The Complexities of Coercion in Mental Health: Knowledge, Unknowns, and Paths Forward

Hello to everyone, um, in the audience, students, staff, faculty, and our beloved community members, um, in here with the Sandra Rosenb School of Social Work. I'm going to, I have a little bit of an upfront sort of uh talking to introduce this event, to introduce uh to commemorate the passing of someone special, and to present our speaker. So, bear with me.

Um, this lecture is part of the biennial Deborah BB memorial lecture series, and I'm Tally Moses. I'm associate professor at the school, and I get to do the honor of organizing this event every other year, which is what biennial means, which we were just discussing, weren't we? But not biannual, biennial. It's very, this lecture series is dedicated to the memory of Debbie BB, who was a graduate, uh, a graduate of the school of social work's MSW program in the 80s, and she specialized in the field of mental health. And she, uh, by all accounts, was a tireless, committed, uh, advocate, and, uh, you know, for the, for individuals with serious mental illnesses in Madison.

She moved here from Indiana. In Madison, she, uh, took on a project of finding food and shelter in the winter for, uh, Madison's, uh, unhoused residents with mental illness, and was pretty successful in doing so. After graduation, she worked at, um, a halfway house for people with serious mental illness. That's part of that was part of, um, Goodwill Industries. And on a very tragic day in 1989, she, uh, was tragically killed by a resident of that halfway house who was in the midst of a mental health crisis.

Um, I looked it up a little bit, and interesting to note, and I'm not sure this is accurate, but that this resident had been institutionalized, and a month prior to this, to this really, um, to this killing, he wrote the, uh, judge asking to be reinstitutionalized. So, that's an interesting little anecdote there. As incredible as it is, Debbie's parents, um, Richard and Marilyn BBE, established a scholarship in their daughter's honor in 1991, 34 years ago. And over the years, the BB scholarship has been made possible with contributions from Debbie's extended family members, neighbors, friends in the, um, in the Southbend, Indiana community, as well as donations from various charitable organizations in Madison, including, um, Goodwill.

This scholarship funds, uh, this lecture series, and it's also, it, it also, uh, there are scholarships given every year to, uh, students who have demonstrated or talked about a commitment to working with people with serious mental illness. Close to 70 scholarships have been given since the time that, since initiation of this, of this, uh, scholarship fund. And this year, I'd like to say that Sydney Walker and Kayn Howard were the recipients of the BB scholarship. I know it's pretty remarkable what the BB family has done, and I, uh, we give heartfelt thanks to them, for the various and various others who've contributed to this, to this scholarship fund, for their really meaningful contribution to individuals, to our students, actually.

And I also want to, before I forget, um, thank staff, and especially Jason Lee, our communications manager, and our department manager, David Barger, for making, um, this, this event happen. I would like to, we wanted to also remember and briefly, briefly, uh, honor the passing of Dr. Maryanne Test in January of this year. Um, Maryanne Test was a member of faculty at what was then just the school of social work at UW Madison. Uh, between 1978 and 2001. She is, uh, after earning her PhD in clinical psychology at Northwestern. She moved to Madison for a job at, uh, Mendota State Hospital, as it was called at the time. Now it's the Mendota Mental Health Institute. She took a position, um, and became the associate director of the Schizophrenic Research Unit. In 1972, she became the co-director of the Program of Assertive Community Treatment, known at the time as the Training and Living Program. Those of you may recognize the name PACT, well-known, well-known names.

The context, of course, is a time, and many students know this, of course, when ramifications of the national deinstitutionalization movement, starting in the 1960s, were starting to be felt and seen, um, where thousands of persons with severe mental illness were returned to communities that were wholly unprepared to meet their significant needs. It was during these early years in the 70s that at Mendota, that Dr. Test and her colleagues, Drs. Leonard Stein and Arnold Marx, developed and implemented and developed, implemented, and first piloted, uh, evaluations of the Program of Assertive Community Treatment. And they were driven by a belief, um, that people with serious mental illness could live fulfilling, productive lives as valuable members of the communities outside of the hospital. And this model sought to provide comprehensive, individualized, flexible, community-based care to persons diagnosed with schizophrenia who would otherwise have been hospitalized.

Early evaluations, uh, demonstrated that the PACT program was successful in treating people with schizophrenia in the community. Um, there have been many, many replications of PACT program models supporting these early findings, and PACT has also evolved over the years, as it should. The creation of the PACT model and its dissemination revolutionized the approach to delivering services in our public mental health system, and its impact has been far-reaching, as many of its key features were incorporated in the NIMH's Community Support Program model. And also, this model has been extended to serve other people with co-occurring illnesses, people, uh, who are homeless, jail diversion programs, and even children with serious mental disorders. Two years ago, the BB's, uh, lecture was part of the celebration of 50 years since the initiation of the PACT program. So, it's had long legs, and, and Dr. Test was the pioneer, one, you know, one of the pioneers of this program throughout her illustrative research career. Dr. Test remained a close partner with consumers and family members. She was also the only professional member on the committee back in 1979 that, that formed national, the National Alliance on Mental Illness, NAMI. So, she was at the table, as they say, in the room where it happened. Um, and she made that, that room happen. Not least on a more personal note about Maryanne Test. She was the very essence of kindness. Um, she touched the lives of everyone who crossed her path, um, including me. Um, I can't say enough about that. But a very, very, very kind and special person she was. And she is survived by her cat, Asha, who was, uh, her beloved. Uh, and Asha is still around, and at 22 years, she's apparently doing well. We should all be so lucky in cat years.

Now, um, turning to this lecture. Um, this lecture series has always featured, uh, always invited prominent social work scholars and practitioners whose work focuses on people with serious mental illness. Our presenter, Dr. David Cohen, hailing from my alma mater, Luskin School of Public Affairs at UCLA, where he's been since 2013. He held the Marjory Cromp Chair, uh, in Social Welfare between 2013 and 8, 2018, when he transitioned to positions as associate dean at the school, but still is conducting research, uh, as well as the administrative. Dr. Cohen has, uh, earned his MSW degree from Carleton University in Ottawa, Canada. That's in, near Toronto. I don't know where it is. I don't know where Ottawa is. And his, uh, he earned his PhD in Social Welfare at UC Berkeley. He's held various research, academic, and leadership positions at the School of Social Service at Université de Montréal, Canada, and the School of Social Work at Florida International University, and other positions that we just don't, we just will condense things. Yeah.

So, Dr. Cohen studies psychoactive drugs across the often shifting and fuzzy boundaries of medical, recreational, and illicit drug use, drug uses, showing how sociocultural factors, not just drug properties, shape legal status and therapeutic effects and promises. He evaluates claims about biological, deterministic views and biological treatments of distress and misbehavior. His work explores how schools of thought in mental health impact notions of ethical care, informed consent, and harm reduction. Dr. Cohen has advised governments, research agencies, courts, media, and community groups on reducing harms associated with psychotropic drug use. Dr. Cohen, David, um, also researches in, uh, involuntary psychiatric detentions, using public data that reveals government's weak accountability for coercive care of the sort. He has authored or co-authored over 120 articles and chapters. His last co-authored book was titled *Mad Science: Psychiatric Coercion, Diagnosis, and Drugs*, back in 2015. He has received numerous awards and mentions for his writing, research, teaching, mentorship, advocacy, also an illustrious career.

A couple of housekeeping notes before we move on to the lecture. Um, if you signed up for CEUs, you're good to go. So, if you didn't, and you'd like CEUs, please sign up at that table back there. Um, there was also something else I was asked to say. Um, link to live captions also available at the table out there. And there's food after the talk, so please stick around and socialize a little bit with us, and, uh, after the talk. And without further ado, I'd like to invite Dr. Cohen up to the front. Thank you kindly. You're welcome. Just press the buttons and press this button. This button. Yes, that. Beautiful. Thank you very much. Thank you, Tally Moses, for, uh, your warm welcome. Um, it's always a special time to, to, uh, commemorate the death of someone who was, um, who was, who left the world in an untimely manner. Probably didn't have time to, um, you know, arrange her affairs. Didn't know, you know, she's, she's gone very early. So, it's a very sad thing to, to think that someone was, um, taken that way in the prime of life. And, um, so I'm, I'm very happy to be here for this occasion.

I've often looked at situations where sensational events, murders, accidents, or so, create changes in mental health policy. In fact, historians of mental health policies often remark that policies only change when there's some kind of sensational, striking, tragic event, one way or the other, that makes them stop for a second. Later on, when historians continue to study the event, they find that there was more to it than what we originally called it. For example, Tally said there was a mental health crisis, or this person who murdered, um, Deborah BBE, was in the midst of a mental health crisis. Later on, we look into it, and we, we dig deeper into it. We find the word "mental health" obscures almost what's going on. It's so, so simple the phrase. What does it really mean? Was it something in their mind? Something they were thinking? Something they were lacking? Something they did? Something someone else did? Something society did or didn't do? And the word "mental health" seems so, so inappropriate, so just inadequate, almost to say what exactly happened. And we never quite understand until the next sensational, striking event. So, uh, hopefully, what I will say tonight will, will honor, uh, the memory of, uh, Deborah BBE.

And also, I want to say something about Maryanne Test, because exactly, almost to the month, 40 years ago, I was at the University of Madison, Wisconsin, in April of 1984. I had applied for PhDs in social welfare. I was a little Canadian, and, um, I applied to the University of Toronto, the only school with a social welfare PhD. Of course, they were going to accept me. And then I applied to three US universities, and the first one that came through was the University of Madison, Wisconsin. They said, "You're accepted, and we'll pay your tuition, and we'll give you money, and we'll." I thought, wow. And the University of Toronto, of course, they refused me. They said, "We don't understand what you want to do. We don't know." And all the others here, um, accepted me, and eventually, I made my way to Berkeley, California, where, for some reason, I was attracted to the Southwest. But I came here to Madison because I wanted to see, cuz my girlfriend used to live here. So I said, "This is the place where it's going to be, Madison, Wisconsin." And I came, and I went to whatever building it was, and there I met Maryanne Test, who was, uh, the, I guess she directed the PhD program. She's the one who signed the acceptance letter and made all these great promises. And we had a wonderful, very friendly, uh, 30 minutes or so. I don't know how I got here. Did I hitchhike? Did I take a bus? Did I take a plane? All that is hazy. But coming and going up the stairs, going to her office, and having this wonderful discussion, which really boosted my ego. So that was just, you know, almost 40 years ago.

This is what happened since. 30 years later, I wouldn't have known that my colleague Tommy Gamori and Stuart Kirk and I wrote a book where we severely criticized PACT, and ACT, a whole chapter just went into it and had many bad things to say about it. And we did that 10 years ago in this book, *Mad Science*. Tommy, uh, who's a professor at Florida State University right now, started this work, and we researched, uh, the history of PACT, its origin from Mendota State Hospital, how, uh, Dr. Marx and Dr. Stein, Leonard Stein, Dr. Ludvig, and also, and Dr. Test, and also Jeff Bransma and, and Frank Farrellly. I don't know if those names ring a bell. They both taught at the School of Social Work. Frank Farrellly wrote a book called *Provocative Therapy*, where he would shock patients and provoke them and ridicule them and, and so forth, to get, get something out of them. And it was in a wonderful book that I learned a lot from. If you ever get a chance to read a good book that'll change your mind, Frank Ferrelly, *Provocative Therapy*, probably published in 1979, maybe. Very, very interesting stuff.

So, enough with the anecdotes. Um, this is the lofty title of, of this talk: Complexities of Coercion. Oh, yes. I have no financial conflicts of interest, but of course, every other conflict I, I have, I must have every other conflict in the book. I have, uh, you know, uh, strong feelings one way or the other. Uh, I've opposed the use of coercion in the mental health field for as long as I remember. Everything I could ever, ever since I could think about it, I thought, this is wrong. And so, um, let me put this glass so that it doesn't slide in an appropriate place. So, so yes. Uh, so this is a bit of just to lighten up the, uh, the atmosphere a bit. And then what I', this is what I'd like to do in a nutshell over the next, uh, 45 minutes or something, or even less, is, uh, okay, what, what do we mean by coercion, at least in the field of mental health? It is a complex thing to study. So many ramifications, uh, so many ways you could look at it. Um, and I'd like to say a few things we seem to know about it, some things we don't know about it, and then talk about specifically, as far as social work is concerned, what could be a path forward based on some of the ideas that I will, uh, bring up. I don't mean to do anything exhaustive at all, like review everything we know and what we don't know, but just kind of mention a few data points here and there. So, by no means can this be considered a comprehensive overall view of, um, what is promised in the title page, you know, knowledge, unknowns, and paths forward. Yes, it's that, but it's not comprehensive, it's partial. It's more like a weaving with some, you know, before you put together the different patches in a kind of a, uh, what do you call those blanket, blankets? It's with all these p, quilts. Quilts. So, you do one, you do another, you do a third, and then you decide how they're going to go together, and you, and this is really, uh, this is, as I was putting this together, this is the style. It was, well, there's this piece, and then there's that piece. So, let's see how they come together. And your questions are welcome at any time. Anytime you feel you want to raise your hand, or I know you just did right there, maybe it's not a question, but I'll be observing like a hawk. If there's a movement, I will, I will look in that direction and decide whether it's a question, but I'll do it very quickly, and then feel free to do to, uh, interrupt or ask questions while this is going on.

So, rather than start with a, a definition, people often have a definition. Coercion is this, is defined as that. Here's examples of coercion. First of all, we have involuntary psychiatric detentions, often called civil commitments, or, you know, involuntary holds that extend into longer holds. Uh, that's one, and every state has one. Every state has a law that regulates this. All 50 states and DC, and even the territories, Puerto Rico, they have a law on involuntary care. It's the oldest mental health policy in the world. It's the oldest mental health policy in America. Nothing is older. Nothing is less evaluated than involuntary care. I want to repeat that. It's the oldest policy. It's the least evaluated policy. We have seclusions and restraints. Seclusions, you leave a person in a room, they cannot leave. If you tell them they can't leave, the door may or may not be locked, so they're secluded by themselves. Restraints are mechanical restraints, belts, cloths, handcuffs, or so. Restraints are used widely in the, in, um, not only the field of mental health but in, um, in, in the healthcare system generally. Restraints are used with, um, people with dementia, with people who might be recovering from surgery, sometimes who are confused. So, restraints are often difficult to stick mostly to the, the mental health field. They're used very widely across the healthcare system. So, they're their own special class of involuntary form of care. They're hard to, to discuss overall, but they're, they're part of the, of the scene. Seclusions, no, are mostly leaving a person in a room and making sure they stay by themselves. That's typical to mental health, uh, work practice.

We have orders for involuntary treatments, or ACT, that is usually, I call it order for, which is that you offer or want to give a person an injection or a drug. They say no, and you, as the practitioner, the physician, believe they really deserve it. It would help them. It would be good for everything for them, for you, for the system, for their future. And so you say to them, "If you do not, uh, uh, take this drug, then I will go get an order, and no matter what, we will forcibly administer it to you." So, we have, we do that, or we, we dispense with getting the order. We just do it. And every single state, no matter what the exact reading of the law says, has a provision to do that. That is the, the, the physician can decide exactly to do it based on their decision. And so, it's not like you have to go to court, like California, in the law, you can't, you can't. Everybody says you can't forcibly inject someone with a medication. Actually, you can, and it's done all the time. But in principle, you're supposed to go and get an order for that from a court, specifically to do that. But it's done, it's done anyways. And so you have that. And not only that, but ECT, if I'm not mistaken, ECT, electroconvulsive therapy, electroconvulsive, the, uh, creation of an epileptic seizure with electric shock through your, your brain, is, um, is, is still forced. In fact, the last case that I was aware of was, was in Wisconsin just a few months ago. And also, you have guardianships and conservatorships, where you take over the control of someone's finances and, and so forth. So, and, and, and you make decisions for them. And so these, you could see this, this is what we mean by coercion.

What do they all have in common? Then you maybe come to a definition at this time, where I guess it's either threatening to use force or using force to make a person do something they either have objected to, uh, you know, said no to, or, um, have indicated that they, they don't want it. Um, so that's really what it is, simply. There are many other definitions that are debated, and we can go now to just, uh, what it's not. What coercion is not, is persuading, persuading someone, bribing someone. For example, I'm a big proponent of offering people money to do the things that we, that they refuse to do. We should bribe them. It's not actually, it's, it's studied. It's like, you know, this economic incentives for behavioral, economic study, the worth of different incentives, and, and maybe we should pay people to do this or to do that. You know, it's not been discussed so much as far as mental health, except for some people to keep them on their medication, to make sure they stay. That's been discussed a little bit. We, we should give people money, offer them money to do that, and it appears to change behavior. That's not coercion to me. Although some other people argue that it is coercion, especially if they're poor. So, if they don't have the money, the money might mean a lot more to them, to these people, than it might mean to someone else. And now you're playing with this sort of imbalance of power. So, it's like, you know, if you're, these experiments they would do, and they would have kids from, with families with different incomes looking and estimating the size of coins, and the children from low income would, would overestimate the size of the coin. It was just bigger than it looked. So, you could see that built into their condition, to their socioeconomic condition, could be a way to look at things that you could say, are you coercing them? Are you leveraging? But I personally go on the side of saying, any kind of seduction, appeal to flattery, so forth, which moves into lying. But nonetheless, it depends. When you, when you think about it, when various philosophers think about it, they debate what is it? What is coercion? What isn't it? And you can get very deep in, in the weeds.

The other thing is, if a person is not protesting, if they're unconscious, there's no coercion. If a person does not say no, even if they're mute, and again, that's that's a qualitatively, if they're mute, if they're not saying anything, they are not protesting either with their speech or their behavior. There is no coercion if you just do what you want. So, I, other people say no, if they're mute, maybe it's the style. Maybe they're feeling overwhelmed, or they're, you know, odded by the situation. Yes, you're right. But again, at some point, you have to draw a line. And personally, I don't draw the line for that. So, I'm in favor of almost anything that seduces meaning because, you know, this is, um, I'm forgetting his name now. Was a, uh, famous, uh, historian and philosopher of language and literature who discussed what happens in a social group when the unity of the social group is threatened. And when the unity of the social group is threatened, this particular person, I believe, whose first name starts with Robert, says, well, you can persuade or you can seduce the members that are threatening the group, or you can coerce. There are no other choices. There is nothing else. You either persuade the conflicted, if you will, conflicting party to join or change the method. You try anything, or you coerce them. And if coercion doesn't work, you kill them. That is, you exclude or kill them. This is the way that that fellow who studied many societies and many instances came as the principle, the only principle to maintain group cohesion, nothing else. So, it's good to think about these, these, these ways. And other people include fraud as part of coercion. Fraud, meaning lying, misrepresenting the nature of the service. "You are suffering from an incurable disease that will require lifelong treatment with drugs." As far as we know, that is not true. It's nice. It happens often, but it's not exactly true. And so that's, that's misrepresenting people in a vulnerable state to follow certain things you would like them to do because it would make things better for everyone else, and maybe themselves too.

So, the complexities when we come to that, that's very easy to say how complex this topic is because, first of all, we've always had coercion everywhere, every country around the world, every season, except maybe in some antiquity. And here, we do have to give some debt to Michel Foucault, who did very nicely go over all the subtleties of the history of how we treated mad people, which we eventually called mentally ill people. But there was a toleration in some places. Madness was not just seen as a possession by the devil, and then it moved to a medical model or a legal model. It was also seen as just a form of a being, really, just a form of being that could be tolerated if you had the power, or if you could be alone enough, if you could isolate yourself, that if you didn't disturb others, they would still know what you were doing, and they were curious about it, and sometimes, you know, just very intrigued, but they wouldn't persecute it in some way by in terms of excluding it or, uh, locking you up or stuff like that. So, there are many, many attitudes, but it's always been there. Always been there. So, it's something that's ingrained. And the other thing, I think I have it at another slide. You could never sell no coercion. There is no public anywhere that would accept no coercion for mentally ill people. They just would not. In my view, there's no place anywhere, no matter what the United Nations has been saying in its, in its, uh, for now 15 years almost, the Convention on the Rights of Disabled People and so forth, that was ratified, signed by 156 countries, including the United States, which did not ratify it, but many countries did not ratify, but they signed and said that, um, it's wrong, any any coercive measure that distinguishes people on the basis of mental illness, which is what all the commitment laws. You're not committed because you're dangerous. You're committed because you're dangerous because of mental illness. So, you could be very dangerous. You could be like, what was his name? Evil Knievel. You remember, you know, he would fly over the, the buses in his car at 140 miles an hour. And, you know, all those people who emerge out of these tricks they do with a broken leg and everything, that's very dangerous, sometimes they kill other people too. And so, um, but that's not considered, uh, grounds for commitment. It's very dangerous to self or others, or self, and so on and so forth. So, again, the idea that we're going to separate people on, it's like on the basis of illness. If we consider that it's a real illness, which I don't, but if we do consider it's a real illness, then we're discriminating on the basis of illness. We have two categories of people, ill people and non-ill people. Two, two legal categories, two rights categories. So, you know, these are inconsistencies and part of the complexities of looking at coercion.

So, we've always had it, and we, we, we compassionately defend it, and we might always ask, "What would you do in your own family if it came to you?" So, it's easy to criticize about others, but what if it, this happened in your own family? Well, it often, usually does happen in a family. That's where it happens. That's where the crisis and the really heart-wrenching issues are, is when, when relatives have to, have to make these decisions about their children, or their parents, or their, um, uh, adult, uh, brothers and sisters, or relatives, or siblings. That's when the, uh, that, that what I call, that, you know, a wordy, this nexus, the center of where social solidarity intersects with individual liberty, very, very complex situation. So, so it's hard to study dispassionately, and it's good for people to, to say upfront what they think about it, so that you know, you, because it's hard to keep your, your bias at distance as you're looking at the topic. That's why it's complex. And of course, it could be studied so many different ways. It's like studying, say, racism. You could look at perceptions, you look at ideals, you look at practices, you look at laws, you look at customs, you look at breaking of the laws. There's so much about how rules are not observed actually, and it's, you know, the, the illegal commitments, informal commitments, all these things which are, are not looked at. They're barely discussed, except a bit more like by journalists, as I'll show you in a, in a second. So, complex this way. Um, what else can we say about it? Oh, yes. So, other things we know without really knowing them. Uh, I've mentioned some of them. Most people think we need more of it nowadays. In the opinion polls, and I did gather, I had these slides with results of opinion polls, but in the interest of time, I just kind of cut them off. But overall, about 60 to 75% of people, when they're queried on that with fixed answers, you know, and fixed questions, they, they are in favor. They're given a vignette of someone losing control and not showing up to pick up their kids at 5:00 p.m. when they're supposed to, and they have a mental health crisis or so. And so they, they're given all kinds of things, or they're threatening, and people given all kinds of options. The respondents say, "Yes, we, we need some more involuntary measures." Other people believe that we don't have any involuntary commitment laws, that people cannot be committed. That we used to do it, but we don't do it anymore, or it's impossible, illegal to hold someone for more than two, three days. They really truly believe we can't hold someone for two, three days. And you'll see, you'll see what we do in a second. So, we can, it, people have, uh, beliefs that, that are wrong, but they, you know, this is what they hear, or this is what they've experienced great difficulty committing someone in their family, let's say. So, it's a very, very complex issue. And then, or, or some people say, "Well, it's a medical thing. It's not medical." Nothing medical about it. In, in medicine, um, giving care against consent is assault and battery. In real medicine, it's assault and battery. People sue their physicians for providing benign care when they did not want this care. They sue them, and they succeed. Absolutely. The law respects that, most cases, despite what you hear in the large issues around vaccines, around tuberculosis. So, you hear of these, the contagious situations where you, you see the public interest to sometimes compel a medical treatment, but in the individual situation, the, the physician's judgment, in other words, the, the, what's the word, the justification for the treatment is not how sick you are, or that a treatment exists, is that you consent. If you don't consent, it can't be done. So, it's not just a medical issue. It's an ethical issue through and through in medicine. In mental health, we, we say, "No, it's, it's just a medical issue." It's less, less of an ethical issue. Actually, it seems that way sometimes. The medical aspect seems to take over the ethical aspect that exists, the ethical space that's given to it in other branches of medicine. So, there's this kind of strange inversion of, of, where ethics fits. And, um, so it's the pediatric model. It's not like a medical model which rests on consent. Pediatric, to your child, for their own good, kindly, but you coerce them to take the, the medicine, or, or do what, you know, they should do for their own good. So, it's a pediatric model. So, so now I'm going to come to a few things. I don't know if there's questions, comments, but let me, let me keep going.

This is something that most people don't think about, but this is recent, at least talking about it. This is an article from September 2024. So, just a year, uh, a year ago, less than a year ago. And this is the New York Times. It's all over the Wall Street Journal. This is Acadia Healthcare. These were 19 states. I don't know. Do I, do I get a light? Do I get a little button? Oh, yeah. You can see it. Great. Thank you. Okay. Well, in at least 12 of the 19 states where Acadia operates, Acadia, by the way, it is, um, it's, it's, it presents itself as just award-winning, the best care in America. So, you know that it's never going to admit to wrongdoing. And it didn't admit to wrongdoing, though it settled with the Justice Department on this just a couple of months ago, millions and millions. But, um, essentially, it's really a major, well-regarded chain of healthcare. And what they did, what they did is that some of its success, you know, the stock price has more than doubled since the pandemic. New York Times investigation found that some of that success was built on a disturbing practice. Acadia has lured patients into its facilities and held them against their will, even when detaining them was not medically necessary in 12 of the 19 states where it operates. Dozens of patients, employees, and police officers have alerted the authorities that the company was detaining people in ways that violated the law, according to records reviewed by the Times, and so on. In a nutshell, some patients arrived at emergency rooms seeking routine mental health care only to find themselves sent to Acadia facilities and locked in. As you read the article, and again, the investigation through a whole bunch of journalists from several, several newspapers to various Acadia facilities in various states. I myself was interviewed for this article because I had been hearing about Acadia for 15 years, and I had passed these on even to the Department of Justice, to these things, and nothing was done until New York Times put a couple of journalists on it, until, until then, we get an article like that. But the fact is, you know, these things happen. And, and what does it mean? It means that records were falsified. All kinds of diagnoses were invented. All kinds of justifications were made. All put in the records, and, and, and, um, would it work in any other branch of medicine? I just want to ask that question. Would, would we, you know, would this kind of work if we didn't have journalists looking into it? Could we, could we, could we fake records for cancer care, for, for other kinds of care? I don't know. The more I think about it, I think it would be very difficult. There's something about the way we practice mental health, the way we understand mental illness, and the way we think it's a disease, but the way we don't validate that and just use the say of professionals who can decide what the diagnosis is, and it's just their say. There's no validation of it. So, it's just their say. So, if they say, and it goes in the records, that's it. That's all we need. That's all the outside person that's looking at this or paying the cost. That's all they need is it's in the record. There's no other checking needed, necessary, or possible. It's just what is done and said that counts as the reality of how we treat it. So, it's easy to falsify and so forth. And the biggest cases, there are many, there, every 5, 10 years, we get a big case like that. There was one of New York Times, police officers after 9/11 that built the system very powerfully with again, completely made-up diagnosis, made-up visits, made-up interventions, and, and you find that is very easy in cases of mental health care. Very easy to just make up whatever happened, when they came, what happened, what was the diagnosis, what was the followup. It's all hearsay in the record. So, it's, there's something about that. But the fact is, a lot of that was going on.

Okay. Also, something very important about that is when this, these articles appeared, people started to write to the newspapers. For example, on September the 1st, while the window was open for people to provide online comments, they wrote, and many of them, for the first time that I've seen, very openly putting their full name, saying, "Here's what happened to me. Here's what happened to my mom. Here's what happened to my daughter or my cousin." And they would just describe whether it was an Acadia facility or many other, just, and of course, the Times published it. There's at least a dozen companies that are named by people that are writing letters. First of all, the unusual thing is they're coming out and saying, "This happened to me," and they're putting their full name. I had never seen that before. I've been looking at the public reactions to situations like this. It's a sensitive topic, a lot of stigma. And so, very unusual. It tells me something, just like was changed. Something was changed. Something in the air that people felt, "Hey, this is important enough that I'm going to say what happened to me." Some of them. So, let me continue.

Oh, so why, what was not mentioned in this article? What was not asked? So, what was, at, what was said, by the way, in, in 80% of the thousand comments that were sent was, "You never mix healthcare with for-profit business. Should never do, do that. It's a recipe for disaster. It's going to just create those things. If, if the people who are responsible for giving us our care are driven by making a profit, then this is what's going to happen. We're going to lock people up for profit." That's what. But there's one or two who said, "Hey, that happened to me in a public institution with no." Just one or two. And so, how that's called an illegal commitment. So, how often does that occur? Well, this fellow Rob Wond, this is his, he gives us, this is his answer. Illegal fraud. That is what happened with Acadia is the norm. He's a journalist. He says that's the norm. What happened there is exactly what happens everywhere. Interesting. Really? How, how does he know? What, what's his evidence? So, his evidence, and this is from his, when did he write this? Very recently. January 29th, 2025. And this is, I think, a Substack, Substack page. Here's a, so it appears on the line if you've got his name there. Rob White Pond. He says he talks about Acadia, and he says, you can see the subtitle: "Two More Investigations Again Reveal Systemic Abuses of Patient Rights." So, Acadia, he discusses, he goes into detail as to what's going on there. And then he says, he talks about the Veterans Health Administration. That goes on a lot at the Veterans Health, the VA administration. They're doing that too. How come? There's a report from the Office of the Inspector General as a result of a number of complaints by people who walked in looking for services and got locked up at the VA. And it was detailed enough and made enough noise that the Inspector General sent a team to investigate. And you should read the report. It's enlightening. It's exactly what you read about Acadia and those stories, except it's in the VA. People walk in with different kinds of issues, and with the records are, you know, there's, there's a statement that they're okay. They're requesting voluntary admission. Uh, they're requesting admission. They're cooperating, but then they get locked up under the, the involuntary law, and they get held and held and detained longer and longer, and they leave, and often, as we see, they commit suicide, as the one lead case that was highlighted in the Office of the Inspector General's report. Not only that, the ombudsmen and the advocates that are supposed to get the complaints do nothing with them. And the IG documents that this is occurring across the Veterans Administration. There's no oversight. There are, the complaints go nowhere. There's no idea of how many people are even making a complaint about anything. So, there's no noise. There's no signal that something could be going wrong. Maybe people complain, but the advocates who are often peer workers don't bring it up to anyone because they don't know who to discuss it with. The sense is, no one wants to hear about it, so no one hears about it. So, this is the veteran's health. And then Rob, who's Canadian, says, you know, well, it, it only also happens with our neighbors up north. So, Prince Edward Island, that's PEI, which is this province. It's the picture. It's like the charm of, of your Pacific Ocean right here. It's just peaceful, bucolic, lots of cows and strawberry patches. It's really, really beautiful. Prince Edward Island, 180,000 people. It also has exactly the same situation. People, you know, with, it's only one or two facilities, but they have a law like we all do. And then they, they have, um, procedures you're supposed to follow, and complaints to be heard, and, um, uh, steps if you, if they want to hold you longer than three days, a form has to be filled and signed by two physicians and so forth. So, these things are not done. Again, a commission looks and finds and investigates and says, this is not happening. So, Rob concludes, maybe hastily, but concludes that, no, that what's happened in Acadia is actually the norm. But what, what is being done here is a hypothesis, a guess, is being stated that this happens a lot. The question is, my bet is, so what do we do about that? Do we test this hypothesis? Do we gather evidence to see whether the data fits with the guess or not? Or do we just kind of, it's unfortunate, I didn't know this happened, and anyways. So, so this is the situation. So, no profit mo, no profit, excuse me, motive is invoked in the, the other cases. And so, why, why pond says, "Hey, it's not, it's not about business." And he says it nicely. Oh, he says, he says, "It's not just about business, it's something else." And what does he say, which is something that I kind of mentioned about the subjective aspect? He says, "When there's no solid objective scientific grounding for psychiatric assessments," and that's arguable if there is or not, but he's suggesting there, it, there isn't, "the slippery slope from well-meaning but highly subjective commitments of mentally ill people to fraud, fraudulent commitments of mentally well people is essentially a cliff over which anyone can fall in any moment." Meaning that it's unclear. We, we might get a little upset about seeing that a mentally well person got committed, which is what, you know, the author of, um, *Robinson Crusoe*, if you ever remember that novel, *Robinson Crusoe*, the, uh, uh, castaway, you know, from the 18th century, Daniel Defoe. I don't know if your generation read books like that, those adventure books. And so, Daniel Defoe made, became famous by exposing the commitment of the illegal commitment of well people. And many, many famous writers and essayists of the early 20th century and late 19th century, uh, became famous by exposing the commitments, the forced seclusion and hospitalization of well people. And so, the question is, well, okay, what about unwell people? You mean, it's okay for them? But we see that unwell people might also be committed, it, for other purposes, and injustices result as a result. The point is, there's a statement of a relationship out there between concepts, between events, and we need to test, and we don't know. We don't know what's going on, and we need to find out what's going on because otherwise, we're misled to think part of the problem in the system is a lack of coercion, whereas we're misled to think maybe we need more coercion. So, unless the system gives an honest accounting of what it's doing, then there's no real way.

Let me continue on on this line here. So, why, why should we worry, after all, about coercion? What's the problem? Well, the problem is, number one, legally and ethically, it's, quote, you know, against the Constitution, unless it's done with real due process. It's a loss of liberty. And the Supreme Court of the United States has called it on two occasions, "a massive curtailment of liberty," unquote. Massive curtailment of liberty. So, it's okay. That, I get that. That's, that's serious. And so, we need to, to be sure that we, we care for how we deal with it. Uh, so, that's number one. And the second is the issue of harm. That is, it can hurt people. This is what they say, and we indirectly might be observing some of that. So, people say, "I was traumatized. This is so stigmatizing. I'm going to run away from the, the mental health system." So, this is what's collected in, again, a number of articles, qualitative and reviews of the literature, which by now must number about a good dozen. Many of them have just come out in the last five years. The last five years, there's a lot more interest in the topic than I think there used to be, maybe it, it spikes. But the last five years, we have many systematic literature reviews, we have, uh, you know, scoping reviews, both of, of analyses of what happens after commitment, and analyses of what patients, ex-patients, juveniles, older people, um, uh, gendered, uh, individuals, and so forth, say about having been committed, their own personal perspectives of the issue. So, we have a lot, and this is what comes out: "Traumatizes me, and I'm running away from the system as a result. I'm not going back. I'm not, I'm, I'm avoiding what is going to be either offered to me or pushed on me again the next time." So, I'll, which could be a good thing. It could be a good thing for them. It might be a very good thing.

Leads to independence. Leads to other things. Or it, it may not be good. It may not help them, actually. Um, so, so that's that.

What's one of the things I want to focus on for a few minutes to highlight some of the research issues is the risk of suicide. Tally, how am I doing for time? I keep looking at my watch, but what, what I lost track of time. Oh, Max. Max. Beautiful. We're, we're coming close. We're coming close.

But at least now, let's get a few little facts and figures and graphs for the, for those of you who just love that stuff. Um, so, yeah, what are its outcomes? What does it actually do when we study it besides, you know, what people say? These whole bunch of anecdotes we gather, you know, in our grounded theory approaches, put all these sayings together and come up with a conclusion. Um, are we saving lives? Are we actually saving lives? They're threatening to, to commit to self-harm, harm other people, commit suicide. Are, are we saving lives?

There is no study. Well, we'll see. There is no study that can answer that question yet. Not one has, in my view, attempted to answer that question. Does it work for its intended purpose? If we say, "My god, we, we, we need to say they're, they're, they're committing. They're going to do something. So, we need to do to respond." And that's our response. We commit. They're committing to kill themselves or to, they're threatening someone else. So, what, what is the result? What is the outcome of our action? Our response, which takes a lot of police and healthcare resources and ambulances and so forth. So, what, what happens? We don't know. We don't know.

However, it's well known that after a hospitalization, people tend to kill themselves much more often. So, what kind of hospitalizations? Let's see first. But what, how much more? So, this is one study to illustrate just one. First of all, let me go back to the previous slide. This, uh, large Matthew Large is a, is a psychiatrist in New Zealand who has studied the issue and he's good to read. This is one of his studies and there are many others. You find them, um, they're, they're meta-analyses. They're systematic reviews of, of studies that have looked to see what happens to people within a set period of time after they are discharged from a psychiatric hospitalization.

So, I'm going to use an example of two Danish studies. Why Denmark? Why Danish? Because they are, um, Denmark is a country with more data on its all of its individuals, on their previous history even before they were born, on what happens to them throughout their lives, and on mixing all the databases of everything that happens to you in, in one way and making it accessible. Well, I guess if you have permission, they will make it accessible. If you're like an insider and properly ask the questions they like to be asked, they'll give you access to that. There's no other country in the world that answers it, that can answer it as well as the, the Danes. They have such a system of data. It's just, it's incredible. If you're an epidemiologist, it's like having gone to heaven.

And so, this is one study with the entire population of Denmark from 1996 to 2009. Is that a question you're having? Yes. Yeah. Is it, is it all involuntary? Nope. We're coming in this study. Yeah. Let's, this study does not distinguish between voluntary and involuntary. We're, okay. And it's important whether, okay. This is the first study. It does not distinguish. It just says psychiatric treatment. So, what does it mean on the, you love using this on, what they do is they just looked at all the people who had committed suicide during 1996 to 2009, and they can tell the death records and everything, and they looked at all the people who had been, and then, and compare them to a control group. So, there, and they came up with something like, I forget the number, 3,000 something or so people who committed suicide, and then they got a control group of citizens born in the same year, of the same sex, same age, and the same year of either entry into the data set or leaving the data set, or they really matched them very well. They had like 3,000 people who committed suicide and about 50,000 controls matched. And then they looked at, um, what they looked at all the people who had been, had received any kind of psychiatric services in Denmark during that year, kind of cross-gathered all the data sets and were able to tell you what was the risk of suicide if you'd had zero psychiatric treatment or medication. That was the baseline risk. It's one. So, if you had no psychiatric treatment whatsoever, your risk of committing suicide was the baseline risk, which is numbered in this study as one.

If you had psychiatric medication only, your risk went up to a fairly eight times more. It was about, actually 7.8. Eight, 7.8 times the risk of committing suicide. Just, you know, that's just an association. Let's wait to see what that could mean. If you had at most outpatient treatment, the risk now is moving to 16 times the base. If you've had at most emergency room treatment only, the risk now is about 46 times the no psychiatric treatment risk. And if you've had hospitalizations, the risk goes to about 94 times. So, it's 94 times the risk of committing suicide after you've been released from psychiatric hospitalizations compared to if you've had no psychiatric treatment whatsoever.

So, that's just an association. This risk you see here is after they put in all their matches, when they just did a univariable, you know, just looking at psychiatric, psychiatric medication only, and the risk of suicide just by itself, the risks were much higher. For example, the risk just with no matching, this was about 140 times or something. But when they put in the age, the sex, the neighborhood, the social class, or whatever else they were matching with, then it, it, it brought the risk down because there are other factors that play into suicide. But that's it. That's what they found. Uh, you have a question, please. Most important factor is what? How do they control for the level of severity? They looked of, of what? Of, of psychiatric? They, they didn't do that. They just looked. That's, that's the issue. So, so wait, wait, wait. That's exactly. And all that they did is they looked, what's the risk of suicide according to level of psychiatric treatment? They actually have about a dozen controlling things, and I don't know if severity was one, but diagnosis was one. They had several kinds of other controls, and this is, this is the final when all the controls are put in, when you control for what. It wasn't actually called severity, but there was a few, there were a few clinical controls, but there was also, are you single? Are you married? All these things played in. Are you male? Are you female? Male was the biggest risk. If you're male, that's the biggest risk of all. But just to tell you, they put in everything they could, but they didn't put in, was it an involuntary or voluntary hospitalization? They didn't do that. It's just hospitalization.

So, when they did that, then they concluded, they said they reasoned at, at one point they bring up, it would probably be wrong to conclude that the treatment causally increases the risk of suicide. Presumably, effective treatment would decrease the risk of suicide of an individual dying from suicide compared to a scenario in which that person did not receive treatment. Rather, the association is likely one of selection, in that people with increasing levels of psychiatric contact also are more severely at risk from dying from suicide. So, if you're more severely ill, severely suicidal, you're probably more likely to be hospitalized rather than just given medication. And so, then you might be more likely to commit suicide after hospitalization because you're more at risk of committing suicide. You're more suicidal. That, that's called a, you know, self-selection hypothesis or confounding by indication. They're being treated for exactly what happens after the treatment. So, it's like, you know, independent, dependent, it's all the same. So, it's a confound. So, there's nothing going on.

But the bottom line is, wait a minute. In a way, what, what their study is, it's a test of whether the treatment works or not. It is, in a way, does the treatment work? So, just on the face of it, oh, it doesn't look like it, because this, this is a dose response. Low treatment intensity, lower risk of suicide. High treatment intensity, high treatment suicide. In a way, it's the first response to what they say, "Oh, presumably effective treatment would decrease." They just observe that it increases, and now they're just going back to, "Oh, but it shouldn't happen that way. This is wrong. This is not the way to think about it." Again, a test was made. They tested the hypothesis, and they explained the results by going before the test. Hey, they go back to square one. Hey, isn't that supposed to be the other way around? After they get facts, it's saying it's not that.

So, let's move on to the second study. And so, people have, um, uh, there's a controversy over this study in the literature. Editorials go back and forth, and people say, "Obviously, it's self-selection. It has to do with their condition. It's not hospitalization per se that is doing this." Some people say, "Well, it may not be hospitalization per se, but you could certainly say that hospitalization didn't help. At least hospitalization could have made it. That doesn't seem to have helped a lot. 100 times more risk? That's astronomical. It doesn't come near anything, say, between ethnic groups or other at-risk groups. It, it just doesn't come. There's no comparison compared to the risks after." And most of the effect is within two to three weeks after, but 80% commit suicide within the 30 days after discharge. So, and there's nothing about, is it, what kind of hospitalization was it? Oh, you have a question, sir. You're probably to address this, but this reminds me of the fact that alcohol intoxication and overdose is most likely right after people exit rehab for those that same time. So, that's what the next study found.

So, here's the next study. Still Denmark. I wanted to just show you five years later, many more people. Now they've got like 1.7 million people. And in my notes somewhere I have, uh, oh, it's, it appears right here. I can tell you just what they did. They did a little something different. They looked at all individuals born in Denmark between 1967 and the year 2000. It's a lot of people who were alive and residing in Denmark on their 15th birthday. And who had been discharged from their first inpatient psychiatric episode at age 15 or older. So, anyone who was born in Denmark, living in Denmark at age 15, and had been discharged from a psych, from a psychiatric hospitalization, they said, "We, I think we had." And then they matched each individual in this discharged cohort with, on age and sex, with 25 comparators without a history of psychiatric admission. They included 69,000 individuals in the discharge cohort and 1.6, 1.6 million matched comparators. And guess what? They did something that everybody said, "How come no one's doing?" They measured the type of admission. Was it voluntary? There it is. Was it voluntary, which was 94% were voluntary, or involuntary, 6%? Just a parenthesis here. That's the lowest involuntary rate I've ever seen in my career. Okay? So, it's so low, it's like maybe Tahiti has has such a low rate. A place you go just to kick back, I guess, might have a lower rate, or that low. But this is so low that it doesn't matter. Even if it's so low, at least they have that, and they can look at it. They can use that in the analysis. Guess what they don't? They don't discuss it besides showing that it's there. They don't discuss it. Said, I said, "Oh my god, where, where is it? We're going to get to it." No. Oh, it must be in the appendix. They have an appendix with data. Nothing. Nothing in the appendix. So, where is it? So, I write to them. Well, what you must, what a beautiful study. You must have results on that. No response. That's typical. That's normal. So, nothing. So, we don't know. We don't know what's going on here. They didn't look at the one thing that could begin to solve what, what does the legal status involuntary have to do?

And of course, what they find overall is they confirm that they looked at all these different mortalities. Suicide was 137 times higher the risk during the first three months than people who had not been discharged from any institution. 137 times. Again, they're confirming, and they're confirming self-harm is 94, 94 times higher. This is the ratio of, though, the risk of people, the division of people who have not been hospitalized with people who have been hospitalized. When you divide something with something else, it usually comes out smaller. In this case, it comes out very big. The, so the, the people who've been hospitalized are much more at risk of suicide or self-harm. They're also at risk for other things, but less all-cause mortality. And in their, um, psychoactive drug use and the diagnosis most associated with, not was the diagnosis least associated with was any mood disorder was least associated with suicide, and what was most associated was a diagnosis of psychoactive substance abuse. So, again, it, it may come in the whole substance thing is, is big in there. It, it muddies the water. It adds, but the point is, we got something, but it's not looked at.

However, five minutes left. But there is, there is a darn study that actually got into the weeds and did what nobody else still has not done. It was published October 2023, and it's from Pittsburgh, Allegheny County. And the reason I think it was done is because the lead author is a data analyst, Pim Wells, has got no background in mental health. Just saw something, was very intrigued, and just went to study it. No background in mental health. Zero. Just a data analyst. I think he was a management consultant for, I forget USB or something, or Kitty Swiss or something like that, and was just into, and that person has done the one study that I've seen nobody else in the world does, and it's not published anywhere. You may, you may hear of it for the first time ever.

And what that person did is they took the 3,700 people who were committed in Allegheny County, who were involuntarily committed, and they followed them. That's them in black here, and that's mortality. He looked at all-cause mortality. But who did he compare them with? He didn't compare it with a general population. Actually, yes, he did. The general population is in yellow. He compared them with cohorts where we would expect high mortality, like people released from jail, like people who are living in shelters, and people on food, uh, food supplements, the SNAP program. He looked at vulnerable populations and other populations that are released from jail. They're often at risk. There is a higher risk of all-cause mortality. And he looked at them for, I think, five years later. And get, so he, this is, this is not only is it a study that has, you know, separates between voluntary and involuntary. It's really going so far out. It, it's a real, to show you my age, it's a Star Trek study. This is very, very interesting. And finds that the risk of those people dying is much higher than any comparable group in an urban setting group exposed to the same kinds of risks and drug use and etc., etc., and diagnosis. And he has an SMI group in there too. He even compares them to a, he went to the Medicaid and looked at all the SMI, serious mental illness diagnosis, psychosis, recurring depression, and he compared them to those people, and much higher. And what's the difference between them? As far as we can tell in this one study, they were committed. They were legally committed. That's the difference. They're, they're part of all these populations, but those, they were committed that year. So, that's the only study. So, now we have a bit more than a hypothesis. We have also a test that there's some relationship probably between coercive measure and a bad outcome. But it's temporary. But it, it compared to the masses of studies that are repeating the same, whatever this is, a drop in the lake. It just disappears instantly.

So, what else? I should stop now. Right. Social work. Social work. Let's go. I was going to talk about my study, but it's just maps and things. Social work. Well, social work. Yeah, we're, I guess many of us are social workers in this room. So, and you know, I've seen a hundred times people make some suggestions or talk about a, a pet project they have or a topic they're studying, and then they say, "Social workers are uniquely qualified." And then they go on to describe whatever they've been talking about. Whatever it is, whether it's birthing cats, or whether it's, you know, uh, you know, handling eggs, or whether it's, uh, uh, you know, doing things with people a certain way, whatever it is that they've been discussing, we continue with social work or uniquely qualified to, and fill in the blanks. And I, I, I can't resist the fact that so, what, what could we be doing? I didn't discuss some of the findings that I wanted to just the last ones in the sense that there is really no accountability. The public doesn't really care. No one really cares about this topic, truly. They care about, okay, how does it affect me or my family or, but they don't really care about it in the, in the big picture. Do we need, you know, they, it's not something that moves them all the time for most people. For others, it's, that's all they live with. But we need a bit more.

Um, so, what do we do as social workers? Well, we tend to think that that what we mean by mental health and care is being allied to someone, is collaborating with someone, is, it's really that the relationship is supposed to be collaborative. We're aligned with them. We're on the same, at the same height. We empathize, and we, we do it collaboratively. We, we review the objectives so that we agree as to what will be done. We may not do it often enough, but that's what we do, and that's what we should do to get informed consent so they know what we're going to be doing with them, and they agree. And so, that's something we're, it's kind of, we say in our DNA to do. And so, for that reason, I really think that, and especially I think with the coming administration, the coming, the current administration, um, in, in the federal government, which for the first time, first of all, has, uh, talked about assessing, there's been some executive order, but assessing the harms of psychiatric drugs, which is the first time ever, and that's, that's something else that, um, we could be discussing here today. But one of the things is that, uh, we need to invest and investigate all the non-coercive stuff that's out there, all of the alternatives and options. We need to be really investigating that. I think that this is the time for some really good studies. They don't have to be controlled, uh, randomized control trials. You can't quite do randomized control trials with an outcome in involuntary care, but you could observe. You could do well, good, well-controlled studies if you want, with, um, just by following people, by accurately documenting what is happening to them and what the outcomes are. For a lot of things, a lot of things, when you look from a big picture, seem to work very well. We just need to understand who they work for. A lot of people have been saying this, we say, you know, we need to understand who this works for, who this helps. Well, we need to think that way about things that are not coercive. That is, things that are all the, I've, I've put a list here of different things that people talk about, both peer respites, or peer workers, or, or people that are hired to, to take your place in, in your, in the family for two, three days. We could put a lot more resources to helping these things that make a difference in a person's life for a moment, just because they think it might be helpful, and then we can test whether it's helpful. Because things that we think might be happening, as I tried to show with my earlier slides, things we might think are happening, or might not be happening, things we might think are not happening, might be the norm. We're not really sure what's going on because the states do not release data. Only eight states give real definitions and counts, just aggregate counts of how many people they commit. The rest just give you this, this stuff that you don't even understand what exactly it is and what it means. It's hard to use. So, there's no accountability. There's no oversight. There's no demand for anything. We don't have commissions of inquiry. Every, maybe every 10 years, we have some commission of inquiry that looks at these things, but there's no real oversight of what does happen at the moment when decisions are made whether to hospitalize or not, and, and people will then be left with the consequences, good or bad. We, we're not there. We, we just rely on what the professionals say in the records, and then later on, when there are, say, legal, uh, issues, then people start looking at the records, they get more testimony, and then a different reality comes out. So, I see lots of arms waving in the back. And so, therefore, um, that's something that we really ought to do in social work, that is not done with other professions right now. No one's studying this. Almost no one. Those who are studying it don't have any money. And I think that the, um, I actually happen to think that a lot of this will be very responsive to, or the, the federal agencies that are getting hacked now, uh, on different topics, might be responsive to stuff like that at this time. So, anyways, thank you very much. Um, until next time. Thank you. Maybe there are some questions. I hope there are some questions. The food's not getting cold, right? Does it matter? Yes. Yes, please. Thank you. Rights Wisconsin 2000 Brad, and I just wanted to say, um, I appreciate that you're raising this, um, as a concern. I think a lot of people aren't aware that's an issue right here in our own state. Um, if you guys are talking about this in your classes, but according to 2019 data from SAMHSA, Wisconsin commits more people for involuntary mental health treatment than any other state. More than 43 per 1,000 people with a serious mental illness, and the average was nine per 1,000 seriously mentally ill people. And, you know, for such a mix, this is Wisconsin right here. Yeah. This is the rates from 200, uh, uh, yeah, 11 to 2008. It's, it's kind of, it's not the highest. It's not the lowest. Okay. So that's what SAMHSA, the data said. So that, I'm not sure that how that matches up. Um, and that wasn't emergency detentions. This was, um, voluntary commitments, right? So that might be some of the difference. Yes. Um, you know, I know we, we've had some really good things happen, like the expansion of peer respites. Um, and I just wanted to put out there, I don't know how many of you guys are following the state budget, but there's an opportunity now, um, to really get on board, um, and to push through full fidelity for community support programs, move to a full fidelity ACT program. That's so important. You all probably know ACT started here in Wisconsin, but yet, you know, in my practice career and all, everybody who taught practice career, we've never had folks in our state. So, I'll get off the soap box, but as a good social worker, I just had to talk to you all here about, um, some of those options. Thank you. Thank you. Um, I wanted to say about this, this is the, the data of the involuntary holds, uh, across the United States in 25 states that had available data. Florida, you see, is the highest here. It's about almost 1% of its population is, is committed every year, at least in that period. Wisconsin had among the best data, one of the eight states with the best data. Wisconsin and, and a few others. Florida had also among the best data. Colorado, Virginia, Massachusetts had pretty good data, and Texas too had good data. And the lowest at the time, if I, yeah, Connecticut had the lowest, lowest rates. But then we found out, this, this was replicated just last year with SAMHSA, and we found out that depending on who gives the data, if it's core data or behavioral health data, the, the numbers are very different. Because core data doesn't count those initial holds. It only counts it usually after then, and that cuts almost the rates in half. So, you need to know what state is giving you the data, like, uh, what, where the data is coming from for that state. The better place. So, in the study we just did, this is not published, it's just, just finished now, we redid this, we added a few more states, a few others disappeared, and then you see we grouped them into, is the data coming from health or social services or behavioral health, or is it coming from the court system? The court system on average is quite low, and in the behavioral health system state, it's double at least. So, they get more information, they count many more people, they count the initial holds, which we found can go from four hours to 31 days, with a median of about 10 days. We tend to think it's three days. Oh, 72-hour hold. We found on average in the states that gifted data, it's about 10 days that people are held. So, it's still, it, it just changes the picture. Oh, it's just a few days or a couple of days. On average, it's 10 days. Changes things a bit. That data is not available, but it'll be coming out soon. Any other questions, comments? Thank you very much, folks. Have some food. [Applause]