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

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

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

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

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

Holly Geiszl

ACMI Board Member


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ROBBED ON THE STREETS OF VACAVILLE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SOLANO COUNTY OFFICIALS ‘DO FEEL FOR HIM’

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

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

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

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

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

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

‘THEY SAY IT HELPS KEEP THE VOICES DOWN’

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

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

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

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

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

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

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

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

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

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

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

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

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

CARE COURT COULD OPEN TREATMENT OPTIONS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘OUR FAMILY IS HIS MENTAL HEALTH SYSTEM’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The first Tuesday of each month from 4-6 pm Arizona time except for holiday weekends.

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

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

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

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

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ACMI ADVOCACY TO IMPROVE  PUBLIC HEALTH AND SAFETY

BY IMPROVING THE SMI SYSTEM OF CARE

ACMI has a proud history of advocacy to protect the rights of those living with SMI and to expand innovative services, housing, and inpatient and outpatient treatment options for these individuals.   A robust, evolving system of care is in the interest of patients, families, and society. A stronger care system for those living with SMI promotes public health and safety. ACMI strives to assure that such a system of care exists in Arizona and that it operates transparently, is accountable to taxpayers, and is respectful of patients and families.  

ACMI Board Members are active policy advocates. Every member of ACMI’s Board has testified to committees at the Arizona legislature …. often remaining at the Capitol late at night to cover hearings. ACMI Board Members draft bills “from scratch” and assist others — on a bipartisan basis — in drafting and revising bills.   ACMI Board Members regularly meet with the leadership of Arizona’s legislature, the governor’s office, the executive branch, and regulatory agencies. ACMI successfully advocates growth and change in Arizona’s system of care through relationships, technical legal work, and policy analysis.

This year, the Arizona legislature passed — and Governor Ducey signed — six important bills that improved multiple aspects of Arizona’s SMI system of care. These change aspects of how the SMI system functions daily. For example, these bills strengthen patient privacy and confidentiality. They expand transportation options for individuals requiring screening and evaluation and create new treatment options for incompetent/non-restorable individuals. Most impressive, these bills were amended several times to reflect informed analysis and compromise among stakeholders, often from across the state. 

Five of this year’s mental health bills were sponsored by Senator Nancy Barto, who has long been Arizona’s strongest legislator in mental health.   In response to growing publicity and concerns about the quality of care and safety at the Arizona State Hospital, in 2022, Karen Fann, President of the Senate,  introduced a “leadership” bill to improve the Arizona State Hospital administratively. 

Ultimately, and reflecting growing acknowledgment of the importance of mental health to public health and safety, there were no “close” votes on any of the SMI bills introduced in 2022. Some bills passed unanimously. The Republican (Majority) and Democrat (Minority) caucuses recommended each bill as a “do pass.”   Governor Doug Ducey promptly signed all.   As the summer of 2022 draws to an end, ACMI is planning its legislative priorities and agenda for 2023.   We are exceedingly pleased with the results in 2022; however, much more must be done. As Winston Churchill said, “Success is not final; failure is not fatal: It is the courage to continue that counts.”  

                                                Holly Gieszl and Josh Mozell

                                                On behalf of the ACMI Board of Directors

*****************************************************************************************************************************************************************

2022 LEGISLATION STRENGTHENING ARIZONA’S SMI SYSTEM OF CARE

Adopted from Summary by Deborah Geesling, P82 Project Restoration

And Former ACMI Board Member

SB1114. Court-Ordered Treatment; Case Records; Confidentiality.

Prime Sponsor: Senator Nancy Barto.

Protects privacy of individuals receiving court-ordered treatment (COT) by sealing court records. Modifies application requirements for emergency admissions for court-ordered evaluation. Outlines circumstances in which courts have concurrent jurisdiction over a patient subject to court-ordered treatment.

SB1210. Mentally Ill; Transportation; Evaluation; Treatment; Law Enforcement; Title.                                                   

Prime Sponsor: Senator Nancy Barto.

Allows a court, admitting officer, mental health treatment agency or evaluation agency to authorize apprehension and transportation of a patient to an evaluation agency by an authorized transporter instead of law enforcement. Helps assure transport of individuals with SMI in a more humane, less traumatizing, and potentially less expensive way. Permits law enforcement to focus more on their primary jobs, not transporting individuals with SMI unless necessary for safety. Establishes a Study Committee on Alternative Behavioral Health Transportation.

SB1310. Dangerous; Incompetent Person; Evaluation; Commitment. 

Prime Sponsor: Senator Nancy Barto.

Establishes procedures regarding detainment, commitment, conditional release, and discharge of criminal defendants deemed incompetent, non-restorable, and dangerous. Outlines requirements for treatment of committed defendants. Requires a court to admit individuals who are not-competent, not-restorable, and dangerous into a secure residential behavioral health facility.

SB 1392. State Hospital; Placement; Court-Ordered Treatment.

Prime Sponsor: Nancy Barto

Removes red tape when patients need a higher level of care at the State Hospital. Allows medical director of local mental health treatment agency that is assigned to supervise and administer patients’ treatment program to request the court to order a patient placed in the Arizona State Hospital (ASH).

SB1444. State Hospital; Administration; Oversight. 

Prime Sponsor: Senator Karen Fann.

Reforms Prohibits administration and employees of the Arizona State Hospital (ASH) from retaliating against a patient due to family participation in Arizona State Hospital Independent Oversight Committee (ASH-IOC) meetings. Requires the ASH CEO/Superintendent and CMO to attend and participate in ASH-IOC meetings. Directs ASH administration to develop and implement an innovative clinical improvement and human resources development plan. Modifies membership and duties of the Joint Legislative Psychiatric Hospital Review Council (Council).

SB1651. Behavioral Health Expenditures; Behavioral Health Services; Public health &  Safety; Serious Mental Illness; AHCCCS Annual Report. 

Prime Sponsor: Senator Nancy Barto.

Requires Arizona Health Care Cost Containment System (AHCCCS) to annually report outlined statistical information relating to expenditures, services, and outcomes of services provided to individuals living with SMI. Provides baseline and provisions for longitudinal analysis.

The first Tuesday of each month from 4-6 pm Arizona time except for holiday weekends.

We will have a featured guest that will discuss a relevant Behavioral Health topic, followed by discussions with attendees on current issues with the Behavioral Health System. This month learn about our AHCCCS (Medicaid) eligibility rules.

AHCCCS eligibility specialists Brandon Ruiz and Julie Swenson will discuss Medicaid eligibility rules and review common misconceptions.

Topic: ACMI Stakeholder’s Meeting

Time: August 2, 2022 04:00 PM Arizona

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

    Aug 2, 2022 04:00 PM

        Sep 6, 2022 04:00 PM

        Oct 4, 2022 04:00 PM

        Nov 1, 2022 04:00 PM

        Dec 6, 2022 04:00 PM

        Jan 3, 2023 04:00 PM

Please download and import the following iCalendar (.ics) files to your calendar system.

Monthly: https://us02web.zoom.us/meeting/tZIudu6vqDspHdaOPI66YyVO1EYY3UYrWtCI/ics?icsToken=98tyKuGurTotHdKVsx6FRpwAA4j4KO3wpmJegqdcsy_MVXZqezXZZ8d7C-FKKcrn

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Meeting ID: 863 1776 0372

Passcode: 795774

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The first Tuesday of each month from 4-6 pm Arizona time except for holiday weekends.

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

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

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

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

Topic: ACMI Stakeholder’s Meeting

Time: July 12, 2022 04:00 PM Arizona

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

Jul 12, 2022 04:00 PM

        Aug 2, 2022 04:00 PM

        Sep 6, 2022 04:00 PM

        Oct 4, 2022 04:00 PM

        Nov 1, 2022 04:00 PM

        Dec 6, 2022 04:00 PM

        Jan 3, 2023 04:00 PM

Please download and import the following iCalendar (.ics) files to your calendar system.

Monthly: https://us02web.zoom.us/meeting/tZIudu6vqDspHdaOPI66YyVO1EYY3UYrWtCI/ics?icsToken=98tyKuGurTotHdKVsx6FRpwAA4j4KO3wpmJegqdcsy_MVXZqezXZZ8d7C-FKKcrn

Join Zoom Meeting

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Meeting ID: 863 1776 0372

Passcode: 795774

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+16699006833,,86317760372#,,,,*795774# US (San Jose)

+12532158782,,86317760372#,,,,*795774# US (Tacoma)

Dial by your location

        +1 669 900 6833 US (San Jose)

        +1 253 215 8782 US (Tacoma)

        +1 346 248 7799 US (Houston)

        +1 312 626 6799 US (Chicago)

        +1 929 205 6099 US (New York)

        +1 301 715 8592 US (Washington DC)

Meeting ID: 863 1776 0372

Passcode: 795774

Find your local number: https://us02web.zoom.us/u/kc1xiBw0Jl

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

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

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

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

Topic: ACMI Stakeholder’s Meeting

Time: June 7, 2022 04:00 PM Arizona

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

        Jun 7, 2022 04:00 PM

        Jul 5, 2022 04:00 PM

        Aug 2, 2022 04:00 PM

        Sep 6, 2022 04:00 PM

        Oct 4, 2022 04:00 PM

        Nov 1, 2022 04:00 PM

        Dec 6, 2022 04:00 PM

        Jan 3, 2023 04:00 PM

Please download and import the following iCalendar (.ics) files to your calendar system.

Monthly: https://us02web.zoom.us/meeting/tZIudu6vqDspHdaOPI66YyVO1EYY3UYrWtCI/ics?icsToken=98tyKuGurTotHdKVsx6FRpwAA4j4KO3wpmJegqdcsy_MVXZqezXZZ8d7C-FKKcrn

Join Zoom Meeting

https://us02web.zoom.us/j/86317760372?pwd=MUJLZnl3cTFqSDRrbllmOUI0Sk82Zz09

Meeting ID: 863 1776 0372

Passcode: 795774

One tap mobile

+16699006833,,86317760372#,,,,*795774# US (San Jose)

+12532158782,,86317760372#,,,,*795774# US (Tacoma)

Dial by your location

        +1 669 900 6833 US (San Jose)

        +1 253 215 8782 US (Tacoma)

        +1 346 248 7799 US (Houston)

        +1 312 626 6799 US (Chicago)

        +1 929 205 6099 US (New York)

        +1 301 715 8592 US (Washington DC)

Meeting ID: 863 1776 0372

Passcode: 795774

Find your local number: https://us02web.zoom.us/u/kc1xiBw0Jl

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

ACMI feels strongly that the IMD exclusion should be repealed!

ACMI Board


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

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

Untreated SMI – BD Hypno Plus Courtesy of Pixabay

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

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

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

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

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

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

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

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

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

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

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

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

Steady Decline In Beds

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

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

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

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

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

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

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

News release about Rep. Grace Napolitano’s bill.

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

April 20, 2021Press Release

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

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

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

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

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

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

5sigletterSupportforHR2611(Napolitano).pdf

PDF icon5sigletterSupportforHR2611(Napolitano).pdf

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

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

Story by Amy Silverman October 22, 2021

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

But it’s not always calm. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wallace is now in Pima County Jail on assault charges. 

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

Advocates for people with serious mental illness call for improved conditions at the Arizona State Hospital, and more beds.https://azcir.org/news/2021/10/21/grievances-reforms-arizona-state-hospital/

by Amy Silverman October 21, 2021

Isaac Contreras lives alone and he says it’s making him sick. 

He’s got a room and a bathroom to himself, but the luxury stops there. Contreras has spent more than a year in “administrative separation” at the Arizona State Hospital (ASH). His lawyers call it isolation. 

Contreras was sent to ASH in 2017 after pleading guilty but insane to breaking his ex-girlfriend’s eye socket, cheekbone and nose, most likely during a period when he was having hallucinations associated with schizophrenia. Previously, Contreras had served a prison term for manslaughter.

As with many people with serious mental illness, Contreras’ diagnosis has changed over the years. In March 2021 it was anti-social personality disorder, intermittent explosive disorder and post traumatic stress disorder, as well as substance use disorder that’s in remission. He’s on a long list of medications.

He and his lawyers acknowledge his past, but say that a lack of proper medical care while at ASH has made Contreras worse, exacerbated during his time in administrative separation.

In his current living situation, Contreras is indoors at least 22 hours a day. Twice a day, he’s allowed to sit outside on a patio. He says that restraints are kept on his legs when he leaves his quarters. At one point, he didn’t have a table or chair; Contreras’ lawyers say that ASH officials refused to provide them, then did so after the lawyers offered to pay for the items. For a three-month stint, he was forced to eat with his hands after his spork privileges were revoked. 

Holly Gieszl, a criminal defense attorney, represents Contreras along with civil lawyer Josh Mozell. Both routinely represent people in the mental health system. 

From left, attorneys Holly Gieszl and Josh Mozell are shown at a Phoenix law office on June 23, 2021. Photos by Alberto Mariani | AZCIR

“ASH didn’t give him the psych and medication support he needed to function on a daily basis,” Gieszl says. “And shortly after he was in seclusion, he started to deteriorate more.”

Mozell says that ASH has kept Contreras in isolation as retaliation for filing more than 300 grievances during the time he’s been a patient. At least two of those grievances were partially sustained, including one affirming that a staff member had physically assaulted Contreras by grabbing him in a bear hug. That employee later lost his job, in part because of the interaction with Contreras. 

In another grievance filed in 2017, long before he was placed in “administrative separation,” Contreras alleged that he was kept in mechanical restraints for 14 hours, despite having been calm immediately beforehand. ASH did not sustain his grievance, so Contreras appealed the decision to the hospital. 

In February 2020, ASH dismissed his concerns for a second time. 

Contreras then wrote to the Arizona Health Care Cost Containment System (AHCCCS), which handles appeals. In November 2020, AHCCCS upheld part of Contreras’ grievance, noting that surveillance footage backed up his claim about being kept in restraints. AHCCCS also noted that “It does not appear that ASH conducted an additional investigation as required” given that the hospital’s second decision letter was “identical” to the first.  

Other grievances were never sustained. An investigator from AHCCCS, which looks into allegations of physical and sexual abuse at ASH, confirmed that Contreras sustained a broken bone in his back after a violent incident with a staff member, but Contreras was said to have provoked the event, not the staff member. 

Along with filing grievances about his living conditions and treatment by hospital staff, Contreras keeps busy by recording videos of himself talking about his situation and finding surreptitious ways to get them posted on YouTube

“This place—if I’d known it was going to be like this, I would have told my lawyer, ‘You know what? Send me to prison,’” Contreras tells the camera.  


The Arizona State Hospital is one element in the state’s mental health care system—and probably its most controversial. 

While institutions like ASH are becoming a thing of the past nationwide, members of the local non-profit Association for the Chronically Mentally Ill (ACMI), and others believe there should be more beds available at the hospital; they are convinced ASH has the potential to offer therapeutic treatment that will help some of the sickest people get better and lead meaningful lives in the community. 

But first, they say, reform is necessary. 

Long time players in the system say oversight at ASH is inadequate because the Arizona Department of Health Services both operates and monitors the hospital. 

An independent oversight committee (IOC) comprised of citizen volunteers meets monthly to discuss conditions at the state hospital. In a draft of the committee’s 2021 annual report obtained by AZCIR, members express concern that patients are complaining about being observed while toileting, without a medical reason. Guardians of patients at ASH have told the committee they are not included in the development of treatment plans. The committee noted that ASH administrators don’t attend IOC meetings.

As recently as August, committee members expressed concern over reports that patients were peeling wood and tile from the buildings at ASH and using the materials to self-harm. The IOC’s annual report included mention of “numerous reports of patients eating laminate from doors, cabinets or paneling.” 

And the committee has worried about patients who claim they have been retaliated against when they complain about poor conditions. At least one advocacy organization is looking into that, too.

In response to questions from AZCIR, Arizona Department of Health Services Communications Director Steve Elliott wrote that federal privacy laws prevent him from discussing an individual patient. 

“ASH uses administrative separation under limited circumstances and when necessary for the safety of patients and staff,” Elliott wrote. 

In response to the Independent Oversight Committee report, Elliott wrote that the toileting concern is addressed with care. 

“If a patient insists on using the restroom within 30 minutes, staff observes while providing the patient as much privacy as possible to make sure oral medication isn’t saved or disposed of. Patients on continuous observation for safety have staff present at all times, while staff make every effort possible to provide as much privacy as possible.”

He did not directly address the concerns regarding guardians not being included in treatment plans, or whether patients are removing pieces of building materials and eating them. 


The 1900 Biennial Report of the Medical Superintendent of the Insane Asylum of Arizona offers far more detail about life in the state hospital than just about any modern document.

The report described two deaths in the 18-month period covered, including one by rattlesnake bite, incurred during an outing to Agua Caliente Hot Springs. The typical daily menu (including a breakfast of mush and milk, meat stew, fruit, bread, coffee and milk) is detailed, along with holiday menus and the superintendent’s Christmas gift to each patient of candy, nuts, oranges and “a useful gift.”

The population was carefully documented in a long list of patients’ occupations, including beggar, locksmith, sea captain, housewife, civil engineer and piano player. “Causes of insanity” included brain disease, masturbation, epilepsy, fright, solitary life, and “want of work.”

But for all that detail, there’s very little in the report about mental illness.

“Complete mental rest and mild physical employment have been found most efficacious in relieving cases of temporary insanity,” wrote Superintendent J. Miller, M.D.

He requested equipment and facilities that would allow for medical interventions.

“Insanity for women is commonly caused by pelvic diseases which may be remedied by surgical means,” Miller wrote, adding that the asylum was also in need of a medical library.

The hospital population was 175 in 1900.

Arizona State Hospital 1920
The Arizona State Hospital, known as the Insane Asylum in this 1920 colorized photo from the Arizona State Library, is shown in this undated photo postcard illustration. Photo courtesy Arizona State Library

By the late 1960s, the renamed Arizona State Hospital housed about 2,000 people with serious mental illness. But a 1970 state law requiring ASH to accept only those presenting a danger to themselves or others shrunk the number of patients to about 300, in keeping with a national trend of deinstitutionalization made possible by the introduction of medications designed to treat mental illness. 

ASH was dogged by state audit findings of facilities in poor condition, overcrowding and lack of staffing in the 1990s. In a 2015 investigation, former Arizona Supreme Court Justice Ruth McGregor found dozens of instances in which Phoenix Police filed a report following a call to ASH and there was no corresponding hospital incident report documenting what happened. In addition, of more than 1,400 assault allegations, only 33 led to internal investigations and 199 to inquiries by Adult Protective Services.

The population at ASH has remained small, in part because of reforms designed to limit institutionalization. 

In recent decades, some states have shuttered their psychiatric institutions as part of the goal of supporting people with mental illness in the community. Arizona stopped short of that. In the Nineties, as part of the exit criteria for the Arnold v. Sarn lawsuit that led to mandated care for people with SMI, a 55-bed limit was put in place for Maricopa County. That number was included in the 2014 settlement agreement in the case and remains the same today, despite the fact that the county’s population has more than doubled in the last 30 years since the cap was put in place.

(Here, it gets a little complicated, as ASH treats both forensic patients like Isaac Contreras, who is there because he committed a crime, and civil patients receiving court ordered treatment. The 55-bed limit applies to the civil side only.)

The debate over the 55-bed limit is heated. 

Chick Arnold, the lead plaintiff in Arnold v. Sarn and a longtime mental health lawyer and advocate, signed the settlement agreement but now says he believes there should be no limit on bed count—that it’s a “clinical” decision best left to medical professionals.

Anne Ronan, a plaintiff’s attorney in Arnold v. Sarn, has a different position.

“We don’t need ASH, we never needed ASH, we don’t need two beds at ASH,” Ronan says. 

“There’s nothing about the problems that the system is experiencing that gets solved by more secure housing at the state hospital.”

Carol Olson, who chairs the psychiatry department at Maricopa County’s Valleywise Health System, has a different perspective. She believes the 55-bed limit should be lifted.

She says Valleywise’s behavioral health units are overwhelmed with patients with SMI, including some who wait for more than a year for a bed at ASH. The county’s mental health units are designed for short term stays of up to 21 days. 

Dr. Carol Olson, chair of the psychiatry department at Maricopa County’s Valleywise Health System, is shown in her Mesa office on July 1, 2021. Photo by Alberto Mariani | AZCIR

On a given day, Valleywise fills 300-325 beds, with an ASH waiting list of a dozen or so. It’s not a large number, but it’s an important population, Olson says. 

“Valleywise has become like a mini state hospital,” she says, adding that that’s unfortunate since it’s not equipped for long term stays, particularly for some of the sickest patients. Many require a private room and sometimes one-on-one staff person. There is no rehabilitation staff and not much of an outdoor area for patients. 

Olson says Valleywise is very selective about whom it suggests should go to ASH. 

“We don’t even consider somebody for an application to the state hospital until they have been with us for three months or longer.” 

Even then, she says, ASH is often vague about why they won’t accept a patient. Olson says they will rarely accept someone who swallows foreign objects, for example, and they often won’t take a patient with a serious substance abuse disorder along with SMI, because such patients can often be stabilized in a short term facility. Olson says that’s not enough, that some need a longer stay in order to be successful and not return to a hospital setting. 

Some patients simply remain at Valleywise, even when there are beds available at ASH, because state hospital administrators won’t take them. 

“If we can’t safely discharge them to the community, they stay with us,” Olson says. 

The health department’s Elliott did not respond directly to Olson’s charge. 

“Treatment at ASH is considered ‘the highest and most restrictive’ level of care in the state,’” he wrote. “Patients are admitted because of their inability to be treated in a community facility or due to their involvement in the criminal justice system.” 

Olson, who has worked at Valleywise since 1991, says Arnold v. Sarn changed things dramatically for the better by emphasizing the value of helping people with SMI thrive in the community. But now she says the pendulum has swung too far.

“Many people were placed in long-term psychiatric hospitals in the 50’s and 60’s who didn’t need to be there and nowadays do well living in the community with appropriate supports. However, there are some individuals with very severe psychiatric conditions who have only minimal or partial response to available treatments, who require a long-term stay in a locked psychiatric hospital for the safety of themselves and others and to avoid behavior which would be likely to lead to criminal charges in the community, but are not able to be admitted due to the 55-bed limit at ASH and the restrictive admission criteria there. Many of those patients instead end up in jails or prisons, which are not appropriate settings for severely mentally ill people and often make their conditions even worse.”

She adds, “I wish there would be some focus on what would be most humane for those individuals.”


In a video posted in September 2020, Isaac Contreras is wearing white sweatpants, a black tank top and shower shoes with socks. His dark hair hangs to his shoulders; he’s got a lot of tattoos, including on his face. He holds up several bottles of shampoo, soap and deodorant, as well as an electric razor, then picks up a Styrofoam container of food to demonstrate how he eats peas with his hands because he’s not allowed a spoon. He doesn’t understand why he’s given hard plastic containers, which could be used to craft weapons, but no food utensils. 

He might be a man overcome by his illness, or Contreras might be the canary in the coal mine. 

Either way, through his videos and grievances, he offers a window into the secret world of the Arizona State Hospital. ASH has long been a mysterious place—it’s located in the center of the city at 24th Street and Van Buren, and many people pass by the barbed wire fencing without knowing what’s inside.  

In 2018, the Arizona Center for Disability Law, which is required by federal law to oversee conditions at facilities housing people with SMI, including ASH, successfully sued for unaccompanied access to patients. 

The center announced that under a settlement, “ASH agreed to provide ACDL reasonable unaccompanied access to the ASH facilities and residents” and to allow the center to conduct “up to three-hour visits twice per week for the purpose of educating ASH residents about their rights and the services that ACDL provides.” 

No journalist has been given a formal tour since 2015, Elliott says.

Public oversight is particularly important, critics say, because the same state agency that runs ASH is also in charge of licensing it. 

AHCCCS, the state’s Medicaid agency, took on oversight of the state’s mental health system shortly after the 2014 Arnold v. Sarn settlement agreement, with one notable exception—ASH. 

“Any reader in the whole world will understand why that’s bad,” says Will Humble, who served as the director of the Department of Health Services from 2009 to 2015. “The fox watching the henhouse. Everyone knows what an enormous conflict of interest that is, and up until now, no one has cared.” 

Humble says that as director, he did his best to “build a firewall” between the licensing division and ASH, but believes the health department should not be monitoring a hospital it operates. 

From Elliott’s written response: “It’s a common practice among states for an agency to license and operate a state hospital.” 

Along with the state licensing requirements, Elliott says several other state and federal entities offer oversight, including the Centers for Medicare and Medicaid Services, adding, “ASH is one of the most regulated hospitals in Arizona.”

“The fact remains they are running and operating and regulating it themselves, and it’s not their fault, it’s the statute,” Humble says, adding that the Department of Health Services provides the staff that does the Centers for Medicare and Medicaid Services certification reviews. 

Since 2018 (state records are posted for three years), ASH has had just one penalty under the health department’s enforcement actions—a $500 fine because an employee allowed two patients to be in a room alone, resulting in a sexual assault. 

There was no penalty for the physical assault against Isaac Contreras, even though AHCCCS found his allegations to be true.

AZCIR reviewed incident reports from the first two weeks of January 2020. More than 175 reports were generated, including 22 marked Code Gray, which indicates combative or violent behavior.

The reports document patients hitting, kicking, biting, chasing, punching and spitting at staff, as well as attacking other patients. 

From one code gray report

Code gray report redacted

It’s not unheard of for a patient to walk naked into another patient’s room. One patient reportedly masturbated during a football game. Another punched a hole in a wall when told they couldn’t have fruit late at night. During a bingo game, a patient made threats against another patient, saying, “I am going to fuck him up….I’ll go for the vital organs.”

Other reports detail patients engaging in potential acts of self-harm like tying a blanket into a knot, punching the shower wall, eating toilet paper and claiming to have eaten baby powder, shampoo and conditioner. 

Three separate incident reports appear to document the same situation, in which a patient claimed to have swallowed at least 10 objects, some sharp. The reports indicated that the patient was to be observed, but there’s no information about what happened next—the spot on the incident report for “determination” is redacted, as it is on all of the incident reports released to AZCIR.  


Isaac Contreras remains in isolation. It’s now been more than 15 months.

Josh Mozell says Contreras does not need to be separated from the rest of the patients at ASH. When he meets with his client, Contreras walks out to the visitor area with someone trailing him at a distance, Mozell says, which indicates to the lawyer that there’s not much reason to fear him. 

Even if Contreras does exhibit violent behavior, Mozell says, there are ways to address that without isolating him. He says some patients have a one-on-one staff person or even two assigned to them. 

Using nursing notes that recorded Contreras’ actions in two hour increments over the last several months, Mozell’s staff built a spreadsheet documenting that Contreras has gone weeks at a time without an issue. Legally, Mozell says, ASH is not allowed to keep him in isolation, noting that hospital officials use the term “administrative separation” although Contreras has made a crayon rubbing of the sign above his door, which says “seclusion.”

Elliott, spokesperson for the health services department, declined to comment on the specific circumstances for Contreras because of federal privacy laws. 

Isaac Contreras used a crayon and paper to make an image of the sign above his door, shown here. Photo by Amy Silverman | AZCIR

Mozell is not the only one who’s concerned about patients kept in isolation.

Laurie Goldstein chairs the Arizona State Hospital Independent Oversight Committee charged with monitoring conditions at ASH. 

ASH isn’t all bad, Goldstein says. Her son spent a year and a half at ASH during 2013-15. She says it gave him the treatment and supervision necessary to live in the community with some support. 

She’d like the hospital to do the same for others, and says she and her committee are concerned about patients kept in isolation for extended periods of time. She will not comment directly regarding Contreras, again because of privacy laws, but he has spoken before the ASH Independent Oversight Committee. 

“We don’t find it particularly therapeutic if somebody was to stay in isolation their whole time and then be released,” Goldstein says. 

The committee is curious about one patient’s living quarters, Goldstein says. So far, hospital administrators have refused to offer many details: “We asked to see it. They said no. We asked for pictures. They said no. We asked for dimensions. They said no.”

The committee is also worried that some patients are facing retaliation for filing grievances, which are almost never substantiated, a concern shared by the Arizona Center for Disability Law. 

“The individual who actually processes these grievances, she’s the so-called patient rights advocate, but she isn’t independent. She’s an employee of ASH,” says Asim Dietrich, an attorney with the disability law center, which has a federal contract to monitor conditions at the hospital. 

“Almost every ASH patient we speak to who’s filed a grievance has also received retaliation,” he says.

Since 2019, ASH has received 585 grievances from patients, according to Elliott. Of those, four were substantiated and another three were partially substantiated. AHCCCS investigates allegations of physical abuse, sexual abuse and sexual misconduct. The hospital handles the rest. The state will not release details of grievances, citing administrative code. 

“I’m literally scared of getting out. Even into the unit. Not that they’re going to hurt me, but I’ve been accustomed to a small environment. I don’t understand how these people expect to help me progress if everything they’re doing is making me worse.”

ISAAC CONTRERAS

Contreras described his situation in a phone conversation with AZCIR in September. He says that being isolated is making him worse. 

“Therapy was good, it helps out a lot, but that’s the only thing I get as far as treatment. All I get is my medication and any time they speak to me, it’s behind the window. I’ve never felt this hopeless before, like there’s nothing for me out there. There’s nothing. 

“I’m literally scared of getting out. Even into the unit. Not that they’re going to hurt me, but I’ve been accustomed to a small environment. I don’t understand how these people expect to help me progress if everything they’re doing is making me worse. 

“I have not even seen the sky, I have not seen the sun come up or go down, I have not had the luxury of that.”