How would bringing back long term psych care look? (and is it a good idea?)

Margaret: [00:00:00] All of it is a calculation every single time of like the reality of what services they can be offered, inpatient versus outpatient and how this kid and this family will respond to it. And whether it'll make them hate care and not return to it even when they really need it. Versus like trust care more and be like able to do it when they really need it in the future.

How Be patient 

Preston: and welcome back to How To Be Patient. The podcast where we learn about patience and how to be them. Mo mostly like patients like the verb or the virtue I guess they say. And, and I wanted to try something new like 

Margaret: he jet lagged you guys. 

Preston: Yeah. I just got back from Japan. Um, I was listening to this podcast too.

Scary. Didn't watch. Have you ever heard of it? 

Margaret: No. 

Preston: It's about, so it, so it's about these, uh, these three friends and one friend loves scary movies. The other friends are two scared to watch scary movies. So they watch the podcast and then they recount it to each [00:01:00] other. And you like, listen along as another friend who's too scared to watch the scary movie.

Um, anyways, I like how they do their intro. So guys, I'm Too scary. Didn't watch. Um, they, they go like, Hey. I'm like, I'm Karen and I love scary movies, and I'm the, I'm this person. I don't love scary movies. 

Margaret: Okay. 

Preston: So I was like, oh my gosh, I should be like, Hey, I'm Preston and I'm a psychiatry resident. And then Margaret could be like, 

Margaret: Hey, I'm Margaret, I'm a psychiatry fellow.

Preston: Fellow, yeah, just, just two fellow docs hanging out to chat. And this is the podcast where we do that. So that'd be our intro, you know. Oh, 

Margaret: I like it. We can just get, we'll steal it from them. 

Preston: Yeah. So we 

Margaret: recited our source. 

Preston: I know we did a lot. So, um, now we watched a 

Margaret: horror. I didn't watch the horror movie.

Preston: Both of us are too scared to watch scary movies. Horror movies. Movies. Yeah. But we, but we are not too scared to talk about the podcasts that talk about scary movies. So shout out to three layers 

Margaret: to 

Preston: watch. Yeah, that's, that's, that's where I like to keep it. So today we have a fun podcast. [00:02:00] Um, we're gonna be recounting my vacation and then I'm also want to hear about Margaret's plans for February with GTFO, your phone February.

And then we're gonna talk a little bit about this executive order from January 20th to bring back long-term psychiatric institutions. I know we kind of like covered this earlier in an an episode, but this time we're taking a twist to it to say like, hypothetically, how feasible is this and what would it look like if they were to come back?

If then we're gonna kind of get into our little Patreon section where we compare ourselves to other countries because, you know, comparison is the thief of joy, but sometimes it can be helpful for building policy. 

Margaret: That's why we're putting behind the 

Preston: seeing how other people do things. 

Margaret: We're 

Preston: protecting 

Margaret: you from it.

Preston: Exactly. So starting on with like the opening session, how are things in our lives? What. Margaret, before I talk about Japan, I wanna hear about how to get off my phone this February. 

Margaret: I did this last year. It is. Get the [00:03:00] fuck off your phone. Why am I saying this? Like, I can't say it. Like, every episode we do isn't explicit.

Get the fuck off your phone February. Which the point of it is actually not to entirely get the fuck off your phone. It's just to be like, return. I wrote on Substack about this, like people romanticize it. But I think just behaviorally speaking, it's like returning the computer to the computer room. So like when we were kids and it was like, I'm gonna go get on like whatever this game or like what, what was that one game that was like Canon Kitty or something?

Flappy 

Preston: Bird? 

Margaret: No, that was your generation Preston. My generation was three years earlier. Many 

Preston: phone were broken on Flappy Bird. 

Margaret: Um, no, but that's phone. No, I'm talking about computer room. 

Preston: Mm, yeah. 

Margaret: How old, I guess When, when are you at 99? Is that how old 

you 

Preston: I had, I had the 97, I had the computer room. 

Margaret: I remember I just made you be like, I was like, whatcha like 12?

Um, anyway, get, so basically I feel like here's my beef. A lot of people in I wasn't [00:04:00] speaking to the micro producers are gonna be mad. Sorry. Um, a lot of the books, I don't know how many Have you read any books on like, 

Preston: I've never read a book. No 

Margaret: approach. Well, that's your goal for 2026. 

Preston: Yeah. Yeah. It's learned to read February for Preston.

Margaret: It's a big goal. Yeah, it's a push goal. If you'll, they do say big, hairy, audacious goals, but, um, no, like, have you read any books about like how to interact with screens or screen time? Screen use, like not being addicted to your phone, dah, dah, dah. 

Preston: I, I've seen ads for them and I like swipe past them, which 

Margaret: Gotcha.

Preston: So the irony's not lost on me as 

Margaret: you're like, I'm good 

Preston: to this girl. Yeah. 

Margaret: So I have been reading those books 'cause like, same. Except for mine is like, let me gather more information than not act on it. Mm-hmm. And so I've been reading those books for forever. Um, we had a guest of someone who, like, one of the only ones of those I recommend is Amelia Hutcherson, the art therapist who had the, uh, book [00:05:00] and we had her aunt talk about that book in season one.

But a lot of the books are kind of like, they're written by this sort of like male engineer archetype that is like, the philosophy of it is like, just do it. Interact better with your phone to optimize your productivity. And oh, I see this very like biohacking, almost like optimization at all costs with no kind of like endpoint.

And 

Preston: so yeah, optimize everything. Enjoy nothing. Type B 

Margaret: Exactly, exactly. Type B type shit. Um, so. I like, was like, okay, well here's what I'm doing. And then I would talk about it a lot on TikTok. And so then last year I made one of my like little journals that I put on my Etsy and made one for Get the Fuck Off Your phone February.

And it's basically all of the things that I have like learned a little bit from those books. But then also just like little tools and kind of like behavioral activation things to help people. AKA me [00:06:00] and my inner self, uh, get off their phone, but also the people who follow me. 

Preston: I mean that's all, that's what we do all the time, right?

We, we try to help ourselves while also helping others. That's what passionate about. 

Margaret: Right. 

Preston: And, and you've been doing, you got me on Brick, I've been using the brick too and that's been helpful 

Margaret: joke there. I can make so obvious.

Preston: I mean, yeah, do a lot of brick related things. I think I told Rob that and Rob goes, you made me think of the character from Anchorman, which brick also could come around and knock your phone outta your hand. That, that could be effective. 

Margaret: Yeah. So I this now I have that And you said you've liked the brick, right?

Which is for those who don't have like a physical, I'm bricked up all like a magnet all the time that you put on your fridge or, or you don't have put on your fridge. It's a magnet you put somewhere. 

Preston: It is on my fridge though, 

Margaret: but it is on my fridge too. Uh, and you have, you have to like go if your phone is, it's never not, funny to say bricked up of the phone.

If your phone is bricked up, it means you can't like get into whatever apps [00:07:00] you put on the list. This is not sponsored yet. Brick. You call us if you, uh, want to, if you 

Preston: wanna get bricked out, 

Margaret: if you wanna get bricked out while being patient. Um, but so you have to bring it physically up there. And I was like, this is working and I support it so much simply because getting up off of this couch.

Having to go do it has been like life changing for me. 'cause then I get up and I'm like, do I really wanna admit defeat in this way? I'm already up. I should like do my dishes and like go have a life. 

Preston: Mm-hmm. 

Margaret: But you, it's working for you, right? 

Preston: No, it works because like my, I have to walk across my hallway to go use it.

So if I like, wanna unlock it, like I'm in, like say I'm in my bed scrolling, I think, is it so worth it for me to get up right now to go do it? And then mm-hmm. I'm like, no, it's not. And then I like go back to like what I'm focusing on. Mm-hmm. So like that part's been nice, is that it makes me sec, like think a second more about it.

Mm-hmm. And then there have been times where I go to work and I forget that I'm like brick outta my phone. Then I just like, pretend it's the nineties and [00:08:00] you know, actually this, this happened to me 

Margaret: one through three. 

Preston: I know. I'm like, oh, the nineties sucks. 

Margaret: Like I didn't know how to use the bathroom.

Things suck. 

Preston: Which, which is a good segue into my catchup, um, portion, which is when I was in Japan, my eon did not work. So I had no internet the entire time there. So I was basically, it was like the whole country of Japan was one giant brick. You were up constantly for my phone. Yeah. Instead of tapping on the fridge, I just, I just tapped it on the island of Japan and was like, no internet.

And like we had some sections of the trip where it was like a three hour car ride. Like we, we went up, um, snowboarding in Hokkaido. Mm-hmm. So we land in the airport and then it's like a three hour drive to Necco through like really like. Deep snow or going very slow bumper to bumper traffic, tight beat, and I'm just looking out the window like I started doing.

Margaret: Was the person you were whispering tight beat all the time? 

Preston: No. No. I don't, I don't, I think it's like a vocal stem for me right now. Comfortable with something and I start recycling the phrases. [00:09:00] But yeah, I did stuff I did as a kid. Like, you ever play that Running Man game where you pretend that there's a little running man running next to the car and he's jumping over obstacles?

Margaret: Mm-hmm. 

Preston: Just, just me. Okay. Why would I, I started, I started watching the little Running Man again. 

Margaret: I, mine was like, if it was raining and you would like be like, pick a raindrop to beat the other raindrop 

Preston: going 

Margaret: across. 

Preston: Yeah. I, I would do that too sometimes. Or I look at myself in the reflection and pretend I'm in like a music video.

Something like, oh, I look really, 

Margaret: that 

Preston: explains 

Margaret: somber 

Preston: right now. 

Margaret: So much. 

Preston: So yeah, outside that Ja Japan was fun. It snowed so much. And I had, you had to get a special powder board, like for the powder. And the best day I had was when I like went and rented it, um, from the place and it was giant, it was bigger than me, it looked like a surfboard.

And I was like, yeah, like this thing cooks. And then I would still fall over and the snow every [00:10:00] time. And I realized maybe this is a skill issue and not a board issue. 

Margaret: Skill deficit. 

Preston: What? No, I lemme externalize to my equipment. It's their fault. It, it, it was so steep that like you would fall over in the snow and you couldn't like, put your hand down so you had to like, oh wow.

Stack snow or unclip and then like snowshoe around. And then, then I would start sweating and I was sweating through my clothes, but it was like still really cold out 'cause it was like 10 degrees. So at one point I just laid against a tree. And you can see on my TikTok, I posted this and I was like, you know, if I was a knight who got stabbed and was bleeding out here, this would be a pretty nice spot.

And then I just sat there for like 30 minutes and just wanted me to bleed out there and without a phone that worked either. So my friends were wonder where I was 

Margaret: without a phone. 

Preston: Yeah. I was living in the moment. 

Margaret: The male mind is a marvel. Yeah. Like, and then I wondered, what if I was a knight? 

Preston: Yeah. Like, I finished, like I lose the battle or maybe I [00:11:00] win the battle, but I've been mortally wounded and now I'm bleeding out 

Margaret: right 

Preston: here.

It's 

Margaret: like women have, like, would you still love me if I was a worm? And you have, would you still love me if I was a knight bleeding out after losing my battle? And 

Preston: no, I, I have, if you really know me, what would my ideal bleed out spot be? It's not a question about whether or not I wanna die bleeding out somewhere after winning a victorious battle.

It's, is it propped up against a tree, looking out over a pasture? Is it in the mountains? Is it by the ocean? Like that's, that's the test. Okay. And 

Margaret: that answer's gonna be in the Patreon side. 

Preston: Yeah. Yeah. That's 

Margaret: for all you comment's, 

Preston: law wonder that's toxic. Deep in the, in the behind the machinations of, of, uh, Preston's, uh, resistance.

So that's all I have to say about Japan. 

Margaret: I have one more thing to say about, okay. Not even Japan, but you told me to speak. Uh, my 2026. I'll be speaking over men more because some, the section that's coming up about the current, it is [00:12:00] listeners, it is January 26th. Today when we are filming this, um, I am amidst two feet of snow in Boston.

Uh, and the world is like also just like not great, but that's an entirely aside. 

Preston: Mm-hmm. 

Margaret: I wanted to ask how your New Year's resolutions are going. I wanna talk about mine because you had put that in the outline and I wanted to say my step goal is going Awesome. That's all I had to say. 

Preston: You're in a step competition, right?

Margaret: I'm in a step competition and it's life changing Step up. It's on this app not sponsored. That is a, a really rinky-dink little app, but it's called Pacer. But you, my friend and a couple of her friends from college have been doing it and they put me in there and there was this one person, Alyssa, the name Dropper, who was like beating all their asses every single week.

And like I live in Boston, Boston's a walkable city, and I take public transits in our public transit Sucks a little [00:13:00] bit, you know, on and off. Mm-hmm. And so I therefore walk a lot and I'm training for a 10 miler in May. And so I take such great pleasure in making it so that I have like 6,000 steps. So the time Alyssa wakes up and checks the score.

Preston: Alyssa's stressed. 

Margaret: It's like, girl, get up, get up. Like literally like my friend text stand up, me screenshots of her other friends being like, today I, she got her text site and then we can move on. Today she got a texta that was from another person in it that just said she has 19,000 steps one day in, in a snowstorm.

And then she said, we must take, we must put her down. 

Preston: Okay. So, so new year's resolution update. Margaret's on top of the hill fighting off, um, potentially weekers. Well, I 

Margaret: lost last week because it's five days, but yeah, I'm, I'm in the fight. I'm, I am. This is my mortal wounding. But what about 

Preston: you? Well, if, if, if you are walking right now listening to this podcast, it is in [00:14:00] solidarity with Margaret and her step goal, my news resolution.

When you first said that, I was like, oh my God, I forgot. But I do remember, I remember my news resolution Triple 

Margaret: E rating 

Preston: to be more, to be more present. And I realized that I accidentally did that by. Bricking myself outta my phone for an entire two week trip in Japan. I, I was very present the entire time and it was nice, you know, the first couple days sucked, but after that I really like, started to enjoy it.

And you notice, like you notice little details that you wouldn't otherwise 

Margaret: goals achieved. Yeah, 

Preston: I take that point. I realized that, yeah, maybe it should happen for a reason. Speaking of reasons and things that are happening, let's reasons and things. Our favorite segment, 

Margaret: main, 

Preston: main part of this, which is gonna be the, the question of bringing back water.

Having you seen heated, 

Margaret: heated rivalry, sorry, 

Preston: the heated [00:15:00] rivalry between, uh, long-term psychiatric hospitalization and not, and also the, the hockey show on HBO. So, uh, we're gonna take a quick break and when we come back, we will, uh, get into the main part.

We were trying to get a video of this and we had a whole run around about how to play news footage, uh, for y'all. Like this is from a White House press conference and we tried to get it through CNN, but there's copyright infringement. So went into White House directly and I spent a lot more time than I would like to on the White House Twitter page and the YouTube accounts and everything on their, on their website.

And I couldn't find anything. So I'm just gonna give you a direct quote from this. So, um, this is from January 20th, uh, when the president was basically addressing new executive orders. So, uh, here he said, signed an executive order to bring back menstrual institutions and insane asylums. We're gonna have to bring 'em back.[00:16:00] 

Hate to build those suckers, but you gotta get people off the street. And then he talks about growing up in Queens and how he could have been a professional baseball player. I couldn't really find much else. Um. Speech. So that's actually kind of what spurred the idea for this episode is that there is this executive order.

What do we know about it? What, what do we know about how feasible it might be? And then what could the future look like? And, and really it's just the concept of bringing back mental, mental institutions hate long term hate, hate, hate to build those suckers.

Why you gotta say it like that? 

Margaret: As many people have said on TikTok, if he was not, so he has the perfect humor for a reality TV star and he should have just stayed there. Hate to build those. 

Preston: So yeah, it's, and it, it's an interesting, [00:17:00] like, this was like a divisive claim and I, I think, um. First of all, I wanna clarify, this is not a political podcast, and so I don't want to be like entering into like this political realm where we're opining on either side.

Like I think I'm bringing up this, uh, because it's relevant to our discussion, but then we're gonna try to keep the rest of the time, um, focusing mostly on the implications from mental health side. So I just, just kind of wanted to clarify that for the audience. However, this was a very divisive, um, topic.

Some people see this as a way to essentially like enforce governmental power because that's how it's been used in the past and, and a lot of, um, people in mental health also see it as like possibly a good thing. So this, this is not like kind of a, a neutrally, uh, perceived policy. And, and I was actually really curious about where this even this came from.

Mm-hmm. It seemed like relatively new to me, and I guess I'd been kind of missing it. So. [00:18:00] Early, like as far back in 2018, um, the Trump administration has actually been talking about, um, re reinstituting, um, mental asylums or psychiatric, like long-term institutions. So back, um, after the Parkland shooting in February, 2018, they, uh, it was first brought up as a solution to gun violence.

And it was like through that lens, like, oh, these people have mental illness, that's why they're engaging with gun violence. And like a possible solution would be to create these, uh, or like to reinstitute them. And then in 2019, um, it was kind of brought up again and like still expanded upon. No executive orders had been signed at that point, but basically that the, the, this was a quote from a, a speech in August of 2019.

Uh, humane Society needs institutions to shelter and care for those, um, who are instead populating the streets. So it, it. The rhetoric [00:19:00] around it is still the idea of like public safety rather than adequate care, I guess is how I put it. Right. And then most recently, um, outside of this executive order, there was a, a different executive order in July of 2024.

And that was, it was called like the, um, like the homelessness and like, um, mental health support act. Mm-hmm. And if you look up, if you look up this executive order from July, a lot of people were reposting it and saying like, um, the president is trying to make it easier for you to be involuntarily committed and like these new orders could like, you know, take away more of your rights.

I was actually looking at the executive order and I, I'll read some of this off to you. I couldn't really find necessarily that verbiage, but it's interesting that like, this has still kind of been a long time coming. So here it says like, section two, restoring civil commitment from the Attorney General.

Um, article one is seek inappropriate cases, [00:20:00] um, some reversals of judicial precedent determination of con of consent degrees that impede United States policy of encouraging civil commitment of individuals with mental illness who pose risks to themselves or the public or living on the streets and cannot care for themselves in appropriate facilities for appropriate periods of time.

And then provide assistance to local governments to essentially, um, like give more funding to people who are like housing these individuals. So, I mean, I guess I have to walk myself back. Like I said, I didn't necessarily see the verbiage initially, but they're saying like, reversal of some precedents that I guess allow for commitment without consent, so, mm-hmm.

But, but it's, it's really vague legal language and, and it's not clear like how it impacts or changes the due process that we have in the current system. 

Margaret: I do think our work is inherently political. And this, you're right, this is not a political podcast, so. I do just wanna say that my stance is a little bit more like the work we're doing as psychiatrist is political, mostly [00:21:00] because it's been so inter, like nationally, globally, political, not just, I don't just mean political in the US and I'm not saying you don't think that, but like, I'm just saying, well, 

Preston: I mean everything, everything is political.

Like 

Margaret: sure. Point 

Preston: blank. Yet this, the podcast is not intentionally 

Margaret: Yeah. 

Preston: A politics podcast 

Margaret: in particular. I think the thing that comes up, right, like we talked about in the episode about like involuntary sort of institutionalization stuff. We even talked about it in the forensics episode with Dr. Bwa. Um, that this topic is hard one, but two, it's, I don't think there's like a coherent, nuanced approach from either side.

And so like mm-hmm. Hearing this news, but then also hearing what, like you talk about like when it's been brought up before, thinking about like. The HHS secretary talk, like connecting SSRIs with being a mass shooter in the [00:22:00] past, allegedly, I think he said that publicly, but a alleged, I'll say it allegedly here.

Mm-hmm. As well as like the, like wellness camps that have been like floated as like the idea for kids' mental health and the, just the general mistrust and lack of collaboration with the like medical scientific community hearing about these orders. It's like kind of like, oh, well maybe it'll get funding and something good will happen with it because god knows we need more services and like in some places assertive care.

But just wondering with this administration and also just depending on like where the funding actually goes is, I can imagine this being money that end if it, if it ends up getting funded, that is either can do some good because we just need funding and the behavioral and mental health and.

Particularly in substance use space, uh, which just got cut as well by them, or like was cut and then put back on like a week ago. Or I can see a coercive [00:23:00] environment and something that is also in the history of psychiatry in the us but I think the, like most damning version of it in modern history is in Germany, uh, when like asylum and institutionalization was part of the onroad into like sterilization and then killing and other, everything else.

So I think the biggest question for me hearing about this is like, where will this funding actually go and will it be aligned with science or will it be not aligned with the science? And then will there be transparency in the institutions that it would be running? 

Preston: Yeah. You're concerned about who's driving the ship.

Margaret: Mm-hmm. 

Preston: And like practically, how will this play out? Because it's easy for us to, I guess, philosophically talk about why things are needed, but it's a whole nother thing to see them. Be executed. 

Margaret: Yeah. Well, and I think, I mean, I think that from like a health policy standpoint, this administration has not really, in my view, been doing awesome in terms of like [00:24:00] building up institutions that are doing well and like allowing health workers and, um, you know, systems to move towards being better after COVID.

Yeah. If there's 

Preston: any history of how things have been applied in the past, it does not, does not inspire optimism about how this would be applied. Yeah. 

Margaret: Well, I mean, you know, I like work in perinatal and I work in child, and both of those two populations are the ones that when these systems have been more conservative and more restrictive as well as like minority people of color, like the, like these are all the populations that when mental health has gone pretty wrong in terms of like over institutionalization and over 

Preston: mm-hmm.

Margaret: Um, kind of paternalism have suffered. 

Preston: The most vulnerable populations to that. 

Margaret: Yeah. Although like, I mean, if we look at the history of mental health, like you think of vets after World War II and like Vietnam and stuff, and they also like, weren't treated probably great [00:25:00] either. 

Preston: Mm-hmm. Yeah. It's, it's, it is a really challenging, like, current landscape for us to think about bringing back a policy like this.

And I was, I, I was kind of curious about like how things have changed, like since we deinstitutionalized in the sixties. So as a quick refresher for everyone, the Mental Health Community Act in 1963, um, put forth by President Kennedy was like, when we deinstitutionalized, so we're, it's been about 60 years, 63 years since we've deinstitutionalized and a lot of things have changed since then.

So, um, I was kind of like. I wanted to use Texas as a proxy just because I practice in Texas and I'm most familiar with the, the, like, legal landscape here. So looking at our kind of pseudo version of long-term acute care, we have our long-term care. We have 10 state psychiatric hospitals for a total of [00:26:00] 2000 beds.

And they're usually at like pretty close to capacity. Um, yeah, a fair amount of patients. The 40 to 60% range stay at these state hospitals for longer than a year, but there's no one in like long-term care. And ultimately the goal of these hospitals is to still rehabilitate and reintegrate to society. So like from my personal experience, I have had a lot of patients that have had prolonged stays on inpatient units, um, at our inpatient, either VA or at our university hospital where the, they were unsafe to discharge.

They had no like no safe dispo. Yeah, essentially. And then they were on a wait list to go to the state hospital where they spent an extended amount of time there. So I mean, like even some of these like acute care. Places where the average stay is five to seven days turned into months. And I'm sure, um, any like psychiatry residents or nurses listening to this have probably either had cases or heard of cases of patients on their unit staying for months at a time because there was just like no option, um, for disposition.[00:27:00] 

The, and then, and then kind of looking at the possible population that would be, I guess, targeted by this. Um, I, I'm, I guess I'm lilac not including is so 

Margaret: interested in this episode. 

Preston: Yes, she's, 

Margaret: for those who are listening, lilac is like all over the place in the video. 

Preston: So I guess I would say this is probably an underestimation because there are a lot of patients that may, um, I guess qualify for like institutional level of care that are currently being like, taken care of by family members and burden, uh, like, um.

Essentially like that need is putting a large burden on families where they could receive more help from the state. Um, however, there are a lot of unhoused patients, um, that would also be like kind of the, the target population or like, especially who is being like explicitly mentioned in these executive orders.

So there are 27,000 un hounded unhoused individuals in Texas is according to the 2023 census, and [00:28:00] an estimated one fifth to one third of, um, chronically unhoused individuals in Texas have some form of schizophrenia, schizoaffective, or bipolar disorder. So by that math there's about six to 7,000 chronically unhoused individuals with severe and persistent mental illness, which would be about three times the current census of all of our state hospitals combined.

So it's 2000 people, but the demand would possibly be around 6,000 where we took to make those adjustments. Yeah, 

Margaret: and I think like. I think it was in, it was in New York, I think it was when it was like Mayor Adams, this is like two or three years ago. That to, to your like point I think, or the point you're leading to, if we have, like, if we give entirely good faith, like that this is gonna be like good mental health care for more people, whatever.

Um, I think there, like in New York, he had made this like statement that like [00:29:00] got super mocked, but it was like, we're gonna take all the homeless people and we're gonna put them in a psychiatric hospital. Um, he didn't say the stats as you are that are, you know, maybe smart and indicating that not everyone who's on the street needs to go or is there because they have a psychiatric illness or something.

But then the question became kind of like, how then, which maybe would be different in this instance that we're talking about if there is funding associated with it. But I just wanted to like name that kind of similar situation of you have 2000 beds and then you'd have 6,000 people. 

Preston: I think like maybe what people are picturing is that you need 27,000 beds.

Mm-hmm. 

Margaret: But 

Preston: it's not every single unhoused person. It's, it's people that are unhoused because of their severe and persistent mental illness. I think that's where a lot of the, the kinda like nuance gets lost in these discussions, as you pointed out. Um, interestingly though, like the process of committing someone to an institution would have changed drastically.

So back in the sixties we didn't have a lot of due process. Mm-hmm. Um, [00:30:00] like you can, people can be, could have been committed to long-term psychiatric care by family members. Um, you know, I think like the classic case that you think of from like a black and white film is some, some guy goes, my wife is hysterical and then she gets sent to this hospital and gets lobotomized and never comes out.

Like that's, that's like what I'm picturing. Um, when I think about like time 

Margaret: or flew off the Cuckoo's Nest. 

Preston: Yeah, yeah, exactly. And so I think there is some concern, like is, are we, would we be, would we be going back to that and not necessarily, at least not how things stand right now. So if you look at 1975 O'Connor versus Donaldson, we, that's when we basically established that if someone is not a danger to themselves or others, you can't commit them against their will.

So like, kinda like the basis of like involuntary commitment and then, um, in Addington versus Texas in 79, 4 years later, they actually increased the burden of proof for, um, [00:31:00] long-term like involuntary psychiatric treatment. 

[music]: Mm-hmm. 

Preston: So it used to be just preponderance of evidence. Now it just became clear and convincing evidence, which will lead us into our next segment.

When we come back from this quick break, we will be playing burden of proof. Bingo. Quickly refresh ourselves. 

Margaret: This is, I'm not gonna, I'm not gonna know, but yes, 

Preston: don't, don't worry. We have the harmonica to help us out. Okay. We'll be back in a little bit.

Okay? And we are back with burden of proof. Bingo. And, and the reason why we're even getting into burden of proof is because this is, these are necessary topics to think about when you think about what it takes for the government to take away someone's rights and put them in an institution. So I'm going to read off a level of, uh, burden of proof and play a [00:32:00] note that goes with it.

And then Margaret, you're gonna try to define it. 

Margaret: Okay? 

Preston: Alright. So we have a skint of evidence. Oh, I'm gonna start lower and then get higher as the burdens oft.

Margaret: Um. Is that just like, I don't know, like a few shreds of evidence? That might be true. 

Preston: Yes. Very close. It is. It is the minimal amount of evidence that is admissible to support a claim. So, you know, you ever see the, the lawyer go, objection, your Honor. It's like one step above an objection. It's like the smallest thing you can say that like won't be objected to.

So, um, example could be I saw a car that looked like the Accused's car at the scene of the crime. 

Margaret: Hmm. Okay. 

Preston: Okay. 

Margaret: So maybe in this case it would be like, I think that my [00:33:00] wife maybe said was talking in her sleep and thought she was talking to someone. 

Preston: Sure. Exactly. 

Margaret: That feels like a skin of a psychiatric illa evidence.

If it was, if it was that standard instead. 

Preston: Right. But if you said. The neighbors told me that they heard my wife talking. 

Margaret: Mm-hmm. 

Preston: Objection, hearsay. 

Margaret: Yeah. Period. 

Preston: That would not be admissible because it's, it's now second order. Mm-hmm. And you can't repeat what someone else said to you. And also, and I guess the idea is like that person is not under oath when they say it.

Margaret: Yes. 

Preston: A cantilla of evidence is never enough to commit someone anyways. You probably haven't even, I didn't hear about it until reading about this before because I don't engage. We, like in mental health, we have never engaged with like this low level of evidence. Like, so cantilla is like really just for possible statements to support a claim that like may later lead on, but it's very small.

Okay. [00:34:00] Next one is reasonable suspicion. 

Margaret: Trying to think of like different words to say for it. Um, I think that would be like. I don't know. The thing that's came to mind is like, oh, maybe like a 50 50 chance. Like there are things that indicate this, 

Preston: that's, that would actually, um, more than a 50 50 chance is actually much higher than reasonable suspicion.

Margaret: Okay. So then like, what, like 30, 70 maybe? 

Preston: Yeah. It's hard, it's hard for me to like, put these into like probability terms. So I'm just, I'm just gonna read off to you. Um, it's more than a hunch. So it has to be, it has to be based off of, um, like concrete observations 

Margaret: Yeah. 

Preston: That you've made. Okay. Like, a great example of this is reasonable suspicion is usually the legal standard for police to briefly detain someone.

Mm-hmm. So these things of like, Terry stops. So [00:35:00] if you see like the outline of a gun in someone's sweatshirt, like you observing specifically the outline of a gun is enough to give, is that a brick 

in 

Margaret: your pocket? 

Preston: Yeah. Yeah. Are you bricked out of your phone right now or or do I have more than a hunch that this could be a weapon 

Margaret: That's, do I have more than a cantilla?

Preston: Um, so just to clarify, so this is more than a cantilla but not quite probable cause this is also never like enough to commit someone. So we're like, we are already way past where we were in the sixties when it was like a skint and off you go. 

Margaret: It's like the vibes are bad. Was the sixties. 

Preston: Yeah. It's like half a cantilla and see ya.

Uh, reasonable suspicion is more than a hunch. And then we, we move up next one more to probable cause. 

Margaret: Is that like 51%? 

Preston: 51%. That's still [00:36:00] too high. Probable cause. Why is it high? Low? Yeah. 

Margaret: Are you sure? I 

Preston: think, yep. Okay. 

Margaret: Say what it is then. Oh, you have to play your harmonica note. 

Preston: Oh, shoot. Okay. My gosh. Okay. So we had skint then we have reasonable suspicion now problem.

Cause

Margaret: I just, a lawyer listens to us. They're gonna, they're gonna be in the comments. They're going, you're ripping us a new one. 

Preston: They're crashing out. Yeah. 

Margaret: Or slash My mom, my mom is a lawyer. Sorry, 

Preston: Sheila. I mean, this, this honestly confuses me. I, I won't even make you read this one off because it says, more than a hint, more than a hunch, but less than a preponderance.

So I'm like, okay, how can you define it by 

Margaret: look that this sounds like 

Preston: word is relative to other things. 

Margaret: This is like DSM type shit that we 

Preston: I know say 

Margaret: like it's a little bit more this way. It's a little, it's a, it's a little bit of this, a little bit of that. 

Preston: Yeah. So, so [00:37:00] basically it's, it's more than a hunch.

You have to have objective facts and then you have to look at the totality of the circumstances. So it can't just be like, I saw a gun in your pocket. It might be okay. And you were leaving the gun store or something. I'm, I'm making this up, but the lawyers can skewer me. Um, so, but you have to take into like, like other context or maybe someone else says he's got a gun or something.

I don't mm-hmm. I don't like this example anymore. I don't want, 

Margaret: I don't like this game. 

Preston: May maybe, maybe, maybe you're, yeah, maybe. Okay. How about this? The, the wall's been spray painted. 

Margaret: Okay. 

Preston: And also you have paint on your hands and then someone else says they saw you throwing a spray can, like, now that's probable cause.

It's more than just, oh, I saw maybe you had paint on your hands or, okay. Someone heard that the sound of a pink hand. So that, that would be probable cause this is now where we actually get into mental health, um, like levels. Uh, so probable cause in Texas is what you need for an emergency detention.

[music]: Mm-hmm. 

Preston: So remember this is less than 50 50 [00:38:00] chance, like it's just. Could you develop a reasonable suspicion based on the totality of the circumstances that this person may be suffering from mental health crisis. So it's like, and the context is not that high of a burden of proof. Um, and then the current threshold right now is if you have probable cause, you can detain someone involuntarily for up to 48 hours to be evaluated by a psychiatrist.

And which is 48 

Margaret: company regular hours or business hours. 

Preston: Uh, depends on who you ask, but it should be 48 regular hours after that. We have preponderance of evidence, which you have been, I think you've been chomping the bit to get this one, which, that's the 50 50. It's more likely than not. So that, 

Margaret: well then wouldn't it be more than 50 50?

Preston: Yes. It'd be 51% like you said. Okay. If you're 51% sure. That's preponderance of evidence. Okay. More, it's more likely than it's not. That is now the burden of proof that the psychiatrist has to [00:39:00] come to. To, um, file for an order of protective custody, and that has to be cleared in, in a court of law. So at this point, to stay in the hospital for more than a couple days, we already have the courts involved.

This is also very different than, than what it was, um, back in the sixties. 

Margaret: See, it's interesting, like we're like talking about this and how like the legal system interprets it, but I don't, I don't know for you, but like one of the biggest things that can be true county to county re regard and like regardless state that you're in is if you go to these hearings, um, so much depends on the judge you have, uh, in terms of like if a patient goes in or not.

And that's not to say that like they're not reasonable judges or like the legal system's not working, but just that, like even if you, as we talk about like this level per whatever level in the law that like when it actually like the rubber hits the road, even now it's kind of like, well, how does. [00:40:00] The judge interpret what, like a criteria three on a section 12, like an inability to care for self in the community, or like serious harm to self risk, whatever.

Um, so it's, it, it's just interesting to talk about this because like there's the law part of it that like kind of is standardizing and like sets the tone, but there's so much variance around that line that is set even by the law. 

Preston: Mm-hmm. Absolutely. And then when you're contemplating the question of long-term psychiatric institution institutionalization, we have this great variance that now leads to a much more intense outcome.

Long-term outcome. 

Margaret: What do you mean? Just, 

Preston: I, I guess what I'm saying is like instead of spending a couple more days in the hospital where you have to be discharged, it could be now being like sent to like a long-term care place for months 

Margaret: or sent to the street and. [00:41:00] Psychotic and not, 

Preston: yeah. Which is also not a good outcome.

Margaret: Guys, do you see our, our nons psychiatry friends? Do you see why we're, we love to opine about capacity and this question can argue about it. 

Preston: Yeah. It's like it's, it's sucks because you wanna say like, oh, just to be safe, keep in the hospital or just to be safe, let's let him outta the hospital. But it's like, I don't know what, just to be safe is like, there's no easy, safe option going forward.

Like both, every decision you make has harm or the potential for harm. 

Margaret: Right. Well, and even like when, not when we're talking about necessarily state hospitalization in general, but like any, the one of the highest risks, I don't think this is causative, but like I think it's more just, it's like a delay type of thing that one of the highest risks for suicide is like the first like week or so after discharge from a psychiatric unit.

Which like, again, I don't think that's causative. I think that is like, it makes sense. Someone's admitted to a psych unit probably because. They were [00:42:00] severely ill slash are severely ill. And so it like you leave that contained environment. But still, I think a lot about in like the emergency setting, especially working with kids who it's like maybe their first time ever meeting a psychiatrist or thinking about inpatient or their parents first time thinking about for the kid.

It's like, what is the risk based on what I'm reading interpersonally with this family and this kid and what they think about all of this and mental health care in general and how sick they are and what I know the actual options are where they could go. All of it is a calculation every single time of like the reality of what services they can be offered inpatient versus outpatient and how this kid and this family will respond to it and whether it'll make them hate care and not return to it even when they really need it versus like trust care more and be like able to do it when they really need it in the future.

Sorry, that's kind of off topic, but I, I know we talked about this more of like suicide risk evaluation, but 

Preston: Yeah, but it's, it's, it's like, it's, it's never easy to, to navigate like kind of these situations and, and you're right, like. It [00:43:00] really does come down to when the rubber hits the road and it's easy to, to talk about these things, then, then, and then you're unsure if, if doing this procedure is dangerous or not.

Um, okay. Final note for today, and I literally mean note, that'd be, that's clear and convincing evidence. And then this one that's spread ponderance. So preponderance, like we said, is 50, 51% clear and convincing evidence is just a little bit more, um, uh, well it's, it's a Is it 

Margaret: a quorum? 

Preston: Substantial more? Yeah.

It's, it's evidence that is precise, precise, precise, explicit and lax confusion. And it has to be considered highly probable. So that's, that's the, that would be with our current system, the burden of proof that you would need to commit someone to a psychiatric institution. That's the current burden of proof that you have to commit someone to get long-term involuntary, uh, medic, uh, like medication treatment.

So this is a much more lengthy court process. And [00:44:00] so this, the hope is that if we were to bring back long-term institutionalization, these systems that we have in place would not be deconstructed. 

Margaret: Mm-hmm. 

Preston: To ensure that the people that end up in these institutions are, are patients that genuinely need them for their care.

Margaret: Right. Then the question remains, even if there's funding, I think the care question remains of like, who's, who's gonna, where Are we gonna get more psychiatrists? Where are we gonna get more people who are gonna treat the really ill? 

Preston: Yeah. 

Margaret: And that's, that's for 

Preston: a different episode. Are we gonna build more state hospitals?

Yeah. Who, who knows? And I think the, the thing that concerns me about kind of holding up this due process system that we have is we have that executive order from. July that I mentioned earlier that says to seek inappropriate cases [00:45:00] to reverse some of this federal or state judicial precedents that we have.

Margaret: Yeah. 

Preston: So everything, everything that I read earlier about the levels of the burden of proof, those are all set by precedents, 

Margaret: right? 

Preston: That you need probable cause for emergency detention. You need preponderance of evidence for an order of protective custody. You need clear and convincing evidence to involuntarily, like long-term, commit someone give them medication.

Those are all from precedents. So if we're considering deconstructing those precedents and then also building, um, these long-term psychiatric institutions, that that could be a dangerous one too. 

Margaret: Right? I mean, I will say, and I think the, like our listeners who come from, who treat or come from immigrant families themselves, people of color, um, but as a, as a woman right now in our current government, I, in terms of these like precedents.

It feels like so many things have changed in the last year and even before this administration, like a couple years [00:46:00] ago with Roe v. Wade and Pro now Project 2025 and stuff. Like, I just, I so don't trust this administration. It feels like things are being precedents that we all thought were kind of like, oh no, those are there now.

Like, we're not gonna take them away our, in some places coming down and hopefully that'll stop, but I don't know. 

Preston: Yeah, the Supreme Court has been setting a new precedent of undoing precedents. 

Margaret: Yeah. 

Preston: Yeah. I think that's, that's probably meant my biggest concern. So, um, just kind of reading off some, some of the general arguments against which we've, I think already almost Exhaustedly discussed these, but just to kind of, um, reemphasize them.

It's, it's a historically abused system and it could be a tool for social control, I think. The common refuting argument to that is, but we have new systems in place now. It's not the same environment that it was in the [00:47:00] sixties, and we have a lot of legal precedents. The then counter argument to that is the current political climate is tearing apart precedents.

Like they're made out of tissue paper and like we don't know if that's safe. So like that, that's pretty concerning. The, the other, I guess, alternative argument is that there are already alternatives to treating, um, patients with like long-term psychiatric needs that aren't inpatient hospitalizations.

There are things like ACT teams, there are supportive housing, they just need more money. So why spend money on these institutions if you could spend more money on these like already institutions that are already in place. 

Margaret: Right. Right. I mean, I think from a quality of life perspective too, like I think most people would say.

Our field, or at least, I guess I can't speak for them. I'd say like, we want, if we're really thinking about the values of like [00:48:00] autonomy versus beneficence, which is like the core of this conversation in psychiatry. Mm-hmm. I think the, one of the ways to optimize, if I was gonna be an optimization bro, but for good, um, the way to optimize that is some of these programs that are that kind of step between and giving them a little bit more funding and a little bit more teeth for when like things get really bad.

Like I don't, I think most of us in an ideal psychiatry world, people with SMI or severe mental illness, so in some of these people that we're probably talking about when we talk about who are living like are homeless and living with mental, I, severe mental illness would be that the least amount of restriction as always is what is used and that they can live in the community and be safe in a community for themselves, for others, and for their general day-to-day.

[music]: And 

Margaret: things like act programs, like the supportive housing, like residentials and stuff, like can provide those. Um, I, I think like, I kind [00:49:00] of wish both, both need funding, but like, 

Preston: like we're skipping a step. We're 

Margaret: Yeah, we're 

Preston: going, we should be like putting more effort into the, like the next lower step for the, like the least restrictive care rather than like going all the way to the final step.

Margaret: Yeah. And like there's, there's this idea in like Catholic social justice teaching that is like the idea of the preferential option for the poor is the way that it's like said. But what that means is that like we build a community with the central idea and that being like caring for the poor. But I think in, in my mind, thinking about psychiatry is we aim to build a society and a community that doesn't cast people out.

Not just into physical suffering and not giving any support, but also there's a way that. The only option being a psychiatric hospital is still a type of casting out better than maybe casting out and having no resources. But yeah, so it does feel like we're [00:50:00] skipping a level, but it also feels like just an uninformed imagination of what we should be aiming for in psychiatry.

Preston: Yeah, absolutely. Um, I, and I think to kind of like wrap up the last couple, um, arguments that these would be, I guess arguments four, um, to summarize, which is a, a strong one that I don't think we've mentioned, which is that institutionalization in a way already exists. It's just often in punitive or carceral care and like we are like, we would just be kind of transitioning those who are like providing the care from the prison system to.

Um, like actual, like hospitals. So it, that could be seen as actually a less restrictive form of care because we're going from Yeah, 

Margaret: true. 

Preston: From prison to a hospital rather than the community to a hospital. And then I guess the, the final argument that I think you already brought up, which is both need funding and [00:51:00] that's in implied in that, is that there are some patients that no matter how robust the ACT team is, no matter how like much funding there is for the community outreach treatment, they just cannot be reasonably cared for in the community and they need to be in some sort of 

Margaret: hospital.

Very sick. 

Preston: Yes. Um, and I think like some people like have trouble acknowledging that on both sides. That like, like, like some people have trouble imagining that some patients can function in the community and some people have trouble acknowledging some patients cannot function in the community and, and that the entire spectrum exists.

And, and it's just finding, like you said, the least restrictive, um, modes possible. I think kind of looking at this more globally, I. Would be optimistic about the benefits of adding more funding to long-term psychiatric hospitalization. But I'm not optimistic about these precedents and legal safeguards that we have to protect patient autonomy holding up.[00:52:00] 

And that makes me worried that this will become a tool to leverage against like the di those who are disenfranchised by mental illness. 

Margaret: Yeah, no, I agree. I think, I think one other part I totally agree with you, I think one other part I worry about is just like there's so much misinformation that this, like the health administration associated with this administration has kind of like legitimized, uh, and then that includes in psychiatry with like having a panel that's like, let's talk about SSRIs and pregnant women postpartum and like basically not have any.

Like having only like one person on there, like talking about stuff with kids, talking about like medications and, and treaters. And so I think I worry like the, I agree with you. There's like potential, like positive and maybe this will just go to places that already exist and need the funding, which we so badly need.

But I [00:53:00] also, beyond being like the precedent's not standing up and like the rules totally changing, I also just worry about more, even more misinformation entering the murky world. That is the evolving, as we talk about all the time in the podcast world of psychiatry and making it even harder for people to navigate, um, and get help and like, think that they're worth getting help and that they don't have to do it alone or like muscle through it.

Preston: Mm-hmm. Yeah. And to your point about. The misinformation of this, I guess whole topic is, the other thing that concerns me is that the rhetoric around rebuilding these institutions isn't, these people need help and we need to find a way to get them help it. It's more so like, we need to clean up the streets.

Margaret: It's get them out. That's like, yeah, 

Preston: yeah, that, that's kind like what I've consistently seen. And I think maybe there's been some time, some points where kind of the executive branch has said like, oh, these people are sick and need help. Like, I guess [00:54:00] that would kind of fall along with the, um, I guess discussion of, of long-term treatment.

But a lot of the other ones have really just been get these people, like I don't, seeing them in the street, off the street where that in contributes to. If you were to take all of the unhoused patients that have severe imp racism, mental illness in Texas, there, there'd still be four fifths of them.

There'd still be 20,000 people that don't have mental illness, that are living unhoused, that have other social issues they need help with. It's not, it's not a solution to, to end homelessness by putting them them all in psychiatric hospitals. It's, it's that psychiatric hospitals are necessary for people that have long-term disabling care and because they don't have access to it end up unhoused.

There's a nuance there, and I think that a lot of that is lost in like the current administration's discussions of this. 

Margaret: And I think it also doesn't, it, it fails to, I think on [00:55:00] a macro level, take seriously the, like, what we do know about like lack of resources and like impact of poor, uh, social resource support.

For a community and the impact on mental health or the likelihood to witness violence or all these other things. Right. And it does what you were saying, and it fragments this idea that, like we do know, which is that like most of psychiatry is a two hit problem, meaning genetic loading and then environmental insults or protectors.

And so yeah, it's just, it's a very like truncated, like, let's get these people out of here approach, but if the money ends up just helping the places that already need help and are doing good work, then we're for it. 

Preston: Right. Yeah. It's, it's, it's hard. It's like, I, I don't know if I like your reasoning, but we may agree on the same outcome, 

Margaret: right?

I mean, I saw comments on this on [00:56:00] like a video of this announcement on TikTok that were like, I don't trust him, but if the money does actually go to treat to like getting more behavioral health services. 

Preston: Yeah. Yeah, exactly. Like I. If it gets the right people treatment. Yeah. Um, who am I to argue with it?

Margaret: You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happy Patient Pod. 

Margaret: You guys missed a discussion of heated rivalry and who would win in a fight? Boston versus Texas. I 

Preston: did not get too much into my bleed out spot, but maybe I'll, maybe I'll blog about it's 

Margaret: come with me. 

Preston: Maybe Ill get into blogging with 

Margaret: me, with, 

Preston: come with me to bleed out in the forest.

That would actually be kind of a fun TikTok, uh, series. 

Margaret: Like a skit, not like a reel. 

Preston: No. Yeah, like a skit. Yeah. Not, 

Margaret: but REA 

Preston: not, I have no thoughts, not r harming myself. Everybody just want you to know, I just, I think the end, 

Margaret: this episode, 

Preston: I'm gonna sexual Preston, the male fantasy of, of dying in a fight and bleeding out.

I is, it's alive and well [00:57:00] without necessarily being suicidal. It's just like, how do I wanna die meaningfully? That's that's what It's okay guys 

Margaret: want one thing and it's honorable annihilation. 

Preston: I have a safety plan. Don't worry. Okay. That's what I 

Margaret: like. Next day. 

Preston: Um, if you, if you like the show, let us know what you think about it.

Um, tell us like how you feel about these kind of like, I think more like contemporary political e episodes, even though I'm like, but I'm, but I'm not a political podcast is what we're kind of saying the whole time. You can always come chat with us and our super fun human content podcast family on Instagram, TikTok, they're at Human Content pods.

You can always contact us directly on our website, how to Be patient pod.com. Margaret's at badard every day. She's on TikTok Instagram, Substack. I'm at it's pre on YouTube and Instagram and Prerow, and TikTok. Shout out to everyone who's leading kind and awesome reviews like this one from Stacey Knows best.

I love the science and also application during the podcast. Boom. Thanks [00:58:00] Stacey. You get it. Stacy, do you know best? And we did not apply any science during this podcast. 

Margaret: We, we did. The science of a good conversation. 

Preston: The science, well, science of the law. 

Margaret: The science of step cap. No way, you know. 

Preston: Yeah, exactly.

We, we stepped up. 

Margaret: It's 'cause I sat on the couch. I was not locked in. 

Preston: True, very true. But, but brick out of our phones, um, full videos are available on YouTube each week at its pre. You can also find us on video at Spotify. Thanks again for listening. We're your host, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aron Korney, Rob Goldman and Shanti Brook.

Our editor and engineer is Jason Portizo. Our music is Bio Benz V. To learn more about our program, disclaimer and ethics, policy submission, verification, licensing terms and or HIPAA release terms. Go to how to be patient pod.com or reach out to us at how to Be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production.[00:59:00] 

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 [01:00:00] background.