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Medicine from the bench: Lessons from a mental health court

I recently completed my psychiatry rotation at the Palo Alto VA. It was a fantastic experience filled with interesting moments. For example, one patient pleasantly reported that he had just become a trillionaire and was writing a book about it. Another coached me on how to con doctors into prescribing controlled substances. (He was very proud of his techniques although they failed on my attending).

However, one of my most memorable experiences came not in the hospital, but during a visit to the Superior Court of California. An enormous number of mentally ill patients wind up in the criminal justice system – a 2015 report by the Treatment Advocacy Center found that more than 10 times as many mentally ill patients are in prisons than psychiatric hospitals.

Once incarcerated, patients may enter a downward spiral. They frequently fail to receive treatment, and upon release, have difficulty finding jobs and housing. This in turn leads to an inability to access mental health resources, and a greater likelihood of committing a crime and landing back in jail.

Many of our patients had been imprisoned but were successfully re-directed to psychiatric treatment. Interestingly, one name repeatedly came up as the person responsible for this transition: Judge Stephen Manley. A remarkable number of patients credited his compassion and fairness as the driving force that helped them turn their lives around.

Given his role in our patients’ lives, my team decided to pay a visit to the courthouse. Judge Manley runs drug and mental health courts in San Jose, and his courtroom has a unique feel to it. It has an almost casual atmosphere despite dozens of defendants crowding into the room on one side, many of them in handcuffs, and a troop of lawyers on the other.

Judge Manley himself has an outsized presence at the bench. He opened the proceedings with a rousing monologue on accountability, honesty, and the importance of personal responsibility. He then began to go through each defendant’s case.

In many ways, his courtroom was like a medical clinic. For new defendants who had just been referred to him, he developed a plan that could help them avoid prison time. The plan might include drug rehab, medication prescriptions, therapy, or a host of social programs. His court even had on-site physicians to determine the best approach to treatment.

Meanwhile, he reviewed the progress of returning defendants. He asked if they had adhered to their treatment plan and found out what was working and what was not. If defendants had continued to engage in criminal activity or consistently lied to him, he would promptly send them back to jail.

Regardless of the outcome, every single defendant received a round of applause after their hearing. Those who successfully got their lives back on track were able to “graduate” from Judge Manley’s program, complete with a graduation ceremony in which they got a picture with the judge and a department store gift card.

Visiting Judge Manley’s court was a fascinating learning experience. It highlighted the interaction of psychiatry with the criminal justice system and ways to use that interaction to reach patients. But perhaps more importantly, it demonstrated the importance of trust in the treatment of psychiatric disease. Judge Manley’s approach worked because he had earned a tremendous level of buy-in from defendants. And that buy-in allowed him to help patients in a way that many doctors could not.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

Akhilesh Pathipati is a fourth-year MD/MBA student at Stanford. He is interested in issues in health care delivery.

Photo by wp paarz

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