 We had a conversation with people from the Department of Mental Health about orders of non-hospitalization. One of it, when we asked for Act 82, is it Act 82? In one of the reports that we asked for an evaluation of mental health system, we asked for a second opinion on that outside of the union. And one of the suggestions was that our current support system or our system or lack of system for orders of non-hospitalization were leading to a particular movement in an untherapeutic way of patients. So we're going to talk about, we sat with Katie, with our lawyer, and asked her to draft sort of the bones of a committee that will make some recommendations to us next year and before session. Alright, let's have Katie come up and go through the bill with us. And if you're going to be team test-parting, just leave both chairs there. Can we make a chair for him? Okay, I'll stop you now. Hi, Courters. Good morning Katie. Thank you for the work, all the work in the meetings that went into this. Why don't you walk us through it and tell us what's in here. Sure. Katie McGlynn, Office of Legislative Council. So as the chair said, we met with some folks from the DMH team and we talked about creating a study committee focused on orders of non-hospitalization specifically. So this language just sets up that study committee and subsection A we're creating the study committee to examine the strengths and weaknesses of Vermont's orders of non-hospitalization. And then in subsection B we go on to list the membership of the study committee, including the commissioners of mental health and of public safety or their designees, the chief superior judge or designee, a member appointed by Vermont care partners, a member appointed by Voss, a member appointed by Vermont legal aids mental health project, a member appointed by the executive director of the department for state's attorneys and sheriffs. The Vermont Defender General or designee, an individual who was previously under an order of non-hospitalization appointed by Vermont psychiatric survivors and a family member of an individual who was currently or was previously under an order of non-hospitalization appointed by the Vermont chapter of NAMI. And we invited representatives of everybody on this group, I think, to come in today because this is a proposal no one's seeing before. I visited by VPS. You did not invite Vermont psychiatric survivors? I thought we did. Well, I'm sorry. I'm glad you're here. The next subsection has to do with the powers and duties of the committee. The committee is to examine the strengths and weaknesses of Vermont's orders of non-hospitalization and may propose a pilot project that seeks to redress any weaknesses and build upon any existing strengths. And then we go on to have the specific asks of the committee. First, the committee has the responsibility of reviewing and understanding existing laws pertaining to orders of non-hospitalization including Act 114. Second, reviewing the 2017 Treatment Advocacy Center report entitled Reimagining O&Hs including the effectiveness of each of the recommendations in that report. The third ask is reviewing existing data pertaining to orders of non-hospitalization specific to both people who are entering the system through the civil door through the forensic door in subdivision C4. If it's appropriate, we're asking the study committee to propose a pilot project for the purpose of improving the effectiveness of orders of non-hospitalization. And at the top of page three, if it's appropriate, we're asking the study committee to recommend any changes necessary to improve orders of non-hospitalization. And lastly, we're asking the study committee to identify any statutory changes necessary to implement recommended changes to orders of non-hospitalization. So those are the responsibilities of the committee in terms of assistance. The committee has the administrative technical and legal assistance of the Department of Mental Health. They're responsible for a report that would be due November 1st of this year to this committee and to the two, one committee upstairs, just house health care. And then in terms of meetings, the commissioner of mental health or the commissioner's designee is to call the first meeting on or before August 1st of this year. The commissioner of mental health or designee is to serve as the chair, the majority of the membership constitutes a quorum, and the committee shall cease to exist on December 1st of this year. So it's a limited time study committee. And then the last paragraph has to do with compensation and reimbursement if folks are not otherwise compensated through their formal employment. And that's the standard language. I have one suggestion for language we didn't put in. Okay. Examiner strengths, the weakness, whatever, and improvements. And it's improvements to the mental health of the patient. I don't know how, that's awkward phrasing, but that's the improvement. Are you in, tell me where you are in the creation? I think we need to, that's the point of it. Right, I'm just not sure where you are. Are you in the first paragraph? I want to add that to creation. Oh, got it. There's places where it says shall improve. Okay. And so it could be improved for, you know, depends on whose experience it is. But yeah, we'll talk about that as we have witnesses. Any questions for Katie? Nope. Okay. I know you're going to be with us for a little bit. I will. I'm going to take some testimony from people who would hopefully be involved in this. Morning talk, Deputy Commissioner of Department of Mental Health. Thank you for the opportunity to just speak to this briefly. I know we have a long list of folks. So I will be brief. And I also know that this is also very new fresh as of, you know, in the last few hours even. Saw this morning. Yes. We've been taking that. And so I will also ask that, you know, some time to digest some of this and come back with other comments from the rest of our department. However, our initial thoughts are that orders of non-hospitalization come up in various places throughout the system of care have been seen as obstacles to care for some folks have been seen. And I think there have been some folks who have described them as being very helpful and others who have found them to be extremely detrimental. And so I think. Can I stop you for a second? Sure. I think just pointed out to me that we did a lot of two hours for this. So in fact, you could do a problem, make a problem statement if you wish. Oh, there you go. So it would be clear to the right. I couldn't imagine it schedule these people for one hour. No worries. I also keep my comments really brief. But as I was saying, there are varying opinions about orders of non-hospitalization. And I think that moving forward with a committee of this membership to pull together to really look at orders of non-hospitalization, how they're operationalized and try to alleviate and mitigate the negative pieces of an order of non-hospitalization. I think, you know, as a state, one of the pieces in statute is that we try to move, continually move towards a non-coercive system of care. And to that end, one of those pieces needs to be looked at as orders of non-hospitalization because that is, by nature, a coercive piece of treatment. It's ordering someone into some form of treatment. And so I think it's imperative for us to take a look at that and assess really the cost-benefit analysis around that to people's health. Because if our true goal is to try to move to a less and less coercive system of care, then we really need to look at the pieces of our system that do rely on, for lack of a better term, coercion. And that would be both orders of non-hospitalization, which this addresses, but also just the commitment, the process, et cetera, both civilly and forensically. Those are both also, again, coming back to the term coercive. They are, by nature, coercive. So I think it's imperative and a major responsibility of the department to take a look at these things to make sure that they are actually truly helpful and beneficial to the people who are being placed under an order, in this case, of an order of non-hospitalization. So as it is written now, the department is in support of this legislation and would look forward to the recommendations from this committee. Thank you. Questions for Fox? There's an excellent description of this at the beginning of the, is that the Act 82 report? Yeah. It was the best one I've seen, so if you need to take a look at that. In fact, maybe Kate could paste that on our website. The description of the orders of non-hospitalization, I'll talk about it, but some information. Okay. Thank you. And also I want to make sure we add these psychiatric survivors to our list of people There's a person nominated by the psychiatric survivors. But apparently we did not invite psychiatric survivors today. They saw it, they're here. I want to make sure they're in contact with them. Okay. Thank you very much. Thank you. Karen Barber? She is actually currently in another meeting. I hope it has been unable to testify today. All right. Sandra Stankard, Dr. Stankard. Good morning. Good morning. Thank you for coming in. Sure. I do. I just have some brief remarks, but I did write them down a few. Okay. A sentiment of email last night. Okay. Fine. Okay. So, well, thank you very much. My name is Sandra Stankard. I'm the Chief Medical Officer at Howard Center and have worked in the Vermont public system since 1993 and Howard since 1995. So I do have a lot of experience as a psychiatrist in that and a community mental health center in working with people that are on orders of bound hospitalization. And basically all I was going to say is I did, I'm not a big fan of the treatment advocacy center where Mr. Stettin works, but I was, I thought he captured the system well. I thought he captured some of the frustrations that we feel, some of the problems in the system. And I was heartened that he emphasized. He's the one that wrote this report. I'm going to comment mostly on the... Thank you. Yeah. Okay. So I'm mostly commenting on that report. And I just want to say from my perspective, I do think he captured a lot of the problems and I was thinking of like better synonyms to absurdity or Kafkaesque. But that is often how it feels that it says one thing, but it's not really what it does. And whatever side of the equation you are on coercion, that lack of, that sort of double message I think is problematic. Maybe you could sort of take us through that process as you see it and where you see the problems. Well, so he talks a lot about the criminal court and what we've been seeing in recent years, because there are two ways that someone can end up on an order of non-hospitalization. One is they commit a crime, they go through the legal court and someone has determined that the person is either not competent to participate in their defense or was insane at the time, criminally insane at the time of the offense. And what that does, this is a non-lawyer talking about what I think happens. So what that does is to put the system in a bind because, for instance, mental health court, which is I think a really good remedy for people who have committed crimes and their mental health problems or there's also drug court people think have contributed to it and so there's a big move to try to help them with that as a way of avoiding jail, which doesn't seem to be a good remedy. And I think it's a really good program. But in order to get into mental health court, you need to be competent. And so if you've been found not competent, you can't go that route. So this is a problem. And sometimes I feel that putting the person on the O&H is a way to clear their decks. And there's no real thought about whether it would happen. And believe it or not, there could be people that have some psychiatric diagnosis, but the treatment that they go to isn't necessarily connected to mitigating their risk for committing a crime again. And so now they're sent for some treatment and as the person, the agency, is designated by DMH to sort of be the ones that kind of hold this order and act it out. But what they're doing may not necessarily have any impact on the risk of criminal behavior. Now when the order is up or if the person fails to comply with that they don't come into treatment or they're using substances, the only remedy right now is to tell Department of Mental Health that they're not in compliance with their order. But what's linked to that is to say that this is going to be a person who meets the statutory requirement for a person in need of treatment, which just kicks in the whole civil commitment process. And so let's say the person is using, technically not in compliance with their order, but there's no evidence that they're dangerous. And someone may not have evidence of dangerous but may still be at risk for committing a crime again. So here you have this thing that you feel responsible for and you want to do due diligence to everyone involved, but it just doesn't make sense that things don't add up. And I think it puts the agencies in a very funny position of either sort of ignoring something. Do you have any designate agencies? Yeah, we're the holders of it. You know, of ignoring this order or just, you know, or I don't know, it's hard. And I think it's also, so that's one area. Now in the civil commitment area, there's similar kinds of problems because someone may come out of the hospital, they're on an order and there's going to be this standard language. You know, you have to comply with treatment, you have to live in a place agreed upon by the agency. You need to abstain from substances. And these are things that sort of people have decided might mitigate the risk of becoming a person in need of treatment because these are people who got there by being a person in need of treatment. But again, these things, and I think substance use is a common one, someone may start to use, someone may start to, you know, we have like in my field good drugs and bad drugs, I mean they're all psychoactive drugs and so there's psychoactive drugs that people like to take in these instances and then there's a psychoactive drugs that they don't want to take, the ones that we prescribe. And so you have people who may be choosing the ones they want to take, not taking the ones we think they should take, but they may not be dangerous. And you know, there's many, many factors that lead to a person being a risk of harm to themselves or others. And so here they are, not complying with the order, but we're asked to say that they are dangerous and we're very bad at predicting that. Once you get out, I think we're, the studies will say we're pretty good at predicting for 12, maybe 24 hours, but we're not really good at predicting three weeks out, four weeks out. And so when I go into court to testify, I'm being asked, when do you think they'll become dangerous again? And the honest answer is, I don't know. I can refer back to what happened before. And this is why everybody, you don't need to be a psychiatrist. This is why everybody's worried. But I can't tell you with medical authority that I know that they're going to be dangerous. I think, I mean, we'll hear from Nami. I think it's very confusing for families because they're very worried. They've seen what's happened before. They're saying so-and-so is doing XYZ. Those have been the ingredients of what's happening. Why aren't you acting? And again, either we will go forward with the case and it may or may not, the person may or may not be in the hospital, or we have a family feeling that we're dropping the ball for their loved one and there's a lot of concern all around. So I thought he'd capture a lot of it. And I like that. I mean, the other thing that I was going to say is that his remedy is clinical work. Well, I'm a psychiatrist. It's talked a lot. I mean, I do prescribe these drugs. I think there's a time and place. But I've also been talking a lot about their limitations and I continue to believe in their limitations. And we've been talking about what I think every good clinician knows, which is relationships. And I thought what was fascinating in this report is that he's really talking about relationships. What he's bringing in is this thing that he calls the black robe effect. And he's basically, he calls the involvement of the judge is called the black robe effect. Oh, I thought you said class. Yeah. Which I had, I read that. Yeah, I wasn't familiar with that term. And I, you know, it seemed like it had like face validity to me. I think sometimes there's the doctor effect. I'm an authority figure. I mean, it's often not. The white coat effect. Yeah. That's my problem. I don't wear one. So, but still like. I'm looking for a blue blazer effect. So I got this suit. But the thing is that, you know, having worked in the system for a long time, I mean, really when I have someone on order, I'm talking to them about what they want in life. And I'm trying to find it's terrible to be coerced. It is a horrible thing. And it's a conundrum to be a doctor and to be an agent of force. And so I've spent a lot of time thinking about if one can, if those things can even live side by side and how can they do that. And for me, the answer has been to try to develop a relationship. A relationship is based on transparency and respect. And so you can say, yes, you're being coerced. I get it. It sucks. But what do you want? And then how can we find places of being in alignment? And usually we agree that going back to hospitals is not a good idea. Where we don't agree is what are going to be the ingredients to get there. But all I can say it's a relationship. And I think really what he's talking about is bringing in another relationship. I think the idea of having this, because I hadn't seen it, you know, having some study group and getting different ideas about, you know, because you're going to hear from other people who are going to come at this from a different perspective. And I think that's really important because we only know what we know from our own perspective. And you need to hear this. But having some group that might come to look at the absurdities, we tried this while ago. I was on some committee, but I think it hasn't happened. And I think an agreement might be training on how the people in the designated agencies might be able to work with people who are not interested in the help that we have to give and are their best practices in ways of engaging with people. Because in the end, I think force is a very, very limited tool. And he actually says that on page two that in Vermont people are talking about wanting to extend the laws that govern force medications. And I was shocked to see that he was saying, that's not really what it's about. And at least my read of it, as you go further, is he's saying it's about relationships. So one other thing I wanted to say that I put in here is, we actually tried this with Judge Crawford, different Crawford many years ago. He said, why can't we use, when someone's going on a revocation so they're not complying in the ultimate remedy right now is to be in court and to put them back into the hospital. But there's all these things called status conferences that happen and we're not involved with the clinicians, the patient. And he said, why can't we use those the way we use mental health court? Bring the person in. We'll talk. This is what he wanted to do. He's a very wise person, as we all know. And this was the problem. No one came. And there was no way to bring them in. So I mean, again, there's going to be a study group. These are going to be things. But we do have some experience over doing that. Thank you very much. That was really interesting. And we'll make sure that we, I'm going to ask Faith the excerpt that article and put it with the rest of our evidence for today. Thank you. Yes, it's online. Do you know what we're trying to find out? I think it's the Act 82 report. There's a part of the study. Mr. or Dr. Steingart. Can you spell it, please? Oh, it's S-T-E-I-M. My name or his name? The author's author. Oh, it's S-S-T-E-T-T-I-M. Brian Stettin. I know the DMA. I think it's on the Act 82 report. It's on our website. It's on our website. It's a separate report from the Act 82 report. But it's also on our website. All right. We can read that for today. Okay. Thank you. I'm going to skip around a little bit. Lieutenant Lamoff was here before I was this morning. I'm sure it's got some things to do. Good morning. Good morning. Thank you for coming in. I'm going to ask you here to talk about sort of law enforcement's experience of orders of non-hospitalization. Unfortunately, it happens that way sometimes. And why don't we introduce ourselves to you? You're not, you're very welcome. CDU Lions, Chippin County. Good morning. Dead Eve, Brunner, Chippin County. That's good morning. Clear air at us. Good morning. Well, who are the chords you're kind of saying? Good morning. And Cummings, Washington County. Good morning. So my name is Marcel Loth. I'm the station commander in St. Albans. I've been on the VSP almost 19 years. Most of my time has been at St. Albans. I have some, I have five years in Chippin County, again, most of my time at St. Albany. Just a little bit of background. I have an embedded mental health crisis worker who's been in my office now for about a year and a half. So I have a little bit of time with that and it's by far the best resource I've ever had in my office in 19 years of work. So we use them almost every day and it's just, again, the best resource I've ever had. So I'm a big believer of this, of any program that involves mental health. We use them yesterday with the gentleman that was killed up in Birch here and every day we have something that works. So as far as my experience with this stuff, Frank County, somebody alluded to a couple of minutes ago, we are really inundated with a lot of issues that I think are singular to Frank County. We have a lot of mental health issues. We have a lot of suicide issues. We have alcoholism issues. Met with DCF the other day. We have more children in DCF Cussie than Chittin County and it doesn't make sense with population difference but we do. So we have a lot of stuff going on. So non-hospitalization orders are big in Frank County so we do deal with them quite a bit. If you are asking how we deal with them, if we have an order to pick up somebody, which happens quite often, we get orders that are sent to us from mental health and they pick up orders. It's changed a lot since we had our mental health embedded worker. We lean on him quite heavily for his advice because he is the expert. We're not the expert in this field. We do get some training now. It's continually growing in the academy and it gets pushed out to troopers on the road. Can I ask you for a second? It's mandated now. Is that not where we put some resources into that? Yes, it is growing every year. It's mandated in a way that's right from the academy level. The hours are growing and the troopers that are no longer in the academy because they're on the road, it gets pushed out to us every year. It's called PowerDMS. It comes across on an internet type training and you have to sign off on it. It's timed, so you know you're actually doing it. It's tested, but the hours are growing every year. So, but again, for me, it's a little I have the benefit of having this gentleman in my office every day. So we game plan and decide how we're going to approach the situation and we lean on him for his expertise and training and education. Now we're going to deal with serving this order. But these are not easy orders to serve. As far as I sit there, there are somewhat coercive sometimes. It's, we go out and we try to speak to family members first if we can and decide how we're going to issue this warrant to take somebody to custody. Typically they go very well. Sometimes they don't go so well. I kind of look at them as it's a necessary it's an order that has to be served. So we have had some cases where there's been a lot of talk about the dangers of taking somebody or taking somebody into custody. So we've had to do some serious thought on some. We had some where we've actually discussed bringing it to make a tactical situation. And we've actually done a couple of days worth of planning to make sure we didn't get to that step. And it's worked well. But it takes some real, we're having a tactical situation where we've talked about using much more aggressive efforts to get somebody that has made threats, severe threats and knew we were coming eventually. But with some plea planning we can usually get around that. But that's not always the case. So you have someone in your office you're working with. We do. And are you also, you're working with DCF in this? So if a social worker has a need for your assistance you go along with them and is that the linkage with the person in your office or so is it just, it happens both ways or is there that linkage that happens after? Just the process I guess. So with our mental health worker? Yeah, and how they might link with DCF. So our mental health worker is in my office every day. So he reports to us DCF, we also have a, we have a connection with them. We have a Northwest law enforcement group that we started as well. So DCF has a person that's assigned to that. So they call us typically once a week we meet and we did, they give us a list like this morning while I'm here at 8.45 they're going to take three kids out of a house. So we know that's coming. So they have a person from DCF that came to our office on Wednesday and advised us what's happening today. So we have troopers that are making made a plan yesterday and they're going up this morning to do that. So we're very integrated with DCF as well because of the number of these type of cases that we do regularly. And then is there, let's rate both the kids that you wouldn't be involved in working with a family but are you involved with a family after that? So we, I- We have a lot in the house. So our, again, our crisis clinician is multi-purpose for us. So we use him for everything and that's part of what we offer that as well. We'll bring him up and he'll try to deescalate because they're obviously emotions are high in any situation, but that's one of them. And he'll offer his assistance, then one thing he does that he tries to get them continued care through NCSS, he'll offer them, he's more the point of the spear I guess you would say for that initial contact, but he'll offer them down suggestions for the next day, the next day, the next day. Sometimes they take it up, sometimes they don't, but we're finding that more and more they are continuing that service. Then they want their kids. Yeah, and they realize that a lot of these people have actually had prior contact with NCSS. A lot of people have. It's not just the kids, the people that lose their kids or the people that we arrested, but people have had prior contact with NCSS at some point in their life and he just reinitiates that contact. It's a phenomenal program. But yeah, so we use them all the time. Again, so we are very busy with these type of orders and these type of situations. And I can't tell you that fun to do, but we do them all the time. I'm sure there's a better way. I can't speak of how, what happens once you're in place and I can't speak of how the process, like Dr. Day or like Maureen Poch said, I can say from my perspective that we deal with them all the time, they're not fun and there's certainly probably a better approach to it. But when we get them, we're very black and white on them. They have to be served. We have to serve them. We just come up with a plan that's gonna be less intrusive and the safest way to do it. Well, how does that work? Someone decides that a person who's on an order of non-hospitalization is not taking their beds or is not behaving in some way or is out of the relapse. And then who makes the order? Who sends the orders from the court or who? All we get is in final order that says this person shall be picked up. How it gets to us, I don't know. We get that order. It simply says a lot of force officers will take this person. Is that a judicial? Yeah, that comes from the judge. We have no input on that. When it gets to my hands or our hands, the decisions have all been made. All right, then how do you know if they're on an order of non-hospitalization or not or do you even know that? I have no idea. When it comes to us, it is a done decision as been made. And then that was a question that came up to us was something that came through the emails this week about me coming here was a condition of that if they take their medication or don't take their medication. In my 19 years, and I ran this up to Major Hopkins in its 30 years, neither of us could ever recall ever seeing a condition of release or condition of non-hospitalization and said they must take their medication or what if they don't. We've never seen that. We've never been put in that position where we would have to enforce that or potentially enforce that. Like I can tell you that there are alcohol conditions like that, that somebody has an alcohol condition that says they can't have alcohol. The way those are enforced is they come to the office every day and they pull into a breathalyzer every single day. And if I may, you know, it's Morning Fox for the record, it's actually fairly common that part of the orders of non-hospitalization say you will take prescribed medications or something of that sort. I think what the lieutenant also speaks to is that of the community interacting with folks, you wouldn't necessarily have any idea who is on an order, what those orders actually say, those kinds of things. The lieutenant's kind of responds. Their interactions with the orders are generally after like Dr. Steinbart has testified saying this person has not been taken to medications. They're in danger and the court agrees and they would vote someone's order of non-hospitalization. It's that revocation that the lieutenant will receive. If the person wasn't in court, someone's kind of still being court, you know, to testify against the revocation of the order. So there are times it would go out to the police another time, the person's in the court at that moment. So you get an order from whomever to pick up a person and what does the order say? To take that person to an emergency room? To take that person to custody for mental health, correct. Into custody, but where are you supposed to take them? Typically they will take them to the emergency room. Okay. And is it for another emergency evaluation? Correct. So they've already had one. No, it's actually right. Once the lieutenant's received an order from the court saying that someone's order of non-hospitalization has been revoked and to take them into custody, if we actually have a bed in that moment and sometimes we do, if we're able, we're a party to the court process, we know that this court hearing is happening. And so if our, I'm saying from our legal attorney generals is that there's so many revocation that's going forward on, say, Friday that we can try and plan to go, well, let's not admit someone into that bed so we know we can just get them straight from the court and into a bed. So it doesn't have to go to an emergency room. But because of the crunch on beds, frequently there isn't a bed. And so yes, they would take them to an emergency room. But they're already ordered to hospitalize at that point. So there's no need for a new emergency exam or something of that sort. Because that court order basically has changed their order of non-hospitalization into an order of hospitalization. I see. Our goal is just to simply help get them into custody. And again, it's a very black and white process. We are taking somebody from their current location into helping them take them into custody. And how much of your workload is involved in just that sort of thing? Getting people with mental health issues into care? I'm gonna be able to put a number on it. I can tell you that the workload, the work involved in the actual process is the planning. Because it could be a very volatile situation. It's not like a search warrant where you go up, these are very, because there's an element of mental health illness involved or mental health crisis involved. So we spend a little more time pre-planning and try to speak to mental health workers. I know that this is history. And if we can, we'll talk to the family. We don't think that's gonna be a safety issue and tipping people off or whatever the case may be. Because we don't wanna make it more aggressive than it needs to be. Because some people have paranoia and they don't like police me and it kind of goes to the territory and you're taking them out of their house. So we put a little more time into it than sometimes, most of the time it's very smooth. I mean, nine times, sometimes it's very smooth. But there are times when people meet us at the door and they're not exactly happy to see us. Any other questions for the 10-up above? My goal for today is to figure out how it works. I've just heard that it doesn't. My scope is very narrow because we have a piece of paper and we just simply act on that piece of paper. But the process, getting that paper to us, I'm not familiar with. Senator McCormack. Do you usually get cooperation or do you end up having to actually physically overpower it? No, it's very rare for us to get to a physical situation. If you take some time and work with the mental health people that know their, they know the job, they know the process, they know what people are going through. Typically we can use that and manipulate that into our approach and it works very well. Your invited worker does the talking. He does a lot of the talking. Since we've had it in place a year and a half it's been phenomenal. It really has. And it's just one person eight hours, 40 hours or five. He's eight hours a day, 40 hours a week. We stretch that as much as we can. And we're trying to get another position, quite honestly. A second shift, a night shift position, if we could we would use it. I think I heard that statistically a lot of the issues take place in the non-traditional work hours, like before 8 a.m. and after. It always happens when he's out of town. It's just the way it is, it is what it is. So I could use 24 hours a day, quite honestly, but no, I mean it does, there are all those times that things don't go the way you planned it. I don't care how well you plan it. And we're human, right? So people act differently than what you could plan, the best plan, all those falls apart. But for the most part we've had very good luck. Besides dealing with people, the who you're targeting people, does this affect them? Is this a psychologist or a, what is his training? The crisis worker? So he was trained, he was a behavioral specialist is where his background originally was. He is not a doctor level. He's not a psychologist. And then we sent him to crisis negotiations school, the FBI school for a week. So he has additional training through how to talk to people and it's a school that our crisis negotiations went through. So he's taken that plus his years of work. So this is a law enforcement officer? He's not. He's not. He can't convince ESS. Somebody had years with them as well in the mental health world. Does he do training of your people? Does he what? Does he train your people? When you have a thing at one in the morning and he's not working? He is not. We don't call. We have called him to get his advice if he's familiar with the person, but we use the on-call person. Man, it gets us then. And this is when I was testifying earlier and it's like I didn't talk about street outreach in the various areas. I got embedded folks within law enforcement. This model, this is the time it's been. So that person might be, it's probably a nighttime job anyway, right? Yeah, we work with the region and figure out from a scheduling perspective what would have the most impact. Any other questions for the time? Well, thank you. Go ahead. Thanks very much. You're welcome. Judge Greerson, thanks for seeing you again. Good morning. Thank you. Good morning. For the record, Brian Greerson, Chief's period, you're speaking to F-203. Can you know all of us, don't you? I do. I do. It's good to be back here. I think you've already received a lot of information. You're going to receive a lot more this morning. I would ask the committee, as they're hearing all of the witnesses, listening to all the witnesses, to keep in mind the different populations and processes that are involved in this issue because, for instance, my sense was that the trooper, to a great extent, was talking about emergency evaluation situations that are different than non-hospitalization orders, which are the subject of this study. Dr. Steinberg talked about mental health courts. She talked about forensic issues, meaning in the criminal proceedings. And so, as you're going forward, you need to keep all of those straight. Forensic is essentially a rising out of criminal charges that have been filed. They're never on ONH, right? No, they are. They are. They are? The process, I did read that. The process in the criminal court is if you are found incompetent, the next step is what we refer to as a hospitalization hearing, but really it's at that point that you're considering whether the individual needs to be hospitalized or subject to a known hospitalization order. That's purely through the forensic side. Other folks may come into the civil system through the process that the trooper was describing, emergency evaluations, where they obtain a warrant sometimes after hours from the court. And the warrant is only to take the person into custody to have them evaluate those cases depending on the level of, depending on the incident or the circumstances, it could be a purely civil ending up in an emergency room for that evaluation and then depending on the outcome could go through a civil process that results in a non-hospitalization order. But if the behavior with the police officer on the scene became so escalated, that could turn into a criminal proceeding and they have to go in a different direction. The mental health court that Dr. Steingarten referred to is really another population. There are individuals who are in the criminal process in the criminal system. They have not been found incompetent. They are generally speaking involved with low level offenses, public offenses, retail theft, unlawful trespass, sometimes referred to as nuisance offenses, just a cycle of going in and out of court. And I think you've all read the newspaper articles that was happening in Burlington a couple months ago where some folks, I think almost everyone involved referred to that as a failure of the mental health system. Whether or not you're of that opinion, it represents a different population of individuals who are in the criminal justice system, not in the mental health court, but still dealing with the same underlying issues. When we talk about the non-hospitalization study committee, that could cover all of those, but I think it's important that the committee understand how the person gets into the system to get on one of these non-hospitalization orders. I look forward to the opportunity to work with the other members of the commission. We touched on this to some degree, about a, I wanna say a year, a year and a half ago, there was a short-lived commission on offenders with mental illness. That one of the recommendations that came out of that commission and made it I think almost to the end of the session last year, touched on this issue of at least the forensic process, and by that I mean when someone is charged with a crime and they're found incompetent to stand trial. At that point, it's the state's attorney, generally speaking, and the public defender who are involved in the process. When you shift to the next phase, which is the hospitalization phase, the consensus, I think, from everyone involved in the system at that point, the process should turn and does turn from punishment, which is no longer the issue because the person's been found incompetent, they're not going to stand trial, to treatment. And it's at that point that the consensus was that the attorney general's office and the mental health project or legal aid who for the most part had the attorneys involved in the civil process should get involved. And that was in the bill, I forget the bill number, I think it almost made it through the process. That, in one sense, is a small change, but I think the feeling was it could make a significant change because those are the same individuals, the attorney general's office and the mental health project or the legal aid folks who will be following that case through a non-hospitalization order, through a breakdown of the hospitalization order, enforcement of hospitalization order. What is a breakdown of the hospitalization order? Well, if they violate the terms of the order and it's the attorney general's office, would then bring either a modification of the order or maybe the behavior has escalated to the point they may be seeking hospitalization, but that starts with information available, I suppose it could be either side, but the initiative would then come from the attorney general's office to if you will review or reconsider the level of treatment. That all happens within the civil process, but those are the individuals who leading the attorney general's office and the mental health folks who are going to be involved in the long run on those civil proceedings and non-hospitalization orders. And so I'm certainly not going to speak for everyone involved in that, but we felt that that was a small change that could make a significant difference in, okay, let's talk about treatment. If we need, if the appropriate order is a non-hospitalization order, what should that consist of? Clearly the mental health project and the attorney general's have a better sense of what treatment is available and what's available in an individual community. And they're not necessarily involved in the circumstances that brought the person to that point. In other words, the state's attorney and the public defender, they have different interests. So I think we did take a step in the right direction and I would hope that through this committee we can reinforce that and maybe find out why it did not, what the problems were and going all the way through. But again, I go back to the idea of whenever you're discussing this subject, keep in mind the population you're really talking about because it's very easy to mix them. The trooper in explaining the process was accurate except that it may only be the beginning of the non-hospitalization process. It's a whole separate procedure for warrants, emergency warrants. And part of my time on the bench was spent in Burlington and presiding over the mental health court. So I'm familiar with that process and the benefits that that court can bring. But again, it's not the same population that we're dealing with usually in the civil commitment process, although some of them may have been through that. Or the forensic process where someone's filing in common, even though they're a criminal court, they have mental suffering from mental illness, but not to the degree that renders them incompetent. So I'm certainly glad to answer any questions the committee may have, but I think at this early stage it's really important to understand where the person is, in what process and how they move through that next phase. I'm not sure that I do, but I will before. I'll make sure I do before we move this through out. I will say one thing. I haven't read the report in a while, but they call it the, was it the Black Road? The Black Road effect. We refer to it sometimes, or it's referred to as the weight of the road. Meaning that when you have the road on and you talk with someone, it sometimes has an effect on them because of the appearance. So weight of the road is a phrase that I've heard before. Just want to correct that, correct it. Any questions for Judge Richardson? No, thank you, though. Thanks, I heard my legional. Joe, I think that you agreed that judiciary should be part of this process. We're a part of the process from beginning to end in any shape and form, no matter how it's been fused and we're there at some point. So yes, when we shouldn't be involved with it, we will continue to be involved and we look forward to working. Thank you. Jack, nice to see you, yeah, come on. I think you know all of us. Oh yes, I've been here once before. You have, but I'm gonna get the gears mixed up now. I have some old people talking, I don't remember much. Yes, good morning. Good morning. I'm Jack McCulloch, Director of the Mental Health Log Projects at Vermont Legal Aid. Thank you for having me. I'm actually glad to be anywhere. I've spent almost all week sick and I'm better now, so. Oh gee, I'm glad you're here too. And I'm the only lawyer in my project who's not sick at the moment, so. We all know the mental health system is in crisis for a multitude of reasons. And I really, like the idea, we greatly prefer if we can have the opportunity to work with the Department of Mental Health in a cooperative way on things that can hopefully improve the system, address some of those major problems. Maybe you could speak about what do you see of some of the major problems too? Well, the things that we see a lot are the people being stuck in the emergency departments, the people being stuck for weeks and months in hospitals, hospital beds, not because they have a clinical condition that requires it, but because they're ready to go and there's no place to put them. And the issue of coercion is, I think, is a major issue. But really, if we could get people out of the hospitals who don't need to be there, that would be a tremendous improvement to the system overall. I want to talk about, I didn't realize until very late yesterday that the focus today was going to be on orders of non-hospitalization, but I do have some thoughts about that. The nature, legal nature in order of non-hospitalization is essentially identical to an order of commitment. It's, the legal standard is the same, the fact that the person has to be mentally ill and in danger to themselves or others is the same as being committed to any of the psychiatric humans in the state. The only difference is that there must be a condition where the person can receive adequate treatment outside of the hospital. And the Supreme Court has recognized that the same constitutional rights apply to orders of non-hospitalization and inpatient orders of hospitalization. It's really burdensome on the mental health system and the judicial system. In, I did a quick review of some of our statistics in 2017 and in 2017 in the mental health law project, we handled about 300 cases relating to orders of non-hospitalization. And these were mostly cases where the, they're called applications for continued treatment where the person's order of non-hospitalization is expiring and the hospital at this date is applying to extended for another year. But there was a substantial group of them, maybe 50 or so, orders of non-h revocations where the person is alleged to be violating the order and the hospital, the state is asking the court to send them back to the hospital. So that's a significant chunk of our case load, both in my office, in the AG's office and in the judiciary. And they take place in every county in the state. And even in the Act 82, Section 5 report, the department admits current O and H practices have very limited influence on only a small percentage of eligible individuals. And there's a real reason to question whether O and H has substantially contribute to improving mental health outcomes, making people better, helping people there in the community. About five years ago, there was a tremendous amount of attention paid over in England when a psychiatrist who was considered to be the father of outpatient commitment or compulsory outpatient treatment in England published an article where he said, he looked at what happens when you put people on their equivalent of an O and H. Does it help them stay in treatment? Does it help them stay out of the hospital? Does it make their lives better? And what he found was that in well coordinated mental health services, the imposition of compulsory supervision does not reduce the rate of readmission of psychiatric patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty. Would you say this is a well-coordinated mental health system? I think we can make it a well-coordinated mental health system. And I think that if we're not providing a well-coordinated mental health system, we should not be making up for it by unreasonably curtailing people's liberty. So my point is that we agree with the purpose of S203. We agree that we should be re-examining the use and effectiveness of O and Hs. And we should consider what changes in the law are justified to make the system serve the people better. I should say in the list of people in the bill, one omission is the state mental health ombudsman at Disability Rights Vermont. And we would encourage the community to add them. Ed Peiglin, the executive director, is here this morning. You're also the young voicemail, is that right, Ed? That was two positions. No, it's one person. It's one person, okay. For the record, Ed? For the record, it's Ed Peiglin, the director at Disability Rights Vermont, which is the state's designated protection and advocacy system. And the Vermont statute creates the position of mental health care ombudsman. And that, statutorily, is the protection and advocacy system. Okay, done. We don't agree that the bill should specify that the treatment advocacy center report be part of the study. I'm concerned that that's really tipping the scales in one direction, because they're a very heavily pro-coercion organization. If the department wants this entity, this report to be part of the study, it will be, there's no question about that. But I think it's not making it objective and impartial to include that in the legislation. Which report is that? The one that, the Steading report that Dr. Steincard talked about earlier. Okay. I don't think that should be part of the conversation. I'm sure it'll be part of the conversation. I think specifying that in the legislation biases it in one direction. Okay. And I think they're, I haven't, I think that's what brought this up to begin with. Isn't that a good thing? That we should wonder about the effectiveness of our system? I do think we should wonder about the effectiveness of the system. And I'm concerned that having that in the bill, maybe a small point, is to say, we're gonna always have ONHs and we're gonna fix them in a certain way that the Steading Advocacy Center proposes as opposed to having your Y open and one of the questions clearly should be, should we even have orders of non-hospitalization? And so that's an observation for what it's worth. I didn't know that this, that that report was gonna be part of today's discussion. So I didn't go back and review that, but I can tell you when Mr. Steading was in Vermont about a year or so ago, I was, had an opportunity to meet with him and some other advocates. And I think that the one thing that you've heard about this black robe effect is, and he talked about that when we had, seems impractical to me. And let me tell you why that is. When we were talking, he said that what he would like to see is a system whereby the way someone gets on in order of non-hospitalization is, before that ever happens, they have to come into the courtroom, have a hearing with the, in front of the judge, the judge explains to them how important it is that they follow the terms of the order and make sure they do what's right. And one thing I think is a bit patronizing. But beyond that, the way orders are non-hospitalized, the way people actually get out of a hospital in practical terms is I'm sitting in my office and I get a call from the AG's office. And they say to me, your client so-and-so is ready to leave tomorrow. And we'd like then to agree to an ONH, can you talk to them? And I'll go to the hospital or I'll call them up more often and I'll say, here's what they want to do. They want to get you out of the hospital tomorrow and they want you to agree to the terms of the order. And I talk to them about all the terms of the order and explain to them what each one of them means as they have any questions. And they'll tell me yes, that all of a sudden it's fine with me, I've talked to them, people are ready and I'm ready to go. Or they'll say, well, item number three, I don't agree with, can you get that changed? Or they're asking me to do a year, but I only want it to be six months or three months, can you get that changed? And then I go back to the AG's office and I say, we have an agreement or we'll have an agreement if you can make this change or that change. And it happens and then the person goes out the next day. The hospital doesn't even wait for me to sign the order because they know once I've said we have an agreement when they send it to me in writing, I'll sign it, we'll file with the court and that'll be in order, the judge will sign it and that'll be in order in the court. If the system has changed so that instead of saying, your client gets to leave tomorrow or even sometimes this happens, your client's leaving in two hours, he'll be calling and make this happen. If all of a sudden the system says, your client can't get out until they go and sit in the courtroom in front of the judge and have the judge tell them what they have to do, people are gonna be stuck and locked up in hospitals longer than they need to. And I don't think the system can really, can really have a lab. I don't think the judicial system can adapt to that very quickly because all the judges that I've spent time in front of are very, very busy. And they usually don't have time to drop everything and go through kind of pro forma here in the patient. But I'm very enthusiastic. I think that this is an opportunity. You know, the chair knows that year after year after year I come in here, the department of mental health is proposing something and I'm trying to hold back what they're doing because I'm trying to protect my client's rights. If this is an opportunity for me and other patient rights advocates and the department of mental health to, he worked in cooperatively to do something that will actually make things better for our clients. That's what I'm very enthusiastic about that. Thank you. You might be having an answer to the question. Questions for Jack? Thank you. This is good. The people who are subject to all of this, if I'm getting it right, they are in some cases have not been convicted of a crime. They've been in trouble. They've caused trouble, but have not really been in trouble. The mental health issue is being dealt with first, but there's also people who've been convicted. There may be people who've been convicted of something at some time, but the order of hospitalization does not grow out of a conviction of a crime. It does not happen? No, never. And most of the clients that we deal with are people who are in the mental health system through the civil process. They've been brought in through an emergency exam. They've been through the process of an application for involuntary treatment, and then this is how they get to the order of non-hospitalization. So these are dangerous to themselves or others as opposed to criminals? Allegedly, yes. Well, allegedly they've found that to be that by the court. Well, some, yes, some, no. Some people, sometimes a person goes out on an order of non-hospitalization, pursuant to an application for involuntary treatment where the hearing is not taking place on the involuntary treatment. They've been there for a month or two, and they get ready to go without ever having had a hearing that convinced them to the hospital. What was I gonna say? Yeah, yeah. Okay, lots of things to be looked at. Thank you very much, I appreciate it. Lori Emerson? Good morning. My name's Lori Emerson. I'm the executive director of the National Alliance on Mental Illness of Vermont. So thank you for inviting us to be here today. And also naming Nami Hamat to be able to designate a family member to be on the committee to review the orders of non-hospitalization. A lot of families are involved with this experience with orders of non-hospitalization, and they may call Nami Hamat because their loved one may not be complying. And I think that this could be one of the issues that a lot of folks may have is they are responsible to manage their own health. And in doing so, they make those choices. So if they are at home and they don't follow treatment, and a lot of times it's because of the factors of their illness, that they may have severe anxiety, they may have severe depression, where it's very difficult for them to continue to seek that treatment that was ordered. I think it's good that we can have that discussion within the committee about all of these different factors. And one of the things that we really want to see is that we're not getting to that point, that we need orders of non-hospitalization. We really need to look at the continuum of care that people are getting treatment in the community. And the focus on mobile crisis teams embedded within police departments, emergency rooms are very effective as well as peer support. And what we really see is what really helps people with their mental health is relating to other people with that same lived experience and getting that support. So if we're really concentrating more on the front end to help people maintain their wellness as opposed to getting to that point of needing hospitalization, we're gonna really help to decrease those numbers. And I agree with Dr. Stein that it's all about building relationships with caseworkers, with therapists that you're working with. And unfortunately, I think some of the challenges we have is the workforce, with the designated agencies being able to provide that support with low wages, people are going elsewhere, seeking employment. We hear from family members that their loved one has had three or four case managers in the past couple of years. How can you build relationships without that support? So we really want to encourage the committee to look at the continuum of care. And I wasn't really prepared that this was gonna focus on orders of non-hospitalization. But I did want to raise those points that if we're looking at improving the system of care, we need to look at the whole system. This is one component that can help with those very few individuals who may continue their treatment through a court order out of the hospital, but it is very difficult for people due to some of the factors with their illness. And with the violations of the orders, family members do find themselves in that position, what do they do? And all they want is their loved one to get that treatment. And it's better to come from a point that it's voluntary. That's how they're gonna manage all of the symptoms that they may experience. And by forcing medication treatment it makes it a lot more difficult. So we really appreciate looking at the effectiveness of the orders of non-hospitalization and having a family member involved who has had that experience. Thank you very much, Lord. Questions for Lord? Thank you. Thank you. Thank you. I'm Devin. And it's Wilder, right? Yes. Would you like to testify for a few minutes, Dr. Devin? Sure. Devin Green, Vice President of Government Relations for the Vermont Association of Hospital and Health Systems. Thank you for having us in here today to speak to this bill. I'll be brief since we will need to digest this a bit more but we have placed improving the mental health system as one of our top priorities for this year. And I think anytime that we can bring together all of these people, the judiciary, the healthcare providers, advocates, family members, to work on any part of the system, we are happy to be involved with that. So we look forward to participating. I think that's all I have to say at this point in time. That's great. Thank you. Thank you. I was just trying to tell you that I miss Karen Barber. Where's Karen Barber here? Oh. I'm sure Fox said everything I was going to say. Oh, okay, all right, for some reason I didn't think you were here, and you were here, but you came in a little bit. Sorry, yeah, I was upstairs, yes. Are we good then? Yes. Okay. Well done. And my apologies for not having you on the list, it's just an oversight. Tell me your last name, please, I've forgotten. White, like the color. Okay. So I wish I could begin by thanking you for inviting me, but I wasn't inviting you. Yeah. And I think that's a problem. I think it's emblematic of what's happening in our mental health system that the people who are most affected by it are left out or not given a voice. Did you speak up to some of it? Yes, I said, I think the fact that the Vermont Psychiatric Survivors was not invited to this, to testify before the committee is emblematic about what's happening in our mental health system, and that is the people who are most impacted by it and its deficiencies don't have a voice in it. And while this particular statute does say that the Vermont Psychiatric Survivors can appoint one person with experience of a organ of non-hospitalization, I think that's a recipe for actually tokenism and marginalizing this kind of one individual on this committee. And so I would suggest that if you are sincere, I have no reason to believe that you're not, and hearing the opinions and voices of people who are impacted by orders of non-hospitalization that you expand the number to five people, and not just those who have experienced, personal experience of orders of non-hospitalization, but anybody who has a lived experience of having any kind of mental health crisis or a mental health challenge, because orders of non-hospitalization affects anybody who has been labeled with a mental illness. We all live in fear that our agency can be taken away from us on very little evidence and with very little recourse. And we all have different opinions about our experiences and about O and Hs, and if you've heard me speak, I've done some police trainings, and one of the things I remind people is if you know one person with a mental illness, you know one person with a mental illness. The only thing we have in common is that we're discriminated against on the basis of this label. And so I think you have to have many more voices on any of these committees when you want to include the voice of somebody who has the experience of being labeled with a mental illness. And I don't think, like I said, I don't think the person needs to actually have experience necessarily with O and H, because we all live in fear of O and Hs. The other thing I feel kind of important to say is that the vast majority of people who have been labeled with mental illnesses are law abiding, non-dangerous people. And I think when I come up to the legislature, I get this idea that the only people you think have mental illnesses are criminals or people who are violent and that's just not the case. And oftentimes, when somebody has committed a crime and they also have a mental illness, we just conflate the two as if the mental illness caused a crime. And there's just no proof of that. And I think it's something that we need to be really careful about conflating because once you've been labeled with a mental illness, you're just discriminated against all the time at every round. And it's because of attitudes conflating mental illness and violence and mental illness and criminality that causes it, makes it so difficult for us to get jobs, makes it so difficult for us to have housing, have partners and marriage and all of these things. And there's just simply no proof that mental illness makes you more prone to commit crimes. I mean, I know when I was psychotic and manic for a year, I didn't commit any crimes. I didn't have any run-ins with law enforcement. And I think it's also important to remember that the people who are closest to a problem usually are closest to the solution to the problem. And when I think about my own path to overcoming psychosis and mania, it wasn't relationships that was the thing unless you count the relationship with myself. Because what I think beyond the coercive nature of open ages, the real harm I think the real danger, the real effectiveness of open ages is that to overcome a mental health challenge, it takes the person, right? You have to be responsible for your own health, your own wellness, your own, you have to want it. And what I see with O and H's is that people have just given up their agency. They've put their energy into getting off the O and H and not into reclaiming their lives. You know, the thing that helped me most, I mean, there's this poem Invictus, I don't know if you know it, Invictus. But I mean, that's really, so I mean, that's what brought me back to health is, you know, I mean, I do every morning think whatever gods they might be for my uncomfortable soul, right? I do feel like I am the master of my fate. I do feel like I am the captain of my soul. And that's what it's going to take to overcome a mental health challenge. And you take that away. When you say, when you order somebody to take medicine or to do this, you have taken away the very thing that they need to get well. You've taken away their agency, you've taken away the fact that they are the captain of their soul. And that's why I think in the system that we have in Vermont, we see people just flowing through the system, right? We don't seem to understand that you can't actually get better and never be seen from again. I mean, I was a psychotic in Manifold for a year. I haven't seen a doctor in three years. I don't take any medication, right? Even though I supposedly have a severe and persistent mental illness. It's because I actually got well. No one, you know, I was told I should take medication and I refused, but I take care of myself. And I think you take that away when you put someone on an overnight. You don't say you have to take care of yourself. You don't say you have to figure out how you got into this situation. You just say follow these things on a sheet of paper and they just either follow them blindly and never dealing with the underlying issues that got them into the situation that they're in or they give up completely because they feel like you've taken away their agency. So I think also you need to be careful about opening up this box because, you know, most O and A's right now are in the civil side, which I'm most familiar with are achieved through stipulation. That is people in the hospital and they say, if you want to get out of the hospital, stipulate to an O and H. And everybody wants to get out of the hospital. So they'll stipulate to an O and H. They never go before a judge. They sometimes don't even read what the stipulation, what the orders are. They just want to get out of the hospital. And I actually would like to see more people go before judges. They probably don't want to go because I don't think a lot of these O and H's would ever get ratified by a judge because the people are competent to weigh the risk and benefits of the medications that are being proposed. And a lot of the O and H's, I see, the people have not refused to take medication. They simply are not getting better. I have a person who became super suicidal after she was put on an O and H. And one of the requirements, and she stipulated to get out of the hospital. And she just ended up basically going to the emergency room every week after she was on the O and H. She just didn't want to live anymore. And that's not, that's one story, but it's not, I've heard that from lots of people. They just, they stipulate, they give up, they just want to get out of the hospital and then they regret it. And then it's the trauma of that experience that just causes them to get caught up in the system. So, I think be careful what you wish for, because... We don't know what we wish for. Yeah. That's right, right. Be careful about it. Because if, you know, a lot of these O and H's are not, I don't think they would survive a judicial scrutiny. So, I'll leave it, I'll leave it there. Thank you very much. Any questions from Ms. White? No, thank you. Yeah, I'd love to. Thank you very much. Oh, go ahead. I was wondering if there is a place in the United States, a state in the U.S. or another country that you would point to that has a system that works better than our system and that we can use as a model or use anything? No, I think that's good that there's no model. Because, I mean, I think Vermont needs to dig to whatever place that they Vermont the first state not to have slavery. We need to dig back into those values and figure out the first state to not force people to take drugs. Because I think the more you force people to take drugs, the more it symbolizes that your system is one that's not functioning. This system operates too much on crisis because mental health crises, I really think that's a Nazi-Moron because, or not maybe a Nazi-Moron is not the right word, but these things don't happen overnight. There's a slow buildup. And our system is just really operating on waiting for that slow buildup. And one of the things that we could do is to think more about holding people accountable before the crisis. Because this whole thing about street outreach, mobile crisis, embedded peers, all those things, all those resources are going into dealing with the crisis. That's why we're putting our money. We're not putting our money into preventing or even just getting to the problem sooner. And the designated agencies, they're not utilizing best practices in some cases in terms of getting people therapists. Because usually you call your therapist when you have a crisis, right? If you don't have a therapist, what do you do? You go to the emergency department. There's so many things that we could be doing sooner instead of just always operating in crisis, which is just another symptom of a system that's not working. Thank you. Senator McCormack. I come to you with great sympathy. I'm fine to agree with that. I memorized Invictus when I was 14. Isn't that a great call? Yeah, yeah. I can still do it. We can do it together in unison. We'll be very dramatic. We'll be very dramatic. We'll help shout each other out. I also was the sole dissenter in the committee when we passed the bill on forced medication. Okay, so I just want to run this fight because as strong a libertarian as I am on this issue, I've never been entirely confident in my own position. And it's this, if you remember many years ago, Mark Vonnegut wrote a very interesting book in which he said that autonomy and agency are purely theoretical. If you're psychotic, he said that he was in a state where he really was not free because he wasn't thinking right. And that he really regarded the forced medication as a good thing. And I've never been able to, as I say, ultimately I've come down on the side of agency and personal freedom. But I've never been entirely comfortable with it. How do you answer that argument that when you're psychotic you're really not free? That was not my experience. I was the one who was telling my doctor I was psychotic and then he thought that meant I wasn't because I was aware that I was. Which is just a stereotype, right? It's a stereotype that people who are psychotic don't know they're psychotic. Therefore, if they know this, they think they're psychotic, they're not psychotic. And therefore you can be psychotic for over a year and destroy your life. I think there is a point where the thing is, psychosis rarely happens just in a split second and there are stages when you are aware of what's happening and then it's different types of psychosis. Some psychosis is seeing things, some psychosis is that aren't there, hearing things aren't there, feeling things aren't there, smelling things aren't there, or just delusions of thought. You're just in a different reality. But even in a different reality, there's still a rationality to it, right? So, an example I sometimes give is that the police officers in North Hampton saw this one man in a fight with another man, right? He was seeing somebody who wasn't there, right? And he was in a big fight. And the police officer merely walked up to him and said, both of you, break it up. And he did immediately, right? And so you're not, it's a different reality. And the same thing with me. When I was psychotic, you could say things to me if you entered my reality, right? I had a friend that said, you know, you should stop giving money to everybody who's walking down. And everybody who asked you for money, I would give them money. They said, you want money? Oh yeah, here's money, let me go to my ATM, let me give you more money. And this homeless man came up to me and said, you know, you don't have to give money to every homeless person who asks. You just set aside a budget every day, maybe a dollar, and just give out a dollar. And I was psychotic, you know, showing people to my ATM, but after that I gave people a dollar, right? So you're not unreachable necessarily, but as I said, you've met one person with a mental illness, you've met one person with a mental illness. Although I feel like I am an expert on psychosis since I spent so much time in that state, but. Well then, let's say that might there not be a person with a mental illness who really needs to have drugs for us now? I like that terminology, yes. You might want to force drugs on somebody who's psychotic for control purposes, but that's not treatment. That's forcing drugs on somebody to control them. When you're talking about forcing drugs on someone to treat them, I think those are just incompatible concepts that force drugging somebody, it's treatment. You have to be involved in your treatment to get better, right? You have to be in a therapeutic relationship to be have treatment. But if we just want to control somebody, yes, let's call it force drugging and if you've met the due process requirements to do that, maybe you have to do it, but let's not call that treatment and let's not hope that this person is now in treatment because they're not, you're just controlling them for public safety purposes. So that's how I would respond to Mark Vonnegut. Well, thank you very much. You're welcome. We'll get back to this good next week. Okay, community care, you're not going to believe this, but we have some time. If you could be back here at 10 after 11, we invite somebody coming in to call around the house.