Association For The Chronically Mentally Ill (ACMI) believes there is sea change going on around mental illness and what has worked and what has areas for improvement. Among the most promising changes is that SAMSHA and mental health “think tanks” as well as community-based organizations like ACMI are discussing the need for additional research on biomedical aspects of serious mental illness rather than just focusing on “stigma” or general mental health or “wellness.” Not enough research dollars are targeted to investigate the root causes of mental illness and effective treatment modalities from medication to effective interventions in housing and social supports. People living with serious mental illness like schizo-affective disorder are trying to survive this devastating biological brain illness. Often without adequate support.
ACMI is encouraged by the proceedings of the White House Mental Health Summit (Dec 2019) which will provide additional funding dollars designated towards research on Mental Illness research.
Some advocates believe that “mental health problems tend to be under-researched, undertreated, and over-stigmatized.
We need to start focusing on treatment over punishment. Research that will lead to better treatment and outcomes – measured by changes in jail and prison incarceration rates, number and length of hospitalizations, and treatment compliance over a sustained period of time. Mental health treatments remain largely inaccessible to many, especially those from lower socio-economic or disadvantaged groups. These families often lack advocates for their ill family member and can not afford private attorneys to make the system “bend” to become more patient-focused. One estimate by the Epidemiologic Catchment Area Survey reported that 40 percent of adults with severe mental illness did not receive any psychiatric care within a one-year period. Many individuals will continue to suffer from serious mental illness until we can reduce barriers to treatment access. This is a tragedy — and a likely reason for the recent tragedies in which untreated individuals living with serious mental illness engaged in acts of violence against others in the community. The National Institutes of Mental Health (NIMH), the nation’s largest funder of mental health research, has seen flat budgets since 2003, and currently funds less than 20 percent of the proposed research trials it receives. This tight funding environment discourages new researchers from entering the mental health arena and slows research progress.
is important in the general conversation to ensure parents, teachers, physicians
and other primary caregivers identify the early signs of mental illness; most
are present before the late teenage years.
importantly, in Thomas R. Insel, M.D. director of National Institute of Mental
Illness directors’ message he indicates the real need for basic research.
This is promising!
we want to offer the most effective mental health treatments, we need
cutting-edge research to test those treatments and understand how they work.
think it is beneficial for all families to submit comments asking for
more research dollars target research for serious mental illness.
the Treatment Advocacy Center- (December 18, 2019) The National Institute of
Mental Health (NIMH) has a history of failing to prioritize serious mental
illness in its research. Unfortunately, their recently-released five-year strategic plan draftsignals their intention to continue to ignore those with the
most impairing disorders.
Despite seeking public comment, the NIMH’s plan, even by the
standards of federal reports, is almost unreadable. While the issues are
complicated, the explanation of why they are vital shouldn’t be. However, it is
not written in a way that is easy to understand or make sense of. For example,
Strategy 3.3.C on page 28 reads “Enhancing the practical relevance of
effectiveness research via deployment focused, hybrid
by our founder, Dr. E. Fuller Torrey, the Treatment Advocacy Center has put
together a comprehensive analysis of the five-year
strategic plan, highlighting how it would fail those with severe mental
illness. We identify sixteen concrete examples of research initiatives the NIMH
should be pursuing today, initiatives that could help people with serious
mental illness recover and live better lives.
the Treatment Advocacy Center submitted our public comment to the NIMH. However,
we urge you to submit your own here. Use our comments, but also share your story of how the
decisions of NIMH affect you and your loved ones. These stories are vital to
help NIMH understand why their proposed priorities are misplaced.
Here are some points to consider:
The report fails to reflect the
urgency of our national mental health crisis:
As Dr. Torrey summarized, “Overall, I would say that this report is promising
for people who plan to be affected with a serious mental illness in 2050 or
beyond, but for anyone who is currently affected, the report offers no hope. I
personally find this unacceptable and inexcusable.”
Where are the people who are
experiencing the consequences of our failed mental health system?
Except for one paragraph on the increasing national suicide rate, there is no
indication whatsoever that mental health services for individuals with serious
mental illnesses are an increasing public disaster. There is no mention of
homelessness, criminalization of mental illness, the fact that emergency rooms
are overrun with people with mental illness, or the burden of the failures of
the mental health system on law enforcement.
Continued misplaced and
unbalanced priorities: The strategic plan is strongly
weighted towards basic brain science, with a continued strong emphasis on
genetic research. It ignores the fact that the genetic research to date has
been remarkably unproductive and likely to continue to be so, as described in a
by Dr. Torrey and Dr. Robert Yolken published in Psychiatry Research in August.
can submit feedback online via the NIMH
request for information page, or mail your comments
to: NIMH Strategic Planning Team
6001 Executive Boulevard, Room 6200, MSC 9663
Bethesda, MD 20892-9663
Institute of Mental Health Strategic Plan- here are the four priority areas.
From Bedlam- When Dr. Kenneth Rosenberg trained as a psychiatrist in the late 1980s, the state mental hospitals, which had reached peak occupancy in the 1950s, were being closed at an alarming rate, with many patients having nowhere to go. There has never been a more important time for this conversation, as one in five adults – 40 million Americans – experience mental illness each year. Today, the largest mental institution in the United States is the Los Angeles County Jail, and the last refuge for many of the 20,000 mentally ill people living on the streets of Los Angeles is L.A. County Hospital. There, Dr. Rosenberg begins his chronicle of what it means to be mentally ill in America today, integrating his own moving story of how the system failed his sister, Merle, who had schizophrenia. As he says, “I have come to see that my family’s tragedy, my family’s shame, is America’s great secret.”
Dr. Rosenberg gives readers an inside look at the historical, political, and economic forces that have resulted in the greatest social crisis of the twenty-first century. The culmination of a seven-year inquiry, Bedlam is not only a rallying cry for change, but also a guidebook for how we move forward with care and compassion, with resources that have never before been compiled, including legal advice, practical solutions for parents and loved ones, help finding community support, and information on therapeutic options.
Cheryl Roberts, executive director of the Greenburger Center for Social and Criminal Justice, says “Asylums never went away; they just grew into two varieties: posh for the wealthy (in the form of a handful of fancy $100,000-plus a year mental institutions) and prisons for the poor.”
Jonathan Sherin, MD, PhD, director of Los Angeles County Department of Mental Health, doesn’t mince words. He says we did not get rid of asylums in Los Angeles in the 1960s with deinstitutionalization: we just substituted the local asylum for an ‘indoor” one called the Los Angeles County jail and an “outdoor” asylum called skid row. John Snook, director of the Treatment Advocacy Center, agreed that the dismantling of the asylum was really “trans-institutionalization”- transferring the fate of patients from asylums to streets and prisons. We still hospitalize people, they are “micro-hospitalizations”, says Snook, referring to the average length of stay of three to five days. “The state of California is a canary in the coal mine from day one,” he said, because it emptied out its hospitals early. In 1975, the city’s “containment” policy squeezed people with substance abuse disorders, mental illness, and other disabilities into a fifty-block radius skid row- helping it become what a Los Angeles Times reporter called “a dumping ground for hospitals, prisons, and other cities to get rid of people with nowhere else to go.
to Dr. Edwin Fuller Torrey (an American psychiatrist and schizophrenia
researcher. He is the Associate Director of Research at the Stanley Medical
Research Institute and Founder of the Treatment Advocacy Center), the United
States currently has just 2 to 3 percent of the psychiatric treatment beds that
we had sixty years ago: “We have so few beds available for people with mental
illness that there’s nowhere to put them.” Because emergency rooms are legally required to
treat anyone who comes through the door, people with serious mental illness (SMI)
often wind up staying there for days or even weeks at a time waiting for a
psychiatric treatment bed. We see that all across the country.
Dr. Sherin, Snook, and many other policy experts hold partly responsible for this
mess is the IMD (Institutes for Mental Diseases) exclusion rule, enacted in
1965 as part of the Medicaid and Medicare legislation. “The IMD exclusion
explicitly prohibited Medicaid from paying for patient care in state or private
hospitals that specialize in mental health care. It prohibits federal Medicaid
payments for services delivered to individuals aged twenty-two to sixty-four years
residing in IMDs, defined as “hospitals, nursing homes, or other institutions
with more than sixteen beds that are primarily engaged in providing diagnosis,
treatment, or care of persons with ‘mental diseases’ other than dementia or
intellectual disabilities. To repeat- no mental hospital with more than sixteen
is encouraged by some recent actions:
One sign that America is waking up to our
mental health crisis is the 21st Century Cures Act of 2016, which provided
additional research and treatment reforms.
· The creation of a mental health czar position in the Department of Health and Human Services now occupied by Dr. Elinore McCance-Katz, MD, Ph.D.
Dr. Elinore McCance-Katz, MD, PhD. has returned
to SAMSHA with a priority to address Serious Mental Illness, something that had
not been a priority at SAMSHA for years.
SAMSHA focusing on evidence-based practices.
The recent White House Mental Illness summit (see
Increased discussion about changes to the IMD
The rise of celebrity candor about their
personal experiences with mental illness.
Arizona we are fortunate to have strong laws to help persons with SMI that do
not have the insight to understand they are ill. We are often contacted by
families from other states that do not have our strong laws.
will also lead the nation is providing a new level of care that is less
restrictive than a level 1 psychiatric hospital, but more than community
living. This level of care – secure residential treatment – will be a closely
monitored program that will assist the chronically mentally ill in their
Federal Rural Resources Guide: A
listing of Federal programs that can be used to address substance use disorder
and opioid misuse in rural communities
Community Assessment Tool: Provides
a snapshot of county-by-county data about drug overdose deaths and
socio-economic conditions in a county to help leaders build grassroots
solutions for prevention, treatment and recovery
School Resource Guide: Guide
for teachers, administrators and staff about resources available to help
educate and protect students from substance misuse
some folks that suffer from mental illness may also suffer from personality
disorders or violent tendencies, most persons with mental illness are not
violent perpetrators when treated appropriately. For individuals that have a
mental illness but do not have violent or personality disorder which predispose
them to violent tendencies, they should not be in jail or prison.
is not unreasonable to have persons with mental illness that continue to be
violent even when appropriately treated that they may end up in a psychiatric
unit of a jail/prison.
those persons with serious mental illness (SMI) that are imprisoned, it is
inhumane to keep them in solitary confinement. There is an effort in Arizona to
do more reach in and preparation for services when released. We are hopeful
that these efforts will provide effective in reducing recidivism and achieving
better outcomes for individuals exiting jail/prison.But Persons with
SMI tend to have longer stays in jails and prisons and to be confined in a
Special Management Unit with only a few hours a day out of their cell, no real
treatment for their SMI, and limited recreational activity. Sometimes, those
with SMI are placed in isolation cells. It is ACMI’s position that jails or
prisons are wrong placements for this population. As discussed in the article
below, “Confining people with serious mental illness (often shortened to SMI)
in solitary jailhouse cells has been repeatedly identified by correctional
officials, advocates, and psychiatrists as detrimental and cruel.”
under the best conditions, the jail/prison environment is not therapeutic in
nature but punitive in nature.
Let’s look at the purpose of Prisons and jails.
According to the “prisons’ theory,” also referred to as deterrence, the theory
claims that the primary purpose of prisons is to be so harsh and terrifying
that they deter people from committing crimes out of fear of going to
prison. Other reasons stated for the
need for prisons are four major purposes. These purposes are retribution,
incapacitation, deterrence, and rehabilitation. Retribution means punishment
for crimes against society. Depriving criminals of their freedom is a way of
making them pay a debt to society for their crimes.
By the 19th century, prisons were being built for the sole purpose of housing
inmates. They were intended to deter people from committing crimes. People who
were found guilty of various crimes would be sent to these penitentiaries and
stripped of their personal freedoms.
major use of modern jails is what is often referred to as pretrial detention.
In other words, jails receive accused persons pending arraignment and hold them
awaiting trial, conviction, or sentencing. More than half of jail inmates are
accused of crimes and are awaiting trial. The average time between arrest and
sentencing is around six months. Jails also readmit probation and parole
violators and absconders, holding them for judicial hearings. The major purpose
of pretrial detention is not to punish offenders, but to protect the public and
ensure the appearance of accused persons at trial.
Jails in some jurisdictions are responsible for transferring and transporting inmates to federal, state, or other authorities. Jails are also tasked with holding mentally ill persons pending their transfer to suitable mental health facilities where beds are often unavailable. Jails also hold people for a variety of government purposes; they hold individuals wanted by the armed forces, for protective custody of individuals who may not be safe in the community, for those found in contempt of court, and witnesses for the courts. Jails often hold state and federal inmates due to overcrowding in prison facilities. Jails are commonly tasked with community-based sanctions, such as work details engaged in public services. https://courses.lumenlearning.com/atd-bmcc-criminaljustice/chapter/section-6-1-jails/
Nationwide in America, people suffering from mental illness are 10 times more likely to be in jail or prison than in a psychiatric hospital.
People with mental illness are frequent fliers – 90% of people suffering with mental illness are repeat offenders, with 31% having been incarcerated 10 or more times
People with mental illness cost more while incarcerated. In Broward County, Florida, it costs $80 per day to house a person without mental illness, but $130 a day for someone with mental illness.
People with mental illness stay longer- In New York’s Riker’s Island jail, the average stay for an incarcerated person is 42 days, with mental illness it is 215 days.
People with mental illness are difficult to manage- In Wisconsin, a 2010 audit of three state prisons reported that between 50 and 70% of the prisoners in isolation were mentally ill.
People with mental illness are Most likely to commit suicide – In Washington State the prevalence of mental illness among incarcerated people who attempted suicide was 77% compared with 15% among the general population.
In 2012, American prisons and jails housed and estimated 356,268 people with severe mental illness.
it make sense to send someone that may be unable to make right decisions based
on their mental illness to jail or prison?
Greene Sterling Arizona Center for Investigative Reporting
of America’s county jails escape lawsuits seeking reforms for inmates with
serious mental illness. Now Arizona’s Cochise County has joined hundreds of
other small counties innovating ways to keep people with serious mental illness
out of their jails. But it comes too late for Adrian Perez, who has spent the
past 13 years cycling in and out of jail, and solitary confinement, which only
makes him sicker.
Perez hobbles into the courtroom in leg chains and jail slippers. He sits. He
pokes at his black beard. He rocks.
34 years old, and he knows he has schizophrenia. He knows he hears voices no
one else can hear.
wants to get better but he doesn’t know how to get better.
he cycles in and out of the Cochise County justice system. He’s been locked up
in the county jail at least 16 times in 13 years. He’s been charged with
misdemeanors like shoplifting or disturbing the peace, which are handled in
justice court, and he’s also been charged with two felonies in Cochise County
Superior Court. One case, in which he took a neighbor’s truck for a joyride,
was dropped because of Adrian’s mental illness. Today he’s facing a second
felony charge for allegedly stealing an auto part.
time around, he’s been isolated in solitary confinement in the jail for 23
hours a day for close to two months. There is no doubt, his family says, that
solitary is making Adrian sicker.
people with serious mental illness (often shortened to SMI) in jailhouse
solitary cells has been repeatedly identified by correctional officials,
advocates and psychiatrists as detrimental and cruel. But because there’s no
aggregate reporting system in place no one knows exactly how many people with
mental illness are confined to jailhouse solitary cells – or for how long. And
in many county jails the practice persists.
welcomes court hearings because they get him out of solitary. On this September
morning, Adrian is in Cochise County Superior Court, charged with stealing a
device that measures the working speed of an engine, called a tachometer, from
an auto parts store. The tachometer cost $112.29. Adrian sold it for five bucks
to buy cigarettes. He is charged with trafficking in stolen property.
Adrian has been found incompetent by psychiatrists to stand trial due to his
mental illness, Judge Tim Dickerson might later drop the auto part case. But
first the lawyers have to file papers and the judge has to issue rulings. That
could take weeks.
art-deco style court building is nearly a century old. The courtroom has tall,
geometric windows and rows of small, uncomfortable chairs. Adrian stands behind
a wooden podium with his public defender and addresses the judge.
want to get help as soon as I can,” Adrian says.
white-bearded bailiff ushers Adrian out of the courtroom. Adrian’s accustomed
to walking in shackles, but he’s lost a lot of weight lately and yanks up his
baggy red-and-white-striped pants with his cuffed hands, which gives him a
few hours, he’ll be back in solitary at the Cochise County jail, getting
Small County Jails A Dumping Ground
report Adrian’s story, the Arizona
Center for Investigative Reporting examined hundreds of pages of court
and police records and reviewed government reports and research papers from
correctional groups and nonprofits that advocate for people with mental illness
who end up in jail. The Center attended community criminal justice coalition meetings,
reported on proceedings in the Cochise County jail and Cochise County Superior
Court, and interviewed Adrian, his family, his jailers, county and state health
professionals, advocates for people with mental illness, psychiatrists, lawyers
decades of reform efforts on behalf of people with SMI, small county jails and
their solitary cells remain a neglected dumping ground for this vulnerable
group of Americans.
want them there. Not their families. Not their jailers. Not the lawyers who
have filed class action lawsuits throughout the nation intended to reform
prisons and jails for people with SMI. Not the state legislators scattered
across the country who have passed laws limiting solitary confinement. Not the
advocates, judges, lawyers, behavioral health providers and county correctional
officials who are trying to figure out new ways to keep people with SMI out of
reform efforts – class action lawsuits, court diversion programs, state laws –
often aim to fix the problem after, not before, the person with mental illness
has entered the criminal justice system. And the reforms often target prisons
while neglecting the large numbers of people with mental illness confined in
smaller American jails.
is less than a month. But inmates with SMI who live in poverty and can’t pay
their bail, like Adrian, can stay for several months or even a year. And if
they can’t adjust to the general jailhouse population, if they are at risk of
hurting themselves or other inmates, many end up in solitary confinement, where
their SMI often worsens.
& let thousands of daily readers know
your business cares about creating a HEALTHIER, MORE INFORMED Tucson
largest behavioral center in the county is my jail and that is common in most
rural communities in the United States,” Cochise County Sheriff Mark
Dannels says during an interview in the sheriff’s substation in Sierra Vista in
population of Cochise County is about 126,770, scattered across 6,000 or so square
miles of high desert and sky island mountains. Mental health services are hard
to access in remote rural areas – so much so that in a recent
county residents singled out mental health and substance abuse treatment as the
top health priority.
southern stretch of Cochise County flanks the Mexican border, and Dannels is
known nationally as an immigration hardliner. He’s a stocky Midwesterner, 55
years old, who settled in Cochise County after a stint in the military.
we helping them or hurting them? I will tell you right now we’re hurting
them.” — Cochise County Sheriff Mark Dannels
is the first to admit jail is no place for a person with mental illness. He’s
trying to collaborate with county mental health advocates, the courts and
providers to come up with ways to keep people with SMI out of his jails.
are “severe mental health folks,” Dannels says. “Are we helping
them or hurting them? I will tell you right now we’re hurting them.”
rubs his forehead. “But what else do we do?”
the general population, they’re assaulted or picked on,” he says.
“These are the severe ones that take their clothes off, that are smearing
feces on their bodies, I don’t have a place to put them.”
was part of a well-intended reform movement. American jail and prison
administrators began replacing
corporal punishment with solitary confinement more than a century ago. It
sounded so much kinder. But it didn’t take long to see the harmful impact of
solitary on inmates, especially inmates with serious mental illness.
state prisons, including those run by the Arizona Department of Corrections,
have been forced by class action lawsuits to limit solitary for people with
Metzner, a forensic psychiatrist who teaches at the University of Colorado
School of Medicine in Denver, and a nationally recognized expert on
correctional mental health systems, says isolation often exacerbates serious
mental illness. It reinforces abnormal social interactions, increases social
withdrawal, and heightens the risk of suicide, he says. In the “worst
places,” inmates have “so little control of anything,” he says,
they smear or throw their feces so detention officers will “feel as
helpless and angry as they feel.”
policy change in this arena traditionally comes from litigation, but that’s
slowly changing as states start to limit the use of solitary. Most efforts
focus on state prisons, and largely ignore jails. Eight states this year passed
laws limiting solitary confinement. Arizona is not one of them. In
2015, the American Civil Liberties Union backed a bill requiring Arizona
prisons to keep records on the solitary population. That bill died. And this
year, a bill
seeking to limit solitary confinement of pregnant and postpartum women
prisoners also failed.
policymakers debate solitary, Adrian keeps ending up there.
don’t know why,” Adrian says. “I don’t know why they do it.”
A Devil Inside Him
a horse kicked Adrian Perez in the head. He was visiting his grandparents on
their ranch in the Mexican state of Chihuahua, and the horse spooked at
something and ran right over Adrian, then a small boy. After his grandmother
wiped off the blood, Adrian seemed fine.
brother Richy, only a year older than Adrian, took it harder than anyone. Richy
felt obligated as the big brother in his Mexican-American family to take care
about keeping quality reporting alive in Tucson?
boys’ father, Blas, was a Mexican farmworker who settled in eastern Cochise
County after obtaining legal permanent residency in the United States. Their
mother, Blanca, mostly raised the four kids, Richy, Adrian, Eric and Ana.
bought land in Winchester Heights, a remote farmworker community about 15 miles
outside of Willcox. On weekends, the boys mixed cement and carried construction
blocks as their father built the family a three-bedroom house. The family moved
in after Blanca was diagnosed with terminal lung cancer. As the eldest, Richy
promised his mother he’d always take care of his siblings.
Blanca’s death, Adrian seemed more withdrawn. When his dad told him to
straighten his room or clean the yard or do his homework, Adrian either talked
back or broke things.
back on it, Eric says, the family “didn’t understand mental illness very
joined the Army National Guard, but took care of Ana and Eric when his father
and Adrian moved briefly to El Paso. In Texas, Adrian was certified as a
bilingual electrical assistant, and Blas went to trucking school in hopes of
earning more money.
few months later, in 2004, Blas died in a trucking accident.
quit the National Guard and worked in the fields near the house he had
inherited from his father. Richy was 21, old enough, he thought, to take full
responsibility for Eric, 14, and Ana, 12. Adrian tried to help but couldn’t
hold down a job for long.
mental illness remained undiagnosed for years. None of the siblings remember
when, exactly, Adrian started hearing voices. One insulting voice, which Adrian
called “Tony,” made home life even more chaotic. Adrian episodically
screamed at Tony while batting at the air and throwing things.
thought Adrian had a devil inside him.
undiagnosed schizophrenia likely caused Adrian to chase four people up and down
a Willcox street in 2006. No one was hurt, but someone called the cops, who
tackled Adrian, shackling his legs and cuffing his wrists. In the back seat of
the patrol car, Adrian panicked, slamming his head repeatedly against the door
and bars in front of the window.The officers turned on the siren and lights and
hightailed it to a small county jail annex in Willcox. When they forced Adrian
into a restraint chair, he fought even harder, breaking a staffer’s
pleaded guilty to criminal damage and resisting arrest, promising to pay $135
for the broken glasses. And he spent three months in jail, in part because he
couldn’t pay his $3,000 bail. He didn’t pay his mounting justice court fines,
and failed to appear in court to explain why.
Adrian came home from jail, he often walked 15 miles from the house in
Winchester Heights to Willcox. If Adrian didn’t return home, Richy says, he
automatically called the Cochise County Jail, figuring his brother was there.
day in 2008, Adrian walked into a neighbor’s yard, and, right in front of him,
drove away in the neighbor’s red Nissan pickup. Sheriff’s deputies arrested
Adrian on a felony charge – knowingly taking unauthorized control over a means
of transportation – and a misdemeanor, criminal damage.
way, it’s the best thing that could have happened, because it led to his
schizophrenia diagnosis. Adrian’s public defender requested a so-called “Rule
psychiatric examination to see if Adrian was mentally competent to stand trial
for the felony charge in Cochise County Superior Court. He wasn’t, a
psychiatrist said. He smiled inappropriately and couldn’t communicate in any
meaningful way. It was suggestive of psychosis.
judge sent Adrian to the Arizona State Hospital in Phoenix to see if he could
be “restored to competency” in order to stand trial for taking the
red Nissan. This is a common practice in both federal and state courts.
Advocates say it benefits the criminal justice system, not the person with
mental illness, who can spend six months being “restored” while not
getting appropriate, sustainable mental health care.
Adrian finally had a diagnosis – “Schizophrenia,
– at least three years after he showed symptoms of the illness. Richy, who’d
long wondered if the horse kick had caused Adrian’s bizarre behavior, began to
realize his brother had a complicated condition likely spurred by genetic and
understood he had schizophrenia, but he thought the doctors could fix it.
State Hospital psychiatrists tried different combinations and doses of
medication to treat Adrian’s psychosis. Even so, staffers noted Adrian was
often “confused and internally preoccupied.” After six months, the
doctors could not restore Adrian to competency.
Cochise County Superior Court judge dropped Adrian’s 2008 felony charge for
taking the neighbor’s truck on a joyride.
Driving 90 Miles For Treatment
siblings say they often tried but couldn’t always get him necessary mental
Adrian was poor and lived with a serious mental illness, he was entitled to
community-based mental healthcare paid for by Arizona’s Medicaid agency,
AHCCCS. It should have included, among other things, psychiatrists, meds,
counseling, caseworkers, therapy, skills training, transportation, supported
employment, personal care services and family and peer support.
the sort of “community based mental health care” that a young lawyer
Arnold envisioned for people with SMI when he filed a class action
lawsuit against the state of Arizona and Maricopa County in 1981. Arnold
was settled in 2014, and helped force the state of Arizona to provide
comprehensive community mental health care to people living with SMI.
mental health experts, family members and advocates say the care is difficult
to access in rural Arizona – including Cochise County.
When Arnold hears about
Adrian’s case, he calls it “dreadful.”
pushing for more oversight to ensure people with SMI get the care they are
and others like him in rural counties can run into frustrating roadblocks. In
Cochise County, public transportation is limited. The county currently has
three full time practicing psychiatrists – and they’re all in Sierra Vista.
People with SMI sometimes get treated by psychiatrists who don’t reside in the
county but provide “telemedicine” via video screen, or by onsite
nurse practitioners. The county has two in-patient mental health treatment
centers with a total of 38 beds. Behavioral health providers change titles and
alliances, making it difficult for people with SMI to access help.
go through [behavioral health] providers down here kinda like disposable
napkins. They come and go, come and go,” Sheriff Dannels says.
Willcox, a railroad and cattle ranching town, only has about 3,500 residents
and limited mental health services, Eric and Richy have driven Adrian to
appointments in places as far away as Safford (a 90-mile round trip, in Graham
County) and Benson (a 68-mile round trip).
Adrian was in jail, he got his antipsychotic meds from the Cochise County
Health Department. When he was living at home, Adrian was back on AHCCCS.
Sometimes, Adrian ran out of medicine. Caseworkers came and went. And Richy
says Adrian was never offered job training or supported employment. Adrian
wanted to work in the fields, Richy says, but no one would hire a guy with
Ana and Eric left home. Richy stayed – and struggled. He worked. He drank. He
worried about Adrian.
and Adrian built a small shed in the backyard. Adrian called it his “cabin”
and spent hours in it, taking apart electrical gadgets and listening to Cypress
Hill belt out songs like “Insane in the Brain.”
a while, Adrian was under court order to get “Title
outpatient mental health treatment. Usually, this type of court-ordered
treatment lasts a year. Adrian was compliant, getting AHCCCS-funded meds and
therapy in nearby Willcox, and was staying out of jail.
Richy checked into a six-month rehab program in September 2018. A social worker
placed Adrian in a group home in Douglas, but he ran away. He began living on
Willcox streets. He was not complying with the court order to get outpatient
months later, Adrian allegedly stole two Steel Reserve beers and a bottle of
Kung Fu Girl wine from the Safeway in Willcox. He sat outside of the grocery
store drinking wine and yelling at customers. A Willcox police officer arrested
Adrian on 10 misdemeanor charges – including two counts of disorderly conduct,
criminal nuisance, littering, shoplifting, criminal damage, obstruction of
government operations, drug paraphernalia use (the cop found a meth pipe
nearby), escape in the second degree and consumption of liquor in public.
police went through Adrian’s backpack, they discovered he’d stolen food and a
pair of socks from a nearby store. And he’d swiped a medical alert display and
two surgical prep packs from the local hospital.
pleaded guilty in Willcox Justice Court to shoplifting and agreed to pay $676
in restitution. Then he was released from the Cochise County Jail to Sonora
Behavioral Health Hospital in Tucson to continue mental health treatment.
for reasons that aren’t clear in the records, Adrian left Sonora Behavioral
Health about a month later. That’s when he allegedly stole the tachometer and
got charged with the felony. Adrian returned to jail. He couldn’t pay his
$3,500 bail as he awaited a resolution of his auto part theft case.
stayed in jail for six months. He was released in July for yet another court
ordered stay at an inpatient mental health facility – this time at Community
Bridges in Benson. This time, Adrian had agreed to get treatment as part of a
“mental health diversion program” that would spring him from jail.
But Adrian ran away, the facility reported. It was the second time that he’d
refused court ordered treatment.
was on the streets for a few days, then made his way back to Richy, who was
fresh out of rehab. The brothers lived together at home for about a week. But
because Adrian had violated his agreement with the court to get mental health
treatment at Community Bridges, a deputy took him back to jail – and solitary.
The New Asylums
with mental illness have ended up in American jails since the mid-twentieth
century, when a nation-wide “deinstitutionalization” of asylums
began. Those asylums had been created in the early nineteenth century, in part
to rescue people with mental illness from abusive jails and prisons, former
Washington Post reporter Pete Early writes in his 2006 book, Crazy.
months, Early, who has a son with SMI and has become an
advocate for people with mental illness, embedded himself in the county jail
in Miami, Florida. “Our jails and prisons have become our new asylums
because there is nowhere else for the mentally ill to go,” he concluded.
Cochise County Jail, a complex of brown and white buildings topped with razor
wire, sits at the end of a road that winds past black cattle grazing beneath a
cluster of thorny desert mesquite trees.
time Adrian goes to jail, he enters the booking area. He is patted down. He
changes into his jail uniform in a small adjoining room with benches and a
toilet. Once dressed, he puts his hands on the wall, kneels on a bench, and
allows his restraints to be put on. Then he is photographed, fingerprinted, and
a white medical bracelet with a computer code is attached to his wrist. He
generally starts out in the general population. But his behavior, or the
behavior of other inmates who torment people with SMI, lands him in solitary,
the only place his jailers say they can keep him safe.
jail was built back in the early 1980s, and is cramped and poorly designed.
Detention officers are forced to do their paperwork in the hallway. The jail is
loud, too. During a recent tour, Kenny Bradshaw, the jail commander, says
staffers call the clang of slamming metal doors “thunder.”
plumbing is faulty. The elevated inmate exercise courtyard leaks rainwater into
the jailhouse. The inmate commissary is no bigger than a closet. And the bleak
special handling unit with six solitary cells was designed to punish the most
dangerous inmates, not people like Adrian who can’t think straight.
jail tour doesn’t include the solitary pod. Bradshaw says the pod smells of
feces and a guy in one of the pods is in a highly agitated state. A visitor
would only make him worse.
is a tiny room where a detention officer monitors real-time videos of the
solitary cells, and one screen shows Adrian. He’s moved his mattress against
his door and is lying on it in a fetal position.
lot of our maximum security cells were used for very dangerous combative
assaultive inmates,” Bradshaw says. “We can’t use those cells for
those kinds of inmates anymore. A lot of time we have to put mental health
inmates in there because they’re so disabled they can’t survive or be put in
general population…I don’t think we’re doing them any good by doing that.”
doesn’t help that the family of an inmate with SMI who killed himself in 2018
sued Dannels and the county for the inmate’s alleged wrongful death. The inmate
had been in solitary, but Joel Robbins, his attorney, is unsure whether he was
in solitary when he died. (Dannels and the county haven’t responded to the
lawsuit, filed at Cochise County Court in September.)
jail itself can house up to 250 people. These days, about 30-50 inmates on any
given day in the jail “really need psych services,” Bradshaw says.
The Cochise County Health Department provides in-jail mental health treatment,
including meds prescribed by a psychiatrist via a video monitor. But even the
sickest inmates have the right to refuse treatment unless the court orders it.
lawsuits and state laws haven’t been more effective in limiting the numbers of
seriously mentally ill inmates in jails, counties are trying to figure out
Of the nation’s 3,141
counties and county equivalents, 507 counties, including all of Arizona’s
counties, have joined Stepping Up, a national initiative
that aims to keep people with SMI out of jail. The initiative, set up by the
American Psychiatric Association Foundation, the National Association of
Counties and the Justice Center of the Council of State Governments, encourages
data collection, stakeholder collaboration and measuring results.
Pretty Yavapai County in
north central Arizona, where almost a quarter million residents share more than
800 square miles of grasslands, mountains and yellow pines, has come up with a
model program with measurable results.
In 2015, Sheriff Scott
Mascher and his chief deputy, David Rhodes, decided to come up with a way to
keep inmates with SMI out of the county jail.
They knew they couldn’t
do it alone. They huddled with health care providers, other law enforcement
agencies, court and housing officials, social workers and family members, among
others. Today, the Yavapai Justice and Mental Health Coalition focuses on
community-based treatment aimed to keep people with mental illness out of jail,
and, if that isn’t possible, to collaborate on in-jail and post-jail mental
health treatment plans to reduce recidivism. But it’s expensive.
2018, the sheriff and his team had hustled together a total of about $2 million
from the Arizona Legislature, the Department of Justice and the Yavapai County
Attorney’s Office for their Reach
That should last three years.
University measured 2018 results.The university reported 1,104 people were diverted from
entering Yavapai County jail. Bookings declined by nearly 10 percent.
in Cochise County, collaboration hasn’t been as successful. Superior Court
Judge Laura Cardinal, who sees people with mental illness cycle in and out of
her courtroom, jail, and mental health evaluations, blames it on
agrees we need to develop solutions,” Dannels, the Cochise County sheriff,
writes in a text message to the Arizona Center for Investigative Reporting. He
thinks he’s got one – taking over a section of the nearly empty Cochise County
Juvenile Detention Center. He hopes to move jail inmates with mental health
issues into a secured wing of the detention center where they can get
treatment. He’s working with county leaders to see if they can “move that
Out Of Solitary, For Now
day in late October, Adrian calls Richy on the phone. Adrian is out of
solitary, out of jail, and in Canyon Vista Medical Center, a hospital with a
locked mental health floor in Sierra Vista. It’s more court-ordered treatment.
says he’s getting shots that make the voices easier to deal with.
hasn’t heard Adrian sound this good in several years. Richy is 36 now, and
hasn’t had a drink in over a year. He’s married, goes to church and feels his
life is finally coming together. But he never forgets his brother.
Adrian calls Richy twice a day.
one of these calls, Richy patches in the Arizona Center for Investigative
Reporting. Adrian slurs his words and talks fast all at once. His voice is
he still hear Tony the bad voice?
yea,” Adrian says. “Sometimes when I go to bed I understand that he’s
here…They [the voices] are kind of mean they’re kind of scary but I can deal
says if anyone needs electrical work, he’d be happy to do it.
then it’s time for dinner, and he hangs up.
few days later, a hospital social worker calls Richy. Adrian assaulted somebody.
The details aren’t clear. Maybe it was in the hospital. Maybe it was on the way
to another court hearing.
Richy doesn’t know where Adrian is. He calls the jail over and over.
he finds out Adrian is back in the hospital.
least Adrian is safe and out of jail, Richy thinks.
The Association for the
Chronically Mentally Ill (ACMI) was created approximately two years ago by
families with children that have serious mental illness and strong advocates
that work helping such families. All board members are volunteers, and none work
for any behavioral agency nor receive monies from AHCCCS or any provider
stories we often encounter are of persons with SMI who are not thriving nor
able to advocate for themselves. They do not attend peer-run groups, their
families have not received family support services, they often are isolated,
and encounter law enforcement at alarming rates. This is the small sliver of SMI population
with Chronic SMI that is treatment non-adherent. Treatment non-adherence occurs
when a person/patient’s decision-making process is most profoundly impaired
(because their health condition is psychiatric in nature and happens to have
core features, like anosognosia, which impair judgment about their health
care). Another aggravating factor is the fluctuating nature of the impairment
since people with severe psychiatric conditions experience variable periods of lucidity.
serious chronic medical condition that coincidently involves the brain should
not result in a criminal sentence. We do not criminalize people with diabetes
when their disease becomes unstable even if they are not adherent to the
dietary requirements or medication schedules. A brain disorder is no different
and should not be treated as a failure of proper moral behavior. It should be
treated as a chronic disease. We also believe that not having appropriate
housing is a harmful factor for those individuals that struggle with brain
disorders. No one gets better when faced with the struggles of homelessness.
ACMI’s Over-arching principles:
Our three specific goals are:
(1) develop more
Lighthouse-Like Community Living Homes,
(2) develop a
“Secure Residential Treatment Program”, and
(3) recommend criteria
and processes for provider-selection, provider accountability (oversight), and
implementation of person-centered provider culture related to (1) & (2).
Passage of 2747, 2754, 2755 & 2756 will provide resources towards these
Our biggest challenge is that many different
sources fund society’s interactions with the Chronically Mentally Ill: AHCCCS,
RBHA’s, Medicare, Medicaid, Counties, the State, City Police Departments,
Courts, Jails, Prisons, Hospitals, Emergency Rooms, Etc. Major reform will
require redeployment of public funds involving intense opposition from entities
from which funding is redeployed, even though such entities would have a
corresponding expense reduction.
From the Interim Report
and Recommendations from the Committee on Mental Health and the Justice Reform
“Today, a person
experiencing a mental health crisis is more likely to encounter law enforcement
in a time of need than they are to receive medical assistance. Local law
enforcement reports across the country reveal approximately one in ten police
calls involve mental health situations.4 Local court users and jail populations
reflect this reality. Nationwide, rates of serious mental illness in jails
are four to six times higher than in the general population.5 According to the
National Alliance on Mental Illness (NAMI), 2 million people with mental
health conditions are booked into jails each year. Nearly 15% of men and 30% of
women booked into jails have a serious mental health condition. Further, the
majority of these individuals are misdemeanor offenders, or are serving time in
jail for non-violent offenses. Many of the individuals are homeless and most of
the crimes are “survival crimes”. In
fact, most people in jail have not yet gone to trial.6 “
next two years, the association and its members determined that appropriate
housing, including secure housing, was a fundamental requirement for the
treatment of those with SMI. Working with influential legislative leaders such
as Nancy Barto, Heather Carter, Kate Brophy McGee, and Sylvia Allen, among
others, the legislature passed a series of laws. These laws specifically
included money set aside to provide secure housing for those persons living with
SMI who are otherwise non-adherent to treatment and whose recovery therefore is
made more lengthy and dangerous. The Appropriations Committee appropriated $3.5
million to launch this effort in 2019 with an RFP form the Arizona Department of
Housing followed by competitive bidding in early 2020. ACMI is proud of this remarkable success
story and the hope it brings for the chronically mentally ill.
In October 2019 The Committee on Mental
Health and the Justice System issued a report with recommendations to the
supreme court of Arizona, which included broad-based recommendations for
changes to the justice system that would impact the way persons with SMI were
treated. The Committee recommend legislation that would provide for
“enhanced services” for people with SMI that are non-adherent to
treatment. Specifically, in Appendix B(D)(1b) ,
the Committee recommended “housing or residential placement that provides
the patient with stable, safe and, if necessary, secure residence to enhance
compliance with the treatment plan and protect the safety of the patient and
There is, therefore, a somewhat rare concurrence
between the work of ACMI (a small start-up non-profit) and the legislative and
judicial branches of our government with regard to the need for secure housing
for those patients with SMI who are non-adherent to treatment.
its members have every reason to hope, if not believe, that the executive
branch of our government also approves of such necessary and appropriate
The Committee’s report is a remarkably succinct and compelling overview of opportunities and challenges facing Arizona’s behavioral health industry and those who received services in that industry. It bears reading by all engaged in mental health policy in Arizona.
The highlights of the
fall under the
• Legislation, Policy,
• Training and
• Data Resources and
• Court Improvement
• Community Services
• Diversion and Early
• Programming and
• Access to Technology
The full report
provides a blueprint for evolution and refinements of our behavioral health
system for years to come.
Cheryl Roberts of the Greenburger Center for Social and Criminal
Justice has been working for many years to provide an alternative to
incarceration for individuals that are treatment resistant.
“For those who refuse treatment, like Santos, the default is often the streets. Yet undeterred by this reality, the public fails to fund robust supportive housing and some officials and advocates still fail to acknowledge the value of court-mandated treatment or admit that we need to develop a wide variety of intensive supported housing and yes, some involuntary commitment beds to deal with serious cases, at least until they are stable.” Cheryl Roberts
like this are happening too frequently for individuals that are not treatment
adherent. Leaving untreated psychosis can have a dire impact on the individual,
their loved ones, and their community.
advocating that all individuals deserve a chance for a life with dignity. And
we believe that until there is a period of stability in a safe recovery-based
environment, recovery is unlikely to begin. Individuals that are treatment
adherent tend to have trust with their treatment teams and a support system
that works for them. Secure residential
treatment is not for individuals that are adherent to their treatment.
Secure residential treatment is also not intended for
individuals that have encountered a setback with their illness. It is for those individuals that have been
highly unsuccessful with the current system, systems where they walk out
because they do not believe they are ill. We believe that this is not a
permanent placement for individuals, but a temporary arrangement to gain
insight to start on a path for long term stability and a move towards more
independence. The opponents of this philosophy offer no solutions for this
segment of the population. Providing the same ACT team, peer support, and
community living does not work for someone that is highly psychotic and lacks
insight. Remember the definition of insanity- doing the same thing and
expecting different results. ACMI strongly believes that providing secure
residential treatment will provide a valuable missing service.
Few are guilty, all are responsible: How
to fix a system that let a homeless man kill four other homeless men on New
By Cheryl Roberts New York Daily News
Oct 10, 2019 | 3:01 PM|
As a former town judge
and current bond agent for the Columbia County Bail Fund, I bristle at reports
blaming the recent deaths of four homeless men on the Bronx Freedom Fund for
bailing out the suspect, Randy Santos. I also bristle at those who point the
finger at the Brooklyn judge who tried to divert Santos into mental health
treatment after an earlier arrest rather than locking him away.
Like appears true of
Santos, approximately 90% of the people I have bailed out have a mental illness
and or substance use disorder. And while our bail fund’s volunteers go to
incredible lengths to ensure our clients are connected to services, sometimes
services are not enough, especially when someone refuses treatment or does not
comprehend that he is seriously ill.
As a local judge in
upstate New York, I had no good options to address the needs of people living
with serious mental illness. Though New York City judges have more options,
they are not mental heath professionals and cannot supervise a defendant once
he or she leaves court. Yet judges are left to develop “treatment plans” and
evaluate sometimes unknowable risks about mental health conditions and potential
violent outbursts in a field where medications have not fundamentally changed
in the last 30 years, basic scientific funding and research has lagged, and
even seasoned psychiatrists would have a hard time diagnosing these defendants,
a population, along with the homeless, many psychiatrists avoid at all costs.
Attempts to lay blame on
the district attorney for failing to be tougher toward Santos may also be
misplaced. Under the status quo, whether a DA diverted Santos or prosecuted him
for previous charges, it’s quite possible that neither would have done justice,
made the community safer or avoided tragedy. At some point, Santos would have
re-entered society, most likely the worse for wear, after spending time on
If blame is to be laid,
it should start with the public and elected representatives, especially federal
officials, who failed to fund mental health services or research for decades.
That’s the real root cause of this problem.
According to the
National Alliance on Mental Illness, between 2009 and 2011, states also cumulatively
cut more than $1.8 billion from their mental health budgets, with New York
State scoring the second largest cuts in the nation, totaling $132 million.
Perhaps it is not surprising then, that between 2009 to 2018, the city’s 911
calls involving “Emotionally Disturbed Persons” rose from 97,132 to 179,569.
Ironically, the mental
health profession and certain mental health civil rights organizations are also
at the core of our unraveling mental health system. Where has the American
Psychiatric Association been for the last 30 years as their most ill patients
have been criminalized or driven to homelessness?
And shame on groups that
still advocate for complete deinstitutionalization, who refuse to acknowledge
that mental institutions never really went away, they just morphed into two
types: posh mental health facilities costing thousands of dollars a month, or
prisons and jails which cost just as much but often deliver poor treatment, if
For those who refuse
treatment, like Santos, the default is often the streets. Yet undeterred by
this reality, the public fails to fund robust supportive housing and some
officials and advocates still fail to acknowledge the value of court-mandated
treatment or admit that we need to develop a wide variety of intensive
supported housing and yes, some involuntary commitment beds to deal with
serious cases, at least until they are stable.
Until the public stops
stepping over people like Randy Santos and demands that our tax dollars fund a
public health system geared toward the most ill and potentially most dangerous,
there will be more tragedies like last week’s.
Let’s start by building
on, rather of tearing down, the work Thrive NYC has done to raise awareness
about mental illness and instead direct more Thrive funding to the most
seriously ill. Then, over the long term, we must insist that funds to build new
jails are at least in part spent on the real needs of those living with serious
mental illness and substance use disorders.
Roberts is executive
director of the Greenburger Center for Social and Criminal Justice.
We mentioned Trieste
Italy in an earlier blog. How are People with Serious mental Illness Faring in our Jails? Trieste
is a city and a seaport in northeastern Italy. The metropolitan population of
Trieste is 410,000, with the town comprising about 240,000 inhabitants. Trieste
has a culture that embraces its most vulnerable people and, as a community,
takes care of them. In 2017 while visiting Trieste Italy, Kerry Morrison, (an
advocate in Los Angeles) discovered a unique mental illness community culture.
Kerry Morrison found a mental health culture and treatment model in which every patient was cared for and, no one was left to pitch a tent and fend for themselves. This practice of caring for the most vulnerable is in stark contrast to what we see in America’s largest cities.
I am excited to see if
the Trieste model can be transferred to a city the size of Los Angeles.
Possibly achievable if piloted in a smaller community neighborhood.
We would like to see all our vulnerable populations housed and treated with respect and dignity.
Kerry Morrison had seen enough.
She was not a clinician or policymaker, and she didn’t know what the answers
were. But she knew she was looking at failure, and she knew she could no longer
All around her, in the heart of
Hollywood, people were living in subhuman conditions, sprawled beside
storefronts and at bus stops. Their clothing was shredded, their bodies were
black with grime, and their unattended madness was a daily indictment of public
compassion and will.
“I couldn’t reconcile the sight of
cranes, signifying progress, while stepping over mentally ill people on the
street,” said Morrison, who was director of the Hollywood Property Owners
Alliance for many years, and a decade ago began taking a closer look at the
growing homeless population.
I remember wondering briefly, when
I met Morrison back then, if she was more interested in cleansing the streets
on behalf of the business interests she represented than in helping those who
were suffering. But she and I were soon sharing notes on our daily interactions with those who were struggling, and on social
workers who against all odds were making a difference.
“I felt called to this,” Morrison
She reached out to professionals, joined boards, helped launch a campaign to identify and help the 14 most dreadfully ill people living on the streets of Hollywood. Morrison researched mental health policy and the history of what went wrong in the United States, and in particular in Los Angeles, where against a backdrop of economic progress and wealth, sick people were living in squalor.
Morrison won a fellowship to
further her studies, checked out mental health programs in other U.S. cities,
and traveled to a town in Belgium where families “foster” adults with mental
illness. Last year, she gave notice to the property owners group that she’d be
leaving her job in February to devote her full attention, unpaid, to her cause.
But it was a trip to Trieste, on the uppermost rim of
the Adriatic in Northern Italy, that turned her despair into hope. It was
there, in the summer of 2017, that Morrison found a mental health model in
which every patient was looked after and no one was left to pitch a tent and
fend for themselves. And it was there that she began mapping a plan to bring
the Trieste model home to Hollywood.
Morrison tells a story about that
first visit to Trieste, when she asked a young psychiatrist named Tommaso
Bonavigo how he handled one difficult case involving a seriously troubled
“He said he started going out to
his house to find him and I said, ‘Excuse me, Tommaso. You went to his house?’”
said Morrison. “I said, ‘You know what, Tommaso? I almost wish I hadn’t heard
this because the chasm between what you’re doing in Trieste and what we’re doing in Los Angeles seems
It is, in many ways — especially
given the scale of the problem here. But when Morrison got back home, she
refused to let the thousand and one challenges cloud the promise of Trieste.
There, Morrison had found, the program was patient-based, not
bureaucracy-driven. The philosophy was to focus on the person rather than just
the illness, to treat people as full-fledged members of the community, address
individuals’ specific needs and closely monitor the progress.
One of the first people she went to in Los Angeles was Dr. Jonathan Sherin, the new director of the L.A. County Mental Health Department.
“I told him, ‘Jon, you gotta see
this,’” Morrison recalls.
Sherin knew about Trieste but had
never been there. He listened to what Morrison had to say, then talked it over
with L.A. County Superior Court Judge Jim Bianco. Bianco works in the mental
health division and has long been frustrated by the number of sick people who
end up homeless, in jail or in psychiatric lockdown because so few alternatives
“Bianco and I … both agreed —
we’re going,” said Sherin. “And we went.”
So did 10 other curious locals,
led by Morrison, and they liked what they saw. Upon their return, they began
pitching others on the wonders they’d seen, and the momentum grew. It was
decided that a section of Hollywood, with about 100,000 people, high levels of
addiction and mental illness but not as many services as skid row, would be a
good place to test Trieste.
But how to pay for a pilot project
Thanks to voter-approved
Proposition 63 in 2004, which taxed millionaires, about $2 billion is generated
annually for mental health services in the state. Sherin appealed to the Mental
Health Services Act oversight committee to take a shot on a new strategy that
focuses on outcomes rather than process, and $116 million was freed up from an
The deal now awaits a stamp from
the county Board of Supervisors.
Two weeks ago, a delegation of
three dozen local and state officials and members of nonprofit service agencies
went to Italy with Morrison for a closer look. L.A. Mayor Eric Garcetti’s
homeless services leader, Christina Miller, went along, as did California Assemblyman
Richard Bloom. L.A. Dist. Atty. Jackie Lacey was there, too, along with
representatives from the LAPD, the L.A. County Sheriff’s Department, and the
office of county Supervisor Sheila Kuehl.
And I tagged along to see
firsthand what all the excitement is about.
I’ve written a lot in the last 15
years about what works and what doesn’t, about how our streets were turned into
asylums, about a friend I’ve been trying to shepherd through the failing
system, and about how we’re now averaging nearly three homeless deaths a day in
In Trieste, I was curious about
How do they do it? And can we
The first question, I can now say,
is easier to answer than the second.
No magic was involved in Trieste.
When mental institutions were closed 40 years ago in Italy — about the same
time as in the U.S. — Trieste innovated while the U.S. abdicated, falling
miserably short on the promise of community clinics.
Under the leadership of a
psychiatrist named Franco Basaglia, Trieste built a coordinated network of
treatment centers, embraced patients as full-fledged members of the community,
invited family members to participate in their loved one’s recovery, built
relationships with employers who hired the patients, and didn’t let bureaucracy
or billing entanglements sabotage good outcomes.
When someone has a psychotic
episode in Trieste and there’s a call for help, it’s usually a mental health
team that responds, not police, and the team often has already built a
relationship with the client. At one mental health center we visited, a nurse
described a recent event in which she responded to a distress call and spent
seven hours with a patient who eventually agreed to come in for help.
The doors of community mental
health facilities are not locked in Trieste, and we were told that if patients
choose to leave, staff members follow them to make sure they remain connected
Psychiatrists at one mental health
center said they had only five cases of involuntary commitments last year. It
happens rarely because when people have easy access to regular help and begin
to know and trust care providers, they’re easier to treat, and not as inclined
to have their conditions deteriorate, or to resist therapy or medication that
As ideal as this all seemed, there
were times when Trieste sounded a little too good to be true, and it was hard
to know in just five days what the long-term outcomes look like. The program
has been criticized over the years, by those who favor more institutionalization,
and Italian budget constraints could threaten its survival.
But what we saw was so vastly
superior to the bedlam we call a system, I felt a sense of shame when Los
Angeles briefly took center stage in Trieste.
Care providers from around the
world were in the northeastern Italian city of about 200,000, with daily
presentations and panel discussions from attendees, many of whom spoke of
innovative programs to help those in need. And then Morrison stepped up onstage
with Anthony Ruffin, of L.A.’s mental health department, to talk about
Hollywood’s sickest homeless people and the mostly failed efforts to rescue
Photos of the Hollywood 14 were
displayed on the big screen. A majority of them were African American. They
were sprawled on streets and huddled under blankets, like storm refugees or
casualties of war. Three of them died, Morrison told the crowd.
She also talked about how we
usually have about 5,000 mentally ill people locked up in our jails at any
The conference center fell silent.
In the richest country on the
planet, this was the state of Hollywood, the world’s mythical capital of
It was like seeing our own
abominable failure with fresh eyes, and it wasn’t entirely clear that even with
a map in hand, we could find our way to a better place.
We have 40 times the population of
Trieste and 50 times the challenges.
There was no evidence of NIMBYism
anywhere; we’ve got it everywhere.
In five days, I didn’t see a
single homeless person in Trieste. Trieste has no drug epidemic, even as ours
rages, and it’s harder to help people with both a serious mental illness and a
Especially when they live in
The Hollywood pilot will serve
those who are housed as well as those who are unsheltered, but there will be
legions of the latter. At one point, Miller asked the lead psychiatrist in
Trieste — Dr. Roberto Mezzina — his thoughts on treating people with a mental
illness who are homeless and may be for quite a while.
“It’s impossible,” Mezzina said.
On one of our days in Trieste, we
visited a recovery home where four residents live. Michele, the house
supervisor, talked about how he himself once went through storms of depression
and had no desire to go on living.
“It’s like going under the sea,”
In the Trieste program he was
prescribed medication that helped, he got a job, and for the first time in his
struggles with mental illness he saw doctors he believed were truly invested in
him getting better.
Michele supervises four residents
who are now where he once was. One, who works as chef, was in the kitchen
making a birthday cake for another resident, who works as an elder care
assistant. I asked Michele what happens if relatives call and ask how the
residents are doing.
He reacted as if that were an odd
question. They are happy to talk to relatives about clients, he said, “if it’s
for the benefit of the person.”
The reason I asked is that in the
U.S., laws protecting patient privacy often keep family members in the dark,
and we can add this to the list of needed American reforms and challenges for
Also, Trieste has no shortage of
mental health facilities for its clients, no matter the severity of their
illness. We have epic shortages of everything. We also have a disjointed,
beastly bureaucracy and criminally tortuous billing systems designed to beat
the breath out of hope.
So this won’t be easy to bring
home, or to scale up to our vast need, and no one in the L.A. delegation was
under the illusion that it will be. There were gasps when we learned that
Trieste has enough staff to make two or three daily home visits to check on
clients in the throes of crisis. That’s a huge investment, and going forward in
L.A., covering the cost will be yet another monumental challenge.
But our comparative debacle of a
system makes it all the more critical that we blow it up, and it’s unforgivable
that it’s taken this long to try something new.
I’ve seen programs in Los Angeles
that echo the Trieste model on a small scale, some of them quite effective. But
even those get battered by bureaucratic interference and debilitating resource
The Hollywood pilot has to be
built to eviscerate those problems and free a well-trained army of people to
serve a far larger population, and whatever clicks in Hollywood has to be
rolled out to the rest of the county as quickly as possible.
Mental illness hits about a
quarter or more of our homeless population, but this is not about ending
homelessness. It’s about ending our inhumanity, and finally helping those we’ve
left to languish and even die at our feet.
What comes next is a year of
planning out the specifics, siting urgent-care and community health centers,
recruiting Hollywood businesses to hire participants, convincing residents this
will be a community asset and not a burden, hiring clinicians and outreach
teams that include those who were once in need of help, and lining up enough
housing to give the pilot a chance.
“I’m out on a limb on this one,”
Sherin admitted when I met with him in Hollywood one morning after I got back
from Trieste, and we discussed the promise and the challenge.
Sherin said Los Angeles has
focused for too long on easier cases while giving up on those with more severe
and hard-to-treat symptoms. In the pilot, he envisions several teams of 10 to
12 staffers assigned to groups of 100 to 125 clients, and he doesn’t want those
clients endlessly shuffled from streets to jails to hospitals without a
constant, coherent effort to help them break that cycle.
“I don’t give a rap what time of
night it is, you take care of them,” Sherin said.
The doctor said he hits the
streets with his outreach teams once a week or so to stay in touch with the
need. Anthony Ruffin, who is helping build the pilot and whose dogged outreach
efforts I wrote about two years ago, wanted Sherin to check on a man with mental illness
and meth addiction who has been living on the same patch of sidewalk near a
coffee shop for 10 years.
When we got there the man was
ranting, taunting passersby, screaming profanities and insults.
Sherin sat next to him on the
sidewalk, took the full brunt of the eruptions, and waited him out. They talked
quietly for a few minutes. The man said he was out of his medication, and
Sherin promised to come back and bring him some.
We have way too many such cases
and we can no longer have people camped outside for 10 years, and sometimes
longer, as we shrug or throw our hands up in surrender, or tell rattled
merchants or residents we’re sorry but we don’t have any answers.
The man was still ranting when we
left, but Sherin said the pilot won’t shy away from tough cases like this one.
It will take them on because it’s the humane and moral thing to do. Whatever
happens, I found it encouraging that the county’s mental health director
doesn’t consider himself above sitting on a gritty Hollywood sidewalk to
connect with someone in desperate need.
When I checked back in with
Morrison after my return to Los Angeles, she had moved on to Rome, where she
was looking at more mental health innovations and trying to learn from them.
She said that Trieste for her was still the gold standard, and she was ready to
begin the hard work of bringing Los Angeles into line.
As the headline said on a Morrison
blog post two years ago:
“Once You’ve Seen Trieste, You Can’t Pretend It Doesn’t Exist.”
We work with
stakeholders to improve care for persons suffering from chronic serious mental
illness through cost-effective network enhancements:
(a) a person-centered culture (instead of program-centered),
(b) financial & other incentives, based on performance & outcomes, for providers to better serve this population;
(c) more Lighthouse- like homes, i.e. community living properties with 24-hours per day and 7-days per week supportive staff inside these properties,
(d) humane, well-regulated facilities for secure residential treatment, involuntary as medically appropriate, for those who need more intensive care for a longer period of time to gain insight and continue their recovery in a less restrictive setting; and,
(e) other possible solutions.
encouraged to see a focus back on research and understanding individuals that
lack insight into their illness.
HIGHLIGHTS ANOSOGNOSIA, CRIMINALIZATION OF SEVERE MENTAL ILLNESS IN CALL TO ACTION
ARLINGTON, VIRGINIA – On Thursday, Dr. E.
Fuller Torrey gave the
keynote speech at the American Psychiatric Association’s IPS Mental Health
Services Conference in New York.
Widely considered a celebration of Dr. Torrey’s monumental
career, the speech focused on one of the most important questions facing modern
mental health care: what did American psychiatry get so wrong that caused our
system to fall apart?
Dr. Torrey’s answer identified five key causes:
A misunderstanding of the causes of psychosis;
Ignorance regarding the role lack of insight (anosognosia) plays in providing effective care;
A failure to prioritize care for the tens of thousands of individuals being discharged from state hospitals;
An overreliance on a top-down federal approach versus directly coordinating care with state and local communities;
A failure by NIMH to effectively oversee the system or to prioritize serious mental illness care.
Dr. Torrey, speaking to hundreds of community psychiatrists,
detailed how emptying state psychiatric hospitals without a plan for how people
would be treated in the community led to a series of tragic outcomes, including
homelessness, criminalization and a system collapsing under the weight of
ineffective, unresponsive programs.
He concluded the speech with two calls to action.
First, he asked the IPS to prioritize the problems he listed,
noting that “America needs IPS to solve these matters.”
The Treatment Advocacy Center is a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illness. The organization promotes laws, policies and practices for the delivery of psychiatric care and supports the development of innovative treatments for, and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder.
are tent cities under freeway structures and along various streets. People that
self-organized in the popup tent compounds are most likely not individuals
suffering from untreated serious mental illness. I believe that persons in the
tent communities are far more likely to be homeless due to affordability,
addiction, or past felony convictions (which make it more difficult to find
I am in
the downtown area of San Francisco this week, and one cannot ignore the
devastating effect of not treating persons with serious mental illness. The
lack of dignity is palpable. The stench of urine is overpowering even despite
the businesses paying cleaners every morning to wash down their storefronts.
People should not live in cardboard boxes and relieve themselves on the
sidewalk. Some of the folks I observe are too ill to even beg for food. They
are fighting demons I cannot see, arguing with invisible enemies within. As
Chick Arnold once said, “They are dying with their rights on.” Meaning that in the interests of protecting
certain civil rights (ability to choose one’s lifestyle i.e.: ‘he’s his own
Guardian.’)” But at what cost?
I was on a docent tour at the Legion of Honors yesterday, and a gentleman from Germany was discussing the weak social system he observed in the Bay area. He said not helping vulnerable people is intolerable to Europeans, but that they pay a high cost to achieve that; about 60% of their salaries. We don’t want to become a socialist state, we need to support cost effective solutions that are working:
Lighthouse like supervised community living homes and
Yet that often seems what we continue to do when dealing with
the chronically homeless and mentally ill.
Which is why I’m always on the lookout for out-of-box ideas. I’d
like to cite two examples of such thinking in helping individuals step away
from the streets-jail-emergency room treadmill.
The staff at St. Joseph Healthbecame concerned when it kept seeing the same
patients cycle through its two hospitals in northern California. It was obvious
why. There was no safe place for these chronically homeless and often
seriously mentally ill patients to go after they were discharged.
St. Joseph’s Hospital began paying for five beds at a local
clean and sober house. That soon grew to fifteen beds. The hospital pays a
yearly amount for the building and insurance, screens potential candidates and
provides clinical case management for residents during their stay. A community
homeless advocate provides 24-hour non clinical staff. Funding for two nurses,
a social worker and a health coach — comes out of the hospital’s operations
The goal is to stabilize patients enough to move them out of the
program in 21 days, but longer stays occur if needed. St. Joseph’s
estimates it saves as much as $1,500 per patient per day by keeping them out of
the hospital. And its success rate with patients is good. About half of the
homeless who go into respite move into transitional housing with assistance
from the team.
According to Healthcare Dive, more and more hospitals are
stepping up to deal with homelessness and whittle down accompanying high
medical utilization costs. Their efforts range from providing post-discharge
respite care to residential case management to
donating money to build new housing units for
homeless and low-income individuals.
Most successful programs
rely on strong community partnerships.
I serve on the board of the Corporation for Supportive Housing, a
national organization focused on the homeless, and it estimates that healthcare
systems have invested between $75 million and $100 million in housing projects
that CSH supports, according to my friend and CSH spokesman Robert Friant, who
was quoted in the Healthcare Dive article.
Twenty-five cells were converted to rooms. Instead of
bars, each has a door and its own bed, sink, toilet and television. Clients eat
in a communal dining area. Staff from nonprofit organizations and civilians
employed by the sheriff’s department provide warm handoff services — outside of
the criminal justice system. The cost to reconstruct the cells was $10,000.
Items such as televisions and kitchen appliances were donated. The goal is to
keep individuals from cycling back into the criminal justice system.
“Chances are Apple’s plan will save Albany County taxpayers
hundreds of thousands of dollars a year, make the city safer and save lives,”
Of course, housing the homeless in jails is unorthodox and makes
some advocates uneasy because it can cause further stigmatization. But living
on the streets is dangerous and deadly. Studies show the average life
expectancy for chronically homeless individuals is in their early 50s.
One reason why the St. Joseph Hospital model and Sheriff Apple’s
method appeal to me is they were solutions that originated from the local
community up, rather than the federal government down.
I began this blog with the cliche about insanity. I will end it
with another quote that I repeat over and over and over again on this blog and
in my speeches.
‘Never doubt that a small group of thoughtful, committed
citizens can change the world: it’s the only thing that every has.’ Margaret
As we wrote
about in our August 2019 blog, “What
are the consequences of an inadequate number of long term public psychiatric
inpatient beds?“; we
seem to have no shortage of short term stay private pay psychiatric hospitals,
but we still lack the long-term public beds. Until we repeal the IMD exclusion,
there will be no motivation to ensure that patients that need longer stays in
the hospital will be permitted to remain in the hospital. Utilization managers
apply pressure to discharge patients to outpatient treatment. There is also an
undercurrent of belief that anytime someone needs hospitalization, it is a
failure on the part of the outpatient treatment team. Unfair access to
hospitalization, when in a behavioral health crisis to appropriate admissions,
seems to be a parity issue.
Let’s look at a medical model of a physical lifelong
disease process. A person who is obese and has type two diabetes may require
readmission to a hospital for re-regulation of their treatment for their
Uncontrollable insulin levels may be due to one of the
a) the patient not taking medications as prescribed,
b) eating sugar despite warnings, or c) generalized signs
of changes in their metabolic system.
Upon patient stabilization in the hospital, the
outpatient treating physician is not penalized for the initial admission.
Why is mental health inpatient treatment any different
than medical inpatient treatment for physical diseases?
Isn’t the head part of the body?
This is a parity violation!
Phoenix to get new psychiatric hospital, but some say it won’t fill the need
The Phoenix area is in desperate need of more in-patient
hospital beds for individuals with psychiatric needs, mental health workers
But some fear the new $19.5 million, 96-bed private Phoenix
Medical Behavioral Hospital opening in central Phoenix next spring won’t
be the solution.
Caliber, a development company, bought the building at
14th Street and McDowell Road for $10 million and is putting $9.5
million into renovations. NeuroPsychiatric Hospitals will run the
facility, company spokesman Jim Hummer said.
Hummer said the hospital will only treat adults and expects
a majority of its patients will come from senior living facilities. The company
owns similar facilities in Indiana.
Some in the mental health community question whether the new
hospital will effectively serve the community given the long-term
care patients with chronic mental illnesses require.
beds in the Valley
There are currently 433 licensed, state-run in-patient
psychiatric beds in metro Phoenix, according to the Maricopa
Integrated Health System. An additional 144 beds are slated to be available
by April 2020 at Maryvale Hospital in Glendale.
Even with the additions, Phoenix is still in need of
in-patient psychiatric beds, health care officials said.
“Everything that I’ve read indicates that Phoenix has a
lower than typical number of beds for the population that we
have,” said Dr. Gene Cavallo, vice president of the Maricopa
Integrated Health System. “For a metropolitan area of this size, we still
have a need for more.”
Arizona ranked fourth worst in the nation, with 4.4 beds
available per 100,000 people.
offers private beds
The beds opening up at the Caliber-owned hospital will
be for voluntarily-admitted patients.
These patients may have public or private health insurance.
The difference, however, is there is no court mandate or petition that
forces someone to enter Phoenix Medical Behavioral Hospital like the
patients publicly-operated hospitals must take.
Unlike other private hospitals, Hummer said, Phoenix Medical
Behavioral Hospital will have a two-armed approach in its treatment, part
medical and part therapy. He said patients are usually treated with medication,
but this hospital will also have a team of psychiatrists and therapists
who will be there to help patients.
But even that won’t meet the Valley’s needs, one mental
health advocate said.
Meeting community’s needs
Charles “Chick” Arnold has been a mental
health lawyer working with Valley families of people who are mentally
ill for more than 30 years. Arnold successfully sued Arizona in 1989,
alleging that Maricopa County did not provide a comprehensive community mental
health care system as required by the state.
There are two types of people with mental illnesses who may
need a psychiatric hospital, Arnold said. And their needs are quite
The first type is those who’ve suffered a momentary mental
health crisis, like environmental depression or a psychotic episode, Arnold
said. Such people may need admittance to a hospital for short period of
time, roughly 30 days, because their illness can be addressed relatively
“The time someone needs to spend in the hospital is based on
a number of factors: quick response to meds, social and family support, and a
plan for when they’re ready to leave the hospital.” Dr. Gene Cavallo, vice
president of the Maricopa Integrated Health System
The second type is people with mental illnesses
such as clinical depression, schizophrenia or bipolar disorder. These people
may need to be admitted to a psychiatric facility for a longer period of time
and their illnesses are a lifelong struggle.
“The time someone needs to spend in the hospital is
based on a number of factors: quick response to meds, social and family
support, and a plan for when they’re ready to leave the hospital,” Cavallo
The new hospital will focus on those acute mental illnesses
and patients will typically stay in the facility for less than a month, Hummer
“People that come to us are in a crisis
situation, so they’re either threatening to harm somebody, harm
themselves, they may have hallucinations, they may be psychotic,”
Hummer said. “One we get them back to their baseline of where they have
been before all of these things happened, that’s when they’re discharged from
the hospital. Our average length of stay is anywhere between 15 to 21
Arnold said the real need is with that second group. Without
more long-term beds for them, they will continue to cycle in and out of the
Phoenix area’s jails and emergency rooms, Arnold said.
“Do we need more beds?” Arnold asked, “Well,
we don’t need these kind of beds.”
“What they’re offering is short-term hospital space for
people who have substance abuse or behavioral health issues,” Arnold
said. “There are a lot of private hospital options that, frankly, don’t
generally serve this particular population very well in the absence of any type
of follow up.”
Laurie Goldstein, vice president of the Association for
the Chronically Mentally Ill in Arizona, has a son with schizoaffective
disorder who went through many short-term facilities on his way to a
About 40% of people with psychotic disorders don’t recognize
they’re ill, she said, complicating a physician’s ability to give them a
“Everything nowadays is very short-term,”
Goldstein said. “So I think taking someone, whether it’s public or
private, to a psychiatric hospital where they want to tweak their meds for
three days or five days, and then say that’ll stabilize them outside — that
just doesn’t happen.”
Hummer said NueroPsychiatric Hospitals was contacted by
health care people in metro Phoenix saying there is a need for a hospital like
this one and asking them to help.
Chuck and I had an
opportunity to meet with Cheryl Roberts and Francis J. Greenberger while in New
York City this past fall. We discussed
their pilot program to develop an alternative to incarceration pilot facility
to provide a secure “locked” therapeutic environment for those with
serious and or chronic mental illness or personality disorders.
the New York Daily News printed an Op Ed by Green
burger Center Executive Director
Cheryl Roberts about the need to rethink the jail closure plan. There are better ways to provide treatment
and rehabilitation to people living with serious mental illnesses and substance
use disorders and to end the cycle of homelessness and incarceration.
city of Albany recently changed the name of the county jail from the Albany
County Correctional Facility to the Albany County Corrections and
Rehabilitative Services Center to reflect its broader mission to provide
housing and services to homeless people.
Most importantly, staff from nonprofit organizations and civilians
employed by the Sheriff’s department will provide these services outside of the
criminal justice system.
Florida, over the past two decades, nearly 9,000 people have been referred to a
program created by Miami Dade County Judge Steven Leifman to divert individuals
with serious mental illnesses away from the criminal justice system and into
comprehensive community-based services. Annual recidivism rates among
participants went from 75% to 20% and the jail population dropped by 40%,
allowing the county to close one of its jails and save $12 million a year.
New York City finalizes its plan to close Rikers, more diversion and less jails
space is needed.
long ago, Albany County Sheriff Craig Apple changed the name of the county jail
from the Albany County Correctional Facility to the Albany County Corrections
and Rehabilitative Services Center to reflect its broader mission to provide
housing and services to homeless people. Most importantly, staff from nonprofit
organizations and civilians employed by the sheriff’s department will now
provide these services — outside of the criminal justice system.
cost to reconstruct the cells was $10,000. Things like televisions and kitchen
appliances were donated.
the first clients to be admitted will be people released from jail who find
themselves homeless. The goal is of course to keep them from cycling back into
the criminal justice system.
are Apple’s plan will save Albany County taxpayers hundreds of thousands of
dollars a year, make the city safer and save lives. That’s what happened in
Miami-Dade, Fla., when a judge started providing services and treatment to
people who constantly cycled in and out of jails, hospitals or homelessness.
the past two decades, nearly 9,000 people have been referred to a program
created by Judge Steven Leifman to divert individuals with serious mental
illnesses away from the criminal justice system and into comprehensive
community-based services. Annual recidivism rates among participants went from
75% to 20%. The jail population dropped by 45%, allowing the county to close
one of its jails and save $12 million a year.
to Miami police, officer shootings of people with serious mental illness went
from two a month to six in the last eight years, over a time period during
which the number of arrests in Dade County went from 118,000 to 54,000.
build on this success, Dade County just broke ground on its own “one-stop shop”
facility to allow judges the ability to provide people with serious mental
illnesses accused of misdemeanors or low-level felony level crimes with an
off-ramp from the criminal justice system with the goal of never seeing them
again, at least not behind bars.
facility will offer treatment for mental health, substance abuse, and primary
medical care needs, including eye and dental care; a court room; a crisis
stabilization center where police can bring someone instead of arresting them;
short- and longer-term residential space; a day activity program to teach
self-sufficiency skills; and a supportive culinary employment program.
New York City grapples with how to replace Rikers in the name of progressive
reform, it’s still not too late to consider building “one-stop shops” like
Albany and Dade County.
York City has already demonstrated a remarkable and unprecedented ability to
reduce the jail population. Now, it must address the core populations that will
make further reductions more difficult.
host communities of the proposed borough-based jails and advocates want smaller
facilities. The shortest route to delivering them is to do what Albany and Dade
have done — to make room elsewhere to better serve people with specific chronic
needs such as housing, mental health and substance-abuse treatment — none of
which are or should be the forte of jails or the city’s Correction Department.
it moves jail beds out of Rikers and into the boroughs, the city has a rare
opportunity to build more treatment and rehabilitative beds, and to finally
right the wrong of the decades-long mass incarceration of people with mental
illness. Incarcerating this population has not been fair, effective or fiscally
responsible to them or their families, nor to corrections officers or
is the time to ensure that mental health treatment is provided outside of the
criminal justice system and in the public health system, where it belonged in
the first place.
Roberts is executive
director of the Greenburger Center for Social and Criminal Justice.