The ethical dilemma of involuntary mental health treatment

Several states have changed their policies in recent years to make involuntary commitment easier for people with severe mental illnesses.

But forced treatment still raises civil rights questions, with some saying it can harm, not help patients.

Today, On Point: The ethical dilemma of involuntary mental health treatment.

Will James, host of KUOW and The Seattle Times’ “Lost Patients” podcast.

Dominic Sisti, associate professor of medical ethics and health policy at the University of Pennsylvania. Director of the Scattergood Program for the Applied Ethics of Behavioral Health Care.

Laura Craciun, a mother who struggles with bipolar I disorder with psychotic features and anosognosia.

Stefanie Lyn Kaufman-Mthimkhulu, founder and executive director of Project LETS.

Part I

DEBORAH BECKER: This is On Point. I’m Deborah Becker in for Meghna Chakrabarti.

Understanding mental illness of a loved one often means looking back.

JON CHANG: Tell me about Nick as a child. I mean, what was he like growing up? What kind of son was he?

LAURA CRACIUN: Adorable. He looked like a little Ewok in a Star Wars film. And when he was younger, he would excel at any sport we introduced to him, including gymnastics and hip-hop dance, and was the best charades player I'd ever seen, and just so creative.

BECKER: That’s Laura Craciun, an artist on Cape Cod, speaking with On Point producer Jonathan Chang about her son Nick.

We should note this story contains descriptions of violence.

Nick was an athlete with a big heart, Laura says. … But there was something else that clouded over his childhood.

CRACIUN: The thing that plagued him most of his life, really, was that he could hear and see things that weren't real. And that started very early on in diapers. We would see him sometimes leave the house, saying there was something in it, and he didn't feel safe. And he also had anxiety that we were going to die.

BECKER: Laura visited three different neurologists, who prescribed ADHD medications … but not much more. Laura says she trusted their expertise. But years later, Nick got a different diagnosis.

After graduating from high school in 2020, Nick Craciun was living with his father in Cambridge, Massachusetts and struggling to keep a job.

In 2022, his father lost his job as a caretaker … and was at the risk of losing his home.

That April, Nick ran away from home without notice.

CRACIUN: We had a large search going on, not just through the police, but through social media, all his friends, no one was finding him.

BECKER: Laura feared the worst. Months passed by without any word about Nick.

CRACIUN: Eventually, I bothered his friends in Boston so much with a guilt trip that one of them did feel bad. And she said, I've heard from the guys that he's around and that he's just hiding in south of Boston. So that was my first indication of hope that he was alive, but still, she wouldn't reveal her name to police. They couldn't follow up. It was difficult.

BECKER: It took three months before Nick finally returned home that July. He had no explanation for his disappearance, other than saying he came back because he remembered their yearly Fourth of July celebrations.

And the Nick who returned was a different person.

CRACIUN: His hair was wild. His eyes were wild and overly opened. He had awkward social cues and he had lost 20, 30 pounds and had no possessions except the jeans and t-shirt he had on. And a few days after, we all sat down as a family. And in a living room setting with eight people present, Nick told us what happened while he was gone.

As if everything was normal. But we were hearing a story that made no sense. It was that he was living in a car in his friend's driveway, hiding between the seats at night. And then during the day, he would travel into the woods, climb trees and hills without clothes on to get closer to the voices in his head.

We tried to figure out what to do next. We asked his lawyer that we had hired when he went missing, what we should do, and he said have him go to the Cape Cod Hospital, and we were able to get him there. He wasn't happy, and when he got to the ER, because he was over 18, the clinicians wanted to speak to him alone, and when I was able to get through to them, they said they were concerned. But if he's not a danger to himself or others, we aren't allowed to hospitalize him against his will.

BECKER: For Laura, Nick’s refusal to receive treatment is personal.

CRACIUN: I myself had experienced mixed mania. Bipolar runs in my side of the family. The first time I realized I was bipolar was when I was medicated and actually felt relief from the pain that was in me.

BECKER: Laura has benefited from treatment for 30 years now. And she became increasingly desperate as she watched her own son deteriorate.

Today: we’re going to explore this idea of involuntary mental health treatment. The experience of families like Laura’s. What some of the research shows, and the ethical dilemmas surrounding committing someone to treatment.

By November of 2022, Nick started to pose legitimate safety concerns.

CRACIUN: His father and he had an argument that got violent, where he was chopping vegetables. His father was using a very sharp butcher knife. And in the middle of the argument, his son grabbed the butcher blade, not the handle, and wrapped his fingers around it. While he was arguing. So of course, his father stopped chopping and he stayed very still. And it was shortly after that, that Nick went up to him very close to his face and said, do you want to die three times in a row?

BECKER: After that, Nick was committed to McLean Hospital, a psychiatric hospital in Belmont, Massachusetts. There, Nick received the diagnosis: bipolar I with psychotic features. Nick also had anosognosia, a condition where a patient is unaware of their neurological deficit or psychiatric issue. Laura was told that he refused medication.

CRACIUN: He believed that medication was going to make him worse. He had no faith that he had any sort of illness. So when we got in front of professionals, he did his best to pull it together and not repeat what we were seeing and what we were hearing. And he was able to speak coherently and almost reign, he almost learned the language of how to speak in front of a professional so that they wouldn't be able to commit him without his permission.

BECKER: In Massachusetts, as in most states, there are laws that allow emergency restraint and hospitalization of someone, if they pose risk of serious harm – to self or others – because of mental illness.

But advocates like Laura say that the bar to prove this potential harm is too high, and often it’s difficult to receive help when you need it.

CRACIUN: We had many moments where all these crisis helplines trying to get the story, right? And when they finally arrived, it was too late. That episode had passed. And so it was a very frustrating process when we tried to get him help.

BECKER: Without treatment, Laura says Nick became a shell of his former self … though there were times that she saw the son she remembered.

CRACIUN: There were moments where he was very kind and thoughtful, but they were almost exaggeratedly so. And he would give us generous gifts from each of one of his paychecks. And this is the loving child that we knew, but it was also accompanied by belief that He was unclean and that there was a big conspiracy against him and the FBI, you know, so there was a lot of tensions.

CHANG: The fact that there were still those moments of kindness, did they give you hope? Or did that make it even more difficult to process what Nick was going through?

CRACIUN: That was more of a sadness, because here there's this beautiful person who is so loving, sweet, and kind, totally out of control. His moods were out of control.
This was not the son we knew. 

BECKER: Last December, Nick had his fifth and most recent psychotic break at his father’s home.

CRACIUN: He asked his father if he could sleep in the same room with him because he was afraid to sleep alone in that living room on the couch. So his father dragged his mattress off of the bed and instead of sleeping on the couch, Nick walked around the coffee table and laid down with his father on that mattress. His father was extremely uncomfortable and said, I'm sorry, I need more personal space. And instead of replying, he elbowed his, you know, father so hard and yelled, shut up.

So his father stood up. But was almost dizzy and falling down. So he couldn't quite get away from Nick, yelling to the neighbors for help as he was leaving his apartment. And when he got to the doorway, his neighbors were alerted, they were coming out of the doors.

BECKER: As they continued to struggle, neighbors called 911.

CRACIUN: Meanwhile, Nick continued punching and putting his father in a headlock with multiple punches. And then his father wanted to pin the arms so that he wouldn't get punched anymore. So he backed his son up to a wall, and that's when Nick started to bite him.

And he was biting so hard. He did get through layers of clothing and drew blood. The police report said that when they arrived, his father was on the ground. Nick was on top of him. pinning his lower half with his knees and had both arms on either side of his head, headbutting him forehead to forehead and also smashing the back of his head down to the pavement.

BECKER: Nick and his father were taken to separate hospitals for care.

Nick Craciun is now 22 and has been incarcerated since December 27, 2023, at Bridgewater State Hospital, that's state facility for those deemed criminally insane. And those whose mental health is being evaluated for the criminal justice system. In March, Nick was moved to a county jail, still without medication.

Laura Craciun believes Nick is not a criminal. He’s a person in need of help, she says. And in need of policies that would allow people with severe mental illness to receive involuntary treatment — sometimes called Assisted Outpatient Treatment or AOT.

CRACIUN: I'm at a loss as to how it got to be so bad, except if there were an AOT law,  we're going to see a huge difference in getting those criminal populations down from the mentally ill population or the tragedies that have occurred. So I have a lot of hope and I hope that more conversations come out.

BECKER: Massachusetts is one of only three states that does not permit involuntary outpatient mental health treatment.

Across the country, families like Laura's have been pushing to make it easier to mandate treatment to people with severe mental illness.

In cities such as New York and San Diego, officials have taken steps to allow more involuntary treatment. Especially for those who are unhoused. Here’s New York City Mayor Eric Adams in November of 2022:

ERIC ADAMS: That is just so irresponsible, that we know that this person is about to probably go off the edge and harm someone, but we’re going to wait until it happens. Not in this administration.

BECKER: In California, Governor Gavin Newsom overhauled the state’s mental health policies last October – the changes which included loosening long-standing rules about who’s eligible for involuntary treatment.

But opponents say forced treatment is not effective. And can sometimes harm patients and compound trauma. They argue that forcing a treatment protocol takes away a person's right and their agency to deal with their mental health. Coming up, we’ll talk about some of the changing policies around the country and the ethical challenges of involuntary treatment. I’m Deborah Becker. This is On Point.

Part II

BECKER: Today, we're talking about mandating mental health treatment. Several states and cities have been considering changing policies to make it easier to Involuntarily treat people with mental illness. We'll talk about some of these efforts and some of the ethical dilemmas surrounding them.

Joining us is Will James. He's host of the "Lost Patients" podcast. That's a collaboration between KUOW and the Seattle Times. The six-part series examines the difficulties of treating serious mental illness through the lens of Seattle. Will James, welcome to On Point.

WILL JAMES: Thanks, Deborah. Really glad to be here.

BECKER: We just heard Laura Craciun's story in Massachusetts about her son, Nick, who is now incarcerated with untreated mental illness. Is her story, does it sound familiar to you? Do you think you heard that from a lot of the families that you spoke with for the podcast?

JAMES: So familiar. It is an absolutely very common story among families across the country right now.

In fact, when we see these pushes to expand involuntary treatment, to open up laws to make it easier to involuntarily commit people, a lot of that push is coming from families like Laura's. Families who are trapped in these terrible situations where they are watching a loved one decline.

They're watching their loved one's mental health deteriorate. Their behavior grow more erratic. Sometimes the loved one becomes homeless, gets into increasingly dangerous situations. And the family is left just feeling utterly helpless and powerless. And I, in the course of reporting this podcast, sat with a family that was in a situation much like Laura's. And just the sense of helplessness and fear and stress was absolutely palpable.

BECKER: And that's basically because what makes it so difficult, is the laws are pretty strict in terms of who meets the criteria for involuntary commitment. Is that right?

JAMES: That's right. For a lot of our country's history, we had a need to treatment, a need for treatment model for involuntary mental health care.

So what that looked like was, in a lot of the last century, for instance, a doctor or two would look at a patient and say, "Yeah, they need care, they need treatment. So we are going to treat them whether they want to or not." And then at some point in the middle of the last century, we started to switch.

There were all these revolutions in psychiatric care in this country, and it switched to a dangerousness criteria. So what that meant is in order to treat someone against their will, they have to essentially be a danger to themselves, at risk of dying, essentially. Or, at risk of really harming other people.

And there are good reasons for that. Before that, involuntary treatment was overused and led to all sorts of abuses and a terrible era in our history. But when we see it switched to this dangerousness criteria, almost immediately, for instance, here in the state archives in Washington state, we see families writing to the governor, saying, telling stories almost exactly like Laura's, struggling with often grown-up children who are declining.

Acting more radically, and the family feels absolutely helpless.

BECKER: So is it a case of the pendulum swinging back because it went too far? Do you think? Or are there just, obviously, this is a complicated issue. There are so many factors, but is that a big part of it?

JAMES: There is a argument right now that, exactly as you said, we swung the pendulum too far in the direction of patients' rights.

But it is very complicated, that is a very common argument that the public has internalized lately due to mostly the sight of seriously mentally ill people who are homeless on the streets of cities like Seattle. Like New York, like Boston, all over the country, here in the West Coast, we started seeing that phenomenon really grow in the public consciousness about a decade ago. In other parts of the country, it really became more prominent during the pandemic. But It's really a reaction to the sights of seriously mentally ill people out in public on the streets.

BECKER: And so a lot of this effort to change what's happened with our system right now is coming from families who have loved ones with serious mental illness.

I wonder, what do patients say, who've been civilly committed to treatment? What typically is the experience like for them?

JAMES: Yeah, there are really two, kind of, there are many views on this issue, but you could split them into two camps. And one is led by, essentially, by patients, families, and some psychiatrists.

And as you said, they want these laws, they want it to be easier to involuntarily commit people, but there's also a patience rights movement. And this is a movement saying involuntary care is a really blunt and flawed and risky instrument of psychiatric care.

The experience of being strapped to a gurney and taken, usually first to an emergency room for evaluation, a chaotic emergency room that is loud and full of people, while the patient is in psychosis can be deeply traumatizing. It can deepen distrust in psychiatric care. It can worsen symptoms. It's almost like you couldn't design a worse scenario to put someone who's feeling paranoid and terrified into, than a chaotic emergency room hallway.

And also, a really powerful part of that argument is that some of the public's desire to get people off the streets who are seriously mentally ill, I think is rooted in a misunderstanding of what actually happens when someone is involuntarily committed. I think there's a view that these serious mental illnesses are physical, purely physical brain diseases that can be cured by the right medication.

And while there is some truth to that, that there is a physical element to these illnesses, and that medication is a powerful tool. It often does not work like that. These illnesses blur the lines between someone's personality and wishes and a diagnosable illness, and it's hard to tell where one ends, and one begins.

And the medications we have are essentially unchanged from when antipsychotics first emerged in the 1950s. I mean there have been some tweaks, but they work basically the same. And they can lessen symptoms, but for most people, they won't be a cure. They often come with really brutal side effects that some people find intolerable.

So the result of involuntary treatment, I think, often fall short of the public's imagination and sometimes the family's imagination of what their loved one is getting.

BECKER: I want to bring someone else into the conversation here. Dominic Sisti. He's an associate professor of medical ethics and health policy at the university of Pennsylvania.

He's also director of the scatter good program for the applied ethics of behavioral health care. Hello, professor Sisti. Thanks for being On Point.

DOMINIC SISTI: Hey, Deb. Thanks for having me.

BECKER: So tell us a little bit about what we know about whether involuntary treatment is effective. I know that research on this is mixed and it's hard to find because the population can be so different.

And as Will told us, there are so many complex issues involved here. But what do we know about the effectiveness of this form of treatment?

SISTI: Yeah, I think you nailed it. It's mixed. There are folks who do well and get better. And after a certain amount of time, it might be weeks, months, or even years, are able to reintegrate into society and build and recover and have happy lives with support. There's other folks who don't do as well. And it is the case, I think, that medication and medical interventions are just one thing that these folks need. They need wraparound services, they need support, they need transitional care, moving from a hospital back into the community.

If these pieces are not in place, inpatient hospitalization won't be as effective. So the outcomes really will depend on the quality of all the other services that may wrap around the patient. So it is absolutely true that hospitals themselves are not a cure all. They're a necessary component, I'd say, to a comprehensive mental health care system.

But they're not sufficient.

BECKER: And yet we hear that many states and cities around the country are trying to increase the use of hospitalization or involuntary treatment, California, New York City. I just wonder if we could just touch on those and explain those a little bit. In California, it's my understanding, Professor Sisti, that this effort basically expands the legal definition of when someone can be treated against their will. Is that right?

SISTI: Yeah. So it expands out the notion of grave disability to include things like substance use disorders, and being unhoused with a substance use disorder. So the idea there is to try to get folks into treatment.

And off the streets. And there are evidence-based treatments for substance use disorders, of course, that folks have trouble accessing. So the idea is to get folks access to those treatments. The problem is rounding up folks for mental health treatment, substance use disorder treatment, et cetera, is not going to work unless you have the capacity to deliver high quality,

ethically administered treatment to folks and settings for that. And currently there just aren't the right, there isn't the capacity to do this. And, in California, there is this huge investment in building new psychiatric spaces, hospitals, recovery centers and those are definitely necessary.

BECKER: And a funding mechanism, right? Using some of the millionaire's tax to help pay for some of these things. So there could be money too, right?

SISTI: Yes. Yes. There's, I think, $6.5 billion also slated to be used for this. So I think that the idea is good and right.

It's just I think the idea of rounding folks up now before the system is built is the problem. I don't know that we want to begin the process of involuntarily committing people to nowhere, in other words.

BECKER: And in New York City, obviously there has been a lot of attention to proposals by New York City Mayor Eric Adams and what he wants to do to deal with folks who are unhoused in New York City.

And it's similar, even though New York already has what's known as Kendra's Law, right? Which requires intensive monitoring of folks who are severely mentally ill when they're involved in the criminal legal system.

SISTI: Yeah, so I think these are a little bit different. So I think Kendra's Law zeroes in on folks who appear to be at risk for violence towards others.

What Mayor Adams, I think, is attempting to do is to take care of folks who are arguably a risk to themselves. And really, I think it's about the unhoused in public places that he just wants to play somewhere. And I'm not sure it's the greatest policy, but I think, the intention is good.

Having folks out on the street, in encampments in Times Square, wherever they may be. That is just arguably an undignified way for people to live, who can't manage their own lives. And so the idea is to get them into treatment right away. The problem is in the involvement of the criminal justice system.

And when you involve the criminal justice system with people with mental illness, you're taking them down a road of we think about, we worry about involuntary treatment as problematic and traumatizing. And ERs as being a very bad scenario. Imagine being in a holding cell with psychosis.

That's even worse. When we think about rounding folks up, they often end up involved in the criminal justice system. That is not where people with serious mental illness should be. It's the exact opposite of a therapeutic setting, and that's what worries me.

BECKER: But doesn't most of this, most of these policies involve some arm of the criminal justice system?

Who would oversee the care and make sure that someone is adhering to it? And who would put the teeth in if someone didn't adhere to a particular plan, right? Some of it has to involve the criminal justice system, right?

SISTI: Maybe not. I think what you're touching on here is a really big problem.

And that's the fact that our mental health workforce is so lacking. We have just such a need for more psychiatrists, psychologists, social workers. And public mental health providers. So we could ostensibly build a mental health system that involves public mental health workers who go out to crises, maybe alongside police officers, but not police officers leading that intervention, right?

And so I think it isn't necessarily the case that the criminal justice system needs to be involved in mental health crises. Many cities have created programs involving crisis intervention teams that have social workers on them. These need to be the norm and not the exception.

BECKER: I wonder if you can tell us what's happening in Washington State regarding this. We talked a little bit about California, about New York City. What are the efforts in Washington State to perhaps expand involuntary commitment because of all of these powerful stories from families who have loved ones with severe mental illness?

JAMES: I think that currently, while these families have been beating this drum for years and even decades. A lot of the political pressure to act on this right now, as in New York City and California, comes from a somewhat related but different place. It is the public's sight of people who are unsheltered on the street and are acting erratically, making people uncomfortable, making people scared.

There was a news station here a few years ago that made a one-hour documentary called 'Seattle is dying' that got a lot of national attention, and it was about this perceived kind of chaos on the streets of Seattle. And the proposed solution in the documentary by the makers of this were to essentially round everyone up who's in crisis and forcibly take them to an island off the coast of Seattle that used to be a prison and forcibly treat them there.

So there's a huge political pressure here in Washington state and Seattle. Our leaders have said that despite what's going on in California and New York, we are going to focus on expanding capacity for the mental health care system and not tweaking these involuntary treatment laws. But that's not to say they work well.

I sat with a family who had to wait, in some cases, days or weeks for a loved one who was in crisis, to have a crisis responder arrive who had the power to involuntarily commit them. And it was a devastating experience.

Part III

BECKER: Conversations about these issues have recently played out in communities across the country. As we've mentioned, opponents say forced treatment, sometimes, oftentimes is not effective, sometimes can harm patients. They say improving treatment, and doing things such as addressing affordable housing should be the focus.

Forcing treatment might be politically expedient, but it's not necessarily effective. To hear more about this, we reached out to Stefanie Lyn Kaufman-Mthimkhulu. Stefanie is founder and executive director of Project LETS. That's a grassroots organization that provides access, political education, and resources for people with the experience of mental illness or disability, trauma, and neurodivergence.

She says treatment needs to improve and describing it as the solution is an oversimplification.

STEFANIE LYN KAUFMAN-MTHIMKHULU: I work with thousands of psychiatric survivors, and I'm connected to so many more and generations of us who understand that how that language is utilized and weaponized against us to position us as people who we should just really accept it voluntarily. And if we just accepted that type of care voluntarily, we wouldn't end up in those circumstances.

BECKER: Stefanie says involuntary treatment is a short-sighted option that dehumanizes people and causes trauma, particularly because it typically involves law enforcement serving as the first point of contact during a moment of crisis.

KAUFMAN-MTHIMKHULU: We know that trauma and depression does affect our body minds too, having this holistic picture of how we end up in these circumstances and what leads us to the point where the only option that we're willing to invest in is policing, is caging, is confinement, is removal, is forced medicalization. If somebody doesn't have a home, taking them to the hospital and injecting them with anti-psychotics, only to dump them back out on the street, what is that serving?

BECKER: Instead of involuntary treatment, Stefanie says genuine care and relationships should be at the core of addressing mental health crises.

STEFANIE LYN KAUFMAN-MTHIMKHULU: There are things like supported decision making for people who aren't able to fully make decisions by themselves, but we need relationships. Like we need community.

We need people who have the time and the space and the energy and the capacity and the skills to support each other and love each other enough to not want to turn to and rely on these systems that is not working, and is actually further harming and killing our people in the process.

BECKER: That's Stefanie Lyn Kaufman-Mthimkhulu.

She's founder and executive director of Project LETS. And as a reminder to listeners, if there are significant mental health concerns that you or a loved one might be experiencing, the number for the National Suicide Prevention Hotline, which is free and confidential, is available at 988. So Dominic Sisti who, as we said, is an Associate Professor of Medical Ethics at the University of Pennsylvania.

You heard some of those concerns from Stefanie. She says it's dehumanizing. The law enforcement involvement is sometimes traumatic for folks, and it takes away people's agency when they might need more wraparound services and more complex care. And Will, of course, has told us that a lot of what's driving this push for more mandatory mental health treatment is the fact that we're seeing so many sick people on our streets and something has to be done. How do we thread this issue? We're asking you to figure it out, Dominic. Can you do that for us?

SISTI: Yeah, I actually completely agree with what Stefanie had to say. And it's so complicated. About 10 years ago, a couple of colleagues and I wrote a paper around the need for more psychiatric hospitals.

And we argued that we definitely need more psychiatric hospitals, much like we would need intensive care units and dedicated units during a pandemic, which we found we did need. So we need a certain level of emergency critical care units for the mental health care crisis, but that is not sufficient.

We need wraparound services that support people in a holistic way, as Stefanie described, that engage in coordinated care, to the extent that the individual has capacity or autonomy. We should respect their wishes. We should try our best to do what patients want and value their decisions, to the best of our ability.

Now, if their decision is, I don't want to take medicine ever, and that is like one of the things that will actually help them advance in their recovery, we need to figure out ways to help them understand what recovery entails and that it might entail medication, right? That doesn't mean physical restraints and forced injections.

There are ways to get people to understand what is good in the long term for them. And if it involves medication, you can figure that out. It also is important to mention that peer support can be really effective. And so while I mentioned the need for lots of psychiatrists, psychologists, social workers, et cetera, we have a major workforce issue.

We can do a lot of basic on the ground outreach and engagement with people with mental illnesses by setting up programs that use peers and people with lived experience to engage with folks and get them the treatment, get them into the treatment that they need.

BECKER: But doing what patients want when that can be hard to determine, when the patient has a brain disease, that affects the way they communicate what they want.

I think it can be a real dilemma to try to figure that out. And that's the question.

SISTI: It is. And it's a real paradox. I think, we deal with this with patients who have dementia, for example. And we figured it out for the most part, that you look to care partners, you look to surrogates, you look to family members to gather collateral information about what the patient's sort of fundamental values are in their life, what their life goals are.

And we try to piece together a picture of what the authentic wishes of the person are. And they may, the patient themself might endorse certain aspects, but they may be so sick that they don't remember or endorse other aspects, and those are the sort of trouble spots that you have to work on, but it's not like mental illness, schizophrenia, bipolar disorder, et cetera, are the only conditions where this is a dilemma.

This happens in other areas of medicine, and we've figured out ways to navigate it.

BECKER: Before the break, we were talking about Washington state, and you mentioned that Washington state is trying to do some of the things that Dominic mentions, is trying to expand capacity and really beef up, perhaps, the mental health system.

And many of the people who are concerned about involuntary treatment say there's no infrastructure here to involuntarily commit more people. So tell us a little bit more about how Washington State is doing with that plan, and if it might be a potential solution. I'm looking for who's doing it right here?

Can you tell us?

JAMES: Totally. What I'm hearing from the clip we heard and from Dominic is a something that I hear a lot. And it's that there's an argument that this focus, this fixation we have in our politics right now on involuntary care is a distraction. It's like saying, "We don't have enough trampolines and big enough trampolines to catch people jumping out of burning buildings without wondering why all these buildings are burning." So the effort in Washington state has been to say, why are all these buildings on fire? Why are all these people hitting such a low point before they receive help?

What we see in Washington state in the Seattle area, for instance, is a real focus on building up walk in crisis centers so that if somebody is experiencing a mental health crisis, there's actually a bed for them to go, which is not the case in many parts of the country. The problem with crisis care, again, is that we see people in really severe mental health distress, get trapped in this loop between emergency rooms and jails and homelessness. And back to the emergency room and to prison and then back to homelessness. And, involuntary commitment or crisis treatment, the risk is that it just becomes another stop in that churn, right?

You're involuntarily committed, you're released back to the street, you're involuntarily committed, you're stabilized, and then you're released back, and you decline again.

BECKER: That was such a great part of your podcast. Can I just say this? When you said you don't use the term broken system.

JAMES No.

BECKER: Because you can explain it better than I can, because each part of the system, at least in the story you were telling in the podcast, had worked the way it was intended. And yet the patient still fell through the cracks.

JAMES: The way that our system, if you want to call it that, works right now is that there are these discreet points in the system that do their job, which is like stable, making in an emergency room, making sure someone is not going to imminently die.

Involuntary treatment, where somebody is, again, stabilized to the point that they are no longer a danger. Jail, holding somebody who has committed a crime, but then the person is released out into the world. And what, Professor Sisti is saying, and others are saying is what's needed is some sort of long term, steady care that sticks to the patient.

That doesn't require them if they're disorganized by psychosis to make appointments and keep appointments and fill prescriptions. And that is what we don't really have. And one of the reasons that this conversation about involuntary commitment is so interesting and difficult is that there are different threads in our history of intention when it comes to psychiatric treatment.

There is a desire to heal people. And there's also a desire to make people we find inconvenient, go away, disappear. And in this conversation about involuntary commitment, you hear both of those threads. And it's really important to figure out which of those we are following, because in some ways, the intention we put into this is going to determine the outcome.

BECKER: Yeah. It also made me wonder, when you said you don't use the term broken system, when you're talking about involuntary treatment, if there's almost that same underlying belief, right? That treatment will be part of a system that will be effective for someone, and that may not necessarily be the case.

JAMES: Yeah, here in Washington State, I spoke to some people who were involved in involuntary care here. We have what are called designated crisis responders. They are mental health professionals who go to a site of someone in crisis and they determine whether someone meets the criteria to be involuntarily committed.

And one of them told me, in an ideal world, my job wouldn't exist. I wouldn't need to do this, because there would be such a universe of treatment options before somebody hit absolute rock bottom that this wouldn't really be an issue. When you hear Laura and Nick's story, like we heard at the beginning of the show, you can imagine all these different points where Nick might have received help or intervention before he was hurting his father. These crises don't happen overnight. They often come after months or years of decline. And the fact is that we don't have a lot of infrastructure in our country, or a lot of imagination about what could exist before somebody hits their absolute lowest point.

BECKER: Dominic Sisti. I wonder in the last few minutes that we have, how far are we really from maybe taking a creative look at redoing our system of mental health care, so it might better serve and truly serve? Because it sounds like that's an issue here, and truly serve folks with severe mental illness.

SISTI: Yeah, so I don't even use the word system, let alone broken system. I don't even think we have a system. It's just this patchwork of dysfunctional programs that kind of try to interlock but don't always work. So I don't know that we even have a system. But I do think, again, in the last 10 years since I've really been looking at this issue from an ethics perspective, I do think that there has been a transformation in public consciousness around the fact that this is really a moral stain on our society.

That we treat people who are really our most vulnerable brothers, sisters, family members, loved ones in this way. We don't offer, we don't have the programs, the care, the treatment options in place for people who are sick. And imagine if this were the case in cancer or another area of medicine.

Where kids were going without leukemia care, for example, there wouldn't, no one would ever stand for that. No politicians would stand for that. And that's exactly what's going on right now. We are just turning our gaze away from thousands, hundreds of thousands of people who have serious mental illness.

And I don't know that there's creative solutions coming out of Washington, but the states and municipalities are coming up with good ideas. I think I do agree with Governor Newsom's approach. I think he's got the right idea. There's obviously details which are to be worked out.