Tony Mantor: Why Not Me the World
Autism is a complex neurodevelopmental condition that affects millions of people worldwide.
It is characterized by difficulties in social interaction, communication, and repetitive behaviors.
Although autism is becoming more widely recognized, there is still a lack of understanding and awareness surrounding the condition.
As a result, many individuals and families affected by autism struggle to find the support and resources they need.
Why Not Me The World podcast aims to bridge that gap by providing valuable information and insights into autism, fostering empathy and understanding, and promoting acceptance and inclusion.
Nashville based Music Producer Tony Mantor explores the remarkable impact his guests make by empowering their voices in spreading awareness about autism and helping break down the barriers of understanding.
Join Mantor and his guests as they delve into the world of autism and mental health to explore topics such as diagnosis, treatment, research, and personal stories.
Together, we can create a more informed and compassionate society for individuals with autism.
Tony Mantor: Why Not Me the World
Jhilam Biswas Reveals Paths to Mental Health Reform From Forensic Hospitals to Freedom
Dr. Jhilam Biswas, a board-certified adult and forensic psychiatrist, discusses how mental health issues intersect with the criminal justice system and the urgent need for reform.
She shares insights from her research and clinical experience working with incarcerated individuals with mental illness, explaining why mental health care in America's prisons is a humanitarian crisis.
• Director of Psychiatry Law and Society program at Brigham and Women's Hospital and co-director of Harvard Mass General Brigham Forensic Psychiatry Fellowship
• Research shows delays in psychiatric treatment lead to increased violence and worse outcomes in forensic settings
• Individuals with autism have higher comorbidity with serious mental illness and are more vulnerable in law enforcement interactions
• Mental illness evaluation processes vary based on setting, with court-ordered evaluations having strict timelines
• Three main pathways to incarceration: substance use disorders, traumatic brain injuries, and untreated mental illness
• America's largest jails have become de facto psychiatric hospitals, which Dr. Biswas calls "a human rights violation"
• Currently championing two legislative reforms in Massachusetts: the Timely Treatment Bill and Critical Community Services Bill
• Mental illness is treatable but often cyclical, requiring consistent medication and support
• When people suffer from psychotic disorders, they often lose insight into their condition, making treatment refusal a symptom rather than a choice
Tell everyone everywhere about Why Not Me, The World, the conversations we're having and the inspiration our guests give to everyone everywhere that you are not alone in this world.
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intro/outro music bed written by T. Wild
Why Not Me the World music published by Mantor Music (BMI)
Welcome to why Not Me? The World podcast, hosted by Tony Mantor, broadcasting from Music City, usa, nashville, tennessee. Join us as our guests tell us their stories. Some will make you laugh, some will make you cry. Their stories Some will make you laugh, some will make you cry. Real life people who will inspire and show that you are not alone in this world. Hopefully, you gain more awareness, acceptance and a better understanding for autism around the world. Hi, I'm Tony Mantor.
Speaker 1:Welcome to why Not Me? The World Humanity Over Handcuffs the Silent Crisis special event. Today we're joined by Dr Jillam Biswas, a board-certified adult and forensic psychiatrist. She is the director of the Psychiatry Law and Society program at Brigham and Women's Hospital and co-director of the Harvard Mass General Brigham Forensic Psychiatry Fellowship. She chairs and contributes to numerous psychiatric, forensic and medical committees at both state and national levels. Her research focuses on improving mental health laws to better support patients and families, while advancing criminal justice reform. With her expertise in mental illness risk assessment and more, we're thrilled to have her share her insights with us today. Thanks for coming on, thank you, I think you're doing such a huge service.
Speaker 1:Thanks for your kind words. I really appreciate you taking the time to be with us today. It's truly inspiring to see your impact as a mental health advocate and your leadership across various boards. Can you share with us your journey and how you reached this point in your career?
Speaker 2:A lot of what I've done is research. So I worked at a forensic hospital for many years and I realized that it was very hard to get the courts to allow us to provide medications for psychotic illness in time if somebody didn't have the insight into knowing that they needed it. So what we ended up doing and I was the principal investigator in this research project is it took years to get all the agencies to sign off on doing a research study in the carceral setting on mental illness. But what I did in the forensic hospital this is all those individuals you're talking about with mental illness, but also a lot of my patients did have an autism diagnosis Not all of them, but certainly we do see a correlation of individuals with autism who might have a comorbid, serious mental illness like bipolar disorder or schizophrenia or PTSD.
Speaker 2:You know, because what happens when you have autism and you're having difficulty with social cues and having difficulty with reading social situations? It can't. It just makes you more vulnerable to fall into difficult situations meeting up with law enforcement law enforcement not necessarily reading you right or reading you well and it resulting in something that's much bigger or spiraling out of control. And so a lot of times when I was working at the forensic hospital in Massachusetts. These individuals would have mental illness, but also have this diagnosis of autism and also a diagnosis of traumatic brain injury. That was another really common thing that I would see in individuals, and so we did a research study, because one of the biggest issues that I found in forensic hospitals and working in the incarcerated, in a system with patients who are incarcerated, is that it's very difficult to get standing doses of treatment for them.
Speaker 1:So, going over everything that you've done so far, what was your next step to finding more information?
Speaker 2:So we ran a study and we showed all of these different adverse events that occur while we're waiting for the courts to allow us to give treatment, and those adverse events you know were like patient on patient assaults, patient on staff assaults, climate incidences where you know the individual is either victimized by others or, you know, throwing things or breaking things in the unit and really just causing a lot of disruption. And so what ends up happening with these delays to treatment in carceral settings or forensic hospitals and actually in Massachusetts we see it even in our acute care settings is it's not a healing environment necessarily for people.
Speaker 1:Can you expand on why that is?
Speaker 2:Because the other people are so sick around them, or they themselves are so sick and there's this delay to care. So anyway, all that to say, we did this research study. We found that when we do provide treatment to individuals in forensic hospitals, things improve dramatically and these adverse events decrease dramatically. Actually, I'm going to be president of the Massachusetts Psychiatric Society in April.
Speaker 1:Wow, that's awesome.
Speaker 2:Yeah, and I'm working with a group of other organizations to really help change some of the laws in Massachusetts to bring time.
Speaker 2:It's called the timely treatment bill and we're trying to bring better psychiatric care to people in inpatient settings and in forensic hospitals and in prison settings antipsychotic treatment when they have psychotic illness. The other thing we're doing and Anne Cochran, I know, connected me to you for this is what my hope is is, rather than having people get care in these locked settings, really bring that level of care to the community through assisted outpatient treatment and wraparound services. Individuals with autism definitely have a higher comorbidity of serious mental illness, but also are in proximity to others with serious mental illness due to living in group homes or living in various institutions with people with serious mental illness. And getting timely treatment to these individuals, rather than these delays to care, I think it's key to keeping individuals with serious mental illness in the community and with family members and reducing sort of the high burden that caregivers feel, I think, in providing care for their loved ones who have serious mental illness and comorbid autism.
Speaker 1:When do you get involved with a patient that's been incarcerated? Do you step in before they enter the court system, or only after they're already in it?
Speaker 2:Yeah. So when working in a forensic hospital, they need charges. They need criminal charges actually to be in the forensic system and then the court will have clinicians within the court determine you know what this person needs a higher level of care and they'll get diverted into a forensic hospital and that's where we see them as forensic psychiatrists providing care in that setting. However, now I don't work in a forensic hospital. I actually work in a regular academic hospital in Boston called Brigham and Women's Hospital and I still see a lot of forensic issues that come up in the hospital setting. You know people with criminal charges who are needing medical care but then also have a psychiatric illness. We see it also in our inpatient psychiatric units.
Speaker 2:I also have a private practice called Psych Expertise where I do evaluations for the court, for attorneys, for organizations that may need a mental health evaluation, for an employee, or a school may need a mental health evaluation for somebody who might have been suspended due to some issue and then turns out there's a mental illness involved and we need to know that it's treated in order for them to come back to school.
Speaker 2:So I end up in a lot of different situations thinking about how did this person get in trouble. In which context did this person get in trouble? Is it related to their mental illness or their autism diagnosis? And how do I provide recommendations for them to return safely into whatever institution that wants to have them back? And how do we do that? Well, I also have done evaluations for people who are in a forensic hospital or a jail and then are going back into the community. How do we keep that individual safe in the community with services, so that they don't end up in this cycle of incarceration? So what ends up happening is basically, I just think of myself as giving mental health consultation to various social systems, whatever they may be, because all of our social systems are interacting with people with mental health issues.
Speaker 1:When someone comes to you tells you they need someone evaluated, what is that evaluation process entail?
Speaker 2:Great question, the evaluation process. I think, if I were to drill it down, it's a psychiatric evaluation. A psychiatrist is a medical doctor. We go through medical school and we do a psychiatry residency and then we have a subspecialty in understanding how people with mental illness may interact with the law. And so I use a lot of my training and experience to do an evaluation. But a lot of what I'm doing is looking at the psychological factors, biological factors, environmental factors and social factors, social determinants of health that may have resulted in the illness that I'm seeing. And how do we intervene in all of those various factors so that individual can be stabilized from their crisis and then be maintained in a lower level of care or in the community? And the way that I do that is I get a very deep social history, developmental history, substance use history, mental illness history, medical history, legal, you know, like there's a lot of ways to get all this history and then we use all the components that we have kind of sussed out in the examination to describe what we're seeing.
Speaker 1:Once you determine what you think is happening, what is the next step after that?
Speaker 2:So the next step, after kind of thinking about what is happening, you make a diagnosis. If a diagnosis is available to make or not, you can make a diagnosis. Sometimes it requires more testing, depending on what the issues we're seeing. Sometimes it's a deep dive into the past medical history and legal history or, if it's a case, kind of going into the you know the components of the court case and making a clinical opinion on that diagnosis. So saying there's this diagnosis and in my clinical opinion this is what we need to do next. And then in that clinical opinion we offer treatment recommendations also.
Speaker 1:How long does it take from the initial meeting with a patient to assessing their condition, making a diagnosis and prescribing medications or other treatments they might need to move forward?
Speaker 2:So it happens on a case-by-case basis. It really depends on the story and it really depends on the situation. Some stories are really hard to figure out. You know, somebody might be very high, functioning and they're living a very you know functional life, but there's just a missing link that results in a bad situation or a bad outcome. It may take a deep dive into the history, doing interviews with family members and friends and institutions that they're part of their caregivers, their treatment providers, and so that can take some time.
Speaker 2:The other thing I always say about a psychiatric diagnosis is it's hard to make a diagnosis of psychiatric illness in one snapshot. You really need multiple evaluations and you need to see someone over time or you need to be able to retrospectively or look backwards into their history and say, okay, this is what they looked like at this point in time and this point in time, and then, through that pattern, you can really say what that diagnosis is. All psychiatric diagnoses actually do need to occur over a period of time and cannot really just happen for one day to get a diagnosis.
Speaker 1:When you're involved with the legal system and the court requests an evaluation of an individual, do they provide enough time to conduct a thorough assessment? This would help explain why the person acted as they did, allowing the court to make an or the necessary actions that they may need to continue.
Speaker 2:Yeah, I mean, I think that's a great question. So I think different evaluations require different periods of time. It depends on the decision that the court is making. One decision the court will make is let's say, somebody comes off the street after an assault and battery. There's just some obvious mental illness signs that the court is seeing like the person is not making sense, they're confused, they're disheveled, their hygiene is bad. You know they're talking to themselves.
Speaker 2:That's kind of a quick and dirty snapshot view that someone in Massachusetts we call them court clinicians. There are psychologists and social workers at every court that will do a quick and dirty evaluation and say, look, this person needs a longer mental health evaluation versus you know what. They can actually have their day in court. They can get arraigned, they can go to a jail setting for a pretrial period. There is an evaluation that's done within the day in that setting. Then if there needs to be a longer evaluation, by statute in Massachusetts law, in the Massachusetts general laws, it's chapter 123.
Speaker 2:We have lots of different statutes that describe how much time you'll have to do a psychiatric, a forensic psychiatric or psychological evaluation and once someone ends up in a forensic hospital from the courts you have 20 days to do that evaluation and then make a determination of whether they need to stay in the hospital or if they can kind of go back into the jail setting. So that's what we see in the forensic setting. However, a lot of situations the courts will allow the person to go right back into the community and have the evaluation done in the community. Now, as a private forensic psychiatrist, I will do those evaluations out in the community over longer periods of time. Or if someone's been able to pay bail, they will be out to have those evaluations done out in the community. So it just sort of depends where the person ends up and what their history is. That determines how long we have to do those evaluations.
Speaker 1:When you conduct an evaluation and propose a hypothetical treatment plan, but the individual is placed back in an environment where they regress, how do you support them to regain stability? If time constraints or unaddressed issues lead to new challenges surfacing, how is that situation managed to help them get back on track?
Speaker 2:It's a big piece of detective work. I think Every puzzle is different and you have to put the pieces of the puzzle together to figure out what's going on. It depends on the kind of mental illness we're seeing. You know, if it's somebody with autism spectrum disorder, they may be able to articulate everything that's going on. They're connected to their family members. We'll have direct contact with everybody. They will have some insight into what their issues are and we'll be able to provide care and treatment more quickly.
Speaker 2:What I often will see with people with serious mental illness, like a psychotic disorder whether it's resulting from schizophrenia spectrum disorder or from bipolar disorder or from substance use that then causes a psychotic disorder those are often the three big pathways in which we see a psychotic illness.
Speaker 2:Those individuals might not have a lot of insight into what's going on and will be.
Speaker 2:You know, one of the symptoms of psychosis may be that they don't have insight, they're not engaging in care and treatment and they don't want treatment.
Speaker 2:At that point we really do need to get the courts involved to help us provide some psychiatric treatment, which we call you know there's various names for it, but we call them antipsychotic medications that every state has laws around in order to provide that care in a way where the individual doesn't have insight that they need the care, and so it ends up being somewhat compulsory, right, but we need the court to mandate that, and in those situations, they can just take a lot longer because there's so many procedural hurdles.
Speaker 2:And we need to protect the due process, obviously, of the patient themselves, especially if they are refusing treatment and they do have insight. And you know we're just missing something. Certainly, due process is important, but the problem with due process currently is our court systems take a really long time to hear the cases, and so that's what my research showed. In one of the forensic hospitals in Massachusetts, it took up to 61 days to get medications to an individual who had acute psychosis, which is why I have worked with multiple other organizations the Massachusetts Behavioral Health Services Organization to bring a bill to the Massachusetts legislature called the Timely Treatment Bill.
Speaker 1:Can you expand on this bill that you brought to the legislators and what it does?
Speaker 2:More timely medications to people with psychotic illness, because right now in Massachusetts and I know in other states because I talk to psychiatrists everywhere this is a huge issue.
Speaker 2:We cannot get care to individuals with serious mental illness who have an insight problem, who can't tell that they're ill, and that's a very common problem among people with psychosis and that I do think results is a multifactorial, but it is a factor that results in this cycle of homelessness and incarceration, because if you're coming off your meds and you become sick and no one is monitoring you and you don't have ties to care and you've burned bridges with your caregivers, you do end up in this cycle of losing your housing, ending up on the streets using substances, ending up with head injuries and then that is this downward spiral into interactions with law enforcement and crime and then ending up in the carceral system. One of my deep sadnesses is the fact that some of our largest jails in the country LA, chicago's, cook County and New York Rikers are some of the biggest psychiatric hospitals in our country and that shouldn't be the case. I think that's a human rights violation to have our carceral systems provide psychiatric care.
Speaker 1:Yes, I've heard that the prisons are exactly that the largest psychiatric hospitals in the country, and it's up to them to take care of them.
Speaker 2:And they really don't know how to take care of them, which ultimately create more issues Exactly, and so it is important in those settings to really get a forensic psychiatrist to do an evaluation and provide recommendations. It's very sad that so many people with mental illness do end up in the carceral system. But just having that psychiatric evaluation that follows them, that people can read and say, oh, this person has this diagnosis, oh, this is this person's history, these are the medications that might be helpful, or here are some ways this individual can cope with their mental illness, that is such an important report to have for that individual and to have that level of psychiatric analysis done for that individual who's in the carceral system, I really think that that's so important.
Speaker 1:Many prisons aren't equipped to handle inmates with mental illness or medication needs. Guards often lack training to recognize these issues, mistaken genuine distress for defiance. This can lead to inmates being denied proper medication, escalating problems and ending up in solitary confinement. How do we create a better system so that some of these people don't fall through the cracks and wind up in places they don't need to be, because it may just be a medication issue rather than a personality issue? What do we need to do?
Speaker 2:This is such an important question. It's one I personally struggle with every day and think about every day, because I think there are some key things to educate society about when it comes to mental illness and how people end up in the criminal justice system. One is substance use is like one of the biggest issues that results in violent behavior and then results in someone with mental illness or substance use disorder to be incarcerated this impulsive behavior that comes from substance use. Another is traumatic brain injury. Traumatic brain injury is a really big deal in the United States. People end up with concussions and a series of concussions over the course of their life, through sports, through fights, through lots of different car accidents. This is an issue and it does actually cause people to have personality changes, to become more impulsive, to not necessarily pick up on all social cues or to self-medicate with substances their symptoms that they're experiencing. So that's another way where we see violent behavior. And, lastly, we see a lot of violent behavior when someone has mental illness that is untreated untreated mental illness that results in a lack of insight and self-awareness that somebody is ill.
Speaker 2:That is the third way I think people do end up in the carceral system due to having a mental health issue and we know that as psychiatrists. When I'm doing that evaluation I know I see those factors and those are three things we could divert back into the community and provide intensive treatment for and help society understand, look, that treatment might need to be mandated for a short period of time until that person develops insight. That's gonna be the way to keep people in the community. But there are a lot of little problems we end up along the way in being able to provide that level of care. I think in the United States and I think that is resulting in a carceral system problem of mental illness. We need that medication, treatment and the therapy that goes along with it, and housing that goes along with it and occupational therapy and physical therapy that goes along with it to be in the community. And the community needs to have a deeper understanding of what causes violence impulsive violence in individuals, not necessarily premeditated violence.
Speaker 1:Now you said that you were involved in some type of legislation. Yes you were involved in some type of legislation. Yes, what type of legislation are you trying to get changed or improved upon? That needs to be under the microscope and you think is just really, really important?
Speaker 2:Yes, very important. So different states end up with different sets of issues that result in the same problem, which is people with mental illness end up incarcerated. And in Massachusetts, I have to say, we have the lowest number of incarcerated individuals like rate of incarcerated individuals in the country. So not in terms of numbers but in terms of the rate of incarceration, we had the lowest amount. However, those who are incarcerated are more likely to be mentally ill in Massachusetts and our judges have done a great job of creating new standards in Massachusetts that they recently updated in 2024 to really think about mental illness as one of the things they consider when they're looking into a case. And I was just involved in one of their annual meetings and provided some mental health education at their annual meeting because they're really looking into this issue.
Speaker 2:But what I think is an issue in Massachusetts is that we're a very rights-driven state where treatment is important, but to maintain someone's rights to refuse medication is it takes precedence in Massachusetts. It's not the case in all states, but a lot of states do follow the same thought process and while I think that's absolutely important for people with disabilities to have all of their rights intact, what sometimes happens is these individuals in maintaining their rights to stay off medications and not get mandated treatment, they end up in the carceral system because they end up in a violent situation and then end up in the carceral system with criminal charges. And so in Massachusetts, two things we need to do to do we don't have any assisted outpatient treatment laws and we do have one filed with the legislature right now at the statehouse, called the Critical Community Services Bill that we've just refiled in January to help us bring this level of intensive psychiatric treatment into the community rather than just in locked psychiatric units.
Speaker 1:That sounds like a great piece of legislation. What do you see coming out of this?
Speaker 2:The hope is we can provide antipsychotic medications to someone with serious mental illness and a psychotic disorder in the community, monitored, while giving them all the other services. They need to stay in the community and the other thing that we are trying to do in Massachusetts we have this timely treatment bill that's also in the legislature that we just refiled in January to reduce that time that it takes for the court hearing to happen in order to get medications to an individual who has a psychotic disorder, is lacking insight and is refusing care and therefore has ended up in this cycle of needing multiple hospitalizations or ending up homeless, or ending up with multiple criminal charges and in the jail system. Right now we have no safety nets in either of those two spaces to provide medication treatment for people with psychotic disorders in Massachusetts. So those are the two bills that I'm really hoping we can push during the time that I am president of the Massachusetts Psychiatric Society. So that's one of my goals.
Speaker 2:But what I will say is this is a nationwide problem In the nation, every state, whether they have those AOT laws, assisted outpatient treatment laws or timely treatment laws in the inpatient settings. Sometimes they have major staffing shortages. They don't have psychiatric care necessarily available very quickly, or they don't have the psychiatric beds or they don't have the wraparound services needed in the community to keep people off the street and in a shelter system with psychotherapy, with other types of community services needed for people with serious mental illness. So every state has saw a version of this problem.
Speaker 1:It seems that if you get this passed through, this would be a good bill to take to the House and try and make it national.
Speaker 2:Yeah, I mean, I think what has happened is this issue has become a state-by-state basis issue and every state makes their mental health laws and their determinations of how they're going to manage people with mental illness. You know, the hope is what the Supreme Court does is give the bottom. This is what you have to do, but states can have a higher level of scrutiny than what the Supreme Court deems to be needed. That is a really important legislation to pass, I think, at a national level to really recognize this as an issue, that this cycle of homelessness, constant psychiatric hospitalizations and criminal justice interactions is a result of individuals with mental illness either remaining untreated or self-medicating with substances, also having these other morbidities like autism or traumatic brain injury or other types of personality disorders. They all play a role.
Speaker 1:Yeah, I definitely agree. Now, what would you like to tell the listeners that you think they really need to know about what you're doing and, of course, what you're trying to do with legislation?
Speaker 2:That's a great question. Serious mental illness is treatable. Symptoms of autism can be alleviated with really good therapy. We do have treatments available.
Speaker 2:Serious mental illness is a waxing and waning illness. It can come back. It's not necessarily curable and so people need to stay on medications to stay well. One of the issues we see with serious mental illness, which is a biological illness it's a disease like any other disease that we see in other organs in the body needs maintenance and needs treatment. It doesn't just go away I mean it can for a period of time, but it comes back, and when it comes back it's unpredictable.
Speaker 2:What I really want people to understand is when people can get very sick from mental illness. They can lose insight into their well-being, into their self-awareness and into reality in general, and that experience a lot of times can be very distressing. So, even though if a person is telling you they don't want treatment or they're not able to give you a very clear decision of what they want, part of that is the illness itself. Part of that is the distress, the emotional distress that they're experiencing from being in psychotic illness. And so, even though it feels sometimes really wrong to provide psychiatric care to an individual when they're refusing it. You can actually restore their wellbeing and dignity much faster with medications and I think we really need to understand that and there's a lot of resistance to that understanding of mental illness, I think, in this country.
Speaker 1:Yeah, well, this has been a great conversation, great information. I really appreciate you coming on.
Speaker 2:Absolutely. I really appreciate you having me. Thank you.
Speaker 1:It's been my pleasure. Thanks again. Thanks for taking the time out of your busy schedule to listen to our show today. We hope that you enjoyed it as much as we enjoyed bringing it to you. If you know anyone that would like to tell us their story, send them to TonyMantorcom Contact then they can give us their information so one day they may be a guest on our show. One more thing we ask tell everyone everywhere about why Not Me, the world, the conversations we're having and the inspiration our guests give to everyone everywhere that you are not alone in this world.