#13 - Exploring the Intersection of the Mental Health and Criminal Justice System [RICK CAGAN]

Chris Miller: And then I just hit the button, which means you're officially live.
Rick Cagin: Okay, good.
Chris Miller: In the dining room studio here in Lawrence, Kansas.
Rick Cagin: Oh, my.
Chris Miller: And it's been a little bit since I saw you last. We were drinking some coffee and some tea. Yeah. How has it been since then? Um, it's been good.
Rick Cagin: I'm just trying to live the good, retired life, which is not in the rocking chair, but busy doing stuff with you and other community projects.
Chris Miller: Would you have predicted you were going to be on a podcast whenever you retired?
Rick Cagin: No, because I think when I retired, I didn't know from podcast of my generation. I'm 72, so it's like, how do I get a podcast? Finally, I figured out how to get the app and started listening to them. So it's been very, uh, interesting. But no, I would not have guessed that people in my network were doing podcast and they were doing blog posts. I didn't know what all this stuff was.
Chris Miller: Right. What's your thought about the podcast so far?
Rick Cagin: Oh, I've been joining it. I listened to, uh, one of yours the other day. It was a short one.
Chris Miller: Oh, the solo episode?
Rick Cagin: Yeah.
Chris Miller: There's no real guidebook for retirement.
Rick Cagin: No. Uh, there's an old guy talked to just before I left my full time employment in 2018, and his rule of thumb was get out of the house every day. And so that was kind of a simple, elementary idea. But I think the most salient, uh, uh, you know what you're retiring from. Uh, but unless you have something to retire to, then you're in rough shape. And that was kind of my old man's dilemma. And he didn't make it very long, so I'm trying to stick around for a while.
Chris Miller: Yeah, I see that too. In my family, I have someone that I know really well, and they left their job, but they didn't have another plan after that. It was like they were just so excited to leave because they did manual labor. So they were like, oh, I can't wait. But then a week or two weeks after that, it's like, what do I do?
Rick Cagin: Yeah, you can only organize the garage but so many times, and, uh, so you got to have purpose. Uh, so I think the plight for a lot of people in my generation or my age group is isolation, loneliness. So maintaining the social connections and having been a person who didn't spend, uh, a lot of time in the community where I live while I was working, because of traveling and such, I neglected those kind of local, uh, relationships. So it's been interesting to cultivate some of that more.
Chris Miller: Yeah, I can really empathize with you because I was traveling as well. And then just recently, it's like, oh, hey, here's Lawrence. There's all of the people that we could talk to and all this opportunity that's popping up. So I'm glad that part of that for both of us is our paths being crossed. But you haven't always been in Lawrence?
Rick Cagin: No. Well, no, I mean, only since 2006. Yeah.
Chris Miller: And you grew up in the south?
Rick Cagin: I grew up in South Carolina. Yeah.
Chris Miller: Um, what's growing up in South Carolina like?
Rick Cagin: Well, interesting. I mean, segregation had a big impact on kind of my consciousness and just kind of watching it as a child, not watching kind of the conflicts that my parents and their peers kind of live through. And I was a Yankee kid, um, brought up in a Jewish household, uh, that relocated to South Carolina. So we were already kind of out of our element. We were already a minority, uh, in the white community. Uh, my parents were very I wouldn't say clannish, but they hung out with a lot of the other Jewish people. But their friends included people who were of Greek ancestry, lebanese and, uh, Roman Catholic, because Roman Catholics were not looked well upon in the kind of the Bible Belt of the things have changed there dramatically over the years. The experience of growing up there was different because of those factors.
Chris Miller: And when did you leave South Carolina?
Rick Cagin: Yeah, I left pretty, uh, much. My parents shipped me off to a boarding school in New England. So I was 14, which I wouldn't recommend parents doing that to their kids, but they were kind of both ups plus and kind of downside to that. But I was pretty much gone from the age of 14. Wow.
Chris Miller: So you show up to, let's see here. Where was it? Phillips.
Rick Cagin: Uh, academy in Massachusetts. Yeah. One of a few Southern boys.
Chris Miller: And it's way different there.
Rick Cagin: It's way different. I mean, you got a lot of blue bloods. Uh, but I got a chance to have a friend who was African American, from Charleston, South Carolina, uh, which is not my town, but just ironic that I had to go 1000 miles away to develop a friendship with, uh, someone, uh, who was black. Yeah.
Chris Miller: Because you go from the south to a boarding school in Massachusetts, and then you're looking at colleges and are you considering several different colleges? I know that whenever we talked, it was like the norm was you needed to go to Ivy League if you're coming from the school. Yeah.
Rick Cagin: There's a lot of kids whose families went to Ivy League, and they were kind of pinning their whole life on getting into Harvard, Yale or Princeton or one of the others. And if they didn't because their grades weren't good enough or their family didn't have enough pull, then they were contemplating suicide or something.
Chris Miller: It was everything to them.
Rick Cagin: It was everything to them. So, yeah, a lot of kids went, uh, to Harvard. I went to Princeton, but a lot of kids went to the other Ivy League schools, but not everybody.
Chris Miller: So, what's Princeton like?
Rick Cagin: It's interesting looking back, because historically, Princeton was kind of seen as kind of the most southern of the Ivy League and kind of catered to that southern elite. And so there was kind of a history there, uh, that I wasn't aware of at the time. The year that I came in 73, was the first year in which women were admitted.
Chris Miller: That's nice.
Rick Cagin: Yeah. So, uh, before that, of course, had been an all male bastion. It was a good education, and I think it was a good pick. I probably didn't take full advantage of it. Uh, I'm not sure anyone knows how to do that, but yeah, I think.
Chris Miller: Most people looking back on university, they're like, man, had I known all these things, there are so many opportunities that I could have done.
Rick Cagin: Yes, exactly. So I was kind of on a narrow path, which I had started in boarding school, of looking at psychology and kind of delving into that and doing volunteer work in mental hospitals and summer camps for kids with emotional distress and majoring in psychology, and to the exclusion, maybe, of a more kind of broad based education. Wish I had taken more history, political science, but yes, psychology, philosophy, those were very strong interests.
Chris Miller: And is there any reason why, you think, growing up, was there a certain thing that sparked your interest in those fields?
Rick Cagin: I can't say that there was. It's just, um, this idea of I mean, and, uh, it was very different in in 64 when I arrived in boarding school than it is now in terms of our kind of concept of mental illness or abnormal behavior. But I was just fascinated by it and just picked up everything I could read. But in those days, it was a lot of the kind of old school stuff freud and some of the people who kind of followed in his tradition. But, um, yeah, it branched out from there. And it was a good education, but wasn't sure what to do with it. Um, I left Princeton thinking, that all right, the path for me is a degree in clinical psychology. But there was only one place I wanted to go to school, and, uh, I didn't get in. It was a small graduate program in Tennessee and, um, that I think is now part of Vanderbilt University.
Chris Miller: Ah.
Rick Cagin: And I think, yeah, I actually applied a second time, but by then I was kind of off on a career path and so mental, ah, health and my involvement in those issues had to wait about 40 years for me to come back to.
Chris Miller: Wow. So you had said whenever you were in college, you volunteered at a mental health hospital.
Rick Cagin: Yeah, well, actually, I started that in boarding school. They, uh, had a volunteer program, and the taxi would come pick you up and take you. And we went over to Danvers State Hospital, which was an old school asylum, sitting up on a hill, very spooky, looked like an old castle with seagulls flapping around and just, uh, imposing, uh, kind of edifice. And they dropped me off at the volunteer office and they gave me a set of skeleton keys to go from one ward to the next. And I ended up in the so called ward for criminally insane. And not a whole lot of orientation. Uh, some people might not have come back, but I was fascinated by it. I did it for two or three years.
Chris Miller: And what were you doing when you would go there?
Rick Cagin: There's one guy I played chess with all the time, and, um, so it was kind of a circus in this ward because people were just milling around all day, just kind of walking around in circles, taunting each other. It was a very mixed group of people. Who knows what their diagnoses were? They were all, uh, heavily medicated. Those who kind of had more cognitive abilities would kind of torment and torture some of those who had less. But, uh, somehow I gravitated towards this guy that goodness knows what he or any of the others had done to end up there. But he was obviously someone who had been educated. And he invited me to play chess and he beat me consistently until one day I actually lucked out and beat him. And then I never heard from him again.
Chris Miller: He just didn't come around after losing.
Rick Cagin: Yeah. So I felt like, okay, what have I done? But I had no education or any clinical skills. It was just going there and hanging out and trying to be a friend. Uh, it's not like I had a job to do, feeding people or taking out the trash or anything. No, it was just hang out and just kind of watch, quote unquote, kind of the craziness of this place.
Chris Miller: Mhm. Well, he must have really enjoyed beating you. It must have done something for him.
Rick Cagin: I think so, um, because a lot of the people there just were not communicative. I don't remember any serious conversations, but we seem to relate to each other.
Chris Miller: Wow. So that's one of the things that I hope we get into. But it's the changing nature of these mental health hospitals or health care institutions.
Rick Cagin: Yeah, absolutely. Because when I finally came to Kansas, um, however many years later, I would say 50 years later, and getting involved in this field and, uh, it was a little trepidation about my first visit to a state hospital because I didn't know what to expect. My last experience in South Carolina, in New Jersey, and in Massachusetts had all been the kind of the old school asylum model, which thankfully, is history now.
Chris Miller: And there's a woman that you had mentioned to me earlier, but you said that she was the one who led a transition or a change to those old school asylums prior to that. They were what was her name again?
Rick Cagin: Well, uh, yeah, you can look her up. Uh, I don't have a lot of detail, but her name was Dorothy Adix, and I think she was from New Jersey. And, uh, this would have been 19th century, the standard of care for treating people who were experiencing mental illness. And we didn't call it that in those days. If you go back to the founding of the state of Kansas, the first constitution had language in it that said, uh, people who are insane or incompetent in some other unflattering terms were denied the right to vote. That was in the Constitution. Well, it was a different time, of course, because women and African Americans, maybe others, were also excluded from, uh, the franchise. Uh, and it wasn't until somewhere around 2010 that we were part of a campaign to get that language stripped. Well, actually in legislature toned it down, they took out the word insanity and put in mental illness. But you still had the prohibition against voting. So in 2010, there was a campaign which the voters approved a, ah, constitutional amendment to strip three words mental illness or out of that section of the Constitution. But going back to Dorothea Dix yeah, 19th century, different attitudes about mental illness and people were especially those who were afflicted by mental illness, who didn't have means of support, families, um, that could take care of them. They were assigned to kind of dungeon type of care, and you shackle them and it's just brutal kinds of experiences. And so, uh, Dorothea Dix, um, mounted a campaign which eventually Congress provided land grants to the states to establish these state mental health hospitals. Or they may have even called them asylums back in the day, but at least they were a standard of care above the dungeon. But it was still a confined experience and we didn't have medical treatment for mental illness. And so it was basically keeping people contained in a building and that was about it. There was no real treatment.
Chris Miller: Yeah. Excluding them from the general public and keeping them yes, contained in a, uh, separate space.
Rick Cagin: Exactly. And so you have that history that progressed over the years as treatments developed. And the big breakthroughs came, perhaps starting in the 70s, with the development of medications that could, uh, support people living outside. And so what started to happen about that time was this deinstitutionalization movement. You had promises made going back to the we now have the ability to transition people out of the hospitals, but, um, we don't have community based care. So promises were made, okay, we'll shut down beds in the hospitals and we'll provide community based support. It didn't happen. And so severe consequences in communities all across the country.
Chris Miller: So was part of that shutting down these asylums?
Rick Cagin: It was. And Reducing here in Kansas. By the time I got here, uh, there were only two state hospitals, and both in the most remote places you can imagine. I mean, Osotomy down in southeast Kansas and Larnet out west uh, not close to population centers. So let's move these people in the 19th century model, early 20th century model, let's move these people as far away from population centers as possible, created all kinds of problems, and that's what we're living with now. There used to be a state hospital in Topeka, and there might have been one other, but they were all closed. And so you vastly reduced the number of beds, and people didn't have the right level of supports. Still don't in many cases, but didn't have the right level of supports to live, uh, some kind of productive life. And so that kind of led us to what we call the criminalization of mental illness, mhm.
Chris Miller: Okay. Because the fix to a mental health crisis, since all of these hospitals were being shut down, and since it was supposed to be a more progressive time, the fix in the M moment was just take them to a jail.
Rick Cagin: Well, take them to a jail after they had committed some minor or more serious offense. But that was the predicament for, uh, people with serious mental illness. In many cases, they were untreated. Um, they didn't have the supports from family. They had burned bridges, lost employment, many cases homeless. So people get in trouble, they might exhibit bizarre behavior, maybe at, uh, two in the morning, so the cops will pick you up, and the alternative is we'll take you to jail, and maybe if you were lucky, you would find your way to the state hospital. So I think one of the things we said for a number of years, and I think may largely still be true, is that we had four to five times as many beds for people in the criminal justice system. In jails primarily, but also in prison, uh, for people with mental illness, as opposed to the number of beds we had in our state hospitals. And the, the message or the takeaway from that piece of information is not that we want to take all the people with serious mental illness or incarcerated and put them in the state hospital. We don't want them to be in institutional environments at all. We want them to be to have the supports, to get access to treatment, to have employment whenever possible, to have decent housing. And those things are missing for a lot of people. And so you're seeing incarceration rates of people with mental illness, or the percentage of beds in county jails could be 30 or 40% similar kind of percentages of beds in state prisons. People have gotten into trouble as a result of their illness, not had the treatment and supports that they need to be successful.
Chris Miller: Yeah. That is the pernicious cycle, right? It is, yeah. To go from developing severe mental illness, and then there's some crises, and there can be family trauma and separation, and before you know it, then you're homeless, and you need a place to stay. So you sleep in someone's garage and then you get arrested for trespassing and you go to the state hospital or you go to jail. Then they transition you to the state hospital, and then ultimately you leave and you may be with your family again. And then it can start over.
Rick Cagin: Yeah. And as you said, there's trauma for the individual, there's trauma for the family. And the family members for many years and still for many of them today, really don't know how to deal with the situation. Whereas society in general carries a lot of stigma associated with mental illness, which the individual who has the diagnosis internalizes. The family members who might be the people who could be a catalyst for some change carry that same stigma. And so they're aware of the kind of behavior issues for their loved one, but they don't understand them. They are fearful in many cases and calling out for help. Where can I send Johnny? Uh, in other words, let's get rid of him because we don't know kind of how to handle this. And so it's been as important as new treatments and access to treatment is for individuals who are affected. Education for family members is so critical, uh, because if we can get someone out of jail or out of the hospital and into community treatment, but their family still is kind of living with that stigma, perhaps not wanting to have anything to do with Johnny, then what are his chances of success?
Chris Miller: Right? Yeah. It's a paradoxical thing because someone who needs medical attention with this fear, mental illness, may not communicate that because of a variety of things, but particularly their family, they may feel embarrassed or they may feel ashamed. I know for me, and a big part of why Rick and I are having this why you and I are having this conversation, it's so funny doing this. You don't know speak third person or first person, you know what I mean? Because I'm talking to you. Yeah, but we know that people are going to listen. But I'm just going first person. But a big reason why you and I are having this conversation here is because I have personal experience with this. And you worked with Nami, the National Alliance of Mental Illness. You're head of the organization here in the state of Kansas for a stint, for some time. So you have a lot of background there as far as, like, the policy and the administrative side and the way that these things have changed. Now, neither of us are trained clinicians, and we're not pretending that we are, but it's something important to talk about. So you were talking about having a family that's supportive or educated and they're not being like a lot of those resources for education. So let's talk about Nami a little bit.
Rick Cagin: Sure.
Chris Miller: So how did you get connected with Nami?
Rick Cagin: Well, so here I am in Virginia in the 90s, got remarried to a woman from Kansas, and we lived together in Virginia for a number of years, but, uh, then decided to relocate here as the children started, um, having babies. So we both quit our jobs in Virginia and can move west. It's a different environment in the Midwest and Kansas, uh, than on the East Coast. Philanthropy is not as robust, and opportunities for employment not as robust. But one of the great opportunities that surfaced as I was looking for work was the position at Nami, Kansas, for executive director, which had been open for a few months. And fortunately, I was able to latch onto that at the end of, uh, 2005. So I moved here and, um, kind of worked for the organization full time until 2018, and then part time until just, uh, last year.
Chris Miller: Recently, yeah. You had been affiliated with government work prior to that?
Rick Cagin: Yes. Um, and no. I mean, my professional career was largely in the nonprofit sector. I did have a stint working for the Cooperative Extension Service in Virginia, uh, doing rural development in the early 90s. But most of my work was around advocacy, community organizing, managing nonprofit programs, and mental health was always kind of in the background, in the periphery. Uh, I think what I've discovered more since I've been working, uh, with Nami and that group is that mental illness really affects everything. It's just so pervasive. Um, but at the time, you would encounter I would encounter homeless individuals on the street in various cities that I travel to. I could see kind of the mental illness behind the homeless condition, but it didn't understand all of the dynamics, even, uh, though I had been through that kind of self education 20 years before. So I can only imagine how the average Jane or John kind of relates to mental illness if it's not in their family, and if they don't have that personal experience and kind of the history of public programs and how they relate to people with mental illness.
Chris Miller: Yeah, one of the things that you had mentioned that I got excited to hear, because it's a side of the house that I know that personal experience side. But one of the things that you largely looked into is the system side.
Rick Cagin: The system side, yes. Yeah. And I think one of the things we have said over the years is that there is not one mental health system. There are multiple mental health systems, and they're not very well integrated. Now, if you kind of look at the environment, you say, well, we've got a couple of state hospitals in Kansas. And so parts of this would be true for your audience who might live in other parts of the country as well. There's a state hospital system. There's some sort of community mental health system in Kansas. We have 26 community health centers that cover the entire, uh, state. Uh, but the VA has its own kind of system of care. And we have nursing homes, and we have, as I said before, we have more people with mental illness in jails and prisons than we do in our state hospital. So that's another system, uh, of care. And they don't talk to each other very well. And the continuity of treatment from one to the other is very, uh, inconsistent.
Chris Miller: And part of these systems, you have Nami playing a little role in all that. And I'm reading now largest grassroots membership organization of individuals living with mental illness in their family for over 40 years now. So there's over 1000 local affiliates in 50 states. And Nami, Kansas, has, whenever this is written, 13 local Nami groups.
Rick Cagin: Yeah, there might be more now, right?
Chris Miller: So nami. Is it's funny? Like, as we talk, we're talking about systems. And then I'm also thinking about experiences here, because one of my goals is for a while, I would talk to people about my family. And my brother was diagnosed with schizophrenia whenever I was, what, 1516 or 14. Uh, it was middle school, high school for me. And I remember that being such a turbulent time. A big reason why was because I had no idea what that was. And my mom didn't, my dad didn't, the rest of my family didn't. So I just saw all this stuff happening. And it's hard to be a bystander or someone who's observing whenever there is turbulence happening. And a few years into all of this, my mom heard about this group called Nami. And I was like, what is Nami? And she went to a support group. And at this support group, there was a whole bunch of other different people who were going through it. May not have been carbon copy to what my brother was experiencing, but were going through similar struggles with a, uh, severe mental illness that may be in crisis or their loved 1 may no longer live with them. They may be in a state hospital, they may be behind bars. And all of these people came together and they would talk about it. And on top of that, there were resources for them to use. And there's these programs like Nami Family to Family and Connections and these things that are intentionally designed to bring others together and to educate loved ones or even people who do have some, uh, type of severe mental illness on what all of this is. And one of my goals, my first goal, primary goal, is really just have a good conversation. But one of my goals here is to provide exposure and shine a light on Nami and what they're doing, because I know how important it was to my family and still is. Yet I would love for a family to listen to this and think, oh, wow, we could use that. We could take part in that. Because for some people and you had given me an example of, say, a 50 year old man who has been struggling with a mental illness, be it schizophrenia. And they go in and out of psychosis and they're living in their mom's basement, and now their mom's aging and she says, I don't know what to do.
Rick Cagin: Yeah.
Chris Miller: And the thought is, man, I wish you had come to us sooner. I wish that you had been aware of all of these resources. And these resources aren't going to completely fix people or completely change things, but they are going to give education support, which is important. So one of my goals is there are a lot of families out there who have people in their lives that have severe mental illness and they're scared to talk about it, they're ashamed to talk about it, they're embarrassed. And due to that, it's going to take them a lot longer to find resources.
Rick Cagin: Exactly.
Chris Miller: And hopefully one day someone will listen to a conversation like this. It doesn't have to be this conversation, but use it as an opportunity to learn about it. And then they think, oh, just in time rather than too late.
Rick Cagin: Exactly.
Chris Miller: Because a lot of times we hear about mental health crises being too late.
Rick Cagin: Well, yeah, I mean, it's a great story that you share about your own family. And I think one of the key points, uh, talking about your brother, for example, is that 50% of cases, um, of serious mental illness begin, ah, by age 14 and 75% by age 24. So what that tells us is that window of opportunity between 1416 and 24 is really the critical time. If we can engage those individuals early and get early intervention and treatment, their chances of success are phenomenally improved compared to the 50 year old person who's living in mom's basement for his whole life. I won't say his is a lost cause, but it's a very tough situation to remedy one, because he doesn't have, he doesn't live independently, he probably doesn't have employment, uh, history that's kind of adequate to support him. So I think one of the things we have to establish is kind of the need to normalize a conversation around mental illness. It's something we can talk about. And maybe sometimes people make comparisons to, uh, how cancer was stigmatized years, um, ago. Now we talk about it freely. Uh, AIDS, another kind of issue, uh, that was highly stigmatized. And a friend of mine back in Virginia, I am sure, succumbed to AIDS. But when you asked his family, uh, what happened to him, it was, oh, he got pneumonia and he didn't get over it, or something like that. So I think part of normalizing the conversation is to say that one in four of us will have some type of mental illness in any given year. So that doesn't mean a disabling condition like schizophrenia. But we all have mental health challenges, uh, all the time, and most of us kind of work through them. Loss of a loved one. Divorce, loss of employment. These are things that can trigger kind of a feeling of instability in terms of our emotional life. So what that really means is, over a lifetime, that's 100% of us. That's absolutely all of us. But when you look at conditions that are potentially disabling, like schizophrenia and bipolar disorder and major, uh, depression, post, uh, traumatic stress disorder, we're talking about one in 17 and about 6% of the population. Not a high number. But do the math. In your city of 50 or 100,000 people, do the math. That's a lot of people. And so what that means is that when in the faith community on Sunday morning or Friday night or wherever, when the religious leader is looking out over the congregation, if they're observant, they know, uh, who in their congregation is affected. They know the families who are kind of dealing with these issues at home. They know why certain people aren't showing up to worship. And, uh, so we really think that, among other, uh, venues, the faith community is a logical place for us to begin to try to reach families, uh, who are in distress.
Chris Miller: That's a good point, and that's I know something that you are working on locally, building a network of churches.
Rick Cagin: We're trying to, yes. We started a few years ago a project called Interfaith Mental Health Outreach, and we now have six congregations, uh, that are participating. And the point is really to provide some support within the faith community. Part of it is a recognition that the faith leaders in seminary or wherever they got their training, mental health was not a skill set that they developed for most of them. Um, and so they're like me and you, uh, they don't have any particular clinical expertise, but they see the pain and suffering. And, um, so part of it is to be a support within the congregation and to create a mental health team made up of advocates who volunteer to do some of this work and who get some training through a program called Mental Health First Aid, who are not tempting to be clinicians of any type. Their main job is to provide support and to make sure that people in the congregation are connected to resources for treatment, whatever is needed, uh, for counseling, for medication, for employment, for housing. Uh, and I come back to employment and housing, uh, a lot, because those are really, shall we say, the cornerstones of a recovery orientation. If my only choice as a person living with serious mental illness is to live in a facility, group home, nursing home, state hospital, or possibly a correctional facility, that's not a life. And the foundation to my having some success and achieving a level of recovery, uh, is based on being able to live independently and to have some means of support. Yes, maybe a disability ah, check is necessary to provide some means of support. But I could also work part time and, uh, that really kind of nurtures my well being as much as providing some needed income.
Chris Miller: Mhm, I think, uh, a lot about this stuff. It was funny. For the longest time, every time I would talk to people about my brother and the experience my family has had, I would always say this thing like, man, I really hope within the next century we're going to be able to figure out more about mental illness and mental illness research and really have a I mean, the golden word would be cure, but really have more, uh, wise choices and approaches to handle this. Because we see all of the tough situations and tough stories. And I know that here in Lawrence, whenever you go to the public library, I love that place, uh, shout out to a lot of the people who work there, but I will walk there and they have so many different resources for people who are homeless. And one of the biggest kind of factors with homelessness is mental illness or addiction disorders.
Rick Cagin: Exactly.
Chris Miller: And, uh, oftentimes the, uh, shelter and the employment is so important and especially when it's paired with like education and counseling and treatment, then that is a, uh, great system. It's just really hard to get it to them. So one of the things I wanted to do was I'll share a little bit of this story that I have in my head and that's whenever I grew up, I was the baby of four kids. But I always was four years younger than my brother. Three years or four years. And every school I went to, I was always in his shoes. So I'm not going to say his name. And, uh, it's tough. And this is something that a lot of people in a similar situation struggle with. For instance, I was looking at Lawrence support groups here and it's hard to talk about this stuff because you don't want your loved one to sound like a bad person.
Rick Cagin: Right.
Chris Miller: Especially whenever they are going through crisis, then sometimes they'll do something or they'll have an action that you just can't really pin on them. And all of the trauma that I experienced and that my family experienced, it's difficult to communicate because you don't want to disparage the other person involved, which results in less people communicating. It results in people not being vulnerable. And that is an antidote to community. That's not what we want. We want community, we want sharing. So the story that I have growing up, my brother was always the big dog. I was always in his shoes. Whenever I was in second grade, he was in fifth grade. Whenever I was in 6th grade, he was in 8th grade. And whenever I went to the high school, everybody knew him. So it was always, oh, your name's Chris. Oh, that means you are his little brother. And oh, how cool is he? He big skateboarder. He got really good at. It was always on YouTube, traveling around. Super smart kid. He was in the gifted learning, uh, kaleidoscope. He made it in immediately, whenever he was in first grade. I applied three times. I think they let me in at the end just to let me in. But he was in there, so I wanted to be in there. Super smart cat was involved in chess, chess club, all that stuff. But there was, uh, a moment to where things started changing, and he went from being this really smart kid to part of it was he was just a younger guy. He was involved with skateboarding, and there's a stereotype with skateboarding that there's smoking and drugs and drinking and like, juvenile activity. And some of that's true. I think skateboarding is a really awesome activity with great community, so it doesn't have to be true. But he got caught up with some people. So smoking, weed, drinking, and one of the things they would do is they'd go to door to door and just try or go to in the in the night, they'd sneak out of the house, walk down the road, and go to different cars and just try the door handle. And if it was unlocked, then they would rummage through there and see if there's anything of value. And they got caught a couple of times. They got in trouble, got sent to jail. And the whole entire time, my parents are like, hey, you need to wisen up. But one of the things there was, they take people's medication, and it would be a Valium, or a Prozac, or a Xanax, like, you name it, whatever that medication may be. And I think a lot of people do this, uh, I don't know how many, but I was talking to someone in law enforcement the other day, and they're like, yeah, that's a really popular thing to do. And whenever you take all this medication and you're not prescribed to it, I don't think that's the best thing for the brain. As well as smoking weed and doing all this different stuff, it's kind of like, uh, a whole concoction in your brain if you do it all at the same time. So I say all this just to say there is like, some stuff happening. But I don't know how it all happened. But what I do know is after a while, my brother stopped going to school. He didn't want to go to school. He stopped wanting to hang out with his friends, which was weird because he was this highly social person. And we shared a bunk bed. I was on top bunk. And it got to the point to where he would just lay in his bed with his hood on for days. And my parents didn't know what to do. My dad kind of functioned with the iron fist. So his whole thing was, if you're not going to school, then you need to go to work. So we got a job at, uh, some fast food places, but he couldn't keep the jobs, and he always ended up back on the bunk. And it led to this disagreement with my dad that was like, hey, if you're not going to work or if you're not going to go to school, then you need to live somewhere else. And he had to figure out what to do. And all the while, as this intensified, and as I was getting a little later into high school, there was moments where there was violence, and my brother would get violent and attack my dad. And I'm the little guy. I'm the little bro. And I was involved in athletics. And there was a couple of moments where I was like, man, could I even do anything? I was just so intimidated by my big brother that I never really intervened. But it was really hard to see this, uh, atrophy or trying to think of the right word, but progressively getting worse with my brother. And I didn't know what to do. My family didn't know what to do. At some point, he is kicked out, okay? My dad kicks him out. And I, uh, remember there being moments where I'd go home, and if they left, I'd be like, oh, my gosh, what if he comes back? And I laugh at it now, but in the moment, I'm scared as a little boy, and there was a lot of these moments. And sometimes he would come back and my family would be like, all right, let's try again. But finally, one time he gets arrested, and he gets put in jail. And then in jail. Um, it was either maybe they did a mental assessment on him, or maybe he got released. There was some crisis, and my mom had figured out about Nami, so she called this thing called Copes, and they came out, and they were like a mental health unit. And then they took him to Family Health, which was a mental health facility, uh, in Tulsa, Oklahoma. And then he started to get treatment. So once he starts to get treatment, we're like, oh, sweet. Wow, there's a light at the end of the tunnel. So he goes through this process. He's getting treatment, and he gets released maybe, like, two weeks after. So he's looking me in the eye. Now he's talking. My parents are going to get him his own apartment, and they're going to pay the rent. And he has these pills he needs to take. And I was on him about it. I was in high school. I was like, hey, man, you need to take these pills. And he's like, all right. And my parents were all on them. And there was one day where I walk into his room and I find all of his pills untouched in his closet. And I was like, what the heck? Like, you need to be taking these pills. So I told my sibling or not my siblings, my parents. And they're like, Mac, you need to take these pills. You need to take these pills. And ultimately, he doesn't take his pills. We find him in the trash can. And it's wild because all of this pain and suffering that went in to get him to the treatment facility, we finally got medication for him, and he didn't take his pills. And at the time, you're helpless, like, what to do? And the more I read about it, it's pretty common for people who have schizophrenia or bipolar disorder to not take medication because they don't feel like they need medication. And you're a great listener as I talk and talk. But there's a great book by Dr. Xavier Armador to where he talks about this. And this whole book is about his brother who has schizophrenia, and they've gone through such crazy, turbulent times. They finally get his brother this medication, and then he finds that medication somewhere else. His brother isn't taking it. And there's this concept anisignosia. Yeah, anisignosia a lack of self insight. It is your self concept, your ability to determine what you can do and what you can't do. It's frozen in time. You are no longer able to see that you do need help, that you do need this medication while everybody on the outside can see. It would be the equivalent of if you woke up one day and someone says, rick, you need this medication to walk your dog today. And you're like, no, I don't. I just walked my dog yesterday. I walked in the past two years. I'm going to walk them tomorrow. And they're like, no, you do. And you're like, no, I don't. And then if I kept trying to convince you that you needed medication to walk your dog, you'd be like, all right, Chris, you're crazy. I'm out of here. I'm, um, losing my trust in you. I don't know what's going on. And then if I got doctors or your family to start telling you, hey, Rick, you need this medication to walk your dog, then you'd be like, what in the world is going on? You'd be scared. You'd probably want to disconnect from all these people because you don't need medication to walk your dog. You just did it. And a lot of people who have severe mental illness are in a similar spot. They are unable to see. And I hate saying they are like, I'm weighing them, but oftentimes it's just an inability to see what's going on in your life, and you no longer you don't need medicine. Uh, you didn't need medicine whenever you were 15 and skateboarding everywhere, like, uh, big on YouTube. But things have changed, and everybody else can see it, but you can't see it. And this in a signosia, it happens with people who have brain injury. It's just an inability to take care of yourself. And whenever there's no self care, then yeah, it's a messy thing. Um, I'll hop back into this story, but this is something that you've seen a lot and you've heard about a.
Rick Cagin: Lot, seen a lot. I mean, we all have blind spots, but I think this notion of anasygnosia, which is a diagnosis unto itself, is kind of pretty hard to get around. Uh, if you're having a conversation with a person who's experiencing that lack of insight, um, they're more likely to say, well, no, you're the person with the mental disorder, not me, I'm fine. I don't need the medication. I don't need to see the psychiatrist. Um, yet, at the same time as your story is indicating, they might be self medicating with alcohol or other substances. So it's very tough. And, uh, the book that you're referencing, I'm not sick, I don't need Help, is really critical in terms of creating a methodology for having a conversation with a person who does not see things as you do. So, uh, I think part of your story kind of gives us an opening to talk a little bit about the connection between mental illness and addiction, which is so important. I mean, we've always said, in terms of the data, that more than 50% of people with a serious mental illness also have some substance use issue. And the reverse is true. More than 50% of people with a substance use disorder have, uh, an underlying mental illness. But I've gone further in recent years. I mean, that's just the data. But I've kind of tested this out with all kinds of people, um, peers who are living with mental illness, family members, clinicians, um, prescribers. Um, and my notion is that virtually 100% of people with some type of substance use, uh, issue, be it alcohol, marijuana, other, uh, illegal drugs or addiction to the Xanax, and the the other things that they may find in the medicine cabinet, virtually 100% have an underlying, perhaps untreated mental illness. So I think part of the issue is and the numbers may have changed a little bit, but somewhere 40, 50%, uh, even at times, 60% of people with serious mental illness are not in treatment. And sometimes it's the lack of insight, but there are other reasons. Insurance coverage, kind of access to treatment, which may be limited in certain, uh, areas of the state or country, particularly in rural areas, not to mention stigma. And so when you've got a treatment system that is fragmented and underresourced, and you've got maybe half of the adults and children, maybe more than half of the children who have a mental health condition who are not in treatment, then you've got a problem. I mean, right now, post pandemic mental illness, mental health has been elevated way above anything we could have expected in terms of the national conversation. But we haven't done certain basic things like have universal screening for kids. So go back to that notion that 75% of lifetime cases of serious mental illness emerge between the ages of 14 and 24, we should be screening young, uh, people in that age group. Uh, and so the naysayers about universal screening will say, well, we can't really do that, because if we discover 100 kids in the school system today that need, uh, some support around mental health, we don't have the community resources, we'll overload the system. And so it is kind of a dicey issue. A little bit of chicken and egg. Um, but, uh, I think we have to identify people within our families, within our educational institutions, within our faith communities, within our social service programs. And doggone it, if there are not adequate resources in the community, we have to be champions for them and with them to demand that we improve mental health treatment resources. If all of those people, or if even half of that 50% walked into the mental health center tomorrow, there would be no way that they could cope with staff and resources. I mean, even now, even in the best of community mental health centers in Kansas, and this may be true across the country, if you walk in today, maybe you can get a screening. But to get an appointment with a therapist or a medical provider to get medication, you'll be on a waiting list. And so from there, we ought to at least mention what the standard of care is for serious mental illness therapy. Talk therapy for most conditions is part of it, but that is not enough by itself. In many cases, medication may be necessary, uh, but not in all cases. And we need kind of more access to support programs that are focused on case management, uh, housing, uh, other support and employment. Those, again, are kind of the foundational pieces to helping people get to a level of recovery. We can get you the therapy, we can get you, uh, on a good medication regimen. But if you don't have those other supports, then your chances of relapse are increased.
Chris Miller: Right. The screening, that's a really interesting idea. I hadn't thought about that. But having a screening for potential mental illnesses for you said get like a universal screening for the youth.
Rick Cagin: Well, I mean, this was a recommendation out of a commission created by George W. Bush. Uh, so it's been on the table for quite a while, but it's not been acted on. It's not been implemented by his administration or any succeeding, uh, administrations. And at the state and local level, it's pretty much nonexistent. So when you look at this epidemic of school, uh, shootings, for example, and other kind of workplace events, what if you almost always hear about some kind of mental instability for the shooter? What does it take to kind of figure out, yeah, maybe I'm not going to kind of get into the whole gun control issue. That's, uh, kind of a separate conversation. But at least having mentioned it, the proponents or the opponents to any type of gun control will say, let's focus on mental health. I'm, uh, not sure that it's one or the other, but clearly, what if we had recognized that that 16 year old kid had been increasingly isolated? No friends. I think it was a relatively recent shooting in St. Louis where they discovered from some journal entries or Facebook post or something on social media that he was saying, I'm alone. I don't have friends. I don't have girlfriends. Uh, I'm kind of missing all those social components that are kind of foundational to good mental wellness. And no surprise. And then maybe you've got teachers and other students who say, yeah, I noticed Johnny was a little doing some weird things now and then dropping out, being very antagonistic. So, I mean, there were maybe no one could have predicted the shooting at the school. Uh, but what if we had intervened with him? What if we had identified him? Maybe not an official school screening, but I think in other community venues, we have ways of saying this is a person who is lost and needs some help, and we let him go his way until the day he acquires the weapons and does the awful deed. And so I think because of the school shootings, because of the pandemic, we are in this kind of period of heightened awareness about mental health and more is being done. Maybe not enough. But, uh, I think there's this kind of a hopeful sign at the present time which I hope that we can sustain.
Chris Miller: And do you think it's increased since the pandemic due to isolation and separating people? And probably people lost their jobs or they no longer saw their workplace environment, which also the stress of potential, uh, pandemic and getting sick and something we don't know about. All of these factors caused mental stress.
Rick Cagin: So I think here we are having a, uh, conversation, for the most part about more serious mental health conditions. But earlier we said that virtually all of us will experience some type of mental distress in our lifetime. And this has been a period where more and more people got to that point because of all the things that you've mentioned, that maybe they were not having a psychotic episode and maybe they didn't end up in jail or the state hospital or, um, being restrained in some type of facility. But they were unstable in terms of their, uh, mental well being and needed some help. And so you have this proliferation of online therapists, uh, and conversations which I think are good about kind of normalizing mental wellness. I mean, we are kind of not disconnected at the neck. I mean, we are one organism and we have dysfunctions in various parts of our body. And our brain is not immune, uh, from that. And so I think it's good that we can talk about it. And let's hope that this will result in kind of more resources being deployed for treatment, more awareness on the part of the public, greater involvement of families, and the kind of Nami education programs that you were talking about. And ultimately more people in treatment. And, uh less suicide.
Chris Miller: Right? Less suicide, yeah. Less rash decisions being made. I was listening to something the other day, and this person said, on average, it's almost like, you know the school shooter before you know the school shooter. If you hear about something, then this idea of being detached from society, a lack of self care, a lack of communication, increased isolation, some of the things that you referenced, whenever you hear that, it just makes us think that our acknowledgment needs to be way better. We have to be way better at that. Returning to my brother, he's currently in a facility where there's a whole bunch of different people with a similar condition all living together in a home. And I was speaking with the woman who ran this facility. She was giving us a tour. And there's been a couple moments of psychosis with my brother. And for those who don't know, psychosis is imagine just a jumble of your neurochemistry and your brain kind of checks out for a couple of days. And oftentimes this is where you have a lot of mental health crises. You have, like, the psychotic episodes. Um, but it is craziness, and people need to be stabilized. And really, the goal is that nobody gets there. So whenever I was sitting and talking to this person, we had asked, what do you do in moments to where because all these people have schizophrenia in this home, what do you do in moments of psychosis? And she said, well, we just don't let them get there. Oh, that's not going to happen. Don't even worry about that. We're not going to let him get there. And it made my family and I a little sad because we let my brother get there. And there could have been things done to have prevented it. And there was a moment where he was in psychosis and he was not making sense to anybody, talking only to himself. He absolutely zero self care. And he had his own place, and he had left his place just running around outside this apartment complex, and he started beating on his neighbor's door. And his neighbor was scared, understandably so. And his neighbor called the cops, and the cops showed up. And my m brother felt scared and ended up being physical with the cops. So the cops took him off to the county jail, middle of COVID So as he's awaiting trial, they keep pushing trial due to COVID, and then he needs to get competency to be tried. So then they sent him to another place, and it's like a two and a half year old deal due to COVID and due to this system that we have in place. And then he gets moved to this home. But I say all that to say, the sooner we can acknowledge things, the less severe the prognosis. The shorter the hospital stays. The less likely you go to the hospital, the stronger the family can be, the better support system. Like, there are so many benefits and silver linings to being good at, ah, acknowledging things quicker and attending to them. And I know that I was talking to somebody, the person who connected us both. We were sitting down, and I, uh, had asked him what's one thing that you'd like to add to the conversation? And his one thing was he had regretted whenever his loved one was dealing with something that he didn't attend to it immediately. Like, they didn't look into it because they just shrugged it off. Like man. She's young. This is kind of like, what happens. But they waited until a crisis, and it's a really hard thing to do, right? To know, what do we do? Do we do something about this? But what he had really impressed on me was, like, do something about it. The sooner the better. Like, the things that we're talking about, it's like, okay, how can we get better at doing something sooner and recognizing when we need to do something?
Rick Cagin: Yeah, all the things that you're saying are so, uh, right on. And we need to kind of have a side conversation about mental health and the criminal justice system. But I think on your last point, there's kind of this issue of parity between, uh, dysfunctions in the body, physical illness, so to speak, versus mental illness in mental illness. Uh, for a lot of people, the standard of care has been kind of, let's wait till we get to the crisis point. And what if we looked at primary care the same way? Uh, we're going to wait till you have a heart attack and then we'll start treatment, or we're going to wait till stage four cancer before we intervene? No, I mean, it just doesn't make sense to anyone. But for a lot of people with serious mental health conditions and substance use, we're waiting until that crisis flashpoint. Kind of making this kind of comparison, I think, is important for policymakers to understand that we need early intervention for that group of people 14 to 24. We need early intervention for returning veterans. We, uh, need early intervention for all of those people living with untreated mental illness. But I want to come back to the criminal justice piece, um, because your, uh, brother's experience is very comparable to many, many other experiences. And some very bad situations have developed in various, uh, places around the country where that person who is having a psychotic episode and has an unpleasant interaction with law enforcement ends up, uh, dead as a result of kind, uh, of brandishing a weapon or running from the police and they get shot. And then it's a whole nother mess. Kind of. Sorting things out on the other end. So one of these, uh, events took place in Memphis, uh, maybe 20 years ago, and became the flashpoint for the development of a model called Crisis Intervention Teams within law enforcement. On the one hand, it's important for all of us to be aware of some of the signs and symptoms of mental illness. So we can intervene as family members or clergy or social service providers. Uh, but for law enforcement, this is critically important, because it hasn't been their plan. But they kind of ended up being kind of caretakers for a lot of people living with serious mental illness and without the skill set to intervene appropriately. And so when you're dealing with someone who doesn't have the same cognitive capacity as the next person, and you see them maybe trespassing or taking, uh, something that doesn't belong to them, other kinds of, um, illegal behavior, whether it's misdemeanor or felony, they're just responding traditionally as they have with any other part of the population. So CIT, as we call it, is a model in which law enforcement officers get training on recognizing the signs and symptoms of mental illness, on kind of understanding something about not at a clinical level, but understanding some basic things about different diagnoses, medications, their side effects, and most importantly, on the law enforcement side of their training. De escalation. So Deescalation is kind of a term of art in CIT. And it's getting a lot of, um, kind of recognition in other law enforcement encounters, given all that has happened through the Black Lives Matter kind of period that we're living through. So if the officer can de escalate the situation, uh, perhaps restraints are not necessary, weapons are not necessary, tasers may not be necessary. And so cops with this skill set are increasingly important. And now, in many communities, like Lawrence and other places in the state and around the country, we have mental health professionals kind of riding with law enforcement, showing up at the scene of a disturbance in response to a mental health call. And so their objective is keep the individual safe, keep the officer safe, keep the public safe, and as much as possible, avoid taking this person to jail. Because even though we might say treatment in the state hospital or in the community mental health center might be less than adequate in some cases, uh, treatment in jail, for the most part, is nonexistent. There's some great exceptions to that, more and more. But jail is not the place to create another treatment system. But if you're in jail, yeah, maybe your medication should be continued. Maybe you should have access to train, ah, clinicians. But if we can avoid taking the person to jail, if they haven't crossed that line into a serious criminal behavior, um, it's time to take them somewhere else. But where? The emergency department in most communities are kind of ill equipped, but that's where a lot of people end up. But in Lawrence, we're anticipating, uh, this spring, I hope, long awaited opening of a crisis center called the Treatment and Recovery Center. And this is a model that's emerging more and more across the state and across the country. And so it is a place where people can chill, uh, recover from about of substance use, uh, be evaluated and monitored for a short period of time to decide whether they can be released back to the community with the right supports, or if they are seriously ill enough to need to go to a mental health hospital. And, uh, so it's a great model. Uh, it's international at this point. And we have in Kansas, uh, about eight or ten local CIT councils, which we're working with to make sure that they're, uh, supported not just by the training that they get, but by their partnership with substance use and mental health providers.
Chris Miller: Yeah, that's beautiful, that proposed system, because whenever you think of leveling up your mental health, you don't think of going to jail, right? That is not the best place to level up. And there's increased isolation. And whenever you get out, then you may have a criminal record, which makes it more difficult to find employment if you get to the point to where you're able to get employment. And we know, like you had said, employment is one of the best cornerstones to establish stability. But if you go to jail, and if you get to the point to wherever police officers are even considering taking you to jail, it's not going to help you establish that consistency that you need. So the CIT training is really, uh, answered prayer, right? Like, it's something that needed, something that needs to happen. It's something that needs to be done. And having mental health professionals there is big time.
Rick Cagin: Yeah. Law enforcement will tell you pretty consistently that the training they get, it's 40 hours to be certified as a CIT officer, but they will tell you it's some of the best training that they've had in all of their law enforcement career. But I think what makes it most effective are the officers who have lived experience with mental illness, maybe a family member, or maybe they've been a part of a number of arrests where, looking back, they can say, oh, my goodness, I wish I had some skills to deal with that situation differently. And one of the things that you talked about that was troubling for your brother and for so many other people is this issue of competency, uh, really described as competency to stand trial. And so if you are arrested for a serious crime and you are seriously ill, uh, the first thing that your defense lawyer or the judge is going to kind of look for is an assessment of your ability to kind of, uh, aid in your own defense. And so being able to have people deployed around the state to do these competency evaluations is critically important. And historically, in Kansas, most of those evaluations for competency meant people had to go to the state hospital. So what did that mean? There was a long line, a long waiting list. And if your brother ends up in the jailhouse and he has to wait a long time for competency evaluation, then he's sitting in jail, which is not a good place for him to be. And then what happens? He gets evaluated. He's determined not competent to stand trial. Then he goes through a competency restoration process of mental health treatment. And here's what happens next for a lot of people. We've now determined you to be competent to stand trial, which is a pretty low standard, but still an important standard. So we send you back to the county jail to wait trial. Whereas you've been on medication and involved in treatment while you were having your competency restored, you go back to jail and, uh, medications, or the same medications may not be available or available at all, or you refuse them. And the jail is not a place that has authority to administer, uh, medications against your will. So back to Anasygnosia and no, that's not me. I'm not that quote unquote person with mental illness. I'm not taking those meds anymore. So you decompensate over a period of days or weeks, and then your trial date comes up and lo and behold, m, uh, the judge and the lawyer say does not appear competent to stand trial, needs to be reevaluated. And so, uh, I've certainly known individuals who have been on that kind of merry go round for years, literally moving between the jailhouse, the state hospital, and kind of never having their case adjudicated. And so it's another part, another aspect of this whole dysfunction in our, uh, treatment, uh, system.
Chris Miller: Wow. Yeah. My experience, it took about two and a half years for my brother to get to the point to where they released him and put him in a home that he's court mandated to be in. And if he doesn't stay there for the year, then he's going to go back to, I guess, the state hospital. And then it's like, well then what's next? Do they go through and redo the competency again? Because they just declared him non competent. Right. So it's like, where do you go from there? And I think a lot of families are asking that question. It's like, what's next? Where do we go from here? And that's some stress that I'll put on myself. I have a few siblings alongside my brother, and my parents are both aging. I mean all to say that what do I do whenever my brother gets to the point to where there's no longer a state funded home for him? Right. There's no longer these things for him. And that's very overwhelming to think about. And I can only imagine how many families or how many individuals are asking that same question of what is there to do? And, uh, I wanted to read that book you mentioned, but I didn't read it. The book crazy.
Rick Cagin: Yes.
Chris Miller: What's the premise of that book?
Rick Cagin: Yeah, the title of the book is Crazy, and it was written by Pete Early, who's a former Washington Post reporter. Uh, but it's more a story about his own experience with his son, who had a psychotic break in that age range. I think he was a college student. It's not all that unusual, uh, for mom and dad to send Johnny off to University of Kansas or whatever. University bright, rising star student, excellent athlete. And then in the freshman or sophomore year, something happens. Johnny's, uh, part of that one in 17, he has his first psychotic episode. University is talking about throwing him out, or maybe he was arrested. The folks can't understand what has happened. They don't have this knowledge base around mental illness. I think that's a huge issue. So Early's book is really about the system itself, which is crazy, not a pejorative term around the individual who is living with mental illness. And I think what he found in his own personal experience was that he had many difficulties and barriers to getting treatment for his son, including the fact that his son was an adult, being over 18, and could decide to say, dad, no, I'm not doing that. I'm not taking these meds. I'm not going to that hospital, which left the dad in the predicament of the only way he could get his son help was to get him arrested and to report to the police that his son had attacked him, had some violent interaction with him. It was the only way he felt at the time that he could kind of stop what was going on and kind of get through and maybe get some help for his son. And so he kind of followed this experience through the judicial system in Dade County, Florida, and in the jail. And I, um, think it has really led to an explosion of inquiry into what we're doing in our jails, uh, how better to deal with the mental health population in the jails, but also in the court system. And so now we have a trend and emergence of mental health courts, behavioral health courts, drug courts, veterans, ah, courts, specialty courts that are kind of looking at the charges against the individual in some context in a lot of cases, not all cases, providing for some type of diversion. So we might say to Johnny, okay, you've been arrested and convicted, but we could suspend your sentence, but it's going to be on a contract basis. You stay out of trouble, you see your therapist. However often you take the medications that are prescribed, you focus on employment and independent living. And three, six, nine months later, when they come back, they've kind of checked all the boxes off. You're free to go. Or maybe even on a pre conviction basis, um, a pretrial diversion. There's opportunity for individuals who may be charged with a misdemeanor, uh, or a low level felony to avoid prosecution, uh, through a recognition of the mental illness or substance use and a proper course of treatment, and, uh, kind of getting their, uh, life together with all the supports that we've been talking about.
Chris Miller: Yeah.
Rick Cagin: So I think those are important developments. They're not as pervasive as we would like them to be. So we got a lot of educating. I mean, we've talked about all a number of kind of aspects of society, but training law enforcement, training family members, educating people themselves who are living with mental illness. Judges, prosecutors, defense lawyers, uh, these are all people who kind of need, uh, a base of knowledge around how mental illness affects their professional work.
Chris Miller: Yeah. And the medication side and the medical side is also really interesting to me, because whenever my brother was in a mental hospital, we would call him and they would go check to see if he wanted to talk on the phone. And oftentimes it was, no, he would never want to talk. And that was tough for me, right. Because that's the big bro, and I haven't seen him in a while. And I got called to check in on him, and he's like, no, I don't want to talk. But in the back of my head, I also know that in those homes, there's a ton of medication, and oftentimes these people are sedated heavily. And it really makes me wonder how much of him not wanting to talk is the medication. And I've read things about people working in these facilities which shout out to them. I'm so incredibly grateful for people who, one, are in the medical field, and two, specialize in mental illness. But the way that this stuff is dispensed and the way that this medication is used, i, uh, think deserves some.
Rick Cagin: Um, assessment, much definitely closer scrutiny. I think there's this concept of chemical restraint. You can have handcuffs on a person or more serious forms of restraint, but, uh, medications now can give you that same effect. And so that is not the model for medical, uh, treatment of mental illness that we would, uh, support. And in fact, um, I think the place where we want to get to is a very close monitoring of medications and a very kind of deep conversation between the individual who's taking the medications and the prescriber about the side effects, the right level of medications, whether it's working or not. And part of the problem in our multiple systems of mental health care is that when you leave one treatment venue for another jailhouse, state hospital, group home, community, mental health center, more than likely the prescriber psychiatrist or other prescriber is going to have their own idea about what's good for Johnny. And notwithstanding the fact that you've been stable on a medication that your private provider may have gotten you established on, if you had another kind of relapse, uh, for a variety of reasons and ended up in jail or the state hospital, they're going to switch that all around, or they're going to have a different formulary. And so the drug that you've been taking and getting from your local pharmacy with your private provider is not available, and so they're going to try you on something else. Uh, and so there's all kinds of confounding issues around medication. And one of the things I want to talk about, uh, is the influence of tobacco on mental health and substance use treatment, because the constituents of tobacco smoke interfere with the metabolism of a number of psychiatric medications. So what does that mean? It means you're taking well, we'll combine that with another statistic about kind of the prevalence of people with mental health and substance use who are using tobacco products, which is very high in the addiction community, that could be 75% to 100%. For people living with schizophrenia, that could be 60, 80%. And it might kind of trail down to other disorders of, uh, maybe 40% or so. But still, people with mental illness and substance use conditions are using tobacco products at a much higher rate than the general population. And whereas tobacco use in the general population has declined year after year in the behavioral health community, it's pretty flat. And so, because tobacco smoke affects recovery in a negative way, and the fact that quitting tobacco would improve, uh, relapse, uh, rates would improve recovery, may allow people to take less medication and get for the same kind of behavioral impact. So this idea that the place your brother was in at one time, everyone seemed to be perhaps sedated, is not uncommon. That's not a state of mind that is conducive to recovery. It is done for the benefit of the program and the staff. And I think what we're seeing in the aging community, in nursing homes is a similar trend of chemical restraint. You got these old folks whose memories are failing and who become perhaps belligerent in kind of some of their behaviors. And so, uh, restraint by chemical means creates kind of an easier management system for the people who are running those facilities. And that's definitely something that we want to see go away.
Chris Miller: Yeah, that definitely deserves scrutiny. And like we both said, medication can be helpful. And I encourage people who are in crises to find proper medication that can be administered to treat what's going on. And I know I have been in situations where I've been fearful for my life because somebody was not being properly treated. And I know a lot of other people may feel similar way. So it's not like people shouldn't take the medication, but the chemical handcuffs is overkill, right?
Rick Cagin: It is.
Chris Miller: When you think about that strategy, it's a way to keep people there like you said. And it eases novelty. Right. It just keeps everything the same because everybody's all drugged up. But it's no way to help people level up their mental health. It's no way to help people increase. So if you keep doing it, then there's going to be more people who come in and nobody's going to leave. Right. Because there's no ways to really improve. So that's definitely something that I think deserves further examination. And one thing I hate doing, especially when I'm on the microphone, is like critiquing the status quo without providing alternatives.
Rick Cagin: Exactly.
Chris Miller: So I'm grateful that you are here because with the advocacy background, you can articulate and think through potential strategies or potential systems that could be better than the ones that we currently have. But yeah, medication that needs to be fine tuned and there's no reason for any population why chemical handcuffs should be the way to go.
Rick Cagin: So I think one of the kind of big questions, uh, put out there for the audience is why should we care about any of this? And I think you've already made the case that for the families who are affected by serious mental illness, you got a rationale. You want to help your loved one. And, uh, you may not know how, and there are resources through Nami and other organizations to kind of get started. But if you're one of many people in the country who don't have any personal experience with mental illness yourself or with a loved one or possibly even a close friend, why should you care? And so I uh, think piece of information may be important for all of us. And that is the cost of untreated mental illness. And this figure is dated now is in excess of 100 billion with a b dollars per year in the United States. That's a lot of money. Now what is that cost attributed to? Some people might say, well, it's expensive to keep people in the state hospitals or in the county jail. What we're really talking about is something on the level of 80% of that cost is lost wages to individuals who are not in the labor market and lost productivity for those who are, but who are not functioning at a higher level.
Chris Miller: Wow.
Rick Cagin: And so this is basically the economic argument. Why should corporate america care? Uh, why should Main Street businesses care? Why should local government care? This is a cost to our community. And so making investments in law enforcement programs, in treatment programs, in independent living programs are critically important. And it just brings us back to that cornerstone issue about housing and employment. If people can work at least part time and live independently, then they're contributing to the economy. They're not part of that 100 billion dollar deficit. And maybe mom and dad don't have to worry as much about what's going to happen to Johnny when they age out. Mhm, that's a big issue. What provisions are we making for Johnny when we're gone and will the system be adequate to take care of him and so many others?
Chris Miller: Yeah. And you mentioned tobacco and the disproportionate rate of tobacco use and tobacco addiction, particularly with the population that uh, like mental illness population and I've seen, I uh, think on average I'm seeing less and less cigarettes around me. Mhm, and that would make sense to you saying the general population like cigarettes are going down, it's steady.
Rick Cagin: Yeah. I mean, if I go back to my experience as a kid in the asylum in Massachusetts, what did people do all day? They sat around the hospital, gave them rolling papers and loose tobacco and so they just smoked all day long. Uh, and so the mental health system in, uh, a previous era really contributed to this addiction to nicotine that they are now living with. And it's only relatively recently that mental health treatment venues prohibited tobacco use and jails for the most part are prohibiting tobacco use. Um, I think this is really part of a big part of why the Surgeon General said a number of years ago that people with serious mental illness, uh, live up to 25 years less than the general population. When you look at actual causes of death, they are linked to cancer and heart disease and lung disease that come from long term tobacco use. And because tobacco use is so disproportionately higher among people with substance use, uh, issues along with their underlying mental illnesses, I think it's critically important that we get tobacco treatment programs, uh, integrated in other, uh, mental health, uh, treatment programs. And there's resistance, uh, it's coming down. But there has been resistance over the years because, uh, mental health professionals and family members said well, come on, don't take Johnny's cigarettes away. I mean, that's his coping mechanism and that's all he's got, man. But it's killing him and it's reducing possibly the efficacy of his medications.
Chris Miller: Right.
Rick Cagin: And so more and more the behavioral health community is coming around to this. But part of the problem is staff in those programs might be smoking at a higher rate than the general population as well and it's just one more thing for them to pay attention to in an already overburdened system. So there's some barriers, but that work is very robust now in many places around the country.
Chris Miller: Yeah, like smoking cessation, like getting people to stop.
Rick Cagin: Yeah, I mean, it's important for all tobacco users to quit. But nicotine is so powerfully addictive and Big Tobacco has done, uh, everything within their means to target certain groups of people people of color, people living in poverty and people with substance use and mental health disorders. That's their main constituency right now because everybody else is quitting more and more.
Chris Miller: Because it's important and it matters. And I am grateful that you have the, uh, background to add some real oomph to this conversation. So thanks for being here you bet.
Rick Cagin: Always.
Chris Miller: Yeah. It's been a lot of fun, um, all the conversations we've had, and we will have. And I know looking back at my experiences and thinking about my brother, I just recently visited him a couple of weeks ago, and he doesn't make any eye contact. He doesn't really talk. He doesn't have the best self care. But I'm grateful that my family got connected with an organization like Nami. And it is not limited to Tulsa. It's not limited to Kansas. So if anybody that you know, or if people are going through things, encourage them to look into resources like this. Because, like we were saying, the quicker things can get addressed, the quicker people can get plugged into a healthy system, the quicker medication could be explored, then the less severe the prognosis, the less likely they get hospitalized. The shorter the hospital stays, the stronger the family unit. It goes on and on, and if you feel like you're too late my family and I felt really bad when we were thinking about my brother and all those moments of psychosis that he had. Um, and we just didn't have the education. So I encourage people to be gracious, but also to be proactive and educating themselves and others about this. But all to say, good to have a conversation.
Rick Cagin: It's great to have a conversation. And people should get connected. Remember, recovery is the goal. We don't really talk so much about cure yet. Uh, our understanding of kind of brain chemistry and brain development is still progressing, but not at a point where we can solve these things with a pill or something. But recovery is possible if people can get access to treatment. It's been a pleasure to be a part of this conversation with you, Chris, and thank you very much for the opportunity.
Chris Miller: Yeah, let's move the needle a little bit via conversation and socialization. No, good talking to people. Great.
Rick Cagin: All right.
Chris Miller: And that's what we're doing here. Okay. All right, folks, we'll see you next time.