 Good morning. This is the house health care committee. It's Wednesday, April 14th Just a few minutes after 9 a.m So this morning our committee is Turning our attention to sections of a Senate bill s3 Which deals with issues of mental health services and Corrections in part are in large part And has come out from the Senate with several provisions that but it is it is a bill that is currently in the house judiciary committee But the chair of that committee has asked For the house health care committee where we have jurisdiction over issues of mental health and health care Has asked for our review and input to in particular several sections but the entirety of the the bill and And we have this morning invited several witnesses to testify and then It's an opportunity for us to talk amongst ourselves have some committee discussion and perhaps and make some Proposals possibly make some proposals to the language that's come over to the house judiciary committee so with that I Guess I'll start by welcoming deputy commissioner of the department of mental health morning Fox Who we've invited and it's joined us and I understand that you many ways are taking have taken In part the lead on some of these issues is that So let me just welcome you and have you introduce yourself and then we'll begin by Inviting your thoughts on what's in s3 and then entertaining hopefully entertaining questions from committee members Or no, thank you chair Lippert for the record morning Fox deputy commissioner department of mental health I'd like to just begin by thanking the committee for taking the time to review this bill as Chair Lippert mentioned it has been something that I've really pretty much taken the lead on for the department in regards to The Provisions within s3 S3 actually began in the last biennium as a separate bill that was known as s183 at the time and Was revived if you will this session under the moniker of s3 and Began as close to s183 At that time. It's gone under some revisions to the point where You have the the copy now that was passed by the Senate earlier during this session The provisions of this bill are Pieces that are what I see is very important in our system of care It's been a long-standing issue one that I've testified on in many times in regards to The intersection of the criminal justice system and the mental health system Individuals who Come into the mental health system through the criminal justice system have continually come into Complexities that place the Department of Mental Health the criminal justice system public safety and treatment all at Crossroads if you will sometimes at odds with each other sometimes in sync One comment that I know that has been put out there at at sometimes is that the Department of Mental Health does not Engage in public safety and I wanted to just clarify that that's not accurate That It's not our primary goal like the Department of Public Safety in that sense however There are safety concerns that the Department of Mental Health and providers do have to take into consideration when treating individuals This bill Contemplates several different aspects it contemplates Chains some changes in how and when particular evaluations are are Are achieved in particular the separation of competency and sanity evaluations when both are being ordered The Provision that is in this bill Basically suggests that when a competency and sanity evaluation are being proposed that the sanity evaluation Be held until the evaluator can Make an opinion or form an opinion that the individual is competent to stand trial and at that point if they feel that the Individual is competent to stand trial that they would go forward with their sanity evaluation and creating two separate reports This is an industry standard supported by the association of Psychiatry and law the overarching National Association of forensic evaluators is also recommended by The bar association that they be Separated as well as there are other states that have done similar Legislation to separate these these types of evaluations This bill also Contemplates various pieces of notification to help provide notification for Victims of crimes or victims of Well the crime existed but whether or not an individual is the actual perpetrator or not May not be determined, especially if someone is incompetent to stand trial and it hasn't been necessarily determined that that individual Did commit the alleged offense? However, there are still victims that are involved and so this bill does contemplate The ability for the department to notify the state's attorneys or attorney generals if they happen to be prosecuting the case that An individual that is under the care and custody of the commissioner In a secure setting if they're being discharged from a secure setting That or from custody that the department would notify that state's attorney Of that information that they are being discharged now from custody or from a secure setting So as to be able to notify any potential victims so that they're aware that The individual that is had been alleged to have committed the act May no longer be in a secure setting This bill then goes on to contemplate Notification of the state's attorneys or attorney generals for individuals who are in the community on orders of non-hospitalization and We have spoken out against this provision On the notification for on H's I've been following the testimony quite closely and I Don't believe I've heard any testimony yet that has supported The inclusion of this in the in the bill and it's my understanding that and hope that House judiciary is looking to strike that it that language from from the bill The on H notification piece Is quite concerning as it does relate to more detailed information Really getting into Protected health information how a person is engaging in treatment. It is also fraught with concerns as to what what is meant by the intent of That they are not following their their order of non-hospitalization it creates conflicts between the treatment providers as well as The person that they're providing treatment for a main and Significant bedrock of treatment for any individual is having a solid trusting relationship between the individual and Their therapeutic provider and having that therapeutic provider basically having to play the role of sort of a probation officer and Letting an individual know we will have to notify the department to notify the courts if you miss an appointment miss a dose of medication You know do something else that's a Contrary to your order of non-hospitalization Those types of of events do happen while people are in orders of non-hospitalization, but it's not always indicative of a person doing poorly or That their treatment is not sufficient and so it's been our suggestion as well as others that this language be struck from the bill and Live in the study section of this bill and from my perspective The language should include that we would look at at this provision and determine if it should be included and if so how And and so that's the a major piece of that The other other major provisions that will likely talk about further as well are the Corrections assessment on mental health services. Oh Yes Yeah, right, sorry, I'm me myself So this is very helpful Deputy commissioner to have you walk through this. I'm wondering if Before moving because I think you were about to move on to sections five and six. Is that right? Yes, sir Could because and and I think there's more there's certainly more to talk about there But I'm wondering if we could just make sure that we Understand the department's position on each of the provisions in the earlier sections because you've you've met you've spoken to one of those sections and said that you recommend It's removal. You've described some of the other sections, but have not at least in my mind I didn't necessarily Understand what whether the department had a position on those other provisions and I think in the interest of clarity it might be helpful to Before going on to sections five and six where I think they're I anticipate they'll be Considerable more discussion to walk through the first the first to to revisit the provisions you've described Indicate what the department's position is or is not on each of those is that would that work for you? That's perfectly fine. Yeah, that would be great. So in section one Part two, which is on the top of page two of s3 That's where it discusses this separation of sanity and competency evaluations And we are in support of of that language As I mentioned earlier, it is a an industry best practice at standard And so we definitely support support that provision that you had of course said that previously and I Draw drew an assumption from that but I but I think it'd be helpful to speak to be explicit. Yeah, I'm Trying to be as explicit as I can without getting too explicit Okay In regards to The notification pieces When an individual is is Section is section two isn't there a section two that has to do with Council And oh, yeah, sorry Yes, no, my apologies We definitely support in section two Vermont legal aid having party status and representing individuals in these in in these cases in that the Mental health law project and Vermont legal aid Have the expertise and knowledge of the system and believe that and we believe that they can best represent the defendants When we're talking about commitment cases when an individual is found incompetent to stand trial or Not guilty by reason and sanity and looking at hospitalization hearings things of that sort We also support the department having the ability to call witnesses and be present in these hearings as well As happens currently we do not have party status in criminal court proceedings and so it is not I don't want to say it's common But it's it's definitely not uncommon that the department and the designate agencies are unaware of the outcomes of criminal court cases in that are being resolved With either orders of hospitalization orders of non hospitalization as a result of an individual being found by the court is Either incompetent to stand trial or not guilty by reason and sanity And so this would allow us To a be aware of this information and to best advocate for Whether or not an individual should be hospitalized And meets that that level of care and need or whether Their Their treatment needs would be best met in the community on an order of non hospitalization Then going into Section three On the notification provisions When an individual is determined to be incompetent to stand trial And their charges are the the way this bill is written it Looks at and envisions that The department would notify state's attorneys or attorney generals When we're discharging an individual who has been Found incompetent stand trial and their charges have been dismissed And so If their charges have been dismissed There would be no notification of a discharge Only when the state's attorney or attorney general keeps charges open Would there be at that time That if we're discharging an individual from a secure setting or from the care and custody of the commissioner That we would notify the state's attorney or attorney general if they're prosecuting the case For the reason to notify victims of that release We're we're good with that language. We're comfortable with that We feel from a from a HIPAA perspective that We're a we're providing the least amount of information possible in that all we're really notifying the state's attorney is the individual is being discharged From a secure setting not to where they're going not to what their diagnosis is not to what their treatment has been solely that they're being discharged and as long as there's a Criminal court case it helps us to feel more comfortable about sharing that information We're also aware that there are many other states that have similar provisions and the federal regulators And and other federal agencies have not taken Any concern with other states providing this and so again that has made us feel comfortable that This falls within the confines of Not not being in violation of of HIPAA in that sense As far as not guilty by reason of insanity If a person is adjudicated but has not guilty by reason of insanity We would provide that same notification to the state's attorneys And the way this is is written and it is envisioned Is that for cases of not guilty by reason of insanity? it does not limited to whether or not the charges were dismissed or not And again, I think the department is is good with with that Given that historically here in vermont NGRI adjudication is extremely rare and when it does happen It's almost always for extremely violent types of crimes and so again Because of the narrow scope of The information that we would be providing to the state's attorneys We again still feel comfortable in being able to provide that information And not being in violation of of HIPAA run mute Thank you Morning fox did you use fox did you use an acronym that I didn't I would soon as I would you just Please share what that stood for because I'm not sure everyone will yes as soon as I said it I knew I needed to clarify NGRI Is the acronym for not guilty by reason of insanity Got it. Okay. It's just that some of us don't live and eat these Acronyms, so I was sitting here and I know I know what that means, but I can't Right My mind might not be the only one No, and I and I apologize too because you know my history Is having worked in a forensic facility before That was run in another state And I ran their maximum security units there providing evaluations and assessments and court testimony Related to cases and so it's just a part of my vernacular and I apologize. No, okay. Well, thank you for clarifying. Okay So let's see Other provisions There is a Provision as well. I believe it's section four of this bill Uh and goes on into uh page seven Section so just just to clarify that the section that you talked about previously the onh The department does not support and recommends that that's part of section three That that recommends to put it in the study And if it's in the study to say if it's included if so if it should be If this should be done, how should it be done? Correct. Mike, I don't want to put words in your mouth. I think that was close to what you were saying It's not clear that department is is still just a little uneasy about This type of notification in general. And so I think we need to discuss that and the HIPAA implications And whether or not this is even feasible within HIPAA and then if so then how how would this work? Because again, there's a lot of information and for what purposes Yes, okay, and I I think has been communicated informally to We some of us that it is the intention of the House Judiciary Committee to delete that section from the current Their redraft of the bill That's my understanding anyway Representative Donahue Some other answer too Okay, just very quickly on that. I've been listening in To testimony and yeah yesterday afternoon actually the Center for Crime Victim Services Testified and would like to see it removed So just for folks to be that that perspective what they want it in the study, but they think as It is now it shouldn't be included. So, okay Representative Peterson and Representative Goldman and Representative Peterson I think I think we're gonna take some questions now before we move on so that we Are questioning. Yeah, you may have said this but I'm not understanding. Um, and thank you and good morning. I'm sorry. Good morning. Um What did onh is a non-hospitalization order? What what does that mean like logistically? Like what what happened? But where does the person go? Sure. So really what an order of non-hospitalization is is that an individual is being Placed under the caring custody of the commissioner. Uh, it's a form of commitment There's two types of commitments that where an individual can be placed under the caring custody of the commit of the commissioner either an order of hospitalization where they're Ordered under the caring custody of the commissioner and placed in a hospital Or an order of non-hospitalization Which places an individual under the caring custody of the commissioner. However, that their treatment Can be provided in the community And so an order of non-hospitalization the The language of the order of the order itself will have many many variables it can be as as limiting as an order of non-hospitalizations that says You need to live at a secure residence like the middle sex therapy or community residence And it needs to be that specific that a judge has to order an individual to that Specific location and that they require that level of of security Generally, otherwise orders of non-hospitalizations will have provisions in it that are generally The general types of provisions you'll see are that you'll continue to engage with your treatment team. You'll take medications as prescribed Maybe live in a mutually acceptable You know residents You know things of that sort And and whatnot And And generally if a person is in violation of their order of non-hospitalization the designated agency is really the the arm of the department that kind of Operationalizes the order and so it's really up to the designated agency to determine So if an individual missed a dose of medication Is that something that is concerning? Is that something that should require, you know revision of their order, you know, do they you know those types of things? Quite frequently what happens on an order of non-hospitalization if an individual will say Does decide to not take a medication or skips an appointment with providers. They're going to work to continue that treatment in the community If they're unsuccessful in kind of maintaining that engagement The designated agency can then come back to the department and recommend either an amendment to their order of non-hospitalization or Oops, you just went silent Fox Fox, we can't hear you You've gone silent Something you can't hear you. Yeah At what point did you guys lose me? About a minute or so ago This is my problem with zoom and I apologize. That's why you just saw me I've just moved my keyboard away so I can be close to my laptop My laptop apparently likes to just intermittently decide to mute me and mute my speakers as well Didn't show you officially muted, but you suddenly the sound was gone. Yeah so and then I think you were saying that in order of hospital non-hospitalization That you try to engage the community the designated agency will try to engage with them They'll determine whether like is missing one medication Is that is that rise to a level of having to do anything further or just to re-engage the client? But that there there could come a point which and I think this is where you may we may have lost you Is there could come a point where the agency would deter as the arm of the department may determine That they may determine that there's a need to either amend the order of non-hospitalization Uh-oh, that's exactly what happened before that's the point That's the same moment. They don't want us to know. Yeah. Yeah, I think I think when they get to the word revoke Maybe that's what I keep thinking about to say but They they could either seek to amend the order of non-hospitalization or to seek to completely revoke the order of non-hospitalization thus converting the order of non-hospitalization into an order of hospitalization And and we tried to do that in conjunction with the designated agency and and and the department You know, we're also looking at How is the individual doing and do they actually Kind of meet criteria for needing to be hospitalized And so generally, you know missing a dose of you know, one's medication is not indicative of needing to be hospitalized More so a pattern of that or an increasing in their symptoms Endangerousness things of that sort would be more indicative of the the need for a complete revocation of one's order of non-hospitalization Could I ask one more question please? Yeah Um, is it possible that an individual would be in the community? Or they are always going to be in a supervised setting because you're saying miss one dose of medication So i'm just trying to picture that dynamic It it varies from individual to individual Some individuals on orders of non-hospitalization may be living in their own apartment Some may be living in a in a congregate group home type setting or intensive residential Um at the secure residential Everyone there is you know by statute has to be on an order of non-hospitalization Thank you On on this point, uh fox would you could you give us some general sense and not specific to the number but but Many there are numbers of people on orders of non-hospitalization. This is not a rare situation is right. No, there's there's roughly 300 plus individuals at any given time On an order of non-hospitalization. Don't quote me on the number, but yeah, but that's a rough area Yeah, so just to give members a sense that this is not like an exception. That's done with just a handful of people Uh, represent. I'm sorry. Well, yeah, just to jump in on the number about how many do you know roughly? How many per year actually get revoked and a person needs to be re hospitalized? Or is it fairly rare or is it fairly frequent? Well, I'd say it's more rare than frequent Anecdotally A dozen or more maybe uh in a given year. It's It's not a large number. It's not in the hundreds by by by any means Right. Okay. Thank you Represent Peterson you had a question still Yes, thank you, uh chair Um My my question has Changed as we I've listened here a little bit. Um And you you said or represent donahue you sent an email Um, outlining the section that I guess judiciary is removed from the bill And I think that's the same language that morning fox indicated Did not but Just a general overall question Is that removal going to make victims less safe? Not in my opinion, no With with that information it was the way this language was written Basically, uh a designate agency is kind of through us Would be required to We we'd have to notify a state's attorney if an individual missed an appointment And Frankly, I think then if a state's attorney receives that information and tells a victim, what are they to do with that information? It it's not really helpful. It could create more anxiety. In fact, uh and really kind of increase someone's trauma response Uh, not really having much information that they can do anything with I think that's kind of the part of the basis of some of our concern with that section aside from the the HIPAA We're talking about a medication that someone missed a treatment You know section that someone missed they didn't come to this type of treatment You know, they didn't take this type of medicine and we're really starting to get into much more protected health information and again From a victim notification piece I don't see it as very helpful to an individual to just be told someone missed an appointment Like do we tell them then next week they missed one again? Yeah, um, and then three weeks later they missed a dose Gotcha. Thanks for your patience. I I was trying to put it all together Again, if I may uh, I this is this is indirect but are in informal but Representative donahue having been following the testimony in house judiciary I think you mentioned that center for crime victim services We're also asking to have this section removed so they they their their role is particularly looking out for the interests of victims I think that's actually for the exact reason that the deputy commissioner just said that it could be creating false Impressions about what's happening with the particular individual. So but that it would still be put potentially still be put into the study That would be followed up When we get to those next sections as to maybe that should be changed revised modified in some way So if I may add the Vermont medical society document also is supporting that change, right? There's a document in our website. Okay. I'm you're ahead of me. Okay. I was just looking through the documents Yeah, well, we're going to hear from them At new or at 10 o'clock. I think yeah, yeah Right As I said earlier too, I've been following this very closely have been in almost all the testimonies whether I'm testifying or not And I've yet to hear anyone testify in support of keeping that provision in Okay, so represent page Yes, deputy commissioner, and maybe this will be part of the study but at what point When should professionals notify Um the authorities, um, you know when somebody's missed their medication or what have you know Is there a period in which in which uh, you know law enforcement states attorneys should be notified And will that be in the study? You know I think that that's the intent of putting this language into the study is if it's going to happen When should it happen at what point? With what information and for what purposes? You know I think the the question is does You know for for instance missing a dose of a medication telling states attorneys And uh, you know That information What's that useful for well, okay I One dose I can understand not releasing that information, but you know how many doses before you do notify or You know, right? And I think I think we want to be careful about about that because a every individual is different And You know, I think there's a lot of pieces and I again, I think this is the conversation that the study group would get into is uh the impacts of of an individual not taking medications and you know in this example And What their current presentation is Things of that sort What their history is what their history is, you know like went off medications There's a lot of factors. I think that that could come into play that that would need to be considered on a case-by-case basis Um, but again, I think that's that's what the meat of of the study would would really need to take a look at again If if that this type of notification could happen For folks who are in in the community And I guess in many cases there's no real answer to this question, is there? In some there won't be Well, might if I may might might it also be the case that there may be in terms of what you were saying earlier uh prior to possible notification of the law of the state's attorney or law enforcement is the possibility of a revision Of the order of non-hospitalization actually adding other provisions to it and or the possibility of revocation Which would I mean so there's there's there's other there's other steps that it seems that there may be Available short of that type of notification But but I I don't pretend to be expert in this area, but just as I'm listening out hearing that there that there's a Degrees of of actions that could be taken Now you're exactly right chair Lippert that you know, there's already within the processes and statute the ability to amend orders and you know different avenues to Seat to you know and keep keep an individual engaged in their treatment As long as you know that treatment is seen to be you know a positive and helpful thing and and a needed thing And as long as it's determined that the person should remain in in custody I think I mean it does it does still have the question of is there a point at which something else needs to happen And I think that's what I see the study trying to engage with the study committee trying to engage with And I think that gets completely represent pages President Goldman I'm just wondering what the role of the clinicians are in this decision Is there an intersection between the clinicians and the and the law enforcement and how that happens? I mean if someone's missing a dose of medicine that seems to be a clinical There is a clinical problem So I'm just wondering where that fits in if it does Well, I guess my my first response is an individual missing a dose of medication isn't necessarily a clinical problem There are many reasons why why someone might miss a dose of medication Someone's sick You know things of that sort pharmacies make mistakes don't get delivered And so I want to be careful that we don't just say you missed a dose doesn't matter why And That's a clinical problem. No, no you know, I think From a clinician perspective, I think I think their responsibility is to their client. They're there to provide treatment and support to to the client And then I think it's on on them as far as their clinical assessments as to how an individual is doing And you know, occasionally, you know, if they're if they're being successful in the community And living independently have engaged in services Working volunteering, etc You know those all those types of factors need to be taken into into account as they're you know working with the individual If if they're starting to fail in the community as a result of Not following some of the conditions in the order That's when you know, they may approach the department to say we want to amend the order of non-hospitalization Or we think we need to revoke it Generally what happens is They will reach out to us before they get to a place of asking for a revocation to let us know Hey, I think you know, this individual is is struggling right now And it may be that they're in complete compliance of the order, but they're just struggling And and such And so we have those conversations When we also have a care management team at the department That works with each designated agency to review the individuals who are on orders of non-hospitalization On a regular basis just to check in As these are individuals under the care and custody of the commissioner And so we find it incumbent upon us to make sure we're aware of how they're doing and that it's not just occurring in a vacuum if you will And so we try to keep close clinical tabs too and making you know recommendations or having those conversations of Should we consider an amendment to their order? Should we consider a revocation? Things of that sort. So there's that consultation piece as well Yeah, that's very helpful because it seems to me that it's going to start with the clinicians They're the first ones that are going to notice so when you say designated agencies You're actually talking about clinicians and I'm just learning this system. So that's helpful to me. Thank you. Yes So it occurs to me. I I I'm making certain assumptions and I shouldn't be in terms of your availability Fox, what what is your availability to us this morning because I I'm we're spending We need you guys have me all morning. Oh, well, that's a that's the right answer Seriously, I'm pleased to hear that because I think because I really I appreciate that As much as anything, but I do I do want to note that we're going to be hearing from A witness at 10. So we may need to pause some of this hear from them And then because because they are not available all morning They are they are going to be available only for a window of time starting at 10 So just so everyone understands that and those doctors and their limited availability Yeah, you got Okay, so represent page and then represent Donahue and then I'd like to suggest that we Move move on if we can Okay, um, you mentioned that we have about 300 patients I guess at anyone or During the year. How many clinicians do we actually have that are that are helping these? These individuals And what and what's what's there? What's their background? What's what's there? Their ability to help these Well, all of them are seeing a psychiatrist at the designated agency Yes, and unless unless there's no medications being prescribed, which I would find highly unlikely for an individual on an order of non-hospitalization But and in that case, then I'm sure the psychiatrists are being consulted But may have decided to Decrease or or discontinue or not start a medication But generally they're they they have psychiatry that are following them And then are working with social workers and case managers And then it depends on what other services they need. Would they be receiving individual therapy? You know group therapy Other other types of supports through the designated agency So, you know our designated agency has some 5000 Plus employees throughout the designated agencies Not that they're all involved with individuals on orders of non-hospitalization, but So, yeah, but you know from types of in types of clinical services and clinical Clinicians that they'll be working with We were talking about psychiatry, social work, mental health counselors Things of that nature. So there's enough to go around the health I believe so, I think it would be fair to say that individuals who are In what would be the serious mental illness and I think these individuals those fall within that category are Those those resources are prioritized Yes represent down here and then let's move on to the next section so, yeah, I mean, I think the The reason for this bill and so forth is addressing a really important legitimate issue and concern around Danger public safety treatment needs for people who have been involved potentially and or accused of violent crimes, but I don't want to lose Because I think the impression there are 300 a little more than 300 folks in any given year on an OH and That might create an impression on people that there are 300 plus people who have been accused of a violent crime Or on an OH and I think it's important to distinguish many of those folks are through the civil system An OH through the civil system I'm just checking the foxes is nodding that in other words they've never They have not even been charged with a crime and then one can also be on a an OH Coming in the door from the criminal system, but it does not necessarily mean the charge even was for a violent offense Right to representative donahue's point The vast majority of people on orders of non-hospitalization are through civil court not through criminal court And also to representative donahue's point I mean Many individuals who are placed on orders of non-hospitalization through the criminal court are For folks who have not committed violent crimes And and such like that so to be Yes, and this and this bill doesn't Address civil OHs at all when this whole discussion. It doesn't even touch on those. This is only criminal process Correct Right, that's those are important distinctions in terms of the numbers particularly it could give a completely wrong impression Let's move to uh, I think that's that was section three. We were mostly talking about there So I think in section four We're looking at what this bill envisions. I believe uh, I don't know how to actually call it but Jay Within section four Submit to a reasonable mental examination by a psychiatrist Or other expert when a court ordered examiner pursuant blah blah reports that defendant is not competent to stand trial The way I understand this is that This would allow The state's attorneys to Have an individual Uh Meet with a forensic examiner or expert of their choice Beyond just the neutral evaluator That the court may have ordered There's been some testimony I believe from the defender general that phrase this as a doctor shopping And if the state's attorneys don't like the neutral evaluator's Uh opinion that they could doctor shop until they found an evaluator whose opinion that they did like The as part of one's natural defense The defense council can also do that the defense council That's part of an individual's defense is that defense council can Hire their own expert DMH does not want to get kind of in the middle of Who's doctor shopping and who has that ability? But the way I personally and I think the department how we view this is that Regardless of doctor shopping Um, if the defense has their expert and the state has their expert in the end The experts will be cross examined by lawyers And either the judge or if there's a jury they will make a decision and a determination as to Their whose opinion whose expert opinion That they're going to accept So I think we're relatively neutral on on this piece But as far as if it were to go forward I we would not be opposed to it In that again in the end the judge or the jury will decide whose opinion they're going to accept Okay, and let me say that I think sections one through four, which we've just gone through our It's important for us to understand But they're in large part really the province of the judiciary committee in terms of some of the judicial But it's but I think it gives it's an important piece for us to understand the context Of of what what's being talked about here generally So but I see those are primarily judiciary decisions So I see that our Yes, I think our witness is uh has joined our screen our next witness and so um I think what I'm going to do is to Welcome and I'm sorry. I'm I'm going to ask you to introduce yourself Because I don't I don't believe we've met before and uh both introduce yourself by name and your role. We've invited you And uh in your role with the Vermont medical society Uh Yeah, you can hear me. Okay We and to say that we've been hearing from uh deputy commissioner morning fox And walking through the sections of the bill Um We have not yet reviewed sections five and six, but we've reviewed the other sections and asked the department their point of view on those and so we Thank you for joining us this morning and we understand you have a narrower Window in which to be with us. So we'll pause our testimony with with deputy commissioner fox and uh welcome your testimony Oh, thank you so much and thanks so much for for having me here. My name is dr. Simi raven I'm the the president of vermont medical society Um, and I'm uh very pleased to join you and to talk about uh s3 um So I'll I'll share a little bit of my background in the area Great and just to give you some perspective on where where i'm coming from in my interest in this area um So I wear a couple of different hats. I'm the president of the vermont medical society and I also serve on faculty at uvm and the department of psychiatry and for uh many years at Yale university school of medicine in the division of law and psychiatry I'm also chief medical officer at howard center in burlington Um, and I I just wanted to note that the vermont medical society has identified forensic mental health And forensic mental health infrastructure is as a real priority. So We share your dedication in this area and I want to thank you for your work Um, I'm a forensic psychiatrist, which means I trained as a physician and then in adult psychiatry Um, which is a specialty that focuses on cognitive psychological and emotional health And then I completed additional training in forensic psychiatry Which is a field that kind of has a a wide umbrella and encompasses both care of people who Experience mental illness and have justice involvement and also A wide range of psychiatric evaluations for the courts Another piece of the work is violence risk assessment So in my work I care for people who experience mental illness and have violence history um, I also Perform uh competence to stand trial evaluations and criminal responsibility evaluations and train different clinicians in these areas um Let's see. So and I got sort of interested in this work, particularly, uh, the Um strengthening and improving forensic mental health infrastructure in vermont through my clinical work First in inpatient settings now in community mental health settings When my colleagues and I recognized That there are a number of areas where we can improve our systems of care For people who experience mental illness and have justice involvement Um, I was really excited to see uh, this legislation this proposed legislation that has the formation of a forensic mental health working group um, and I really see this as the having the potential to Do a number of things First make our community safer And really support a specific subset of people Who experience mental illness and have justice involvement? It's a very specific and sort of narrow subset people who have been found not guilty by reason of insanity And people who have been found not competent to stand trial um, and my perspective is that having robust community support would um Prevent people in this this narrow group from being hospitalized longer than is necessary um And help people be successful in the community so sort of to say it another way when we have Appropriate programs for insanity equities or those who've been found not guilty by reason of insanity uh, those individuals I can lead more lead fulfilling and Robust lives in in in the communities and our communities are safer And I think that the formation of this Working group would be a first step in that direction So I have a number of specific comments if I may Yes, and then uh, at some point if you do willing to entertain questions as well I would be happy to um, entertain questions as we go along because I know that it's sometimes hard if I go from topic to topic To to switch gears. So I'm very happy to um Discuss questions as we as we move along great. I'll take the lead and trying to just Interrupt you as as necessary Sure. I'd be happy. You're happy to do that um, so one of the Issues that has come up and is outlined in s3 Is the separation of evaluations for competence to stand trial And sanity or criminal responsibility evaluations And I want to thank you for addressing that issue um, I strongly support um, the separation of those two kinds of evaluations I essentially if and and I'll I'll just Describe this a little bit My understanding is it's it's uh, if an evaluator is evaluating someone's competence to stand trial And they recommend they would recommend that an individual be found not competent to stand trial They would stop there and not perform a criminal responsibility or sanity evaluation and I think that that is really the the most ethical and appropriate Way to go rather than having someone go forward With a criminal responsibility or sanity evaluation For someone who would be recommended to be found not competent And I'll I'll explain why Really an incompetent defendant really can't adequately participate in that criminal responsibility evaluation um Because I essentially if somebody is found incompetent or recommended to be found incompetent The evaluator is saying that they have an impairment that impairs one of the two prongs of competence The ability to work with an attorney or to meaningfully negotiate and understand the court system And that sounds like a really high bar, but in practice, it's a pretty low Bar it's not uh, sometimes when I'm working with trainees they ask, you know, they're often difficult relationships with attorney and client But it's not the ability to work with a specific attorney, but the general ability to work with any attorney And on the other hand the other prong Negotiating the criminal justice system and the court system is really very complicated But what we're what we're looking at when we evaluate competence to stand trial It's not a quiz of can you navigate the legal system, but an ability To learn to do that and to understand sort of the very basic framework. Some of the questions we ask are Who is the judge? What does the judge do? What is the role of a defense attorney? Are they on your side? Are they on the other side? What is evidence and then we'll do some education and then See if people are able to return to retain that Um So it's Just to um note also that the american academy of psychiatry and law and the american bar association strongly recommend separating these two evaluations and not performing a Comp a uh criminal responsibility evaluation when someone is Not competent to stand trial In and I I guess I should just also make clear these these this these Few sections of the bill in sections one through four are the primary responsibility of our house judiciary committee Who which who has jurisdiction of the bill? I see Yeah, just so and so we're I don't intend for us to try to take extensive testimony on all sides of this issue There may be others who hold a different point of view But we have heard that the department also shares your support for this Um, now I'll uh gladly move on to other other pieces of it. Sure. Um, one of the one of the pieces that Caused some concern for me Uh, it was in section C. Is this an area that this committee is is looking at it's it's around Notification to the criminal courts Um of non adherence to orders of non hospitalization And and again if I may uh that we we were just We've just been talking about this the department of mental health has indicated their Support for taking this out of the bill and putting it into the study Uh, and again, I think we've heard indirectly and informally that the house judiciary committee intends to do the same So i'm just trying to not have us belabor Issues that have already Uh I think I think that that that's the direction we understand that they're going and that uh So i'm happy to hear your comment, but I don't think we'll get into it deeply Sounds good. I I support that that as well. I think it's a complex issue And should be the work of the of the work group both the logistics of it and the dynamics of it And as a a clinician i'll just i'll make one comment as a clinician that Uh, it brought up a conflict for me that when i'm working with people clinically. I see myself as Allying with them and being sort of in their corner And having um and this a robust notification requirement would create a bind where I would feel that i'm sort of reporting on my My patients and having that be the the work of the work group to think Think through how to do that practically and thoughtfully makes a lot of sense to me um, I think i'm just So I guess my my last comment would be to emphasize the importance of the work group and um urge uh adequate resources to be put um towards the work of that group so that expert consultation can be Uh included and i'm very very happy to answer any questions that have come up Well, I would like to you used to phrase earlier which and I'd like to In terms of the the the charge to the work group. I'd be interested in understanding and giving your your background You you mentioned I believe the having robust community support For and and forensic infrastructure and I'm I'm wondering if You can help me or us understand whether that Translates necessarily into a free into an individual freestanding or a specific freestanding forensic unit as a Or if there are other ways other Community infrastructure that also would be part of potentially addressing some of these issues. I think That that that would be something I you know a few if you would Comment on I'd appreciate sure. I I think that those are um, uh somewhat somewhat separate I do support having a freestanding forensic Hospital or unit. I think having the mechanism to have I Have that kind of treatment separate potentially separated from general civil commitment and general clinical care is important In terms of community Forensic programs. I actually see that as somewhat separate and there are two areas where I think that we could really Use other kinds of community programs. We don't have in vermont The first that comes to mind that I think is a real gap and I hope is the work of that work group Is competence restoration When someone is found not competent to stand trial in vermont We don't have a formal program that helps them gain or regain competence Um other states have formal programs that exist both in hospital and community settings Where people who've been found not competent have a Combination of sort of essentially kind of classes to help support Comp them gaining or regaining competence to stand trial I and one element of that is sometimes treatment Um mental health treatment and sort of class work Um, the literature reflects that the majority of people who undergo competence restoration And go through competence restoration programs Regain competence. So we kind of have a missed opportunity here where most of the people who have who are found not competent to stand trial Uh, ultimately don't regain competence or gain competence And resolve their uh criminal charges. So that's a A significant portion of individuals who don't Then um go forward and resolve their uh criminal charges Um, whereas the literature shows that most people the the range is 60 to 80 percent Can be restored to competence Um, and I think that's a really important Gap That's yeah, so you so that that is referenced in the charge to the working group So I'm hearing your support for that being part of the charge to look at competency restoration models Yes and and the other area of uh, sort of community support is is sort of much broader there Sort of a menu of community forensic programs with Um, uh varying data and evidence behind them about That serve to support people Who have who experience mental illness and have criminal justice involvement? And that's sort of a a wide group Um, everyone from people who have been found not guilty by reason of insanity and are transitioning to the community to Make sure that the people who fall in that group have both robust clinical support that is Focused on and has expertise in that area to more practical supports around housing and other practical things and I think and And I think that though that people are most likely to be successful when there are specialized Supports in the community Right now we we don't have those kinds of specialized supports in our communities So can I ask you this would be I think some there's some assumption and maybe rightly or wrongly so on the part of the general public and any Of us who don't work in this field That if someone were to be hospitalized in a specific forensic unit that that would be Uh that they would not Ever be discharged to the community and I think there's some general And so can you comment on that because I think what you're one of me as I'm hearing you You're suggesting that someone might be part of a specialized forensic unit and At some point transition into the community as well so it's uh exceedingly rare to non-existent that someone is hospitalized indefinitely And I think that that's a good thing. We don't want people to be when somebody is Is ill and There's a tragedy and they Harm someone else or have and are found not guilty by reason of insanity The aim is to support people so that they can be well and Maintain their health and transition in a safe and supported and successful way to the community People do not spend their lives in psychiatric hospitals And that's that's I think that's I think there may be more of understanding that but I think there may be less of an understanding that if someone's in a forensic Hospital that they might not that that might be seen as an alternative to incarceration And that there might be a longer period of time served there served if you will or there So I I'm just posing questions, which I think are out there and maybe some assumptions and again Your comments are welcome I see um I guess I I'm not I I hope I understand your your question correctly. It sounds like Um, they're you're saying that there's a an assumption that if someone is committed to a forensic hospital That they stay there for a long period of time sort of as an alternative to incarceration Is that is that it? Yes. I think there's I think there is an assumption by many people that if only we had a forensic unit we could Make sure that they're there for a very long period of time so from my view the The aim is not to have people out of the community and hospitalized for long periods of time um, I think that sometimes I mean and some sometimes that happens when there aren't robust supports in the community And we can't transition people I think the aim is to have appropriate treatment which sometimes takes some time and that appropriate treatment um, usually starts in a hospital setting and Continues in a community setting and I would say what we in vermont have the opportunity to do is to have more More of that treatment happen in a robust way with specialized services In a community setting so that people can transition out of hospitalization effectively And safely and successfully Okay, let me turn to others to quit if you can you take a few more questions from her? Yeah, uh, represent peterson then represent don't you Yes, thank you, uh, chair lipper, uh, doctor. Thank you for your testimony. Um, you you mentioned 60 to 80 percent of the the folks that are not not competent to stand trial can be restored to competency uh, and Are we missing out on all that now? I mean we don't have the forensic facility per se but we have other facilities where we I assume can can work with these folks and And get them to the competent levels so that they can then stand trial. Is that happening in vermont? So I'll speak to my knowledge of it, but this would really be an issue that deputy commissioner fox can speak to more in more detail um, if in my experience, uh, some people their competence is restored through general treatment and, uh, I think some people are captured that way that they, uh, um, do Regain or gain competence, but I think it's a very small proportion compared to a formal competence restoration program Okay, so we we don't have the formal, uh, program is what you're saying That's exactly right And does that formal program require a facility separate from something else or is it can't can't could it not be done in you know a couple rooms in a in an existing hospital or setting So competence restoration programs are sometimes done in hospital settings often start in hospital settings Um, but also are done successfully in the community Okay, so people live at home for for people who are able to live at home and then do it as, um Uh in in a community based setting Okay, that can be more, um, that doesn't work for everyone, but it does work for some people Okay, so so Someone commits a horrendous crime of some kind. Okay found not competent to stand trial not not insane at the time, but incompetent to stand trial. They're in the hospital They're being worked with but then they're put in in a community facility Somehow and and then worked with there. Is that how the the flow would go so to speak? So I think there are there are a number of different ways this can work. Um The competence restoration programs, that's one of the pieces that is very flexible I there are people who have been found not competent to stand trial on relatively relatively minor charges And that's someone who maybe could go back to their family home. And if they have the structure and support I could for instance go to Go someplace and work with someone to through a curriculum and receive the Medical care that they need But you bring up a really interesting point too of someone who has Maybe harmed someone in a more significant way is found not competent to stand trial And is in a hospital Psychiatric hospital setting that's also a setting where many states have their competence restoration programs within forensic hospitals and that is that is more the More the norm Evidence on a range of models So those folks would probably if the crime is severe that they would probably stay in there And be worked with rather than released To a home or or yeah I think the two The two things that would be considered are how how ill is that person and what kind of treatment do they need? And then it's also important to consider risk Violence risk. So both of those things are are important considerations for the context. Thank you Thank you. Thank you. Representative Donahue Yes, thank you, doctor. Um, this is jumping the gun on the same question. I want to ask dmh, but But we hadn't gotten to that part of the the bill yet I'm I'm looking at the scope of the work group the charge for the work group which Just in addition here in your testify. We're talking about competency Restoration programs whether we should create one and what it would look like The notification to victims issues when somebody's in the community The issue of states that have not guilty by reason of insanity but also guilty but mentally ill Whether or not we need a forensic facility What it should look like and what effect that might have on length of hospitalization or being in a facility treatment program options in the community and Recommended draft language for statutory revisions if that's required for any of these things So I'm wondering and I know the issue of length of time has been raised but beyond that I'm wondering about But the number of members in the work group and And their makeup in terms of their stakeholder interests versus expertise in these assorted issues How successful do you think this work group is You know, what what's the what's the prognosis for the for the outcome that's being hoped for in your opinion So from my view, it's really important that the work group has enough time to really delve into and evaluate a number of really complicated issues that you've Delineated so I think that having adequate time and and I think the the minimum amount of time that I can imagine is 6 to 12 months And then having resources for that work group Because they're I I think it would be a much richer discussion if we can bring in regional and national expertise is that So can I also just make a comment because I think some of us are also learning as we hear witnesses and testimony and I think the Indirectly what I was hearing in part from your testimony is that Being found not competence in sam trial does not equate with having committed what many people would say is a horrendous crime Exactly right. Yes, and I but I think that I think the two get conflated often and that there may be There are instances of Individuals who are found not competent to stand trial for whom the criminal charge Which is an alleged charge at that point still But with whom for whom the alleged charge could be in fact relatively minor Certainly, but they were found not competent to stand trial and I think that goes to what represent peterson was asking about uh, who kind of the economy of who can be Part of a competency restoration process in the community versus in in a hospital setting, etc And safety and risk issues Not all again just to reiterate not all individuals who are found not competent to stand trial pose a risk to the community By nature of the crime or the risk that they otherwise would pose Am I am I understanding that properly? I think that's absolutely right and and my work Performing not competence to stand trial evaluations and Supervising trainees who are learning how to do that. It's a wide very very wide range of both risk and severity of the charges Okay, that's it's helpful for me to kind of make that delineation as well And that's not to say that there aren't there aren't instances where there is a you know a Tremendously horrific alleged crime because they haven't been to get judicated fully but But and where they might not also they wherever they might also be not competent to stand trial represent johnny If I could just add to that because I think it's important for people to know that that in vermont statute And not guilty by reason of insanity also Does not necessarily mean that there was a proof Or any kind of conviction of the crime? Yeah Yeah, I think in some states that finding requires finding of underlying facts That show that the crime actually did get committed But the person was insane But vermont law does not require that factual finding in statute For somebody to be found not guilty by reason of insanity So they also have not been proven to have committed the crime necessarily Okay Other questions for doctor is it raven raven. Thank you. I Want to make sure I try to hear your name properly raven Uh, represent page Yes, thank you chair. Thank you doctor. Um When somebody has created As committed allegedly a horrendous crime and goes to this forensic facility And then is declared competent Do they then go and be tried for the crime that they initially did? And it's so That's the case. Then do they go in and if they are This is a whole realm of of items, but If they are then declared uh competent to stand trial And charges are brought to them and then they're found guilty They then go into the correctional system or do they go into a different facility? It seems to me kind of sat I understand it, but it seems kind of sad that okay, you were declared incompetent Then become competent. You then go to trial You see where I'm going with this. It just seems so very sad to me, you know For everyone for everyone, you know I think we are talking about, you know, we're we're talking about we are talking about um Tragic, you know the situations that are potentially tragic and very sad And I I can Maybe delineate a little bit of the the pathway that you're alluding to I think you're You're exactly right if someone is found not competent to stand trial And they go through a program or regain competence through treatment They would then work with their attorney to elect a Defense strategy And potentially go through trial and they could be potentially found guilty not guilty Or if the if they want to elect a and Insanity defense they could be found not guilty by reason of insanity So they're multiple different outcomes And there are many reasons someone may be not competent and then regain competence. It's it's fairly broad and some people have long lasting Impairment of competence and some people for some people it's transient And I guess to follow up Do they then go into the correctional system if they're found guilty? Or is it a special another type of treatment Facility or long-term facility for them if someone was uh, if a question of competence came up and somebody and someone were then evaluated for competence to stand trial Found not competent but regained competence Then they would They would and found ultimately found guilty. They would go to corrections As as as they would if they had not been found not confident to stand trial initially That's exactly right. And and and there was not an insanity defense subsequently Right, okay, uh represent Peterson Yes, uh, this may be uh, thank you chair and thank you doctor. This may be a question that that might be crazy, but The I think it's relevant. Um The people game the game the system. I'll use that phrase when it comes to competency to stand trial Can they can they play a game and is that is that found out in the in in the ensuing? Questioning psychiatric help to make sure that those who are trying to get away with a crime You know, uh, all of a sudden are incompetent to stand trial. I mean, does that happen and does it happen frequently? In my experience, it's exceedingly rare Um, people generally don't want to be found not competent to stand trial um, it's I think um, it can often be embarrassing to people to to Be found not competent to stand trial Um, and but it's qualified psychiatrists a qualified psychiatrist can make that determination probably pretty quickly So there are actually I I think generally so There are really rigorous guidelines put out by the american academy of psychiatry and law About how to conduct competence to stand trial evaluations And they're quite rigorous about record gathering questioning of collateral people in the individual's life and treaters As well as questions that take place in the in the actual interview with the individual and it's fairly regimented and quite rigorous and I One of the things one looks at In competence to stand trial as with most forensic evaluations is malingering Or deliberate misrepresentation Um for a specific goal Thank you Um, raves in golden Good morning, and thank you for testifying. Um I was just thinking about your the following these questions about an individual who is found competent to stand trial So go through that whole process And then lands in corrections and I imagine that's pretty individual But are there programs and corrections that can support this individual or are they pretty much left To the system now in the corrections world. How does that work? So they would essentially be treated like anyone else Going into the correctional system. And as we we know People who struggle with mental illness and substance use disorders are overrepresented in our correctional settings And there are healthcare I resources in corrections So they would Essentially be like any anyone else going into the correctional setting And I think there is a provision in this bill to do an assessment An inventory if you will of the ability the availability of mental health services For individuals in corrections as in it As compared to those in the community, so This is it's not to say that there are adequate resources, but there There is as a part of this proposal. There's a there's a section to say that's do an inventory to find what is What is the current status of that? I I do think representative goldman you allude to something important that I think is aside from this bill But important to mention here um Court diversion uh programs that look at people who really shouldn't be in corrections And this is before usually before people have criminal charges, but divert people from the court system into Different kinds of treatment structures Okay, other questions, uh for dr. Robin Oh represent black Thank you, doctor. Um so I guess I'm trying to I'm trying to understand So I you know, I watched a lot of the testimony in both senate and house judiciary um And I'm thinking about um I'm thinking about several high profile cases. Um in particular. I'm thinking about um Kelly carol I believe is her name that were carol kelly the mother of the young woman who has testified um in both um committees What in s3? I mean, it seems to me s3 seems to be responding to A lot of these instances. What particularly in it? What are we missing in our system now that it addresses so that we're not having these situations? Um Rather than just responding to them once they've happened Can you speak to that at all or am I miss reading? I'm not sure. I know enough about the Instance you're referring to to fully understand the question. I have some passing familiarity, but wasn't able to See the testimony I guess I'm addressing does it address any of the concerns before Something is I don't know I It just seems to be in response to situations happening rather than Preventing them and you know, we we talked about with the corrections this revolving door between corrections and the department of mental health Is is this working group this study group? Is anything that they're going to be doing addressing? These issues before they happen rather than responding to them after they happen So it's I I think you're talking about the potential to prevent people experiencing, you know, the very Rare but tragic instances when someone who experiences mental illness Is violent towards another and commits a crime or kills another person And and I just want to highlight here that that while this happens It's exceedingly rare most most people who experience mental illness are more more likely to be victimized than to hurt others But it's still an enormously important To prevent those tragedies There's a Body of work I sort of a encompassed by I it's sort of a Fancy term the sequential intercept model which looks at ways of diverting people From the criminal justice system to treatment and making sure that people Are sort of intercepted at different places And receive treatment rather than have justice involvement the most basic foundation of that is good access to good mental health treatment And I I don't think that this work group addresses that specifically though There there are many organizations and individuals who who do Thank you I was seeing if there were any further questions and not seeing any at this time Wanted to thank dr. Robin for bringing your expertise and to Say that we're fortunate to have you working in our System of care here in Vermont as I understand you have a As you said, I believe are you now the medical director for the Howard Center? So that's correct and and thank you and thank you all for your your work on this Great. Thank you very much I think so much uh committee I'm going to suggest that we take a stretch from the screen and uh So this is I it's 1035 Let's let's take a break till 1045 Go off youtube go off screen and go mute And then we'll come back and follow up with our deputy commissioner morning fox