Senator Cindy Friedman Explains What It Takes To Fix A Broken Mental Health System

We sit down with Massachusetts Senator Cindy Friedman to talk about how mental health laws change real access to care, and why families still hit walls even when “parity” exists. We dig into AOT, crisis diversion, insurance limits, and the practical fixes that keep people out of ERs and jails. 
• her personal path into serious mental illness advocacy and why systems matter 
• what changed after the Mental Health ABC Act 2.0 and why outpatient demand rises 
• why reimbursement rates still skew against behavioral health despite parity laws 
• how crisis-first funding leaves ongoing care underpaid and hard to find 
• trauma as a driver of worsening illness and the gap in trauma-informed support 
• why Massachusetts has no AOT law and how old legal standards shape treatment today 
• addressing fears of coercion while explaining least restrictive court-ordered services 
• co-responder teams that pair police with social workers for de-escalation 
• restoration centers as an alternative to ER screening and quick discharge 
• mental illness inside county jails and how sheriffs can shift outcomes 
• rural mental health access challenges plus telehealth parity and community clinics 
• why psychiatric meds are not one-size-fits-all and how insurers resist trial periods 
if you know someone who has a story to share tell them to contact us at whynotme.world one last thing spread the word about why not me our conversations our inspiring guest the show you are not alone in this world 

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Transcript

Welcome And Mission

SPEAKER_00 0:06

Welcome to Why Not Me, embracing autism and mental health worldwide, hosted by Tony Mirator, broadcasting from the heart of Music City, USA, Nashville, Tennessee. Join us as our guests share their raw, powerful stories. Some will spark laughter, others will move you to tears. These real life journeys inspire, connect, and remind you that you're never alone. We're igniting a global movement to empower everyone to make a lasting difference by fostering deep awareness, unwavering acceptance, and profound understanding of autism and mental health. Tune in, be inspired, and join us in transforming the world one story at a time. Hi, I'm Tony Mantor. Welcome to Why Not Me, Embracing Autism and Mental Health Worldwide.

Why Senator Friedman Advocates

SPEAKER_00 1:09

Welcome to our special event, Crafting Justice, Empowering Autism and Mental Health through Legislation. Joining us today is Senator Cindy Friedman, a dedicated public servant representing Massachusetts 4th Middlesex District. Elected in 2017, Senator Friedman has emerged as a leading voice in the Massachusetts Senate, especially in the fight to address serious mental illness and improve mental health care access. As co-chair of the Joint Committee on Health Care Financing, she has drafted and championed transformative legislation, including bills to expand mental health parity, increase access to care, and address systemic gaps in treatment for severe mental illness. Her commitment to compassionate policy solutions is reshaping the Commonwealth's approach to mental health. She brings a wealth of knowledge and we're thrilled to have her join us. Thanks for joining us today.

SPEAKER_01 2:05

Sure.

SPEAKER_00 2:06

What was it that led you to get into advocacy for those with serious mental illness?

SPEAKER_01 2:13

Well, there are two parts of it. One is we in our family have had some experience with serious mental illness. So I have experience with certain types of mental illness, and it's really, really hard. You can't change somebody. You can't, you know, you individually can't make them better. This is an illness, right? But it's sometimes it helped me to figure out even if I couldn't help our family member, is there something I could do to make the system better? I remember when I started working for the senator whose seat I took because he passed away. I remember in the very beginning, I was looking at something and I went into him and I said, you know, mental health treatment in this state sucks and we should do something about it. And he said, Okay, what do you want to do? So we got involved in understanding the system and how it was working and how it was not working. And I think those two pieces led me to

Mental Health ABC Act Results

SPEAKER_01 3:12

my interest.

SPEAKER_00 3:13

In 2022, you did the Mental Health ABC Act 2.0, correct?

SPEAKER_01 3:19

Yeah, yeah.

SPEAKER_00 3:20

Since it's been passed, and now that it's been implemented, what are some of the changes that you've seen come from it?

SPEAKER_01 3:26

What I have seen change is access has changed. And there appears to be a lot more use of mental health services, and there's more of an awareness of mental illness and mental health services. And those are the big changes. I'm the chair of healthcare financing, so in the Senate, and so we look at cost trends and you know what are the drivers of healthcare. And if you look at what's driving healthcare in Massachusetts, one of the pieces is outpatient behavioral health because we're making it a lot more accessible.

SPEAKER_00 4:04

Now that the bill has been in effect for some time, you've observed it, you've seen how people are engaging with it. What adjustments or improvements would you suggest to better support those who might need the assistance that this bill addresses?

SPEAKER_01 4:20

Well, I think reimbursement still is an issue, the rates of reimbursement and the funny weird ways that we reimburse. So there's supposedly parity, right? But there's still a really lack of parity between medical services and, well, physical services and behavioral services. There's still a parity difference. We still pay much more for, you know, specialty care in physical or illnesses

Parity Gaps And Trauma Reality

SPEAKER_01 4:50

that you can treat with a uh a pill or treat with a procedure than there is with, you know, treating mental illness. So I see that. And then I also see that there's really problematic ways that we will pay for things, right? So we don't pay, you know, we pay for crisis interventions more than we did before. We pay for inpatient, but we don't pay as well for ongoing care, which is what stops people from going into crisis and needing intensive care. And I think the other piece that I've seen, and this is more general, and I just don't know exactly how to deal with this. So much of what is driving the illnesses that we see is trauma. I don't see really how we are addressing trauma in a really efficient and meaningful way so that people over time don't get sicker and sicker.

SPEAKER_00 5:49

Yeah. So what about AOT? Does Massachusetts have an AOT law in place yet?

SPEAKER_01 5:57

Uh outpatient assisted treatment?

SPEAKER_00 5:59

Yes.

SPEAKER_01 5:59

Um, no, we don't. We're the only, what are we, two left that don't?

SPEAKER_00 6:03

So, in your opinion, what do you think needs to be done in order to get AOT in place in your state?

SPEAKER_01 6:10

I think what I think there needs to be a reevaluation of the lawsuits that are preventing it from happening. Because the whole understanding of mental illness and and treatment for mental illness has evolved over time. Certainly the understanding of mental illness has evolved over time. And when there were court cases that were, I think, in the very early 80s, that basically do not allow other than a judge to determine whether somebody can be treated against, basically treated against their will. And it's very, very hard to do that in Massachusetts. So you need a substitute judgment where the judge says, this person is incompetent of deciding, so I will decide for them. And then it's very limited around how much treatment and how the kind of treatment that you can receive. And there, you know, what we learn and know now is that there are a very small set of people whose illness prevents them from knowing that they're ill. And so if you don't know that you're ill and you continue to have these horrible symptoms, you either end up in jail, or if you're lucky, you end up in an emergency room, which then puts you into maybe treatment or, you know, maybe an inpatient setting for three days, whereupon you can, you know, check yourself out. And what we see is that there are uh again, a very small but important set of people who can't be treated because of this cycle of, you know, our inability for somebody to say, look at this person, please, before we have before we put them in jail, please look at them and determine whether they're able to take care of themselves.

SPEAKER_00 7:58

Yeah, I've heard that the biggest hospital for the mentally ill in the country is the LA County Prison. Yes, we definitely have to find a way for that to change. But how do you get your point across to your fellow senators that if they can be treated, if they can be diverted away from the judicial system, that a very high percentage of those that go in front of a judge and is diverted to a better facility will not show up in front of that judge again by this happening? Not only does it save the court its time, but it saves the taxpayers hundreds of thousands of dollars, if not millions of dollars. How do we get that point across to them that there is a better way?

SPEAKER_01 8:55

It's a hard sell for

AOT And Legal Barriers

SPEAKER_01 8:58

a number of reasons. People who have this kind of illness do not present themselves as poor, you know, it's not pretty. Sometimes it's amusing to people, but often it's scary, right? And so we quickly demonize them. So that's the first thing. You're not dealing with puppies and kittens here, right? Which people seem to care more about than in human beings. So I think it's really and I understand very much the concern that once you allow people to be treated against their will, all of the pictures of all the women 100 years ago whose husband decided they didn't like them and they stuck them in an asane asylum, right? I mean, that's still really to a lot of people, that's really or you know, a horrible, we, you know, we closed all of our mental health inpatient hospitals because many of them are horrible. So it's really getting through that. And I think that if you look at the bill that we filed, there's really nothing that happens to you as the person who we're trying to get treatment. Nothing happens to you ultimately if you don't follow the court, but it gives everyone else an option to get you to a place where you are where there's going to be more treatment available, right? So if I'm a parent and I want to, I want to get my very, very psychotic son assisted outpatient treatment, I go to the court and petition the court to require the least restrictive services for this person, right? And if the court says yes, what's great about it is the state then has to say, okay, we have to provide these services, right? But if the patient in that case doesn't follow the treatment plan, all that can happen is the people can bring them back to court. But nothing is, you know, we're not gonna put you in jail. But there's real evidence that says a black robe effect is real for people when they're in the middle of a psychosis. So that's kind of what I think we have to start explaining to people. Look, this is a tool, but ultimately you're not gonna be punished if you don't do this.

SPEAKER_00 11:10

Right. I was speaking with a gentleman one time about his son that was going through psychosis. He had been in a situation where he had a conflict with the police at one time and he was very afraid of them. Later on, he was in a situation where he was walking down the street, no clothes on, thinking he was completely invisible, and he had another run-in with the police. Right. It turns out the police that came to the complaint was really good. They looked at him, asked him what he was doing, and his response was, You can see me. So they had said yeah. Then they said, Why don't you get in the back of the car and we'll take you to a place that can help you? And because he had been handcuffed before, so he said, Don't put handcuffs on me, which they didn't. On the way to the hospital, they asked him if he liked music. He said yes. They turned on the radio, he got a chance to listen to the music that he liked, and they finally got to the hospital. At that point in time, the doctor looked at him and said, There's nothing I can do. He's not a threat to himself, he's not a threat to others. So the policeman said, Okay, where do you live? And the doctor asked him why he asked that. He said, Because I'm gonna drop him off and put him in your place because evidently he's not a problem. So the doctor actually took him in and they were able to help him for a short period of time. He was very fortunate. We don't usually run across people that are like that. So, number one, how do we get more information out there to help create that kind of atmosphere? And number two, we have to get the doctors to realize that, yeah, he might not be a threat to himself or others right now, but that doesn't mean that five or ten minutes later, that he couldn't be. We need to find a way to help them so that they don't become a problem. Right.

SPEAKER_01 13:09

Well, first of all, there are incredibly effective programs here in Massachusetts and maybe in other places, but we've developed and sustained a co-responder model where if somebody is, you know, if the police get called about an incident and somebody seems to be having a psychotic episode or something, a police officer and a social worker will go out to that place or that house. And so the police are trained not only in protecting, but in de-escalating. And then you also have somebody there that really understands, is trained in dealing with people who are in the middle of psychosis. And this, I can't tell you how effective this has been. Every year we have police chiefs, there are these uh annual legislature

Selling Reform Without Fear

SPEAKER_01 13:58

days, and they come in and they tell us what their priorities are. And this past year, every their number one priority was to keep the co-responder model because it really works for them. And we can't expect our police to be, you know, psychologists. I mean, that's not fair, right?

SPEAKER_00 14:14

Yeah, that's right.

SPEAKER_01 14:15

We can train them in de, you know, good training is really important and de-escalation is the techniques are really important. But having that person, having that team, those two makes such a difference. And then the other piece is that we're starting this in Massachusetts, but other places have done it, like especially Brare County, where they have these restoration centers where the police or EMT, any first responder or anybody can bring somebody who's in the middle of a psychosis to a place where they immediately get somebody is there and they can de-escalate and they can figure out what this person needs. And those are really, really effective too, right? Because the police get really frustrated because they take this person who they know is sick to the emergency room. And then the doctor says, Are you a threat to yourself? Are you a threat to others? No, goodbye. Because it's the emergency room, you know? So having a different way to get these people into a health care system versus a criminal justice or judicial system is really important.

SPEAKER_00 15:21

Are you familiar with Sheriff Buckley down in Barnstable County? Oh, yeah. She's brand new. I had her on my podcast, and of course, in Barnstable County, the sheriff doesn't do patrol, they take care of the jail system. Right, right. She has implemented a system to where she's helping the people that are incarcerated so that once they get through their time, that they don't come back. Oh, that's true. So in her area, it's kind of like we were talking about the LA prison being the hospital. Well, that's what's happening here. Because of her success, how do we build on that so that these people that do wind up incarcerated can get help, not just in one spot, but all across your state?

SPEAKER_01 16:13

So you should talk to, well, there's two things. First of all, you should absolutely talk to Peter Contusian.

SPEAKER_00 16:19

Okay.

SPEAKER_01 16:20

Because he's the he's the sheriff of Middlesex, and he's been doing this longer than anybody. He has an amazing understanding and commitment to treating people with mental illness. I mean, really, he walks the walk, and he's done it for a very, very long time. He's been involved in this. So I think Middlesex Sheriff's Department and the Middlesex County, which is Dilarica, is really the model. It's really through the bully pulpit and encouragement because the way that our sheriffs are set up in Massachusetts is they're really independent. They get elected. So forcing people to do it is kind of unless we change the structure of the relationship of the county corrections and the state, it is kind of hard. But there are more and more people that are starting to look at this because it is. I think the last time we saw was like over 70% of the people in the Middlesex County prison was uh, they had, I think over 75% of

Police Response That Actually Works

SPEAKER_01 17:22

them had an open mental health case.

SPEAKER_00 17:24

Yeah, that is unfortunately a big number. With all the technology that's going on in the country, Massachusetts has a lot of cities, yet they have a lot of rural country area that leaves a lot of people underserved. So how do you as a senator find ways to legislate, not only for the cities like Boston, but for the smaller areas that struggle with budget and because of that have a hard time taking care of their people? How do you handle that so that those that are underserved can get help too?

SPEAKER_01 17:57

Well, it's money, right?

SPEAKER_00 17:59

Very true.

SPEAKER_01 18:00

Down to money. Do we have the money to implement and sustain? And we don't. It's very, very hard to, you know, to provide these kinds of services. First of all, because it's rural and it's hard when it's rural because people are so far apart. Workforce is an issue. How do we get the workforce? And then how do we sustain it with what money do we use, right? So for better or worse, money tends to go where the most people are. But I think we can definitely do a better job because there are definitely areas, once you get west of Worcester, that you could put something in place and probably have enough of a geographical service area that you could support it. But it will be very expensive and we just don't we don't spend our money on that.

SPEAKER_00 18:47

Do you have funding opportunities available for telehealth or digital health solutions focused on non-physical digital methods of providing health care support? It won't be the same as a one-on-one meeting, but at least if there's an issue there, hopefully something can be done so it doesn't go into full-blown psychosis.

SPEAKER_01 19:08

Yeah, we do have behavioral health, the telehealth parity, which, you know, the insurers hate. They say it's supposed to quote cost less telehealth. Well, it does cost less because that person doesn't end up in the emergency room. So it does cost less. So we push telehealth pretty hard. And then we have set up these community behavioral health centers, and they are across the state, and they have a front door, you know, an open door policy where anybody can, you know, come in and get services or get evaluated if it's an emergency. So we have started to set up a more geographically dispersed system.

SPEAKER_00 19:49

Now you also serve as co-chair of the joint committee on health care financing, correct? How does that intersect with mental health care and pharmaceutical affordability in Massachusetts? Can you expand on that some as to how that works?

SPEAKER_01 20:04

So we get we are responsible for all of the legislation that is filed within the healthcare space. So there's mental health and substance use recovery, that's a committee, and they hear bills, and then 90% and 95% of the time, those bills that they hear and they vote favorably to move along come to our committee.

SPEAKER_00 20:26

Okay.

SPEAKER_01 20:26

And same with pharma. We get all the pharma bills.

SPEAKER_00 20:30

How do you see the role of pharmacies evolving to ensure people can access and afford the medications they need to manage their conditions, stabilize their health, and of course improve their quality of life?

SPEAKER_01 20:45

Well, again, we have mental health parity in this state, and we've got pretty strong laws. So if an insurer has on their formulary something that is um the equivalent of a medication for another condition, then that's supposed to be available, right? The problem is, you know, like you have high blood pressure, right? So you take Lipitor, or you have or you have high cholesterol,

Jails As Mental Health Backstop

SPEAKER_01 21:10

you take Lipitor, right?

SPEAKER_00 21:11

Yes, that's right.

SPEAKER_01 21:13

There's no such thing in behavioral or mental health. Maybe, you know, maybe um a drug will work, maybe it won't. Maybe you need to take three drugs, maybe it's a cocktail. Do you know what I mean? And the way you figure that out is you try it and you see if it works, right? And so insurance companies don't like that.

SPEAKER_00 21:37

Yeah, that's true.

SPEAKER_01 21:38

You know, they don't like that. They want to know, you know, will the causaryl work? I don't know. We have to try it. Is lithium right for this? Do they need lithium and depict? Like, you know, maybe it's just held all. I mean, they just you don't know. And not from anybody's like malice or misuse. It's just everyone's different. This is an illness where it's very, very individual.

SPEAKER_00 22:01

Yes, I get that. I have had the opportunity to speak with several different people. They have been able to find the correct medication. They've come out of it. They're living a good life. It's just great. But they lost 10 years doing this.

SPEAKER_01 22:16

Right. So and we have not yet broken the the code to, you know, to schizophrenia. And so you know.

SPEAKER_00 22:24

I've talked with several senators and legislators across the country. Now are you full-time or are you full-time part-time as a senator?

SPEAKER_01 22:32

We're full-time. Massachusetts is full-time.

SPEAKER_00 22:35

You're full-time. Okay. Well that's great. So with that said, what does your constituency look like? What are you getting for feedback from them on serious mental illness?

SPEAKER_01 22:47

In what way? Like what what do you mean?

SPEAKER_00 22:50

When they make appointments to come to talk to you, they're looking for changes, they're looking for help. What's some of the things that they might be looking for things that you might have looked at or other things that you might say hey this is a good idea. Is there anything that they bring to you in their meetings that just may stand out from others?

SPEAKER_01 23:09

Yeah they're access access and access and insurance. You know access and and like especially for parent like parents I can't get my child here. My child is sitting in the emergency room for 40 days or, you know, my child had an incident in their school and they want to kick them out now. Well what's wrong with your child? Well they have, you know, they're autistic and they're seriously autistic and one of the things they do is they lash out and they're not being bad. They're just suffering from what's going on. So I hear a lot of that I get a lot of that and for a very long time we I just got lots and lots of calls of like my child can't be placed they can't find a place this person

Rural Access Telehealth And Front Doors

SPEAKER_01 23:58

won't pay that person. So it's really a lack of access to the right treatment. And to treatment, you know, that what I see is that this treatment is not one and done. And as much as you want it to be and as much as the insurers want to treat it that way, that's not how it works. And that's really what I think is so difficult, right?

SPEAKER_00 24:21

Yes, that's so true. Now I've heard of some states that once diagnosed they only have a certain time that they can be in the hospital. Right. Then they kick them out. Right. Then they go to another hospital and it's like a bouncing ball. Do you have that problem in Massachusetts?

SPEAKER_01 24:36

Yeah. The insurers will pay for X amount of days up to seven days as up to sometimes up to a week sometimes you know but yeah no they determine the the length of treatment.

SPEAKER_00 24:49

Then I've heard once they got kicked out of one hospital, they would go to another hospital, spend the seven days or whatever the time frame may be with that one, get released, then that hospital would find that unknowing to them, the other hospital was first and then that second hospital didn't get paid. Have you run into that scenario at all?

SPEAKER_01 25:13

No I haven't run into situations where that were because they thought they were being still in another hospital?

SPEAKER_00 25:20

No, they were in another hospital but that hospital couldn't keep them right they were released from that first hospital then they went to the second hospital and because of that across those fine lines and ultimately that second hospital did not get paid.

SPEAKER_01 25:36

Oh no I have not heard of that but I would believe it if somebody told me it was true.

SPEAKER_00 25:43

Sounds like insurance you know yeah unfortunately it does. Now in closing what do you think the listener needs to hear that you think is very important on legislation that you're trying to do legislation that you have done that hopefully will make a better scenario for those living with serious mental illness This is an illness and we have to constantly remember that this is not a choice

Medication Coverage Realities And Closing

SPEAKER_00 26:12

it's an illness and this illness affects your ability to think in a way that is you know the common way of thinking right the way we look at reality.

SPEAKER_01 26:25

This is an illness that challenges that right and remembering that it's an illness you know working about against the stigma and then requiring that it be treated like an illness you know that it is treated like anything else heart disease, diabetes, any other illness that people have, that it be treated that way.

SPEAKER_00 26:44

Yeah. Yeah, that is good and so true. One last question any legislation or bills that you see coming up that we might not have talked about that still can help many, many people?

SPEAKER_01 26:59

No, I think there's going to be a lot of pressure on all of the strides that we've made in Massachusetts because of what's happening at the federal level and how much money we're losing with you know Medicaid and SAMHSA and the grants that have come from the federal government that have been really really important to helping address mental illness. They're all at risk and that's what we're spending an inordinate amount of our time trying to figure out.

SPEAKER_00 27:28

Yeah that's what I hear from a lot of people. Well this has been great great information great conversation I really appreciate you taking the time to join us today. Sure well thanks for doing this oh it's my pleasure thanks again for taking time out of your busy schedule to listen to our show today. We hope you enjoyed it as much as we enjoyed bringing it to you if you know someone who has a story to share tell them to contact us at whynotme.world one last thing spread the word about why not me our conversations our inspiring guest the Joe you are not alone in this world