The Center Cannot Hold: My Life as a Patient and a Legal Professional | Professor Elyn Saks

good afternoon everyone welcome thank you for joining us for an auspicious event in the life of Penn law and the University of Pennsylvania we we believe here at Penn law school that that law is deeply connected with other spheres of study elsewhere in the university and this and we also believe in connecting with the very top scholars and policymakers and thinkers from around the world and this this event embodies both of those principles we have in Ellen sacks one of the leading thinkers on law and mental health and we're so glad to have you a professor Sachs speaking on the center cannot hold my life as a patient and a legal professional this event is the capstone of an issue we've been a series of events on mental health and we've been working with our students and community throughout the year our theme in with our students for the Center on professionalism has been mind your mind applied positive psychology and the law school experience this year as programming has provided our students with tools to think about their own lives as they enter a profession which has high rates of substance abuse and mental health issues and it's this is a tremendous continuation of that discussion about the importance of focusing on mental health issues in our society and in our respective professions I'm also so glad to see so many colleagues from around the University of Pennsylvania coming to the law school this is an issue of course that cuts across so many disciplines like bioethics and medicine and nursing and and other parts of the university represented here so it's great to see you in it in attendance um I want to thank dr. Saul Feldman for his important work in the public and private sector on mental health care especially his commitment to creating community-based centers that provide behavioral health care and and developing specialized training programs care providers I want to thank the Bay Area foundation for human resources for supporting this event and providing us with the resources for this and many other efforts and events relating to behavioral health law and policy and finally this is a joint effort and co-sponsors from both here at the law school and around the university who are helping include and laws Center on professionalism our fun for the study Bay over your health law and policy the Perelman School of Medicine's scattered their program for applied ethics and behavioral health care so I look forward to the lecture and I will turn over with appreciation to the really the organizer of this who have the vision to bring professor Sachs Thank You Dean Ruger thought that thanks to all of you this is really quite an extraordinary turnout don't tell him but this is a better turnout than we had for Jeb Bush a couple of weeks ago so it's really quite gratifying to see before before I introduce professor sacks just a few thank-yous the Dean mentioned the three sponsoring organizations but behind those organizations there have been a couple of people who have really been tremendously helpful so that the vision is not at all mine I've just really helped to facilitate it so Thomas's view runs the scouter good program gen Leonard who runs our Center of professionalism a third year law student here anna marion a postdoc working with Steve Joffe over in the bioethics program isabel pereira the four of us sat and really thought about what sort of event would connect the work we do in the law school of the work of the center on professionalism Dom's work in the Medical School and cut across the University's focus on behavioral health and mind and mindfulness and and professor Sachs struck us as the absolutely.i yes be sure to bring in in addition I really want to thank my friend and colleague on the faculty of the law school Stephen Moore sitting sitting right behind professor Sachs Stephen spent well over a decade on the USC faculty he held the Oren Evans chair at the law school the chair that Professor Sachs now holds he's continued his extraordinary work on mental health law and policy at hem and like Professor Sachs has appointed both in the law school and the medical school and so really thank you Stephen not only for introducing me to Professor Sachs without which maybe maybe you would have said no and not come to Penn so I'll never know that but but I'm really grateful for that and after professor Sachs is talk today professor Morse will take the stage and engage professor Sachs in a 10 or 15-minute interactive conversation before we open the floor to questions and answers so thank you so much for that Steven I'm honored and frankly quite humbled to be introducing professor sacks to you today if one looks at her academic accomplishments they are daunting on an awe-inspiring and rather intimidating she she graduated as an undergraduate first in her class at Vanderbilt University was awarded a Marshall scholarship to study at Oxford received her JD at Yale where she worked on as an editor of the Law Review later went back and on the side got a PhD in psychoanalysis she holds a chair at USC law school and is appointed in the medical school she has an honorary Doctorate from Pepperdine University she's written five important books and endless influential articles it's it's a vita that i can think of few of any law professors at any law school in world that can equal that and and you know just to not leave it out I should mention that she's also the recipient of a MacArthur Genius award so and there I think one should underscore the word perhaps genius so it's really quite an extraordinary academic background but her life as we know and I think as the title suggests has not only been about academic accomplishment in her gripping book which which I've read now twice and most recently finished all of a few days ago professor Sachs recounts her long struggle with mental illness her debilitating psychotic episodes her losing battle to avoid psychotropic medications and her eventual diagnosis of schizophrenia these remarkable academic achievements and these remarkable challenges add up to a life that I think can only be described as extraordinary but what I find most compelling about her work and about Ellen is that despite the extraordinary Ness and I think that's really a word that's appropriate here her story is profoundly and utterly human like all of us she spent her life seeking personal and professional satisfaction she takes pride in her intellectual accomplishments relishes her friendships loves her family finds meaning in her work delights in a good joke adores her partner as she writes on the very last page of the center cannot hold and I quote the humanity we all share is more important than the mental illness we may not when I read that and read her book I was reminded of something written 2,000 years ago Plato's apology where Socrates utters the famous phrase the unexamined life is not worth living in her tireless effort to understand herself professor Sachs has done more examining than Socrates could have ever thought possible in doing so she has inspired countless others to reflect to introspect and to find meaning and who they are and in what they do she has in these profound ways helped us to understand what it means to be human so Thank You Ellen for spending your afternoon with us today talking both about your journey and about your work thanks to all of you for being here to share it with us please join me in welcoming professor [Applause] [Applause] it's great to be here thanks for having me can you hear yeah yeah okay so thanks for the kind introduction to the program by Dean Ted Ruger I really appreciate it really and I and the introduction by Eric which I think may be the nicest introduction I ever got so thank you so I want to thank Eric for inviting me here I'm also delighted that Eric's family could come his psychologist father who's done important work in the mental health and mental health law space and his mom and his brother and sister-in-law and wife so 75 percent of the audience is and I also want to shout out a whole o2a friends on your faculty including Stephen Morse who left as I came in and we shared the same name of our chairs as was said and I'd like to thank Sally Gordon who was a classmate of mine at Yale Law School Howard Chang and Michael Noll who were who were faculty members with me at USC and we're so sorry that they left but I'm sure you're happy they're here so so I'm going to talk today about my wife with mental illness both my struggles and my managing to craft a good life for myself in the face of a brave prognosis at the end of the talk I'll discuss some policy implications of my story recognizing that I'm an N of only one and I will discuss a cluster of mental health law issues and I'm delighted again that we have psychologist dr. Saul Feldman here and we'll look at some of his major issues as well so I want to speak to the to you about a subject that I would like to see get more attention in our research the relational aspects of schizophrenia good psychiatric treatment has kept me alive sensitive and wise psychiatric treatment that has recognized the centrality of relationships to my healing has allowed me to flourish as mental health professional mental health students mental health law students professors you know that people who struggle with mental health disorders are not just walking symptoms that can be cured by a pill mental health and mental illness involved whole people who live in relational political and social context we need to understand people in the richness and conformist of their lives I have titled my talk today schizophrenia and I making peace with mental all of us my title is an attempt to convey that schizophrenia is a relational illness by relational I mean that it involves personal identity that it profoundly implicates one social world and that it has political meanings as well so that's what I want to address today the identity the social and the political aspects of schizophrenia and I'll be discussing these three aspects by using excerpts from my memoir the center cannot hold my journey through madness as a window into these issues I've left time at the end for discussion and I'm eager to hear your thoughts and questions about my reflections I first became seriously ill as a Marshall scholar studying ancient philosophy at Oxford at first it seemed like I had depression with mild paranoid features which is actually often had schizophrenia begins but then my illness involved evolved into a pure thought disorder rather than a mood disorder despite much resistance I eventually found my way to a psychiatric hospital for with strong encouragement for my doctors at the University who might seem at the urging of a doctor friend I had graduated in his class Victorian at Vanderbilt and been accepted as a Marshall scholar at Oxford but I was in terrible shape I spent much of my time wandering the streets of Oxford mumbling to myself and contemplating various ways to commit suicide to rid the world of my evil I had absolutely no insight into the severity of my condition I had no awareness there that there might be a gap between how I saw myself and how others saw me I entered the hospital voluntarily about it after a week - of being mayor everything changed it wasn't something a doctor or a fellow patient or a nurse said it was a simple look into a mirror I saw myself reading from my bar it was the first time I'd actually seen myself in weeks and it felt as if someone had punched me in the stomach good god I thought who is that I was emaciated and hunched over like someone three or even four times my age my face was gone my eyes were simultaneously vacant and full of terror my hair was wild and filthy my clothes wrinkled and stained it was a business of a crazy person on the long-forgotten back ward of a hospital for lunatics ending the passage the gap between who I imagined myself to be in whom I saw in the mirror that day was profound and unavoidable far from making peace with my mental illness until that moment I did not truly understand that I had a mental illness to make peace with that moment that look in the mirror was the beginning of a journey that would last a quarter of a century in retrospect there was no accident that they Chong I chose to listen most to to listen to most on the psych ward after that experience was the Beatles once there was a way to get back homeward once there was a way to get back home I needed to find my way home finding my way home and finding my way back to a relational right life now I think Freud was a brilliant thinker and he got many things right but I don't think before it got right is his view that intense soccer talk therapy is inappropriate for people who are psychotic according to Freud analysis wasn't appropriate because an individual who was actively psychotic could not form transferring to the analyst for interview was absolutely not consistent with my experience in my experience and need to be in a relationship to be part of a social world and maybe most profound precisely when someone is psychotic finding my way home and finding my way back to a relational life I began my first work of the psychoanalyst at Oxford and it was difficult painful work when I noticed from my first experience with intensive talk therapy is two things first my analyst was hugely helpful in diffusing a sense of that went along with the thoughts I was having my thoughts were violent and deeply disturbing about myself and other people my analyst mrs. Jones was able to tolerate everything it's difficult for me adequately to convey how helpful it was to me to have someone listen not judge me and not threatened to put me in the hospital or call the police as might have happened in the US shame is a fat powerful component in a psychotic illness we understand the shame that comes from person and the aging process whose soils or himself we see it we smell that we feel the shame offered for individuals with a psychotic illness the shame is every bit as real and every bit as intense but it's invisible to others second I'm notice that as I felt more related to my analyst mrs. Jones I began to make more friends make friends again and be able to work again and I realized that someone could object by questioning the direction of the causal arrows here fair enough my point is that as I became able to share my internal experience as I could relate to someone without change my ability to interact with the world around me became much better I want to note and emphasize that the most helpful thing that I had a consultant that I had in England said two things first I needed to be in intensive psychotherapy five days a week and second I should be back in school as a way to exercise my mind a lot of people were saying withdraw from school go back to the states I think the consultant was right and I will be forever grateful to him I finished my degree at Oxford then I came back to the states to study law at Yale my transition was rocky for someone not familiar with the psychotic illness it's difficult to understand that at this point I did not really believe I had a mental illness my thought was that I was somewhat somehow different from other people and not in a good way like that through the exercise of willpower I could tame whatever was wrong quite literally like one has a wild horse in a corral that you must tame the challenge as I framed it points in my life was to take that woman I'd seen in the mirror and tamer and groomer or maybe just make sure she always stayed at home when I went out so I began yeah loss well I was not in treatment nor was I on medication parenthetically my analysts and Oxford mrs. Jones never suggested that I consider medication even though I was psychotic most of the time within several weeks after loss will be gained again I became overwhelmed one night and the library of the Yale Law School I went out on the roof and became quite psychotic I was taken to the hospital by one of my professors the next day whose assignment had sent me over the edge at the hospital I found myself in a small private room waiting for a doctor the attendant was kind and I readily gave him the telephone wire bell which I proudly made the evening before when I've been floridly psychotic on the roof of the Yale Law School and not satisfied with my jeans and t-shirt wanted to accessorize it also picked up a six-inch nail that I kept in my pocket which resulted in my first experience of being mechanically restrained many people who are psychotic carry things which could be used as weapons not because they want to hurt someone but because they're afraid that someone might want to hurt them shame and fear are accused to the relational aspects of the illness shame is a pervasive spirits of people with psychosis often we are ashamed of what we're thinking and so we hide our thoughts from other people the shame may play itself out in many ways after my experience of being restrained in the emergency room five months of hospitalization ensued hospitalization involving long term restraints and seclusion forcible medication and little privacy in the beginning I was even watched as I took a shower and went to the bathroom and was not a lot of privacy with when talking with other people even with my parents I believe the hands-off approach perhaps it could even be caused benign neglect and the Oxford Hospital was much preferable to the over interventionist approach often driven by risk management concerns at the American hospitals as I've come to say I am very Pro psychiatry but very anti force generally in my experience people do not like it when forces exhorted in their relationships and my experience is exactly the same and treatment relationships after two weeks enter an emerging commitment emergency commitment I was faced with the question of whether I would try to get out of the hospital the doctors it's kind of funny put me on a emergency commitment because they said I was dangerous to myself and others and they also said I was gravely disabled and the reason they gave were saying that I was gravely disabled was I couldn't do my Yale Law School homework which made me wonder about much of the rest of New Haven I could contest their motion to civilly commit me to me the choice seemed clear I would demand to hear I defied the commitment I brought this up to my father who's also an attorney and my father was equally clear do not contest this because if you lose you now have been civilly committed and you're gonna have to report your commitment every time you apply for a license to practice law he said to me you certainly don't want anything in your record where a judge orders you to stay in the hospital effort be forever grateful to my father that I do not have the burden of a civil commitment in my background that to this day I might be forced to disclose when I speak about the political dimensions of schizophrenia I speak not only about the social stigma which is real and pervasive I also speak about these life events that can follow an individual with schizophrenia for decades there are profound political aspects to this illness that can become huge burdens that people with schizophrenia calorie and is important that you who may connect with people with schizophrenia are aware of them and are aware that they can affect a person's life choices so we've discussed the personal identity aspects of the illness talk some about two social aspects and I touched upon the political aspects I want to push these ideas further by talking more about the centrality of relationships to heal healing does not occur in isolation it's painful to me when I speak to mental health professionals working in community mental health centers who measure their caseloads in the hundreds I have a good friend who's a psychiatrist at kind of the premier mental health community mental health center in Lausanne she has 350 patients how on earth you treat we have 350 patients healing begins in relationship and in all kinds of ways a patient's relationship with a mental health professional is an integral part of the healing I worried tremendously that this point has been lost on our policymakers of course other relationships are healing as well after I was hospitalized upon returning to the states I took the rest of that year off what would have been my first year of law school to return Yale had a policy that if you were withdrawn for psychiatric reasons you needed to be evaluated by the head of student health psychiatry to see if you were ready to return like any good student I like look this guy up you know there were no inter and there was no web or anything like that so I'm looking at periodical indices and you know article chapters and so on a 900 article by this guy students were thrown from squall for psychiatric reasons evaluating them for readmission questions you want to ask and answers you want to so I was like totally well-prepared what I did when I went into the interview and it unfolded exactly as he had laid to him and I was readmitted thankfully okay after I was housed okay so I returned to Yale Law School the following will fall and during the second try I made my closest friends and a man named Steve Benke he's in his her knee and a clinical psychologist with an appointment in clinical ethics at Harvard's Department of Psychiatry we speak on the phone pretty much every day we're very good friends according from the text one of the worst aspects of schizophrenia is a profound isolation the constant awareness that you're different some sort of alien not really human other people have flesh and bones and insights made of organs and healthy living tissue you're only a machine with insides made of metal medication and talk therapy away this terrible feeling the friendship can be as powerful as evil either but Steve and I weren't contracts class together and a couple of times he asked me for an assignment other than that we've never really spoken one evening though we sat down at the save table of the law school dining room the dinner conversation that night was casual and pleasant drifting from one subject to another classes law journal summer jobs I noticed that Steve seems engaged too now if he not if he smiled but after a while it began to look like simple politeness as our classmates got up to leave the table I realized that I wasn't ready to go just yet and there began wonder those conversations that last for a lifetime one in which there's a media comfort and acceptance the equivalents of someone's strong hand offered to you when you most need to grasp it that first talk flew far and right how we got to get out who our families were then philosophy of religion what matter to us and why Steve had graduated from Princeton as second in his class and then moved to Rome where he lived with a group of Benedictine monks and read Latin at the Vatican he considered entering the monastery and studying medieval philosophy but decided against it because it ceased to hold his interest at least as a long time commitment so instead of becoming their monk Steve came to Yale Law School and so did I and neither of us was really quite sure why sometime later it occurred to me that at the very moment I was being tied to a bed in a psychiatric ward screaming bloody murder and afraid for my life Steve was singing Gregorian chant and a monastery overlooking the ancient city of Rome and here we were now come to the same place from two very different directions it was past midnight when we said good night and as I walked back to my room I had the distinct feeling in the middle of my usual muddle that I've been unexpectedly blessed I don't know why I decided to tell Steve the truth about myself I don't know why I thought I could trust him but I did I believe from our very first conversation that this man would be a significant friend and a force for good in my life once the possibility came to mind I realized how much I wanted it to happen but I didn't believe it could happen unless I revealed the truth about myself and let him see me in full so much of what I did on a daily basis was about faking it I knew I would never fake it with him and so on a rainy afternoon at a pizzeria in New Haven I shared my history aside from doctors and therapists it was the first time I'd ever done this with anyone anywhere and in the passage with that Steve support I couldn't have made it so successfully through law school if I could have made it at all he was a second set of eyes who could see me slipping when I couldn't he was a rock who could support me when I was about to fall and he was a true friend who helped me find meaning and pleasure in my life when meaning and pleasure felt like different memories after Steve graduated from Law School of New Haven my then analyst dr. white Ann Ann said he was going to close his practice in three months two years earlier than I had planned on leaving the neaten news of dr. Wright's leaving shattered me I returned again to what icy asteroids mistake that psychotic people don't form transferences with their animus in fact my transferences were quite powerful at the end of my first two analytic relationships could have easily landed me in the hospital fortunately neither did when white gave me the news of his planned early retirement Steve was traveling around the country interviewing for PhD programs in clinical site he sent this up it was terribly wrong and came to New Haven to see me reading from the dentists I opened the door of my studio apartment Steve would later tell me that for all the times he seen me psychotic what he saw that day shocked him for a week or more I had barely I was gaunt and moved too so my legs were would my face looked and felt like a mass since I pulled down all the shades the apartment in the middle of the afternoon was a near total darkness the air was faded the place was a shambles Steve has worked with many patients who suffer from severe mental illness to this day he will say that I looked as bad as anybody he had ever seen thank you for coming Steve I finally said crumbling world war voice tells the clocks to stop time as time has come is cut to come here why he is leaving Steve said sombrely I'm being pushed in a braid the situation is grave I'm own gravity is pulling me down tell them to get away I'm scared so that's an example of loose associations where words and a sound alike or a loosely related but put together don't make sense killing takes place in many forms in too many venues I could not have survived this illness without close friends family and colleagues who've known me of course of my illness have been there to helping killing takes place in relationship as wonderful as Steve was and is he was a friend like a brother around the time I had received tenure or shortly after I ran into a man named well a man I thought was cute friendly and smart a man with whom I tried to flirt in the library on weekends where he was the library on staff and I was working for tenure and one day I saw him in the hall and I mustered my cards let's have let's have lunch sometime so we went to lunch it has been over 18 years since I had had a relationship because I was just too tormented to be able to do that supported from the text when it came to my personal life after my illness had quieted down somewhat I started nurturing a fragile but growing hope for a relationship with a man named well a USC librarian and an artist again I tried flirting with them - no - no avail who knew who had to do that but after he left USC he invited me to lunch and then he invited me to see the California Poppy reserve in Lancaster not far from Los Angeles like about an hour away I kept saying how cold I was hinting you should put his arm around me and he never did I was really deflated but when he brought me home he got out of the car and he kissed me a long lingering kiss at night and the thought I had and this is literally the thought that went through my mind was hot this is even better than getting an article accepted the next day we'll meet bill brought me a feather from his parrot with whom he had lovingly described at the restaurant I asked my friend commander ferillo friend can't you Kenny that night I don't know why I put it this way but I said Kenny do you think a guy plucking a feather from his bird toupee sent your computer means he likes you which can he responded without a beat I don't know how long but one thing for sure he likes you better than he likes his bird which actually at that moment was not true he definitely liked this bird enemy back to the text I wanted her relationship with will and slowly I began to believe it actually might happen eventually I told well that I love Tim and he was the first man I had ever really loved in that way and he said that made him very sad at the right moment I told him about my illness and he responded as gently and kindly as a person could if sees friendship have made me feel human roll was making me feel like a woman and Dignitas OMB's when I say my relationship with Steve made me feel human don't take that metaphorically I did not feel like a human I felt my insides were made of metal and the things that happened to other people the feelings people have were part of my life I believed I was something else it was these two relationships with Steve and with will that brought me not simply to think but to feel that I am human and capable of loving relationships no heat pill could have healed the relational part of myself I needed other people for that okay today Steven will are my closest friends and I think of them as my two pillars but there was a point where I thought I lost Steve I separate suffered from an episode of what's called Capgras syndrome and what you believe a person has been taken over by someone or something else they may look the same but the person is no longer really that person this half of episode happened to me in the mid 90s when I was in a struggle with my analyst Dr Kaplan about how much medication I should be on we reached a compromise which I wasn't entirely happy with but with which I had agreed I was scheduled to give two talks the first on Sunday and the second on Wednesday at a conference in San Francisco once I traveled to San Francisco and checked into my tell I started falling apart Kaplan suggested that I give my first talk and then return to LA between talks which is about four or five days which would have made a lot of sense it would have been a lot cheaper a lot more comfortable but for me haven't took a home between the talks would represent a failure if I had to choose between being set and being a failure my choice was clear I would be sick reading from the text a sickness took a new horrific turn for some reason I decided that both Kaplan and Steve are Impostors they looked the same they sounded the same they were identical in every way to the originals but they had been replaced by someone or something was it the work of alien beings I had no way of knowing but I was terrifying it was struggle but I delivered my Wednesday paper and fled back to Los Angeles shaking a completely paranoid and nearly ten years of treatment I had never missed an appointment with dr. Kaplan now I didn't go to my next two scheduled sessions that it didn't call him to say why he called me Ellen we're not at your appointment what's going on I did not respond it's not him don't say a word it's not him and when what's happening nothing I think it's important that you come to your sessions he said I expect you to be here tomorrow is there something I can do I know what's going on and who you are and are not I said finally that that doesn't get us anywhere he said talk to me straight nothing no answer because you were not you okay then I'll see you tomorrow any hung up I did not attend our next session Steve sensing that something was very wrong was calling frequently they did not return any of his calls will of course recognize that I was very agitated but he didn't know why what's going on he has the to call themselves Kaplan and Steve are Impostors I said the real ones are gone and they've been replaced the ones who are leaving messages on the answering machine are fake she was everlasting credit world stayed calm ending the passage eventually i acceded to captain's encouragement to go on more medication and the delusion pass this was Will's first experience of me as delusional and he passed with flying colors he didn't get too scared he didn't get angry he didn't flee any tree with kindness and care the only way to understand why the catco's episode was so disturbing to me to understand that if these relationships were a tether to my own humaneness if i lost these ties to my humaneness i might literally no longer be human please understand again I'm not talking to metaphor here when you hear patients talking this way don't assume they're speaking in metaphor they might mean quite literally but with a loss of relationship they no longer feel human I've been talking about myself in relationship I would like to return to say a few more words about my relationship for my mental illness and how I conceptualize that relationship but I moved to Los Angeles from New Haven my analyst and I've developed a way of talking a sort of heuristic about my illness and my relationship to my illness there were in our way of speaking 3 means Ellen professor Sachs and the lady with the medical shorts I could not integrate these three aspects of myself how could I be a thinker of big thoughts an academic if my mind were so damaged how could I be both professor Sachs and the lady of the medical charts and where did Ellen fit in on all of this what took a huge amount of effort and what was ultimately self-defeating was to keep these three self separate I wasn't sure I want to add as well this is not anything like multiple personality these were just aspects of my my game I wasn't sure who was a real made this confusion expects itself at an intense ambivalence or taking my medication for many years my motto was quote the less medicine the less effective Steve was a virtual Saint as I spent literally years of our relationship going through time and time when I tried to get off my medication with disastrous results it's simple isn't simply that I didn't like the side effects with my psychiatric medication the need to take medication reach to the core of my identity if I could get by with that medication I wasn't really mentally ill and the lady in the charts would disappear only l1 and the professor would be left as a real mu this cycle culminated in one final effort to get off my medication several years after I'd been on the faculty at USC this passage involved two of my post faculty members named and her name Michael reading from the text well white had supported me in my many efforts to get off medication which I undertook with great gusto and failed miserably at each time one battle between Caplan and me concerned the use of meds early on we really locked horns on this half one thought I should just stay on the meds and get on with my life as I said for me the motto was the less medicine the less effective and that held sway part of the way that I could prove that I wasn't really mentally ill which I resisted mightily for many years was to get off medication and so I kept trying and trying and trying I decided to make one last effort to get off I thought I'd never really tried hard enough and I put a lot of extra supports in place to keep me true to my goals I started the record reduction I hid what I was feeling when I started feeling bad the days and nights were harder now to share physical efforts of containing my body and my thoughts felt like trying to hold back a team of wild horses sleep was spotty and filled with dreams that left me awake and sweating in terror nevertheless I dropped down again months before I'd accepted an invitation to attend a workshop at Oxford or present a paper at the time I boarded the plane home I was a complete wreck when I walked into captain's office my first day back I headed straight for the corner crashed out on the floor and began to shake all around me were thoughts of evil beings poised with daggers they'd sliced me up in ten slices or make me swallow hot coals Kaplan would later describe me as quote writhing in agony even in this state which but he accurate or described as acutely in Florida psychotic I refused to take more meds the mission is not yet complete immediately after the appointment with Kaplan I went to see dr. martyr a schizophrenia expert who was following me for a movement disorder caused by the medications called part of dyskinesia he'd never seen me go before and had been under the impression and I had to disabuse him of it but I had a mild psychotic illness and my primary concern was minimizing tea tea once in his office I sat in his cab folded over and began muttering I was a shepherd I couldn't remember when I'd slept or what I when I died be in Oxford before Oxford did it matter if we were all gonna die anyway anyone who walked into that one would have thought mortar was treating schizophrenic Street person and weakest later people told me that's exactly what I worked with had explosions and people trying to kill is it okay if I totally trashed your office I think you need to take you need to leave if you think you're gonna do that said martyr okay small fire on ice tell them not to kill me tell them not to kill me what have I done wrong all the explosions hundreds of thousand with thoughts introjection Allen do you feel like you're dangerous to other people or to yourself yes that's a trick question I said I don't think you asked him Eko health law professor she meets the statutory criteria for commitment in the language of the statute not sure what you do but that doesn't work no it's not a trick question you said I'm serious I think you need to be in the hospital I could get you into UCLA right now and the whole thing could be very discreet hahaha you're offering to put me in the hospital hospitals are bad they're mad they're sad one must stay away I'm God or I used to be my husband that made a marginal note when he was reading this next time God or used to be he said that you quit a refire and then he asked who would have the authority to fire God actually good I give life and I take it away forgive me for I know about what I do I really think a hospital would be a good idea martyr said no thank you oh so very much I said all right then but if I were you I would say away from work for a while you don't want your colleagues to see this Thanks banks bang bye see you soon oblivious to the look on his face I love the next morning I dragged myself to my office which was my hideout of refuge and I ran into my colleague yet in the hall and he quickly figured out what was happening happening Ellen what the hell was going on I thought you were kidding at first you're not are you does anyone else know about this is it okay for anyone else to know I wouldn't mind telling Michael I said not the Archangel one the other one suffice to say that Ed eventually brought me to the hospital showing the good judgment to follow my doctor's advice rather than tackle me to the room and take me to the ER as others including Ed's internists wife were recommended and eventually I've seen it - everybody's demands to take more medication I could no longer deny the truth and I could changing the wall that kept me Ellen professor Sachs separate from the insane woman I'd seen in that mirror long ago lay smashed and in rooms and then another event pushed me past the point of no return and accepting that I deed had a minute all of us I got a new drug quoted from the text because of the risks of my meds Kaplan suggested one of the new classes of antipsychotics and drug called site prep so I'm in the end I was on like five times the normal dose and still having a lot of breakthrough symptoms so he changed me to seven called clozapine which is actually the Cadillac in terms of efficacy for psychosis but very cumbersome you have to have a weekly blood test for six months and then every other week and then once a month but it works really well but anyway originally with the olanzapine or the Zed preps the change was fast and dramatic first the side effects were much less than they were with nothing more important the clinical result was not to overstate it like daylight dawning after a long night I could see the world in a way I'd never seen it before the illness was still there but it wasn't pushing me around as much as it once did finally I could focus on the task at hand unencumbered by the threat of lurking demons the most profound effect of the new drug was to convince me once and for all that I actually had a real illness as I said for twenty years I struggled with that acceptance managing to hold on to the belief that basically there was nothing unusual about my thoughts everyone's mind contained the chaos that mine did they were just better off at managing and thought I've my problem I thought had less to do with my mind it had to do with my lack of social graces I wasn't mentally ill I was socially malodor of course that wasn't true and there's no way to overstate what a thunderclap this revelation was to me and with it my final and most profound resistance to the idea that I was bit mentally ill began to give way ironically the more I accepted I had a minute all of us D'Alessio Melissa finally it became accident and not essence at which point the riptides that had kept sucking me in set me free I was finally able to integrate the three parts of myself I was indeed Ellen the professor and the lady of the charts all three were me and I was all three it was making peace with the lady of the charts my mental illness that allowed Helen and the professor to flourish and enjoyed the men you were all wonderful relationships that had blessed my life so I've been enormous ly gratified that my memoir the center cannot hold has been well received which money's from a MacArthur grant actually have a funny story about that so when I got the MacArthur award my school gave me a lovely reception and they gave me a t-shirt with a picture of Einstein and a picture of me and said only one of us is uh only one of us as a certified genius to which I said I've been certified many times now never in that way so with monies from the cart I founded the Saks Institute for mental health law policy and ethics at the law school we've gone through six or seven years working on topics at this intersection the goal of the institute is translate ideas into action to better the lives of people with mental illness we're your sisters your brother's your sons your daughters your colleagues and your friends we want in the words of Sigmund Freud whatever one wants to work and to love with a little help or perhaps a lot of help for mental health professionals family members friends and colleagues we can indeed find a life worth living thank you very much [Applause] I'm going to talk about the right to refuse her let's just have a conversation okay right I think I know how Oh turn those oh yeah them yeah I think I know how okay all right good it's a real honor and I mean an honor to be on paddle with Ellen sacks I've known Ellen for 30 years she is not only a fabulous scholar she is a wonderful friend and she is an inspiration to anybody when I'm teaching my mental health law class and I want the students to understand what it's like hot rate is like from the inside the first reading and the mental health law class is the first chapter of Ellen's book the center cannot hold and I give it to judges when I'm doing judicial training because unless they have the experience and their families they don't know either people just as Ellen said people think that people with severe mental illness are talking metaphorically they're not it feels an alternative reality so I start with an anecdote that I tell with Ellen's permission some years ago before the center cannot hold came out she called me up to talk as we often talk she called me up and she said Stephen I have a question for you what do you think my diagnosis is I said you diagnosis she said yeah my diagnosed I said well Ellen you're odd she copped to that immediately then she said no really what's my diagnosis of major mental disorder I said frankly I have no idea and that led to a conversation she was thinking of writing the book the lead mental health professional who was treating her at the time as she told me didn't want her to do it he said people are gonna just say oh you're the crazy law professor and she wanted my opinion and I knew Ellen to be a person of valor of courage of character and I thought she had a story to tell that the whole world should know so I encouraged her so my first question to you would you talk a little bit about how you came to make the decision to do this amazing book thank you so much you know I thought about it for many years and I don't remember the moment when I finally committed I'm gonna do this but I you know I talked it over with my friend Steve I talked it over with my psychiatrist I talked it over with you one of my friends is a geriatric psychiatrist said you know you basically want to become known as schizophrenic with a job and that's not how I wanted to be known but I thought it would just send the wrong message that this is just too awful to say out loud to do it under under a pseudonym and this person now says she was wrong it was it was a good thing to do one thing actually happened around that time which was Michael louder do you remember that story he was a Yale Law School graduate I mean he had schizophrenia I don't think he was ever able to work but he had a wife and they lived near Cornell like thing because as I recall and he stopped taking his medication because he thought he didn't need the meds anymore and he became floridly psychotic and he killed his wife and their unborn child and that you know that happens it's horrible it's terrible but it's not the whole story about mental illness and if people don't tell the story of non-violence and success and kindness or whatever people are gonna have important misconceptions that was that was another motive it also made it me feel a little bit scared more scared about doing it because what people say gotta watch out for her you know she may yeah there was one person in the law so an administrator who after my book came out came and told me she she's glad she didn't know I had schizophrenia before we started going out to dinner and I said why and she said I never would have gone dinner to dinner with you and I thought a kind and smart and well-meaning person had such fantasies about what schizophrenia means that she like wouldn't go to a public restaurant one of the issues that Ellen has written about more in terms of policy that in terms of her personal story is the right of people with severe mental illness to be able to refuse treatment and competence to refuse one of the things we know as Ellen is very aware is and she said not only are these drugs not a relation provider but they are only moderately effective and for many people the side effects are very aversive people who have had a lot of experience in the mental health system they understand that not much as work or that the side effects have been very aversive and by the way the death study this shows that that's about as true with the second-generation psychotic antipsychotics as it is with the first the first we thought the second generations were so much better but now we know it's simply not true in light of that oh and how does that experience you can talk more generally about the right to refuse and competence how should that affect our thinking about the right to refuse how effective or ineffective or in a better think it's a very important question you're gonna force someone to do something that's not gonna help very much it's not doesn't really may make a lot of sense I think a right to refuse is extremely important I just think it's really important and that the standard of competence or refuses what the standard should be and I think like half the jurisdictions in America have had that standard so for me native helped enormously but other people they haven't or they don't know what the side effects or whatever I mean I'd like to say you know if the choice is between slobbering at night and being psychotic on the sovereign I even if the choice is between gaining some weight or being psychotic I'm going to gain weight if I gained 100 pounds I might feel differently and people have different you know risk benefit calculus is about in their own life and what I like to say is sort of you know an important decision for everybody her/himself to make you know what matters to them and why and and what they can do how do you think if you lack capacity to decide that in a benign either should step in so if someone were to say doctor for my lawyer I you know this medication has helped me enormously in the past I really wish I could take it but a voice tells me that if I take it it's gonna cause a nuclear holocaust I don't think that person has the capacity to refuse meds and I think we should you know require them then to take meds but I do think you know what's really one of the really important things is you know the efficacy of the drugs and the side effect you know profile and I think more people are going to be willing to be on drugs the better drugs we happen the better they feel when they're on drugs I think it's an important thing for society to do is try them or try again getting good ones if I can put it that way No one of the one of the things that people who do clinical work realize is if the patient agrees with the doctor's recommendation applications competent ha ha ha hey doesn't agree with the doctor recommendation well then there's a really serious question about and any any honest clinician will tell you that's the way things are so how do you think that should affect our ability to force people to take drugs no I think I think that's a good and interesting point but I would say that if someone is wait I was gonna say so you're said question again yeah the question is how should the fact that people tend to think when patient agrees with the doctor the patient's confident they don't agree because even if they're not confident when they agree the overwhelming likelihood is someone else is gonna say take the medication so why go through the trauma at the time and the process and so on to do something where the outcome can be done without without that so I do think it you know I think you know theoretically it doesn't make sense if you're confident you're confident if you're incompetent you're incompetent but in terms of practicalities I think I don't think that's a bad are you suggesting that when there's disagreement virtually always the person will be overridden that tends to be the case yeah well that's right and that's my question is is that wise yeah well some people say you know what what what's the use of a right to refuse medication and virtually everybody's decisions it's gonna be overridden but I actually say it's not that clear because it may be that a lot of doctors knowing what the standard is aren't bringing their patients to corner cuz they know they're gonna lose so that with the standard you are giving more people all right one of the things that you talked about and Ellen has written so compellingly about the overuse of mechanical constraints and seclusion in the United States which is not used in the UK and it's not because the UK population is somehow different from us it seems to me there's obviously something social going on we agree entirely force is vastly overused in our system I was wondering how you feel about the increasingly common practice of outpatient involuntary commitment that is where the person is not forced to go into a hospital against their will but must go for outpatient community treatment and they only will be hospitalized that they don't show up now how well that's enforced is another question but in principle yeah no it's a it's an interesting concept I think by and large it's a good thing on the one hand though you're coercing more people than you would have on the other hand you're keeping more people out of the hospital so it has benefits of cause some on both sides what I like to do I like this kind of one free shock idea where you know people say well my got whole patients you know after they get treatment thank you well I think the studies show about 50% say thank you but you know so maybe the idea of like trying involuntary treatment if the person isn't you know committed to it I'm then seeing whether they do thank us and if they do they can write an advance directive saying if this happens again and I don't mean to commit but standards I still want to be treated or you know that kind of thing so and then the same with outpatient you know try it once and see what happens no I mean the the data on outpatient commitment for those who don't know it is the very few there aren't very many good studies of the efficacy of outpatient commitment but everything depends on dose and intensity in other words if you keep people in outpatient commitment to significant period of time with significantly intensive treatment then it seems to succeed and that leads to my next question which is what are we going to do about the insufficiency of community mental health care it's a terrible problem and it's a terrible problem dalton has written about ah so what are we gonna do about insufficient community treatment because what we you know LA County Jail and Cook County prison and Chicago and maybe one other place or the big Rikers Island they're the biggest psychiatric facilities in the country it should not be that way jail and prison is are not good places for people with mental illness so I actually I had a student I don't usually remember my students last name surname was Petra one day she said to me instead of writing a term paper can I do a documentary it's la right so he thought he initially use a handheld video camera that would be totally fine well she called about a month later our professor says I got a really good cameraman and I'm negotiating with a director I thought she must have industry connections Marlon Brando was her father but she wrote she made a 70 minute documentary about people on Skid Row and LA and that kind of it was really amazing she had one guy who she's interviewing saying you know I get picked up for you know crimes like you know trespassing or you know indecent you know not increasing in disclosure but disturbing the peace and things like that and they bring me to jail and then they say to me you know get on line and my voice is saying go over there so I go over there and they beat me up and they mark mark me up just having an infraction so when you have two people with the same charge or the same conviction and the same sentence if you have a mental illness you're likely to stay considerably longer than if you die and that's not good it's not a good place for mentally ill people to be yeah the the actual level of provision of mental health services in jails is dreadful probably half the jails in the United States there's no mental health treatment whatsoever there's no treatment for substance abuse even though it is very common this leads to my next question and you raise the data places like Rikers in the LA County Jail are huge repositories for people with severe mental disorder which is true by the way disproportionate to the rates in the population and so a lot of people say well what we've done is we've simply moved our incarceration from state hospitals to jails and many people call for a reinstitution of more involuntary inpatient hospitalization would you be in favor of that no it's at heart so maybe one fair question it's really a hard question I think you know before I would endorse something like that I would endorse trying less restrictive things like outpatient commitment or like just really encouraging people to to seek treatment sometimes I talk about you know should we should we be studying ways that we can use force more or should we study ways where we don't need to use it as much and I'm talking with some folks at UCLA to do a study and have three groups one group will be people who get on medication and immediately take to it and say I'm never gonna get off often the other end are people who either don't get on it or trying to get off of it and in the middle or people who start out and that latter group not wanting it but what I call tip to wanted medication and if we could figure out why they tip perhaps we could encourage other people to tip faster and that would be one of the McArthur kartha projects go on mental health and law discovered that if you treat mental patients with dignity and respect and you explain to them what is being done even if you are in fact coercing they don't feel coerced and they're much more likely to cooperate this has also been shown in studies with with citizen and police encounters and mellitus and you treat people with dignity and respect they will treat you back with the same dignity and respect as it turns out though at least in Los Angeles I can't remember if it's a third of the cases where injury occurred or just a third of the cases where excessive force was used have mental health disorder given network not post to a third of the population yeah in fact when you look at the rates of violence associated with severe mental disorder it's more likely that they're going to be a victim then they're going to be a perpetrator in fact the rates of of serious violence among people with the most severe mental disorders is no higher than in the general population at large so Ellen is absolutely right well I think maybe Eric it's time to open it up to the entire audience there are microphones and I will I will just call on people and answer and Ellen will answer the questions thank you for that inspiring talk I actually had a question the K'NEX of it with the UK and experiments by Rd Lang who was very NT any sort of medication for patients psychotic of schizophrenia because I think his fundamental belief was that schizophrenia and some of these things were a pathway to a different reality maybe a higher reality and our existing drugs and treatment of course part of the reason why the UK went negative forced treatment in in post confinement was in large part because of Lang's philosophy then and and it was quite successful what he ran out of that little building that he did where he had all the patients but never never gave them allopathic drugs at least but they were free to use other substances some of them were psychedelics and LSD and other things so I'm just wondering what your reaction to that is his entire philosophy that the medications were sort of dumbing them down and bringing them back to a logical structured world but this was taking them to another reality which ya know it's an interesting question there in fact when I volunteer that the chronic psych hospital an Oxford one of my patients had been a patient of our dua and we're described running through the woods naked you know it was just very non-traditional for what I knew about you know mental health care but he he liked him and he like you know he liked his time there is it a higher reality I mean I think there are all sorts of philosophical to love you know issues around mental illness and how do you distinguish it from eccentricity or difference and can it actually be a higher level kind of being all sorts of philosophical questions and I say I understand it as a biochemical illness that needs medication and intensive therapy because that's what makes my life better you know and if someone else has a view that it would be better to hallucinate a lot you know they'll have access to things that other people don't have totally you know totally their decision I don't I don't think it's a higher reality but I know I got some people do sir dr. sacks thank you for your for your lecture and your inspiring book I couldn't put it down once I started reading it I'm Mitch Feldman I'm chief of general medicine at University of California San Francisco and better known as Eric's brother in this context I - I think maybe two questions one piece of your book that really got me and my gut was reading about physical restraints yeah and from your experience in England can with your experience in the US and as an internal medicine particularly trainee I wrote and signed a lot of orders for physical restraints on patients thinking that I was preventing them from harming themselves and doing good and I read that passage from your book with a lot of regret that I had been involved with that I'm curious about the legal issues around that and why are we still permitting that to go on in the hospitals here what are the legal precedents around that I had another question also if I can just throw it out there at the same time which is having come from San Francisco with just a terrible epidemic of homelessness there the other place where patients are going in in addition to the prisons are out on the streets and we give them the right to choose to go live on the street if they're able to say they're not going to harm themselves or others and can tell you that where they can find their next meal even though it may be out of a garbage can and that doesn't feel like appropriate treatment and I'm wondering about your thoughts about housing as a as a part of the key pieces of treatment for patients with serious mental illness great questions thank you yeah they're all there you know I have a really bad memory so if I repeat myself put your hand up and go like that anyway so mechanical restraints I wrote my law school no mechanical restraints I went actually to one of my professors who was a psychiatrist at the law school and told him I was writing this and that it must be very sorry to Grady to get painful he said Oh Ellen you don't understand these people are different from you and me they're psychotic and they don't experience restraints the way we would and I did not have the courage in that moment to say no we're not different it's a really horrible experience when I wrote my Law Review no on their strengths there were doctors and I know how many are still around who thought restraints for a form of treatment and that patients felt safe and restraints and that they liked them I've never met a patient who's been in restraints who ever expressed that opinion and then they also say well even if they know you know they don't feel they don't feel safer they are safer they keep people from hurting themselves or others actually there's a lot of evidence that people in restraints are harmed a lot one two three deaths a week which was the figure quoted in a series of articles in The Hartford Courant die and restrain say aspirate their vomit they have heart attacks they strangle given that we can staff special someone or someone's dangerous to others put them in a seclusion room query are we really saving people's lives or causing their you know death so it's it's not an easy question and I have thoughts of that but an ideal restraint regime would look like I don't know if we want to go into that level of detail why don't you take it okay so first of all I would say we should only use mechanical restraints when we absolutely need to an example would be transporting someone in a an ambulance to a hospital you don't want someone to like you know go up to the front and strangle the driver that's a really awful way to say it to disrupt things that might affect driving or if someone needs to be at close quarters with a nurse or a doctor or an attendant you may need to do that to protect other people but otherwise I don't think we should use restraints the second thing I think is we should really procedurally board room the use of restraints so we should say you have to check every 15 minutes that's pretty standard well I would also suggest that every hour you actually have to go in the room take the person out of restraints and see how they do and then every three hours do something else because if you procedurally burn the use of restraints they're going to be used less and that was the experience in New York they had a restraint law that like after an hour of the doctor had to come in and let the patient have surprise surprise most people were released before at that point so procedurally burned English can actually help people and then also you know I just wouldn't do foreign six point restraints pine someone spread eagle through a bed I had the you know good fortune to never having been abused by self but a lot of patients with psychiatric histories do also have an abuse history and tying someone spread-eagle to a bed I would think would be quite triggering and traumatic I used to have nightmares about being restrained it was really I also used to have a fantasy that somehow I was able to lock all the doctors and nurses and the seclusion will restrain them all open the door and let all the patients leave the way we cope with you say the homeless question is a really interesting question I have a good friend who used to be an accounting man a hostel clerk now she has half time private practice and half time she goes to people at you know Santa Monica beach and connects them with connects them with services I think there's an interesting question they've added homeless mental illness and whether that should count as grave disability one theory is if you're living on the streets and you aren't able to provide essential food clothing or shelter for yourself another theory is if you provide food clothing and shelter to the same degree that other homeless people do it then you're not gravely disabled I think a case could be made for the first and that if you are mentally ill there's a possibility that we will be able to treat you get you well and get you off the streets whereas you don't have that with someone who doesn't have a health challenge but I think it's I think it's an interesting and important question and it's another scandal you know that jails in prisons that's the scandal homelessness is a scandal we even have it you know at USC a very wealthy school we have kids who sleep in the in the library in the stacks of the library because they can afford housing and we should we should do better there used to be the case that we would clean get people off alcohol and drug get them in medical treatment get them in psychiatric treatment and then give them housing the new kind of theory is housing first if you don't have housing everything else is so much more difficult so let's get people housed and then we'll work on medication and physical health and things like that thank you thanks so much for professor Sachs Steve Jaffe the division of medical ethics here and also a pediatrician you in talking about requiring that people take medication against their will you drew a distinction between people with and without competence realizing this law was so clear to tell who is which I'm curious your thoughts on the notion of a psychiatric advanced directive where somebody who are clearly competent says if and when I find myself in a position of incompetence do not medicate me I think psychiatric advanced directives are a great thing I mean I would have two reservations one is they're not like used very much even in regular medicine so I remember I was having an intake interview I was gonna have some kind of procedure or physical health history and the intake person asked if I had an advanced directive and I said yes and she said that's where it was or what was in it or anything like that there was nothing about it just just said yes and and then the second thing is you know changing your mind so I tell a story I was in college and it was exam period and I kept going to my friend's room and asking for cookies and one day I said to her look you know please don't offer me cookies I'm gaining weight I shouldn't keep eating them and if I say I changed my mind I really want them to say no and if I said I really changed my mind still say no so the next night I went upstairs and I said you didn't invite me to have cookies and she said well you told me not to I said well I changed my mind you said you told me it doesn't matter but I really changed my mind I just got off and I walked a mile and got myself cookies so it's you know it's sort of an interesting interesting phenomenon but I think advanced directives are a really good good idea also doing a study on something called supported decision-making I talked about that No so it's basically instead of just finding someone incompetent an important gate Guardian to make their decision you say to people pick one or two people in your life who you trust know you who care about you and have the help you make decisions and what we're studying we're at USC UCLA UCSD and n states to me right now we're talking about I am in Texas and we have two sites in Spain we're gonna study who people pick and why we're gonna setting their satisfaction with the decision making process and downstream effects like less hospitalization more independent living more independent working and our hope is that this is really effective most jurisdictions don't have an SDN statute but most jurisdictions guardianship statutes say guardianship has to be the least restrictive alternative and our argument is SDM is less restrictive which I think it really is so this could you know if effective when we study it if it turns out to be effective and desired it could kind of change the way we deliver health care and I think that could be really cool what it basically does is it restores more people so kind of being the architects of their own lives which I think is a good thing thank you professor for being so open a Patronus it is inspiring thank you I was wondering how after being diagnosed you managed over the years to reveal the relationship with like kind of the outside world with other people all right because one thing I found with mental illness is that once you get diagnosed like you entire life it becomes about that and kind of becomes difficult to relate to anybody on both sides I was wondering how you handle that yeah it's a really good question so as people know schizophrenia has positive symptoms like delusions of hallucinations and disorganized speech and negative symptoms like apathy and withdrawal inability to work an inability to have relationships a lot of the Burg societally and for individuals of schizophrenia resides in the negative symptoms and we have decent meds for the positive symptoms but not for the not for the negative symptoms how did I manage to avoid those well I think like first few years I kind of had negative symptoms but I think I really think it was the therapy that kept me connected to people to the world I had lunch with a student you know couple of years ago who said basically professor Sachs I don't understand I have the same diagnosis as you but I can't seem to make friends and you seem to have a lot of friends how do you do that and basically what I said was uh I don't really know but it seems to me that if you try to be a friend to other people they'll be a friend that it's sort of vacuous advice but it's sort of true as well and I you know I'm really glad that I had that going forward because it just made my life so much better to have rich and full and caring relationships and I really feel bad for people who who aren't able able to do that and again I think a lot of it had to do with with the therapy thank you i Ken Weiss from the department of psychiatry you mentioned jails being the largest providers of mental health services and cities and in my work and I see a lot of criminals as a forensic psychiatrist there same people that we're seeing in the hospitals the jails the emergency rooms they just revolve around in a shuffle around from one to the other so police it seems to me have a lot of power in their discretion to make on-the-spot determinations separating you know mad from bad right and they don't really do a good job a lot of them don't care a lot of them are quite arbitrary indeed and this is very troubling because I see people who languish in jails simply because they did the same sort of thing like running away from an officer that someone else did and they were taken to a crisis center my question is in your policy work or discussions any way to move the discussion along in educating police or in dealing with that kind of authority in helping persons with mental illness that's a great point and a great idea I think police do have a lot of power I think a lot of police don't understand we're making efforts in LA to educate police so they've spoken to me they speak to other people they have like as far as I understand two weeks of you know eight hours a day on mental health and mental health responses else yeah and they have a hard time distinguishing that versus bad and I think that we need to encourage police to understand that and to do the right thing one thing I think that's happening in LA and around the country so when we did our year at the Institute on criminalization of mental illness one of the people who spoke was this guy named Steve Life man who's a judge in Miami who set up what he calls a mental health port which is like patients opted into it it's their decision they instead of instead of being convicted and sent to jail they're given sentenced to treatment and if they finish their treatment successfully a lot of times they can have their record expunged when we talked about this at my event one of the people there was Jackie lacy who's the head prosecutor in Los Angeles you might expect the head public defender to jump on this idea but the head prosecutor dropped on her and she's starting a mental health court in Los Angeles and I think you know I think that's a sort of thing to do and one of the ways to try to have you know keep people out of that criminal system and in to a healthcare system but it's a really good point and it's a really important problem one thing to notice about this if I can interject is that in the bad old days the idea was to try to keep the patients in the hospital now when people go to inpatient we try to get them out as quickly as possible because hospitalization is so expensive and so with not clear what cops ought to do in many cases question over here um my name is Riley and I'm an undergraduate student psychology and I also represent a group of students on campus who have lived experience of mental illness advocating for other students with mental illness and one important line of work that we do is securing accommodations for students I'm an illness and I just want to know your thoughts on an educational institutions responsibility to accommodate students who struggle with illnesses probably very very good question a lot of their groups on campus who are supporting each other on doing this kind of thing yeah I mean accommodations are required right they're not required if you're violent they're not required if it's gonna pose a severe burden you may know more about the ADHD than I do but they're important and they're and they're good and I have some students say when their friends find out that they're getting mad they get angry at them and look down on them at the law school you know for the L SAT for example we don't know who gets accommodations and on law school exams we don't know who gets gets accommodations but I think you know some people with mental health disorders are as fully intelligent and hardworking as any good student with a Dementor almost but can have extra challenges because of the mental illness and trying to work with that I think is a good and important important things to think to do your do you all experience stigma among other students or do they not know or I think the problem that's identified most often by students who do need accommodations is the inability of or the lack of organization on the part of the administration and faculty members that make it extremely difficult for students to communicate with professors about the accommodations that they need even though they receive gum through the school not all professors are educated they're not all knowledgeable right about like school policies in the law or the rules so that's I think a big problem there okay we have time for one more question okay so this is the finale this is it make it good in your book you talked about at least initially your reluctance to take medication because of your stint in rehab as a teenager and the messaging there surrounding that occasion that it means your week and all and mind-altering substances are bad do you have thoughts on the messages we should be sending generally about medication yeah I you know I was in a drug program I was not much of a druggie but my parents kind of overreacted it was a half the school program I was in it for a year to when they've reached no drugs not even medication um and when I became ill that was one of the reasons I was reluctant to take medication because I thought that would mean failure and would it be changing Who I am and I just had real troubles with that the one good thing about being in the program is I sort of got over all the counterculture ideas live for the moment achievement doesn't matter etc before I got to college when I got to college I worked hard and did well when that opened lots of doors so that was a good thing and the bad thing was like giving me a lot of negative feelings about about medication I don't you know I don't really know I have never really had a substance problem what the what the norm is these days and like alcohol Anonymous Narcotics Anonymous if they have groups and are okay with people taking psych meds or if a preach that they shouldn't I hope it's the former and not the latter but I don't I just don't know that that world so do you have any thoughts about [Music] I'm sorry about social messaging sir for general consumption I I recall that you commend media and press when they bring attention to mental ailment mental health issues so I was wondering if you had a lot of additional thoughts on all the issues surrounding medication and the statements there because we have to take medication prevail on the group to ask one more question we have two and a half minutes so please we won't take that long this is a follow-up to the student Riley the question she asked my name is David Ramirez I'm the director of the Counseling Center at Swarthmore College where the director for 25 years we've had a number of students matriculate through Swarthmore College with schizophrenia and graduate and go on to leave very bright light as you write mr. Sachs and I want to say that in my time this is really a message to this group of the current and future lawyers that one of the things that clinicians often encounter is the college counsels obligation to manage risk management for the institution and to allow for certain kinds of practices that might for which there might be arguably an unpredictable outcome I think as you make the case that you make in your book is that connection to society and to one's work really could make a difference if a person can he treated and continued to be part of a system that's what we try to do whenever possible so I wonder if you have any thoughts for the current and future generation of attorneys who might find themselves in the position of advising their institutions about an attitude in terms of approaching allowing a student with a visible recognizable a serious mental health problem to continue to be a student yeah I mean one argument is someone did that positions you know not going to be able to do the work and maybe affect other students upset them they've got a scare but you know another side is you know if there's dialogue about what mental illness is and how 25 percent of us have something or other and that we know we can work together and and that kind of thing I think that's really really an important an important message and important practice I can't when I look back on when I was readmitted you know I was forced to withdraw I have no doubt that if what I went through happened today they would not let me back in school and I think that's too bad you know and I think there are a lot of students who aren't look back in who who could and you know yeah but I you know and obviously risk management concerns are an issue but I hope I would hope they wouldn't dominate you know what we do to help people yeah just just to follow up on that there are in the room the number of people who serve currently or have served as general councils to the University Penn and other universities I think that suggests the degree to which these issues have really emerged as as ones that universities both as legal entities and as entities supporting the students have become much more attuned to what when I asked professor Sachs earlier today when the last time was that she was in Philadelphia I always asked that question because so frequently people say the 1980s and then I get to brag about how much the city has improved she said the last time she was in the city was when she was an inpatient at a psychiatric hospital in Pennsylvania and so I sat here this afternoon listening to her and watching her and feeling as we're talking about how people bounce between institutions of jails and-and-and the streets or mental hospitals how how incredibly far you have come and how doubly pleased we are to have had you here so thank you professor mark [Music] you

Channel: University of Pennsylvania Carey Law School

Views: 4,967

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Id: axMsWcV_e6Y

Length: 88min 56sec (5336 seconds)

Published: Wed Jun 12 2019