, I've been 10 years doing this off the bench, and they all still come to my meetings. You can call your judges and tell them, can you help us organize? Can you help us get this going? Find a justice in your state that could maybe do it on a statewide basis. And then you pull these groups together, and when we do these stepping up meetings, because we do them in a county, and we bring the whole county together, and we do it by Zoom now, that means our attendance has almost doubled, we get the housing people in, we get the reentry people in, we get the NAMI people in, we get the crisis center people in, and half of the value of the meetings is then finding out what they're doing in their own county, they don't even know that. So I'm a big, big believer in convening, but judges can be a very powerful force to help you do that. And then when you bring the people together, you can look at what does it take to get this person successfully into reentry, what are we missing in our county? And so sequential intercept mapping, I like to describe it as getting in and out of the system. Where do you get in and out? Do you get in the beginning, do you get in the middle, do you come out and cycle all over again? You gotta break that in and out cycle, but using your community and pulling it together instead of just working in isolation is so, so important. And then that pulls in our medical community. When I was starting the Judges Leadership Initiative, which is a group of judges working on mental health courts, there were two in Ohio, six in the country, and we learned about each other by just calling each other up. So we put this group together to try to put something together. We came up with a book we call Mental Health Jargon for Judges, and maybe we did mental health jargon for juvenile judges. And then we joined with a psychiatrist in Fort, said the Judges Leadership in Psychiatry Initiative, and I kept saying, you need a guide for the mental health professional. And we've done one. When I got on the board, we did one. And this is what you're gonna get, and it tells you what you can do to get into the mental health criminal justice system and what role you can play at all these different levels. It's a very valuable tool. You can order a whole bunch of them and order information on the front cover, inside the front cover. Use that to give to all your staff so they can understand where they can intersect in the criminal justice system to make their voice heard, because we're not effective without the treatment side, as I said when I began. So my message is to use your leaders to do the convening, and then you can be partners with them. Thank you so much, everybody. And for our final scripted panel question for you today, we brought to you, we're always talking about the Judges and Psychiatrists Leadership Initiative. Judges are leaders in the criminal justice field. Psychiatrists are leaders in mental health. But what we often miss are the individuals who go through and have lived experience. And I think that's why we wanted to make sure that Thad was here today and offering you that perspective. So Thad, I'm hoping that you can offer some insight in what can mental health professionals learn from your expertise, and what do they most often miss when working with community members with justice involvement? Well, they miss a lot. You know, I think that many people that study psychiatrists, the psychiatry division, must understand that you got to be cultural sensitive, even relate to people that's in our situation for the African American community and those that's been incarcerated. Like was mentioned earlier, I served more than 28 and a half years in Louisiana State Penitentiary at Angola. From my experience there, I realized that no one was born a criminal. And there's a lot of good people in jail, right? And I always, through my 28 and a half years, I seen people come and go. And I was always curious about what would make a person come back after leaving a place like this. So from that, I went to studying, you know, the limited material that I had available, of why or the cause and the reasons of people coming back to prison, which led me to the psychological part, you know, of things. I wanted to come home and I wanted to start a group that would be able to address the things that I want to go through while incarcerated. All the residual effects of the things that happens in jail, you bring those things back to the street switch. So therefore, you know, forming a group such as the Formerly Incarcerated Peer Support Group, it led me to studies, you know, with post-incarceration syndrome. Post-incarceration syndrome is a symptom that can only resize in people that have been incarcerated. But the mistake that the psychiatrists made, they address everything with post-traumatic stress disorder. It's a close kinship, and it has a lot of things that are similar, but there's a major difference. It can only be residing in people that was incarcerated. So with that in hand, one must understand that the studying of something that has very little material, such as people incarcerated and the impact it has on, you know, your mind, then you got to realize that, you know, wow, what can we do? What can we do as psychiatrists and the Psychiatric Association? You got to put down the prescription pad and stop addressing everything with medicine, and to be able to come and sit down and talk and realize that the problem that we have, it's different, and it has a lack of knowledge, and it should be addressed in an educational way. And this is what we do at the Formerly Incarcerated Peer Support Group. I gave, I intended to give a platform where guys can come home and address all the many ills and the problems that they face upon coming home. I did that. I did that by sitting around with my friend, Zach, and we came up with ideas and thoughts, and then other people that came along and took part in what we did. It's impossible for any community organization to be effective without the help of people that's really invested in it and want to do their jobs, such as the psychiatrists and social workers, doctors, students. All these people played a major role or are playing a major role in many of the reentry programs that's located here in New Orleans, I can speak of. To speak about this also, Louisiana incarcerates more people than anybody in the nation. Louisiana incarcerates more people per capita than anybody in the world. So inside of Louisiana, New Orleans lock up more people than any city in Louisiana. So psychiatric division, I welcome you to the epicenter of the most incarcerated states, most incarcerated place in the whole world. So if we can address this by educating and setting up programs inside the community, I think New Orleans would be a good place to start, since we're the epicenter of the incarceration capital of the world. I think that being down here, it's not only a coincidence that's mental health awareness month, but it's a sign that things can change if we work together. If we work together, we got to put down, again, we got to put down that prescription pass. And we got to attend meetings. We got to go try to find places where formerly incarcerated people, reentry programs meet at. Then we can become more educated. Because we have a saying that, when you're amongst those with greater knowledge than you, then you're obligated to teach. But when you're amongst those with lesser knowledge than you, then it's your turn to learn. So when we're amongst those with equal knowledge, then we got to share. We got to share. We got to make sure that the things that we have learned, the things that we was taught, coincide with the help that the people that we're supposed to service. So therefore, you know, it gives me great honor to be able to represent and talk about some of the things that formerly incarcerated people go through, some of the things that the African American communities are going through. And I am glad that I had the assistance of others to start a group such as the formerly incarcerated people. So we can educate the educated. Meaning that we can talk to the psychiatrists and show them how they can help us. How we can work together. This is what's needed. This is what I think that once it begins to happen, you will see a major change inside our communities. These are the things that, you know, that we got to bring back. We got to bring back to our city, to our communities. And recognize that if we're gonna help, if we're gonna be part of the system that cares, we got to address these things amongst the people that is most affected. Thank you. Go ahead, Justine. So I have believed from the beginning that we need to have people with lived experience on all of our committees. Because so often we tell them what we think they need and we don't ask them, what do you need? So when we put our seminars together, our conferences, we always have somebody up there saying, this is what worked for us and not what we thought worked for us. Remember what the most impactful was, we had three juveniles who went through the system. We had to get up and tell this audience what was good, what was bad, and what worked for them. And it was such an eye-opener for the professionals in the audience. So I absolutely echo what you're saying. We have to listen to what they need and what they want to really be effective. So we have about 10 minutes to gather some questions from the audience before we roll into some breakout sessions. So I'd like to invite anybody who would like to ask a question, please direct it to a panelist or if it's for the whole panel, please just let me know. And state your name, please. Hi, my name's Ralph Aquilla, I'm a psychiatrist. I just wanted to share real quickly that before I left New York City, I'm now in Philly, we got a grant from the city of New York and together with Fountain House, we're able to bring 10 people from Rikers Island directly, young men, all of color. And the key was really, it wasn't my cycle farm by any stretch of the imagination. So I agree with you about putting down a prescription pad. It was about the community. And for the first time for many of these young men, they felt part of a community, they were respected. And I could share with you that seven of the 10 are still working, still living in their own independent apartment. Three are, they didn't go back to jail, but they're not with us anymore. And I thank you, Mr. Tatum, for everything you said because you're spot on and peers were the bottom line and the essential piece of this. But my question to you all is that it's really to all of you, at least from my experience, community is really the key factor in the beginning of really moving forward with this. If I, yes. It's, you know, it's an important factor. And in order for us to move forward, as you speak about, again, you know, we have to work together. We have to understand that, you know, in order, we got to put down our original teachings and integrate with those, you know, and be willing to learn from each other. And this is the only way I think, you know, again, I can echo, you know, what has already been said about if we're going to help, if we're going to move forward. And if you, I'm only assuming that this conference was put together and you guys came down here looking for a reason or looking for ways to better what you was doing. And if I'm, was there any help in, you know, addressing some of the things that you can't go back and look into, then I say thank you. Anyone else want to comment on that question? I was just going to totally agree. And I think one thing I think we kind of as fields can miss and, you know, I think we understand that community is important, obviously. But I don't think we really kind of like understand how important it is and how community building itself is a really powerful psychiatric intervention that other things really can't compare to. I mean, just having a place to belong, like period, changes people's lives. And I say, you know, for the folks who work with, I think, you know, involving family, when the family's available and wants to be there in support of involving clergy, involving preachers, like creating that community so that if something's going on, you have that, you know, you can sign a release, you can do everything transparently. But so that there's an open dialogue and an open conversation so that this person that we all care about is having a tough time. There's a dialogue here so that we know we can actually communicate about this stuff and, like, figure out what's happening before things, you know, go to places maybe they've gone before. And so I think that's also, I just want to say, like, you know, we, it's not just so you're just there working with that patient who may need an injection, right? Like you said, put the prescription down, talk to people, get to know them, get to know their families, get to know people that are involved in their lives, have them come in if they feel comfortable with it, right? It doesn't work for everybody. And if you've got that and you have that, to me, that's the hugest asset of treatment, that there's some sort of connection with someone in their family, someone in the community. If there's, like, a religious leader, somebody, when I get those folks involved, things go so much faster. I'm going to go to the back night for the next question. Hi, I'm Rennie. I'm a psychiatry resident. Can you talk about the use of and consequences psychologically of solitary confinement during and after incarceration? Who would like to take the solitary confinement on? Could you ask about the implications of solitary confinement before and after incarceration? I think it's the worst thing you could possibly do. If you're in a psychotic state, if you're in a breakdown, and then you put in a vacillation, I'm not a psychiatrist, I'm just a judge, but I think it's the worst thing you can do. Solitary confinement... I don't think you can do it nowhere in prison, but in prison, I could be wrong. You can always isolate yourself from things, but I don't think it's... I don't think it's good. I really don't. I don't think that, you know, solitary confinement could be addressed. It's a deep, deep thing that one goes through, right? And it gives you many avenues, many avenues to think about a lot of things, you know? So, solitary confinement is a place where you want to be isolated from, you know, the main populations. So, when you speak of solitary confinement, the only thing that comes to my mind is being put off from people. So, it gives you a lot of time to think and time to investigate and research a lot, and if you have the material available. And I don't know, personally, if I've ever seen any research that has ever shown mental health benefits to solitary confinement like so. I think that's, you know, not true. I concur that it's terrible, and I would say that it's especially an issue for us, for, like, our patients when they end up in correctional facilities, for people with mental health issues, especially if they're suicidal. They're gonna be placed in safety cells that are essentially solitary confinement, and it's just kind of like a downward spiral. And a lot of this is because our jails aren't equipped. They're not hospitals, and they're not even remotely like hospitals. So, I can't tell you how many times I've gone in to check in on someone, and they're like, oh, this is where we put the violent folks. This is where we put the folks that need higher security, right? And all you have is someone who's completely psychotic, right, and playing, and, like, the cell's a mess. There's feces on the floor. Who knows how many days they've been sitting there, right? And the reason that happens is because nobody there knows what the heck to do. Nobody knows what to do. And so, what we need to do is, I mean, like, let's just face it. Our jails are sort of like hospitals now, right? And if you're gonna throw people in these places, you better be able to really take care of them, and I think that's something we need to do. I think maybe that's something we need to do as doctors more is say, hey, we really need to, anyway, it's happening more and more, but, and I don't think correctional facilities are all the place to provide treatment, but the fact is the folks that come into those places need treatment, and they're just not equipped to do it. It's not at all. Thank you for your question. We'll come to the front mic. Excuse me. I'm Bennett Cohen, psychiatrist in New York. So, I have, I guess what we would call here a case. I just want practical advice from anyone on the panel. So, I have a, I'm gonna change a few things, 60-year-old guy with classic schizophrenia. He believes a chip was implanted in his head, and because of that, he's calling 911 like 100 or 200 or 300 times a month. So the DA and the local police are upset because it is messing up their crime stats. So they are mandating him to like four months of substance abuse treatment, which is totally irrelevant. So we are not usually dealing with this. So what should I do? Can I appeal, should I appeal directly to the judge or his lawyer is not that helpful? Would it be outrageous for me as a psychiatrist who's treating this guy to contact the judge directly? Just looking for practical advice. Thank you. What sort of setting are you treating him in? I don't want to say too much on proxy issues, but it's an inpatient 21 day rehab facility. Is he under court order? Yes, yes, he's mandated. There's a court order that exists saying he has to go to this three month rehab facility, which no one who's worked with him thinks would be helpful. You could write a letter to the judge, but you would always copy everybody involved. So there's not what they call ex-partying, but I think you could do that and then try to reach the judge and say, this is totally inappropriate care. Here's why. Copy everybody. If you have a defense attorney, insist he send it. If he won't send it, send it yourself, but copy everybody to get around the ethnic issues. Yeah, that transparency thing is to make sure everybody can see everything that's going on is so important. It just still takes trust. When it's not there, it doesn't mean anything bad's happening. How do you know? Oh, okay. For the patient himself, I mean, for his care, obviously I don't know a ton about it, but I mean, it just sounds to me kind of like why assertive community treatment exists. Like, it sounds very much like an act case. Sounds good. Thank you. Thank you so much for your question. Back mic, please. Hi, I'm Anna Turner from Jacksonville, Florida, and I just want to say thank you for mentioning to reach out to judges and get them involved. We were able to implement Judge O'Leifman's program in Jacksonville, and it's changed my patient's lives. It's changed my own life. I love working on it. And just a shameless plug, we'll talk about it Wednesday at 1.30 if you want to come hear about it. But I guess my question is for Zach or anyone on the panel, because you had mentioned medication-assisted treatment. So in our, and I think that buprenorphine, the opioid epidemic is a real thing, and I love that we treat it like a health problem. But unfortunately, in the 80s, we didn't treat crack the same way, and we arrested all these poor people. And now, the majority of my patients that I have trouble with treating medication-wise are addicted to crack, and I can't get them resources. So I'm just wondering, do you have any other advice or recommendations for them? I mean, I'm totally with you. I practice in the San Francisco Bay Area now, and most of my panel has methamphetamine use disorder. I mean, just from what I've heard, at San Francisco General Hospital last year, 74% of psychiatric emergency visits were related to meth use. It's really terrible. And the persistent psychosis that can come from it is very difficult to treat. I really wish I had answers. I mean, there kind of is an answer, which is contingency management, which is unfortunately essentially illegal, based on just kind of antiquated anti-kickback statutes. You can't kind of pay people enough with the variable rewards they have. Medicaid, because it counts as a kickback. So, yeah, I don't know. I would do anything for kind of like a buprenorphine for stimulants, but. We've got meth is everywhere, like in the Bay Area. That's like what we've seen primarily. More than opioids, I'd say. Folks that we work with. Oh, it's an opioid group, I think you're catching up. But I think for folks that are willing to take it, folks that, because I get patients that come in and they're like, yeah, I get psychotic when I take meth, and I have a tough time not doing it, but they relapse, they have slips. And so some of those folks might come on a low dose or something because they have some persistent psychosis and things like that. But really, that's why I say, again, hopefully just try and find a connection this person has in the community. Find what resources they have. Who cares about them? Find who cares about them. And again, you gotta be careful about it, because not all family relationships are healthy. Not everything can go bad, but if there are any sort of relationships that seem healthy and available, use them, find them, and that's, and for some of my folks with the substance issues, that's what I've found, is just knowing that there are folks that love them, that care about them, that are gonna listen to them and aren't gonna leave them if they mess up, right? They just have a slip or mess up, right? And so again, with a lot of folks that are dealing with meth, if and when you can do that, that's what we deal with. We can't do that and just try and open up another care, have a connection, and we're there for them. But yeah, it's really tough coping with meth. That, I mean, just sort of how we go about dealing with that and what we have to answer. Again, working with peer support specialists and building community with people. I mean, there was a small study in California of 34 women formerly incarcerated. It wasn't looking at meth or stimulant use, but just looking at the kind of community support that was especially helpful for them. They looked at family, friends, and other, including peer support specialists, people they didn't really have a defined relationship with before, and they actually found that they had the highest life satisfaction associated with the other category, like the peer support workers. So I think, yeah, again, it's like a very underutilized intervention. Nice, thank you for your question. First, Mike up here. I have sort of a lengthy question, so bear with me. And first, just to lay out my bona fides and all this, my first medical school rotation was in Hultberg State Prison outside of Philadelphia. I worked in a women's medium security prison, Cambridge Springs, Pennsylvania. I just covered for a colleague last week at the Erie County Jail, doing suicide assessments with individuals there. I worked at state hospitals. And getting back to the beginning of this, I've often given this a lot of thought that when we deinstitutionalized the state hospitals, one of the things we didn't look at, and we were over-optimistic as a profession, we should have taken some responsibility for this, that we thought Thorazine was gonna fix everything. We thought we'd put everybody on meds, everybody stay well, they stay in the community, and nothing bad would happen. We were quickly disabused of that notion. So in looking at the situations that exist, I don't know if you can ever make a prison a therapeutic environment. I'm hopeless about that. I don't think it's gonna ever happen. We try and make it less abusive, but I don't think we're ever gonna make it therapeutic. On the state hospital side, they still exist, but they deal with civil law. So you're dealing with people who are civilly committed. I imagine a third way. Is there a third way to construct a facility where you divert people who we all obviously know don't belong in jail? They are there because they are problems to the community, and they have a lot of mental illness, bipolar disorder, schizophrenic patients, people with substance abuse issues. Is there a third way to construct a facility where you take the controls of some of the things we have in the incarceration system, the justice system, and combine it with a therapeutic environment that is really therapeutic, but is not jail, build in drug treatment, build in appropriate mental health treatment, and offer this as a diversion for those individuals who don't meet the civil commitment standards, but they're still a problem for society. They are disruptive. That is why they get in trouble with the legal system. And then we put them in a system that is ill-designed to address their underlying needs. And we fail. I mean, obviously, we're failing miserably. We're spending enormous amounts of money. We're failing by almost any measure you look at. We're not gonna put them back in the state hospitals because then you're back to the same problem of civil commitment issues. Is there really an initiative to at least pilot something to start a third way and say, look, why don't we spend our money, enormous amounts of money, we spend a little bit more intelligently, and let's give a third way a crack and see what happens. I have often wondered about that because when people were living in the state hospitals in the 50s, some of them were okay, some of them were good, some of them were terrible. A lot of them were terrible. Yeah, a lot of them were terrible. But when they got out, statistically, they were dying. I mean, in the 50s and 60s, they were dying 10, 15, 20 years sooner than people that were in the institutions. So making, some people just cannot survive on the outside. I think we have to admit that there is a small subset that just can't, they won't take their meds, they won't decompensate, whatever the reasons. And so we're trying a lot with our group homes. We're trying to use the group homes as sort of, not without the teeth of the court system, but a way to sort of give them a group setting. We've dramatically increased our funding for our group homes. We're trying to get some more training for the operators because they're kind of like the in-between where they can't make a community on their own. They don't have the family support. It's not quite the institutionalization. And then we're also doing a lot with outpatient commitment treatment to not make the hospitals the restoration center for people that don't need that level of care. We keep them in six months, we don't restore them, we let them go with no support because they've done their time. We keep them in, we can't restore them, let them go with no support, they cycle back. So we're trying to use outpatient to get them into those settings that can give that support. So there's some real efforts and there's some private psychiatric hospitals in Ohio that are trying to do sort of a step-down environment for those that, you know, face it, there's some that just aren't gonna make it in their community for various reasons. And those that can, we try to give them those outside supports. The closest thing I can think of of what you're talking about, just like in San Jose, we have some supportive housing options where folks have their own apartment, right? Sometimes they have a room in, but they have their own apartment. But there's case managers, there's doctors there, there's primary care doctors that are coming in, there's folks from different programs. So it's sort of like a community where there might be like 100 people living, right? Then you got all these other resources around. These places are far from perfect. They don't always, but there's a lot of good folks doing good work there. But I think that could be a pathway. And I think if that's something I've really invested in, that could be really helpful. Since the people I work with, housing is everything. It's just being on the street, it's just, that'll make you sick, period. Yes, and I think one of the things that need to be done to advocate more, you know, decarceration, right? Because if we can understand that the carceral environment's not fit or suited for, you know, for mental health patients, then we can also understand that, you know, we got to study why they're not taking this medicine, why they're not doing this, or why they're not doing that. Because if we, it's like the chicken and the egg thing. What's come first, you know, the mental health problem or the substance abuse problem, you know? So when, if you're dealing with people with mental health problems, should be in a facility where they can more, be more, you know, ready or willing to accept it, you know, the treatment that they're getting. Because when you're trying to do it inside a carceral environment, you got too many disruptive, you know, factors, you know, because the carceral environment's meant for punitive and stuff of that nature. Whereas, you know, if something come about, I was speaking to Zach about this, because he, you know, he goes inside prisons and it's come second nature, you know, prison rules first. Everything that's, you know, inside that carceral environment take place on more of a punitive nature rather than, you know, medical terms and helping people with mental health issues. So I think that, you know, what we can do, or what you can do rather as a psychiatric association, you know, advocate more decarceration and more help for people with mental health facilities. Thank you. Thank you for your question. Back mic, please. Okay. Thank you. Hi, my name is Nancy Chinoy. I'm a psychiatry resident at Baylor in Houston. So much like you mentioned some of the other prisons, Harris County has like a jail unit that essentially has the largest contingent of psychiatric patients anywhere in the city, which is a bit of a problem. But our city has a crisis intervention training that the police have really responded well to that's decreased the number of people who end up in the prison system who perhaps shouldn't really be there, should be in the hospital. What kind of conversational tips do you have from our end in psychiatry regarding our interaction with law enforcement and in areas or in cities where there is good communication between police and law enforcement in psychiatry, how do we take that to the next level with judges and with, I guess, people who have more sort of legislative power? So when I started realizing that I needed to try to do something about this mental health issue, like I said, we had two mental health courts and we had 100 trained CIT officers. I made it my mission, when you campaign for state office, you go to 88 counties and you have hundreds of speeches and I just made every speech I gave about CIT and mental health courts. And so as I said before, we have 285 specialized dockets now but we went from 100 CIT officers, it took 15, 20 years to get there, we have over 7,000 trained every single county and we have over 3,000 support like the dispatchers, EMTs, hospital personnel, library personnel, library personnel, we have a lot of persons with mental illness, and every one of those then becomes involved in community instead of being isolated and they're trained to try to take them to diversion instead of to jail but we've also become a victim of our own success because we don't have enough crisis centers for them to drop off. So now we've started a huge movement in Ohio to have crisis centers where an officer, instead of going to an emergency room, I can't wait four hours, I got a call coming in, take them to jail, we now are trying to develop a whole system, the state of the mental health department is very involved in it, the foundation that I work with on stepping up is very involved, so that we have these crisis drop-off centers 24-7 in the office here, it's like Arizona, if there's anyone from Arizona, they're my model, you drop them off, eight minutes, fill out the paperwork, you're gone. They triage it, do they need to be detoxed, do they need to go across the street to the hospital because they're really sick, can they just have a couple hours and get the family involved and get back on medication, and so that's a real solution to back up CIT, we get a lot of CIT officers, we have them, but now they need to have some place to take these people, and so getting the courts involved is huge because I saw that if we're doing good just through the health courts, we needed the CIT partners and we've trained them to understand these issues. So again, getting our department of mental health funded, our CIT, our NAMI office put a lot of grants out so that small communities that couldn't afford to send an officer for a 40-hour training because they don't have two officers, give them a grant to hire somebody to cover when they go to the training, we've got some two-day trainings, different versions to help, and lots of advanced CIT courses now, so we've really pushed that as a partnership with the courts to make a difference. And I'll say this as a resident, reach out to judges, they love hearing from you. A lot of them love hearing from you. They love talking to mental health professionals because they're looking for other folks who want to help, and so I'm telling you, email a few judges that you think might be interested, you're gonna hear from probably all of them. All right, and I'll tell you, I'm not a huge fan of the system work, I'm not a big fan of the judges I work with because they have power, they have heart meds in the right place, there's lots of things you can do. So I think, you know, just reach out to people and I guarantee you'll get, if you're a psychiatrist and a failure, is that right? They're gonna be excited to hear from you. Thank you so much for your question. I just want to make sure we're, we're kind of running low on time here, we do want to get some information from the crowd, so I'm gonna take the people who are standing up here for questions, I want to make sure I get to them. Front mic here. Julie Ridge, New York City, first placement in grad school was one of the three largest psychiatric centers in the world, Rikers Island. I just wanted to quickly respond to the gentleman about solitary confinement. If you haven't heard these two words, look them up. Kalief, K-A-L-I-E-F, Browder, B-R-O-W-D-E-R. I think he, and it's his anniversary coming up, but his suicide is one of the saddest stories and worst commentaries on solitary confinement. This one, two parts, very quick. I don't know the exact stats, but I think that without housing, when you're decarcerated, recidivism is well over 50%. We have laws on background checks that are in place for at least 10 years, and then you have to work very, very hard to get that off your record so they can't look at it unless they look deep, deep, deep. So two parts, Mr. Thelen, how hard was it for you to find housing? And the second part is a legislative, you represent two states. We're campaigning in New York, Fair Chance for Housing, to get rid of the background checks, and nobody wants ex-felons living with them, but they don't realize that one in 10 people in New York is an ex-felon, so they're already living with us, but housing. You know, fortunate for me, you know, I didn't have a problem with housing, but I'm very familiar with discrimination, housing of formerly incarcerated people. What I would say is that, you know, they also got something on the books where they're supposed to overlook that, but of course they don't. Yeah. So I would think that you attack, you know, the housing authorities in your community, and you address these matters that, you know, whether you, when you're locked up, you know, 80% of the people that's locked up coming home one day, and when they come home, they need somewhere to go and places to stay. This is something that needs to be addressed on a manner of, you know, with legislators and other people that has a say in a lot of things. So all I would say is, you know, address the, you know, the housing authorities and the legislators in your community. I'm glad you have a home. When you combine housing with mental illness, it gets even worse. So what, we did three things. One is, I don't know if you know about ASH vouchers, Veterans Assistance Supportive Housing. They are not allowed to look at their criminal background for ASH vouchers, so that's a powerful tool. Secondly, we started two programs. One is the Landlord Mitigation Fund, and the Landlord Incentive Fund. Landlords get an incentive bonus if they rent to somebody with mental illness and come out of jail or prison, and the Mitigation Fund will cover things like theft or damage or they go off the fence or they skip. Instead of returning something to an insurance policy, they can recover from the Landlord Mitigation Fund. These are tools to try to encourage the landlords to rent as well. Housing is a huge thing. When you do the sequential intercept, or no, when you do the, yes, sequential intercept mapping, housing is always one of the top two needs. Not treatment. Housing and crisis centers, they don't have to come up with the top two needs. It's interesting, not treatment. And if you don't have housing from the beginning, I started doing this, I said, if you don't have a house, you're nowhere. So that's a huge effort. I could talk for hours on that. Thank you so much. Back, or Michael? Okay. Go ahead. Thank you. My name is Michael Champion. I'm a psychiatrist practicing in Honolulu, Hawaii. And I wanted just to make a comment, but then wrap that into a question for Mr. Tatum. And let me just prelude that by saying I'm interested in your suggestions about how to use peer support in the prisons and jails, and how psychiatrists can best nexus with that to support it. But let me say first that the lens that I put to this is having worked now at this criminal justice mental health interface for about 30 years. First job was in a prison as a mental health worker back in 88, and have done a stint for about four years as the sole psychiatrist working in a supermax facility with hundreds of men who are in solitary confinement long-term. I'm really glad that in this presentation that the issue of post-incarceration syndrome has been highlighted, because when we work in the sequential intercept model and building off-ramps upstream, and we focus on people with serious mental illness, one thing where we tend to, I think, overlook and not pay attention to is those folks who enter the justice system without a serious mental illness and emerge with serious consequences that need to be dealt with. So the incidence of trauma is extremely high for people coming into the corrections environment and also when they emerge from it. So it's important to emphasize trauma-informed approaches. And there certainly are groups, like the Prison Compassion Project or Human Kindness Foundation, that are really trying to shine light and attention to that. So this is extremely important. Now, working as a psychiatrist or a mental health worker in a carceral setting, it's extremely important to connect with the ability to use peer support. And this is something I've found in my career is not typically very popular with administration to support and build. So with all that said, I really appreciate your thoughts about how to build peer support in a carceral environment and how psychiatrists can participate in supporting that and partner together. Well, I think that peer support allows a group of people that's with lived experience to come together and talk about some of the challenges that they're facing or about to face if they're already incarcerated. If you're no longer incarcerated, I think peer support is a good tool that's needed to be established in each and every community because it gives people, again, with lived experience an opportunity to come together, talk about some of the challenging things that they're facing. Like such as with the group that I'm associated with, we got a curriculum that we use in order for to prepare you for when you're coming home and the challenge that you most likely will be facing. And to have this inside of an institution could be very, very instrumental in the recidivism rate and very instrumental in the transitional part of coming through our society. It also can be used to educate family members and friends about things that they can do to facilitate those that's coming home. I think what we are trying to do, what we've been trying to do, is get inside the carceral facilities to be able to prepare guys coming home. But the one thing I want to address is that in most re-entry programs, it gets you prepared for jobs. And some even address housings and things like that. But no one, no one addressed the mental impact that prison have on people coming home. And they're associated with slavery as well. When the Emancipation Proclamation came about, and everybody was, and we were so-called free, no one sit back and say, let's give these people some mental health evaluation, address some of the things that they went through, all the trauma that they experienced, all the trauma that they've seen. So I know guys that have been locked up 20, 30, 40, 50 years that's coming home. The peer support group is a very effective tool for these people, because it's allowed them to be amongst their peers, allowed them to talk about things that they would no longer, they wouldn't talk, not even with psychiatrists. This is why we invite the psychiatrists to come to our meetings. So they can share things, or see things, or be educated about certain things, and they can be able to address their patients if they have any patient that's in prison. I'm a big supporter in all of our groups of peer supports, but I also want to mention non-peace families to families. Families need support to understand what's happening, to feel not alone, to have tools. And we really push that with a lot of families to families programs, where other families teach the courses who've been through the experience. And that peer support for families to then support the person with the mental illness is so vital. So I just want to make sure everybody really keeps that front and center, and we don't have that in your community. Yes, family support, it takes the temperature down on everything, because if the family's involved, again, there's all of this. People coming out of jail, any family you're going to have issues, you're going to need dynamics. And if things aren't quite right, or people aren't talking, there's not communication, it's just going to make things worse. When people know their family's involved and they're caring, I'm telling you, it can make such a big deal. Because I'll just tell them both, I was going to say, if people have supportive families and you feel like it's going to be a safe way to point of contact, involve the families whenever you can. I mean, I think it's such a good question about how to logistically implement this stuff in a correctional facility. And it kind of speaks to how different it is to work in one versus a hospital. We aren't in charge. The doctor doesn't have the last say in anything. You have to often go with the guard to see a patient. And I don't have a great answer for it, but I was curious, because I know that you were doing a group in Angola before you got out. So I was curious about how the groups got started there that were peer-led. Yes, there was a self-help program that was established in prison. And what it dealt with, most of it was substance abuse issues. But through those classes, we learned that. Even people that use drugs, sometimes it start off under peer pressure, where you smoke a weed because your friend's doing it. But what keeps you on that? It's like a dog that's lagging his tongue. When he's happy, he lags his tongue. When he's sad, he lags his tongue. So if I'm getting prepared to go to a concert, something like I'm supposed to uplift my spirit, why would I need drugs to do it? So I think that these are the things that need to be talked about. And this is what we talked about in prison, is how the peer support group became what's brought about and thought about while I was in prison. They bring this type of organization to the group. Did the administration know about it? Yes, yes. It was a self-help program. Not that they were so much supportive, but they allowed you to do it. Got it. Thank you. We have a very unique program in one of our prisons, our Belmont prison, peer supports for veterans. We have the young kids that are coming in that are going to maybe get out in one, or two, or three years. We got an army to agree if they go through sort of a boot camp type experience in prison and get rehab, they can go back. The military will take them back. And so they organized a pause. And they used the older vets in the prison who are not going to be getting out soon as peer mentor supports for the younger vets that have come in. It's a very unique program, but very successful. And Colonel Moe, who was in Hanoi, Hilton, when he was in the military, severely tortured and murdered, gave a speech when we opened that program, talking about how it was when he was in prison and tortured. And I tell you, it was one of the most moving speeches I've ever heard from someone who's been incarcerated in a different environment to those young kids. Thank you so much for that question. I did have two more questions that were left. And I was going to rework our breakout session. So sir, before you ask your question, I'm going to ask you a question. What are the barriers to getting psychiatrists involved with the criminal justice system? The other gentleman behind you left and snuck out. I think he got scared because the questions came on the screen. So you are going to be our breakout answerer today. Putting you on the spot, hot seat. I think a problem of communication between two different systems. Because psychiatrists, I mean, I think also about the Italian situation, because I'm Italian. But also about what I've been saying today. Psychiatrists and mental health professionals are not used to talk with the criminal justice system and use different languages. And this could be the same for the other part. So the first important thing is to get in touch together and to discuss clinical cases. Great. And now you can ask your question to the panel now that you've passed that. And I'll come back to your comment as well. OK. Yeah. Thank you for the debate today. I'm Jacopo Santamroggio from Milan, Italy. And what you said has made me pose this question. But also, I would like to share this thing. Because in Italy in 2010, there have been a politician commission about the closure of the six big forensic institutions that take care about 1,200 people with mental illness and forensic issues. Because these big institutions have been evaluated not appropriately good for the standard of care. And then 30 smaller residences, called the REMS, Residency for the Application of Safety Measures, have been applied in all the country. But the problem that I would like to share with you is that the criminal system is responding to the needs of beds. Because these 30 REMS are not enough to provide the assistance, the therapeutic assistance for persons with mental illness and forensic issues. And so around 400 people have been recovered in the general hospital, psychiatric wards, but also in the prisons. And so we have these big issues in Italy in this period. Was the question around psychiatric beds and the use of psychiatric beds and how? I'm a little confused by the question. Yeah, it was just to share. OK, OK. Actually, the EPA will be releasing, hopefully in July, the psychiatric bed study from Dr. Jeffrey Keller from his presidency. It should be released to the public in late July, is what we're being told. So there actually will be a study from the EPA around psychiatric bed uses in the United States. Obviously, it's United States based, not for you in Italy. But it might be a good resource when that comes out in July. Thank you. And if you want to jump up to the mic, that'd be great. Hi, I'm Eileen McGee from Ohio. And I'm a member of the Assembly. I wanted to answer that question that was on your list. I think the answer is that lack of exposure and fear of the unknown. And the Assembly is currently addressing this in terms of trying to push for residency training to require an exposure to the corrections system in some form. And so we're working on that. I also want to share an anecdote as another way to stop. My husband is an attorney. And he had a client who had multiple incarcerations, short-term local county stuff mostly, had serious mental illness. And he would be fine while he took his meds. And he'd stop taking his meds and instead go smoke weed. And then he would do disruptive things. And sometimes, he wound up in the local hospital. And sometimes, he wound up in the local jail. Well, one time, he wound up in the local jail. And it had just been refinished. And it was beautiful. And it was absolutely gorgeous. And he decided that he was going to act out. And he stuffed stuff into the toilet and backed up the toilet. And it actually spread over to the judge's beautiful new headquarters, the judge's office, and ruined a lot of stuff. So the judge called my husband up. And he said, we want you to stop being this person's lawyer and become his guardian. And we're going to transfer you over to the probate court because we want you to consent to the use of a long-acting injectable because the patient himself would not. It's been over 10 years, maybe even over 15 years, since my husband has been this man's guardian. He's had zero arrests. He's had stable housing. He's been to the hospital for a short stay once. And that was because he got the check everybody got when COVID started. He somehow accidentally got direct access to that check. My husband, as his guardian, is both financial and person. And because my husband wasn't controlling his money, it was like, wow. And he went out and spent the whole check on weed. And he got sick. So that's another mechanism is to use guardianship. Thank you so much. Hi, my name is Christian Grekel. I'm a psychiatrist in Eureka, California. And I wanted to piggyback on what my colleague just said. I think exposure during training is important. I primarily see myself as an outpatient psychiatrist. But when I moved to Eureka last year, I was just interested in doing something different. I had sort of lost faith in some of the medications in outpatient psychiatry. So I just wanted to do something radically different on a part-time basis. So I have to say, working at the Eureka County Jail or Humboldt County Jail has been by far the most gratifying experience in my career now 13 years in. And I just think that it was sort of a, it was just something I wanted to do that was different. But I feel like if other psychiatrists here, maybe folks like me, having had these profoundly good experiences working with a very sick population, perhaps more will try that themselves. I've been profoundly grateful that I tried to do that. We did the grand rounds the first time when I was on the Supreme Court. And we would take all the students down to a mountaintop court and sit in the back with the judge when they did those sessions. And then sit in the front and watch the hearings. We wanted to have some internships going through the jails, but we felt that cost money. And we didn't quite have the ability to raise it. So now that we're doing the grand rounds, we're encouraging them to do that. But I think getting those kids down there and exposed really will be key and important to see it for themselves rather than just to hear it in a lecture. I also think, do I get more people working in my settings? I pay them more if I can do this than I do. But I think that's a big limiting factor for folks coming out of residency, medical school. They got loans. They're starting their families. And then they go to do this work, which is really hard. And it's not always valued. And so I think, I don't know what to do about that. But I'm going to keep doing it anyway. I just need aids, I believe. I need a lot of aids. Can you make a 30-second comment? 30-second comment. I actually had a very quick question about the previous slide, the Judges and Psychiatrists Leadership Initiative. Is that opportunity open to residents? Let's talk. Cool. Let's talk. Well, thank you for letting us know that. I will have to reach out to our partners at CSG to get that fixed very quickly, as we are hoping to get people signed up. I do just want to make a quick note here. An invitation to attend Doctors, Judges, Legislators, Formerly Incarcerated Transitions Clinic, second and fourth Tuesday of the month, 6 to 8 PM Central. Currently virtually via Zoom. And there will be a sign up and back with Joy. So that is to join Thad and the group here that he is doing. So we all said exposure, getting involved, learning from others. This is your opportunity to do that as a psychiatrist or a mental health professional here today. Sir, you had a question? No, I have a comment. Timothy Summers, I'm from Mississippi. Listening to all of the comments and et cetera, it sounds like you're not working with the same prison systems that I've worked with. The prisons, they're businesses. So all the stuff about having groups come in and all that stuff, it really doesn't work like that. So I was having a discussion with a young lady the other day who's interested in working in prisons. And I shared with her an experience that I had once when my goal and intent was to go into the prison business because it was such a lucrative business. And the first thing I did was to attend an annual meeting of the American Corrections Association. And I went there. And I went there not only looking at opportunities to make money, but also to find out how to rehabilitate people who were incarcerated. And so when I went to this meeting, I was making comments and saying things about rehabilitating prisoners. And everybody would look at me whenever I would talk about rehabilitation. They're going like, who is this guy? Where did he come from? So I was going to go to a lecture that was a presentation by the attorney general for the state of Texas. And the title of his speech was, How to Increase Your Inmate Population. Now, think about that now. How to increase your inmate population. So I mean, that's not the same thing as what psychiatrists do in that system and so forth. So again, as we approach these problems, let's remember now, basically, the prison systems are existing the way they are structured to make money. It's a money-making deal. And it's a very lucrative business. And it must have been 30,000. Do we have a private-owned system in Mississippi? Well, we have both private and public. We don't find that with our public systems. That's not their goal. But our private ones, it is. Yeah, well, I'm saying, I know, irrespective of what you might say, I know that's the way it is. And unless we address the politics of the economics of prisons, we're not going to be as effective as we ordinarily would be able to be. I think that's an excellent point. And I think that also applies to solitary confinement. Because prisons, and security is going to rule. They're not always going to do things the way they want to do. And we can have all our ideas about what we think would be better for them. They're always going to do what they feel is going to keep them safe. It's going to make their lives easier. And so what I think we need to do as mental health professionals is have more conversations around solitary to find out, OK, why? Why? Because there are certain gang leaders, there are certain folks that you want to isolate. Like, what's going on? How can we do this more effectively? Because if we just sort of wag our fingers, they're not even listening to us. So thank you, everybody, for your time here today. If you are interested in getting involved with the Judges Psychiatrist Leadership Initiative, we are looking for trainers. We're looking for content experts. We're looking to expand our train of poolers. We will be doing a train the trainer session in the middle of September. We're targeting right now September 10th in DC. And we are looking for individuals who can dedicate one day to do a state day, one day every couple of months to do a statewide training for judges in their state or their region. So we are looking for people who have some time to dedicate and volunteer for us. So please take a picture of our contact information here on the screen. Feel free to drop by Joy. And if you do get a flyer, make sure you exchange that for your free guidebook. And thank you so much. Also, remember, please, if you would like to sign up for the peer support group with Thad and Zach, there is an Excel sheet in the back. Thank you. Can you go back to the side? Thank you.

psychiatrists

mental illness

criminal justice system

community involvement

recidivism

trauma

incarceration

case management

peer support workers

solitary confinement

opioid epidemic

transitioning from prison