Tony Mantor: Why Not Me the World
Jhilam Biswas Reveals Paths to Mental Health Reform From Forensic Hospitals to Freedom
Wed, 14 May 2025
Send us a textDr. Jhilam Biswas, a board-certified adult and forensic psychiatrist, discusses how mental health issues intersect with the criminal justice system and the urgent need for reform. She shares insights from her research and clinical experience working with incarcerated individuals with mental illness, explaining why mental health care in America's prisons is a humanitarian crisis.• Director of Psychiatry Law and Society program at Brigham and Women's Hospital and co-director of Harvard Mass General Brigham Forensic Psychiatry Fellowship• Research shows delays in psychiatric treatment lead to increased violence and worse outcomes in forensic settings• Individuals with autism have higher comorbidity with serious mental illness and are more vulnerable in law enforcement interactions• Mental illness evaluation processes vary based on setting, with court-ordered evaluations having strict timelines• Three main pathways to incarceration: substance use disorders, traumatic brain injuries, and untreated mental illness• America's largest jails have become de facto psychiatric hospitals, which Dr. Biswas calls "a human rights violation"• Currently championing two legislative reforms in Massachusetts: the Timely Treatment Bill and Critical Community Services Bill• Mental illness is treatable but often cyclical, requiring consistent medication and support• When people suffer from psychotic disorders, they often lose insight into their condition, making treatment refusal a symptom rather than a choiceTell everyone everywhere about Why Not Me, The World, the conversations we're having and the inspiration our guests give to everyone everywhere that you are not alone in this world.https://tonymantor.comhttps://Facebook.com/tonymantorhttps://instagram.com/tonymantorhttps://twitter.com/tonymantorhttps://youtube.com/tonymantormusicintro/outro music bed written by T. WildWhy Not Me the World music published by Mantor Music (BMI)
Chapter 1: Who is Dr. Jhilam Biswas and what is her expertise?
Hopefully, you gain more awareness, acceptance, and a better understanding for autism around the world. Hi, I'm Tony Mantor. Welcome to Why Not Me? The World, Humanity Over Handcuffs, The Silent Crisis Special Event. Today, we're joined by Dr. Gillum Biswas, a board-certified adult and forensic psychiatrist.
She is the director of the Psychiatry, Law, and Society program at Brigham and Women's Hospital and co-director of the Harvard Mass General Brigham Forensic Psychiatry Fellowship. She chairs and contributes to numerous psychiatric forensic and medical committees at both state and national levels.
Her research focuses on improving mental health laws to better support patients and families while advancing criminal justice reform. With her expertise in mental illness, risk assessment, and more, we're thrilled to have her share her insights with us today. Thanks for coming on.
Thank you. I think you're doing such a huge service.
Thanks for your kind words. I really appreciate you taking the time to be with us today. It's truly inspiring to see your impact as a mental health advocate and your leadership across various boards. Can you share with us your journey and how you reached this point in your career?
A lot of what I've done is research. So I worked at a forensic hospital for many years, and I realized that it was very hard to get the courts to allow us to provide medications for psychotic illness in time if somebody didn't have the insight into knowing that they needed it. So what we ended up doing, and I was the principal investigator in this research project, is
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Chapter 2: What challenges exist in providing timely psychiatric treatment in forensic hospitals?
It took years to get all the agencies to sign off on doing a research study in the carceral setting on mental illness. But what I did in the forensic hospital, this is all those individuals you're talking about with mental illness. But also a lot of my patients did have an autism diagnosis.
Not all of them, but certainly we do see a correlation of individuals with autism who might have a comorbid serious mental illness like bipolar disorder or schizophrenia or PTSD, you know, because what happens when you have autism and you're having difficulty with social cues and having difficulty with reading social situations, it can't, it just makes you more vulnerable.
to fall into difficult situations, meeting up with law enforcement, law enforcement not necessarily reading you right or reading you well, and it resulting in something that's much bigger or spiraling out of control. And so...
Chapter 3: How does autism intersect with serious mental illness and law enforcement encounters?
A lot of times when I was working at the forensic hospital in Massachusetts, these individuals would have mental illness but also have this diagnosis of autism and also a diagnosis of traumatic brain injury. That was another really common thing that I would see in individuals.
And so we did a research study because one of the biggest issues that I found in forensic hospitals and working in the incarcerated, in a system with patients who are incarcerated, is that it's very difficult to get... standing doses of treatment for them.
So going over everything that you've done so far, what was your next step to finding more information?
So we ran a study and we showed all of these different adverse events that occur while we're waiting for the courts to allow us to give treatment.
And those adverse events, you know, were like patient on patient assaults, patient on staff assaults, climate incidences where, you know, the individual is either victimized by others or, you know, throwing things or breaking things in the unit and really just causing a lot of disruption.
And so what ends up happening with these delays to treatment in carceral settings or forensic hospitals, and actually in Massachusetts we see it even in our acute care settings, is it's not a healing environment necessarily for people.
Can you expand on why that is?
Because the other people are so sick around them or they themselves are so sick and there's this delay to care. So anyway, all that to say, we did this research study. We found that when we do provide treatment to individuals in forensic hospitals, things improve dramatically and these adverse events decrease dramatically.
Actually, I'm going to be president of the Massachusetts Psychiatric Society in April.
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Chapter 4: What legislative reforms is Dr. Biswas advocating for in Massachusetts?
Great question. The evaluation process, I think if I were to drill it down, it's a psychiatric evaluation. A psychiatrist is a medical doctor. We go through medical school and we do a psychiatry residency. And then we have a subspecialty in understanding how people with mental illness may interact with the law. And so I use a lot of my training and experience to do an evaluation.
But a lot of what I'm doing is looking at the psychological factors, biological factors, environmental factors, and social factors, social determinants of health that may have resulted in the illness that I'm seeing. And how do we intervene in all of those various factors so that individual can be stabilized from their crisis and then be maintained in a lower level of care or in the community?
I do that is I get a very deep social history, developmental history, substance use history, mental illness history, medical history, legal, you know, like there's a lot of ways to get all this history. And then we use all the components that we have kind of sussed out in the examination to describe what we're seeing.
Once you determine what you think is happening, what is the next step after that?
So the next step after kind of thinking about what is happening, you make a diagnosis if a diagnosis is available to make or not. You can make a diagnosis. Sometimes it requires more testing depending on what the issues we're seeing. Sometimes it's a deep dive into past medical history and legal history or if it's a court case kind of going into the, you know, the components of the court case.
and making a clinical opinion on that diagnosis. So saying there's this diagnosis, and in my clinical opinion, this is what we need to do next. And then in that clinical opinion, we offer treatment recommendations also.
How long does it take from the initial meeting with a patient to assessing their condition, making a diagnosis, and prescribing medications or other treatments they might need to move forward?
So it happens on a case-by-case basis. It really depends on the story and it really depends on the situation. Some stories are really hard to figure out. You know, somebody might be very high functioning and they're living a very, you know, functional life, but there's just a missing link that results in a bad situation or a bad outcome.
It may take a deep dive into the history, doing interviews with family members and friends and institutions that they're part of, their caregivers, their treatment providers. And so that can take some time. The other thing I always say about a psychiatric diagnosis is it's hard to make a diagnosis of psychiatric illness in one snapshot.
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Chapter 5: How does forensic psychiatric evaluation work within the court system?
that the court is seeing, like the person is not making sense, they're confused, they're disheveled, their hygiene is bad, you know, they're talking to themselves.
That's kind of a quick and dirty snapshot view that someone in Massachusetts, we call them court clinicians, there are psychologists and social workers at every court that will do a quick and dirty evaluation and say, look, this person needs a longer mental health evaluation.
versus, you know what, they can actually have their day in court, they can get arraigned, they can go to a jail setting for a pretrial period. There is an evaluation that's done within the day in that setting. Then if there needs to be a longer evaluation, by statute in Massachusetts law, in the Massachusetts general laws, it's chapter 123, we have lots of different statutes that describe
how much time you'll have to do a psychiatric, a forensic psychiatric or psychological evaluation. And once someone ends up in a forensic hospital from the courts, you have 20 days to do that evaluation and then make a determination of whether they need to stay in the hospital or if they can kind of go back into the jail setting. So that's what we see in the forensic setting.
However, a lot of situations, the courts will allow the person to go right back into the community and have the evaluation done in the community. Now, as a private forensic psychiatrist, I will do those evaluations out in the community over longer periods of time. Or if someone's been able to pay bail, they will be out to have those evaluations done out in the community.
So it just sort of depends where the person ends up and what their history is that determines how long we have to do those evaluations.
When you conduct an evaluation and propose a hypothetical treatment plan, but the individual is placed back in an environment where they regress, how do you support them to regain stability? If time constraints or unaddressed issues lead to new challenges surfacing, how is that situation managed to help them get back on track?
It's a big piece of detective work, I think. Every puzzle is different and you have to put the pieces of the puzzle together to figure out what's going on. It depends on the kind of mental illness we're seeing. You know, if it's somebody with autism spectrum disorder, they may be able to articulate everything that's going on. They're connected to their family members.
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Chapter 6: What does a forensic psychiatric evaluation entail?
We'll have direct contact with everybody. They will have some insight into what their issues are and we'll be able to provide care and treatment more quickly.
What I often will see with people with serious mental illness like a psychotic disorder, whether it's resulting from schizophrenia spectrum disorder or from bipolar disorder or from substance use that then causes a psychotic disorder, those are often the three big pathways in which we see a psychotic illness.
Those individuals might not have a lot of insight into what's going on and will be, you know, One of the symptoms of psychosis may be that they don't have insight, they're not engaging in care and treatment, and they don't want treatment.
At that point, we really do need to get the courts involved to help us provide some psychiatric treatment, which we call, you know, there's various names for it, but we call them antipsychotic medications that every state has laws around. in order to provide that care in a way where the individual doesn't have insight that they need the care. And so it ends up being somewhat compulsory, right?
But we need the court to mandate that. And in those situations, they can just take a lot longer because there's so many procedural hurdles. And we need to protect the due process, obviously, of the patient themselves, especially if they are refusing treatment and they do have insight and, you know, we're just missing something. Certainly due process is important.
But the problem with due process currently is our court systems take a really long time to hear the cases. And so that's what my research showed in one of the forensic hospitals in Massachusetts.
It took up to 61 days to get medications to an individual who had acute psychosis, which is why I have worked with multiple other organizations, the Massachusetts Behavioral Health Services Organization, to bring a bill to the Massachusetts legislature called the timely treatment bill.
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Chapter 7: How long does it take to diagnose and treat mental illness in forensic and community settings?
Can you expand on this bill that you brought to the legislators and what it does?
more timely medications to people with psychotic illness. Because right now in Massachusetts, and I know in other states, because I talk to psychiatrists everywhere, this is a huge issue. We cannot get care to individuals with serious mental illness who have an insight problem, who can't tell that they're ill. And that's a very common problem among people with psychosis.
And that I do think results, it's multifactorial, but it is a factor that results in this cycle of homelessness and incarceration. Because if you're coming off your meds and you become sick and no one is monitoring you and you don't have ties to care and you've burned bridges with your caregivers, you do end up in this cycle of losing your housing, ending up on the streets.
using substances, ending up with head injuries. And then that is this downward spiral into interactions with law enforcement and crime, and then ending up in the carceral system. One of my deep sadnesses is the fact that some of our largest jails in the country, LA, Chicago's Cook County, and New York Rikers are some of the biggest psychiatric hospitals in our country.
And that shouldn't be the case. I think that's a human rights violation. to have our carceral systems provide psychiatric care.
Yes, I've heard that the prisons are exactly that, the largest psychiatric hospitals in the country. And it's up to them to take care of them. And they really don't know how to take care of them, which ultimately create more issues.
Exactly. And so it is important in those settings to really get a forensic psychiatrist to do an evaluation and provide recommendations. It's very sad that so many people with mental illness do end up in the carceral system. But just having that psychiatric evaluation that follows them, that people can read and say, oh, this person has this diagnosis. Oh, this is this person's history.
These are the medications that might be helpful. Or here are some ways this individual can cope with their mental illness. That is such an important report to have for that individual and to have that level of psychiatric analysis done for that individual who's in the carceral system. I really think that that's so important.
Many prisons aren't equipped to handle inmates with mental illness or medication needs. Guards often lack training to recognize these issues, mistaken genuine distress for defiance. This can lead to inmates being denied proper medication, escalating problems, and ending up in solitary confinement.
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Chapter 8: How are patients supported when they regress after evaluations and treatment plans?
As psychiatrists, when I'm doing that evaluation, I know, I see those factors. And those are three things we could divert back into the community and provide intensive treatment for and help society understand, look, that treatment might need to be mandated for a short period of time until that person develops insight. That's going to be the way to keep people in the community.
But there are a lot of little problems we end up along the way. in being able to provide that level of care, I think, in the United States. And I think that is resulting in a carceral system problem of mental illness.
We need that medication treatment and the therapy that goes along with it and housing that goes along with it and occupational therapy and physical therapy that goes along with it to be in the community. And the community needs to have a deeper understanding of what causes violence, impulsive violence in individuals, not necessarily premeditated violence.
Now, you said that you were involved in some type of legislation?
Yes.
What type of legislation are you trying to get changed or improved upon that needs to be under the microscope and you think is just really, really important?
Yes, very important. So different states end up with different sets of issues that result in the same problem, which is people with mental illness end up incarcerated. And in Massachusetts, I have to say we have the lowest number of incarcerated individuals, like rate of incarcerated individuals in the country.
So not in terms of numbers, but in terms of the rate of incarceration, we had the lowest amount. However, those who are incarcerated are more likely to be mentally ill in Massachusetts.
And our judges have done a great job of creating new standards in Massachusetts that they recently updated in 2024 to really think about mental illness as one of the things they consider when they're looking into a case. And I was just involved in one of their annual meetings and provided some mental health education at their annual meeting because they're really looking into this issue.
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