Podcast Summary:

Why Not Me? Embracing Autism & Mental Health Worldwide
Episode: Judge Milton Mack: A Man on a Mission to Reform Mental Health
Host: Tony Mantor
Guest: Judge Milton Mack
Date: December 18, 2025

Episode Overview

This pivotal episode features Judge Milton Mack, a pioneering advocate for mental health reform in the legal system. Drawing on decades of experience, Judge Mack discusses the systemic flaws in America's approach to mental illness—particularly the reliance on crisis response and institutionalization—and outlines tangible reforms aimed at early intervention, community-based treatment, and diversion from the criminal justice system. The conversation is a candid, solutions-focused exploration of how systemic change can improve outcomes for people with mental illnesses, reduce costs, and foster genuine recovery.

Key Discussion Points

Judge Mack’s Journey and Motivation

• Origin of His Passion
  • As a new probate judge, Judge Mack was struck by the inefficiency of the mental health system, observing repeated hospitalizations and no real progress for individuals.
  • Quote: “I don't think this is working. I'm seeing the same people over and over and over again... just in this revolving door.” (02:55, Judge Milton Mack)

Systemic Problems in Mental Health Care

• The ‘Revolving Door’ Phenomenon
  • Patients repeatedly cycle through hospitals without lasting recovery due to the crisis-driven model.
  • The system’s focus is on stabilization, not long-term well-being.
  • Mack's metaphor: "Imagine a train going down the tracks and the bridge is out. We can dial up the engineer and say, the bridge is out, stop the train, or park ambulances at the bottom... That’s how the mental health system is working. We wait for crisis..." (04:02, Judge Milton Mack)
• Outdated Models & Lack of Outpatient Focus
  • The 1963 Community Mental Health Act sought to replace hospitalization with outpatient treatment, but only the first half (institution reduction) was achieved.
  • This led to mass incarceration of untreated individuals with mental illness: “We got 2 million people in America with serious mental illness in jail every year.” (06:31, Judge Milton Mack)

Policy Innovations and Legislative Reforms

• Shifting to Early Intervention and Outpatient Models
  • Judge Mack helped pass bills in Michigan to make outpatient treatment more accessible and use mediation instead of hospitalization or court hearings when possible.
  • Example: Genesee County saw a 70% reduction in hospitalization and a 90% compliance rate with outpatient treatment. (17:49, Judge Milton Mack)
• Mediation over Hospitalization
  • Michigan's unique system allows families to file outpatient treatment petitions directly to probate courts, offering mediation as an alternative to adversarial hearings.
  • “If you get a mediated agreement with someone who has a mental illness, you have engagement, you have the likelihood of compliance.” (09:58, Judge Milton Mack)
• Changing the Standard for Intervention
  • Michigan no longer requires someone to be imminently dangerous to themselves or others; now, evidence of mental illness and risk of deterioration is enough for intervention.

Financial and Societal Benefits

• Cost Efficiency
  • The “revolving door” costs millions in hospitalizations and incarcerations, yet achieves little.
  • “For $4.9 million, we got nothing. One individual had 46 visits to the ER. Clearly not working.” (07:38, Judge Milton Mack)
• Stakeholder Engagement
  • Judge Mack emphasizes that frontline stakeholders—hospitals, law enforcement, courts—are all victims of a broken system.
  • Law enforcement: “One third of all the people in this country with a serious mental illness, their pathway to care was through law enforcement, which is kind of staggering.” (23:21, Judge Milton Mack)

Behavioral Health Leadership & Culture Change

• Role of Judicial Leadership
  • Encourages judges to become leaders in mental health reform, despite a general tendency toward introversion and legislative reluctance.
  • “Judicial leadership really does matter... You have to find the judicial leadership at each level.” (13:34, Judge Milton Mack)
• Changing Organizational Culture
  • Challenges persist due to the resistance of hospitals, agencies, and courts to implement new laws and standards.
  • Emphasizes the need to shift from a mentality of “we don’t give people treatment they don’t want” to early, appropriate intervention.

The Importance of Early and Humane Intervention

• Freeing People from the Illness
  • Addressing untreated mental illness is not a deprivation of freedom; rather, it restores autonomy.
  • “You’re not depriving people of their freedom when you’re freeing them from the impact of mental illness, which is left untreated.” (26:21, Judge Milton Mack)
• Priority of Outpatient and Community-Based Care
  • Assisted Outpatient Treatment is more humane and effective than hospitalization, jail, or homelessness.

Expanding the Definition of Diversion

• Mental Health Diversion Council Work
  • Judge Mack shifted the focus from post-arrest diversion to true prevention: preventing people from ever entering the criminal justice system.
  • “I want to focus on people before they end up in jail… help people stay well so they don’t get in trouble with the law.” (19:38, Judge Milton Mack)

Addressing Legal System Gaps

• Educating Legal Professionals
  • Many lawyers, judges, and DAs don’t understand mental health, leading to poor outcomes.
• New Legislation for Misdemeanor Diversion
  • Proposed and supported bills that would send individuals with mental illness charged with misdemeanors into treatment—dropping charges and avoiding unnecessary evaluations.

Notable Quotes & Memorable Moments

• On the Crisis-Driven System:
  “We wait for crisis, and then we intervene... The system was not designed to permit early treatment. It was designed to wait till that magic moment just before someone actually killed themselves or killed someone else or did something terrible.” (04:20, Judge Milton Mack)

• On Mediation and Engagement:
  “If you get a mediated agreement with someone who has a mental illness, you have engagement, you have the likelihood of compliance.” (09:58, Judge Milton Mack)

• On Costs and System Failure:
  “In the prior fiscal year, we spent $3.3 million on hospitalization, $1.6 million on incarceration, for a total of $4.9 million. And for that $4.9 million, we got nothing.” (07:38, Judge Milton Mack)

• On Systemic Challenges:
  “We have all the makings of a mental health system, but the stakeholders don’t communicate with one another... So it just hasn’t been working.” (15:30, Judge Milton Mack)

• On Changing Culture:
  “We’re changing the culture, and that’s huge. Change the culture of an organization is hard to do.” (15:59, Judge Milton Mack)

• On Early Intervention:
  “We need to intervene early. We don’t wait to treat someone with cancer under stage four. We do just as much damage by waiting to treat mental illness.” (26:15, Judge Milton Mack)

• On Humane Treatment:
  “Assisted outpatient treatment is the most humane treatment possible. It’s better than being treated in the hospital, far better than being treated in jail, and far better than homelessness.” (26:35, Judge Milton Mack)

Timestamps for Important Segments

• Judge Mack’s Background & Entry into Mental Health Reform: 02:44–04:50
• Systemic Failures and ‘Revolving Door’: 04:52–06:50
• Outpatient vs. Inpatient System; Legislative Wins: 06:51–09:00
• Mediation and New Petitions Process: 09:35–11:00
• Blockages & Resistance to Change: 11:01–13:20
• Judicial and Behavioral Health Leadership: 13:34–16:50
• Early Intervention & Anosognosia: 16:52–18:45
• Mental Health Diversion Council & Upstream Diversion: 18:45–20:35
• Legal System Education & Misdemeanor Diversion Legislation: 20:35–22:30
• Stakeholder Engagement & Financial Arguments: 23:01–24:32
• Comparisons with Other Models (e.g. Judge Leifman in Florida): 24:32–25:52
• Final Advice & Call for Early Intervention: 26:04–26:54

Closing Thoughts

Judge Mack’s work and insights illuminate a path forward for mental health reform grounded in compassion, practical solutions, and data-driven policy. By focusing on early intervention, prioritizing outpatient care, engaging all stakeholders, and championing legal reforms, he points the way to a system that truly serves people with mental illness—helping them recover, reducing systemic costs, and building safer, healthier communities.