Advocating from Inside the Prison System

Dr. Jhilam Biswas: [00:00:00] People think mental illness is behavioral, and it is actually a medical illness, like a stroke or a neurological illness. It's something that is happening in the body. And yes, not all of our treatments work perfectly, but it's treatable because it's biological.

Margaret: Preston, how are you doing today? 

Preston: I'm doing fantastic. I, I'm excited to ride along for another Margaret led episode. This, this time with a guest. 

Margaret: Well, you, you can ask questions. This time I won't be, uh, drilling into you about psychoanalytic therapy this time. Okay. Um, but yes, I am really excited for our guests.

We have on, um, it's Dr. Jhilam Biswas md. I know Dr. Biswas from Real Life and from training and residency. She is also a forensic psychiatrist. Um, you are president of Massachusetts Psychiatry Society at this point, right? You're no longer President-elect. You are president. [00:01:00] That's right. I'm resident as well as being in the Mass General Brigham Harvard Fellowship, teach leadership and teaching and forensic psychiatry.

And we are so excited to have you on. You're such a resource. Um, did I miss anything? I know, I'm, I'm sure I missed a lot of things in your introduction. 

Preston: Yeah, so we were just bonding over the money tree that she has in the background. It's, it's the same as mine. It, it, it really balances out all, all the other like diplomas and decorum in her backdrop.

Margaret: Preston, you don't have a single diploma back there? No, it, mine is all 

Preston: his plans. 

Margaret: My God. It was the only only wall I had, but 

Preston: if I had a diploma, it would go there 

Margaret: if he had a diploma. Oh my God. Um, oh, we're so excited to have you on. Um, we are gonna be talking about prison based psychiatric care as well as how that has turned in your career to advocacy as well as leadership.

Um, but I wanted to start with a basic question for all of us to kind of do as our icebreaker, [00:02:00] as our listeners know, we always start with that. I don't know how much people outside of psychiatry considering going into forensic psychiatry know what a forensic psychiatrist is or like what it's the like questions that just general mental health practitioners have about this stuff.

So our icebreaker for all three of us is what has been your introduction and your training to forensics or working in either a prison setting or where you're more interfacing with like law. So Dr. Also gonna have a much more than we will, I'm sure. But what was your introduction to this kind of work, I 

Dr. Jhilam Biswas: guess?

Oh my gosh. Well 

that is such a great question and I'm sure so much is gonna come out in this podcast in terms of all of this. Um, but I think to answer your first question, the formal answer to what forensic psychiatry is, and to be honest, I don't even think psych, most psychiatrists know what it is. I certainly didn't know going through [00:03:00] residency and kind of learned about it in my third year and was like, I think this is it.

This is what I wanna do. But forensic psychiatry is the study of psychiatry and the law, and what that boils down to is people with mental illness, particularly those with serious mental illness. End up intersecting and, and kind of becoming entangled with the legal system for various reasons. And we can talk about that, whether it's through, you know, criminal issues that come up, kind of unpredictable violent behavior or guardianships or capacity or test, being able to write a will being unduly influenced.

Um, what else can I think of, uh, you know, psychological distress from an accident that needs to be articulated to the court. So I. People in a moment where they are dealing with mental health issues are [00:04:00] often dealing with other social institutions outside of a hospital. Right. And so what I tell my fellows and residents is that forensics cl for society or co liaison, psychiatry for society.

I like that. And what, right? Yeah. I, I'm like, maybe I should coin that term, but patent, 

um, 

maybe I just did, um. But it's, it's really providing consultation and education to social systems on mental illness, whether they be courts or, you know, the State House or the legislation or, or, um, jails, schools. I, I'm just kind of thinking through places where I've had to do this, and it comes up in, essentially everywhere in the c.

It really does. You know, I, I practiced college health for a while during my career as well. And I found [00:05:00] so many times, not only was I doing college health work, but I was often asked by the deans or, you know, somebody outside to say, can this student come back to school? Hmm. Can the, is this student mentally well to come back to their clinical rotations, whether, and it's not necessarily medical rotations, but other rotations where you do clinical rotations, um, after a leave of absence.

And so there's just so many ways in which psychiatrists need to provide evaluation, consultation and recommendations to a question outside of treatment. And I feel like that's what forensic psychiatrists do, but I do find that my job is always evolving, uh, as a forensic psychiatrist. 

Margaret: Do you remember, first of all, I think that is like the best, like definition I've gotten because there is so much that.

As you go through training, you learn like this is something that you shouldn't do as a general psychiatrist because we need someone specially trained or like, this is a setting, it happens in for, you know, [00:06:00] different, different aspects often in the emergency setting that is like the main place. I feel like clinically you might run into it as a resident, but, um, do you remember like one of your fir you mentioned like you thought third year this might be it.

Is there a specific clinical situation or like topic you were learning or researching about that made you feel like, oh, this is like clicking, this is clicking for me in a way. 

Dr. Jhilam Biswas: Totally, totally. And so there, I'll bookmark the third year of residency 'cause that was another pivot moment, but I don't think I ever really knew what I was doing.

And I, it's relatable. I would, I mean, right. Like I just, I, I really feel like my whole life has been beginner's mind. I'm like, oh, that's so cool. And then I find myself going down another path and another path. But as. Coming to this point in time, I feel like you do a lot of connecting the dots and you're like, oh, that's how this interest came to be.

And it was actually one of my mentors at the Brigham who pointed it out to me one day where I, I had told this mentor that I [00:07:00] was a sociology major in college, and I, I just got real, I was just very interested in social systems. And that's, I think where it started, um, is I was very interested in social systems and I realized like.

I wanted to really understand health systems. And then I was very interested in global health issues and how do we provide care kind of rather than patient, not just patient to patient, but in a macroscopic way. How do we task share so we can provide care for large swats of people in places where they can't get care?

So I found myself getting interested in sociology and then interested in global health. And that's kind of why I went into medical school. I thought I was gonna be an OB, GYN. So I went into medical school saying I'm gonna do women's health and that's why I'm gonna be a doctor. And then I went to medical school and I was like, no, I actually love family medicine 'cause I love treating the whole patient.

And then my very [00:08:00] last LA rotation was psychiatry and I was like, oh, this is awesome. Because this is where I get to sit with all the juicy stuff of psychiatrist, of, of what the patient really wants me to hear and what they want me to help them with. 

Preston: Well, what better way to treat the whole patient than to take a look at how they sit in society like it, it's not just the whole patient, the context of the nuclear family, but their circumstance as a member who lives in a, in a community of humans.

Dr. Jhilam Biswas: That is so true, 

and that's, I think what it was. It was like psychiatry was the deep dive into a person, but then as I was doing psychiatry residency, I was like, but I like this deep dive. But I wanted to have kind of social impact in a way that. I love psychodynamic therapy and I did a lot of, um, exploring of that in residency along with global mental health work.

Um, but I was kind of like, where can I [00:09:00] make a little bit more impact in what I know to be true? But I feel like this, the world doesn't really know, the world doesn't really understand psychiatric illness. And I feel like we do, we start to, and then we realize the world doesn't really jive with everything that we know.

And, um, and so I had this rotation in my third year of residency with Dr. Tom Gutile. Who did the psychiatry and law, he would like, he had his book that he had written, um, and that was the course. And so he would give everybody his book and each week we would read a chapter of his book and he'd be like, just tab out any questions you have about anything, and I will answer them.

And then every week we would ask him a million questions from that chapter. And he is, he's just an incredible mentor too. Um. Now at Mass Mental in his eighties. But he coined the term Never Worry Alone. 

Margaret: He like actually coined it, right? Like everyone, people will say that, but [00:10:00] like, he like actually maybe coined it.

No, he 

Dr. Jhilam Biswas: coined it, he wore it on a t-shirt one time. That said, never Worry Alone at our forensic conference called American Academy of Psychiatry and Law, he was like known to go to the forensic conferences every year. Like everybody's dressed up in suits because, you know, they're, they're expert witnesses that testify in court and he's like in Birkenstocks, in a t-shirt that says, never Worry Alone.

That's awesome. 

That's, it was a amazing, he did the best job in kind of making forensic psychiatry accessible and I think it was in the t-shirt in the Birkenstocks. But, um, but he, he made it accessible for me, I would say. Um. In the way that he just handed out the textbook that he had written. And he was like, ask me anything and I'll sign it at the end of the year.

And I was like, I just really find this interesting. Like, I find it interesting that we can educate people outside of the hospital walls, not just in, in consult liaison. We often educate other primary teams, other medical [00:11:00] teams. But like here, you're, you're telling you, you get to talk to the judge, you get to talk to a legislator, you get to talk to a dean.

Um, and you get to help them understand and maybe, and I, I found that to be really interesting and I realized back, maybe it comes from my interest, interest in social systems and sociology, but that's kind of what helped me enter into forensic psychiatry. 

Preston: That's fine. Like the, the city council is the primary team in this situation.

They're like, Hey, we've got a consult, we have mental health consult for you. Oh yeah, 

Dr. Jhilam Biswas: that's exactly right. 

Margaret: The city council is my consult team. Preston, what's your experience been with forensic so far in your training? 

Preston: Um, it's actually been pretty condensed. Um, I, I've had mentors that I've done, or not, maybe not mentors, but just like attendings that I've rotated with, have done forensic psychiatry fellowships.

And I think the, the interesting part is they had not been practicing forensic psych psychiatry, so they all had different [00:12:00] opinions about it. And the only context that I really was familiar with, it was in the, in the context of, uh, not guilty by reason of insanity. So whenever we would have this question of competency for someone who is committed some sort of crime, people would say, oh, that's up to a forensic psychiatrist to decide.

You go to the, in front of the court and do a lot of like judge related things, blah, blah, blah. And that was kind of how it was distilled down to things is awesome. True. And, and I was like, oh yeah, judge. True. It's not sounds. Um, the, the only other thing that I knew is people would talk about these like large case reports, the, because I would say like, oh, I think this, this sounds like kind of interesting.

I'd like to do it. And they're like, someone told me. And, and I guess I'm, I'm saying these like negative things that have been said about it. 'cause I really am excited, totally excited to, to hear you dispel them. We're just kind of like, offer your opinion. But they would say, you know, it was really interesting for me to learn while I [00:13:00] was in fellowship and I enjoyed the theory of it, but then when I got out into practice, it was like writing a dissertation once a week and, and every week I was just so tired of like reading through hundreds of pages of documentation trying to formulate this so it, it can be hard when you're practicing.

And I was kinda like, oh, that sounds like a lot. But also you're describing kind of work as like a Swiss army knife where you're going between. Articulating to juries, to educating the public and then kind of navigating autonomy and all these things in between, which none of those really graced my ears when I was, when I was hearing the disgruntled opinions of my uppers.

Mind you, this is while I'm just like trying to, to bury myself in like the daily progress notes I have on the weekend while I'm covering a unit and I'm like, Hey, how is forensic psychiatry, by the way, 

Margaret: getting paged 80 times during? So true. 

Dr. Jhilam Biswas: Yeah. I mean all, it's all true and it's not that bad. I mean, it, you know, it's just, it's so funny.

Okay, [00:14:00] so forensic psychiatry, uh, the way I describe it is a deep dive and if what I fell in love with is. I was finding myself having to do a deep dive on everybody as a psychiatrist in my patient group, but not getting the time needed to do that deep dive. And in forensics, you can take as much time as you want to do that.

Right? And, um, and you build for those hours, you know, like, you know, it's a, it's a different type of work where the deep dive. Allows you to do a better job and makes a bigger impact. So you actually feel the rewards of doing that work. And it is true that the reports are long. I'm, I'm not gonna lie, that part is true, but what I found my forensic fellows saying a lot of the time is like, yeah, but I feel like I really learned something out of that.

And now I feel like I'm an expert in that area and I could do more of those and [00:15:00] that I could do more cases like that and it would be easier each time. And you do start to develop these areas of expertise, which is kind of cool. 

Preston: Yeah, I think some people like being the submarine, they wanna do the deep dive.

That's true. And some people might not be like, as built for it, you know? Like you don't wanna be the, the Titan submersible or that No. The um, nobody wants to be that people that imploded Yeah. When you go down and so, so maybe take your venture somewhere else. Okay. That makes sense. 

Margaret: I feel like my, I think my experience for forensics is like, you know, smattering of things throughout in the emergency department, working with you at different points.

Um, but my experience is like, of, I think from the outside was I in undergrad was like my, my dad as a primary care doctor, my mom's a lawyer and I didn't, I was like, which one do I want? I could have done other careers, but I was kind of in between the two. 'cause I liked English, [00:16:00] uh, and I liked helping people, which is overly cliche.

But, um, I did a, like internship one summer after college at like the state's attorney's office, um, because my, like in, in my like small town Illinois, but worked on a case that was like a juvenile case where there had been an accident with a gun, basically. Mm-hmm. And it was an awful case and there was a death.

And also the question of like adolescent boys, like. Are they responsible for this? Who's responsible for it? And I remember getting to the end of that summer and being like, I have got to get here earlier than like prosecution. But I feel like there can be that kind of carceral view of when people hear forensic psychiatry or they hear, I'm sure you get all sorts of reactions when I'm, well, I'm sure you don't tell people, like on airplanes, that you're like, yeah.

At different points when you've been more or less clinically working in, um, [00:17:00] like state prison systems or the carceral setting. After we take this break, we'll come back and we'll talk a little bit about what that is like when you're clinically practicing in that setting and then talking about how that your background in forensics, the work you do in forensics and this view of cl to to society has.

Believe led to some of your advocacy work and political work in, you know, 2025, where everything's kind of messy. So we will be right back.

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We know that 87% of sepsis starts in the community, so it's important to make the conversations there. 

Margaret: If we know anything, it's that. As many reps as possible, hearing as many iterations of presentations is how we recognize it better and more quickly. And this podcast can help all of us with that. And you can listen to the sepsis spectrum wherever you get your podcast or watch it on Sepsis Alliance's YouTube channel to learn how you can earn free nursing CE credits just by listening visit sepsis podcast.org.

So the question I'm curious about is, I know you, again, we've said Swiss Army knife, you do many things, you wear many hats at this point. But what is it like to practice psychiatry in a jail setting versus a prison setting? Because I think this is just something, even like, I don't know this at all, but what is a day in the life like?

Dr. Jhilam Biswas: Wow. Okay. So it's okay. [00:19:00] That is an interesting question and well, I read your, I read your chapter in the Kaplan,

didn't know you would ask it. Yeah, no, that's a, that's a really interesting question. I haven't been asked that before, but like a jail is more for, um, if you're serving two and a half years or less, um, if you are not getting a long sentence for a certain type of a crime and, and prison, prison sentences tend to be much longer.

And for particular types of, of, um, crimes that lead, you know, that can be anything from, uh. Assault battery, like a pretty rough one to murder and arson and rape. So it can be, you know, longer sentences, but the typical jail individual, you know, there is a lot of mental illness in jails, and you'll hear about this, uh, just kind of around that.

Some of our largest psychiatric hospitals in this country are [00:20:00] jails, cook County Jail, um, LA County Jail, Rikers in New York. Um, because a lot of, and this is kind of where my research, uh, it gets me passionate about this issue is that. A lot of people with mental illness end up in, in situations where they're entangled with law enforcement due to the fact that they're not on regular treatment or they're not treated at all, or they aren't able to engage due to their inability to have any insight into what's going on in their lives.

As we know that a lot of serious mental illnesses have that component to the disease and what ends up happening. Oh, and substance use, traumatic brain injury are two other really, really big reasons, and probably bigger reasons than mental illness as to why people often end up in jails for headier crimes that are, um, violent in nature or often, you know, trespassing or robberies, things like that.

So, so there. Jail can [00:21:00] be a very busy place for a psychiatrist to, to do their work. Um, there's just a lot going on and there's a lot of patients, but really at the end of the day, so are prisons. But what I think psych, a lot of psychiatrists find prison work really fulfilling. You get this longitudinal period of time to take care of a patient who may not have ever gotten care before.

I find what I have found my fellows to say and residents who have rotated at hospitals, um, that are also prisons. Let me backtrack for a second and explain to you my clinical background. Um, before kind of being at an academic center and really running a forensic fellowship with, um, my co-director Matt La Dr.

Matt Lehe, um. I, I worked at Bridgewater State Hospital, which is actually, it's, I think it's one of a kind, there may be one other one in Texas where it's a Department of Corrections run institution that's a medium security prison. It's con considered a medium security [00:22:00] prison, and it also is a Jaco accredited hospital.

So it's a really bizarre combination, which a lot of people can't wrap their minds around. And there's a lot of advocacy around whether we should have something like Bridgewater or not. Like should a hospital in a prison be the same thing? And that's a question for another day. We're not gonna get into that.

But, um, uh, what I have found is while can you provide really good care sometimes to individuals who are in prison in a setting like that? And, um, there's a lot of statutes in Massachusetts on how you can provide psychiatric care and do psychological evaluations, forensic evaluations, like not guilty for by reason of insanity, which we call a criminal responsibility evaluation or a competency to stand trial evaluation.

So now this is a me so I have worked in this setting, which is a medium security prison, but with a lot of mental health care and a lot of medical care provided. So it's, it's kind of a different place, but what I will [00:23:00] say is kind of what, what. Uh, psychiatrists who work in prison settings say a lot and what I have experienced myself is that you get a population that ends up being really grateful because they get to know you.

They're often really ill when they first get there, be because of the circumstances that have led them to that situation. They often burn their bridges. They might be homeless or they get better and you can reconnect them with their family members again. And then they start developing relationships with family members in a very contained way where their families can come visit them, you know, over a period of time and actually get to know them and help, you know, maybe reintegrate back into the community.

That's not everybody, but I've seen a lot of like really nice success stories in kind of the setting of being able to take care of a very sick person who then gets better, who recognizes the value of psychiatric care, and then goes on. To [00:24:00] do well in the community once they're discharged, and I think that's the most gratifying part of, of psychiatric work and prison systems.

Quick 

Margaret: question. What, what makes someone end up in like Bridgewater, like this unique situation, like how men, this is gonna be a, like, maybe a crass way of asking this. Like how mentally ill do you have to be to end up there versus like seeing a psychiatrist in a prison setting? That's not all like, let's say in Massachusetts, not also in a hospital.

Dr. Jhilam Biswas: Yeah. When it pertains to your legal charge, I would say is one of the key ways to get into a place like a forensic hospital, whether it be Bridgewater or all states have some version of this, um, a forensic hospital that will take care of those individuals. They're stratified in different ways, but um. To get to Bridgewater, two reasons.

You're either very seriously mentally ill and you need kind of medications and you're refusing them. Um, [00:25:00] that may land you in Bridgewater or you've been sentenced and you're serving your time in prison. That that may land you in Bridgewater, but it won't be Bridgewater. It'll be, there's a, there's another unit right next to Bridgewater for people who have prison sentences, but for everybody else.

It will land you there when there's a question of were you mentally ill at the time of the event that you, uh, you know, committed this alleged incident, at that point you need to be evaluated by a forensic psychologist or psychiatrist who will then do that evaluation for the state. Um, and so if you're not, or so if like the NGRI Preston that you said, that's often somebody who will end up at Bridgewater and also somebody who probably is incompetent to stand trial.

Like they're so ill, like, it's not depression or anxiety that'll land you in Bridgewater unless the depression anxiety caused some psychotic features that land that need [00:26:00] require an evaluation for the time, for the time of the event. Outside of that, it's, you're so mentally ill that you probably won't be able to stand trial and you need to be restored back to mental health so that you can stand trial and move on with your life.

So in the legal system, and this is kind of getting into kind of the ins and outs of the law, you need to be a, you cannot, um, give due process and have a trial for an individual who cannot comprehend what's going on. They don't have a factual understanding or they don't have a rational understanding of their alleged charges, I mean, of their charges and their alleged crime.

And so you need an evaluation for that. So those are kind of the three big mechanisms in which you land into a forensic hospital. 

Preston: So when you're performing these evaluations, and let's say you find someone to be incompetent to stand trial, are you also the physician that helps restore that [00:27:00] competency?

Now, are you both the evaluator and the Cure? 

Dr. Jhilam Biswas: Awesome question. That was such a good, that was such a good question. No, you are never. Yes, because, and, and so this is, and this is something Tom Gutta has written much about. Um, but you never, you're never evaluate alone, right? You evaluate alone. Don't worry alone.

It's true. You, you don't provide the clinical care if you are the objective forensic evaluator. You can't wear both hats because there's a conflict of interest. 

Preston: So what's that like? If they're not your patient, then I guess that seems like a unique situation 

Margaret: Yeah. 

Preston: Where you're providing an assessment, but this isn't someone that's under your care, so to speak.

I guess that was, that was kind of like the second question that was followed by that 

Dr. Jhilam Biswas: great question. You are the consultative team. Expert. Expert that is providing consultation on a question. So you are providing [00:28:00] consultation on the question of is this person actually competent to stand trial? You may offer recommendations for treatment because you're a doctor, but you will not follow through or carry out that treatment.

You will only be able to provide consultation because the treating provider is a totally different role than the evaluator who is much more objective. My job. In an, in an evaluation isn't to just listen to what the patient says and write it down on paper. My job is to push back on every detail that the patient says, to make sure it's true with the collateral data that I have.

Um, whereas a treating psychiatrist is really looking at the patient as a whole, really think about what does this patient need from me and what can I provide for that person to live their best life or to do better and live their full potential. So it's two very different roles. 

Margaret: This is maybe a question that you will definitely not know off the top of your head, but knowing you, you actually might, um, [00:29:00] is there ever a resource issue with this kind of thing?

'cause I'm, I'm thinking of like where I'm from with like, in like more middle Southern Illinois, um, and like maybe in this case, right? You end up at the forensic hospital. So you're, you're there. You need at least two forensically trained PhD or MD level people to do one of these cases. Is there, like, when the rubber hits the road, what do ev, does every state have enough people to be able to do this or like, is, are there delays?

How does that ev does, does do we run into a resource issue even with just this? 

Dr. Jhilam Biswas: We 

Margaret: sure 

Dr. Jhilam Biswas: do. 

Um, where is there not an access issue in, in psychiatry and mental health care? Right. So yes, of course there is a huge resource issue in this situation. I think what you'll find is one psychiatrist, a clinical psychiatrist, will take care of a lot of patients, a lot of clinic, uh, patients in a clinical setting, and [00:30:00] then the forensic evaluator's a different person and they'll just get assigned different cases that require different evaluations.

When it is in a forensic hospital, um, you can be pri you can also be privately pulled in by the attorney on the case to say, look, this person has this legal case. I think they have some illness here, and you need to explain this to the court. And the, the attorney will bring you into the case as a forensic evaluator.

So you, you come in through totally different paths as a forensic evaluator. Whether that's a psychiatrist, psychiatrist, or often forensic psychiatrists will get pulled in on all the medical biological issues that come up. In these cases, um, forensic psychologists are, are very able to handle kind of competency to stand trial types of cases.

Criminal responsibility. It's one of these medication issues or, or serious mental illness with psychotic features, like things like that, that, that have a, a pretty clear cut medical component with medical recommendations that, um, forensic psychiatrists do that. [00:31:00] So what's nice is you can task share a little bit when it comes to forensics, depending on the case and the treat, the treatment is often provided by the psychiatrist and nurse practitioners that are working within the jails and the prisons providing the clinical care.

And those people 

Margaret: don't need to be forensically trained. No work in that setting. Okay. 

Dr. Jhilam Biswas: They don't. But I have found more and more people get trained in that area because even when you're doing some documentation, it's good to know your jurisdiction and how, you know how to think about these cases. Um, in a forensic hospital, I'll say Mo, most of the psychiatrists are forensically trained, but there's a lot of jails in prisons that are not forensic hospitals and forensic psychiatrists are not in those spaces.

It's just regular psychiatrists who aren't trained in that area. Addiction, psychiatrists, a lot of addiction psychiatrists 

Margaret: in that area. Yeah, I was gonna say, I feel like I'm thinking, thinking of that. I think one of the things that I wanted to touch on before we start talking about how your work's evolved [00:32:00] is for a person who's like, let's say they're a med student, they're someone who's not a psychiatrist, they're not having exposure to forensic psychiatry.

Um, they're thinking about patients who are in the carceral setting that we treat. What do you feel like are the ethical balances that you're often considering or that come up the most in discussing treating patients in like, like the Bridgewater setting, um, in terms of balancing values of society, like you're saying, right.

Versus an individual's wellbeing, you know, autonomy, beneficence, all of these things. I'm, that may be too broad of a question, but any themes that come up? 

Dr. Jhilam Biswas: Yeah. 

Margaret: Well, I think the 

Dr. Jhilam Biswas: first piece that comes up when you bring up a question like that and is, I think I often, what I found myself ethically dealing with, kind of in the carceral setting is helping [00:33:00] everyone else understand this is mental illness, this is not behavioral.

Sometimes I get mad at the word behavioral health because I'm like. Isn't it kind of stigmatizing, it's like saying it's a behavior when it's truly mentally mental illness. And we've also turned, turned the word mental illness into mental health. And anyway, I'm not gonna get into all of that, but, but there is something in which sometimes I often am so surprised when people can't see that this is psychotic illness or man mania or you know, or bipolar illness.

You, you know, you'll be with correctional officers or, or other, uh, staff or honestly, a lot of them are well-meaning and I work with them and, you know, they, they wanna provide kind of compassionate security so the person can get care. But what you do find is you're doing a lot of education and helping people understand these are biological illnesses that require medications to stabilize.

And I find myself edu like saying that a lot in a [00:34:00] many, many different. Parts of my life, and not just in corrections, but I think a lot of times people think mental illness is behavioral. Um, and it is actually a medical illness, like a stroke or a, you know, or a neurological illness. Like, and it's, it's something that is happening in the body.

And yes, not all of our treatments work perfectly, but it's treatable because it's biological. 

Margaret: It makes, what you're saying makes me think of like the split that like, there's been de-stigmatizing in some ways of like mental health when it's like anxiety, depression and, and I would say even with that, like mild to moderate anxiety and depression and whereas there's been not any de-stigmatization of actually like knowing and holding in community people with like SMI and it precedent actually reminds me of like the video you did when it was like a headphone company or something [00:35:00] had.

A stigmatizing some, some ad they had that was like about mm-hmm. Schizophrenia and it, yeah, it was a headphone 

Preston: company. They made a joke that was like, not sure if you're passing someone on the sidewalk and they're listening to their headphones or they're just crazy because it was like, you know, they were talking and they're like, are they talking to themselves, like responding to internal stimuli or are they listening to our headphones?

Margaret: Mm-hmm. 

Preston: And that was just kind of like open and accepted. And I was like, I dunno. And, and so like stigma in this video, they were like basically imitating people with schizophrenia. 

Dr. Jhilam Biswas: Yeah. Yeah. Well that's what happens when it's behavioral and not Yep. Yeah, yeah. Medical. 

Preston: It just feels in poor taste where we can Yeah.

De-stigmatize the, the equivalent of the common cold, I guess, for mental health. But then when you have things that are malignancy or something. Yeah, no, that's, that's still, yeah. That's a behavior still not touchable. Yeah. [00:36:00] And to, to clarify for our listeners who maybe aren't as psychologically inclined when, when you say behavioral versus mental illness, I think to the lay person that kind of sounds the same, right?

Right. How would you help someone understand the distinction between like what a volitional behavior is and the, the product of mental illness actions that are the product of mental illness? 

Dr. Jhilam Biswas: I'll tell you, you know, I've, I've done a deep dive into kind of thinking about serious mental illness and in, and the carceral system and sort of the cycle that people with serious mental illness end up in.

And in thinking a lot of, and then stigma and the, and the social stigmas around that, and social stigmas around inpatient psychiatry and what kind of care we provide in those settings. And what I have come to realize is there's two types of mental illness, the kind with insight and the kind without insight.

And that is the ultimate separation. People with insight. To their mental illness or mental [00:37:00] health issue, will get care, want care, want to get better, want to reach their highest potential are, are really de-stigmatizing certain areas of mental illness like A DHD or OCD or depression and anxiety, some forms of PTSD, um, you know, tick disorders and lots, lots and lots and lots and lot of other things that I think are treatable, workable.

People can get care and live a, a full life. And, um. So there's that area which has really become destigmatized, which I think is wonderful. Um, and then there's the, the illnesses where people can have insight but sometimes lose insight. And I think it is that psychotic component that comes with certain serious mental illnesses like schizophrenia and bipolar disorder, and sometimes PTSD and sometimes depression and other illnesses that result in sort of a psychosis, eating disorders, for example, [00:38:00] can, can kinda land in that bucket.

Right. And it's, it's, it all divides down into insight, I think. And, um, it is the, the population that doesn't have insight often will fall off their medication regimen or not engage with care, or not believe in care, become too paranoid around care. And then it lands them in really negative situations. Um, and that is, that gets more and more stigmatized because people are conflating the two types of illness.

I feel like I'm kind of like fleshing this out as we're talking. I love it. I'm 

Margaret: like, I'm I'm locked in right now with you. 

Dr. Jhilam Biswas: Yeah. And, and I think that it's, it's this, we cannot conflate the two because the two require very different types of interventions, and I think the general population is trying to give one type of care to the other group that requires a very different type of intervention, [00:39:00] compassion and understanding of biological disease and the re requirements of medication.

Margaret: I wonder if there's almost a kind of social denial, like, like a, like not, not to go back to the psychodynamics, but. In the culture of denial of mortality and in, in this case, this, like, not just that it's maybe unpleasant or scary to see, not because of violence, which I, one of the papers that we have cited from you in our notes, the first sentence is like, people with mental illness are not inherently more violent, which I just wanna say right now.

Uh, but that there is this really, you know, horrible and like almost existentially terrifying thing that if this can just happen to someone and you can't will your way out of it, you can't behave your, your way out of it then that if you accept that and actually have compassion and work to make a world or community that can, you have to accept it, that it could happen to you.[00:40:00] 

And I think that that like the denial in modern healthcare, especially in the US of like. This can't happen to me if I just do all the right things, nothing bad will ever overtake me versus this could happen to any us, any of us. How do we design a world in a government that can handle it? And I don't have to fear this person from, from an existential level.

Preston: Everyone likes to think I would do differently if I was in that situation. I, I hope that if I experienced a manic episode, I would have the willpower, the behavior to pull myself out of it. Therefore, you must have it because otherwise this is an, an impossibility for anyone to escape and makes us all equally vulnerable.

And mortal is much, much scarier world to contemplate. 

Dr. Jhilam Biswas: Yeah, it really is. And perhaps it's that denial that makes the stigma even more intense. Ironic. '

Preston: cause [00:41:00] that means society doesn't have insight into it. It all comes down to insight. It's 

Dr. Jhilam Biswas: true. It's the denial of our mortality, our, the denial of losing your mind.

That is really scary. And what, but what is scarier as a psychiatrist that's worked in this area is watching society allow that individual to stay in that state because they want to believe it's behavioral and not medical illness. And making it really hard for us to provide treatment like medications, um, during a period of time where somebody has no insight but is an extreme distress around their psychotic illness.

Preston: And that is, I think that's a great segue into your paper that we discussed, which is treatment delayed is treatment denied. 

Margaret: As also part of your advocacy work. We'll take one more break and then we'll be right back to talk about that and also talk about one of the impression's, constant rants [00:42:00] online and offline, which is hating from outside the club.

And I think that this gets into, and that Dr. Biles talked about as well, um, dealing with very severe mental illness and kind of what comes up with it.

Preston: I really enjoyed the treatment. Delayed is, is treatment denied. And, um, to, to kind of summarize for the listeners and also I guess for the author, which was kind of, I feel like a kid at the front of the classroom right now being like, I read this paper and I know what it's about. What I 

Margaret: learned in voting school is, yeah.

Yay. 

Preston: So the, the crux of the paper is, is that. When you have people that have severe mental illness and they become involved in the the legal system in some way, one of the issues becomes compelled medications or re restoration of competency. And when we [00:43:00] involuntarily commit someone to compelled medications, we're trying to uphold benefici in opposition with autonomy.

And we try to kind of continuously uphold the patient's autonomy along this whole weird bureaucratic process. But paradoxically, we can't apply the same principles that we do with autonomy in other medical situations. So we talked a lot about kind of substitution of interests being one way that we kind of try to swap out, which is what would I want if I was in your shoes or assuming that you know, you were of sound state of mind.

An example of this would be like, if I was unconscious and brought into the emergency department, I would hope that people would still wanna operate on me or, or intubate me or something to keep me alive because I'd be of sound of, of, of sound mind and awake. But if you're of sound mind, then you're not mentally ill, so you wouldn't be treatment in the first place.

So now we're, we're [00:44:00] kind, we can't apply this principle in the same way. So, so we ironically try to uphold someone's autonomy while they don't have autonomy in that sense. And then we extend this whole legal process in an adversarial way. And the entire time that this happens, people get worse and their outcomes get worse and they, they don't get the medication they need because they're just kind of in this custodial holding pattern.

Margaret: And they're in a setting where they can do things while still sick that can worsen how they're viewed in the legal system or. By other people who they're in that setting with like, you know, even very well intentioned. But like, if, if someone attacked me and like punched me, I definitely would treat them different than someone who hasn't, not even punitively.

Just like, how warm am I gonna be? How long are we gonna talk for If they move, I'm gonna, and that's not even to say systems where maybe there's violence within jail or prison settings. [00:45:00] 

Preston: Yeah. And it's funny that, so we, we create these systems to uphold people's rights, but then we kind of hurt the very thing we set out to support by creating this convoluted bureaucracy that people have to navigate through.

Dr. Jhilam Biswas: Yes. 

And it burns out everyone involved, like trying to go through the system, the patient certainly, but all of the healthcare force that is involved in that waiting period and that adversarial hearing and, and all of that. 

Margaret: Could, could you tell us a little bit about kind of the clinical story of, with this paper I know has led and been part of the research and then advocacy that you're now part of?

Um, I wonder if you could tell just for, for those who are maybe like less clear on like, what, what would this actually look like because we're kind of talking an abstract, so maybe an [00:46:00] example made up case or something where this, how the systems are versus like what it would actually look like if we knew like took that there might not be capacity there, like better care would look like.

Dr. Jhilam Biswas: Yeah, no, I mean, so such an interesting, uh, you did a great job talking about the issues and um, I, you know, it, every time I think about it, it sort of makes me think even more, um, about, you know, so. How to deal with this. 'cause it's complicated. Nobody is wrong in this situation. It's just that we are taking the healthcare perspective in this issue.

And this is why psychiatry and law or medicine and the law are so interesting. 'cause this is, we are all about wellbeing and the legal system is all about freedom. And um, and this is where, this is probably the space in which we class the most. And, and, [00:47:00] and there's a lot of juicy conversation here, but I think in a lot of ways the system has shifted more towards freedom and, um, upholding the rights of individuals who want to refuse treatment.

Um, which is fine, but that has repercussions. And as a forensic psychiatrist and I have a lot of other psychiatrists that I'm starting to meet around the world that are seeing the same thing is one of the. Side effects of that is this homelessness, incarceration problem that we have where people with mental illness that is left untreated because the individuals might not have insight into needing that care, um, cannot maintain housing, cannot maintain good relationships with their families, cannot hold their jobs, cannot maintain being a parent anymore.

And if they're not getting the care, they're getting worse. And as psychiatrists, we know a lot of what happens when somebody remains [00:48:00] untreated with mental illness. You know, not just does their illness get worse, their, they have a higher risk of accidents, a higher risk of suicide, a higher risk of violence, a higher risk of getting a traumatic brain injury.

And lots of other comorbidities come along with untreated mental illness, like the kinds we're talking about. And so, um, what I found as a clinical doctor working in a, uh, in, in a carceral setting. Was that most of the time when I was asked to do this clinical work or the forensic evaluation for an individual who was entangled with the law had allegedly committed a crime, was that like, and I always say that I was, feel like it was at the bottom of a well looking up at the system and where it failed the person and it was patient after patient, after patient, and it was almost, which moment in time did they get off their meds and the system couldn't catch them and they ended up in [00:49:00] the forensic hospital after something bad happened.

Right? Like it, it wasn't the homelessness route, it was the you got. You know, arrested for doing something. 

Mm-hmm. 

Then they, they're in this situation because they're so paranoid that their water is poisoned and that the FBI is after them, that they're running away from the FBI, they commit a crime. They end up in the hospital and now they're refusing antipsychotic medication like C Closin or an Invega Sustaina shot.

You know, these are two really great medications. We know that work. Um, and I can't get them to take that medication 'cause they. They're too ill, they're, they're too psychotic. They don't trust the, the, the reality around them to be real. And so what ends up happening is then you, if, if you can't medicate, you end up only medicating during emergency situations.

Like if some, if they're assaultive or they get hurt by a patient, or they're [00:50:00] so unhygienic that they're getting sick from being unhygienic, which would be like hunger strikes or, you know, never showering, not eating well. You know, like there's just a lot of things that happen with people who are experiencing psychosis that are, that are really dangerous and they deteriorate during that period of time.

And so then you have to file to the courts to get medications. Not always every state does it differently. Massachusetts has particularly a high threshold, and I'm not even gonna get into the details, but my research is on those details. Um, having an adversarial hearing and literally. You know, being an expert that explains why you think the person, the patient needs medication while the patient disagrees with you.

And it's like you're having this adversarial hearing to pro provide them the medication they require to stabilize. Um, and that delay to even get, forget the, like [00:51:00] demoralization that happens to everybody, including the patient, the doctor, and everyone in between in that situation. But beyond that, the waiting period.

Um, and that is kind of where my research comes in is there's so many adverse events that happen to the patient and the people around them during the waiting period while a patient is psychotic. Um, that society needs to understand that like 

Margaret: mm-hmm. 

Dr. Jhilam Biswas: It is not okay to leave in a patient untreated in a hospital for mental 

Margaret: illness.

It's kind of like this false idea that I feel like comes up a lot in psychiatry and in the. Non SMI population. But this idea of like, okay, it's either exposure to medication as like a risk or no risk of exposure to anything when the reality is it's exposure of the side effects of medication and the reduction in autonomy, or it's not treating the illness, the illness worsening in this specific setting, which can be a lot of different things you've already [00:52:00] mentioned inherent to the illness and possibly inherent to the setting that they're in at that point.

And it's not just, I don't want them to have medic be forced to take meds. It's like you need to look at the global picture and context that they're in at that point. 

Dr. Jhilam Biswas: Right. And and I just wanna add that one last piece of stigma that comes from the 1960s and seventies, like one flew over the Cuckoo's Nest and like shock therapy and ECTP.

There's sort of this. In the language of standing up for autonomy for patients with mental illness, there's also this sort of like, veiled psychiatrists are evil, right? Which we're just 

Preston: kidding. Margaret's evil. I, I'm a little bit evil.

Dr. Jhilam Biswas: Walk around like with Oh, witch, you know, doctor wear witches, you know. Yeah, forcing medications, like we don't like to do this. Like, it is not fun. This is not the fun part of our job. [00:53:00] 

Margaret: This is, we did a burnout episode and my, one of the moments we talked about per mind was when someone was like, I did a restraint.

Or like, I didn't even do the restraint. I just was like there for a child patient who was first break psychosis and like biting someone. Their parents were there and it would, their parents were upset and dah, dah, dah. And I got back to sign out at one point and the nons psych resident was like, oh, you're psych.

You must have loved that though. Like, not sarcastically. Oh my god, 

Preston: that's I'm evil. And yes, I did. 

Margaret: You're like as an evil witch. I did enjoy little children suffering under my guys, like 

Dr. Jhilam Biswas: Exactly. I went through all this medical school and then psychiatry was, so I learned, learned into Ginger 

Margaret: brighthouse to go into it.

Yeah. 

Preston: So Jhilam, when you think about building institutional systems, a lot of them in the law. From outside of the club, seemed to be built on these like fundamental philosophical principles. For example, the burden of proof in a criminal case is so high [00:54:00] because we've determined that it's better for a guilty man to walk free than for an innocent man to be convicted.

So when we think about that for treatment of these, um, patients with psychotic illness, what do you think is worse for a mentally ill patient To go untreated or for an otherwise like, healthier anti-psychotic patient to be given medications against their will.

Margaret: Okay. Or what's the number needed to treats, which is like, people don't wanna say that, but that is like kind of what it Yeah. Boils down to in some, some ways. Like, and it's 

Dr. Jhilam Biswas: like, couldn't that question be posed to every medical specialty? 

Margaret: Mm-hmm. 

Dr. Jhilam Biswas: Right. But like, why when it's psychiatry, it's like. Yeah, but your medications are evil, so Right.

But your 

Margaret: illness is like literally inside itself. Antip psychiatry movement really did a big, they did a big one on us. 

Dr. Jhilam Biswas: It, it did [00:55:00] it. I feel like we're all living under the baggage of that. And, but it's not just psychiatrists that are, it's, it's like our, the, the world is they, you know, and, and there are some really big, I, I really do think it's a human rights violation to incarcerate the mentally ill rather than to provide hospitals for them.

And the unintended consequence of deinstitutionalization, and I'm not saying we need to create a million state hospitals. We can do this differently, but, but land, there was no other option outside. Once they deinstitutionalize these patients, there wasn't another plan. It didn't work because you, you, you actually have to talk a little bit about mandated treatment in this population, and people hate talking about that.

And I kind of feel like I've landed in this weird spot where I end up talking about this a lot. Mm-hmm. Because at sometimes the way through stigma is to talk about it and why it's important and, and to put it [00:56:00] out in the open, like using the word restraint. Like everyone is like, ooh, you know, like it's too stigmatized, but if we don't talk about it, we'll never fix this problem.

We have to get through it. 

Preston: You, you say that, that sometimes that's the way, I think that's the only way to get through stigma is to, to cast a spotlight on it and talk about it. Like, I think you spent a lot of your career literally pointing out elephants in rooms to people who, who are kind of beating around these bushes.

Don't wanna talk about it. Yeah. Yeah. I'm a professional elephant spotter. I, you're, 

Margaret: I feel like the, um, not to go back to the society level and again bring dynamics into it, but there's. There's the history of it. There's like the reality of what psychiatry has done in history. Although I would say if you look at other medical, like history for things, there's been a lot of evil and other specialties too because we, they didn't know or because there were, you know, bad players at, in, in there.

But also that there, [00:57:00] as you describe it, there's kind of a splitting off of the bad part into psychiatrists. Like if you psych, you psychiatrists are controlling and just psychiatrists in the sixties and seventies wanted to medicate and control people. And in the, you know, forties and fifties do ice pick lobotomies and all these things because you people and everyone else was good and the patients were actually secretly good in all settings and psychiatrists just were bad in controlling.

And it's like that is, you know, probably true in a number of places. I don't, I think psychiatrists having to encounter their own evil urges as all humans is important. And I've said that, but like. I also think it's convenient if it's like, actually if psychiatrists just hadn't been evil, there was no mental illness to begin with.

Mm-hmm. Like there was no one who was trying to, the denial, yes. 

Preston: Mental illness was invented by psychiatrists, gotta spend money, money to make money.

Dr. Jhilam Biswas: But it's that social denial of admitting that mental illness [00:58:00] is true and it happens. Yeah. It's easy to scapegoat a group of people that are providing care for that and not that, not that psychiatrists are, I'm just saying that there is this, sometimes the subtext in this part of the conversation that it gets, it gets that way.

Yeah. 

Margaret: No, I think, um, I know we're nearing the end of the episode here. I, I wonder if we, which I'm sad we're not gonna have time to talk about the gender disparity in cognitive load and emotional labor. Yeah. Uh, to women position burnout, which I would love to talk about, but, um, for another day. Um. Can you tell us a little bit about how this has translated in your research and your clinical work has translated now into the advocacy you're doing at the state level as well as, you know, outside of advocacy, politically advocacy through your leadership at NPS or the Massachusetts Psychiatry Society?

Dr. Jhilam Biswas: Yeah. Oh boy. That is sort of like a big brand. It's [00:59:00] like this is one branch of kind of a lot of things that have led me to want to lead NPS, but I do think as a forensic psychiatrist and, and running a forensic fellowship, the advocacy is a really big part of the work. As I said, it's CL for society and really what are you doing if you're educating social systems, you're sort of advocating for things, right?

Is what I'm realizing. That's kind of what this is. At the end of the day, what we're doing, what, you know, I have found myself doing and I, I feel like if I don't do it others. Also follow me. You know, I, I think there, there's, there's, this is, this is going into cognitive load a little bit. I love it. But 

just, 

just to say that, uh, in a way as, as a woman in my early mid-career with young kids, um, taking on this role, I just maybe in a way wanna role model it to other peers.

So that [01:00:00] younger people want to lead things again. Um, professional societies and, and just to really bring out this whole piece that we started with is we're in a really messy time politically in the world. And we, you know, we were doing a lot of canceling in 20 20, 20 21 of each other and getting rid of the a PA and getting rid of like our medical societies and our professional societies we're like, we're going out on our own and doing our own thing.

Great. But right now we also need a very big physician voice as one, two to go up against the big forces, uh, that may get rid of science and they get rid of medicine. You know, you don't know. So I think this is the moment to take on our professional societies, reshape them into the way we wanna see them moving forward.

'cause it's gonna be different from what it was in the past because it wasn't quite working for us in this generation. Um. And shift and change and role model and get [01:01:00] back involved in our professional society. So we do have a bigger voice in the political system speaking out on things. That's to answer the kind of bigger global question.

Um, do I have time to talk about the kind of, the, the way from like the correctional medicine and research that I ended up in? Advocacy? Yeah. Okay. Alright. So, so to answer your Preston, do 

Margaret: you have a question? And you were gonna say something, Preston? No. 

Preston: Okay. So I'm just responding to internal stimuli over here.

I'm like, I'm thinking of things that are funny and I'm like, okay, Preston, pay attention. Like don't say anything. 

Dr. Jhilam Biswas: Really all of this to say is I just got really interested in why are we not treating people with mental illness, um, in moments that we can, building systems that can, and I, I realized it was a lot of the stigma around the kind of care that is required.

Mm-hmm. Uh, for this population. When they lose insight, you know, they end up in the legal system. We need to provide medications. Um, you can't, you [01:02:00] can't deescalate psychosis. I've learned the hard way, uh, over many years of working the car system. I've seen many people try to deescalate psychosis through like talking and reality checking.

Yeah. 

Preston: No amount of reason. It, it's like. It's like you, you're trying to use Disney books at a Caesars Palace. Totally. You just got the wrong currency. You know? 

Dr. Jhilam Biswas: It's, it's so true. But a lot of system, a lot of systems need education, really needs psychiatrists actually to explain that. Like actually this person just needs medication and some time and they're gonna get better.

You know, let me just, let me just tell you this, this is, this psychosis is not deescalation right now. Um. 

Margaret: We're not gonna brief ccb t this out. We're not gonna brief, brief psychoanalytic. Yeah. 12 sessions just so we got it. 

Preston: This like this patient's decompensating. I need a chase lounge and a and a couple ink blots.

Okay. Well too much 

Dr. Jhilam Biswas: again [01:03:00] on psychodynamics. Okay, 

Preston: sorry. 

Dr. Jhilam Biswas: Dial it back. It all comes back to psychodynamics. Not too much on it, 

but, but really to make a long story, a decade story short, it is my clinical like frustration with the situation ended up in doing research with trainees and getting people involved and understanding the issue.

We did the research. It took a really long time to do it in a carceral setting 'cause there's no good IRB situations in in there, which are internal review boards to do research. Anyway, we finally got the research published. We're still doing research in this area. That research has really helped a lot of, um, other mental health groups, at least in Massachusetts, say, oh my gosh, we've been seeing this issue.

You have the data. Let's write the legislation now. And so we've written some legislation on the Timely Treatment Act, and we've written legislation, um, through, with a lot of families who care a lot about this issue on assisted outpatient treatment. [01:04:00] Massachusetts is one of two states that doesn't have any, um, assisted outpatient treatment either.

Uh, 

Preston: I think that's, that's so beautiful that frustration is often the driver of this change. Yes. And, and that's how it's true for me with the things I've advocat for as well. I think it's almost always driven by frustration or, or perceived, uh, injustice. So 

Dr. Jhilam Biswas: yes. 

Preston: Just kind of reflecting on, on that and to anyone else who's listening, if you're frustrated with something, stay frustrated and then do something to change it.

Dr. Jhilam Biswas: And maybe I don't wanna, I don't know if we still learn this word in psychiatry, but like sublimate it in a way. Yeah. Like do something constructive that gets people together and then everybody's kind of involved. And I have found like clinical education, research and advocacy are all really one thing in this story.

It comes from like seeing the problem doing, taking care of those people, doing the research, and then suddenly, like other [01:05:00] people see it too, but they just don't have the research to back it up. And then you're off and running. I started testifying on these bills while I was also involved in the Massachusetts Psychiatric Society.

Mm-hmm. Um, and it's all, it all came from the grassroots, basically. And I realized what an amazing platform we have and every state has one. We're like, you can actually get involved with other psychiatrists, you can write your own legislation. We all hire lobbyists that work in the State House. And then you can actually testify on that legislation and, and have it go through the process to possibly become law.

And that's like where I'm at right now, where like these two bills are gonna be heard along with other things, other issues that I really care a lot about. But assisted outpatient treatment and Timely Treatment Act, these are both, um, about to be heard again at the State House. I mean, they've lost multiple iterations by the way, this Massachusetts, 

Margaret: when do you, when will they be heard again?

Like you knock down 

Preston: five, get up six. 

Margaret: What, what is like Yeah. By the [01:06:00] way, 

Dr. Jhilam Biswas: this is a messy 

Margaret: story. Um, yeah. Which I appreciate it when you did the grand rounds that like this. I think this is real advocacy and also you and I have talked offline of like sometimes in med school or residency or other academic settings.

It can be like, oh, you should do research 'cause you're a researcher or you should be a leader. 'cause it's like. You should be a leader 'cause you feel like you're a leader. And I just so admire your story and resonate with it so much more as like you have come to this work because it mattered so much to you that it pissed you off and that 

Dr. Jhilam Biswas: really pissed me off.

Yeah. 

You know, I can't tell you, but I'll, I'll say, I don't think I've ever said this on air, but like the, it really pissed me off when I was getting cross-examined in the adversarial hearings on like, why do you, you know, why do you think Haldol would work and not Zyprexa and like questioning me on my medic?

Like the choices, like nobody in the room had any medical background and they're just like [01:07:00] questioning me on. Like, like I'm, I'm a bad guy for providing, you know, in Vega to somebody with psychosis. Like, I was like, am I evil? Like, I would have to do my own reality checks to be like, am I evil 

Mark? That really pissed me off.

Oh my gosh. So yeah, that's what it takes. That's what it takes. When will it be 

Margaret: up for? When will it be? Do you have like a timeline of when it'll be up again? 

Dr. Jhilam Biswas: Oh, that's a good question. Um, no, we're waiting for a hearing date. It, I have learned, I just testified on decriminalizing psychedelics and, um, smartphone smartphones in schools in the past two weeks.

And I found out a week before that I had to testify. So you don't find out, you don't get a lot of advance notice it 

Margaret: turns out. But it'll be sometime this fall. I'm hoping This fall. Yes. Well, this episode will be coming out late. Summer, I think, or early fall. So if you are in Massachusetts and you wanna call your [01:08:00] rep, get out and vote or tailgate, get involved, vote, get involved, yes, be annoying professionally, which is what I view some of my work as.

Dr. Jhilam Biswas: And honestly, you talk to so many, you have such an amazing audience of people who are in at that grassroots training level or in healthcare, but maybe not in medicine. I just wanna tell you this story sounds like, oh wow, she's, you know, now advocating and president. But it came from just, just being in the mud and realizing that's where you really know what the problems are.

You don't really know it if you're, if you're at the top and looking down, like you really know it when you're in it. And, and don't underestimate what you're seeing right now and what's really kind of getting you kind of jolted up or getting under your skin. 'cause that's real data on what might be your path.

Margaret: And I'm, I'm glad that I think your work is so important for the patients you see from a systemic [01:09:00] level, but also knowing this is like a systems issue to have you on and have people in healthcare and not in healthcare who listen to the podcast, hear your work, to inspire them towards their own advocacy and to understand a stigmatized group that I think even in the hospital setting, like someone comes in and there's any involvement of like, mention of police or jail or prison or crime, um, it, I think people close up and, and this helps to open up those stories to be able to better treat people regardless of, of anything, because everyone deserves good treatment.

Dr. Jhilam Biswas: It's so true. And honestly, that's one of the reasons why now I'm at an academic center rather than in a forensic or prison setting, because I wanna show, I wanna make it more accessible to trainees to see themselves doing that kind of work too. Like, oh, she's kind of this normal psychiatrist and she worked in a prison.

Like, 

just try to make it [01:10:00] more accessible in one normal way. She's like, doesn't, she doesn't 

Margaret: look dead on in the eyes. Like 

Dr. Jhilam Biswas: she's not dead in the eyes. She's nice. She doesn't look like flaw marks on her neck. She's not 

Margaret: so evil. 

Dr. Jhilam Biswas: Exactly. 

Margaret: Exactly. 

Dr. Jhilam Biswas: Um, 

Margaret: Preston, do you have other thoughts? I'm sorry, I, I did interrupt Preston at one point to be like, no, shh.

So I'm like apologizing. 

Preston: No, that's, that was a, that was a much needed redirection, I think. Um, and, uh, Jhilam, you told it way better than, than I think I could. So the, the only conclusion I have is that. We talked a lot about you being a Swiss Army knife at the beginning of this episode, but then I kind of had this realization towards the end is that you wear one hat, it just has many faces.

So the, the consultant, advocate, educator, doctor, are all kind of the same role here, and it's just which direction you turn, you are that thing to [01:11:00] society, which, which I, I think in a way is like beautiful and poetic, that you can be so many things in one thing at the same time. And, and really it's just the pursuit of justice that I think captures that.

So, Aw. I I don't have anything else wrapping up for that. That 

Dr. Jhilam Biswas: was, that's 

Preston: really beautiful 

Dr. Jhilam Biswas: and I think everybody has that. I think when you're just authentically being yourself and being the person, why did you come into medicine, be that person and find that person again after all the training that like erodes all of that out of you.

You slowly bring that person back and then you can wear all the hats and be the same person. 

Preston: So as we wrap up, I know we've talked a lot about your advocacy already. Are there any specific things that you wanna make sure you share or promote with your work? 

Margaret: We'll ask social people like their, like their websites, their handles, but also when we have Dr.

Funk on, we direct people towards her 2018 QTC resource paper. Um, if there's anything [01:12:00] that you would like people to read or look at, this is your chance to platform yourself that book. 

Dr. Jhilam Biswas: Yes. Um, yes. So I, uh, if you're interested, if you're in Massachusetts and you're interested in, um, advocacy, of course, look at the Massachusetts Psychiatric Societies website.

Um, if you are an attorney and you need a forensic psychiatrist, I have, I, I do that kind of work as, um, it's www.psychexpertise.com. And lastly, if you're interested in some of the air, this piece that I talked about around lacking insight and, and people with mental illness who end up in this homelessness incarceration types cycle.

And, um, that level of criminal justice reform, which is really getting into the deepest issues, I think. Um, we, I have come together with this amazing group of international psychiatrists and others, judges, uh, attorneys, and we [01:13:00] have just started a group called the International College of Neuroscience and Neuroethics called icon.

If you just Google Icon International College of Neuroscience or Neuroethics, either one, the website should come up. We just started it this year to start bringing more and more psychiatrists and other mental health professionals who really understand this issue to come together to start educating the world on why we need to treat untreated mental illness.

Margaret: I love it. Wow. We'll have all of those linked in our show notes. Um, and what about just 

Preston: movies? You think everyone should watch 

Margaret: Preston 

Preston: or like a book that you're reading? 

Dr. Jhilam Biswas: Oh boy. The book I'm reading is Covenant of Water, 

Preston: which is Oh, I've heard good things about Abraham. Recommend Abraham. 

Dr. Jhilam Biswas: Yeah, it's a big one.

It's, it's a, it's a big book 

and it's just so beautifully written. Uh, Abraham Verghese second big novel. Um, he's, he's a internal medicine [01:14:00] doctor. And how do you not get burnt out? 

Oh, I write about it. I write about it. You for part two. Just kidding.

Margaret: Oh my gosh. Well, thank you. Yes. So much just aside, thank you so much for coming on the show. I know you are obviously very, very busy. Um, and so it is really so great to be able to share your expertise and your voice in the field with our listeners. 

Dr. Jhilam Biswas: Thank you so much for having me on. This is an honor and it was just so fun to be with both of you in the same room and, uh, answering these awesome questions.

Thank you. 

Preston: Alright, well, um, thank you Jhilam for being here. Thank you Margaret. As always. Thank you to our listeners for listening, doing what you do best. Um, bring us along for your dog walks or car rides. If you liked the show, let us know. If you have other ideas, um, please reach out to us, uh, on happy patient paw.com or the degree not critiques.

Margaret: Now, if you [01:15:00] have other ideas, 

Preston: we don't accept, we no longer accept critiques as of, uh, as school Evil psychiatrist. 

Margaret: We no longer accept them. 

Preston: Sorry. It's, it's, it's our new evil thing to do. Margaret and R'S Instagram page is now up to like 2300 followers. Oh yeah. So if you want to grow how to be patient, you can also DM us there.

It's a really easy way to reach out to us. Shout out to everyone else who's leaving the great feedback. I know you guys had a lot of questions about forensic psychiatry and we tried to get through some of those today and we will kind of keep turning out more episodes with your requested topics. Full episodes are Preston.

Margaret: I have a review for someone, but oh, we, we had a positive review. Back on Apple Podcast, they said must listen. I'm not gonna read the whole thing 'cause it's long and that would make me feel weird to, let's read it. But I love listening to this podcast so informative. I like the banter between you two, listened on my long run today and it kept me entertained.

So we love being part of your commute. On Monday mornings when we released the episodes, you entertained 

Preston: long runs. Okay, here's, here's a new one that I got as a DM on Instagram. Honestly, I love you guys so much. You guys are honestly [01:16:00] the best podcast that I've listened to yet. It's realistic, funny, and nice to hear from a clinical psychology student's, POV 

Margaret: and not evil.

Preston: Yeah, evil wasn't mentioned a single time in there. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aaron Corny, Rob Goldman, and Shahnti Brooke, our editor and engineers, Jason Portizo.

Our music is Bio Mayor Ben V. To learn more about our program, disclaimer and ethics policy, submission verification, and licensing terms at our HIPAA release terms, go to our website, how to Be patient pod.com or reach out to us at How Do Be patient@humancontent.com with any questions or concerns. All the cited articles will be listed in the show notes.

How to be Patient is a human content production.[01:17:00] 

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.