Illustration by Peter Thomas Ryan

The state has left thousands of mentally ill people without counseling, services or even homes. And the worst may be yet to come.

It was Christmastime in the Valley, a harrying season for many people, but even harder for those marooned by the isolation of mental illness. The woman’s family had noticed disturbing behaviors and feared she may soon harm herself or even others.

They petitioned Maricopa County court to evaluate her through Arizona’s involuntary commitment process – a process much touted after accused Tucson shooter Jared Loughner, who many believe is schizophrenic, drew attention to the importance of treating mental illness before a crime is committed.

Authorities admitted the woman into the county psychiatric hospital, where she was stabilized for two weeks, diagnosed seriously mentally ill, court ordered to receive outpatient treatment, released, and then… the case was dismissed.

Because there was no treatment. Not in Arizona’s new mental health desert.

Shortly after her release, the woman had another episode, and her family faced the prospect of reinitiating a commitment process that was essentially a bridge to nowhere. What will happen to the woman? She may resort to the desperate methods of the teenage girl who repeatedly sought help but, unable to get into the Valley’s backlogged clinics in time, sliced her arms so she’d be rushed to an emergency room. Or she may end up like the man who’s become a regular at Phoenix’s Urgent Psychiatric Care Center (UPC), stuck in a so-called “revolving door,” spinning in and out of crisis, seemingly no way to step out into the light.

Faced with a $1 billion-plus budget deficit, the state has slashed mental health care funding by more than $60 million in the last few years. The most significant slices came in the past year, first with the suspension of Arnold v. Sarn, a decades-old lawsuit requiring the state to provide services to the seriously mentally ill (SMI), who currently number 42,000 and suffer from conditions such as schizophrenia, bipolar disorder and major depression.

That paved the way for service cuts that affected some 12,000 adults and 2,000 children. As of July 2010, SMI individuals who do not qualify for AHCCCS, Arizona’s Medicaid program, no longer receive therapy, case managers, housing, transportation or brand-name medication. Non-AHCCCS adults receive only crisis services, generic medication and doctor visits related to prescriptions. Children are given only crisis services.

Translation: They’ve taken the “mental” out of mental health care.

“The Arizona behavioral health system is a very well established system that’s been a national model for years and is now under attack from many different fronts,” says Dr. Chris Carson, CEO of Connections AZ, which runs the UPC. “It’s in turmoil.”

But the dismemberment of Arizona’s mental health care system is no One Flew over the Cuckoo’s Nest story, with the state playing Nurse Ratched’s icicle-hearted overlord, severing patients’ lifelines with a distant signature and a deft scalpel. Rather, the state is more like canyoneer Aron Ralston in 127 Hours, who, trapped under a boulder, takes time to examine the alternatives, feels he has no choice, and then deliberately and consciously cuts off an arm.

Except, in this case, there may have been other choices. In this case, the choice will likely come back to haunt us. And in this case, an even bigger rock is about to fall.   

His name was John Goss, and he was one of “those people” – the ones shuffling along the streets every day, the ones we give a wide berth. Nights, he probably slept under a bridge, or if he was lucky, in one of Downtown Phoenix’s “schlock supervisory care homes that comprised what I then called a mental health ghetto,” says mental health lawyer Charles “Chick” Arnold.

It was 1981, in the wake of the deinstitutionalization of the ’60s and ’70s, when states unshackled their electro-shock therapy patients and took a wrecking ball to insane asylums, releasing the mentally ill into a new vision of recovery-focused community treatment programs.

Arizona was a bellwether in that vision, becoming the first state – and remaining the only state, Arnold says – to enact a statute mandating the creation of a full range of community-based services and residences for anyone with a serious mental illness, regardless of financial or other qualification. Arizona also became the first state to create an office of a  public guardian who would connect the mentally ill with those services. Arnold became the guardian of 600 people in Maricopa County, one of whom was John Goss.

Goss was a smart man who had read the statute, and he came to Arnold’s office daily, complaining that the reason he was aimlessly ambling the streets was that these community mental health services didn’t actually exist. So Arnold filed a class action lawsuit, Arnold v. Sarn, and with characteristic governmental swiftness, 10 years later the Arizona Supreme Court had decided the state was indeed violating its statute, and the plaintiffs and Arizona Department of Health Services (ADHS) had agreed upon a blueprint to do something about it.

That blueprint gave rise to Arizona’s unique and multilayered mental health care system: The health department contracts with a handful of for-profit and nonprofit Regional Behavioral Health Authorities (RBHAs), which in turn contract with several Provider Network Organizations (PNOs) to run community clinics. The system included a range of subsidized group and individual residences, case managers and a court monitor who served as a watchdog for the system and an ombudsman for the mentally ill.

But the lawsuit remained open, because the court monitor’s audits continually gave the system “dreadful” reviews, Arnold says. The state complained that the audits’ questions weren’t indicative of patient recovery, and that adhering to all the mandates would cost hundreds of millions of dollars.

Still, thanks to the statute and lawsuit, Arizona had built a mental health system with robust laws, a smorgasbord of services and numerous dedicated advocates, including a woman in government who continually championed for the seriously mentally ill, because her son is one of them.

Ronald Brewer has schizophrenia and has lived in Arizona’s state mental hospital for the past two decades, after being found not guilty of sexual assault and kidnapping by reason of insanity. For much of that time, his mother, Jan Brewer, fought to maintain state funding for mental health care.

“There were conversations back in 2008, 2009 to the director of the health department [where Brewer said], ‘If I tell you to cut X million dollars, where are you gonna get it from, and you can’t take it from behavioral health,’” says Laura Nelson, deputy director of the Division of Behavioral Health Services at ADHS. “She said that about as long as she could say it.”

Then in January 2010, Republican Governor Jan Brewer released her new budget, which included two shocking blows to behavioral health: $36 million in cuts, and the repeal of the state statute.

The plaintiffs in Arnold v. Sarn tried to persuade Brewer to keep the state statute, Arnold says. They made a deal: Brewer would erase the repeal order from her budget if the plaintiffs would agree to suspend Arnold v. Sarn and dissolve the office of the court monitor until June 2012.

“I was livid,” says Arnold, who had gone into private practice and was no longer directly involved in the lawsuit. He appealed to the new judge on the case, Karen O’Connor, telling her she had to hold a hearing. “The deal was made on a Thursday,” he says. “The judge is told Thursday afternoon by Joe Kanefield, appointee for the governor, that she has to have a hearing Friday, the next day, because if you don’t, the legislature is going to repeal the statute…. It’s extortion. It’s outrageous pressure.”

Not surprisingly, no one came to the Friday hearing. O’Connor held another hearing the following Monday, “and 28 people showed up; 27 of them spoke against the deal,” Arnold says. “Anyone who knew anything about this said, ‘You can’t do this. It’s the only safety net.’ The judge says, ‘I’ll take it under advisement.’ Then she goes into her office and signs the deal.” 

With that, the state took its mental health care system’s watchdog to the pound, and many insiders believe it will be permanently put to sleep. “This case is over,” Arnold says. “It will never come back. The governor, who was seen as an advocate, has severely compromised the interests of the mental health community. And I don’t see us coming back from that.”

With Fido out of the way, the government could break its state statute and cut services to SMIs without fearing the lawsuit’s bite.

The young man received a letter in May 2010 from Magellan, Maricopa County’s RBHA, informing him that since he was not eligible for AHCCCS, he would no longer receive brand-name medication, case management, therapy or other non-medical services starting July 1. He was given information on community resources and resource fairs and told to contact his clinical team to help him create an individual plan for the transition.

But he was nervous. The brand-name medication he was taking was helping him and, like many new drugs, had no generic alternative. He knew that older, generic antipsychotics increase the risk of a permanent neurological disorder. He became so anxious he had to be hospitalized for two days. While there, representatives from Magellan and provider networks visited him, talking to him about his options and creating a plan. A few months later he was taking generics and doing well. At a grassroots mental health organization meeting, he commended the work of the providers, saying, “It was a horrible thing you guys had to do, but it was a very sensitive way you approached it.”

“We do not come from a place where we just send someone a letter saying, ‘It’s been nice but unfortunately we can’t do this anymore,’” says the health department’s Nelson. “This whole process has been an incredibly individualized approach to each person.”

Before the cuts, Nelson explains, the mentally ill got the same services whether they were on AHCCCS or not. So there was no incentive to apply for AHCCCS. Now, AHCCCS-covered people still get all the services (counseling, case managers, name-brand medication) that AHCCCS-ineligible people lost. So health care workers converted thousands of eligible individuals to AHCCCS. This saved the state money because it moved people from a state-funded program to a largely federally funded Medicaid program.

Richard Clarke, CEO of Magellan of Arizona, explains how that was done: “On the adult side, there were 7,508 individuals [in Maricopa County] who were affected by the cut. We converted 1,690 of them to Title-XIX (AHCCCS) status doing a high-touch, high-relationship process – meet every person, assess their financial status, design individualized treatment for them.

“There were about 2,769 who had third-party insurance that were never being billed because the state was paying for it. So we got them connected with their third-party insurance. Then we had to transition everybody else to this new benefit structure, and we did it by going one person at a time. It took us six months. We made a commitment that we would not transition anybody till we felt we all had a competent transition plan.”

One of the biggest concerns was that because of the housing cut, thousands of SMIs would be booted onto the street. Not so, Clarke says, rattling the figures off the top of his head: “In Maricopa we have 21,000 individuals suffering the challenges of a serious mental illness. This [housing] cut only affected 231 people who were receiving the state subsidy. We found that 90 of them could be on Medicaid, so we converted them to Medicaid. Then we transitioned 79 into independent living. Forty-six went into assisted living because they actually needed a higher level of care. Eight were transitioned to live with their families, and we supported the families through that transition. Six are still receiving their housing from VA. We still have two individuals that almost a year later we haven’t been able to find a safe alternative for them, so we’re funding them.”