Justin Ray: Hospitals Without Walls

Welcome And The System’s Gaps

0:36 Michael: Welcome to Holding It Together, kinda. I'm your host, Michael Makniak. You know, we've all had those moments where life feels like it's slipping through our fingers. You know, we've had a bad day, we lost a job, maybe we just completely feel overwhelmed. But what happens when the thing that's slipping away is our own mind? What happens when the very system uh that's you know designed to catch us decides that we're not quite sick enough uh to be saved or to garnish or be worthy of help? Today's guest is someone who's spent over 30 years, like me, uh working in the uncomfortable gaps where families in jails and hospitals, as well as insurance companies, um, all seem to collide.

1:29 Michael: Sounds familiar again. I'm not talking about myself here. Justin Ray is a board certified psychiatric nurse practitioner. He's a 22-year retired Navy veteran, and he's a clinician, but Justin he refuses to stay in any single lane. This guy's all over the place in a really good way. Uh he's seen the mental health system, folks, from the inside of a state hospital, from the correctional facilities, from the outpatient clinics. And today he's here to talk to us about the reality of crises, uh, the exhaustion of the frontline care, why we never give up on our clients or patients, or a family member who uh you know, you know is struggling and is in trouble.

2:27 Michael: All right, here I am with my new friend Justin Ray, who, as I just said, does not look like he's got enough years under his belt to have all the experience that he's had. Justin, welcome. Really happy that you could be here. Thanks. And where are you where are you coming from? You're coming from South Carolina? Chesapeake, Virginia. Oh, Virginia, okay. I knew it was down there somewhere. Yeah. So I do this with every guest because as my listeners know, I I don't like to read bios. I want to ask you, Justin, tell us about yourself and and a bit of your history, but more importantly, tell me what has you real fired up right now.

Justin’s Road Into Psychiatry

3:06 Michael: What are you excited about and what gets you out of bed in the morning?

3:10 SPEAKER_01: Yeah, so I come from uh rural Maine. 15 kids are in my eighth grade class. I lived in a city called Lincolnville. Four towns went to the same high school, and I think there were like 118 kids in my senior class or something. And I tended to rank at the very bottom because at the time in my life, if I had a GTO and lived in an apartment, I would have made it in life. So that took me to the Navy. The Navy woke me up and showed me that there's life beyond Maine. So yeah. Right. So I ended up going to the Navy as a hospital corpsman.

3:45 SPEAKER_01: When I got assigned to my first duty station at Portsmouth Naval Hospital, they put me in psychiatry. And so that's where my journey in mental health began. I went to school on the side, I got picked up for a program, went to nursing school, got commissioned. We were at war, right? 10 more years war, I guess you could say. And we had absolutely no mental health assets. So Marines were getting blown up, dismembered, PTSD, and we didn't have a lot of psychiatric assets. So I was never going back into psychiatry, but I had great leadership.

4:16 SPEAKER_01: And so they encouraged me. They said, We need we need you to help us. So I went back to school, became a psych NP, and I've been doing that ever since. And a lot of love. And when you say what gets me up in the morning, you know, it's the complete disparity that we see in our society. And somebody's got to do something, right? So, you know, I mean you're you're a big advocate for the families, right? And so that's kind of what ACT is all about. We're in people's homes, people's apartments, people's sidewalk, you know, delivering care.

4:52 SPEAKER_01: So that's what gets me passionate. I have a lot of ideas. I'm trying to convince the city, you know, to let me incorporate. But as you know, most of the mental health care comes in the way of correctional system, state hospital system if you have the beds. We spent a lot of money on acute inpatient psychiatric hospitalization when we could probably do it cheaper, better, faster elsewhere or other means. So those are the things that get me fired up in the morning and you know, how to keep these clients in the community.

5:22 Michael: Yeah, it's just one of these things where you just look at this bureaucracy and this red tape and say there's just got to be a better way. We just can't keep doing it this way. And and yet we still do. You know, Maya Angelou said uh every day feels like a sameness wheel. One day's rolling into the next. And that's I mean, you know, I've been in this game as long as you have. Well, I'm a little bit older than you, so I've only got a few years extra. But actually, you started before me, really, because you went right into it by joining the Navy after school.

5:51 Michael: So you've actually had more experience than I do. And we've been on the sameness wheel for 30 plus years, right? Fair enough. Let's talk about Maine for a second because it's funny. I was I was in Newport, Rhode Island getting an award from the the National Probate Judges Council or College of Probate Probate judges, and they have a guy there from way, way up in Maine, and he he said to me, and and this guy is always at the stuff, and he's pretty well-loved probate judge. I don't even know if he's still around, but he said to me, you know, when you get to the border of Maine, which takes however many hours from Newport, Rhode Island, I don't remember.

6:31 Michael: He goes, if you drive 10 more hours, you're just about to my house. I mean, it's a big place, man. Yeah. Yeah. That's where you were from. You were from somewhere up there, 10 hours north of the border.

6:45 SPEAKER_01: No, I mean, I was right on the coast, actually. So if you look at Lincolnville, it's if you if you're in the middle of the state, you go down to the to the coast line. That's basically where we were. Oh about two hours north of Portland.

6:59 Michael: It was and it was so it was that small. It was that rural, even that far.

7:03 SPEAKER_01: Oh my god. Oh, yeah. Really? The town I live in has one stoplight.

7:08 Michael: Yeah, yeah, it sounds like the town I grew up in, but it certainly had more than 15 kids.

7:14 SPEAKER_01: 15 kids in my eighth grade class, yeah.

7:16 Michael: And folks, just for clarification, when Justin said he was put into psychiatry, that did he did not mean he was put into a psychiatric unit. It meant that he was he was given the duty or assigned a duty to get into the the psychiatric aspect of care, which he absolutely expounded upon.

Combat Trauma And Overloaded Care

7:34 Michael: One thing that I wanted to point out for people right here, right now, is and this data is old, it's probably even more dramatic than this. We talk about soldiers and all of our men and women who are in all the various services, and my son is one of them, which you folks who listen have met, he is in the Air Force. And they say that nearly half, it's it was back in the, I don't know, maybe five, 10 years ago, it was 42%. I guarantee you it's over that now. Nearly half of all the people that come back from our chosen skirmishes overseas.

8:11 Michael: And as we speak right now, we're still in a skirmish with Iran for some reason. We don't need to get into that. And and nearly half of these folks that are coming back after serving our country will have some form of PTSD and or traumatic brain injury, the acquired brain injury. Have you heard that stat and is it updated since then, Justin?

8:33 SPEAKER_01: I haven't heard the numbers. They they vary, they have over time, but I mean it's definitely high. Yeah, yeah, definitely higher than the probably needs to, should be. Well, yeah, I mean, we're we're in the military. I mean, our our job is to go into combat. And so it's kind of the risk, yeah.

8:49 Michael: And and a lot of that speaks to the great mil the great medical care that people are surviving these these injuries that in the old days used to frankly kill them. Right. But now, you know, you're getting you're getting a head injury and you're in and we're able to you're so you got it, you can survive. But we, you know, m and my point in all of this is that the VA is a great system. It really does well once you get into it. It's hard to get into, but once you get into it, it does really well for our for our soldiers and our veterans.

9:21 Michael: We need to get more people into it. And it wasn't meant for this kind of volume. We were talking 50% of soldiers getting psychiatric care. Nor is our public domain in this in the public sector set up to have the kind of volume that we're seeing in it these days. I think that's fair to say. Would you agree?

9:41 SPEAKER_01: Oh, yeah, absolutely.

9:42 Michael: Yeah.

ACT Teams Without Office Walls

9:43 Michael: So you mentioned the ACT team. What does ACT stand for for those who don't know? And what is ACT? I want everybody to make sure they're clear about the important, just unbelievably important and fantastic program that is ACT.

10:01 SPEAKER_01: Yeah, so the ACT stands for the assertive community team. That's kind of how I would say Virginia as a as a state manages, you know, every city basically has what we call a community services board. Uh, is they they have different names, but that's basically what it boils down to. And then most of those community services boards have an ACT team. We covered Portsmouth for a long time as well. So Chesapeake's Act Team actually covered the city of Portsmouth, who had their own CSB, but they didn't have their own ACT team.

10:31 SPEAKER_01: So we we removed ourselves from there a couple of years ago, and so they are starting to form their own ACT team as well. But our jobs are to be the hospital without walls. That's kind of what we call ourselves. We're like the last line of defense to the hospital for the community. We go out into the community and see our clients where they are. They don't come to us because they don't have the transportation, they don't have phones, they don't have, you know, a lot of the things that most of us probably take for granted.

10:59 SPEAKER_01: So we go out to them and we deliver care. I'll I've I'll give an LAI beside a dumpster in the hallway, you know, wherever we can. So that's kind of what our purpose is to deliver care into the community. We're in people's homes, apartments, we're on the sidewalk with them if that's where they're living at the time, that kind of thing.

11:18 Michael: I mean, ACT is designed to really work with the patient or client from where they're at. There's a work in psychology and in social work, like called um, I know it's patient-centered, but it's also there's another word for it that it's escapes me right now. But I love your hospital without walls analogy or description because that really paints a great picture. You know, is more and more. I mean, the movement has been since the 80s has been deinstitutionalization. And frankly, in my estimation, the ACT team sprung out of the desperation that the mental health systems felt after deinstitutionalization, because frankly, the money didn't follow the people out into the community.

12:05 Michael: The idea behind deinstitutionalization was to get people out of the hospitals and into the community and let them have meaningful lives that were in congruence and collaborated with the rest of us, so to speak. And that's in quotes, I suppose. But we didn't put the money with them. So the we had this influx of folks with mental health issues in our communities and a complete lack of services that were designed to help them. And in response to that, most, if not all states that I've come across have accepted some form of uh assertive community treatment teams, these act teams.

12:46 Michael: And the way you have it set up is unique to your state. Uh, it's different than the way that we have it set up up here. But the mission is the same. It's to get out there, to be assertive, to get off, get off of your desk chair and get out into the community to find the people who can't get off of their desk chair to get in to see you, right? Right. Right. I I I think of it kind of like I think of two different models. We have the medical model, which we all know. Basically, yesterday I had to drive an hour, 45 minutes to go to a specialist for my back that I messed up a month ago.

13:25 Michael: It's doing great now. Thanks for all the emails and and everything. Everybody, I'm much better. I'm not cured, but I'm much better. So that's us, right? We that's the medical model. We go to where our doctor is. But under this act model and under a lot of the the treatment modalities that teams and organizations have adopted is this new role where we're we're not only having people come to us, but we're also going out to the folks who are either, as Justin said, gravely disabled or or by virtue of socioeconomic issues, unable to come to us for the care.

14:00 Michael: And that's so important, isn't it, Justin? I mean, to to make sure that that bridges gap, that gap is bridged, that gap is bridged, I guess is the right way to say it.

14:10 SPEAKER_01: Yeah, I mean, no, I mean, the seriously mentally ill are not coming to you for an appointment, right? I mean, they're seriously mentally ill. So they're having hallucinations, delusions, and they can't think straight, right? That's the biggest problem, in my opinion, with schizophrenia is thought uh, you know, thought process problems and whatnot, disorganization. And yeah, so so they're not gonna be making it in for the appointment, they're not gonna be on medications, they're gonna deteriorate and just gonna keep going in this independent loop of hospitalization, hospitalization, jail, hospitalization, jail, you know, and that's where we have it.

14:42 SPEAKER_01: So, like doing away with the institutions, you know, were there some bad things done? Sure, but should we have gotten rid of the whole thing just because of a few bad actors? But that's what we did, you know. I'm not blaming Kennedy, but like you get rid of the institutions, put them in the community with no funding. What do you expect?

14:56 Michael: You know, so absolutely, but it was a complete throw the baby out with the bathwater. I mean, yeah, it and it on paper looks and sounds great, it sounds so inclusive and everything, but it really has worked out to be a complete nightmare. It really has. And we have been struggling to catch up with for with it for for decades and decades, and and I think we're doing much better, but but we got a long way to go, especially with more and more folks ascribing to the concept of mental illness and mental health issues.

15:31 SPEAKER_01: Yeah, we we definitely we need more from our lawmakers, you know, I'll say for sure. We need we need more knowledge, you know, because uh it seems like a lot of these decisions are being made in a vacuum, you know. Like I deal with people who just don't even know who they are half the time. You know, if you get somebody's gone to the state hospital and they've been there for six months and they've been deemed unrestorably incompetent to stand trial, right? Okay, so then they're gonna come out and and you know, they're not gonna get charged, but then the judge is gonna expect that I'm gonna restore them in the community, you know, with with with nothing, with zero teeth, right?

16:09 SPEAKER_01: I don't have any medical uh I mean we're starting to do the mandatory outpatient treatment, we're starting to have some of these processes, but we need more because if we're saying that the client is is incompetent and they're unrestorable, then I need to have some level of authority in order to be able to treat them because they're just gonna refuse.

Court Orders, Rights, And Reality

16:28 Michael: You know, I've said that and this is something that I had no idea that you and I would get into, but let's get into it because I think it's a really important thing. Okay, folks, we've talked about it, I think, in the past, this this concept of outpatient, uh outpatient commitment statutes. I live in an area where we don't have them and we probably never will. Basically, what it says is that folks with severe mental illness, criminal, criminally charged or not criminally charged, right, can be placed under supervision via a court that will mandate them to continue to engage in treatment.

17:03 Michael: It's for the safety of themselves and the safety of the community, particularly if they tend to be a threat to the community in some way. And it's usually petty crimes like panhandling and trespassing, right? Stupid things like petty shoplifting, you know, stuff like that. Right. So under these, under these laws, the concept is that hey, if you don't come in to see me or you aren't taking your medications or seeing your psychiatrist, I can theoretically, and I'm talking from Justin's perspective, I suppose, not me, Michael Macnac, but somebody who's licensed to do this, I can theoretically call the police, have you picked up and brought in to to be seen either in an emergency room or in a psychiatric environment.

17:46 Michael: Did I sum it up pretty good?

17:48 SPEAKER_01: It's basic it's basically psychiatric probation, is kind of how you would how you would.

17:51 Michael: That's a great that's perfect. Because I was going to use the criminal probation analogy, but psychiatric probation works great. And and I think that's a fair I think that you asking for that and you saying that you need that is such a fair assessment because otherwise you don't have teeth.

18:08 SPEAKER_01: I have nothing. So I mean, let's let me give you an example, right?

A Gazebo Case Study In Crisis

18:11 SPEAKER_01: So let's just say I go out into the community. I'll give you a perfect example. So it was it was about this time, uh two years ago, we had a client and she was living in the gazebo beside the building, okay? And she's very, very sick. She was not cooperating, she would not speak to me. She'd come into the building during the day, right? Because it was cool. You know, she was very malodorous, but you know, it's what it is. But she wasn't taking medications. I didn't know how much she was eating or drinking.

18:38 SPEAKER_01: I didn't know she had money available to her because she wasn't cooperating, right? And so at the same time, she didn't really necessarily meet the criteria. She's free to be homeless, she's free to be psychotic, but and but she's not yet a danger to herself or others. But one day on a Friday, we're getting ready to go on a three-day weekend, right? And the heat index is 105. And I and I become acutely aware that this woman is not gonna be able to go into the building and is gonna be exposed to this environment for the next three days.

19:06 SPEAKER_01: She's already gone on two weeks like this, enough's enough, right? So I went down to the petition of the magistrate for a temporary detainment order, right? Now, in this case, the magistrate declined, which really made me upset. I'll just say that. We ended up getting in the hospital waiting for the shift change. But long story short, right? Let's say you have something like this, and the client ends up in the hospital. The dog goes up and says, Hey, you're not well, you need medication. And the patient's like, The heck with you, I'm not taking crap out of my face, right?

19:34 SPEAKER_01: So, what does the what does they what do they do? They go to the judge and they get a forced medication order, okay? Because they can force medicate in the hospital. So they force medicate the client, and what happens? Well, miraculously the client gets better, but now they're discharged back to the community with nothing. Not that nothing. So, like, the expectation that the client's now gonna come out and start taking, continue taking meds, it's not gonna happen. And so we're just gonna keep repeating this process.

20:00 SPEAKER_01: In the meantime, everybody's looking at me like, what's going on here? And I'm like, Well, if until you guys give me some resources and some teeth and some ability to fact change, I there's not a whole lot I can do. I mean, because these these clients really do not believe they're sick, they believe they're fine. You're the problem. We call it anusgosnia, right? And like it's a thing. And so it's it's just very interesting to me how we we manage this kind of thing where we say, okay, they're very sick, and in this setting, we can mandatory treat them, but in this setting, they're free to make whatever choice they want to.

20:34 SPEAKER_01: Okay, well, that's just going to lead to bad outcomes, and so you'll have to be okay with that.

20:38 Michael: And it's so counterintuitive because in the structured setting of an inpatient stay, to be able to mandate, mandate, you know, to be able to force medications, they don't need the big safety net that you're talking about. Out in the community, we all need a safety net of some kind. Sure. And out here in the community, we don't have that mandate. And we can get into the argument, and we can, you know, you and I could probably pick one side or the other for or against, and we could probably have an all-day great debate.

21:06 SPEAKER_01: Well, Mike, let me let me just let me see, let me give you something right here, right? So I've thought about this for I was in corrections for three years, right? So so I've thought about it for a long time. So the answer to this is make a board, make a five-member board. I don't care who it is, a firefighter, teacher, police person, whoever it is, a five-person board that the provider has to present the case to, right? Take it out of my hands. I don't need to be the one make the make the, but let me show you what's going on.

21:32 SPEAKER_01: Let me show you that the danger that this person is in, and let me show you the danger that they can also possibly produce to the community. And then you guys decide, right? So take it out of my hands. I understand that abuse happens, and I'm perfectly happy having a safety net, but do something.

21:47 Michael: I I agree with you a thousand percent. I mean, I give you and I think both fall down on the same side of this argument. I I I just think it's it's outrageous and preposterous that we don't have this in place global for the safety of so many people that that could be helped. I mean, yeah, we're we may have to force them to be helped, but but you know, God, can you imagine if we can help some of these folks that you're just like the the woman you're describing and have her be able to look back on and say, Wow, Justin, thank you, man.

22:18 SPEAKER_01: You were really looking for So the woman I'm describing, right? The woman describing was in the state hospital for over a year, okay, at the end of the day. She is now out. I'll be seeing her today. I'll be taking her, we'll be going to a couple places to shop. She'll buy some sweet tea. She loves sweet tea at Chick Fila. That's what she calls it, not Chick fila. Yeah and and McDonald's. And the difference in how she is now, and you know, she's on clausural, right? The miracle drug. And and I've had to fight her a lot on staying on this drug, right?

24:28 SPEAKER_01: Because she gets the salaria and the hypersalivation. She doesn't like the atropine drops. So it's kind of always a fight. So, you know, I kind of go to my way to like, hey, you know, I'm gonna help you. I need you to help me. And we're in the process of getting her a guardian, which is a long, which is a way long process. But she's so but now she talks about stories about when she used to live on a boat years ago and her mom, and she smiles, and that's like a completely different human than she was when she was living in the gazebo.

25:04 Michael: I'm sorry, I was muted there for a second. It's very interesting to hear all this from a provider perspective, especially when you start talking about that that interaction where she remembers or doesn't remember how she was and she sees the value, but I mean the the impact in the the the drugs and the medications, the symptoms. What am I thinking of? The the bad, the bad side of the side effects of some of these and they can't be ignored either. But my goodness, I mean the the upside is is so much poof, so much when you just we're also we're also coming in.

25:49 SPEAKER_01: I mean, psychiatry, it's never been a better time to be in psychiatry. I mean, the things that are currently in the pipeline now, like we're going in a completely different direction, antipsychotic-wise, where we're talking about the muskineric revolution and Cobenfi and you know others that there's I think there's 10 muskinerics currently in the pipeline under active trials.

Clozapine, LAIs, And Future Meds

26:09 SPEAKER_01: And so it's a completely different way of approaching the disease process. I've seen like like cognition to shift. And now we've come to find out that clause, we believe that closmural is also a muskineric drug because we could never figure out like why is this the magic medication? Because it doesn't really have a lot of D2 affinity. So what can it be? But now when we think about the hypersalivation, right, that makes sense that it's hitting M1 probably in the brain, and that's a byproduct, procolinergic like effects and whatnot.

26:42 SPEAKER_01: So who knows at the end of the day? But like I think we're good, I think we're in the treatment of schizophrenia, we have we're going in a completely different direction, and I think you'll see way less of the side effects. So, like you said, the Katie trial showed that you know we we shorten lives by about 15 years just from medication.

27:00 Michael: Yeah, I that is a scary truth of psychiatry, psychiatric meds, hype psychotropic medications. The it is 15 to 20 year difference between people who are on them and the rest. So I so it's very interesting because I think that you uh and I I'm not saying that you're unique in this at all, but I I like the fact that you are you represent probably a great majority of people who are providers and who are sharing some of the same frustrations that the family is going through in trying to figure out what am I doing and why is it just me feeling like it's me against this system?

27:39 Michael: Do you sometimes feel like it's you in a family against the system for the benefit of their loved one?

27:45 SPEAKER_01: Oh, bro, that's that's what you when you talk about what gets me juiced up. Yeah, oh yeah. Like so I'm like Tom Brady with a tip chip on my shoulder. I was picked in the sixth round, right? So like if I don't have if I don't have an enemy to look at, you know, so that's just kind of how how how I feel. So like I work for the city, I love the city, but also at the same time, the city's I have to fight the city, right? And so yeah, I mean it's just you know, we spend a lot of, I talk a lot about this, we have a morning meeting every morning, and I talk a lot about this to the team, and I say we spend a great deal of time running around doing crisis management, right?

28:18 SPEAKER_01: And it's because we don't have the resources we need. And what I mean by that is there's some clients, no matter if they're in treatment or not, they're going to need constant supervision. It's just what it is. Otherwise, they're just gonna decompensate, get into drugs, whatever it is, and end up in a bad situation. So I always talk about this idea called balahack. So in Chesapeake, there's a road called Balahack Road, and out there there's really nothing, right?

Housing, Supervision, And Pragmatism

28:44 SPEAKER_01: Like 15 miles to the nearest drug dealer, you know, it's just like farm country and whatever. And I keep saying, give me a 10,000 square foot space out there, 10,000 square feet. I'll house 30 to 35 of these guys. We'll have a garden, we'll have chickens, a pig, and a cow and all the things because Chesapeake City's motto is work, live, farm, play, right? So we'll farm, but but we'll, you know, and we'll do things and teach, you know, real-time skills like community and economy. And let's have a farm stand, and you know, we don't have time to argue about whether President Clinton is secretly still the president because you're delusional.

29:22 SPEAKER_01: Go out and pick cucumbers if you want lunch, you know. So, like we have to have these things available and the structure available for these clients, otherwise, because you know, you can't you can't have housing on a thousand dollars a month, not in Chesapeake. There's there's no way nowhere, nowhere, and and and they're not working, they're not. I mean, can we get them there? So that's always the goal, right? The goal of ACT is to get them as independent as possible. So I've had clients, we have clients currently who are working, right?

29:48 SPEAKER_01: We're trying to get other clients to that place, but it requires a great amount of resources to get them there, you know.

29:55 Michael: And so and I like the idea that you put forth with regard to this farm, this working farm. The problem is that if you get that many beds out there, you know, in that big of a space, you'll next thing you know, there'll be a gas station across the street and a liquor store right down the road, it'll start being discontinued. But but it's a great idea, and and I think that some of it's also turned on its head in the last decade or so, where we're looking at things like the concept of a forever home for folks that we don't have to keep moving people through.

30:27 Michael: I I and and it's just kind of contradicts a lot of what I believe in, but it's okay to say, hey, this is a this is a place where a guy could feel permanent, this is a place where a guy could feel at home, and he's going to be at home for as long theoretically as he wants to be. Whereas we've always been forced in our thinking for some reason to constant constantly be moving folks on to the next level, next level, next level community, right? Well, you know, uh sometimes I think we really have to take a good hard look at ourselves as providers, our systems as providing care and the capabilities, but also the individual and his capability to live within that framework and realistically assess what is the ultimate right?

31:17 Michael: And and and sometimes we have we can have a pretty good assessment of that, in spite of what I don't know, probably the better laid ideas or the moral or ethical obligations want to push us toward. Does that make sense? Am I saying that?

31:31 SPEAKER_01: Yeah, I mean, so the reality is some a lot of the clients on the ACT team are not gonna make like we're we have a we have a department called Permanent Supportive Housing. And so if you're homeless for over a year and you meet certain requirements, then they they their job is to put you in housing. But like it's to me, it's like okay, why they're not gonna make it, right? We we might place them, but they're gonna get thrown out. Like I already know this, right? And and and I would say that I'm the cynical guy on the team.

31:59 SPEAKER_01: AJ, one of the nurses, is Mrs. Optimism all the time. Like this morning, she was so optimistic, driving me crazy. But I'm just trying to be realistic and say, okay, I'm glad that we have this resource, but we're we they don't have supervision. If they don't have supervision, like they're gonna go off and they're gonna do they're gonna bring somebody in the house. I mean, I could tell you stories for days. Oh, I know, you tell.

32:22 Michael: And and it and one of the things I mentioned in another episode was it really bothers me when that misoptimistic pushes back on me and says, Well, you don't know that, you can't know that for sure. You know, okay, you're right. We don't know 100% for sure, but you know, the the likelihood given this man's history is that X, Y, and Z is gonna happen. And and and I and I I think that that we have to be realistic about what we what our our consumers, what we can expect of the system, and the system itself has to be realistic of what it can expect of itself and not have all these pie in the sky ideals and uh that that we just we can't attain.

33:07 Michael: So let's let's ratchet it back a little bit, pump the brakes a little bit, and have a have a realistic discussion about how we can therefore more realistically address the needs that we face. Does that make sense?

33:20 SPEAKER_01: Yes, absolutely. I mean, like, and that goes back to my five-person board thing. Like, I mean, go ahead and check me. Anytime of the day, check me. I have no problems being checked, I've no problem, you know, I think that's necessary.

33:31 Michael: Well, that's one of the that's one of the cornerstones of the model that I've created up here in Connecticut, is that willingness to be held in check. The willingness for us to have somebody looking in and say, this could be done better. We should be doing this. Right hand, you need to talk to the left hand. You know, because as soon as we start seeing those those fragmentations, as soon as we start seeing the glitches in the system, we should be able to have somebody to say, I'm the checks and balances, I'm pulling it together because we we got to catch this before it becomes a catastrophe for us and for our mutual benefit of our of our client.

34:14 Michael: Well, from so I'm really happy to have you on and to and to share your provider perspective because I think it's much in line with, and maybe to the surprise of some people, frankly. Maybe it surprises some people to hear how much you are in line with their way of thinking about the way the system operates. But the nice thing about offering you this platform and this and this voice is to say to folks, we do care. And I honestly do believe that, that Justin Ray did not get into this business because he doesn't care about the people.

34:47 Michael: I honestly believe that, you know, despite the in spite of the treatment that I got at the second emergency room that I went to because my back hurt, you know, in spite of the treatment that I got there, I do believe that the doctors are there because they care, the nurses are there because they care. We wouldn't put in this much time and education and money if we didn't. So it's it really is nice to hear your perspective about how much you you do care. And and in that regard, do you think that given your your long time with the Navy and then in corrections and now out in the community, all of this experience has it made you what has it created in in you in terms of being a practitioner?

35:29 Michael: How does that how has that impacted you positively, negatively, or both, or or what? That's a great question.

35:38 SPEAKER_01: I would say, you know, it's it you definitely can't be nervous if you're gonna do this kind of a job, right? Because you're in people's homes as they're at war with each other, and I mean I all sorts of different things. It's definitely made me more interested in the science of things. You know, I I find myself, you know, just reading a lot more, doing a lot more research, doing a lot of writing. I write a weekly brief on LinkedIn that I like to do talking about mostly about new and emerging treatments and different kinds of things, why these dysfunctions happen and how medications can be helpful.

36:17 SPEAKER_01: It's definitely giving me a huge experience in the LA LAI market. You know, I you my goal is always to get an client on an LAI, period. Like that's always my goal.

36:28 Michael: And tell me what an LAI is.

36:30 SPEAKER_01: So long-acting injectable, you know, something that we administer an antipsychotic that lasts for a long period of time, sometimes two weeks, sometimes three, sometimes a month, sometimes three. Half year is allegedly has six months. I yeah, no, a hundred percent no. I don't think I agree with that. Yeah, but uh month is a good one.

36:50 Michael: A month, a month is a good, is a good yeah.

36:53 SPEAKER_01: Sure. So so that that that's been the definite positive on me. I would say negative wise, I probably have become much more cynical than I probably maybe I should be or need to be. I'm just a practice, I'm just think in pragmatic terms and practicality, and it's like, okay, this is great, but like what are we really accomplishing? You know, maybe we should be looking at other things that we could be doing with our resources. But you know, the thing is that they're not listening to me, they're listening to other people, and other people have different ideas, and that's but I I love the the word pragmatist.

37:24 Michael: I hadn't thought of that because yeah, I think that's I think that describes me as well. I yeah, and I and I I I definitely have cynicism too, but but I'm gonna call it pragmatism for now on because it just sounds better. Right. Do you think do you think that it's made you more less or has it changed your empathy? And and and and if so, toward whom?

37:46 SPEAKER_01: I mean, I would say no, I don't say it has changed my empathy. I mean, I'm very empathic, like it breaks my heart. Like when she was living in the gazebo, it broke my heart, you know, like this poor woman, you know, and it's like like we're offering her all sorts of options housing-wise, and she's refusing them all. And it's like, it's so hot outside, and it's just like, what, you know, what are we doing? And then, you know, so it definitely breaks my heart for for a lot of these clients who are just not just them, but the families.

38:15 SPEAKER_01: I mean, we've got a kid right now who's living in a car, right? And the heat index is getting getting ready to be turned up, you know. So we were talking this morning about options that we might have available to us and some moves that we might be able to make. And, you know, we're having to communicate with the dad and the mom who, you know, they're separated on like how we're gonna make all this happen and stuff. But you know, we're we're definitely the people on my team are ballers, you know, they are down for the fight and they're gonna be out there doing things and making things happen, and that's why I love the team.

38:46 Michael: Yeah, that's that's well, and that's great. And it's great that you guys have that love for each other because a lot of times you got to back each other up in this work, too, you know. Yeah, and yeah, I mean, the families you touched on the families, and I know that in some of your work, and by the way, you got you have to send me over your bio for people so that they and let them know where to find you on LinkedIn so they could check out what you're putting out. Okay, I think it sounds interesting.

39:12 Michael: Sort of a synopsis of the thoughts from the trenches on a weekly basis is really kind of cool, and I'd love to be able to share that as well with them so you could send it to me and I will share it with the tribe for sure. But you talk about the family, and you mentioned earlier your in your corrections work and probation, it probation officers and things along these lines. I had a talk a long time ago with a guy by the name of Banish, Dan Banish. He was the chief medical director for our corrections department up here.

39:44 Michael: And he said a lot of the same thing that you're saying. He, you know, basically he said, I spend, I forget the number, but it was many thousands and thousands of dollars that he spends on medication formulas to try to work with psychiatric patients within the correction system to get them to the point where they are at a baseline that can be worked with. And then he said, what he sees is that they are discharged from the hospital because now they're not under a 40, we call it a 46 4656 up here, but that basically means that he's being evaluated to determine whether or not he could stay on trial, etc. And they're being discharged back into the communities, and once they get to the communities, either they're this medication regime that he's put them on is just thrown out the window, or somebody who thinks he knows better comes along and changes it because this is the way that they do what they do.

40:42 Michael: So, anyway, he was exceedingly frustrated with that, but he was even more frustrated with the point that you made earlier that unfortunately our our correction systems and our and and these these incarceration concepts really have become the final holding, the final net that catches many of the the folks who are who are in this system. And I I know that you've talked about that, so I don't know what else to say about it, but I'm sure you have seen some real horror stories and can share that frustration as well.

41:18 SPEAKER_01: Oh, yeah, I mean, absolutely. So I would say that I would say that corrections is is has its pluses and its minuses because, like you said, it at least can catch them.

Jail As Backstop And Breakdown

41:30 SPEAKER_01: So I'll give you an example. One of my guys was like you had mentioned earlier, outside of a 7-Eleven. Now, this is the where cognitionists play such an important role. So he's got$250 on his EBT card in his left pocket, but yet he's shaking a can in front of the 7-Eleven, right? Why? You have$250 on your card, right? But his cognition is impaired, so he can't think like that. So the manager obviously gets annoyed, calls the police. The police come, take him into the jail and for trespassing, right?

41:58 SPEAKER_01: Now, in that scenario, that was a win for us, right? Because it got him out, it got him out of there, it got him in a place. Being in this authority-like place, then kind of makes you decide to take your medications again. So he started taking medications again, got better, got improved, got out, and he's been money since. Now we hit we have him in assisted living facility. I see him, he's doing great, he's taking his medication, everything's wonderful, right? So in that case, I would say that was a win, right?

42:30 SPEAKER_01: But then there's other cases where you know they go to jail. Like I have one guy in in jail now. He he was transferred because he had charges in another city. But Chesapeake was gonna let him out, they were gonna let him out and not just let him out, but they're gonna take him off probation as well. So now we were in a worse spot, right? So so we've done nothing for him. We haven't even taken him up to for a competency evaluation to see if he's competent. It looks like we're just gonna drop everything and then we're gonna get rid of probation too.

43:03 SPEAKER_01: So now that's just wonderful because because when he's when he's out and he's floridly psychotic, I don't have probation, I have nothing. So we're just gonna go right back to the TDL hospitalization. And the and it puts the cops in a bad situation too, because you know, what if he doesn't answer the door? You know, we know he's in there, you know, the neighbors tell us, right? Because he's in the their backyard at night, which is one of the problems. And so, you know, how do we go? Are we gonna bust in there with because then you then you increase the risk of a bad outcome, right?

43:33 SPEAKER_01: Does does the guy get shot? Like, you know, so these are all just problems where we need help from, you know, the we need something and some form of reprieve where we can go to and say, look, we need to do something about this client. I don't know exactly what, but we need to assist them because they can't assist themselves. So, you know, incarceration is a double-edged sword. It can be helpful at times, you know, it can be not so helpful at times because you can't take the schizophrenic and put them in G pop, right?

44:04 SPEAKER_01: So you put where do you put them? You put them in isolation, and when they're in isolation, they're behind the door 23 hours a day. And what happens with a schizophrenic?

44:11 Michael: He just well, and you know, the the bugs as they call them, right? In inside the facilities, yeah. And and you bring up a great point where we feel very often that it's it's all or nothing, and there's nothing in between, and there's so much room in between for us to be able to create and think outside the box and and talk to people like yourself about who I mean, you've been there, man. And you've been and you see what's possible. You you I mean, I really wish that there was there was more attention paid to folks like you who have seen so much and can offer logical explanations, even that sounds so simple and so I mean commonsensical, but common sense isn't always well.

44:57 SPEAKER_01: They should know if they're showing up for the fifth time. At some point, you should recognize that there's a problem.

45:04 Michael: Like I've said this often before where you have we had a guy that went to the hospital 17 times in one month to the emergency room claiming that his arm was hurt. They never thought to do to just call upstairs to have somebody come down and do a psych evaluation of the guy. Just, you know, come on, just run through that 15 question little thing that you have. It's so simple, it's so easy. But you know, something's not right. This guy keeps saying his arms hurt. Well, maybe his brain hurts, you know.

45:31 Michael: Right. Right. And and and it's just it's just little tweaks like that that can make so much difference and make it so that the the the corrective system doesn't have to be that final net, that final landing place. But I do have to say that an interesting thing that you that you bring up from your perspective as a as a provider and a practitioner, that I learned in my 30 years of doing this, and that I want everybody, all these families that are listening right now, and these providers too, but families in particular, guys, and provider, no, everybody.

46:12 Michael: It's not a setback all the time. Time to have an individual go to a hospital. It's not a setback all the time to, I mean, uh incarceration arrest, I think, is way worse. But but I think that we need collectively sometimes to take a well, a collective breath. And our our clients need it sometimes, and we as a team need it sometimes. We need a timeout. We need to say, okay, hey, pause. Whatever the hell we're doing here is not working. Let's have a collective break. Let's have our client. It's it's okay that he is in the in the unit right now.

46:50 Michael: It's okay that he's there for a few days. While he's there, let's take a breath, let's have a day, but then let's regroup later that afternoon or the next morning and say, okay, what did we do wrong? Where did things go wrong? And how can we improve? Because he's gonna get out here in a few days. We know these miracle cures happen all the time in this system. He's gonna get out in a few days. There's the cynicism, but we're calling pragmatism now. So I think, and that's I and I learned this from watching the system's need for that that that break and the acceptance that's not always a setback.

47:29 Michael: Have you felt that? Do you feel that?

47:31 SPEAKER_01: Well, yeah, I don't. I I mean I've been doing this for I don't even get I don't blink twice if somebody's going to the hospital or jail or but families do, and I can understand why.

Coordination And Families As Allies

47:40 Michael: Sure.

47:40 SPEAKER_01: Well, because they don't deal with it like we do on the level that we do. And and so so the thing is that the important thing is you've got to create networks within these systems to communicate, right? So, like if we have one of our guys in Chesapeake City jail, right, and he's on an LAI, well, we understand that the correctional facility is not gonna pay for the LAI. It's just not gonna happen. I know this, everybody knows this, but we're happy to continue to provide that on our end. So we'll we'll we'll communicate within the system and we'll continue to provide that.

48:09 SPEAKER_01: Now, sometimes the system isn't always the greatest deal. Sometimes we get pushback, and sometimes like, well, we already have a provider, like you said, we have a provider over here who's gonna make those decisions. And I understand that because I worked there too. And this is like, okay, I mean, if you want to go a different direction, that's fine. Just know that we're happy to support you over here as well. You know, we're not we so we want a working cooperative environment, and that's what we lack a lot of times.

48:33 SPEAKER_01: Like I can tell you that these hospitals around here, they don't talk to me. I try, I call them all the time and say, hey, we'd love to collaborate, would love to give you some history. I don't hear a peep until until it's time for them to leave.

48:47 Michael: And that's what makes people so pissed off.

48:49 SPEAKER_01: Yeah, and they should be.

48:50 Michael: Families feel like they they're banging their head against the wall. And right. And frankly, the fact that you are working in a system that's willing to work with the correctional system there is a unicorn as well. Because that doesn't happen where people are reaching across systems very often without being told that they should be doing it. And again, my model, the model that we created up here, is designed to do that. It is designed to breach that gap between when somebody's in corrections and the resources in the community.

49:23 Michael: We could provide the colour the closer that you can't or won't. We're, you know, we're designed and we're we're that's the whole model is based upon that enhanced communication. But the reality that folks see out there is that all that breakdown of okay, the guy's in the hospital, I got three days off. Now I can, you know, worry about uh you know, or the guy's incarcerated, I don't have to worry about it, it's done. Meanwhile, the family is still there, they're still getting the phone calls. What are we gonna do with you?

49:53 Michael: What are we gonna do with your son? What are we gonna do with your daughter? And well, they can't come home to me because I don't have closer room in my refrigerator, right? And and I think that that's the scary reality that a lot of people face. But again, it's refreshing, it's important for all of us to share these stories so that we all know that we're on the same journey, that your journey is not that unique, that problems are there, and they are sometimes universal. And and in in Virginia, in Connecticut, in California, and Texas, wherever you may be.

50:30 SPEAKER_01: You know Rachel Streif at all?

50:32 Michael: Excuse me?

50:33 SPEAKER_01: Rachel Streif, is that name ring a bell? No, tell me that. So she's out there in Arizona, and Arizona really seems to be struggling hard with the with their mental health system. I mean, such so few state beds, but she's a she's a big closer advocate for sure. You know, she works with a provider out there. We're almost where I think like every client this provider has is on clausural. She works for a company, I think, that does finger stick CBCs, you know, because that's part of the problem with clausurals.

50:59 SPEAKER_01: You need weekly blood draws.

51:00 Michael: And well, that's I was just gonna say we should we should let everybody know that. One of the one of the drawbacks of closural is the is it the white blood cell count?

51:08 SPEAKER_01: So, well, this this is a this is an interesting thing to know, right? So, so you're looking for ad granulocytosis or neutropenia, right? So that I don't know what that is. So that's what clawsural can do. It can decrease your new your neutrophils where you don't have any ability to fight fight off infection and illness or whatever else. So that's what you're checking for is egg granular cytosis or neutropenia. As well at the beginning, you're gonna be checking for CRPs and troponins, you're gonna be looking for any possible cardiac interaction, okay?

51:40 SPEAKER_01: That after a little while, you don't have to do that part anymore. You want to keep up with the CBCs for a while, but you know, there's no more REMs. It used to be that you had to do it like this every week for this long, and then every two weeks for this long, and then you go to monthly. Now that we don't have REMs, we can do it however we want to, but because we've set a precedent, you know, as a provider, I'm gonna keep doing it that way at least for a while, right? But what's interesting is and it's funny that more people die from or have negative outcomes from clausural for either pneumonia related to hypersalivation or an ileus related to procholinergic effects than they do from neutropenia.

52:21 Michael: Huh.

52:21 SPEAKER_01: So they're not dying of lack of nutrition, they're dying from so they're not dying from the thing that we're trying to track, which is the neutropenia. They're dying from other things or or having a bad outcome. I should not say die, but having a bad outcome from something that we're not even looking at.

52:35 Michael: Yeah, yeah, that's interesting. So yeah, but closer is has been. I don't know, maybe I'm maybe I'm being hyperbolic, but it seems to me like closeril has been the great quote unquote miracle psychiatric drug.

52:51 SPEAKER_01: Absolutely. I've seen uh absolutely like I said, this woman was living in the gazebo, completely like opposed to any of us, angry, you know, and now she's just she's wonderful to hang out with.

53:05 Michael: Yeah, and and you know, but one of the side problems that people have is having to get stuck every week for the first time. That's true. And then the logistics of getting them there to get the the checks is correct. So, you know, there's these ongoing problems. So, but I mean I guess that kind of opens up a final question for you when you are dealing with folks that are in this uh issue or any other issue we discussed today, or even issues we didn't discuss today. What do you what do you think is the best way that they can become part of the support team and work as an ally with you?

53:41 Michael: Because you know, very often people families are are left out of this. What do you think is the best way to include to actively proactively include families as the that support, as that history holder? What are your thoughts on it?

53:57 SPEAKER_01: I mean, we just we when we go out when like when we onboard somebody, right? You know, we go into their home, we have an interview, they we introduce ourselves, we have business cards. You know, we I can't speak for other people, but as far as the ag team is concerned, they have our cards, they have our phone numbers. I get called at all all the time, right? And what does it mean to me to talk to somebody for five or 10 minutes or, you know, give them some education or whatever it is? So I think I think it's funny because, you know, I have a private practice too, and one of the tenets of that is availability.

54:32 SPEAKER_01: We have five pillars that we call, one of them is availability. And so my clients have my email address, my clients have my phone number, right? And you'd be surprised how many of my colleagues think that that's just crazy. And they're like, Well, what if somebody calls you and they're suicidal? Well, what if somebody comes into your office and they're suicidal? What's the difference?

54:48 Michael: I was gonna say, isn't that the whole point?

54:50 SPEAKER_01: Are you gonna do something differently now that you're on the phone with them than if they were in front of like it's the same process takes place, right? I and so like I think it's important for it, it makes my life easier for clients to have access to me than if they don't, right? 100%. It allows you to be that much more proactive, doesn't it? Correct, and and solve problems and resolve problems and real time. And some people have this idea that, like, let's say a client misses an appointment, they have a memory lapse or whatever, and then some of my colleagues will say, Well, you know, I couldn't see you, so I can't refill your medications.

55:24 SPEAKER_01: And I'm like, that's the craziest thing. I said, So you want to see the client when they're unstable now and make your life miserable. Like, I'm I'm good. I want, I'm gonna keep my client on their medications, right? And see them when they're stable again, whenever we make the next appointment, you know.

55:40 Michael: Yeah, it's so and and one of our commissioners, the the first commissioner that we had is the Department of Mental Health commissioner, when I started my program, gave a gave us an award and was doing a speech, and he basically said, This this program forces us to be proactive because when we're reactive, it's the it's the worst use of our ineffective and inefficient use of our resources. To be proactive and be out in front is the way to be. And I encourage families to hear that and to and to live that creed, right?

56:12 SPEAKER_01: Yeah, and 100%. I want to just go back to one thing real quick. So when we talk about these challenges, right? Let's go back to Balahack and the idea of Balahac Road, right? If I have 35 of these people in one spot, how hard is it for me to get to the labs? It's not how hard, I mean, we we solve so and again, the people are gonna start bringing up the institutions again, whatever, and and I understand that. You put safeguards in place. I don't care, but but the idea that we're gonna have these clients in poverty, disenfranchisement, where they're exposed to like the terribleness of life and prostitutes on every corner, unfortunately selling themselves for drugs, and people out there thinking, well, if they just pull themselves up by their bootstraps a little more, it's gonna be nobody dreams of this life.

56:59 SPEAKER_01: Nobody, nobody comes up in this world and says, I want to be homeless, I want to live in the street, I want to be a drug addict, I want to be mentally ill. So this idea that people can just like, you know, make things better on their own is ridiculous. You know, so we have to first come to the realization society that people need help and and they may need more help than others, and we can decide to provide that or we can decide not to provide that and be okay with the outcomes. You can't have it both ways.

57:28 SPEAKER_01: If we decide to provide it, we have to provide it in a manner that makes sense for the most people, you know, at the most economical way, right? And for me, putting my people who can't afford to live on their own, they don't have anywhere to go because nobody's gonna take them in, kicked out of your hotel, put them in a place where we're supervising them, and we can give them the medications on site. We can do all these things, and I think it solves like 3,000 problems at one. But but it's but it's crazy when I talk about this, like people's eyes get wide.

57:58 Michael: Oh, I know, I know. But but you know, it's the few voices of reason in this crazy storm that I think rise to the top eventually, and and people like yourself, uh Justin, who who are making the difference because they're willing to see it from all the different angles. And you have seen it from way more angles than most. So I thank you for the work that you do on behalf of other people, and I thank you on behalf of all the families who are listening for your insight and for taking your time to be here today.

58:28 Michael: And if you're not careful, I'm gonna pin you down because I think a very important conversation will be around all the different generations of psychotropic medications and what's coming down the pike. If you wouldn't mind, I'd invite you back to do that in another few weeks, maybe. Absolutely. Um, so careful what you wish for because that could be we gotta really break it down because I don't understand it. So you got to talk to me like I'm a third grader. Sure. And and hopefully my audience, uh, they're they're a little smarter than me and they'll be able to do it.

59:00 Michael: But Justin, thanks a lot for being here and really helping to shed light on the provider's perspective for some of these issues because it's very important.

59:11 SPEAKER_01: Yeah, my pleasure.

59:19 Michael: Man, Justin's experience reminds us that these gaps in our system just aren't just aren't, you know, just some blank uh, I mean, just numbers on a page.

Closing Thanks And Where To Find Justin

59:30 Michael: They're there's spaces where real people struggle to hold it together. Whether you be a clinician and you're feeling burnt out or you're a family member feeling abandoned by this infrastructure and bureaucracy and red tape, remember that persistence is a clinical act in and of itself. You don't have to have the whole system figured out. Uh you just have to be the person who refuses to give up on somebody else. So huge thanks to Justin for joining us and thanks for his 30 years of collective service.

1:00:08 Michael: Please check out his work at the South Chesapeake Psychiatry and Transforming Minds Inter and the Transforming Minds Interventional Psychiatry. Until next time, keep holding it together, even if it's just kinda.