Judge Milton Mack

If we can get people the kind of care they need in the community, not only can they get well, but you can save a lot of money. Like in Genesee County, they had a 70% reduction in hospitalization. And the individuals surrounding these outpatient treatment plans are complying with treatment, the level of 90%. And the satisfaction rate's like 92%.

Now, when I was serving as a judge and I'd order some of the central hospital, I don't think my satisfaction level was very high. The average individual didn't appreciate me sending them to a hospital.

But back in Genesee County, what happens is when they order outpatient treatment, a form is sent to the patient saying, a treatment team is going to guide your treatment, and you're on the treatment team. They do everything they can to engage the individual to participate in the planning of their own treatment plan.

And individuals in that situation feel like they're being listened to, and they respond. So I think it's a great opportunity to help people recover from mental illness, become productive citizens, substantially reduce hospitalization or emergency room costs, and substantially reduce incarceration.

All the stakeholders are in these meetings. We even had the Michigan Hospital Association. I suggested they be part of the diversion council. They were kind of curious why they were there. They didn't think they were part of the issue. I said, actually, you're a big part of the issue. If your system isn't working, nothing's working.

With the Diversion Council, we've been developing these statutory changes in 2016 and 18 and 19. So I've kind of expanded the notion of what diversion is. So in my view, diversion is a healthy mental health system that keeps people from involving themselves in the criminal justice system at all. It's a form of diversion, but it's rather expansive.

I mean, the Diversion Council in the beginning was focused on people who are in jail and what could we do for them. I want to focus on people before they end up in jail. You think about it, in Michigan, in an average year, between 150,000 and 200,000 people show up on hospital emergency rooms. On the other hand, mental health courts we have in Michigan, we have a lot. We have over 200 courts.

that do this sort of work. But only about 3% of the people who have a mental illness in our state jails are in a treatment court. The treatment courts are expensive and you can't scale them up. So if you really want to make a difference, go upstream. Help people stay well so they don't get in trouble with the law.

That's true. But we're having one of our bills to create a diversion process for those who are charged with liftometers. So currently in Michigan and most states, when you're charged with a crime, you have a mental illness, they send you to the forensic center for an evaluation. And they have to discern if you're competent to stand trial or not.

If you're not competent to stand trial, they have to make you competent to stand trial so they can convict you. Now, for misdemeanors, sending those individuals to the forensic center is an enormous waste of time, talent, money, resources, resources. Because at the end of the day, all you're going to get is a conviction for a misdemeanor, for an individual who's going to re-offend.

Well, when I became a probate judge, that's when I started hearing these mental health cases, and I had no familiarity with them at all. But it did take me long to say, I don't think this is working. I'm seeing the same people over and over and over again.

So, to be much smarter, so instead of sending this person to the forensic center, you send them in to assess the outpatient treatment and drop the criminal charges. Now, when we put together that legislation, we had the support of the Michigan Prosecutors Association, as well as the Defense Bar. We had the support of the disability rights people.

So they all saw this as a better option, because if we can take someone who's mentally ill, committing misdemeanors, and get them well, then we're not going to have to deal with them again in the criminal justice system.

So let's see if we go upstream and take care of people before they get in trouble with the criminal justice system, then you're just going to significantly reduce the impact at that level.

It's been very enlightening. It's been enlightening for stakeholders to find out how they are victims of a bad system. So, for example, hospital emergency rooms are crying for the fact that their emergency rooms are crowded with people with mental illness. And I point out, well, you know, if we take care of them properly, they won't be coming to your emergency rooms or law enforcement.

You know, one third of all the people in this country with a serious mental illness, their pathway to care was through law enforcement, which is kind of staggering. So people in law enforcement are on the front line. There's not a... police officer around who won't tell you that dealing with people with behavioral health issues is a big part of their job.

If we can take care of that at the mental health treatment level, we help them out. And we even help out community treatment because if you get people on there into treatment and into recovery, it puts less pressure on everybody all the way around.

This person's been hospitalized by every probate judge who's served since 1970, and with multiple hospitalizations, and it just seemed to me that things weren't working. We weren't accomplishing anything, that we were just in this revolving door. I started to agitate for change, you might say. This led to my being appointed to the Governor's Mental Health Commission in 2004.

Right. I think you spoke with Judge Steve Leifman, I believe, already. Yes. And he's a master at that. He's... And it's amazing what he's done. Florida is not a Medicaid expansion state, and they don't have a good civil system for mental health issues like we do in Michigan. So to that extent, Michigan really is in an advantageous position.

And theoretically, we should be doing better than what Judge Leifman is doing. Judge Leifman has got a head start on us. So we're still trying to catch up. But we're trying to, we're moving into, we're relying on crisis centers instead of hospitals. And if we provide outpatient treatment, crisis centers and so forth, and hospital emergency rooms are going to look a lot different.

It eliminates all kinds of risk, all kinds of danger. I mean, you're still going to have situations, but you can reduce a number. You can manage it better.

We don't wait to treat someone. We wouldn't wait to treat someone with cancer when they're stage four. We do just as much damage by waiting to treat mental illness. And you're not depriving people of their freedom when you're freeing them from the impact of mental illness, which is left untreated. And assisted outpatient treatment is the most humane treatment possible.

It's better than being treated in the hospital, far better than being treated in jail, and far better than homelessness. And we should do this, and it's good for everyone.

When I was appointed, the points I wanted to make were the mental health system was an inpatient model in an outpatient world. It was focused on hospitalization and preventing hospitalization, but not promoting that, not focused on getting people well. So I advocated a number of changes, which the commission adopted, but I really got nowhere. But I kept plugging along.

And then one day, Channel 7 came in and wanted to film a mental health case. Early in my career, I probably would not have done that. But I thought, you know, the public should see this. They should see what's going on. So I'm televised a mental health trial. That led to the investigative reporter coming in and saying, you want to do a series?

Filming cases, talking to the family members, talking to persons with mental illness and so forth. And the series was called Waiting for Disaster. I said, the way the mental health system works is you just imagine a train going down the tracks and the bridge is out. So we have two choices. We can dial up the engineer and say the bridge is out, stop the train.

Or we can park ambulances at the bottom of the ravine and pick up the dead and wounded. Well, that's how the mental health system is working. We wait for crisis, and then we intervene. Now, the 2004 Mental Health Commission report said We live in the recovery era where mental illness is treatable, recovery is possible.

People with mental illness can lead productive, satisfying lives if they get early treatment. But the system was not designed to permit early treatment. It was designed to wait till that magic moment just before someone actually killed themselves or killed someone else or did something terrible.

My effort has been trying to change the system. Ironically, I had thought I'd run into a brick wall with Michigan. And I've been a probate judge for 25 years, and the chief justice asked me to be state court administrator, so I agreed to do it. And when I became a state court administrator, this made me a member of the conference of state court administrators.

They drew a paper over here on a topic of some sort. So I volunteered to do a paper on the mental health system and how we can change the system so we intervene early, reduce hospitalization and incarceration, and improve people's lives. They actually chose the paper as the paper for that year that led to creation of a national task force.

In the meantime, all of a sudden, logjam broke loose in Lansing. I was able to get a series of bills passed in 2016 and 2018 that changed the way the process works in Michigan. We're seeing real differences now. Are there other things that you do as well? One of the things I do is I do CIT training for law enforcement.

And I tell them about the new mental health code in Michigan, how it's now an inpatient, it's now an outpatient model in an outpatient world. And when I say that, It's because over 90% of all the treatment for mental illness is on an outpatient basis. So the system should reflect that. We should find a way to help people get help when they need it.

If you go back to 1963, the Community Mental Health Act, that bill was designed to do two things. Significantly reduce the number of people in hospital and provide an outpatient system of care as an alternative. The outpatient treatment system didn't happen. So what happened? We got 2 million people in America with serious mental illness in jail every year.

We have well over 300,000 in our state prison system with serious mental illness because they're left untreated. People think that guardianship is for adults. No. Over half of our guardianships are for people with serious mental illness who never got the treatment they needed when it would have made a difference.

So my objection has been to create a system where we intervene early and avoid the use of hospitals as well as jails and prisons. Because hospitals really are not therapeutic environments, number one. Well, they're more than jails and prisons, but they're designed to stabilize someone. not to get them into recovery, not to get them well, but stable.

So just for example, in Wayne County, which is where Detroit's located, we did a study. Over a five-year period, we had 15,000 petitions for mental health treatment for 9,000 individuals. 600 of those 9,000 people accounted for 36% of all the petitions filed. There was less than 1% of the population, but 36% of the petitions filed.

And they are what we call the front of the faces that rotate in and out of the system constantly. We looked at the top users of the system. We had 79 people who had at least 10 petitions in the previous five years. Those individuals in the prior fiscal year, we spent $3.3 million on hospitalization, $1.6 million on incarceration, a total of $4.9 million. And for that $4.9 million, we got nothing.

One individual had 46 visits to the ER. So at what point in time do we say, this is not working, clearly not working?

We don't wait until someone's dangerous to solve for others. We want to know, do you have a mental illness? Do you understand your need for treatment? Are you faced with decompensation, deterioration? And does this create a risk of harm? The harm doesn't have to be immediate. So, for example, we had a case in Michigan.

At the trial, the mental health trial, the doctor testified that the individual was not presently at risk of harm. However, he had a history of stopping taking his medicine. And the doctor testified that he could be expected to stop taking his medicine in three to six months, and he would then be at risk of harm, harm in the form of drug abuse, suicide, increased risk of dementia, and so forth.

And the Court of Appeal said, yeah, that's good enough. We're kind of looking at the total circumstances to get somebody into treatment. What we've done in Michigan is we actually have a system of mediation for mental health cases, which I think is kind of unique. Works best for petitions where you ask for outpatient treatment only.

So we have a system in Michigan now where you can file a petition with the probate court, don't go to the hospital, don't go to the police department. The person, let me put it this way, When I'm hearing cases in probate court, and I'd ask family members, when did he stop taking his medication? And they say, six months ago, eight months ago. We all know where this is going.

We're just waiting for the magic moment. Well, no, we don't have to wait anymore. So you can file a petition with the probate court and get a hearing on whether to order outpatient treatment. And then as an extra tool, instead of going to a full hearing, you can say, let's go to mediation. So we have mediation centers across the state.

mediators who are trained in mental health issues to mediate these disputes. If you're going to mediate an agreement with someone who has a mental illness, You have engagement. You have the likelihood of compliance. I have four bills pending in the legislature right now. They have passed the Senate around the floor of the House as we speak.

I might get attempts any minute now from Senator Hurtado telling me we got them all done. The bills I had introduced expand mediation so that providers of care will have a better option. The providers of care don't like to petition their clients for treatment. They'll certainly take advantage of mediation. They'll see if their client is beginning to decompensate.

And before it gets too bad, let's go get mediation. We are trying to make the process work better.

So we still have some blockages. For example, if I want someone to get outpatient treatment only, I have to have a psychiatrist testify. If I want them to be hospitalized, a psychologist can testify. To me, it would seem that the higher-ranking medical person ought to be talking about hospitalization. and a lower echelon person talking about outpatient treatment.

There's been tremendous resistance to these outpatient treatment orders. What did you think was going to happen when you emptied the hospitals? What are you going to do with individuals who had to be hospitalized before? I'll just give you a comparison. In New York State is where Kendra's Law was adopted. And that's where in 1999 they started the idea of assisted outpatient treatment.

So New York State right now has about 2,500 people on AOT with a population of 20 million. In Michigan, Genesee County, with a population of 400,000, has about 800 people on AOT orders. So New York City, or New York State rather, used AOT the way Genesee County does here in Michigan. They have 20,000 people on AOT. It's a preferred option to hospitalization.

When we go off the hospitalization route, what that involves is the police go to someone's home, like the parents, and they go down and they effectively arrest the parent's son and then take him out into a squad car in front of the neighbors and transport him to the hospital where he's held against his will for a few days, pretending a trial in front of a judge on a black road.

Now, that experience is pretty traumatic. Yes, that's what everyone says. Why do we have to do it that way? And we don't have to do it that way. We inflict trauma, and then the period of hospitalization is a few days. In fact, we measure length of stay by hundreds of a day. So we say, okay, the average length of stay in Wayne County is 6.25 days.

I don't know what the length of stay is now, but it's typically less than seven days.

Well You know, judicial leadership really does matter And if you're familiar with the Myers-Briggs personality profile, basically I saw a paper on this by judges, and judges tend to be introverts, and they tend to be reluctant to engage directly with the legislature. But you have to find the judicial leadership at each level.

Now, when we formed the National Task Force, one of the recommendations by the National Task Force was every state at the administrative level, Supreme Court level, Every state should have a behavioral health administrator at that level. And Michigan now has one. Illinois has one. Pennsylvania has one. And this provides leadership at the state level.

Michigan and Wayne County, Judge Freddie Burton formed a behavioral health unit within the probate court to monitor this process from beginning to end, to create accountability by the hospital, the community treatment system, and so forth. And then the person he hired to run it has now been hired by the state to run the behavioral health unit for the state of Michigan.

And part of her mission is to find champions across the state. We don't need a lot of them, but we need one for region, for example. This can be copied across the country by each state court administrative office, having someone who's charged with that responsibility to find these individuals who are willing to do this. So I'm seeing progress.

I will admit, for the first 20 years, I wasn't seeing much progress. But things really started to change when that series came out. I had a call from the Attorney Governor's office wanting to know if I would help fix the statute. I thought back to my experience with the Mental Health Commission in 2004, where we made 70-some recommendations that got nothing. So, is this not a wild goose chase?

I was assured it wasn't. So I went up and did that, and things are improving. There is a challenge, though. Implementation is a big deal. So in the 50s, it was one-stop shopping. A person was admitted to a facility, and that facility provided all the services the person could possibly need. Well, now, that's not the case. Now you're in the community.

So now we have stakeholders that all have an interest. Law enforcement is a stakeholder, the hospital, the emergency department. the community treatment system, the core families and other schools and so forth, all the stakeholders. And we have all the makings of a mental health system, but the stakeholders don't communicate with one another. They don't work together.

They don't have warm handoffs one place to the next. And so it just hasn't been working. So in Michigan, what we found was after these laws were adopted, a lot of the hospitals weren't complying with the laws, and neither were the community treatment agencies, and neither were the courts. So we're changing the culture, and that's huge. Changing the culture of an organization is hard to do.

The culture has been we don't give people treatment they don't want, even if they don't have the ability to make that decision. So We're changing that. So the idea is, and you've probably heard the term of anosognosia.

People who have a mental illness that is thought process or compromised, they're not the ones exercising choice, but the illness is exercising the choice. What we want to do is free people so they can make their own choice. Free them from the effects of mental illness. Get them into recovery.

Aside from the economic sense, you know, avoiding jail, avoiding incarceration, which is expensive, especially for people with mental illness who have to have extensive drugs. We spend a ton of money providing mental health treatment in our jails and prisons. in what are not therapeutic environments.