The program’s principles, practices, and evidence by Dr. Sam Tsemberis, who is a nationally recognized expert.

May 11th, 2022 from 6-7:30 pm AZ time (PST)

Dr. Sam Tsemberis, the clinical psychologist that developed the Housing First program to stem homelessness for people with serious mental illness and addiction.

In 1992, Dr. Tsemberis founded Pathways to Housing, based on the belief that housing is a basic right for all.  Pathways developed the Housing First model that provides immediate access to permanent supported housing; independent apartments and intensive treatment and support services for individuals who are homeless and who have mental illnesses and substance use disorders.  The program uses a person-centered harm reduction approach and does not require participation in treatment or sobriety as a precondition for housing.  Housing First is recognized as an evidence-based practice, having been successfully replicated and evaluated in numerous settings across the United States and internationally.  Dr. Tsemberis is a clinical-community psychologist and serves on the faculty of UCLA.  He also serves as principal investigator for several federally funded multi-site studies of homelessness, mental illness, and addiction, and has published numerous articles and book chapters on these topics.

Housing first
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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ACMI feels strongly that the IMD exclusion should be repealed!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 – 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(4-15-22) Is the federal government’s Institutions for Mental Disease (IMD) Exclusion outdated and actually harming Americans with serious mental illnesses?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

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.

Topic: ACMI Stakeholder’s Meeting

Time: Apr 5, 2022 04:00 PM Arizona

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ACMI Giving Tuesday
#GivingTuesdaysACMI

Today is giving Tuesday! Launched in 2012, Giving Tuesday is known as the global day of giving. Please join us in advocating for people with serious mental illness by showing your support. People like you have donated money to help ACMI reach our previous goals. Ever dollar counts! Please consider what can you can contribute.

Today only, a generous donor is matching all gifts made, dollar-for-dollar, up to $15,000!

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.