Severe Mental Illness Behind Bars: A Breakdown in Care with Jesse Bogan

Mark Mullen: [00:00:00] Welcome back to Psychiatry Bootcamp. Today's episode is a personal passion project for me. Now that my son is sleeping through the night, I can officially say that this is the one thing that keeps me up at night the most. There are so many failures of American society. That's not news to anyone working in healthcare.

We see people suffer on an individual level from systemic issues all the time. One area that we have often discussed is ed boarding. It is so difficult to have a patient waiting in an emergency department room that really needs to be. On an inpatient psych unit and watching these patients languish sometimes for days, several days without appropriate treatment, always breaks my heart and challenges my faith in humanity.

So imagine the injustice of having a person with severe mental illness languish in a jail cell without access to treatment for not days [00:01:00] but years. This is what we are talking about today. This is a major problem across the United States. However, my home state of Missouri is the most egregious in the United States in terms of this violation of basic human dignity.

So stick around. You'll learn a lot about how the richest country on the planet treats the most vulnerable members of our society. Um, and today, for the first time, our guest is not a clinician, but a journalist. So standby for more.

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Welcome Jesse Bogan. Jesse is a journalist supported by the Marshall Project and when I read one of his most recent articles, I knew that I had to invite him on Psychiatry Bootcamp to discuss his work. Jesse, wonderful to meet you. Welcome to Psychiatry Bootcamp. Uh, is there anything else you'd like to say to introduce yourself?

Jesse Bogan: Oh, just thanks a lot and, um, this is a population that I, I like to write about and it's very hard to write about. It's nice to be with people who also care about this topic and are des dedicating their lives to it. 

Mark Mullen: We try to, I'm gonna ask you to do a lot in this first question, so I apologize in advance and you are welcome to defer it if you prefer.

Why should psychiatry bootcamp listeners care about this topic that we're discussing today? 

Jesse Bogan: I'm smiling because I, I get this question. I, uh, sometimes and, uh, you know, why should I care? And I don't want to come across as self-righteous in this [00:03:00] interview. Okay. Um, I, that's the last thing I want. I'm, I'm on a path trying to learn this topic as well and, um, and, you know, I've talked to a lot of people, uh, about what we're gonna talk about, but, um, it comes down to is like, why should we care?

I've been asked that on, um, and I think it's very clear that a lot of people don't care. Uh, about this issue and others like it, you know, that nobody wants to touch or deal with. And so, um, me, I suspect a lot of your listeners do care. And so, um, I sure hope they do if they're, if they're wanna be psychiatrists or work in that field.

And so the question is, uh, you know, our, for me as a journalist, you know, I'm an objective journalist. I'm a, I'm not a columnist. And so I've gotta go out and find records and talk to people and interview people and learn, uh, before I can write objectively. So, um, that's what I'm always trying to do. Um, [00:04:00] it's subjective in the sense that I think it's important.

I care, this is a problem. I think that needs to be addressed. There are people who don't know about the problem. And so I would say, you know, yeah, people, there are going to be people who don't care, but there are people who don't know about it, what's get them informed. There's people who are, like I was saying, dedicating their lives to work with people with mental illness to help them and their families.

There's so many ways you can go with that. This is one of them. And, um, there are a lot of people suffering in, in behind bars and also their families as well, and people in the community who cross paths. So I, I'm coming to this interview thinking I'm with in good company with people who do care. 

Mark Mullen: You are 

Jesse Bogan: in good company.

I can tell you do. And I, you sent me a note right after my story came out, and I can't remember exactly what I said, but I was like, wow, it's really nice. To hear somebody who's enthusiastic and cares about something that I do too. So, uh, here we are. So [00:05:00] thank you. 

Mark Mullen: It's really important to me. I've lost sleep over it for years.

I'm so embarrassed to be a Missourian because this is the way we're treating the most vulnerable people in our society and I intend to spend the rest of my life trying to solve this problem alongside you. So if I have an audience, this is what they're gonna have to listen to today. Um, I think I care about it more than almost any other systemic issue in the psychiatric system.

And um, that's really saying a lot 'cause we have a lot to fix. I think what I'll say about why I think this is important and why people should care about it is I could see thinking about people in jail and thinking they've done something to deserve to be there and therefore we shouldn't be spending resources trying to solve some of these problems.

And while I don't agree with that, I can acknowledge that that's how some people might feel. But in the case of a lot of these people who have severe and persistent mental illness, it's highly treatable and they make one mistake, bad decision. Sometimes they just get caught up in a bad situation in the throes [00:06:00] of psychiatric illness.

And I know as a psychiatrist that with appropriate treatment, we can give these people really meaningful lives. They can have meaning in their life, they can have positive relationships, they can affect society positively. And right now we are neglecting them and allowing them to languish and it's a damn shame.

So I guess what I would say is these people can and will get better with appropriate treatment, and that's where we're failing them right now. So let's start by describing the system that we're gonna talk about. So let's say a person has a clear history of bipolar one disorder. They're in the throes of a manic episode, and they are found trespassing in an abandoned building, and that's their crime and they're brought to jail and they're charged with trespassing.

What happens to that person with mental illness at that point? 

Jesse Bogan: Well, there's gonna be a decision. Um, well, you mentioned that they're charged and so Yeah, the, the trespassing, criminal trespassing, going into people's property and lingering and not leaving, that's the flag for, wow, this [00:07:00] person probably has a mental illness.

That's a common charge. A common crime is, is, uh, criminal trespassing. And so if you're looking for folks, uh, who need mental, um, care, maybe, uh, go to a jail, look at the roster, look at the misdemeanor crimes and who's actually in jail on misdemeanors. And, um, you know, the system's complex and, you know, there's decisions made.

I mean, they might decide if somebody is really mentally ill and the, and the charge is low, they may not charge them. They may try to find something out, work something out informally. Um, but in some cases, as, as in what my story's about is some people are charged with a crime. They get booked into jail, and, um, they often end up staying for a very long time because, uh, um, we can't convict somebody.

We can't put somebody on trial if they are [00:08:00] incompetent to stand trial. That's against the law. And so we're forced to deal with these folks. You know, this is different than somebody standing on a street corner yelling. Now they're in court, now they have an attorney. There's a judge in front of 'em, there's a prosecutor.

Oh my goodness. Does this person understand what's going on? Can they help in their own defense? That's the issue. There are a lot more people now ending up in jail in Missouri and other places who are deemed incompetent to stand trial. 

Mark Mullen: So, because they cannot participate in their own defense, right? So someone raises the prosecutor, the judge, the defense attorney, the patient themselves, the patient's family raises the issue.

Can this person understand the proceedings before them? I don't know. And so they request an assessment, right? So how does that, how does the process look like of that person who is being charged with a crime? Do they just get that assessment then the next day? Is that how that works? Once somebody raises it, they go back to jail and somebody assesses them there, 

Jesse Bogan: right?[00:09:00] 

No. No. Um, and the range of crimes, yes. Is criminal trespassing up to the worst murder. And so we're taught, I think you're taught, you know, in society most people with mental illness are not violent. These are criminal cases and um, a lot of the cases are violent. And so, uh, unfortunately, and so, um, yeah, regardless of the criminal case, eventually somebody flags it and requests a mental evaluation.

Missouri. Um, there's a law, you know, there's laws for all this that, that keeps, it's supposed to keep track of the timeline. Um, if somebody, uh, requests a mental evaluation for this, uh, defendant, they're, they're supposed to have that evaluation done in two months in Missouri, and that's the law, not then they need to Yeah.

They, if not though, they can file a report and say, uh, I'm sorry, I, I don't have it, uh, but I'm gonna have it. That kind of thing. [00:10:00] And so, um, what we're finding in Missouri is that, um, a lot of the EVA evaluations are delayed and delayed and delayed. And so, yeah, that, that's an issue. 

Mark Mullen: So even though there's a law saying once this question has been raised, it needs to be evaluated in two months, we have people who have been charged with a crime, but have not really, nothing's begun in their trial yet because they're awaiting this assessment.

They're waiting significantly longer than two months now, even to just be assessed and have this question answered. 

Jesse Bogan: That That's right. And, um, and so it's easy to get confused by this because, uh, we talk about a backlog and, and, you know, people are not getting the treatment they need, but there's, there's a line to get in line.

And the initial line is, you know, once they're in jail, most of 'em are in jail. Some are released on bond, but not very many of them. The initial step is, Hey, this person needs help, let's get 'em evaluated. Yes, there are delays, [00:11:00] but what's like, and so, and then everybody who's evaluated isn't found to be incompetent.

I'm told about 50% of the evaluations, uh, go either way. So, yeah. Right now in Missouri, there's, there's major delays in the evaluations. 

Mark Mullen: How long is the wait to get in line at this point? How long do does the defendant have to wait to be assessed for competency to stand trial? 

Jesse Bogan: Well to be assessed, it can range for, it just depends on where they are, um, and what their situation is.

I mean, my story is pegged to a woman named Megan Jolly, who, who's from St. Charles, Missouri, the the county of St. Charles. And in her case, she's booked into the jail in February, February, March, uh, I believe the prosecutor asked for a mental evaluation. Um, that evaluation was delayed five months before it came back, [00:12:00] and then the judge has to file the order that says, here, you hear ye this person is incompetent to stand trial.

We now designate this person to be in the custody of the Missouri Department of Mental Health. And so by the time they requested that evaluation in March. The final order saying this person needs competency restoration treatment. And the judge is requesting, it was in November, so March, April, may, June, July, August.

Sip, oc no, that's nine months. 

Mark Mullen: And the patient waits in jail, uh, for this assessment to actually be acknowledged by the court and done. 

Jesse Bogan: Yes. And that's the assessment. And so now this person has been found to be incompetent to stand trial and the court pauses their criminal case. So they're in criminal justice purgatory.

We cannot move forward with this case, um, [00:13:00] until their competency is restored. And so from the time they requested the evaluation to the time the judge says, let's get this person treatment, if my math is right, was nine months. Now Megan Jolly has been waiting in jail to get the treatment that she needs to get competency restoration, even though she's been deemed to be in the custody of the Missouri Department of Mental Health that does this form of treatment for folks.

She's still stuck in the jail and it's going on a year. That's almost what we're in November. It's been a year, 

Mark Mullen: so she had to wait about nine months for the assessment. The assessment found that she was not TED to stand trial, and so. Where you'd hope they would be transferred to a hospital to receive appropriate treatment for their mental health conditions that could then maybe restore them to competency so that they can participate in their own defense.

You'd hope that would happen immediately once it's found that you need it. Because we know from my lens now that the [00:14:00] longer mental illnesses go untreated, whether it's mania, psychosis, depression, the harder they are to treat and the less likely you are to be able to restore someone to that prior baseline.

So you, you really need that treatment to start immediately because every day is not only human suffering, but it also makes the problem worse. Instead of sending Megan Jolly to a hospital for treatment the day after it was found that this is court ordered, she has now been waiting over a year to receive appropriate psychiatric treatment that could maybe restore her to competency and maybe allow her to participate in her own defense.

Is that right? 

Jesse Bogan: That's right. 

Mark Mullen: And did you just go through every record in Missouri and pick the worst case to try to make an example outta Megan Jolly. 

Jesse Bogan: No, it was very hard to get to me and jolly, and as a reporter, I rely on access. I need people to tell me things I was saying earlier, and I need records.

And so, um, the hardest problems have, uh, intersections of all kinds of different systems, right? And on this one, it's [00:15:00] legal and it's, uh, it's health, right? And so, uh, mental health. And so, uh, the state of Missouri, you know, I started asking for records early last summer. You know, who's on this list of people who need treatment?

And so, uh, they would not give me that, right? And, uh, initially they wouldn't even tell me the, the number of people who were awaiting, uh, competency restoration treatment because their concern is hipaa, that, uh, they would be sharing somebody's medical records. But, um, as you mentioned, uh, you're a psychiatrist.

People in jail are not improving, right? That's, that's, so I see it too is this is complex, right? But they're also, uh, being harmed, it seems like I'm told by being stuck in jail. And so I'm willing to push things as much as I can to find out who is in this situation. And so eventually, you know, through Sunshine Law, a [00:16:00] records request, I was able to find out, you know, how many people are in this backlog.

So how many Megan Jollys there are before I even knew who Megan Jolly was. And you know, right now there's about 500 people statewide in Missouri, and that's, uh, that are waiting for competency restoration treatment. So their, their cases are stalled in criminal justice purgatory because they don't have the treatment that they need now.

Two years ago, they were half that number, 250. If you go back to 2013, there were 10 people. Waiting to get competency restoration treatment. So 2013, we have 10. Okay? Uh, 2023, 10 years later, there's 250. So this, this has kind of been going up and up and up every year. Um, state mental health experts have seen this.

They've been studying it for years, and so now it's 500. And [00:17:00] so what I wanted to bring to this, um, this problem was I wanted to find human stories because we're just talking about numbers, because that's all that HIPAA allows us to talk about are numbers and stats. And, um, and so I, I set out to try and find people who are stuck.

And I wanted to be close to them to be able to see what that looks like. I failed, I did not, uh, achieve my goal. I did access was very difficult. Um, time, resources for me to be able to get in a position, uh, to con convince people to allow me to be there to see and describe these situations. I didn't, uh, get there.

I, I have more work to do there, but I, but I did stop and, and analyze the problem and I, I looked at, okay, we've been wrestling this for, with this for a long time. What, what has been [00:18:00] proposed to fix it? How is that working out, looking for people who may be in this trap? I, I came across this about a year ago when I was starting out at, uh, the Marshall Project, which is a nonprofit news organization that writes about systemic criminal justice issues.

And I'm based in St. Louis and we have a big jail here in St. Louis and there's people who have been in there for a long time and it's had just classic, just all kinds of dysfunction. And so my first story was, why is there so much dysfunction? One thing I came across was there are a lot of people in jail who have been there for a long time.

Why have they been there for a long time? I come across some people who had been deemed incompetent to stand trial, and they are still there waiting for that treatment. So that's kind of how I came into this. And Megan Jolly is, uh, who I ultimately wrote about the most. And, um, I was fortunate to be able [00:19:00] to find her case.

This is not a press release kind of story, folks. Uh, somebody, one thing led to another by talking to folks. They told me about this woman and her being in jail. And she, um, you know, at one point she was working on a PhD in political science, super competent person. All the reporting shows that. And, uh, she's in her early fifties and she went into Klein kind of around when COVID started, but I'll stop there.

I've been talking for a while, but, um, it was not easy to find somebody like Megan Jolly and then to be able to share her story. 

Mark Mullen: I mean, I, you know, I led with saying that I'm embarrassed to be a Missourian when it comes to this issue. And I'll be honest, I'm not usually embarrassed to be a Missourian. I'm, I am mew, I'm Midwestern, sensible.

I'm a hardworking, I'm hardworking. I have my common sense. I eat my carbs. You know, I, I am [00:20:00] generally a proud missourian, but this is so embarrassing and it's such a gross injustice. And so it doesn't surprise me that political leaders would not want to make your job easy, would not immediately release this, right?

So you're having to go through all of these legal battles to get access to the information that you are legally entitled to. And that's a lot of hard work, and it's a really important story. And we also know that people in these situations are not dying to talk to a journalist necessarily. I mean, maybe some of them are, but some of them are not really in a position where they're thinking about how can I move my case forward logically, right?

They're kind of in a whole different head space altogether. And while you have not gotten to speak to a lot of these people, I have. Right. Because I work at the hospital right down the street. And so when these people are brought, they really, really, really need care because they're being neglected in the jail.

They come to us, they come to me. And while I can't speak to specifically about that, I think you can tell from the tone of my voice that we [00:21:00] really, really need to get this situation under control. Can you tell me what the treatment of these people looks like in the jail? 

Jesse Bogan: Yeah. So, um, not a lot of treatment going on in the jail.

And so what they're, while they're in that holding pattern, they're waiting for a bed to open up in, um, at the Missouri Department of Mental Health, the Missouri Department of Mental Health has, uh, they, they just basically run a forensic system in Missouri. And so there's three places across the state of Missouri where they do competency restoration treatment.

One in St. Louis, uh, one in Fulton, uh, which has a long history of working with people with mental illness and then one in Kansas City. And so there's limited bed space. I think they have 300 beds for doing competency restoration. And so, um, they're full. And so when one bed opens, another one comes in. And then, so they're not only wrestling with, um, you know, [00:22:00] when I went and talked to them, um, in our state capitol to ask like, how the hell could this be happening?

What's broken in the system kind of stuff. Uh, you know, explain to me how this is happening. Uh, one thing they say is that there are a heck of a lot more requests for evaluation. Going on. And so, uh, like, uh, I think it was 10 years ago, they were getting about doing about 350 a year, and now it's about 1200 a year.

Wow. And so, particularly in the last five years, I looked at some data of the number of requests for evaluation and it, and it's through the roof. And so how I was trying to get at it was, okay, well where is this happening? What counties? Is it just a a part of Missouri where this is happening? Or is it the whole state?

And from what I can tell and what I'm told, it's mainly happening across the state. There are more requests for mental evaluations. Now the state will say it's that, yeah, we're slow on doing evaluations, but I mean, where are we gonna put 'em e if they are evaluated? [00:23:00] Right. Because there's a line to get in line.

Yeah. And so, um, while the Missouri Department of Mental Health is, is, is, uh, the one responsible for them because they're supposed to be in their custody, they. As you all know, you know, there's this great balancing act going on between what do we do in state in an institution and what do we do out in the community?

And, and so, um, there, some of these folks are being helped in the community, not very many of them. 

Mark Mullen: So it's a statewide problem. In terms of what's driving this, there's been a lot more competency restoration assessments ordered 1200 now versus 350 previously. You know, it's statewide. But do you know why we're requesting more evaluations?

Right? Is it because defense attorneys are more aware that their patients are having these problems? Is it because there's just more mental illness in the community? Is it, do we know why? 

Jesse Bogan: We don't know why. Well, I don't [00:24:00] know why, but I know I spent a lot of time trying to figure it out. And, and those, what you said was, I, I did hear that, but I can tell you what a judge said.

Mark Mullen: Yeah, 

Jesse Bogan: he said Assist assistance for the mentally ill is incredibly underfunded. Someone is charged with a crime, who needs mental health treatment, can't get it. Therefore, they continue to struggle and re-offend and end up being locked up when all they needed was basic mental health assistance. That's part of it.

And the safety net in, definitely in Missouri where the, the Missouri Department of Mental Health, you know, they used to have, um, uh, emergency rooms for people who aren't accused of crimes. And those closed, you know, by around 2010. And so there used to be one actually right next to where they do competency restoration.

The Missouri Department of Mental Health used to have an emergency room right there. But when [00:25:00] I go to Jefferson City and say, Hey. Is that the reason why we're seeing so many people end up in jail because the state is no longer offering this kind of care to people who haven't broken the law or accused of broken the law.

They don't provide an easy response there. They say there is a safety net out in the state and these hospitals have to rely on the same statutes. So it's a very complex thing. Yes, there's more awareness and mental illness and so that's part of it. Uh, people have been on, um, medications for years now.

There's been extended use of things like meth. What does that look like? Um, you know, things like that. Um, also the changes in offerings in the community safety net. We talked about Megan Jolly and we started her timeline once she entered the jail. Right. Well, I've got a whole timeline for Megan. And, uh, there's all these [00:26:00] stops along the way before she went to jail.

That included being admitted to the hospital, uh, to a psych ward that admitted that included being, interacting with the police multiple times, neighbors emergency rooms. Um, she ran out of the emergency room at one point. Um, so those are all these things that lit that lead it up. I mean, she was, she was paranoid and clearly, um, the medication, if she was on it wasn't working.

And so there's, it's a complex problem we got here, folks. 

Mark Mullen: Sure. And I, that judge's explanation to that makes a lot of sense to me that essentially there is more mental illness in the community because these problems are not being intervened upon. This is the same population of people that in the 1960s were hospitalized for much longer and even 20 years ago.

Right? Right Now, the average length of stay for a psychiatric hospital nationally is roughly three to five days. You don't have to look very far in the past for that number to be triple, [00:27:00] quadruple that Right. The level of treatment that was happening in the community was a lot more intensive and what I will put my finger on as an answer to this question is.

Again, as someone who works in an acute care setting, right, there's a really high bar to proceed with involuntary treatment, and a lot of these people that we're talking about do not have good insight into how their mental illness is affecting them, and they don't want treatment, and they don't necessarily think they have a problem or they do think they have a problem.

And this treatment that I'm offering is not the solution to it. And so unless that person meets a really high threshold of an imminent risk of danger to self or others due to a treatable mental disease or defect, that's a really high bar and imminent risk of danger to self or others, right? Sometimes we'll say it's not illegal to be psychotic, right?

And it's not illegal to be psychotic, but being psychotic is going to lead you to do things that are going to. To bring you into contact with law enforcement. And while I can treat someone involuntarily in the hospital when they meet that really high bar, [00:28:00] once we discharge that patient from the hospital, Missouri has absolutely no mechanism in place for ensuring that that person continues to engage with mental health treatment.

And I personally think that's where people are getting lost is we can do some involuntary treatment while we physically have the person with us. But some other states do have outpatient commitment laws where if a person stops engaging with treatment and has a return of severe symptoms, they can then be brought back to a place where treatment can be rendered.

And in Missouri, we don't have that. And so where do those people wind up when they don't get treatment? Well, they wind up in jail and they wind up having their civil rights violated for years at a time. Uh, Jesse, we're gonna go to break now, and when we get back, we're gonna talk about how this might be relevant on a national scale.

Jesse Bogan: You know, you would think that as a doctor, I would 

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Welcome back to Psychiatry Bootcamp. We're here with journalist Jesse Bogan talking about, uh, the problems that we have in Missouri and nationally treating people with severe mental illness with respect and dignity in the criminal justice [00:30:00] system. Jesse, before the break, we were talking about how we treat people in the outpatient setting before they come into contact with the justice system.

Does that track with what you have found in your reporting? Is that you think that's where the problems lie? Did you come into any stories that kind of drive that point home, or did you have any additional thoughts on that topic? 

Jesse Bogan: I think that, uh, a lot of people do do really good work in, uh, in mental health.

I, I am told that I don't get to see a lot of it, but I keep hearing that, that some people are really good at their jobs. I don't want to come off as so righteous. Okay. I said that earlier. Uh, where I push back a little bit is who gets the help. Who, who does the system want to help? Who do they want to deal with?

Well, we're talking about people who have been deemed incompetent to stand trial. We're learn, we're taught, we learn that mental health doesn't discriminate. Right? That it hits all kinds of families. Well, why are all the people on this backlog that, um, [00:31:00] you know, there's 500 people, uh, in most of them in Missouri jails waiting for treatment.

Why? Why do most of them have public defenders? Megan Jolly, the person I focused on in my story. She has a public defender she didn't before because she had too much money. She could, they wouldn't grant her a public defender, but she lost assets by being in the system. 'cause her home was auctioned off. I mentioned a judge.

Um, her home was auctioned off on the courthouse steps right across from the jail that she's held, held in. Okay? And now she qualifies for a public defender. One judge, um, I got to know a little bit by sitting in his court. None of this is in the story that I wrote, but he mentioned to me, he said, often the mentally ill are completely stable given the proper treatment.

I'd say most are, this is his word, and he tells a very quick story. I had a guy who started a fire in his apartment. [00:32:00] He lived in a fancy place over in the central west end of St. Louis where rents can top $5,000 in the building that this guy lived in, he was charged with arson. He wasn't trying to burn the place down.

He quit taking his lithium. So what did we do? We got him on his lithium again, and they dismissed the case. So I bring that up. Who do? Who do we naturally help? Who gets stuck in the system 

Mark Mullen: is your answer that we naturally help the people that are easy to help. 

Jesse Bogan: I think the people who have the resources and the support to get help, get the help.

But unfortunately with the, these folks, um, you know, they've burned so many bridges with their families, their employers, you know, they, a lot of 'em are homeless and so they, they have nothing left and but the [00:33:00] safety net that, that's offered to them to work with them. And so this is, uh, these are desperate cases.

So if you're into kind of working with that population, this is for you. And so where's the worst place for a mentally ill person to, to be? Is it in the street? Is it in the jail? I mean, some families tell me, God, I'm glad they're in jail. Right? Because I, I don't know where they'd be otherwise. A lot of 'em are, uh, you know, they've been in nursing homes, right?

And they're not like 85, right? Some of 'em are younger and they're nursing homes. What I hear from my reporting is that they get, you know, kicked out of a nursing home, they punch somebody, right? Special victim. When you punch somebody in a hospital setting, that's not good. Or if somebody's belligerent, you know, then they're gonna move to a disparate nursing home.

And so a guy mentioned in my story, his name Tim Beckman, and he [00:34:00] had schizophrenia and he had a guardian, uh, his son was his guardian and he, um, Tim Beckman was belligerent at times, according to the court records. He moved around the nursing home circuit all over the state. This guy is from St. Louis and he, he lived all over the state of Missouri, ends up in Kansas City.

Um, he punched, uh, an aid of some kind and uh, there was a case filed. He was released to the street. A couple days later, he's accused of breaking into somebody's home, making a meal. People come home and they see this guy staring at the wall at a ceiling, eating a burrito in their house. He's arrested. Um, he's taken to the Jackson County Jail where he's takens for eight months and he's eventually deemed incompetent to stand trial.

And he died in his, uh, he died in the jail awaiting competency, restoration treatment. [00:35:00] And so people can die waiting. His, his, he's an example of that and I have a copy of his autopsy. He has no medication in his system, you know, and he has a history of schizophrenia, well documented. Um, he was talented. He was a really good musician.

He used to sing at his church in front of lots of people. I've spoken to his family. Um, but anyway, so. Here's this system that they're in, and they need to be restored. And so there's a treatment program that the state offers. For the most part, the mostly the state offers this treatment to be able to get somebody restored so they can go on with their criminal case.

What does that treatment look like? What they're trying to true is just, you know, they're, it's like law 1 0 1. This is attorney, this is a judge, this is a courtroom. Uh, this is what you're accused of. This is an indictment. This is where you sit, this is where these people are gonna be. And these people while you're in court, um, they're [00:36:00] also supposed to get some medication while they're in competency restoration treatment at a state facility.

They watch. Uh, I have the curriculum I can share with you at some point, but, uh, I talked to some people who have seen this treatment. I wasn't allowed to watch it, but they said some of the times they watch the movie. Uh, my cousin Vinny, you ever seen that? I have seen that. Yeah, Danny DeVito, uh mm-hmm.

Marissa Tome, I think she won an award and it, and it's, uh, it's, it's a kind of a comical, uh, view of the court system, but they're using that to kind of teach them what court is like. And so this system is just helping them get stable enough so they can go back to court. 

Mark Mullen: Um, actually. Down the hall from me is Dr.

Allen Felt House, who is the past president of the American Academy of Psychiatry and the Law, and he's a supervisor of mine. We're gonna have him on to talk about what competency restoration actually looks like, what those criteria are, um, as well as not guilty [00:37:00] by your reason of insanity evaluations, which is sort of a totally separate topic, but in the same realm.

Um, so we will be talking about that on psychiatry bootcamp. You mentioned Law 1 0 1, right? This is Law 1 0 1. You don't need to have a very high level understanding of the proceedings, but you need to know who a judge is, what their job is. You need to know who your lawyer is, what their job is. Let's hone in on Law 1 0 1.

Jesse, I have a question for you about Law 1 0 1. I'm gonna rehear the actual verbatim texts of the Sixth Amendment to the United States Constitution. Quote, in all criminal prosecutions, the accused shall enjoy the right to a speedy and public trial end quote. To me that's plain English. Plain English, even though it was written quite a while ago.

Um, to me, having someone wait for about a year to be assessed for competency and then to wait over a year to actually begin meaningful psychiatric treatment. Right. Two years of wait time incarcerated, languishing in a jail [00:38:00] cell before meaningful treatment begins. This to me seems like a pretty clear violation of a defendant's Sixth Amendment rights.

What am I missing? 

Jesse Bogan: Yeah, I mean, you make a, I mean the, it speaks for itself, right? Um, these folks are in jail for a long time and, um, they're not getting their day in court sometimes, um, for, for years. Like you mentioned, two years. It might be longer, it might be shorter, right? So, yeah, it, it brings up the question of like, why on earth should we charge somebody?

If in some cases if they serve their full sentence, uh, if they were convicted, found guilty and convicted, they, they would've been out by now, but yet they're still in jail waiting for their, for their case to, to pick up again. And so that's happening. Um, out of those 500 people who are in the backlog, dozens of 'em are, are, are accused of [00:39:00] misdemeanors or parole violations, stuff like that.

Yeah. That, that's part of the egregiousness of this issue. And, you know, there's a sense, this seems like there would be a sense of urgency to address it. This has been kind of building for, for 10 years. So, but I do know that, um, you know, other state, there are other states that are wrestling with this, lawsuits have been filed.

One thing as a reporter that I've known, I've been a reporter about 25 years, and I, I don't like this, but it's like nothing seems to move anymore unless you have a law, a law behind you. And is this the right thing to do? Should we adjust our safety net or treatment? Um, or do without a lawsuit? Well, today there's a lawsuit filed, uh, in Missouri this morning.

I haven't had a chance to read it. I heard that it was coming, but, um, yeah, there's a big lawsuit that was filed actually just today on this issue. And, um, in Missouri, I mean, they've already had committee hearings in the state level at the state capitol, you [00:40:00] know, where they talk about this issue and they explain to lawmakers, the Missouri Department of Mental Health explains the backlog and why there's this black backlog.

And then the, the deputies who are, you know, they're complained. They've already complained. They've been been complaining about how is it that we have to take care of these people whenever the law says that they need to be treated. I mean, these discussions have been had. So now here comes the lawsuit.

And so my question as a reporter is like, why, why do you have to wait for a lawsuit to get something done? Even if, I don't know, I don't know if they will get anything done on this. So, uh, I don't, I don't know what it's gonna take. I'm still learning. 

Mark Mullen: I'm interested. I didn't know there was a law that said that a defendant is supposed to be assessed for coy to stand trial within two months.

So in that case, we actually do have a law and it's just not happening anyway, if I'm understanding that correctly. And then the other pieces, 

Jesse Bogan: they have to be evaluated. Yeah, they have to be evaluated within two months, but then they'll, they can delay it. 

Mark Mullen: Delay. In Megan Jolly's case it was nine months.

Yeah. [00:41:00] Um, and then the other piece is, I, I, to me this always just comes down to money. And it's almost, uh, there's some fallacy in doing an hour long episode about this because the state is eventually going to need to pay for this and to expand access. And I, my opinion is that plaintiff's attorneys are the most powerful people in the world because they're some of the only people that can hold powerful institutions like.

States and corporations to account, see also Aron Brockovich. Um, and I, I wonder, um, why it's acceptable for the state to be harming people in this way and damaging people in this way and leading to significant pain, suffering, lost wages, et cetera. And my hope would be that at some point, one way or another, you know, you hope that the state would do the right thing for the people that are living in the state.

But if nothing else, the state responds to monetary [00:42:00] incentives. So I personally am hopeful that some litigation will make some progress on this issue, but I also know that, um, as we're talking about today, that takes a while. And so certainly there are going to be other people like Mr. Beckman that you mentioned that die while awaiting, uh, due process.

And so we'll have to see what happens. So we're talking about Missouri here. My audience is actually really international, like 40% of my audience is not even in the United States, and most, the vast majority of my audience, probably at 99% is not in the state of Missouri. Is this a Missouri only problem or is this a national problem?

Jesse Bogan: No, it's a national problem. And, uh, one thing that I, I, um, iRead on is that, that, you know, there's lots of people in the jail system and everybody says, you know, everybody seems to be aware that yes, there are a lot of people in jail with mental illness. Well, this is just a kind of a, a concentrated sample of those folks.

The ones that are the worst off, okay, there's lots of other folks that [00:43:00] still need help. This is a group that's in really bad shape and, um, this is a group that the state is actually recognizing and saying, Hey, they, they're incompetent. They need help and so let's give them that help. But the system is there to help.

But in some ways it appears to be that it's hurting because they're not getting the help they need. And so one guy mentioned in the story, his name's Joshua Cup. He is 49. He's accused of exposing himself at a popular, uh, Catholic church in school in St. Louis. And, um, his attorney recently argued that, uh, Joshua Cup had been incarcerated more than 400 days, despite facing a maximum punishment of a hundred in days, 180 days.

And so, um, he's listed as homeless and one of about 50 people on this backlog, accused of a [00:44:00] misdemeanor. But these cases, this backlog is forcing us to kind of ask questions like, what do we do for people that don't seem to have help anywhere? So, like Mr. Beckman, miss Mr. Cup, Megan Jolly, every case is a little different.

Other than that, they really need help and they're not getting it. I imagine that's relevant all over the world and definitely relevant here in Missouri, which is where my lab is. You know, in your lab there's some interest you're at, uh, St. Louis University Hospital, right? 

Mark Mullen: That's right. 

Jesse Bogan: There's some overlap there where I got into this, looking at the, our local jail and, and the roster and who's been there the longest.

That's how I can find people. It's a easy sign of mental illness if somebody's been in jail a long time. And so this guy, I went and looked and I noticed that he'd been admitted to the jail in 2018. Okay, we're, we're in 2025. And so a natural question is [00:45:00] why is this guy in jail still se more than seven years?

And so, uh. He was accused of beating his wife. She was beaten. She was taken to St. Louis University Hospital, essentially brain dead. Her family came in for a while, but eventually the machines were turned off. She died. The, the case was elevated from a domestic assault to murder. Okay? This guy, they'd been married for years.

The guy, Mr. Johnson had no criminal history. Apparently he went into deep depression, I'm told, and he would not come out of his cell for years. Okay? That's relevant all over the world. That's relevant all over our country. It's relevant here in St. Louis. This just happened. I went to his trial. I started going to his hearings and trying to lay eyes on this guy.

What does he look like? What condition is he in? Well, he is lost a lot of weight from what he was. He used to be enormous. Uh, he, he's very [00:46:00] skinny now. And, um, I watched him. I asked questions. I asked this judge who I've quoted earlier today. What's up with this case? Why, why is it taking so long? And he told me this guy needed to be maced to get out of his cell, uh, before, so we don't really want to force it, you know?

But meanwhile, his case is dragged on. Uh, so I can tell, I can tell you a lot about that case. Um, but I think it's interesting because he eventually, you know, his case was psyched three times, including, uh, he was deemed incompetent to stand trial and he did go, you know, we're talking about how to get into that restoration treatment, right?

Well, this guy, this guy got the treatment that a lot of people can't get. He got restored and he went back to jail and he stayed for years. And so, um, you know, there's, people come in and outta competency and, uh, you know, cases can linger for a long time. 

Mark Mullen: There are even cases where you [00:47:00] are found in combat at the stand trial restored to competency, and then sent back to jail to actually have that trial.

And while you are awaiting or even participating in that trial, you are, you no longer have all of the functions that were available to you at the psychiatric hospital. You no longer have that staff to patient ratio. You no longer have access to all of the professionals, the therapists, the social worker, the nurses, the patient care techs, the close security monitoring, the psychiatrist.

You just don't have access to that treatment. And so while you are in jail and proceeding with trial, you could then again have reemergence of mental illness and, uh, lose competency, which I think is one of the places where this problem gets really outta control and really difficult to solve. I'd like to ask you as kind of our final major topic, what attempts have been made to fix this system?

Jesse Bogan: Yeah, thanks for asking that. And that's how I tried to approach this because it's been going on [00:48:00] a while. I mean, while it's still news to people, a lot of people, including lawmakers and judges are still learning about this issue. People at the Missouri Department of Mental of Health know about it and, um, there have been some attempts to address it.

And so, um, one thing that changed is Missouri changed its laws, um, to allow people to be treated in the community. So we mentioned there's three places in the state to get competency restoration treatment. Um, they changed the law a couple years back to allow that to happen in the community as well. They also, um, since people are stuck in, uh, so there's outpatient treatment possibilities, uh, people are stuck in jail.

So what's bringing the treatment to them in jail? So there were some pilot programs that are ongoing now that were really kind of slow to get going. Been four jails in the state of Missouri where they can do competency [00:49:00] restoration treatment in the jail, like up to 10 people. That's one thing they did here in Missouri.

And then they also came up with this idea to have forensic mobile teams to reach people. So I'm in a big, the big city of St. Louis, right? There's lots of hospitals like yours, um, but out in remote jails, how are we gonna reach, uh, those men and women? So the idea was to have and fund this mobile, these mobile teams to, uh, to try to reach people.

Those are kind of the three main, uh, changes that they did. 

Mark Mullen: So instead of this model where a patient has to be admitted to a hospital to receive treatment, they're looking at other ways they can bring treatment to folks. Uh, I guess what I would add from the psychiatrist's perspective is treatment does not, treatment does not treatment.

You know, anyone who has been treated for a serious health condition or has been a clinician. Understands that there are different levels of care. There are different levels [00:50:00] of provider training, right? They might need a forensic psychiatrist. And right now Missouri doesn't have a forensic psychiatry fellowship, so we're not turning out new forensic psychiatrists and equating the treatment that you might get in the outpatient setting with the treatment that you might get from this mobile unit who goes to a jail with the treatment that you're gonna get from a high level forensic hospital that has all of that staffing that I mentioned earlier.

Those are gonna be different levels of treatment. And so I think it's good that we're thinking creatively about this problem. We're going to need to think creatively about this problem. Um, but I also fear that we're going to be giving second rate treatment for second rate patients. And I think that could be a new problem in and of itself.

Jesse Bogan: Yeah. Uh, when I went out, you know, as a reporter to go and kind of test, like how, how are these programs working? Uh, it doesn't look good. Okay. You know, just a few people being treated in the community. That was a surprise, like eight, like when I first started looking at it, was like eight. [00:51:00] Okay. And then it was like 16.

So a hundred percent improvement there. Uh, 16 in October, you know, when this law changed to allow some differences, you know, to come, some come up and think creatively it was, find some solutions, you know, there were 250 people on the backlog. Okay? Today there's twice that number. You know, there aren't enough people, and the state has said this, you know, there they, they see it seems like, you know, it'd be good for them to speak for themselves on this, but from what I gathered is they see part of the solution being out in the community that's not going very fast.

These pilot programs in the jails not working out great. And in fact, some people are so psychotic that they don't even qual they, they can't even go to this program. And in St. Louis County, Missouri, there's a medical director, um, who I was very grateful for her time. Her name's Dr. Old Egg and she used to be an emergency room doctor in Chicago and some other places, and she's originally from Missouri.

But I [00:52:00] appreciated, uh, her diagnosis of this problem in her jail. One, she's glad to have the pilot program because it brings in more resources from the state. She has more access to better, uh, and expensive, uh, medicines. Um, uh, slow release injection kind of stuff. Obviously this is outta my expertise, but, so yes, she's glad to be working with the state, but outta 16 people who had been in that program, like two had quote unquote graduated.

Many of them. Just could not participate in class because we say, we say law 1 0 1, it's like the prerequisite to prerequisite to prerequisite to 1 0 1. You know, not to make fun, but this is the reality. She said, you know, they're starting on module one over and over again. They're, they're just not there.

They're too psychotic. Some of 'em are too violent to participate. Okay. And so [00:53:00] she, so that's what's happened with that pilot program that I got to see here a little bit by talking to somebody who's aware of it, the mobile unit, the forensic mobile tanks. Sounds like a good idea. This is from a jail administrator up by Hannibal, if any, if anybody's ever, uh, read, uh, mark Twain.

Hannibal was the town and it's called, uh, Marion County. And so the former jail administrator up there, his name's Keaveny Coates. And, uh, when he found out that I wanted to talk to him about this issue, this is a sheriff's deputy, and I'm a reporter. Okay. I almost missed him and, and I was just passing through his county and he ran out the front of the building and said, Hey, are you wanting to talk about incompetent to stand trial?

Oh my God, let's talk about this. We talked for an hour and a half, him and the sheriff about this issue that you and I are talking about right now. So the mobile unit. And so they're very aware of people with mental illness in their jail. This is the guy who was in charge. This is the guy who talks about they're going to Dollar General to get [00:54:00] coloring books for these people to abide time.

So he's glad to hear that there's gonna be mobile units. When the mobile units were announced, the inference that we had as jail administrators around the state was, thank God. Finally, they're going to start coming to our facility. They're going to start seeing the feces on the wall, the urine being thrown.

He went on to talk about how the mobile unit doesn't come to the jail. It's all like this, like what we're doing now. You know, it's virtual. A lot of it, you know, these are small teams. They can't get everywhere. You know, we're not talking about 20 people on a team canvassing the state of Missouri, you know, small team.

Lots of demand. So they're trying to, apparently trying to do what they can by, by reaching people, uh, electronically. [00:55:00] Somebody in jail says, Hey, is there somebody here to see me? No. They want to talk to you electronically. No thanks. I'll stay in my cell. Remember, Mr. Johnson doesn't wanna leave a cell, but really needs to leave his cell.

He really needs help. And so, uh, they're also not going to court. And so people aren't seeing these people. I don't get to see them in court. Attorneys don't see 'em in court. Family don't see 'em in court. Judges don't see 'em. They, they, it's like this. And so there's a loss of intimacy and connection with people who need help.

I'm getting on the self-righteous horse. I'm sorry, but that's the kind of stuff that I really wanted to achieve with this story. And, and, and this deputy, I'm so thankful that I, that I found him randomly. Deputy Coates, if you ever watch this, thanks for talking to me and tell me what you're really seeing, because we don't really know exactly what's happening out there.

And this gets close. 

Mark Mullen: We've talked about this a lot on psychiatry bootcamp about how [00:56:00] people with severe mental illness are treated in our society. We've talked about how a lot of them are in jails, in prisons not getting appropriate treatment, and this is really important to me. I don't think that what you're saying is self-righteous at all.

I mean, this is not about you. You're not in jail awaiting a Yeah. Competency assessment. I think it's just really important work and it just takes someone that is really moved deeply by it and cares deeply about it, and I don't think it's self righteous to say that I count myself among that number. It's just, uh, really a failure of our society.

Uh, I'm glad to hear that what you're seeing in the community tracks with what Dr. Felt house down the hall has been writing about, which is essentially we can have creative solutions, but at the end of the day when people are too psychotic to participate in treatment or don't think they have a problem due to their mental illness, you can't just hand them pills and expect that to solve the problem.

Right. Psychiatric treatment is not just handing people pills. It is a lot of other things as well. It is. Family therapy, it is psychotherapy. Long-acting injectables need to be used often. A lot of these [00:57:00] people are not going to engage with Freeman voluntarily and look in healthcare, in medicine, there are some people that have medical problems that do not or will not get better.

That is the reality of being a doctor. It's part and parcel of being a healthcare provider that is not this population. We are not even trying for this population. We have made no good faith effort to solve this problem and with appropriate treatment for, I won't agree with the judge and say all of his individuals, but I'll say a lot of these individuals, they can make a meaningful recovery and we're not giving them any chance at this point.

So I think it's super important work. Um, thanks for running through those creative options with me. I'm just gonna ask you at this point if you have any final thoughts for our audience. 

Jesse Bogan: Just that again, that this is a core sample. Uh, this is one specific piece and, and, uh, and, uh, in a, you know, a hole.

Cadre of problems and challenges. And so, um, you know, by focusing on this, we're kind of [00:58:00] pushing other things out to the side. But I imagine by encompassing, you know, you know, looking at the whole sea of problems, uh, would you know that would be good. I, I'm not a problem solver. Right. And that's what I mentioned, the self-righteous, it's easy for me, it's, it's actually not so easy to point out some of these problems.

Yeah. 

Mark Mullen: Yeah. 

Jesse Bogan: But, but, uh, my role, I'm trying to elevate it so people like you and your colleagues and others listening will come up with, you know, creative solutions and um, you know, I imagine there's some really smart people that are watching this program and they're really good scientists. Um, what I run into as a journalist, you know, it's like I, even in my own profession, I can learn the trades of being a journalist, but I've gotta go out and do my job.

And, um, sometimes it's just having my blinders up and doing journalism. In the programs where we work, what I imagine somebody listening might end up working for a State Department of Mental Health. There's thousands of people that work at the State Department of [00:59:00] Mental Health in Missouri alone annually, 60% of the, uh, the people who provide, uh, what, uh, in care treatment, like they interact with patients.

60% of them quit a year. Okay? So, hey, I, I'm Pok, I'm pointing at Department of Mental Health. Uh, well, can I run it better? I, I mean, that's not my expertise. Who's in a position to help these folks, folks, I'm not saying that the leaders can't do a better job at DMH, but it's more than just DMH. It's a lot of, of, uh, forces at play here, including just people just listening and being informed.

And so they'll, they'll think about it a little differently. And so I, I appreciate you guys dedicating this time to this. And so I say this is just one piece. Mr. Uh, the guy that, uh, uh, Robert Johnson, right? And so last week [01:00:00] he was convicted and so he, he was charged in 2018, been in jail this whole time. He is gone through this system, right?

And his case was psyched three times, and he had 11 prosecutors. It was so long, and he'd been maced in his cell, and I went there. One reason to ask his public defender is like, is he competent? And, and he said, yes. That's, we wouldn't be here otherwise. Well, he's awaiting sentencing. He's gonna get sentenced, I suspect, to many years in prison.

So he's gonna go from here to the prison system. Is that somebody that you wanna work with? There's so many other needs. Do we spend our time working with Mr. Johnson, who's now in prison? Or do we find others who maybe we can reach or maybe y'all can reach before they beat their wives to death. You know, is that your place to enter the system?

Is it before they get in trouble? Is it after they get in trouble? You know, all those complex things. [01:01:00] I just recognize as a reporter, there's a lot of people and there's more and more and more of them who need help. And so I naturally just wanna know why and what can be done. And so thanks for letting me ramble on about this stuff and keep this story alive.

Yeah, 

Mark Mullen: I could answer all those questions and I could go on about this for hours, but unfortunately, we're at time. I'm going to conclude us by again reading the text of the sixth Amendment to the United States Constitution, and then we'll drop the mic. In all criminal prosecutions, the accused shall enjoy the right to a speedy.

Public trial. I think speedy means quick, I think, I think speedy means relatively fast, but um, I don't know. I guess I'm not with Professor Jesse, thanks so much for coming on. I really appreciate your time. 

Jesse Bogan: Thank you.

Mark Mullen: Thanks so much for listening to this episode of Psychiatry Bootcamp. If you're enjoying the show, we would love to [01:02:00] know what you think. You can connect with us on TikTok or Instagram at Psych Bootcamp, or you can email me mark@psychiatrybootcamp.com. Visit psychiatry bootcamp.com to sign up for our new newsletter, and you can connect with the rest of the Human Content Podcast family on Instagram and TikTok at Human Content Pods.

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You could find full video episodes now on YouTube and on Spotify. The YouTube channel is at Psychiatry Bootcamp. Thanks again for listening. I'm your host. Mark Mullen. Our executive producers are Aron Korney, Rob Goldman, Ashanti Brook, and me Mark Mullen. Season four is produced by the wonderful Matthew Braddock.

Our editor and engineer is Jason Portizo. Theme music generously donated by one of my [01:03:00] favorite bands. Cave radio. Find them on Spotify. Other music is by Omer Ben-Zvi. To learn about our program, disclaimer and ethics policy submission verification, and licensing terms, and our HIPAA release terms, go to psychiatry bootcamp.com or reach out to me mark@psychiatrybootcamp.com with any questions.

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