The article which ACMI features this week will tug at our heartstrings.  And it prompts us to think about the intersectionality of homelessness, disability, and mental illness (here, paranoid schizophrenia) and the balance of individual civil rights versus our community responsibility to protect those who cannot defend themselves.   

You see, Mr. Rippee has been on the streets for years. The streets took his sight one night after years of little treatment for his schizophrenia when Mr. Rippee wandered into traffic.  Not only did he lose sight, but he also suffered a skull fracture, brain bleed, shattered elbow, dislocated shoulder, and crushed leg.  He endured multiple surgeries. And after each bout in the hospital, Mr. Ripper returned to the streets. “Health care professionals” drove him to his favorite street corner, unloaded him physically and figuratively, and drove away. 

While Mr. Rippee’s story is a California tale, he also would struggle to get services in Arizona. We have far better laws, but these are overlaid on a continuum of care for those living with serious mental illness that was not designed to accommodate physical and neurological co-morbidities like those that Mr. Rippee endures. My clients with SMI, plus developmental disabilities or TBI or autism, often are poorly served by their clinics. And if the client is a patient at the Arizona State Hospital, their treatment plans simply ignore their non-mental illnesses.  There is no “intersectionality” at ASH. 

It’s time we start looking at the “red” end of the continuum of care and asking ourselves: 

“How would Arizona help Mr. Rippee?”  I figure we can do better than California. 

Holly Geiszl

ACMI Board Member


Vacaville man is blind, homeless and schizophrenic. Why can’t California help him?

BY MELINDA HENNEBERGER UPDATED AUGUST 14, 2022 3:39 PM

California fails to help this blind homeless man in crisis | The Sacramento Bee (sacbee.com)

Mark Rippee, 59, blind, mentally ill and homeless, uses a broken broom stick to navigate Vacaville in the summer of 2022. He lost his vision at age 24, after a motorcycle crash caused a serious head injury. His sisters struggle to find him help. BY RENÉE C. BYER

“I think that’s him,” Linda Privatte says as we creep down Monte Vista Avenue, looking in all the usual spots for her younger brother, James Mark Rippee, who has been living on the streets right around the Solano County Building here for 15 years now.

It is Mark, kneeling beside the 7-Eleven, feeling around on the sidewalk for the debit card he keeps losing. One of the day laborers waiting in the parking lot next door thinks that we must be from the county and comes over to offer his own assessment: “Are you doing an evaluation? He decided to be this way. He decided.”

A lot of us tell ourselves that as we walk on by, annoyed and alarmed, not without reason, that the number of people yelling f-bombs into traffic as they push their carts around and around just keeps growing.

But no, Mark did not decide to lose his sight, along with part of his frontal lobe, in a 1987 motorcycle accident on his way back from a Father’s Day barbecue when he was 24. He did not decide to start hearing voices in the years that followed. He never chose to sleep in bushes instead of a bed after those voices convinced him to tear apart his garage apartment at Linda’s home; it’s just that the walls were talking to him, and he wanted to shut them up.

Mark Rippee, 59, who is blind, rests on the ground holding a cigarette in Vacaville on July 27. He said he needs someone to give him a ride to look for apartments and a job. Renée C. Byer rbyer@sacbee.com

He never set out to burn down two different trailers in her backyard, either, though he did start those fires. And his longstanding “decision” to refuse all psychiatric treatment has been a symptom of his schizophrenia, too.

OPINION Yet the system, if you can call it that, has done everything to protect that decision, and nothing to protect Mark.

As a result of that disconnect, we aren’t failing only him, but thousands of unhoused individuals across California. As is too often the case, his survival has depended on the stubborn heroism of his family, in particular his 65-year-old twin sisters. But his predicament shows that even with the strongest possible advocates, in a state willing to spend billions on this challenge, you can still be left to die on the streets. And most of all, what his story illustrates is why the “simple” solutions touted by politicians over the decades have so far solved nothing at all.

Before Mark’s accident, he worked in construction and loved playing the guitar. More than anything else, he looked forward to getting married and raising a family in his Northern California hometown, where the population is just under 100,000 and, as of a year ago, had just under 100 homeless people.

A family photo shows Mark Rippee before he was injured in a motorcycle crash.

For the first 20 years after the night a car swerved into his lane on an S-curve, forcing him off a country road into an abandoned grain harvester, his family was able to care for him. Even with in-home help, this was an all-consuming effort for seven people, Linda says. “It took Cathy” — that’s Catherine Rippee-Hanson, Linda’s twin — “me, Mom, my father when he was alive, a full-time county caregiver living with him,” plus Linda’s husband and later, Catherine’s son.

After the fires that Mark admitted were no accident, Linda still let him stay with her, because how could she turn out her own brother, the baby of the four siblings? “But different things kept happening, and I could tell that it was scaring my children and making them anxious.” Then he got his own place, and then another and another, finally losing the last one the day he threatened to kill their mother with an ax, thinking she was an impostor who had come to hurt him.

“We called the authorities, and he went out on the porch and started a fire,” Linda says. “He lost my mom as his caregiver. He lost his housing voucher that day, and he got evicted. That’s the day he became homeless” back in 2007.

Linda Privatte, 65, caresses her brother Mark Rippee’s hand as she gently tries to wake him up on a sidewalk in Vacaville on Aug. 1. “Is it okay for me to clean your cart out for you so I can see what you need?” she asked. Renée C. Byer rbyer@sacbee.com

ROBBED ON THE STREETS OF VACAVILLE

This morning, the morning I first meet Mark, who is 59 now — “as mankind measures time,” he tells me — Linda has brought him another new sleeping bag, plus bacon, eggs, sausage and a thermos of coffee the way he likes it, with half a cup of sugar. But first, he must finish his morning routine. This involves swallowing a huge mouthful of salt — “I need sodium” — and rubbing his face raw with a toothbrush. Then he pours a bottle of water over his head and his shirt, which is dotted with cigarette burns.

Mark is not alone on the street, and his friend Teresa, who lives out here, too, shouts hello as we sit down in a shady spot to talk. Maybe to control what she can control, she’s sweeping the small strip of sidewalk in front of her with a broom.

Other people Mark knows on this block beat and rob him on a regular basis, though, and when that happens, he says, he fights back as viciously as possible, because he wants to survive. Dangerous as his situation is, he believes that if he leaves this area right around the county building, he’ll lose the protection of the “force field” around it and will die.

Mark Rippee brushes his teeth at a bus stop in Vacaville on July 27. Blinded after a motorcycle accident at the age of 24, he is homeless and often is beaten up and has his belongings stolen while trying to survive on the streets. Renée C. Byer rbyer@sacbee.com

It’s beyond ironic, Linda says, that “he always comes right back to the county building — back to the people who won’t help him.” Or can’t. Over time, she’s decided that it isn’t really cruelty, or even indifference, that keeps them from doing so.

“At first I was angry with the police, and then I figured out that they’re only following the laws, right? And then I was angry with the city, because my God, this is his hometown, where he has lived his whole life, and how can they go past him every day and not try to do something?” Now, she says, she believes that it’s laws that have to change.

Meanwhile, authorities “don’t even go to Mark when we call. They just say we know who he is, and he has the right to refuse any services.”

His sisters worry more all the time that it’s his “right to refuse” that will kill him. “We’re all getting older,” Linda says. “Nothing is happening, he’s getting worse, he still hasn’t been treated. He’s dying out on the streets in front of everybody.”

The many protectors of her brother’s civil rights are adamant that he should get to choose whether to be treated for his severe mental illness, says his sister Catherine, in an interview later at her place, where she’s long been homebound by blood cancer. But as the result of his illness, he effectively “has no free will.”

Mark Rippee’s twin sisters Catherine Rippee-Hanson, left, and Linda Privatte, both 65, say he needs treatment for his severe mental illness and feel California’s system has failed him. Renée C. Byer rbyer@sacbee.com

Linda finds it harder and harder to get out to see him. Because she’s lost sight in one eye and has no depth perception in the other, she has never been able to drive. And many of those who used to bring her to Mark have either moved away or dropped out of her life. “Some people who took me weren’t prepared for what they were going to see.”

Now, after not getting out here for a few weeks, Linda has lots of questions for her brother, like “what happened to your face?” and, “someone said you were asleep in the middle of the road?”

He’s too agitated to answer, at first motioning as if reeling in a fish, and then as if punching a ghost. “I’m not a game, sir!” he yells at no one, and later explains that the voices are being broadcast from a military submarine. Using “mind warfare” that has turned “almost every single person in my life against me,” the guilty parties are, Mark believes, doing all kinds of experiments on homeless people.

Linda has seen him in worse shape: “Some days he’s so depressed he doesn’t talk.”

But she’s also seen him a lot better, and not that long ago. He was hit by a car in February of 2021, and after refusing treatment for those injuries, he fell and broke his hip during a rainstorm. Even then, he refused medical treatment for 25 more days. But during the long hospitalization that finally followed, he was put on anti-psychotic drugs for the first time in his life, other than during 72-hour psychiatric holds years earlier.

Linda Privatte guides her brother Mark Rippee, who is blind and mentally ill, across an intersection in Vacaville on Aug. 1. “He has delusions that won’t allow him to leave this particular area. It’s all that he remembers before he went blind,” said Privatte. Renée C. Byer rbyer@sacbee.com

“The 8½ months he was in there,” Linda says, “we were thinking this is it, they’re going to see that this is what he needs. Look at him, he’s clean, he’s healthy, he put on weight, we’re talking to him normal.”

But as soon as he was well enough, “they just brought him back in a van, took him out in front of here and dropped him off” in the parking lot of the county building.

Before his sister leaves him, he asks her to bend down, hold both of his hands and help him “unplay” several years worth of the messages he’s been sent from the submarine. “You’re saving my life right now, sis,” he tells her.

IF HE ISN’T ‘GRAVELY DISABLED,’ WHO IS?

It makes no sense that a man as ill as Mark is still stumbling around on his own. So why is he?

Teresa Pasquini, a Contra Costa County activist whose son is severely mentally ill, is well acquainted with both Mark’s situation and treatment in California. And as she sees it, Mark has essentially been “locked out” by gaps that make it absurdly hard for some of those most in need of help to get it.

In his case, that’s because as someone whose initial diagnosis was a traumatic brain injury, he supposedly doesn’t qualify for help for his severe mental illness on a medical basis. (Yes, though mental illness is a medical condition.) And in Solano County, he doesn’t qualify for a conservatorship based on his mental illness, either.

Linda Privatte patiently waits as her brother Mark Rippee who is blind and mentally ill, rants on the sidewalk while she was visiting with him in Vacaville earlier this month. “When he was in a nursing home for 8 1/2 months he made vast improvement. We thought that was our proof that he had been treated with medication, that he had been fed and he had been housed and the difference was amazing and then they put him right back on the streets,” said Privatte. Renée C. Byer rbyer@sacbee.com

Say what? There are two types of conservatorships in California. The probate conservatorship, which is what Britney Spears had, is more typically for someone with dementia, or some other incapacitating medical problem, who needs help taking care of himself. Those under probate conservatorships can’t be put in a locked facility against their will. Because Mark’s traumatic brain injury and blindness are considered his primary diagnoses, you’d think he’d qualify on that basis, but because he’s also severely mentally ill, he does not.

An LPS conservatorship — named after Frank Lanterman, Nicholas Petris and Alan Short, the three lawmakers whose 1967 bill ended most involuntary commitment of the mentally ill — is for someone who is so severely mentally ill that he is either a danger to himself or others, or else is “gravely disabled.” People under this type of conservatorship can be forced into treatment.

Yet though Mark is certainly a danger to himself, because he accidentally wanders into traffic on a regular basis, and is also what you and I would consider “gravely disabled,” he somehow doesn’t qualify for that, either.

Mark Rippee uses a broken broom stick as a cane as he navigates along Monte Vista Avenue in Vacaville on July 27. He has been hit by cars and police have been called to rescue him after he’s walked out into traffic. Renée C. Byer rbyer@sacbee.com

That’s because each of California’s 58 counties interprets “gravely disabled” — incapable of taking care of one’s food, clothing and housing needs — a little differently. In Solano County, a man whose clothing is covered with cigarette burns, who can’t keep housing and pushes around a cart full of rotten food is somehow seen as insufficiently compromised.

In 2019-20, according to the Department of Health Care Services, 1,459 people were on temporary LPS conservatorships in the whole state, and 3,672 on permanent ones.

In an email, Solano County Supervisor Skip Thompson’s office explained to Mark’s sisters that he could not be conserved because whenever he’s on even a brief involuntary hold, he improves so much that he must be released under the law: “This is not a situation that we have ignored, nor that we condone,” the email said. “Simply the law requires stringent standards to impose conservatorships — standards that so far we cannot meet.”

“Laura’s Law,” which provides court-ordered treatment in the community for a small number of severely mentally ill people, doesn’t apply to people with traumatic brain injuries.

SOLANO COUNTY OFFICIALS ‘DO FEEL FOR HIM’

Solano County’s director of Health and Social Services, Gerald Huber, tells me that though Mark “may not look like it, he does have the ability to make some decisions for himself,” and that has so far made it impossible for him to get the long-term residential treatment he needs. Which, Huber adds, wouldn’t be available anyway because even the prospect of funding something like that “is pretty bleak for small counties like ours.”

“Everybody knows Mark quite well,” Huber says, and “we do feel for him. If I hear he’s in a hospital locally, that’s when I know he’s the safest.” But then he gets well, has to be released, and quickly declines all over again. And even worse, “every county has a Mark. Every county has multiple Marks.”

Linda Privatte said that this is where her brother Mark Rippee gets dropped off after his hospital or doctor visits in Vacaville, even though she’s told the social workers this is not where he lives. She says he has been living around this area for the past 15 or so years. Renée C. Byer rbyer@sacbee.com

Vacaville City Councilman Nolan Sullivan, who in his day job is director of Yolo County’s Health & Human Services Agency, tells me that “it’s hard when folks have a TBI that leads to a mental decline.” But no one can say for sure that Mark would not have developed schizophrenia even if he hadn’t had that accident, right?

True, Sullivan says. “But from what has been represented to me, Mark has declined service, and that makes it almost impossible to serve him. I’ve wracked my brain. There have been dozens, if not hundreds of attempts to help him.”

Yet his sisters insist that he hasn’t had a proper psychiatric assessment in years, even when he was in the hospital. After they complained that he’d been arrested for nuisance crimes almost 100 times, police stopped doing that, but also stopped responding to reports of psychotic episodes, so that now, according to Linda and Catherine, he isn’t getting assessed for even a temporary psychiatric hold, much less a conservatorship.

‘THEY SAY IT HELPS KEEP THE VOICES DOWN’

What a surprise, then, when on another visit with Mark, I happen to arrive just as a psychiatric physician’s assistant for the county is giving him his first long-acting shot of Seroquel, an antipsychotic drug used to treat schizophrenia. He screams for just a second as the physician’s assistant, Jaron West, does this, but Mark did agree to it, he says, because “they say it helps keep the voices down.”

“We’ve been trying to help him for some time,” West tells me, “but the county doesn’t have any resources.”

Mark Rippee rubs his eye socket where his eye is no longer visible while complaining that it’s gone but he can still feel something inside. He became blind at age 24, after a motorcycle accident that also caused a serious head injury. Renée C. Byer rbyer@sacbee.com

His sisters are incredulous that he was even briefly lucid enough to say “yes” to a shot. Mark doesn’t think it will help, because “the sounds come from outside the ears.” Still, he’s very interested in the other thing that I heard West tell him, which was, “I’ll talk to Officer Potter’’ — Sgt. Aaron Potter, who heads the Vacaville Police Department’s Community Response Unit — “about that housing lottery.”

That’s a major incentive, because as Mark sees it, “what I need instead of a bunch of blankets is rent to get into a place.” He does need that, and in fact is worse off than when last we met, because he’s recently been roughed up and rolled again, relieved even of his cane, and so is using a broken off broom handle to help him navigate.

But without a lot more than drive-by treatment, it’ about s hard to see how Mark could possibly get and keep housing.

It isn’t that he doesn’t know about or believe in mental illness. At one point, he even suggests that he’s actually a little worried his sisters on that front: Linda “and my sister Cathy have some kind of phobia; they always think they’re sick.”

He just doesn’t think there’s anything wrong with him that wouldn’t be remedied by an apartment and the extermination of the extraterrestrials who are tormenting him.

He describes his life as one perpetual “mind rape, just as bad as a woman getting brutally raped. I want privacy in the most intimate areas of my brain.”

Yet, like all of us, Mark is also more than his problems, and he tells me several times that he still wants love: “I got desire, too. It has to have meaning. It can’t be just any girl.”

As he walks away that day, toward the bus stop where he can sit but can’t board because the drivers have run him off so many times, his friend Jackie Burnside stops to tell me what a good friend he is. “I’m homeless, too,” she says, as the result of domestic violence and other experiences that inspired the hand-drawn tattoo on her arm: “Property of Jackie Only.”

Mark “gets mad sometimes and yells,” she says, “but he’s a good-hearted person. When I’m hungry, he buys me food. Don’t get on his bad side, but we’ve been there for each other,” often sleeping near one another beside the tire shop, “just as friends,” for mutual protection.

Mark Rippee shields his face from the sun while trying to take a nap in the shade at a bus stop along Markham Avenue in Vacaville last month. Renée C. Byer rbyer@sacbee.com

CARE COURT COULD OPEN TREATMENT OPTIONS

People like Mark are the reason that Gov. Gavin Newsom and others are pushing so hard for the CARE Courts that would temporarily mandate treatment for those too sick to know they need help.

Thirty-four miles northeast of Vacaville, in Sacramento, we have many such severely ill people, too, of course. Elizabeth Kaino Hopper, of Carmichael, has a 33-year-old daughter who has been homeless on and off since her mental illness swamped her ability to agree to treatment. Those still capable of agreeing to treatment are the ones writing to the ACLU, she says, while “people whose illnesses are harder to treat are the voices we don’t hear.”

Since April of this year, though, her daughter has been much better, because since her arrest for assault with a deadly weapon — “trying to protect herself on the street” — she’s been living on the third floor of the Sacramento County Jail.

Three months earlier, a clinical social worker had assessed her daughter and found her “gravely disabled.” But when Sacramento County dispatched a fire truck — yes, a fire truck — and sheriff’s deputy to transport her, those officers said, “No, she knows her name, knows what day it is, has a box to live in and a dumpster to live out of — that’s food and housing” so she was not considered gravely disabled after all.

As a result, Hopper was reduced to hoping that her daughter would commit a crime that hurt no one and yet was serious enough to “win the golden ticket to get to the jail,” where she’d finally be treated, monitored and often reassessed, none of which was happening otherwise.

So yes, Hopper is a big supporter of the CARE Court idea, despite enormous pushback.

Critics argue that forcing people into treatment would be counterproductive, a horrible civil rights violation and, what’s more, under-funded. (That last objection reminds me of the old Woody Allen joke about two friends complaining about the meals at a Catskills resort. “Boy, the food at this place is really terrible,” says one, to which the other replies, “I know, and such small portions.”)

No one thinks such courts would constitute any kind of cure-all. But as Vacaville’s Nolan Sullivan says, it would at least open up “some new pathways” for helping in situations where right now, “localities are powerless” to intervene.

More treatment would have to be made available, too, it’s true. Because right now, Pasquini asks, “where do you place somebody who is blind, has a traumatic brain injury and the symptoms of schizophrenia? That’s the million-dollar question. You can’t find a bed for a person with schizophrenia, let alone all those other things.”

Mark Rippee, appears lifeless as he sleeps on a sidewalk in Vacaville on Aug. 1 when his sister Linda Privatte spotted him in the early morning. His shopping cart was filled with mostly garbage that she cleared out before giving him a hot breakfast of eggs and coffee with sugar. Renée C. Byer rbyer@sacbee.com

Sullivan says that’s because providers have no choice but to play a numbers game: “For every Mark, you’ve got 100 people in opioid addiction, so how do you triage?”

But there is at least a corner of hope that long-acting monthly injections, if Mark continues to accept them, could calm the voices that torment him enough to make other interventions possible.

Kate Grammy, the Behavioral Health Services Administrator for Solano County, says that a small homeless outreach team that’s been operating for several years is, as of April of this year, working with a mobile crisis team. It’s part of a pilot program that’s shown a lot of promise elsewhere in the state. That’s the team that gave Mark his first shot.

“I’m ecstatic with what I’m seeing,” from the new mobile crisis teams, says Catherine Moy, a city councilwoman in Fairfield, Solano’s county seat, where she ran a shelter for many years. “We piloted that program here,” starting about two years ago, “and one gentleman who had lived on the streets for years,” and became violent on a regular basis, has now been on medication for seven months, “and he no longer has that situation. It takes a long time, and it’s expensive, but I’ve seen it work, and we owe it to them.”

It’s also expensive to go on as we have been, watching people die.

Mark Rippee rests on the side of a bus stop after urinating outside in Vacaville on Aug. 1. “I would like to see my brother receive treatment for the no fault brain disease that he has. I would like to see him have safe housing. He just needs someone to care for him,” said his sister Linda Privatte. Renée C. Byer rbyer@sacbee.com

Grammy acknowledges that staffing for mobile crisis teams is an issue, here and everywhere. But persistence in offering services makes a difference, which is why some people who’ve long said no to services are agreeing to work with these teams.

Even if those teams expand, laws and attitudes will have to change, too, if we’re really going to reach those hardest to treat.

The definition of “gravely disabled” should certainly be expanded to take account of anosognosia, a condition associated with schizophrenia, Alzheimer’s disease and other medical problems, which prevents people from understanding that they need treatment.

And state Sen. Henry Stern’s important bill guaranteeing a right to treatment for unhoused and severely mentally ill Californians ought to be paired with the CARE Court bill, because what does mandated treatment mean if none is available?

‘OUR FAMILY IS HIS MENTAL HEALTH SYSTEM’

After Mark got that first shot of Seroquel, his sisters were briefly ebullient. But then, only two days later, they got a bunch of calls reporting that he was walking on a freeway ramp straight into traffic.

Mary Borchers, who was driving on I-80 toward Vacaville that day, tells me, “I saw a big rig slam on his brakes” on the exit, “and then I saw Mark, and holy crap, someone’s going to fricking run into him!” She called 911, was told that several others had already reported the same thing, and that California Highway Patrol officers were on their way.

By the time she was able to circle back around to see if he was OK, he was with law enforcement who then “left him to fend for himself once again.”

The morning Linda next sees Mark, he’s still asleep on the sidewalk and for many minutes too groggy to talk. One homeless man walking by taunts him — show these ladies your Super Bowl rings why don’t you — and another asks Linda why she can’t take Mark home with her.

On this day, Mark urinates into a cup right in front of us, and never does come around enough to answer her questions about the Seroquel, which most likely won’t kick in for weeks.

Mark Rippee goes behind a bus stop in Vacaville to urinate in a cup and complains there are no bathrooms near where he stays in Vacaville. Renée C. Byer rbyer@sacbee.com

He is able to explain walking onto the freeway, though: He and a friend had been out looking for an apartment, and after that friend disappeared, he somehow got turned around and walked into harm’s way: “I was trying to get us off the street!”

But then suddenly he’s channeling the voices he’s hearing, shouting, “Mark, goddamn you!” and “I turned the controls over to James Mark Rippee!” He is the voices, and how scary would that be?

As we walk away, Linda is crying a little. She always feels guilty leaving him, she says, because “it makes me feel like I’m as bad as our U.S. mental health system.”

That isn’t true, but this is: “Our family is his mental health system.’’ Until laws change, it’s the only one he’s got.

After exchanging “I love you’s” back and forth, Linda Privatte and her brother Mark Rippee embrace in Vacaville after a visit earlier this month. “It’s hard to leave because then it makes me feel guilty and it makes me feel like I’m just as bad as our U.S. mental health system,” said Privatte. Renée C. Byer rbyer@sacbee.com

This story was originally published August 14, 2022 5:00 AM.

MELINDA HENNEBERGER Melinda Henneberger is The Sacramento Bee’s local columnist. She has covered crime, local and state government, hospitals, social services, prisons and national politics. For 10 years, she was a reporter for The New York Times in New York, Washington, D.C., and Rome. She won the Pulitzer Prize for commentary in 2022, was a Pulitzer finalist for commentary in 2021, for editorial writing in 2020 and for commentary in 2019. She received the Mike Royko Award for Commentary and Column Writing from the News Leaders Association in 2022 and 2019, as well as the Scripps Howard Walker Stone Award for Opinion Writing in 2018.

Read more at: https://www.sacbee.com/opinion/article263602568.html#storylink=cpy

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Commissioner, Superior Court of Arizona, Maricopa County
Sarah E. Selzer is a Superior Court Commissioner and presides over
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The first Tuesday of each month from 4-6 pm Arizona time except for holiday weekends.

We will have a featured guest that will discuss a relevant Behavioral Health topic followed by discussions with attendees on current issues with the Behavioral Health System. This month learn about our mental health court from Judge Sarah Selzer.

Commissioner, Superior Court of Arizona, Maricopa County
Sarah E. Selzer is a Superior Court Commissioner and presides over
civil mental health proceedings for patients in the Valleywise Phoenix-
Annex hospital and at the Arizona State Hospital.

After graduating from the University of Arizona’s James E. Rogers
College of Law, Sarah began her legal career by clerking for Judge
Patricia K. Norris on the Arizona Court of Appeals. She subsequently
worked in the non-profit, government, and private sectors: she practiced
commercial litigation at Lewis and Roca, represented licensing agencies
at the Arizona Attorney General’s Office, worked as a career law clerk
for a U.S. Magistrate Judge, and was Associate General Counsel for
Chicanos Por La Causa.

Sarah has served on the board of Trees Matter and the Maricopa Chapter of the Arizona Women
Lawyers Association as well as various committees for the Osborn and Creighton school
districts. Sarah studied environmental science at Wellesley College and she recently completed
a master’s degree in educational policy from Arizona State University.

Topic: ACMI Stakeholder’s Meeting

Time: July 12, 2022 04:00 PM Arizona

        Every month on the First Tue, until Jan 3, 2023,

Jul 12, 2022 04:00 PM

        Aug 2, 2022 04:00 PM

        Sep 6, 2022 04:00 PM

        Oct 4, 2022 04:00 PM

        Nov 1, 2022 04:00 PM

        Dec 6, 2022 04:00 PM

        Jan 3, 2023 04:00 PM

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The first Tuesday of each month from 4-6 pm Arizona time.

We will have a featured guest that will discuss a relevant Behavioral Health topic followed by discussions with attendees on current issues with the Behavioral Health System. This month learn about Community 43, which is Phoenix’s Fountain house.

Since its inception, Kara Cline has been Community 43’s, Chief Executive Officer.  Kara Cline has a long career in leadership positions in the valley.

She will discuss the Fountain house model and programs offered by Community 43, the referral process, some cool events, and what is different about the Fountain house model. It is fine if you are currently in another program for supported employment or have a fantastic clinical team and do not wish to change, maybe there is an event for you.

Topic: ACMI Stakeholder’s Meeting

Time: June 7, 2022 04:00 PM Arizona

        Every month on the First Tue, until Jan 3, 2023,

        Jun 7, 2022 04:00 PM

        Jul 5, 2022 04:00 PM

        Aug 2, 2022 04:00 PM

        Sep 6, 2022 04:00 PM

        Oct 4, 2022 04:00 PM

        Nov 1, 2022 04:00 PM

        Dec 6, 2022 04:00 PM

        Jan 3, 2023 04:00 PM

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The IMD exclusion was enacted into Medicaid law in the mid-1960s. At that time public sentiment, fueled by atrocities at asylums, caused a wave of the desire for community treatment. The end result over many decades was the reduction of inpatient psychiatric beds to 5% of what it had once been; community treatment was now the answer to the treatment of persons with serious mental illness aided by the new psychiatric drugs. The problem is that it wasn’t enough and some people require longer treatment in a secure setting. This population is now overrepresented in jails, prisons (which have become the de facto psychiatric institutions of our time), and on the streets. They deserve more dignity in their lives.

ACMI feels strongly that the IMD exclusion should be repealed!

ACMI Board


Here is a nice article by Peter Earley discussing the same topic:

Posted April 15th, 2022 Advocate Tells SAMHSA To End IMD Exclusion That Prevents New Hospital Beds – Pete Earley

Untreated SMI – BD Hypno Plus Courtesy of Pixabay

(4-15-22) Is the federal government’s Institutions for Mental Disease (IMD) Exclusion outdated and actually harming Americans with serious mental illnesses?

Leslie Carpenter, the co-founder of Iowa Mental Health Advocacy and a member of the National Shattering Silence Coalition, told a federal panel that advises Congress and the Substance Abuse and Mental Health Services Administration (SAMHSA) that it is.

She made her argument during the public comment session at Wednesday’s (4-13) Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC).

In her remarks – limited to three minutes – she explained.

“This policy was enacted in hopes of ending atrocities occurring at our large state psychiatric hospitals by prohibiting Federal Matching Medicaid funds from being used by any facility with more than sixteen beds for people with “Mental Diseases” who are aged 18 – 64. This well-intentioned policy has been a legal form of discrimination on this population of people who have brain illnesses, which are not their fault and no one chooses, and no one deserves.

“The IMD Exclusion didn’t end the atrocities, it both relocated them and worsened them. It has resulted in 169,000 people being left untreated and under-treated across our country on our streets and unsheltered…In addition, 383,000 people with serious brain illnesses are in our jails and prisons, where far too many are untreated and, in many cases, in solitary confinement.

“And many more are dying every single day. They are clearly not better off “in the community.

“The shear fact that 51% of people with Bipolar Disorders and 40% of people living with Schizophrenia are untreated, totaling 4.2 million people should shake everyone on this committee and those listening to the core.

Representative Grace Napolitano’s bill, HR 2611, * (press release about bill below) would end the IMD Exclusion, so that federal matching Medicaid funds could be accessed for not only hospitals, but also many other facilities along the continuum of care up to and including true #HousingThatHeals. This bill now has fourteen co-sponsors and is gaining momentum.

“A recent article in Psychiatry Times is titled, “Psychiatric Care in the US: Are We Facing a Crisis?” Are you kidding me?

“We have had a humanitarian crisis for decades for people with the most serious psychiatric illnesses! Sadly, too few people know it is happening, and even fewer seem to care.

“We implore you to help us to bring this crisis both to the attention of the country and to help us to bring it to an end. It is well past time.”

Steady Decline In Beds

State hospital beds have been steadily declining since the 1960s during the deinstitutionalization era. In 1955, there were 558,922 state hospital beds. By 2005, that number had dropped to 50,509 and by 2016, the number was 37,679. According to the WHO Mental Health Atlas (2017), the median number of psychiatric beds per 100,000 population is around 50 in high income countries.  According to an article in JAMA, Journal of the American Medical Association, the US has 21 psychiatric beds per 100,000 which suggests an overall moderate shortage of beds.” JAMA adds, “There is also significant variation between the 50 US states with respect to psychiatric bed numbers.”

There are many reasons why we’ve eliminated mental health crisis care beds, but the results are the same. According to Modern Healthcare, “Psychiatric patients wait disproportionately longer in emergency departments before receiving treatment and experience longer stays compared to other patients, according to reports released  by the American College of Emergency Physicians…”Almost 21% (of responders) said patients wait up to two to five days for an inpatient psychiatric bed.” In some incidents, psychiatric patients are handcuffed to gurneys while waiting.

In the past, Congress has shown little interest in ending the IMD Exclusion. Former Rep. Tim Murphy (R-Pa.) tried to eliminate it when he wrote the Helping Families In Mental Health Crisis Act, but by the time it was signed into law during the Obama Administration as part of 21st Century Cures Act, that language had been eliminated. Democrats and groups representing individuals with lived experience argued that patients needed to be treated in community settings, not hospitals.

Sadly, what that well-intended argument misses is that when someone is experiencing a medical crisis, few community mental health providers are equipped to help them. Too often this leads to them ending up in jail.

It is encouraging that Rep. Napolitano, a California Democrat, is now pushing for an end to the IMD Exclusion, but my sources on Capitol Hill tell me there remains little interest among most of her colleagues to change the law and no interest within SAMHSA leadership. Opposition by civil rights organizations and peer groups remains high.

Rather than constantly fighting between community services and building more hospital beds, we should recognize there is a need for both. We should meet the needs of each individual based on what would best help them. Instead, we end up fighting among ourselves for table scraps.

Thank you Leslie for your public comments and your ongoing efforts to improve our system.

News release about Rep. Grace Napolitano’s bill.

Napolitano’s Increasing Behavioral Health Treatment Act Supported by LA County Board of Supervisors

April 20, 2021Press Release

WASHINGTON, DC – Today, the Los Angeles County Board of Supervisors unanimously moved to support Rep. Grace F. Napolitano’s H.R. 2611, the Increasing Behavioral Health Treatment Act. The bill would repeal the Medicaid Institutions for Mental Disease (IMD) payment prohibition and require states to submit a plan to: increase access to outpatient and community-based behavioral health care; increase availability of crisis stabilization services; and improve data sharing and coordination between physical health, mental health and addiction treatment providers and first-responders.

“Medicaid is the largest payer of mental health services in our country, and expansion of this critical coverage is long overdue,” Napolitano said. “Without in-patient beds, individuals experiencing mental health crisis are often released from emergency departments and forced to deal with their illness without professional care. They tragically too often end up in prison or on the streets, which not only worsens mental health conditions, but increases the cost of care to the state and the federal government. Providing relief from the IMD payment prohibition would finally give California and other states the ability to use federal funds to cover Medicaid-eligible individuals in need of behavioral health treatment. I thank the Board of Supervisors for supporting my legislation and recognizing that we must do all we can to provide life-saving care to any resident in need.”

“Through my motion, unanimously approved today, the Board of Supervisors will send a 5-signature letter in support of H.R. 2611, the Increasing Behavioral Health Treatment Act, introduced by Representative Grace Napolitano,” said Supervisor Kathryn Barger, Los Angeles County Board of Supervisors, 5th District. “This is important federal legislation that will help provide adequate inpatient or residential mental health treatment beds for individuals between the ages of 16-64 in need of critical services.  I am grateful for Representative Napolitano, who shares my commitment and dedication for providing compassionate mental health care, and ensuring individuals receive the most appropriate care in the most appropriate setting.

The IMD payment prohibition is a long-standing policy that prohibits the federal government from providing Medicaid matching funds to states for services rendered to certain Medicaid-eligible individuals, age 21-64, who are patients in IMDs. The term “IMD” is defined as a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

“Repealing the IMD exclusion is not only necessary to address the mental health care needs of individuals requiring and deserving adequate residential services to heal, it is also an important step in resolving both the critical parity gap between physical and mental health care that continues to plague this field from a fiscal perspective, as well as the societal stigma that interferes with access to treatment at the expense of those most impacted by brain illness,” said Dr. Jonathan Sherin, Director of Los Angeles County Department of Mental Health.

LA County Board of Supervisors Letter Supporting H.R. 2611

5sigletterSupportforHR2611(Napolitano).pdf

PDF icon5sigletterSupportforHR2611(Napolitano).pdf

Aaron Wallace, 39, has been in Arizona’s mental health system for 20 years. Shown here on May 25, 2021, Wallace sits outside a Tucson boarding house where he lived until June 2021. Photo by Alberto Mariani | AZCIR

Some of the sickest people in Arizona live in some of the worst places, like unlicensed boarding homes considered by many to be a thing of the past.

Story by Amy Silverman October 22, 2021

ACMI wants to share a series of reports from Amy Silverman on the state of services for people with serious mental illness in Arizona.

On a hot June afternoon, Aaron Wallace attacked two older women, one in her 90s, at the Tucson boarding home where they all lived. Wallace, 39, has schizophrenia and had not been taking his medication.

According to the police report, Wallace wrapped his body around one of the women, “gouging” her face, then surprised the other from behind, hitting her over the head with an object in the kitchen, possibly a metal skillet. The injury required stitches. Wallace, bloodied after being restrained by an employee of the home, later acknowledged to police that he had been in psychosis and that the attacks were unprovoked.

Holly Gieszl, one of Wallace’s attorneys, says her client had little hope of succeeding in that environment. He had been released from the state hospital in February.

“The option in Tucson was homeless or an unregulated, unlicensed board and care facility,” Gieszl says.

Wallace did “okay” in the boarding home, she adds, “but depending on how he was doing with his medication and visits to his clinic, talking to his case manager, he would be erratic, very bad impulse control, and ultimately he got arrested.” 

Holly Gieszl is shown at a Phoenix law firm on June 23, 2021. Photo by Alberto Mariani | AZCIR

In recent years, advocates have adopted the mantra “housing is health care,” saying that a place to live is one of the most important indicators of success for a person with serious mental illness (SMI). But it’s got to be the right kind of care. Many consider boarding homes a thing of the past, yet those familiar with the mental health care system in Arizona know that even after 40 years of reform, for people like Aaron Wallace, the only other option can be the street. Today, case managers are prohibited from placing clients in boarding homes. Somehow, people with SMI still find them. 

The manager of the boarding home where Aaron Wallace was living when he attacked the older women did not return calls from AZCIR

The Arizona Health Care Cost Containment System (AHCCCS), the state agency in charge of providing mental health care to more than 43,000 Arizonans, did not respond to questions about boarding homes, either. 


John Goss, the inspiration for the 1981 Arnold v. Sarn lawsuit that reformed Arizona’s mental health system, lived in a boarding home. So did other people with mental illness, particularly patients discharged from the Arizona State Hospital to the streets in the 1970s.

Laurie Goldstein, a board member of the Association for the Chronically Mentally Ill (ACMI), a local non-profit, says her son briefly lived in a boarding home several years ago.

“There was a mattress on the floor, no light in the room and the ‘hot meals’—they’d give them a sandwich and tell them to go out to a picnic table and eat.”

Today, there are people intimately familiar with the state’s mental health system who insist boarding homes are a thing of the past. Goldstein disagrees. 

“They exist,” she says, “and they’re awful.”

Also known as board and care homes, boarding houses typically give people with chronic mental illness more freedom than another setting, like a state-licensed group home. Residents come and go as they please, and there tends to be less oversight, meaning it might be easier to use illegal drugs, skip daily medications and avoid therapy and other organized activities. 

There is very little official information available on boarding homes. County health departments are required to license a home with a kitchen and five or more unrelated residents, so Maricopa County does keep a list of boarding homes. But the oversight stops there. There is no monitoring from the state Department of Health Services, which licenses other housing for people in the mental health care system. 

For some, a boarding house is all they can afford. Often, a person with mental illness will turn over a chunk of their monthly social security check in exchange for a room and three meals a day. 

A boarding house may also be the house of last resort because the mental health system has no other place for a person with serious or chronic mental illness to live. These unlicensed homes operate largely under the radar. For this story, AZCIR reviewed hundreds of pages of police call logs and reports from boarding homes in Tucson, Mesa and Phoenix.

The Tucson boarding house where Aaron Wallace was living had 101 calls for service between Jan. 1, 2020 and  June 21, 2021, the day Wallace was arrested. A boarding home on 22nd Street in south Phoenix had more than 340 calls between 2018 and mid-2021, many of them flagged, “mentally ill subject.” In Mesa, one had more than 440 calls during the same time period.

People with mental illness often turn to boarding homes because there are few other options.

Some housing is provided by the U.S. Department of Housing and Urban Development (HUD)—but in Tempe, for example, only 26 of 42 vouchers were in use as of June 2021 because of a difficulty in finding housing.  

The state recently reported a waiting list of 2,800 people in Arizona who qualify for supported housing specifically designed for people with mental illness.

There are people with mental illness that are being released from jail directly to the street.

AHCCCS took over control of the state’s mental health care system not long after the Arnold settlement agreement, and bureaucrats are aware of housing shortages—not only for people with SMI but others who are homeless. They are making efforts to fix that. AHCCCS recently applied for a Medicaid waiver that would increase housing options for the state’s most vulnerable, including people with mental illness. 

But critics like Josh Mozell, an attorney who represents Aaron Wallace and handles dozens of cases involving people with SMI, say if you don’t provide strong case management along with housing, most people will fail. 

Attorney Josh Mozell poses for a portrait in a conference room at his Phoenix office on June 23, 2021. Photo by Alberto Mariani | AZCIR

Arnold v. Sarn, the 40-year-old lawsuit that called for system reform, did lead to the creation of a case management system to track and assist people with SMI, and for many years, case managers have been prohibited from placing clients in unlicensed boarding homes. But today, people like Aaron Wallace still find their way to such settings. 

Jack Potts, a psychiatrist who chairs the Central Arizona Independent Oversight Committee, a volunteer group that monitors human rights conditions for people in the mental health care system in and around Maricopa County, says he’s asked AHCCCS to require the Regional Behavioral Health Authorities in charge of providing services to people with SMI to compile a list of boarding homes. Southern Arizona has such a list, which includes 73 homes as of early 2020. 

Potts also thinks someone should be tracking how many people with chronic mental illness are living in boarding homes, adding that without a case manager’s intervention, people often suffer in silence. 

“When someone’s quietly crazy and living in an unfit environment and they stay below the radar, you leave them alone. I think that the advocacy can be better but one of the other issues is case management.”


Boarding homes may be the mental health system’s dirty little secret, but members of the law enforcement community are well aware that they exist. 

Amanda Stamps is a lead police officer and the crisis intervention team program coordinator for the Mesa Police Department, as well as the department’s point person on mental health. 

She won’t talk about any specific unlicensed boarding houses for privacy reasons but is familiar with several in Mesa, and says they can be a problem because the staff is not trained to work with this “ultra vulnerable population.” 

The Olive Press, a non-profit in Mesa that has billed itself as a domestic violence shelter, is one of the best examples AZCIR found of an unlicensed boarding home plagued with problems.

Between January 2018 and August 2021, police responded to 445 calls at the small residential complex on Mesa Drive, not far from downtown Mesa. The unmarked main entrance to the Olive Press is plastered with signs warning against trespassing and of video surveillance in progress.

On a recent Thursday morning, during a ride-along with a Mesa Police Department community officer, the spot was quiet; two men stood outside, chatting. 

But it’s not always calm. 

On the evening of Feb. 9 of this year, Mesa police responded to an emergency call at the Olive Press for a “man stabbing multiple people.” According to police reports, the house manager said the suspect had lived at the home for two years and that 20 people lived on site. 

A witness told police she was visiting the home when she saw a man “push an older man down and begin hitting and kicking him,” then remove “an 8-inch long kitchen knife” from his pants and begin stabbing an older man, later identified as 80 years old. 

The Mesa SWAT Team was dispatched and released gas to get the suspect to come out. The man emerged wrapped in a blanket. His hands were not visible. Police shot him with bean bags and a K9 bit off his little finger. He was taken into custody hours after the incident began. 

It’s unclear from the police report whether or not the parties involved were mentally ill, but additional police reports confirm that people in the mental health system do live at the address. 

For years, police have received reports that people at the home were “unable to reach case manager in 4 days,” “wanted to kill themselves with a knife,” “was intoxicated and threatening suicide by jumping into traffic,” or “could hear a female screaming as we stood there, but there was no noise.” 

There were many calls for service regarding one woman. Deemed by the court to be mentally ill in 2010, she has been arrested in the past for prostitution. 

In December 2018, police responded to a call at the boarding home because “she is rambling about being with the FBI.” 

Two years later, in June 2020, the woman told police she was “hearing voices saying that her kids are being cut into pieces…says she knows who did it.” She was “ranting about how her doctor is a murderer and that he humiliates her everyday.” 

In July of this year, she called police to say she “wants to turn herself in for prostitution” and later said, “her meds make her watch porn, she lost her legs when she was a stripper and that is why she got arrested but her legs ‘reaugmented’ and that is why she has legs.” 

In August, she reported “she is being held hostage” and says there is a machine gun in the house. 

At her request, the woman was transported to a mental health clinic. 

Sarah Gomez, who operates Olive Press, cited privacy concerns and declined questions about residents with serious mental illness or Olive Press’ status as a boarding house. According to the organization’s website, as of Dec. 1, 2021 the house will only accept women.

Every time someone calls the police from a home like Olive Press, there’s the chance things could go wrong, says Stamps, the Mesa police officer. 

“The reality of it is that when you invite the police to your house, we take over the situation. And we’re trained first for law enforcement,” she says. “We’re not always going to be able to get them the help they need….There are other resources that are better than tasers and guns.”

“A lot of the individuals are not receiving treatment or care,” she adds.

Stamps says police have an easier time working with group homes that are licensed by the state.

“The unlicensed ones pose very significant safety risks that we can’t address,” she says, as police often find “a lot of SMI population in one place that needs more support than the residence is able to provide. I think they might take advantage of people who can’t get into licensed facilities.”

Aaron Wallace, 39, sits outside a Tucson boarding house where he lived until June 2021. Photo by Alberto Mariani | AZCIR

Aaron Wallace has been in Arizona’s mental health system for 20 years. He’s lived in adult foster homes, on the street and at the Arizona State Hospital, where he was a patient on three separate occasions. While at ASH, he was stabbed twice by two different patients. Gieszl and Mozell sued on his behalf, and Wallace received a settlement from the state.

A December 2018 report to the Psychiatric Security Review Board said that he could be “maintained outside a secure facility” if “he could be placed in a highly structured and supervised placement, with an adequate supports in place.”

Wallace was released from ASH in February 2019 and returned to Tucson, where he’d been living. 

Wallace shared his anguish in mid-May during a phone interview with AZCIR. Unlike many people with schizophrenia—who have no insight into their illness, a condition called anosognosia—at the time of the conversation, Wallace understood that he was sick. 

“To be in my fucking head? It’s full of torture, it’s fucking full of demons, it’s hell. It’s suffering. Every fucking day of my life I think of killing myself, but I don’t,” he says. 

Arizona’s mental health system has failed Wallace at every turn, according to his lawyers, Gieszl and Mozell, who say he was too sick to be released from the state hospital, too sick to take advice from his case manager (whom they say resigned from his case) and because of his history of violence, too sick to be placed in a licensed home designed for people with serious mental illness. 

“The system had no place for Aaron. Nowhere for him to live,” Gieszl says. “They finally said, ‘There’s nowhere for you to go.’”

Wallace is now in Pima County Jail on assault charges. 

With the goal of helping the very sickest people with mental illness, Josh Mozell has taken on Chick Arnold’s caseload — and his cause.

Chick Arnold, lead plaintiff in the Arnold v. Sarn class action lawsuit that claimed Maricopa County and the state of Arizona were failing people with serious mental illness, is shown at his Phoenix home on April 12, 2021. Photo by Brandon Quester | AZCIR

ACMI members are working to help spread stories to the public about our behavioral health system of care. Amy Silverman of Arizona Center for Investigative Reporting is doing a series of stories highlighting Arizona’s behavioral health history and ongoing issues.

by Amy Silverman October 20, 2021

Forty years later, legacy of Arnold v. Sarn lives on

Chick Arnold pulls out an old scrapbook packed with newspaper clippings, just in case he forgets anything.

At 74, Arnold has a shock of white hair and a sparkle reminiscent of Steve Martin. Tucked up against the Phoenix Mountain Preserve, his home is cheerful and modern, with a courtyard, high ceilings and brightly colored artwork that pops in the light of this warm spring morning. Arnold’s disposition is similarly sunny, even though he’s spent his career trying to help people whose lives are very dark. 

As he talks, the scrapbook unopened in his lap, it’s clear that Arnold remembers just about every detail of the last 40 years—particularly when it comes to his role as godfather of the state’s mental health care system. 

In 1981, Charles “Chick” Arnold was a young attorney working as Maricopa County’s public fiduciary, assigned to be the guardian for 600 vulnerable adults—the elderly, as well as people with serious mental illness and developmental disabilities. Arnold had a sister with a significant developmental disability and grew up knowing enough about the systems designed to protect these populations to understand that change was needed.

Mental illness—particularly the most chronic and severe cases—is difficult to treat. Matters of the brain have always been confounding, and often dismissed. For the most part, early societies treated mental illness as something other than medical. They looked for spiritual reasons, demons. Despite some scientific advances, to this day, treating mental illness is more art than science; doctors aren’t always sure why a medication works, and a diagnosis can change based on ephemeral elements like behavior. 

In the 1960s and 70s, the combination of media and government attention to both the dangers of institutionalization and the advances in the development of psychotropic drugs meant that it was no longer a given that a person with a diagnosis of schizophrenia or bipolar disorder would live out their years at a locked institution like the Arizona State Hospital

A state law was passed in 1970 requiring that only those who present a danger to themselves or others be housed at ASH, a collection of somewhat majestic-looking old buildings ringed by chain link and razor wire on Van Buren and 24th streets in the middle of Phoenix. The population dropped from 2,000 to 300 in less than a year as patients were released to the street, sometimes with little more than a bus pass and a month’s worth of medication.

Deinstitutionalization was a great idea that was not particularly well-executed in many places in the United States. Arizona was no exception. Out in the community, there was basically no case management system, no counseling, no housing program, no assistance with employment, no peer support.

In the late 1970s, Arnold and others successfully lobbied the legislature to pass a bill that, in essence, requires the state to provide these services to people with serious mental illness, with no cap on the cost. This was huge, particularly in a penny-pinching, libertarian state like Arizona. 

But change was slow. Then a man named John Goss dropped by to see Arnold. 

As Arnold describes him, Goss, who was in his early 40s, was a smart man, a former stockbroker from New York who’d had a mental breakdown and made his way to the Southwest, where he’d previously been a patient at the Arizona State Hospital. One of Arnold’s charges, he was now living in an unlicensed boarding home that was in terrible condition; it had burned down more than once. Goss walked the city, often stopping at Arnold’s office in the old courthouse in downtown Phoenix to say hello. 

On this particular visit, Goss told Arnold he’d read about the new law, and wanted to know why things hadn’t gotten better for him.  

“He nailed me,” Arnold recalls. 

So Arnold turned to the judicial branch of government, becoming the lead plaintiff in one of the state’s longest-running class action lawsuits and a household name in mental health circles. 

(The Sarn in Arnold v. Sarn is James Sarn, then the head of the state’s Department of Health Services.)

The Arizona Supreme Court upheld the case, but the branches of government continued to tangle for decades, as a court monitor conducted annual audits, documenting deficiencies and calling on the court to compel government to fix them. In 2012, with the state in financial crisis following the Great Recession, the court monitor and much of the program was suspended, replaced in 2014 with an agreement that ended the litigation and established guidelines for providing services. 

“Looking back on it, I think we were not enough. The constructs that were intended to be created, the housing opportunities, employment opportunities, the kind of respect piece that had been lacking from our system is still compromised. You know, dignity, respect, or honor serving people with disabilities in a non-patronizing way.”

CHICK ARNOLD

Will Humble was the director of the Arizona Department of Health Services at the time. He recalls advising then-Gov. Jan Brewer. 

“I told Brewer’s team, ‘Look, we can’t go anywhere with a court monitor,’” Humble says. “We’re in a horrible recession. We concede that we’re not going to get all needs met. We’re just going to keep the wheels on state government the best we can.’” 

It was a tough situation. During her time in the state legislature in the 1980s and 90s, Brewer was a champion of rights and better services for people with mental illness. She had a son who spent many years at the state hospital. As governor, she supported a Medicaid expansion that benefited people with SMI (serious mental illness), but she was criticized for dropping her focus on the mental health system. She gets mixed reviews for the decision to settle Arnold v. Sarn.

“They still could use a lot of help today, but we feel very accomplished by what we were able to accomplish,” Brewer told AZCIR this spring. 

“I just know that I worked really hard and I gave it all I could and I saved it. I saved the day and I believe that and I am proud of that.”

Arnold signed off on the settlement agreement. Now, he regrets not pushing harder. 

“Looking back on it, I think we were not enough,” he says. “The constructs that were intended to be created, the housing opportunities, employment opportunities, the kind of respect piece that had been lacking from our system is still compromised. You know, dignity, respect, or honor serving people with disabilities in a non-patronizing way.”

Will Humble was the director of the Arizona Department of Health Services at the time. He recalls advising then-Gov. Jan Brewer. 

“I told Brewer’s team, ‘Look, we can’t go anywhere with a court monitor,’” Humble says. “We’re in a horrible recession. We concede that we’re not going to get all needs met. We’re just going to keep the wheels on state government the best we can.’” 

It was a tough situation. During her time in the state legislature in the 1980s and 90s, Brewer was a champion of rights and better services for people with mental illness. She had a son who spent many years at the state hospital. As governor, she supported a Medicaid expansion that benefited people with SMI (serious mental illness), but she was criticized for dropping her focus on the mental health system. She gets mixed reviews for the decision to settle Arnold v. Sarn.

“They still could use a lot of help today, but we feel very accomplished by what we were able to accomplish,” Brewer told AZCIR this spring. 

“I just know that I worked really hard and I gave it all I could and I saved it. I saved the day and I believe that and I am proud of that.”

Arnold signed off on the settlement agreement. Now, he regrets not pushing harder. 

“Looking back on it, I think we were not enough,” he says. “The constructs that were intended to be created, the housing opportunities, employment opportunities, the kind of respect piece that had been lacking from our system is still compromised. You know, dignity, respect, or honor serving people with disabilities in a non-patronizing way.”

Attorney Josh Mozell sits for a portrait in his office’s conference room in Phoenix on June 23, 2021. (Photo by Alberto Mariani)

Chick Arnold retired at the end of 2020. He says that would not have been possible if not for Josh Mozell, a young attorney who took on Arnold’s caseload—and his cause. Like Arnold, Mozell believes the mental health care system has failed the state’s most vulnerable. As a caseworker for several years before attending law school, Mozell worked directly with people with chronic mental illness. He understands the system’s shortcomings from the inside. 

Mozell, 38, also wants to change the system. He is president of the board of a local non-profit called the Association for the Chronically Mentally Ill (ACMI), whose members push for legislative remedies and other reforms. He sits on an independent oversight committee that monitors conditions for people with serious mental illness in central Arizona. Mozell has the ears of agency heads, hospital directors and police chiefs, and this fall, a joint legislative committee will convene to address shortcomings at the Arizona State Hospital, thanks to Mozell’s lobbying efforts at the state capitol. 

Like Arnold before him, Mozell represents hospital companies and other providers, something that gives him a paycheck as well as insight into how the system works and access to decision makers. 

It’s about all of that, for sure, but there’s something else that makes these men so effective. 

When Chick Arnold walks into a room of policymakers, Mozell says, people fear him—but they want to give him a hug. It’s part of his magic. 

For Mozell, it’s understanding the system in ways few do. The younger lawyer spends a great deal of time with clients who are in crisis. 

On a muggy Friday morning in August, Mozell perches on the edge of a couch in a room at a central Phoenix extended-stay hotel, laptop open. Next to him, Rob Niebuhr shifts his tall frame to get comfortable, casual in a black tee shirt, shorts and Adidas in contrast with the lawyer’s dress clothes. 

Robert Niebuhr meets with attorney Josh Mozell in August 2021 to discuss Niebuhr’s living arrangements and how to get 

Just out of jail, Niebuhr’s wearing an ankle bracelet. He has schizophrenia, and was given a two-year sentence for chasing his stepfather with a dinner knife during a psychotic episode in 2017. The incident ended when Phoenix police shot Niebuhr.

Years later, Tarrill Kertesz sobs as she recalls her son’s shooting. She had called 911 during some of Rob’s previous outbursts when the family lived in Washington State and says the police had helped calm him down. This time was different.

“They shot him in front of me. And I was screaming that we called for help, not for you to shoot him.”

Police reported that Niebuhr came at them with the knife. Niebuhr was shot twice in the back and once in the arm and leg. As soon as he was well enough, hospital staff extubated him in the middle of the night and sent him to jail.

Kertesz found Holly Gieszl, a defense attorney who often represents people with mental illness. Gieszl represented Rob in his criminal case, alongside a public defender. “I don’t know what we would have done without Holly,” she says.

Holly Gieszl poses for a portrait at a Phoenix law firm on June 23, 2021. Photo by Alberto Mariani | AZCIR

Weeks before her son was to be released, Kertesz says she began asking jail officials about the formal plan to transition Niebuhr to the community. The shooting happened in Phoenix and while she’s since moved to Yuma, Kertesz and her husband love Niebuhr and want him nearby; but the court says they can’t see each other. 

When Niebuhr was released, she brought him clothes and a cell phone. They let Kertesz hug her son, she says, “and that was it.”

Niebuhr and Kertesz stayed in touch. 

Within days of Niebuhr’s release, there was trouble. Despite his mother’s pleas, she says there was no workable transition plan. Niebuhr was placed at a setting that has housed sex offenders, Kertesz says, because there was no other place for him. Niebuhr explains that he was quickly kicked out for fighting and bounced to a couple other places before landing at this hotel, which his mother had been paying for. Desperate and running out of money, Kertesz called Gieszl, who contacted Mozell.

Sitting in the small motel room, Mozell sounds more like a case manager than a lawyer as he asks Niebuhr if he knows why he hasn’t been given a place to live (no), how he’s feeling (good) and if he has his meds (yes). Niebuhr is frustrated because he was supposed to be picked up earlier that morning and taken to a mental health clinic to see a counselor. He stood outside at 7:30 a.m., he says, but no one came.

Mozell nods and keeps taking notes. 

Niebuhr starts talking about his phone, which is broken, and pretty quickly it’s clear that he’s not entirely well. The phone was sending him codes, he says. Now he has to get those messages through the television in his room.

The lawyer returns to his office and makes some calls.

Weeks later, Kertesz reports that the system has found her son a safe place to live and he’s being assigned to an ACT team, a high-impact case management plan for people with significant needs. He’s getting food baskets, peer support and someone’s supervising his medication—all of which should have happened automatically if the system was working, Mozell says.

Later in September, Gieszl and Mozell report that Niebuhr is struggling again. 

“It’s up and down,” Gieszl says.  

Mozell acknowledges that he rarely encounters a mental health crisis that is not brought to him by a family member. That haunts him, and reminds him of his time working in the system.

“Everybody on my caseload was alone,” he says. “They had either left their families or their families left them. That is the reality—this group does not have access to any kind of power.”


Josh Mozell estimates that he’s able to help a few dozen people with chronic mental illness a year. There are only so many hours in the day, and not everyone can afford to hire a private lawyer. (Mozell and Gieszl do take some pro bono cases, but they can’t afford to represent everyone at no cost.) That’s where the Association for the Chronically Mentally Ill comes in. The board of directors includes several people who fought for years to get help for their family members with chronic mental illness, as well as Mozell and Gieszl.

Founding member Deborah Geesling describes how she first got involved in the system, through her son. 

As a boy, he loved to do tricks on BMX bikes and play guitar like his older brother. But when Geesling’s son turned 14, something changed.

At first, Geesling says, her son was really anxious. He ran away from their Gilbert home several times. The third of four boys, he told his little brother the record albums hanging on his bedroom wall were whispering to him. He hit his father. The police came.

The young man wore handcuffs and a jumpsuit to his first visit with a psychiatrist. The doctor prescribed pills.  

“I just remember driving away from that appointment feeling relieved, like we really got something to start with,” Geesling says. 

She was right about one thing—it was only the beginning. 

“I called up the next morning to check on him and the person who answered the phone said, ‘That’s your son? He’s a psychopath.’ And he kind of laughed. He said, ‘Give him the number to the homeless shelter and pack his bags.’”

DEBORAH GEESLING

Geesling’s son had his first psychotic episode at 18. He had stopped taking his meds, wasn’t sleeping, sat at his brother’s drum set, hitting one drum over and over. And then it got worse. He landed at a psychiatric evaluation center in Phoenix. 

“I called up the next morning to check on him and the person who answered the phone said, ‘That’s your son? He’s a psychopath.’ And he kind of laughed. He said, ‘Give him the number to the homeless shelter and pack his bags,’” Geesling says.

“After that phone call, I was on the floor. I literally dropped to my knees. I was crying. I was just, I felt like I was in this pit, like, ‘Okay, what do I do with this?’”

In the end, her son was admitted to a psychiatric facility, where he stayed for three months. The following year, he was hospitalized four timesThe doctors told Geesling he was one of the sickest people they’d ever seen. He believed Geesling was practicing witchcraft on him. Her youngest son says he slept at friends’ houses as much as he could, terrified to be near his older brother. 

But pretty much as soon as hospital staff learned her son lived at home, Geesling says, they’d try to release him every time. 

“How about you take him home,” she recalls thinking, “and then you tell me if you think he’s fine.” 

It took years, constant attention and the painful decisions both to seek guardianship and to announce that he had no place to live so he could qualify for housing, but today Geesling’s son is stable and living in an apartment. 

Lately, Geesling has been taking a call a day from someone else whose child, spouse or sibling is in crisis. 

Other ACMI board members take calls as well—and have their own stories to tell. Laurie and Chuck Goldstein charted the costs to private and public insurance companies over many years as the system struggled to finally get their son proper care. Barbara Honiberg’s son was hospitalized 50 times in a decade. Dick Dunseath’s son sometimes walks or even jumps into traffic. He’s been hit twice by cars. 

ACMI is not without controversy. The group is filled with hard chargers who don’t mind making enemies. Like Mozell, they are concerned about pretty much every aspect of the state’s mental health system, but their focus is often on what they see as the need for locked residential treatment facilities for those who are not sick enough to be in the state hospital, but not well enough to come and go as they please. 

Earlier this year, the Morrison Institute for Public Policy at Arizona State University released a report about housing for people with chronic mental illness sponsored by ACMI and funded in part by the Goldsteins’ philanthropic foundation. The study found it’s far less expensive to provide housing for people with mental illness than to let them live on the street where they place a burden on the health care and criminal justice systems.

For the most part, ACMI’S focus has been the Arizona Legislature. They’ve had some success. In 2019, the governor signed a controversial bill appropriating money for the purchase of land and construction of a secure residential facility, creating a new level of care for Arizonans with mental illness who are not sick enough for the state hospital but too sick to live on their own. Funding for the project is $3.5 million. 

That law also created a formal definition of chronic mental illness. 

The 2021 legislative session proved fruitful as well for ACMI, which backed several bills, some of which were successful.

ACMI stopped short of convincing the legislature to lift the bed limit at the state hospital, but did get a law signed that is designed to increase accountability by improving audio and video surveillance at the state hospital. And while the group was unsuccessful in its push to sunset the state’s Psychiatric Review Board, which determines whether a person deemed guilty but insane should be released from the state hospital, a law was passed that is meant to increase accountability by standardizing medical reports used in the decision-making process. 

Other successful ACMI-backed legislation included a law that creates a transition program for people with mental illness reentering the community from prison and one that addresses the process of court-ordered evaluations for people with serious mental illness.

ACMI members’ viewpoints aren’t always shared by other mental health advocates. 

Eddie Sissons worked in various roles in and around Arizona’s mental health system for decades. Like some other advocates, Sissons opposed the legislation that funded the secure residential treatment facility. She wants to see the system take a more “holistic” approach that focuses on peer and family training, as well as facilities that are not locked but offer 24 hour care, such as a longtime program run by the Foundation for Senior Living.

“They have a point,” she says of ACMI. “But it’s not just to rush out with a fire truck. How do we back it up so we’re doing fire prevention so we don’t have the need to go to ASH, to go to secure residential and that I think is a bigger, harder, more difficult discussion to have.”

Sissons does agree with Mozell and others that the mental health system in Arizona continues to falter. 

“I don’t have a magic answer,” she says. “I wish I did.”

Rachel Gold contributed reporting to this article.

John Creamer found himself yelling down a jail cell toilet at voices only he could hear.

ACMI members are working to help spread stories to the public about our behavioral health system of care. Amy Silverman of Arizona Center for Investigative Reporting is doing a series of stories highlighting some issues.

John Creamer sits in his room at a group home facility in Phoenix on June 4, 2021. Photo by Alberto Mariani | AZCIR
John Creamer sits in his room at a group home facility in Phoenix on June 4, 2021. Photo by Alberto Mariani | AZCIR

by Amy Silverman October 19, 2021

Schizophrenia upends life of accomplished academics (azcir.org)

John Creamer has just one question. 

“Can you tell I’m on medication?” 

It’s a heartbreaking ask and impossible to answer for someone who did not know Creamer before his illness. 

Sweet, shy and very low key—whether by nature or the antipsychotic medication—like many people with serious mental illness, Creamer is extremely bright. Originally an English major, he pursued his doctorate in Japanese medieval literature at Yale University so he could study with a particular scholar he admired, and with the hope that an unusual specialty would make it easier to find work. 

After graduation, he landed a job teaching premodern Japanese language and literature in the School of International Letters and Cultures at Arizona State University, but things went bad, possibly because of his deteriorating mental condition, and Creamer lost his job.

Creamer packed his bags for Japan and, looking back, now understands that he had a psychotic episode while he was there. 

“I was in and out of psychosis thinking that people were stalking me, that I was being stalked by a cult. I thought that I was going to get married to a princess.”

Creamer left Japan, traveling to Chicago and Massachusetts, where he says he was placed in mental hospitals by police, and eventually back to Phoenix, where he was arrested on aggravated assault charges after hitting a neighbor’s house with a rock. He thought the neighbor’s dog was a robot controlled by the CIA or Chinese intelligence. 

In jail, Creamer thought someone was spying on him through the toilet in his cell. 

“So I was yelling into the toilet and I was put into the hole, which is solitary confinement,” he says. “It was really bad. I got really psychotic there.”

Eventually, Creamer’s brother, Robert, intervened, hiring lawyers and getting guardianship of John. John got out of jail and into treatment. There’s no cure for schizophrenia, but he’s better. He credits the injectable antipsychotic medication he takes for finally making a difference. 

Without the intervention of civil lawyer Josh Mozell and, later, criminal attorney Holly Gieszl, Robert says, there would likely have been no hope for a happy ending.

“He would be dead or in prison,” Robert says of his brother. “There were many times I feared for his life given his delusions, his situation, and what seemed like an impossible task to get him the treatment he needed.”


For most people, a serious mental illness (SMI) like schizophrenia first appears in early adulthood, in the late teens or early 20s for men and a little later for women. 

There are exceptions. John Creamer experienced his first psychotic episode in his late 40s.

A diagnosis of serious mental illness will often fall under one of several categories. 

Schizophrenia, as defined by the Mayo Clinic, is a mental health condition in which people “interpret reality abnormally.” Symptoms typically include “some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling.”

Again from Mayo, bipolar disorder, once called manic depression, is marked by extreme swings in mood, from high (manic) to low (depressed).

Schizoaffective disorder involves symptoms of schizophrenia accompanied by mood disorder symptoms. It’s often described as a combination of schizophrenia and bipolar, a simplistic definition that is only sometimes true.

Major depression can also be diagnosed as a serious mental illness. 

Ultimately, diagnosis can be a guessing game. 

“Medicine is an inexact science, but psychiatry is particularly so,” Esmé Weijun Wang writes in her New York Times bestselling essay collection, “The Collected Schizophrenias.”  

“There is no blood test, no genetic marker to determine beyond a shadow of a doubt that someone is schizophrenic, and schizophrenia itself is nothing more or less than a constellation of symptoms that have frequently been observed in tandem.”

Wang, a graduate of Stanford University, has been diagnosed with schizoaffective disorder. She’s an accomplished author of both fiction and non-fiction. This book of essays has brought her acclaim for demystifying serious mental illness. 

She’s correct that there’s not much certainty about a scientific diagnosis, but researchers are getting closer, and have identified a genetic marker that increases one’s likelihood of developing schizophrenia. 

One of the most confounding things about SMI is that patients often don’t understand they are sick, a condition called anosognosia. 

Creamer acknowledges that stigma also played a role in his resistance to the diagnosis of schizophrenia. He remembers growing up with an aunt with schizophrenia. A poet, she did not have a good life, Creamer says. 

“I did have a prejudice against mental illness. Because my aunt was schizophrenic and I felt like she couldn’t function in society, but I think there are different gradations of mental illness and that if you think something’s off, then definitely go and get help, go to a psychiatrist because it’s not like a death sentence.” 


In early June, John offered a tour of his group home in west Phoenix, a stuccoed tract home different than his own house, which was designed by renowned midcentury architect Ralph Haver in the Arcadia neighborhood near Camelback Mountain. John’s room at the group home was clean and spare with a library cart packed with Japanese texts in the corner.

It wasn’t easy to be quarantined in 2020. John finished several jigsaw puzzles on his own. 

Creamer is still trying to understand what happened. He talks about it in therapy. 

“I’m going through it. I’m journaling, you know, it’s been a year, but that’s not been that long to come to terms with, you know, the diagnosis. It’s huge.” 

June marked Creamer’s one-year anniversary in the group home. He hopes to be released from probation by the end of 2021 and ultimately return to his home in Arcadia. He’s working on his resume with assistance from supported employment services as part of his mental health treatment.

John Creamer talks about his initial resistance to being diagnosed with schizophrenia at his group home in Phoenix. Photo by Alberto Mariani | AZCIR
John Creamer talks about his initial resistance to being diagnosed with schizophrenia at his group home in Phoenix. Photo by Alberto Mariani | AZCIR

He is grateful for the injectable antipsychotic medication he receives, but Creamer doesn’t like how it makes him feel. 

“The medication makes my face feel numb and I don’t feel as sharp as I used to be,” he wrote in a recent email to AZCIR, and he seems to be tired when he gets the injection. 

“But my doctor says it’s just that I’m resentful about getting an injection. Which is true, I do feel resentful, but I also feel like I don’t have as much energy as I used to. I also sometimes get a shaky hand when I try to pick things up and when I’m typing. Also, I sometimes take a deep breath involuntarily through my nose like I’m not getting enough air.”

Creamer hopes to educate others about serious mental illness, including pointing out the system’s flaws.

“I’m not sure exactly how things can change for the better. I know that someone shouldn’t go through what I went through.”