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.
According 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.
What 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 beds.”
ACMI 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 links below)
· Increased discussion about changes to the IMD exclusion
· The rise of celebrity candor about their personal experiences with mental illness.
In 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.
Arizona 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 recovery.
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
Stories 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.
ACMI is 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 York’s streets
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 Rikers.
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 any.
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 ignore it.
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 says now.
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 patient.
“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 completely insurmountable.’”
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 are available.
“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 in L.A.?
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 “innovations” fund.
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 L.A. County.
In Trieste, I was curious about two things:
How do they do it? And can we replicate it?
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 to help.
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 might help.
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 them.
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 given time.
The conference center fell silent.
In the richest country on the planet, this was the state of Hollywood, the world’s mythical capital of imagination?
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 debilitating addiction.
Especially when they live in tents.
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,” he said.
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 Hollywood.
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 shortages.
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.
We are 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.
There 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 housing.)
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 budget.
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,” Roberts writes.
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 Mead.”
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 disease.
Uncontrollable insulin levels may be due to one of the following reasons:
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 say.
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.
Psychiatric 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.
Caliber 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 different.
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 quickly.
“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 said.
The new hospital will focus on those acute mental illnesses and patients will typically stay in the facility for less than a month, Hummer said.
“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 days.”
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 healthy life.
About 40% of people with psychotic disorders don’t recognize they’re ill, she said, complicating a physician’s ability to give them a drug treatment.
“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.
Today 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.
The 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.
In 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.
As New York City finalizes its plan to close Rikers, more diversion and less jails space is needed.
Not 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.
The cost to reconstruct the cells was $10,000. Things like televisions and kitchen appliances were donated.
Among 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.
Chances 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.
Over 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.
According 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.
To 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.
This 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.
As 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.
New 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.
The 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.
As 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 communities.
Now 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.
While attending a global mental health conference last fall, ACMI Vice President and Founding Director, Laurie Goldstein asked a psychiatrist from Trieste, Italy, “About how many persons with serious mental illness are in your jails?” The psychiatrist looked startled and replied, “We do not send our persons with mental illness to jail.” He went on to explain that if a person is experiencing a psychotic episode and the police are called, the police call the person’s psychiatrist, who treats the person until the person is stabilized. The Italian psychiatrist went on to explain that it is his “responsibility to prevent and also treat psychotic episodes, even if the person is jailed. Community providers remain engaged and accountable for their patients’ progress.
The Trieste Model, labeled by the World Health Organization (WHO) as one f the most progressive public psychiatry delivery systems, is now a collaborating center for mental health research with the WHO. The Trieste model manages to put the person at the center of the delivery system by 24-7 comprehensive treatment through a network of mental health centers that are “capable of dealing with the most severe conditions and of supporting clients in their daily life, with a view towards recovery and social inclusion.” https://zeroproject.org/practice/mental-health-department-whocc-italytrieste/ These 24-7 clinics not only replaced all psychiatric hospitals in Trieste, today fewer people go to jail because of the lack of continuity of care and cooperation between the law enforcement and mental health systems. The “sequential intercept model” enjoys deserved praise; Trieste shows that the first key intercept if effective clinical care.
Whether the Trieste Model is transferrable or sustainable elsewhere is debatable. But its existence and success generate food for thought about the relationship between the mental health and criminal justice systems in the United States and Arizona, specifically. Our communities experience high profile incidents in which an individual living with a serious mental illness commits a horrific crime, often resulting in death or serious injury. Often the individual is receiving services in the public behavioral health system, but in a psychotic state due to inadequate treatment either because of non-adherence or inadequate follow-up.
Reactions to these events are intense and sometimes polarized. Some believe the behavioral health industry “gets a pass” for poor management of potentially violent, seriously mentally ill “patients” who become “criminals.” Some contend that mental illness should never excuse criminal conduct. In terms of city, county and state fiscal accountability, there is no question that law enforcement and the corrections systems shoulder an increasing financial burden of caring for persons who commit a crime while they are enrolled in treatment in the behavioral health system.
Consider that the Maricopa County jail, one of the largest in the country, “books” (admits) approximately 100,000 individuals each year. Of these, approximately 8,200 (8.2%) of the total daily population are identified with SMI; another 16,000 (16%) have a significant mental health issue. Once incarcerated at the jail, the cost of care for these detainees shifts to Correctional Health Services (CHS) and Maricopa County https://www.maricopa.gov/5161/About-Correctional-Health-Services-CHS The Arizona Department of Corrections (ADC) has a similar patient population. In 2015, approximately 26.6% of all ADC inmates receive mental health services; of these, 4.7% are classified as SMI. Nicole Taylor and Karen Hellman, MENTAL “HEALTH DISORDERS AND THE CRIMINAL JUSTICE SYSTEM,” Arizona Dept. of Corrections (2015)
A defining difference in the “system” in Trieste, Italy, and Arizona (and the entire United States) is the presence of multiple payors and the involvement of private insurers in coverage decisions, rate setting, utilization management, and financing of health care services. Nonetheless, we can ask how behavioral health providers can be more responsible and accountable for the ongoing treatment of individuals in their care who become the justice system-involved and end up in jail or prison? Maybe dollars for care and services could “follow” the individual from clinic to jail or prison and back again? Maybe the county and state would bill the providers for treatment of incarcerated members? Maybe community providers would treat the person post-incarceration on a contract basis?
There are no easy answers but many fascinating questions for innovation in the delivery of services, especially person-centered services. The bureaucracies, payor systems, and pages of statutes and regulations are formidable obstacles. But there is an opportunity to examine ways to more equitably and effectively deploy resources of law enforcement, corrections, and the behavioral health system to accomplish two goals:
Reduce the likelihood that individuals living with SMI will become “justice system involved” ––an obfuscation of saying “committed a crime” or “got arrested”
More equitably distribute fiscal and clinical responsibility for treating individuals in jail or prison.
Laurie Goldstein’s question to the Italian psychiatrist was simple but provocative. “How many people with SMI are in your jail?” Maybe Arizona can find some answers in Trieste, Italy, which reduced these numbers through a truly person-centered community delivery system. Trieste, Italy does have a much smaller population that Maricopa County, so questions of scale and the intimacy of community is called into question. It may not be an fair comparison, but best practices may be applied in smaller clinical settings. In 2018, Trieste had a population of about 205,000 and it is the capital of the autonomous region Friuli-Venezia Giulia. The metropolitan population of Trieste is 410,000, with the city comprising about 240,000 inhabitants. Maricopa County is located in the south-central part of the U.S. state of Arizona. The U.S. Census Bureau estimated its population was 4,410,824 as of 2018, making it the state’s most populous county, and the fourth-most populous in the United States, containing more than half the population of Arizona. Wikipedia