Update continued: Food for Thought. 

Mental Health Reform- Long Overdue. 

RE: As discussed in my last article, I have thus far found Mr. ToersBlijn's contributions to the discourse specific to Arizona's shortsighted and graphically inept behavioral health care system very enlightening, and directly relevant to my work as it stands. Thus, as per Mr. ToersBlijn's express permission, I offer my own feedback, as follows.  This is the final aspect of my response in this context. 

My further comments in red, below.

Mental Health Reforms ~ Long Overdue
By Carl R. ToersBijns

(cont., my comments in red)

This will be more tedious in nature as it requires the commitment of community resources in the mental health field as well as the involvement of many groups of mental health advocate groups that may recommend treatment alternatives to the legislative committee that in turn can pass legislation with minimum standards or treatment conditions to the mental health courts or superior courts for behavioral management purposes.

I contend that it will take the greater public's willingness to recognize the matters that I have clarified in my writing, as well as all/any other like good faith data flowing out of the arguably narrow discourse provided therein, by which they- the public- organize grass roots expressions specific to saying "Enough is enough!" Any tediousness of concern to me has more to do with an ongoing lack of public awareness about people such as myself (who are able and willing to offer everything I can in order to bring about the needed reform discussed in this article) and the seriously mentally ill population in general (who must also be more centrally involved in the process, for they too see what is going on, and while not all of them are able to contribute, many can, to a markedly beneficial degree), and the graphic shortcomings of the behavioral health care system that they- the public- fund as taxpayers, at great cost to the state as a whole, but ultimately at the expense of state's most highly vulnerable population on whose behalf these resources have been implemented. It is somewhat common knowledge that the underlying discriminations against the seriously mentally ill, and associated stigmitizations, are still prevalent in all aspects of contemporary American society, so it is only reasonable to expect the public to grasp the fact that in the state system, such issues can and will arise anytime we allow for a treatment system that operates in a vacuum, and gross incompetence will arise. I saw this day in and day out at ASH. It's like the Department of Motor Vehicles, circa the 1970s, on crack- absolute dereliction of duty and willful ignorance personified.  
  
So ask the question – Where should the mentally ill be placed? Today most severely mentally ill persons that run afoul of the law are committed to state prisons. Society has released this responsibility to the prisons rather than mental health courts and every study made has revealed that the mentally ill do not belong in prisons just because there is no other place to put them. Severely mentally ill (SMI) persons do not cope or function very well in prisons and often get worse because of lack of mental health services available or 

provided in most populations.

As I have stated already in several articles of my own, there are most definitely serious problems in the sentencing process of severely mentally ill Arizona citizens who "run afoul of the law", and while my experience in this specific area is still quite limited, I attest to the fact that at ASH, Caucasion men and women are granted access to residential psychiatric treatment there at a rate of 12:1 or so in comparison to African Americans at ASH. It was freaky in there, so few black patients, while a markedly high degree of employees at ASH are black, particularly in the case of behavioral health technicians. Converesly, there are literally hundreds of studies available today that illustrate the fact that modern corrections facilities are dominated by a high majority of African American men and women (prisoners). So again, I say that we can stick to basic facts such as this one, and find therein specific lines of approach by which to get the ball rolling in terms of reform and redress on behalf of mentally ill persons, wherever they happen to be at any given time. It is indeed the system that I am talking about here, but systems are not nearly so mysterious as they can appear, and no system is out of reach when it comes to public action. In sum, the AZ behavioral health system in far too burdened by an inefficient and ineffective system of managed care, with too many mid-level managers and far too much paper pushing. It is a joke, and the inefficiencies themselves are the precise reason why the federal government cut funding to Arizona in this context in 2011-2012: The state failed to meet stated expectations, and the data underlying this failure has everything to do with the fact that the managed care model in effect in AZ today does not work.  

These SMI persons often become targets or predatory non-mentally ill persons and abused and assaulted repeatedly without any relief or protection from the prison system.Therefore they become more traumatized than when they entered the prison system and less likely to recover from such conditions resulting in suicides and other self-harm acts that puts them in a high risk classification.

Of course they are targeted and abused as such. This happens in the public mileu, too, albeit not as graphically or violently as in a prison facility; it is somewhat common knowledge that various facets of recent American history prove the presence of endemic discrimination against the disabled in general that extends into every area of the public landscape (this is the underlying purpose and design of the protections found in The Americans With Disabilities Act), and it doesn't take rocket scientists to realize that persons with severe mental disability are highly vulnerable to such misbehavior, more so, in effect, than any other disabled population. In this context, I attest to having witnessed and experienced the willingness of high ranking state employees, such as the administrators at ASH and members of the state's highest bodies of government, (e.g., the Office of the Attorney General), to blatantly discriminate against the patients at ASH and the client population in general throughout the department of health services client base in the basis of their given disability ; they, the state employees who we the public pay, do this by willfully manipulating, ignoring, and rejecting well established laws and policy specific to their duties and obligations, and they get away with it because the population of citizens victimized by this misconduct have little in the way of voice or other like means by which to address abuse in any form. I am experiencing this today every time I go to hearing in the Arizona Office of Administrative Hearings, where Joel Rudd relies upon untruthful, misleading, and otherwise inaccurate/invalid testimony and other like evidence, all presented in order to preserve the substandard conditions and related patient  abuse(s) at ASH.

There are other negative factors of putting SMI persons into prisons. Arizona has limited bed space for such SMI persons and must choose which SMI are housed within these diminutive treatment centers and which ones are ignored. It has been projected that up to 24 per cent of our prison population is in need for mental health treatment programs, medication and treatment needs.

Another well constructed point in fact. And as I have already discussed, the limited resource base described above includes a marked degree of inefficiency and ineffectiveness in the managed care system itself, which in turn allows gross ineptitude and literal incompetence within the offices of the highest ranking-highest paid state employees whom we, the public, have granted to privilege and related responsibilities specific to the care and treatment needs of the state's most seriously mentally ill citizens. In this context, we are looking at a state system that is greedy by nature, criminal in form and conduct, but this should be no surprise, for these traits are common anywhere we allow for a public resource to operate in a vacuum. The monies flowing to the state via the federally regulated, quasi-privatized managed health care model that is in effect in Arizona today are so grossly mismanaged in general, that the state employees I am talking about take full advantage and exploit this cash flow in any way that they can. There is no better place to see this exploitation than in the administrative offices at ASH, and as illustrated, too, by the misconduct of the Hospital's senior clinicians (psychiatrists, many of whom are from countries like Pakistan, India, and the Philippines, where such exploitation is a given). All of this at the expense of the public in general, including the state's most seriously mentally ill citizens.   

These persons are subjected to lack of therapeutic environments that fosters healing and stabilization. They will risk being out of compliance of their medication because the side effects are detrimental to their coping skills and never talk to anyone about their choices or decisions thus basically left alone to cope the best they can.

I agree 100%. The graphic incompetency and related ineptitude illustrated by the gross misconduct of ASH administrators and throughout the state's behavioral health care system, flies in the face of any reasonable expectation specific to healthy therapeutic environments tha can foster healing and stabilization. I was subjected to very obvious actions designed to destabilize my state of mind when I was retaliated against by the senior clinicians and administrators at ASH because I openly engaged in good faith reporting of staff misconduct. This was imparted on me in  order to preserve status quo and allow for the ongoing failures of ASH clinical staff to provide meaningful treatment and care for the patients committed there. I contend that in the very place where any reasonable person would expect conditions most favorable to the needs of Arizona's most seriously mentally ill patients, the conditions are in fact anything but favorable, and this is directly due to ineptitude, greed, and related criminal misconduct that I have alluded to thus far.    

They are often misunderstood by poorly trained correctional staff and classified to be behavioral misfits and placed into segregation for long periods of time while receiving either no treatment at all or worst, chemically restrained by psychotropic drugs that put them in a state of suspended functioning for the remainder of their time to serve until released from prisons.

Boom! "Poorly trained…. staff… (mentally ill persons) classified as behavioral misfits…. placed into segregation…" Yes the happens, and it extends into every area of the public mileu, particularly in the prisons, and including within ASH. I attest to being classified as behaviorally unethical person when all I ever did was draw attention to staff misconduct at ASH. And I witnessed the willful abuse of patients in this same context in any number of ways that directly relate this specific topic. The fact is, many of the senior clinicians at ASH consider their patients to be social misfits and little more than criminals, in fact. I have referred to this fact in my own writing, staff behavior personified, for example, by one of my primary care physicians at ASH, who expressed confusion and even a bit of frustration when he learned that I am not a felon. (Dr. Pervaiz Ahkter: "Are you really not a felon?") I realized that even there at ASH, seriously mentally ill persons such as I have little hope  equitable and meaningful treatment, and it is all due to the willful incompetence of ASH's senior clinicians and executive administrators. 

Then upon their release date they are given a 30 day blister pack of medication and put out in the street or with families that have no meant either financially or socially abilities to maintain such medication or treatment needs. One must realize there is strong evidence of the large crossover between mental illness, criminal behaviors, incarceration and treatment.

Here, again, we need to look at the managed care system responsible for outpatient care. I learned from a very experienced and highly intelligent charge nurse in the Tucson, AZ, hospital that ultimately referred me to ASH, that the majority of patients circulating through the acute wards of Arizona's public psychiatric facilities wind up there due to gross ineffectiveness in the managed out patine care system specific to issues such as medication supply(s) and readily available resources of all kinds. There is possibly no uglier reality than that illustrated by the case loads of the outpatient case managers in Arizona working for contract based agencies-companies such as Cope, Inc;  La Frontera, Inc., and Magellan, Inc.  I learned firsthand that it is virtually impossible for any one case manager in these agencies to meaningfully meet their responsibilities to there clients. This fact directly contributed, in fact, to my winding up in ASH, because I tried to rely upon such a managed care agency (Cope, Inc) at one point in my relatively recent history as a seriously mentally ill person, and the utter inability of those people to do their job(s) so frustrated me that I immediately relapsed into a state of deep depression and related suicidal ideation. My story in this context is the norm for many/most seriously mentally ill citizens in Arizona. The problem, as such, is neither with the mentally ill population nor the presence of mental illness in our communities. It is within the system entrusted with overseeing managing the care needs of there clientele, Arizona's most seriously disabled and highly vulnerable citizens.  

Today the SMI persons in our community do not received adequate services or treatment as they require thus are stigmatized by society for being abnormal and thereby cast into prisons. This makes it society’s problem and often left unresolved because of funding or lack of services available in the demographics involved with such needs…

Bingo! Stigmatization and discrimination does exist in every facet of contemporary future and society, and I attest to the fact that it also extends to the inner sanctum(s) of public mental hospitals such as ASH, as I have discussed. This is a critical and enormous problem, for these are the places and people who we, the public, rely upon in terms of seeking fair and reasonable mental health care and treatment for our nations' most seriously mentally ill citizens. Indeed, people like myself are not abnormal, in fact- we are affected by impacts of illness. I am dedicated to the notion that public education and formal discourse at a national level must be ignited on a scale never seen, discourse specific to the fact that we, the American people, still harbor unwanted sentiments that directly contribute to the fact that these issues still prevail to the degree that they do. I am willing to declare these sentiments as "unwanted" because they fly in the face of our national character, as I see it; and I am willing to believe that once the shroud of these factors is revealed to our national conscience, we the American people have the capacity to do the right thing. But again, it has to begin with education, and a related exposure of the substandard conditions at public facilities such as ASH (in order to show the pubic themselves these specific realities), and with a focus as well on the unlawful conduct of highly paid state employees who are charged with the duty of abiding by established ethical standards and other like features illustrated by contemporary law and policy in this context. Again, I have gone to great length in illustrating who these people are in Arizona's current public administration. 

Thus we have to ask a few more questions and glean the answers:

- Why severely mentally ill persons aren’t hospitalized or offered outpatient treatment through the mental health court systems?

The courts do offer such, but admittedly, there are very clear shortcomings to the procedural matters that underlie such offerings (as exemplified by the aforementioned racial disparities at ASH). I am convinced that it is again an issue of ignorance and disregard for the fact that these are mentally ill persons. Therein (in the courts) lie the most damaging effects created by societal disregard for such persons.  

- Where do these criminal behaviors originate and what preventive 

measures are available within the community to help them?

This is work assigned to scholars and research based agencies. But at places like ASH, the incompetence and ineptitude of senior clinical staff allows no opportunity for such consideration right there where it most courts, in the places where our most mentally disabled citizens reside. I contend that this leads to the problems associated with what happens when such persons are released into the out patient community.  

- Where do these SMI persons obtain the guns they use to commit crimes and what are the traditional barriers of such activity?

- Are the laws in tune with our socio-political, economic and environmental systems functional or are there dire changes needed?
- What prompts the mass shooting mentality and where are the loopholes, the communication breakdowns and observation reports?

While my ability to speak to this specific issue is limited, I can refer directly to the events and related matters that arise in the cases of Jared Lee Loughner and Jesus Rincon Murietta, wherein there are clear indications of the Arizona mental health system's blatant unwillingness to do the right thing. This, in my experience, is a central concern, because I know that the people most in a position to have deterred these events failed to do so because of their fundamental ineptitude, and the related breach(s) of the public trust. Loopholes are generally created by the willingness of individuals to avoid their established responsibilities, which directly relates as well to "communication breakdowns" (e.g., the administrators at ASH willfully chose to not report Mureitta's escape to the public, and then manipulated the merits of HIPPA and other like provision of law and policy in order to justify this fact), and "observation reports."

  - Who is responsible for this problem; society, policy makers or lawmakers?

Specifically, in the case of the Arizona Department of Health/Behavioral Services and the one's responsible for ASH, it is individuals who refuse to admit the problems that are increasingly becoming brought the fore, and their related roles in creating the problems themselves. But these individuals do operate as a collective, in effect, state employees, and the complicity of agencies such as the Office of the Arizona Attorney General when such problems arise in the public eye )agencies that clearly want to preserve the status quo in this context) graphically illustrates how and 

why such misconduct occurs (and continues to occur).

 - When an SMI commits a crime, what do we do with them and what options does society have to avoid criminalizing the mentally ill persons?

I feel that the question of society's moral obligations in this context supersedes the merits of available options at this time. The crisis at stake in this discourse derives of aforementioned issues relating to stigmatization and discrimination, wherein the public is not even comfortable with discussing these issues, much less taking the care needs of seriously mentally ill citizens to heart. Again, public education and a concerted process of introspective cultural analysis is crucial to this process as it stands today. 

- Can the courts order medication involuntarily and do we need to revisit the forced medication procedures to include more mandatory treatment inside our communities and keep them outside our prisons?

Forced medication, or lack thereof, is not the problem. 
The problem has long been discussed and looked at for the past 40 years. Ever since the courts ruled that an SMI had the right to refuse his medication. The problem is then multiplied by the number of mentally ill roaming the streets without medication. Not all are violent in nature but the fact is many do have drug or substance abuse addictions that exasperate their mental illness.

Forced medication does still exist. I saw it at ASH, and to my reckoning, it was generally administered in a manner consistent with applicable provisions of state and federal law. On the other hand, abuses of these standards does occur, but I am not qualified to speak to the issue. 

Thus the bottom line was the mentally ill persons were criminalized by their own means and the lack of protection for society by the laws passed and that have withstood time after time tests in court to be upheld. The homeless become victims of crime as they try to survive the environment without their treatment or medication needs.

Meaningful improvements relating to the rights of mentally ill citizens (specific to liberty) somewhat occurred in the early to mid 1970s, an era referred to as "deinstitutionalization", which did in fact lead to less people being subjected to unnecessary hospitalization in mental health facilities; in a related note, however, one of my former therapist's  referred to this period, which occurred under the Reagan administration, as "When we pushed all of you out into the bushes….." So, yes indeed, in the public milieu today, the presence of mental illness most clearly manifests in that population of Americans referred to as "the homeless."   

Not all SMI persons are homeless or have alcohol or drug abuse habits. However, they are all stereotyped and classified into the same group regardless of their social backgrounds. Society has stigmatized them severely. The laws, in order to offset this stigmatizing created another factor that also added to the criminalization of the SMI.

I agree 100%. Enough said.

 

Under the HIPAA Act, the government passed privacy laws restricting medical records. This has severely impaired the process of allowing this vital information to be recorded in the National Criminal Information System for firearms background checks. Thus the passage of the HIPAA Act basically thwarted this information to be made available to law enforcement or the licensed gun dealers that submit the forms for background checks.

Case in point: Specific to the cover-up of Jesus Rincon Murietta's violent escape fro ASH in late May, 2011 (and as it related to the brutal killing of April Mott in August of the same year), the administrators at ASH, including at least one representative of the state attorney general's office (Joel Rudd), willfully hid behind the protections (afforded to patients) of the Hospital Information and Portability Act (HIPPA) in order to justify their actions. HIPPA in itself, as illustrated in its findings and stated purpose, is not designed/intended to complicate the process raised above. But again, the willingness of individuals who are bound to abide by HIPPA, the ADA (and other related law and policy in general), to willfully manipulate such standards, is a pervasive, insidious, and very critical problem in this specific context.  

Lawmakers must make a decision quickly how to handle the severely mentally ill persons within our community. The current process of sending them to jail or prison is not working and leaves one important fact in place. We would serve ourselves well to re-evaluate the way we deal with the mentally ill from beginning to end. It must make delicate decisions between the right of others and the rights of the SMI when it comes to treatment, incarceration or other preventive measures.

I somewhat disagree. The issue is not "how (do we) handle the severely mental ill within our community." There as an inordinate amount of public revenue flowing directly into the "handling" of Arizona's most seriously mentally ill citizens, and there are related standards specific to the management of these citizens affairs and care needs. But, as I have stated, Arizona's public behavioral health care system, which directly benefits from this revenue, is so highly inefficient and ineffective, that

the people of Arizona are effectively being ripped off in terms of the expectations that I contend we all share in this context. This extends to the seriously mentally ill citizens most reliant upon this system. Indeed, prison and jail is not the proper place for any person affected by serious mental illness and disability, but until we do what we need to in terms of getting the behavioral health care system up to speed, the problem is effectively unresolvable.   

We must not take away someone’s freedom just because society doesn’t want to deal with the problem and thereby casting them into prisons with an out of sight, out of mind mentality. They are, after serving their time, released back into the community in a worst condition than when they were incarcerated. The cycle returns them to a life of crime, sometimes violent and they are returned to jail and eventually prison.

December 29, 2012

Originally published by permission of Carl ToersBijns 

paoloreed@gmail.com