Medicaid is our social safety-net program in the United States that provides health coverage for some of the country’s most vulnerable citizens. It is essential for people with serious mental illnesses. Sadly, Medicaid law contains the IMD exclusion provision, which excludes payment for services for those unfortunate people needing long-term in-patient care. The IMD exclusion is a significant barrier to meaningful treatment for people with serious mental illness (SMI).

In addition, failing to recognize that involuntary treatment is required for many people with SMI has led to many individuals living lives without dignity on the streets or being punished in our jails and prisons.

There are many reasons why more Medicaid services are needed for the seriously mentally ill:

  • Rising Prevalence: The number of people diagnosed with serious mental illnesses is rising. As the population increases and the stigma around mental health starts to fade, more individuals seek help. This calls for a proportional increase in services. We have not seen this happening in AZ.
  • Complex Needs: Individuals with serious mental illnesses often require comprehensive, long-term, individualized care that can include therapy, medications, crisis services, and sometimes even inpatient care. The current inpatient stays are relatively short, almost always under the 15-day IMD cap. There is no artificial capitation for other medical conditions.
  • Coexisting Conditions: Many people with serious mental illnesses have co-occurring physical health issues or substance use disorders. They need integrated care services that can address all their health needs simultaneously. There is an attempt at integrated care, but there are no shining examples I am aware of.
  • Societal Benefits: Comprehensive services can reduce societal costs, such as homelessness, incarceration, and emergency medical care. Individuals with untreated mental illness often end up in emergency rooms, the criminal justice system, or living homeless, which are more costly interventions than preventive and therapeutic services.
  • Economic Considerations: Early and consistent treatment can help individuals with serious mental illnesses maintain employment and contribute to the economy. Without adequate services, these individuals are at a higher risk of unemployment and homelessness, increasing the economic burden on society.
  • Crisis Prevention: Regular access to treatment can help prevent mental health crises. Crises not only endanger the individual but also place a strain on emergency services, hospitals, and the broader community. Unfortunately, there are many police encounters with individuals in crisis who end up injured, incarcerated, or dead due to the symptoms of their disease.
  • Housing Stability: Stable housing is crucial for recovery. Sadly Medicaid does not pay for housing, only treatment when medically necessary. Refer to the ASU Morrison Institute Housing is healthcare to understand that it is not only the right thing to do for the patient but also saves society about 30% over the cost of treating unhoused people with serious mental illness.
  • Better Outcomes: Continuous access to mental health services has led to better health outcomes and quality of life. Medicaid can fill the gap, ensuring the most vulnerable have consistent access to these essential services. Providing the entire continuum of care is available.
  • Stigma Reduction: By increasing the availability of services and prioritizing mental health, society takes a step toward reducing the stigma surrounding mental illness. This can encourage more individuals to seek help when they need it. Receiving care early is essential to stopping episodes of psychosis and protecting the brain.
  • Future Savings: Investing in mental health now can lead to savings in the future. Providing comprehensive mental health services through Medicaid makes individuals less likely to require more intensive and costly interventions later on. Again refer to the ASU Morrison Institute study.

New York and California have seen the results of not enforcing treatment. Each is now taking small steps to reverse the substantial number of homeless people with serious mental illness. In summary, expanding Medicaid services for the seriously mentally ill is not only a moral imperative, considering the vulnerable nature of this population, but it’s also a wise investment. It can lead to better health outcomes for individuals, reduce societal costs in other sectors like criminal justice, and result in a healthier, more productive, and safer society.

Laurie Goldstein



Bill aims to support people with serious mental illnesses ( published August 1st 2023

The bill was introduced by Sen. Kirsten Gillibrand and Rep. Dan Goldman. (Spectrum News NY1)


N.Y. bill aims to bolster services for people with serious mental illnesses


PUBLISHED 3:30 PM ET AUG. 01, 2023

Sen. Kirsten Gillibrand, Rep. Dan Goldman and Rep. Jerry Nadler on Tuesday touted legislation aimed at strengthening access to medical care for people living with serious mental illnesses.

The “Strengthening Medicaid for Serious Mental Illness Act,” if passed, would generate new services under Medicaid designed specifically for people living with mental illnesses like schizophrenia, bipolar disorder and major depressive disorder, the lawmakers said during a news conference at Manhattan’s Fountain House.

What You Need To Know

·   A bill introduced by Sen. Kirsten Gillibrand and Rep. Dan Goldman in June, the “Strengthening Medicaid for Serious Mental Illness Act,” aims to strengthen access to medical care for people living with serious mental illness
·   Gillibrand, Goldman and other New York elected officials touted the legislation during a news conference at Manhattan’s Fountain House on Tuesday
·  The legislation, if passed, would generate new services under Medicaid designed specifically for people living with mental illnesses like schizophrenia, bipolar disorder and major depressive disorder

The legislation would also set a national standard for care for people with serious mental illness and incentivize states to provide services to treat them.

“Those with serious mental illness have often found themselves in a devastating cycle: going from hospitals to jails to the streets, and back around again,” said Gillibrand, who first introduced the legislation along with Goldman in June.

“Frankly, it’s unacceptable and it’s inhumane,” she added. “It’s a major issue for public safety and it’s a major issue for caring for our families.”

The legislation would provide states with the ability to offer services that would help people with severe mental illness get and keep jobs. It would also allow states to provide access to support services and mobile crisis intervention teams.

States would also be required to abide by certain standards of care, such as tracking disparities in treatment, according to a news release from Gillibrand.

“We are still struggling in the aftermath of COVID, which interrupted mental health treatment for so many, especially the low-income and underprivileged individuals in our community who rely on government services, the community services that were halted,” Goldman said.

“And that’s why this bill is so important,” he added. “It’s important that we get people the treatment they need in a way that works.”

The Institutions for Mental Diseases (IMD) exclusion is a policy that restricts Medicaid funding for certain residential facilities with more than 16 beds, primarily focusing on those providing mental health and substance abuse treatment. While the policy aims to regulate and improve the quality of care, it inadvertently creates discrimination and prejudice against individuals with serious mental illness (SMI). This case highlights the adverse effects of the IMD exclusion policy on vulnerable individuals and the need for reforms to ensure equitable access to mental healthcare.

Case Summary: John, a 32-year-old man diagnosed with schizophrenia, resides in a state that strictly enforces the IMD exclusion policy. Due to the limited availability of community-based mental health services, John has been repeatedly denied admission to residential treatment facilities due to their size exceeding the exclusion threshold. This policy restriction exacerbates John’s condition, denying him access to appropriate care and causing a detrimental impact on his overall well-being.

  1. Limited Access to Intensive Treatment: John requires intensive psychiatric care and monitoring due to the severity of his symptoms. However, as a result of the IMD exclusion, the only available options for him are outpatient clinics or smaller residential facilities that lack the resources and staff to provide the level of care he needs. This restricted access prevents him from receiving adequate treatment and support to manage his condition effectively.
  2. Increased Risk of Homelessness and Incarceration: Without access to appropriate residential treatment, John’s mental health deteriorates rapidly, leading to frequent hospitalizations or encounters with law enforcement. The lack of suitable options under the IMD exclusion policy forces individuals like John into a cycle of homelessness or incarceration, where their mental health worsens, perpetuating the stigmatization of mental illness.
  3. Disproportionate Impact on Low-Income Individuals: The IMD exclusion disproportionately affects low-income individuals who rely on Medicaid for their healthcare needs. Private residential facilities, not subject to the exclusion, often charge exorbitant fees, making them unaffordable for those with limited financial resources. Consequently, the policy further entrenches socioeconomic disparities and denies individuals from lower-income backgrounds equal access to critical mental health services.
  4. Inequity in the Healthcare System: The IMD exclusion policy perpetuates a two-tiered healthcare system, with individuals with SMI receiving suboptimal care compared to those with physical health conditions. While patients with chronic medical conditions can access specialized facilities without similar restrictions, individuals with mental illnesses face discrimination due to the arbitrary limitations imposed by the exclusion policy, denying them their right to equitable healthcare.

Conclusion: The IMD exclusion policy, though well-intentioned, inadvertently perpetuates discrimination and prejudice against individuals with serious mental illness. The policy’s impact on individuals like John highlights the urgent need for reforms to ensure equitable access to comprehensive mental healthcare. Revisiting the IMD exclusion and advocating for increased funding, expanding community-based treatment options, and encouraging parity between mental and physical health services are essential steps towards dismantling the systemic barriers faced by those with SMI.

Laurie Goldstein


After deinstitutionalization, California has tragically come full circle on mental illness treatment – CalMatters


A person sits in a makeshift tent along a barbed wire fence near Highway 99 in southwest Fresno on Feb. 11, 2022. The fence blocks out a grass area that used to be a homeless encampment. Photo by Larry Valenzuela for CalMatters/CatchLight Local
A person sits in a makeshift tent along a barbed wire fence near Highway 99 in southwest Fresno on Feb. 11, 2022. The fence blocks out a grass area that used to be a homeless encampment. Photo by Larry Valenzuela for CalMatters/CatchLight Local


California psychiatric hospitals began closing their doors in the 1960s, starting a nationwide movement known as “deinstitutionalization.” Today, most inpatient treatment for severe mental illness occurs behind bars. Two changes could help rectify this tragic reality.


Alice Feller

Alice Feller

Alice Feller is a psychiatrist and writer based in Berkeley. Her work has appeared in the Journal of the American Psychoanalytic Association, East Bay Express, Laney Tower and the opinion pages of the San Francisco Chronicle and New York Times.

Robbie, our young patient at the county hospital in San Mateo, believed his parents were trying to poison him. 

He refused to come into the house and foraged in the neighbors’ garbage cans for all his meals. Nevertheless, since he was able to survive on garbage, he was judged no longer in need of treatment. 

I was shocked. It was so callous – such a breach of our usual standard of care. But then I spent a year working as a staff psychiatrist at the county hospital in Oakland. I learned that Robbie’s experience was not out of the ordinary; it was the usual state of care in California.

In the 1960s, American psychiatric hospitals began to close their doors. The movement began in California, first with the large state hospitals and then the small community hospitals as well.

By 1994 nearly half a million former patients had been sent back to live with their families, who were often unable to care for them. A quarter million newly discharged patients ended up on the streets or behind bars. 

So many were incarcerated that jails and prisons have become our de facto mental hospitals. Today, the vast majority of inpatient psychiatric care in America is provided behind bars.

Deinstitutionalization,” as the movement to close these hospitals is known, began as a cost-saving measure. In 1965 the federal government abruptly withdrew its financial support for the state hospitals, as well as the small community hospitals providing psychiatric care. 

This was accomplished through a little-known law, the Medicaid IMD exclusion, passed by Congress in 1965 along with the creation of Medicaid. The provision forbids the use of Medicaid dollars to pay for care in a mental hospital. Any psychiatric hospital with more than 16 beds is forbidden to take Medicaid.

Hospital treatment for severe mental illness can mean the difference between life and death, but because of this law such treatment is specifically denied to the people who need it most. No other severe illness is subject to such discrimination.

We have come full circle from the early 19th century, when Dorothea Dix campaigned to rescue the mentally ill from the prisons where they languished, often under shockingly inhumane conditions. Due to her work, people with mental illness were rescued from prisons and cared for in hospitals. 

But today that trend has been reversed. Once again, Americans with serious mental illness are being warehoused out of sight in our prisons. And many more are living unsheltered on our streets. A third of our homeless population today suffer from untreated severe mental illness, most commonly schizophrenia.

Schizophrenia is a brain disorder. It affects 1 out of every 100 human beings on Earth. Good parenting doesn’t prevent it, and bad parenting doesn’t cause it. It begins in adolescence or early adulthood, and without treatment it will be permanently disabling. It leaves the afflicted person living in a psychotic world, unable to tell reality from delusion. 

Lives are derailed. Suicide is common.

Treatment requires early intervention by a specialized team of clinicians who collaborate on patient care. Unfortunately these dedicated programs are rare. Despite mountains of evidence showing their effectiveness, insurers refuse to cover early intervention programs.

While hospital care can provide stabilization and enable the patient to use outpatient treatment, insurance coverage for inpatient treatment is rare.

California can rectify this situation by obtaining a waiver of the IMD exclusion. We need to restore hospital care to stabilize our patients and enable them to use outpatient treatment. We need to mandate early intervention programs and require insurance coverage for this vital treatment. 

These two interventions would do more than anything else to help our mentally ill homeless citizens. It is not a simple lack of housing that leaves so many homeless. Like Robbie, our patient who ate out of garbage cans, they are unable to use available housing due to their mental illness.

Society Helping
Photo by Etactics Inc on Unsplash
Society Helping, Photo by Etactics Inc on Unsplash

Caring for people with serious mental illnesses, such as schizophrenia, bipolar disorder, or major depressive disorder, who also have anosognosia (a lack of awareness of their illness) is crucial for numerous reasons, and not providing necessary care can have detrimental effects.

  1. Preservation of Human Rights: All individuals, regardless of their mental health status, have a right to health and well-being. This right includes access to healthcare and social support. Ignoring or denying care to someone because they lack insight into their condition due to anosognosia infringes upon these rights.
  2. Health Consequences: Without proper care, individuals with serious mental illnesses and anosognosia are at risk of worsening symptoms. This can lead to significant health consequences, including higher rates of hospitalization, physical health problems, homelessness, and suicide.
  3. Social Consequences: Failure to provide care for individuals with serious mental illness and anosognosia has broader societal impacts. It can lead to increased homelessness, as individuals may be unable to maintain stable housing. Furthermore, untreated mental illness can also contribute to an increased burden on the criminal justice system, as these individuals may engage in behaviors that get them into legal trouble, often because they aren’t receiving the care they need. They typically are crimes related to their illness, such as trespassing, public disturbance, or petty crime, but they can sometimes be violent crimes.
  4. Economic Burden: Treating individuals with mental illnesses early and effectively is cost-effective. Hospitalizations, incarcerations, homelessness, and emergency services are all costly societal burdens. Providing continuous, comprehensive care reduces these costs in the long term.
  5. Family Impact: The family and loved ones of those with serious mental illness often bear a substantial burden when adequate care is not provided. This can strain relationships and cause emotional, physical, and financial hardship for the family members involved.
  6. Potential for Recovery: Many individuals with serious mental illness, once appropriately treated, can lead meaningful, productive lives. By providing necessary care, even when anosognosia is present, we increase the chances of these individuals gaining insight into their conditions, adhering to treatment, and experiencing recovery.
  7. Ethical Responsibility: As a society, we have an ethical responsibility to care for those who are most vulnerable, including individuals with serious mental illness. Anosognosia, as a symptom of these illnesses, should not exempt these individuals from receiving the care they need.

In conclusion, while anosognosia presents unique challenges in the care of individuals with serious mental illness, it is imperative that we continue to advocate for and provide necessary support and treatment. The human, societal, and economic costs of not doing so are simply too great.

Laurie Goldstein


Posted by Twisted Sisters Advocacy & Activism for Serious Brain Disorders July 9th, 2023.

Anosognosia affects between 50% and 98% of people with schizophrenia, about 40% of people with bipolar disorder, and more than 80% of people with Alzheimer’s disease.

For a disease that demands treatment above all else, leaving someone with anosognosia alone on the streets until they die is a cruel and unusual punishment for a disease. Why do civil rights activists and disability activists keep harming our family members?  What’s the point of letting them deteriorate and preventing them from getting basic medical care?  In pursuit of an ideal?  Does it matter?  In my experience as a family member of someone who died as a result of severe mental illness and anosognosia symptoms, I am offended to my core by those who wish to maintain the status quo.

Civil and disability rights activism has a human cost here. It is of the utmost importance to recognize the suffering and struggles of those affected. It is also important to ensure that those who need medical care receive it. We do not let our Alzheimer’s patients with anosognosia roam the streets. We speak for them. We care for them. We need to demand more humane treatment for people with anosognosia from severe mental illnesses.

Activists for civil rights and disability are strangers to our loved ones.   They do not understand the pain and suffering we have been through.  There’s no personal connection between them and our loved ones.  No professional connection exists between them. They are not privy to the suffering of my loved one or have intimate knowledge of it.  Because #FamiliesLikeMine don’t have a right to treatment before tragedy strikes, the activists for civil rights can sleep soundly at night despite the pain they cause those whose loved ones die a slow, agonizing death.  What do citizens of this magnificent nation do when tragedy strikes beyond the individual suffering from a brain disorder? They scream, “Why didn’t the family act?  But, what can a family do if the law does not recognize their right to treatment?

As defined, anosognosia is not denial. Anosognosia is a mental illness in which the sufferer is unaware of their condition. A denial of anosognosia’s legitimate importance in the medical community and in our laws and policies is to ignore it. That is a denial.

It is not a denial of the experience of those with anosognosia, but rather a denial of the reality of anosognosia as a medical condition. We need to recognize anosognosia as a legitimate medical condition and ensure that our laws and policies reflect this understanding. This will ensure that individuals with anosognosia can access the care and treatment they need. 

#RIPMarkRippee #TreatmentB4Tragedy #HousingThatHeals #PassSB43ToSaveLives

Untreated psychosis can have severe and long-term effects on an individual with serious mental illness. Here are some potential dangers:

  1. Symptom Progression: Without treatment, symptoms of psychosis, which include delusions, hallucinations, and disorganized thinking, can become more severe and frequent. This exacerbation can interfere significantly with a person’s ability to function daily and may lead to an increased risk of hospitalization.
  2. Physical Health Deterioration: People with untreated psychosis are often unable to take care of their physical health, neglecting things like nutrition, exercise, and sleep. This neglect can result in physical illnesses, from general malaise to chronic conditions like heart disease and diabetes.
  3. Suicidality: Individuals with untreated psychosis may have a higher risk of suicide due to a combination of depressive symptoms, feelings of hopelessness, and difficulty distinguishing between reality and their delusions or hallucinations.
  4. Substance Abuse: Some people may use drugs or alcohol to cope with their symptoms, leading to substance abuse problems. This can exacerbate psychotic symptoms and make treatment more challenging.
  5. Impaired Social and Occupational Functioning: Psychotic symptoms can make it difficult to maintain relationships or hold down a job, leading to social isolation and financial instability. This situation can further worsen mental health and hinder recovery.
  6. Chronic Condition: When left untreated, psychotic disorders can become chronic, meaning that they persist over a long period. This situation can result in a continuous cycle of illness and recovery, leading to a lower overall quality of life.
  7. Cognitive Impairment: Long-term untreated psychosis can lead to cognitive impairments affecting memory, attention, and problem-solving abilities. Over time, these cognitive deficits can make it harder for a person to engage effectively in their treatment and can limit their ability to live independently.

In conclusion, timely treatment of psychosis is vital for better recovery outcomes. This can involve medication (like antipsychotics), psychotherapy, social skills training, and supported employment programs, all of which can significantly improve the prognosis for people with psychotic disorders. Untreated psychosis has far-reaching implications that extend beyond mental health to all aspects of a person’s life. Early intervention is essential to prevent the progression of the disease and maintain the highest possible quality of life. This can often involve involuntary treatment.

Laurie Goldstein

Being an American Canadian Mother of a Daughter With Schizophrenia

Being an American Canadian Mother of a Daughter With Schizophrenia (

Jul 6, 2023

Susan Inman

This mother shares her experience of having a loved one with schizophrenia and the difference location can make in treatment.



My younger daughter has lived with schizophrenia for 23 years. During that time, I have connected with families in similar situations in both Canada and the United States. My daughter’s life has been positively and negatively impacted by mental illness policies in both countries.

My education in the United States left me ill-informed about illnesses like schizophrenia.1 I knew much more about Freud and RD Laing than I did about the growing knowledge base in contemporary psychiatry. This problematic education in many social sciences and humanities also continues to exert a powerful influence in Canada. Both countries share a lack of appropriate public mental illness literacy campaigns. But what differentiates them?

Canada vs the United States

Ignorance led my husband and me to make serious mistakes in selecting a therapist when our daughter began floundering as a teenager. After I wrote a memoir2 about these poor choices, I heard from many families in both countries who made the same mistakes. Our daughter’s therapist’s lack of appropriate science-based training led to an unnecessarily longer duration of untreated psychosis.

Fortunately, we live in British Columbia and when my daughter became fully psychotic, she received the medically based treatment she needed. British Columbia continues to have a strong mental health act that enables individuals with psychosis to receive the involuntary treatment they often need. This access is limited in Canada, as in the United States, by a shortage of acute psychiatric beds.

Additionally, the 23 years of treatment our daughter has received in British Columbia, which have included some lengthy hospitalizations, have not cost us anything. Early on in our daughter’s illness, when I began to attend the national conferences of the US National Alliance on Mental Illnesses, I was horrified to meet too many families who had been bankrupted by their family member’s illnesses. These financial catastrophes were caused either by medical bills or by lawyers’ fees when untreated illnesses led to involvement in the criminal justice system.

Expenses for lawyers have grown among the Canadian families I have met in recent years because the same trends that negatively impacted the United States have spread in Canada. For instance, the powerful peer movement has successfully lobbied to have their training programs exclude any education about illnesses like schizophrenia while they expand their role in service delivery. It is a movement that teaches its practitioners that individuals must always choose their treatments while simultaneously not allowing individuals to learn about the brain-based illnesses that can make real choice impossible.

This is an alarming time in British Columbia. The laws that have allowed individuals like my daughter to lead a satisfying life are in jeopardy. Some provinces have adopted mental health legislation that makes it much more difficult for individuals with psychotic disorders to receive the involuntary treatment they often need to become stabilized and the follow-up involuntary treatment that they may need as outpatients. The Council of Canadians with Disabilities has launched a Charter of Rights and Freedoms challenge against British Columbia’s Mental Health Act. If successful, British Columbia will follow the dangerous direction that Ontario took; those who are a danger to themselves or others can be admitted to the hospital involuntarily, but they or a substitute decision maker must agree to treatment.

Positive Changes

Individuals with schizophrenia and their families have suffered in both the United States and Canada because of persuasive but misguided ideas emanating from human rights lawyers and disability rights movements.3 These groups refuse to acknowledge the existence of anosognosia and the widespread lack of medically based treatment for psychotic disorders, which leads individuals with psychotic disorders in both countries to become homeless, addicted, and incarcerated.

I am inspired by the positive changes I see in the United States as a growing number of governors and mayors push back against the narrative that homeless individuals with severe mental illnesses must be allowed to choose whether they want treatment. My community in Canada is not seeing much of this well-informed political leadership, even though the growing homeless encampments in our cities and towns are full of the suffering of individuals abandoned to their psychotic delusions.

My community is also inspired and guided by the families in the United States who have developed a much stronger voice. I was able to tap into this kind of powerful advocacy last summer when Democrats Abroad and their Global Disability Caucus invited me to organize a webinar on mental illnesses for their annual celebration of the passage of the Americans with Disabilities Act.4 Using helpful resources available from the US Treatment Advocacy Center, American mother and advocate Leslie Carpenter helped an eager audience understand the origins of the current crisis and the further steps that need to be taken. American Canadian psychiatrist Randall White, MD, provided the much-needed, medically based information this group wanted. I helped others understand why the psychiatric survivor movement, which shapes the positions of most disability rights groups, should not be seen as the legitimate voice of individuals with illnesses like schizophrenia.

Concluding Thoughts

As I see it, the bold initiatives in the United States acknowledge the reality of severe mental illnesses and respond in genuinely helpful ways. These efforts can provide the guidance we increasingly need in Canada.

The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times®.

Ms Inman is the author of After Her Brain Broke: Helping My Daughter Recover Her Sanity.


1. Inman S. Personal accounts: becoming the mother of a child with schizophrenia. Psychiatr Serv. 2016;67(12):1290-1291.

2. Inman S. After Her Brain Broke: Helping My Daughter Recover Her Sanity. Bridgeross Communications; 2010.

3. Inman S. Disability rights groups should accept schizophrenia. Medium. June 14, 2020. Accessed June 28, 2023.

4. Carpenter L, Inman S, White R; Democrats Abroad. Americans with Disabilities Act Panel. Facebook. July 26, 2022. Accessed June 28, 2023.

Thank you to those who could attend our May 2nd Stakeholder’s meeting.

Rachel Streiff, Dr. Robert Laitman, and Dr. Ann Mandel presented.

Below are the links to the webinar and slides:

Webinars – Association for the Chronically Mentally Ill (ACMI) (

Downloads – Association for the Chronically Mentally Ill (ACMI) (

Please join us for our next informational event on June 6th, 2023, at 4 PM AZ time. Experts will be discussing Assertive Community Treatment teams. (ACT)


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The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest to discuss a relevant Behavioral Health topic; after the speaker, we will discuss current issues with attendees with the Behavioral Health System.

This month, come hear about Innovations in Clozapine Therapy with SMI advocate Rachel Streiff and special guests Dr. Robert Laitman and Dr. Ann Mandel.

Dr. Robert Laitman practices internal psychiatric medicine in New York City alongside his wife, Dr. Ann Mandel Laitman, and is a co-author of “Meaningful Recovery From Schizophrenia and Serious Mental Illness with Clozapine: Hope and Help.”

Rachel Streiff is a chemical and biomedical engineer who became an advocate for families struggling with Serious Mental Illness after a member of her own family achieved recovery.


Topic: ACMI Stakeholder’s Meeting

Time: May 2nd,, 2023 04:00 PM Arizona

Every month on the First Tuesday until December 25th, 2023,

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Clinical depression has never really had satisfactory treatment options. Recently some newer pharmaceutical medications are showing promise. More research is needed in the area of behavioral health treatments. Read the heart-wrenching Op-Ed from David Brooks, which was recently published in the New York Times, on how it impacts family and friends.

Laurie Goldstein, ACMI Vice President


David Brooks: How do you serve a friend in despair?

A friend’s job in these circumstances is not to cheer the person up.

(Photo illustration by Thomas Sauvin; photograph via the Marks family) At camp, David Brooks gave Peter Marks a lift. How do you serve a friend struggling with mental illness?

By David Brooks | The New York Times

  | Feb. 12, 2023, 5:00 a.m.| Updated: 12:37 p.m.

My friendship with Peter Marks was created around play. Starting at age 11, we played basketball, softball, capture the flag, rugby. We teased each other, pulled pranks, made fun of each other’s dance moves and pretty much everything else. We could turn eating a burger into a form of play, with elaborate smacking of lips and operatic exclamations about the excellence of the cheese. We kept it up for five decades.

My wife has a phrase that got Pete just right — a rare combo of normal and extraordinary: masculine in the way you’re supposed to be masculine, with great strength and great gentleness. A father in the way you’re supposed to be a father, with great devotion, fun and pride. A husband in the way you’re supposed to be a husband, going home at night grateful because the person in the whole world you want to talk with the most is going to be sitting right there across the dinner table.

Over the years, Pete and I often spoke about the stresses he was enduring over the management of his medical practice, but I didn’t see the depths of what he was going through, until we spent a weekend with him in the spring of 2019. My wife noticed a change immediately. A light had gone out; there was an uncharacteristic flatness in his voice and a stillness in his eyes. One bright June afternoon, he pulled us aside and told us he wasn’t himself. He was doing what he loved most — playing basketball, swimming in the lake — but he couldn’t enjoy anything. He was worried for his family and himself and asked for our continued friendship and support. It was the first time I had seen such pain in him — what turned out to be severe depression. I was confronted with a question for which I had no preparation: How do you serve a friend who is hit with this illness?

I tried the best I could, but Pete succumbed to suicide in April. This article flows from what I learned from those agonizing three years and that senseless tragedy. It reflects a hard education with no panaceas.

(Photo illustration by Thomas Sauvin; photograph via the Marks family) New York Times columnist David Brooks, left, with Peter Marks, a friend since childhood.

First, I need to tell you more about Pete. We met as kids at Incarnation Camp in Connecticut. We were campers and counselors together for a decade and remained close for life. At camp, Pete was handsome, strong, athletic and kind. There was an exuberant goofballism about him.

I remember once, in a fit of high silliness, he started skipping around the dining hall, singing, and leaping higher and higher with each skip. He tried to skip right out of the room, but there was a door frame, probably about 7 feet tall, and Pete slammed into the top of the frame and fell flat on his back. The rest of us, being 16-year-old junior counselors, found this utterly hilarious. Pete, also being 16, found this utterly hilarious, too. I remember him lying there in a fit of giggles, with a doorframe-shaped bruise forming on his brow.

One summer, Pete and I led a team of 12- and 13-year-olds in a softball game against a team of 14- and 15-year-olds. Our team miraculously won. In the celebration afterward, Pete, I and the boys piled on one another on the mound in a great wriggling heap of disproportionate ecstasy. We hugged and screamed and high-fived.

I think our celebration lasted longer than the game — a volcano-like pile of male self-approval that is lodged in my memory as one of life’s moments of pure joy.

As the years went by, Pete did well in college, joined the Navy, went to medical school and became an eye surgeon. On evenings before surgery, Pete took great care of himself, didn’t stay out, made sure he had enough sleep to do the job that he loved. On evenings after surgery, he’d call his patients to see how they were feeling. His wife, Jen, a dear friend who was also at camp with us, used to linger around just to hear the gentleness of his tone on those calls, the reassuring kindness of his manner.

He seemed, outwardly, like the person in my circle least likely to be afflicted by a devastating depression, with a cheerful disposition, a happy marriage, a rewarding career and two truly wonderful sons, Owen and James. But he was carrying more childhood trauma than I knew, and depression eventually overwhelmed him.

At first, I did not understand the seriousness of the situation. That’s partly temperamental. Some people catastrophize and imagine the worst. I tend to bright-icize and assume that everything will work out. But it’s also partly because I didn’t realize that depression had created another Pete. I had very definite ideas in my head about who Pete was, and depression was not part of how I understood my friend.

Over the next months, severe depression was revealed to me as an unimagined abyss. I learned that those of us lucky enough never to have experienced serious depression cannot understand what it is like just by extrapolating from our own periods of sadness. As philosophers Cecily Whiteley and Jonathan Birch have written, it is not just sorrow; it is a state of consciousness that distorts perceptions of time, space and self.

Journalist Sally Brampton called depression a landscape that “is cold and black and empty. It is more terrifying and more horrible than anywhere I have ever been, even in my nightmares.”

Novelist William Styron wrote brilliantly about his own depression in “Darkness Visible.” He wrote that “the madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero.” He continued: “I experienced a curious inner convulsion that I can describe only as despair beyond despair. It came out of the cold night; I did not think such anguish possible.”

During the COVID-19 pandemic, Pete and I spoke by phone. In the beginning, I made the mistake of trying to advise him about how he could lift his depression. He had earlier gone to Vietnam to perform eye surgeries for those who were too poor to afford them. I told him he should do that again, since he found it so tremendously rewarding. I did not realize it was energy and desire that he lacked, not ideas about things to do. It’s only later that I read that when you give a depressed person advice on how to get better, there’s a good chance all you are doing is telling the person that you just don’t get it.

I tried to remind Pete of all the wonderful blessings he enjoyed, what psychologists call “positive reframing.” I’ve since read that this might make sufferers feel even worse about themselves for not being able to enjoy all the things that are palpably enjoyable.

I learned, very gradually, that a friend’s job in these circumstances is not to cheer the person up. It’s to acknowledge the reality of the situation; it’s to hear, respect and love the person; it’s to show that you haven’t given up on him or her, that you haven’t walked away.

Time and again Pete would talk about his great fear that he would someday lose his skill as a surgeon, that he would cease to be a healer, that he would lose his identity and self.

As Pete spoke of his illness, it sometimes seemed as if there were two of him. There was the one enveloped in pain and the other one who was observing himself and could not understand what was happening. That second self was the Pete I spoke to for those three years. He was analyzing the anguish. He was trying to figure it out. He was going to the best doctors. They were trying one approach after another. The cloud would not lift.

I am told that one of the brutalities of the illness is the impossibility of articulating exactly what the pain consists of. Pete would give me the general truth, “Depression sucks.” But he tried not to burden me with the full horrors of what he was going through. There was a lot he didn’t tell me, at least until the end, or not at all.

I never told him this, but there were moments during that hard plague year of 2020 that I feared that my own mind was slipping. Cheerfulness is my normal default state, but that year my moods could be dark and troubled. When your oldest friend is battling his demons, it’s natural to wonder about your own.

While I’ve devoted my life to words, I increasingly felt the futility of words to help Pete in any meaningful way. The feeling of impotence was existential.

After a while, I just tried to be normal. I just tried to be the easygoing friend who I always had been to him and he had been to me. I hoped this would slightly ease his sense of isolation. Intellectually, Pete knew that his wife and boys lavishly loved him, that his friends loved him, but he still felt locked inside the lacerating self-obsession that was part of the illness.

Perhaps the most useful thing I did was send him a video. My friend Mike Gerson, a Washington Post columnist, had been hospitalized with depression in early 2019. He had delivered a beautiful sermon at the Washington National Cathedral about his experience before he died of complications of cancer in November. Depression, he said, was a “malfunction of the instrument we use to determine reality.” Then he talked about the lying voices that had taken up residence in his mind, spewing out their vicious clichés: You are a burden to your friends, you have no future, no one would miss you.

That resonated with Pete and gave him a sense of validation. He, too, would describe the obsessive-compulsive voices that would attack him from inside his own head. Mike also talked about the fog eventually thinning, at the glimpse of beauty or of love, and reminded Pete that “there is something better on the far side of despair.”

Still the clouds refused to lift. Jen had some wise words when I asked her what she learned being around him during those years.

“I was very aware this was not the real Pete,” she said. “I tried not to take his periods of negativity and withdrawal personally.”

I wish I had bombarded Pete with more small touches. Just small emails to let him know how much he was on my mind. Writing about his own depression in The Atlantic last year, Jeffrey Ruoff mentioned that his brother sent him more than 700 postcards over the years, from all 50 states, Central America, Canada and Asia. Those kinds of touches say: I’m with you. No response necessary.

“There are moments in our lives,” Honore de Balzac wrote, “when the sense that our friend is near is all that we can bear. Our wounds smart under the consoling words that only reveal the depths of pain.”

The years went by and medications and treatment programs continued to fail. Pete and Jen began to realize how little the medical community knows about what will work. They also began to realize that mental health care is shockingly siloed. Pete saw outstanding doctors who devoted themselves to him, but they work only within their specific treatment silo. When one treatment didn’t work, Pete would get shuttled off to some other silo to begin again. Jen recently emailed me that when she had a cancer recurrence, in the middle of Pete’s depression, she had a “tumor board” — three different cancer experts (a surgeon, an oncologist and a radiation oncologist) — who coordinated her care.

“In our experience, there is none of this in mental health,” she wrote me. In many places, there is no one looking at the whole picture and the whole patient. “If one more mental health professional tells me ‘Everyone did their best,’ I will scream,” Jen wrote. “If this is our best, it is not nearly good enough.”

Pete developed theories to explain why this had happened to him. He pointed to a series of traumas and neglect he had suffered at home as a child — events he had vaguely referred to during our friendship but had never gone into in detail with me until his final years.

He thought part of his illness was just straight biology. Think of it like brain cancer, he’d say. A random physical disease. I agree with some of that, but I’m also haunted by the large number of medications doctors put him on. He always seemed to be getting on one or getting off another as he ran through various treatment regimens. His path through the mental health care system was filled with a scattershot array of treatments and crushing disappointments.

Pete and his family joined us for Thanksgiving in 2021. By this point I was just trying to be as I always had been toward him, in hopes that he might be able to be as he always had been toward me. We all played basketball and board games and enjoyed the weekend. I felt some hope. But Pete appears in one of the photos that were taken that weekend, sitting on the couch, still-faced, enveloped in shadow. One afternoon, he asked my wife to pray over him in the kitchen, plaintively, grasping for hope.

The experts say if you know someone who is depressed, it’s OK to ask explicitly about suicide. The experts emphasize that you’re not going to be putting the thought into the person’s head. Very often it’s already on her or his mind. And if it is, the person should be getting professional help.

When Pete and I gestured toward the subject of suicide, we just talked about what a magnificent family he had, how much they all loved one another. Like Jen, I tried to tell him that this darkness would lift, though as the years went by and the therapies failed, his faith in this deliverance waned.

Pete was always the braver of the two of us. He was the one who would go cliff diving or jump over bonfires without fear. And he was never more courageous than over his last three years. He fought this malady with astonishing courage and steadfastness against a foe that would bring anybody to his knees. He fought it minute by minute, day by day — over a thousand days. He was driven by his selfless love for his family, which he cherished most in the world.

We had dinner a few days before he died. Jen and I tried to keep the conversation bouncing along. But, apparently, their car ride home was heart-rending. “How can I not be able to talk to my oldest friend?” Pete asked. “Brooksie can talk to people. I can’t.”

I don’t know what he was thinking on his final day, but I have read that depression makes it hard to imagine a time when things will ever be better. I have no evidence for this, but knowing Pete as I did, I strongly believe that he erroneously convinced himself that he was doing this to help his family and ease the hardship his illness had caused them. Living now in the wreckage, I can tell you that if you ever find yourself having that thought, it is completely wrong.

Depression can be bitterly ridiculous. Pete died a few weeks before his younger son’s college graduation, enmeshed by loving relationships and friendships.

It’s ridiculous that we still know so little about the illness and how to treat it. I find it unfathomable that it’s been well over a century since Sigmund Freud started writing about psychology. We’ve had generations of scholars and scientists working in this field, and yet suicide rates in 2020 were 30% higher than they were in 2000 and 1 in 5 American adults experience mental illness each year. We need much more research funding to figure this out.

If I’m ever in a similar situation again, I’ll know that you don’t have to try to coax somebody out of depression. It’s enough to show that you are trying to understand what this troubled soul is enduring. It’s enough to create an atmosphere in which the sufferer can share her experience. It’s enough to offer him or her the comfort of being seen.

My friend Nat Eddy, who also accompanied Pete through those final years, wrote to me recently: “Do whatever it is you do to give the wives and children a break — an hour or two when they don’t have to worry that the worst will happen (and pray that it doesn’t happen on your watch, because that isn’t a given). Do whatever it is you do so you can look at yourself in the mirror. True friendship offers deep satisfactions, but it also imposes vulnerabilities and obligations, and to pretend it doesn’t is to devalue friendship.”

I feel sorrow that I didn’t know enough to do this more effectively with Pete. I might have kept him company more soothingly. I might have made him better understand what he meant to me. But I do not feel guilt.

Pete had teams of experts walking with him through this. He had his wonderful wife and kids, who accompanied him lovingly and steadfastly every day.

I’ve talked to Jen about this. Pete used to say he found talking to Jen more helpful than talking to any of the experts. So there is no reason for any of us to feel like failures because we could not alter what happened. Every case of depression is unique, and every case is to be fought with as much love and endurance and knowledge as can be mustered. But in this particular case, the beast was bigger than Pete; it was bigger than us.

I feel like I’ve read a lot about the grieving process for family members but not so much about what grieving is like when your friends die. Death and I were too well acquainted last year. I lost three good friends — Pete, Mike Gerson and my longtime “NewsHour” partner, Mark Shields. I’ve been surprised by how profound and lasting the inner aches have been.

Pete’s death has been a cause of great disorientation. He’d been a presence for practically my whole life, and now the steady friendship I took for granted is gone. It’s as if I went to Montana and suddenly the mountains had disappeared.

One great source of comfort has been the chance to glimpse, from time to time, how heroically Pete’s boys, Owen and James, have handled this loss. In their own grief, they have rallied forcefully and lovingly around their mother. Two months after Pete’s passing, my eldest son married. To my great astonishment and gratitude, Jen and the boys were able to make the trip to attend. At the reception, the boys gently coaxed their mother to join us on the dance floor. It felt appropriate since this is what we did at camp; dancing skeined through the decades of our lives. I have a sharp memory of those two fine young men dancing that evening, and a million memories of the parents who raised them so well.

If you are having thoughts of suicide, call or text 988 to reach the National Suicide Prevention Lifeline or go to for a list of additional resources.

(Nam Y. Huh | AP photo) New York Times columnist David Brooks at the University of Chicago, Jan. 19, 2012.

David Brooks is a columnist for The New York Times.

By David Brooks | The New York Times

Please read the latest report on Reimage Schizophrenia: transforming how we are treated function and thrive.

Published from the Schizophrenia & Psychosis Alliance, the summary of findings published Feb 2023.

BREAKING! Click here to read our new Voice of the Patient Report (, which captures the powerful stories of people living with schizophrenia and those who care for them. The report summarizes the compelling testimony provided during our Externally-Led Patient-Focused Drug Development meeting on Nov. 2, and was submitted today to the U.S. Food and Drug Administration.

The meeting gave our community a voice – and it was heard. FDA’s Dr. Bernard Fischer told us during the meeting that “the FDA recognizes that there is more work to be done to get better treatments for schizophrenia.”

We thank our meeting co-hosts, who joined us to provide a united front in the fight for treatment equity for people living with schizophrenia: American Foundation for Suicide Prevention, Mental Health America, National Council for Mental Wellbeing and NAMI. And we are indebted to the people living with schizophrenia and their caregivers who participated in this effort and made their voices heard.

People with schizophrenia have the right to effective medicines – just like anyone else with a serious disease. We are working every day to make that happen.

Executive summary

Schizophrenia is a serious, disabling brain disease. While medical treatment for schizophrenia has existed for many years, these treatments are often ineffective and can cause debilitating side effects. The result: countless people with this severe brain disease are subjected to a trial-and-error approach, switching from one medicine to another in hopes of finding something that will curb what can be disabling and life-disrupting symptoms.

Many people with schizophrenia have yet to find a medicine that works for them — creating an entire population of people who cannot
work or live independently and can suffer devastating symptoms of psychosis that can lead to incarceration or homelessness. Just as with
heart disease, diabetes or any other serious illness, if schizophrenia isn’t treated properly, it can get progressively worse. With the goal of turning the tide and improving drug-treatment options for schizophrenia, people with the brain disease and their caregivers gathered virtually on November 2, 2022, to describe what it’s like to live with this serious disease and share their experiences with available drug treatments.
Participants not only pressed drug developers to intensify efforts to develop more effective drug treatments with fewer side effects— they also urged the U.S. Food and Drug Administration (FDA) to allow broader access to the “last resort” drug clozapine, which many patients credited with restoring their ability to attend school, work and live healthy and productive lives.

The meeting, “Reimagine Schizophrenia: Transforming How We Are Treated, Function and Thrive,” was co-hosted by the Schizophrenia & Psychosis Action Alliance, the American Foundation for Suicide Prevention, Mental Health America, the National Alliance on Mental Illness and the National Council for Mental Wellbeing as part of the FDA’s Externally-Led Patient-Focused Drug Development (PFDD) initiative. The FDA launched this initiative in 2012 to collect information about patient and caregiver perspectives on drug development — in particular, what people living with a disease consider to be meaningful treatment benefits and how they want to be involved in the drug development process.

Many people with schizophrenia have yet to find a medicine that works for them — creating an entire population of people who cannot work or live independently and can suffer devastating symptoms of psychosis.

A class action suit—Arnold v. Sarn—was filed in 1981 against the State of Arizona, alleging that the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS) and Maricopa County did not provide a comprehensive community mental health system as required by statute. The case proceeded through the court system (slowly), and an agreement was reached between the parties in 2014, which resulted in a Stipulation for Providing Community Services and Terminating Litigation. There were other decision points made during this case, one of which was that the number of long-term psychiatric care beds available at Arizona State Hospital (the only hospital in Arizona which offers long-term psychiatric care) for Maricopa County would be 55 (for those committed under Title 36, i.e., civil commitment). This number, seemingly plucked out of thin air, is absurd considering the size of the population it serves (about 4,500,000 people in Maricopa County, so this equates to 1.2 beds per 100,000 available for long-term psychiatric care).

As you can see from the article by Research weekly, a publication of the Treatment Advocacy Center, the optimal number of long-term psychiatric beds available in any population should be around 60, with 30 beds acceptable as a bare minimum.

As an organization devoted to the care of people with SMI, ACMI is intent on removing this absurd artificial limit to bed capacity at ASH for those unfortunates who happen to live in Maricopa County, Arizona, one of the largest counties in the US, with the smallest capacity to serve people with this terrible disease.

Charles Goldstein, M.D. ACMI Treasurer

    RESEARCH WEEKLY: Two New Studies on Psychiatric Bed Number Targets – Treatment Advocacy Center

    RESEARCH WEEKLY: Two New Studies on Psychiatric Bed Number Targets

    By Elizabeth Sinclair Hancq 

    (March 2, 2022) Two research reports on the optimum number of psychiatric beds have been published in the past few months, both of which validate the Treatment Advocacy Center’s recommendation for 40 to 60 beds per 100,000 population. 

    In this week’s Research Weekly blog, I will first review the Treatment Advocacy Center recommendations and then summarize the two new studies that support those numbers. 

    Treatment Advocacy Center bed recommendations

    Treatment Advocacy Center published a study in 2008 that included a safe minimum number of psychiatric beds, concluding that there is “a need for 50 (range 40 to 60) public psychiatric beds per 100,000 population for hospitalization for individuals with serious psychiatric disorders.” This is considered a minimum number because it assumes the availability of good outpatient programs, including assisted outpatient treatment. 

    This recommendation was developed utilizing the Delphi method, a structured technique to develop a consensus from a variety of experts. Treatment Advocacy Center collected input from 15 experts on psychiatric care in the United States to inform the estimates. The experts were instructed to take into consideration a variety of factors that impact the need for psychiatric beds, including the number of people with serious mental illness who may need hospital care, the adequacy of community outpatient services, how long individuals usually remain in hospitals, short stay versus long stay beds, and how the psychiatric beds are financed. 

    RAND Corporation bed recommendations for California

    The RAND Corporation is a nonprofit and nonpartisan research organization that conducts research to inform public policy challenges. RAND was contracted by the California Mental Health Services Authority to conduct a research analysis to estimate psychiatric bed need in California for the next five years, including variations for types of beds and regional needs throughout the state. The results of the study were published in January. 

    The study authors first determined the current psychiatric bed capacity in California, breaking down the beds to acute and subacute type beds. Acute beds were described as those for higher acuity patients and shorter lengths of stay (days to weeks), typically utilized to stabilize patients. Subacute beds were defined as those used for individuals with moderate to high acuity needs but for a longer duration (multiple months). 

    They estimated the bed needs in the state using multiple methods. In one method, they convened a panel of technical experts, of which I was a member, to discuss estimates of bed need and the various factors that impact psychiatric bed capacity numbers, including how they are utilized and what types of patients they serve. Secondly, they utilized regional variation in rates of serious psychological distress to estimate how bed need may differ by region of the state. Thirdly, they computed the number of beds required by using a formula that includes how many beds currently exist and current bed occupancy rates, wait list volumes, average length of stay and transfers needed to higher or lower levels of care.

    The RAND report authors found that California requires 50.5 inpatient psychiatric hospital beds per 100,000 adults, which is consistent with the Treatment Advocacy Center findings. The authors further break these numbers down by type of bed, suggesting that these bed targets include 26 acute beds per 100,000 adult population and 24.6 subacute beds per 100,000 population. Taking into account how many beds California currently has, the results suggest that California is short 1,971 acute beds and 2,796 subacute beds. In addition, the authors conclude that the shortage of psychiatric beds will only worsen over time, predicting a 1.7% increase in psychiatric bed need by 2026. 

    International Delphi Method 

    The other new research report on psychiatric bed supply need per capita was an international effort conducted by a group of researchers from around the world and published in Molecular Psychiatry in January. These researchers again utilized the Delphi method to reach a global consensus on the minimum and optimum number of psychiatric beds per population. The Delphia panel included 65 experts, including me, from 40 different countries. These included individuals from all six World Health Organization regions and those from high- and low- income countries. 

    The results of the Delphi process concluded that 60 beds per 100,000 population is the optimal number, and 30 beds per 100,000 population is the absolute minimum. A psychiatric bed supply range of 25-30 was considered a mild shortage, 15-25 as a moderate shortage, and less than 15 per 100,000 population as a severe shortage of psychiatric beds. The results from this international panel of experts are again consistent with Treatment Advocacy Center’s psychiatric bed recommendations. 

    These two new psychiatric bed capacity target research studies further validate Treatment Advocacy Center’s previous report on the subject, suggesting a given jurisdiction should have at least 40-60 inpatient psychiatric beds per 100,000 population to meet the needs of their community. 


    Elizabeth Sinclair Hancq is the director of research at Treatment Advocacy Center.

    To receive Research Weekly directly in your email inbox on a weekly basis, click here

    Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.

    As we celebrate these holidays, let’s resolve to help the less fortunate.  The article below, by Steve Twist and Seth Leibsohn, vividly describes the misery of homeless persons in our community.  The most tragic are those who suffer from Serious Mental Illness (a pathological brain disorder) and co-occurring addiction and homelessness, living in our streets and jails.  Approximately 30% of homeless persons and 30% of incarcerated persons are Seriously Mentally Ill.   

    Some are so mentally ill they believe their internal voices and delusions are real and, hence, they are pathologically unable to participate in their own treatment.  Some seek relief with illicit substances, which exacerbates their illness and misery.  To help these Chronically Mentally Ill persons, we need (a) more group homes with staff inside the homes 24 hours per day and 7 days per week, (b) well-regulated and secure residential treatment facilities from which residents cannot leave without authorization, to allow enough time for their treatment to become effective and (c) more beds and more accountability for care at the Arizona State Hospital, including removing the 55-bed limit on persons who reside in Maricopa County.

    These three steps would provide better clinical outcomes at less cost than we now spend on recycling these persons through our emergency rooms, hospitals, short-term treatment programs, the streets, and jails, as their mental and physical health deteriorates.

    We at the Association for the Chronically Mentally Ill (“ACMI”) welcome the attention Mr. Twist and Mr. Leibsohn bring to the problems described in their article.  And we believe the three steps indicated above would be significantly helpful as to the persons who are homeless due to their Chronic Mental Illness.

    Dick Dunseath, Board Secretary of the Association for the Chronically Mentally Ill, and father of an adult suffering with Chronic Mental Illness


    Phoenix neglects homeless, ignores rampant crime in ‘the Zone’ ( published Nov 17th 2022

    Phoenix neglects the homeless, ignores rampant crime in drug-riddled ‘Zone’

    A homeless person, who was included in the annual Point-in-Time homeless street count, sleeps on the [edestrian bridge, Jan 25th, 2022, at Seventh and Lopp 202 in Phoenix (Mark Hemie/The Republic

    Opinion: Nearly 1,000 homeless folks exist in disease, filth and crime. Phoenix is guilty of not only neglecting them but setting a policy to not enforce laws.

    Steve Twist and Seth Leibsohn

    Within an area of central Phoenix, bounded roughly between Seventh and 15th avenues and Jefferson and Harrison streets, there is an ongoing dystopia. Euphemistically and casually, it’s referred to as “the Zone.”

    This past week, an unborn child, at 20-24 weeks of gestation, was found dead in the middle of the street – burned to death.

    There, nearly a thousand of our fellow citizens exist in disease, filth and crime. They are “living” on the streets, in makeshift tents and under tattered tarps, amid scattered garbage, human waste, chronic illness, drug paraphernalia, fire and fear.

    These are the unseen, forgotten and abandoned. They are the mentally ill, walking the streets, talking to the air, battling unseen demons. They are the drug and alcohol addicted, so desperate for another fix or drink they will do anything except seek treatment. They are routinely victims of both crime and neglect.

    No decent society abandons its fellow citizens to live this way; Darfur or Beirut is not our human or scenic aspiration. Not only is Phoenix guilty of shocking neglect of these most needy among us, it seems to be the policy of the city not to use the tools at its disposal to intervene as a force for help and repair.

    Drug crimes, assaults define life in ‘the Zone’

    Nicky Stevens (left, with MAG) interviews a homeless person during Maricopa County's annual Point-in-Time count, Jan. 25, 2022, near Seventh Avenue and Roosevelt Street in Phoenix.
    Nicky Stevens (left, with MAG) interviews a homeless person during Maricopa County’s Point-in-time count Jan 25, 2022, near Seventh Avenue and Roosevelt Street in Phoenix. Mark Henie/The Republic

    Take the cases of crimes being committed against those in the Zone. Those living there are both routine and regular perpetrators and victims of serious crime. Not only are drug crimes the basis for regular escape and anesthesia, but sexual and aggravated assaults, robberies, arsons and thefts regularly define the contours of daily subsistence in the Zone.

    In its 2020 report, Strategies to Address Homelessness, the city of Phoenix acknowledged, because of “Gaps,” “(t)he result is a fluctuating level of encampments along the streets, defecation in public – sometimes on private property, litter and debris, public drug use, lewd acts, theft and other property and violent crimes.”

    It’s only become worse.

    According to a recent complaint that area business operators filed in Maricopa County Superior Court, the city “refuses to enforce in and around the Zone quality-of-life ordinances prohibiting loitering, disturbing the peace, drunken and disorderly conduct, drug use, domestic violence, and obstructing streets, sidewalks, or other public grounds.”

    So, the victims are abandoned.

    People call for help thousands of times

    Article 2 of our state constitution recognizes victims of crimes have the rights to “justice” and “to be treated with fairness, respect, and dignity.” These constitutional rights are promises made by the people of Arizona to every victim of crime, rights that city officials from the mayor on down have sworn to uphold.

    Yet they have become a mockery as city officials refuse to enforce the very laws that have been written to protect victims from harm.

    A model for others? Tempe parking lot will become affordable apartments

    In this limited area of a few city blocks, in just the first nine months of this year, people have called the police for help more than 2,800 times. On average, in just a few square blocks, more than 10 people need help from the police every day.

    Enforcing our criminal laws when a homeless person commits a crime against another homeless person does not stigmatize homelessness: it respects the rule of law and the rights of the victim essential to natural order. It recognizes a humanity that inheres in certain populations too many of us would, evidently, rather ignore. And these prosecutions can result in services being mandated for the homeless perpetrator.

    Actively police this area. Enforce the law

    But Phoenix is so wrapped in the dogma that pushes the failed policy of “housing first” and appeasement rather than treatment that it leaves the victims with neither justice nor respect. It leaves the homeless abandoned to the vicious cycle of desperation and misery.

    The city has been justifying its shameless inaction because of a misreading of a recent 9th Circuit Court of Appeals case. But that case, Robert Martin v. City of Boise, noted, “Nor do we suggest that a jurisdiction with insufficient shelter can never criminalize the act of sleeping outside.

    “Even where shelter is unavailable, an ordinance prohibiting sitting, lying, or sleeping outside at particular times or in particular locations might well be constitutionally permissible. So, too, might an ordinance barring the obstruction of public rights of way or the erection of certain structures.”

    Start policing the Zone. Enforce the rule of law.

    Start arresting those who break the law. Work with prosecutors and courts to screen for services and treatment. Start with a policy not of “housing first” but “protecting victims first.”

    That is what a sane and civil community would do – before it spreads, and before more lives are brutalized and lost.

    Steve Twist, a former chief assistant attorney general for Arizona, is the founder of the Arizona Voice for Crime Victims. Seth Leibsohn is a radio host at KKNT/960am and a senior fellow of the Claremont Institute, which advocates for limited government. Reach them at and