New Times feature
Shadow Dwellers: A SeriesWhat's the one image you took away from the Tucson shootings? We thought so. That mugshot of Jared Loughner is haunting. And for the world, it has become the face of mental illness in Arizona. Here, we know that's not true. A picture may be worth a thousand words, but the story of what it's like to be mentally ill in this place cannot be told in a single photograph.
Tens of thousands of seriously mentally ill people live in Arizona. Some of them look just like you.
Other stories in the series:
Here's a story about a mentally ill man with a gun in Tucson that you probably haven't heard.
On a Monday afternoon last October, Joseph Molina, 34, stopped traffic near the bus station in the city's downtown. Armed with a handgun, he attempted to carjack two vehicles — shooting at passengers — then fled in a Tucson Police Department cruiser after pointing the gun at an officer.
The officer shot Molina. Fatally wounded, he crashed the car into a city bus. No one else was injured.
Molina was pronounced dead at University Medical Center later that day, in the same facility where Congresswoman Gabrielle Giffords remains in serious condition after she was shot in the head on January 8 by Jared Lee Loughner, the man charged with murdering six and injuring 12 others.
Along with the obvious comparisons, Jared Loughner and Joseph Molina had one important thing in common: At the time of their attacks, neither — as far as anyone can tell — was receiving mental-health services.
Hindsight is dangerous — tricky at best. It's easy to say Loughner desperately needed help, now that the pieces are falling together to create a portrait of a deeply disturbed young man.
No one needs hindsight in the case of Joseph Molina. He had a long record of serious criminal behavior and mental illness.
Last March, Molina racked up his seventh felony — the April 2009 aggravated assault of a bus driver with a drywall saw, considered a deadly weapon. No one was hurt in the bizarre episode; after the arrest, Molina told deputies he'd hijacked the bus to get to the police station because voices in his head had alerted him that two men were trying to kill him.
That incident happened within weeks after Molina's release from the Arizona Department of Corrections after completing a seven-year sentence on yet another aggravated-assault conviction. He was in and out of prison since 1994, when he turned 18.
What kind of mental-health treatment he received while incarcerated or in those brief periods when he was "free," basically to roam the streets of Tucson, is uncertain.
What is known is that court-appointed doctors diagnosed Molina as paranoid schizophrenic after the 2009 assault of the bus driver. A Pima County judge later found him "guilty except insane," which led to Molina's latest incarceration, this time at the Arizona State Hospital in Phoenix instead of prison.
Court records show that Molina was said to be "stabilized" mentally within months after he was sent to the hospital, because of powerful psychotropic drugs and counseling.
ASH doctors deemed Molina "competent" enough to be released back into the criminal-justice system for disposition of the assault case.
Molina was taken to the Pima County Jail, but county prosecutors inexplicably fouled up. Authorities released him from custody within days with what his public defender later described as about five days of medication for his schizophrenia and a mental-health provider's street address for a "follow-up" consultation.
Reports show another incident after that: Police used pepper spray on Molina during a routine traffic stop. The cops booked him into county jail, but again, he was back on the streets.
And then he was dead.
Tucson Police Captain Michael Gillooly told the press, "A subject with numerous violent priors who spent numerous years in prison went on a rampage that could have taken the lives of many people in the downtown area."
Another way of putting it: Joseph Molina's death was what mental-health professionals call a preventable tragedy.
Were Jared Loughner's crimes a preventable tragedy?
As society at large ponders the question, here in Arizona we hardly have the luxury. Here — just days after a spree that now has its own logo, "TUCSON TRAGEDY," in bold red and black in the daily newspaper — it's apparently back to business as usual.
Tucson hosted a big gun show over the weekend. And in Phoenix, Governor Jan Brewer ended the week by announcing she wants to cut healthcare to 280,000 indigent Arizonans, including 5,200 seriously mentally ill adults, according to the Arizona Hospital and Healthcare Association.
That's on the heels of massive cutbacks over the past two years. Just last July, an estimated 3,000 seriously mentally ill people in Pima County alone lost almost all their services, including access to non-generic medication and caseworker supervision. Six months earlier, thousands deemed just "generally mentally ill" lost the bulk of their public funding.
A mental-healthcare crisis is gripping the nation, to be certain, with funding shortfalls everywhere. But Arizona already has been among the hardest hit, and now, Brewer who made a name for herself decades ago as a champion of the mentally ill wants to further reduce services in the state. For some of her healthcare cuts, she'll need permission from Washington to avoid triggering federal cuts in funding, and last Friday, she announced she'll ask for it.
Mental-health and criminal-justice experts say Arizona is asking for it, all right.
Though our laws are among the nation's best at protecting the mentally ill and protecting us from the few in that population who pose a danger, not only are services crumbling, but the laws on which they are based often have worked best in hindsight.
Experts are debating whether Arizona's mental-health laws could have been applied to keep Loughner from buying the Glock he used January 8.
It's true that Pima Community College officials, or someone else noticing strange behavior, could have filed a petition that might have led to an emergency-room visit that might have led to a 72-hour observation that might have led to a judge's order making it illegal for Loughner to buy a gun.
But that doesn't mean Loughner wouldn't have gotten his hands on a gun anyhow (consider the case of Joseph Molina), and it certainly doesn't guarantee he would have received any meaningful treatment if he were diagnosed with mental illness.
Or that anyone could have kept him from going after Gabby Giffords.
This is a system that can hardly help its sickest. How can we expect it to identify an all-but-hidden young man? It's tough to blame Arizona's mental-health system for failing Loughner.
But if the simmering political vitriol that's boiled over in the aftermath of the Tucson tragedy may be somewhat misplaced, an examination of the state's failing mental-health system is anything but.
Susan Gerard served in the Arizona Legislature for years and then ran the state's Department of Health Services during much of the last decade under governors from both major parties. Today, the moderate Republican sits on the board of the Maricopa Integrated Health System, the county's hospital board. She's frustrated — on a lot of levels.
"Parents, if you think there's something not right with your kid, you've got to get help!" Gerard tells New Times. Then she catches herself, adding, "However, there's no place you can actually get it anymore!"
She apologizes for laughing — almost hysterically — at the absurdity of what she has just said.
But her point is profound.
"Just having solid laws like Arizona's has not been enough, as people in Arizona know," says James Pavle, executive director of the Treatment Advocacy Center in Arlington, Virginia. "You've got to make those laws work for the people involved and for the community at large or they are just that — laws on the books."
Even before the last few rounds of budget cuts, in 2008, the Arizona Auditor General chided the state health department for abiding by conditions "that raise serious questions about the behavioral health treatment, safety, and overall well-being" of people suffering from serious mental illness. And the National Alliance for the Mentally Ill warned in 2009 that any progress the state had made could be wiped out in the economic downturn.
Last month, Arizona State University released a study by the Center for Applied Behavioral Health Policy and the Morrison Institute for Public Policy. It's called "Public Behavioral Healthcare in Arizona: Preparing for the Storm," and the title is no exaggeration.
The study's co-authors, Bill Hart and Dr. Michael Shafer, reported that since 2008, about $60 million has been slashed from the budget for the state's behavioral health system — a stunning 47 percent cut in non-Medicaid services available to the mentally ill.
That was before last week's proposal.
The authors noted that several of the state's top mental-health experts agree that "the combination of the recession and government officials' reactions to it have plunged Arizona into the equivalent of an enormous social experiment that challenges the core assumptions of [the current status quo].
"Those assumptions rest on the fundamental belief that providing community-based services for persons with behavioral-health disorders is not only morally right, but also policy-right; that access to such services saves lives, preserves families, promotes stable neighborhoods, supports employment and productivity, reduces long-term public outlays, and reduces clients' encounters with criminal-justice authorities, emergency rooms, and the streets. This experiment is now under way."
This "experiment," as they dubbed it, bodes poorly for Arizona's mentally ill. As for that "storm" that the authors allude to in the title of their paper, it's only beginning to hit the shore — in our case, the desert.
Arizona already provides a bulk of its inpatient mental-health treatment in its jails and prisons, for years the state's largest de facto "providers" of mental healthcare.
The odds of a seriously mentally ill person being held in an Arizona detention facility, compared to a psychiatric hospital, are 9.3 to 1. This is second in the nation only to Nevada, according to a study by the Treatment Advocacy Center. (Nationally, the odds are 3.2 to 1.)
Our state's philosophy — if that's what it is — is lock 'em up, find appropriate meds for them behind bars, provide basic counseling when possible, and then hope for the best when, inevitably in most cases, the prisoners are released into society.
Almost by proxy, Jared Loughner has made us uncomfortably aware that this state's mental-health system is in disarray, and it's not going to get better anytime soon.
"For a lot of people, it's out of sight out of mind, until a major crisis happens — Columbine, Virginia Tech, and now Tucson," says the Treatment Advocacy Center's Pavle. "Those events go into the gold championship category. But you've got a whole lot of lesser but equally as important cases that very few people ever hear about. It's not, by any stretch, just about the big ones."
Retired Phoenix cop Alex Femenia recalls the days when he was assigned to patrol a roughneck neighborhood on East Van Buren Street.
It was the late 1970s, and seemingly overnight, he says, the streets filled with what Femenia later learned were longtime patients released en masse from the nearby Arizona State Hospital. His was already a high-crime beat; now it was populated with the seriously mentally ill, many of whom had been locked up for years and now had been dropped into the "community," often to fend for themselves.
Femenia says many of the former (and future) patients were easy fodder for street thugs and, sometimes, for each other.
"It was bizarre, and it was sad," he says, recounting tales of gruesome murders and already difficult lives that got worse for many after the wholesale "deinstitutionalizing" of the hospital.
Unfortunately, no records are available about what happened to many of the hundreds of patients released from the mental hospital during that time.
Some returned to families. Others became homeless, drifting through what remained of their lives.
What was happening in Phoenix hardly was unique — it was a time when the bulk of America's institutionalized seriously mentally ill population was freed from what political leaders came to see as the shackles (literally and figuratively, in many instances) of an inhumane system.
As Pete Earley recounts in his 2006 book, Crazy: A Father's Search Through America's Mental-Health Madness, this country has a long and sordid history of mistreating its mentally ill citizens.
From the tale of the early-1800s preacher outraged after discovering a rag-clad mentally ill prisoner locked in a tiny closet in a Boston jail to the 20th-century "innovations" in electroshock and fever therapies, Earley details a disturbing but fascinating history, including what prompted the decision to deinstitutionalize.
If you've read One Flew Over the Cuckoo's Nest — or seen the classic 1975 movie that Earley says helped gather popular support for the movement — you understand.
Who can forget the evil Nurse Ratched and how she terrorized the mentally ill (or, in some cases, the merely socially unfit) in a setting where lobotomies and utter degradation of the human spirit ruled the day?
But though life for far too many in state institutions surely was horrific, the dramatic alternative — which was to release droves of mentally ill people into society without providing an adequate safety net — wasn't without peril.
Some saw the future, including Dr. Robert Reich, who wrote in the American Journal of Psychiatry, "The freedom to be sick, helpless and isolated, is not freedom. Our present policy of discharging helpless people to a hostile community is immoral and inhumane."
His 1973 piece was called "Care of the Chronically Mentally Ill — A National Disgrace," which tells us that, on some levels, things haven't changed much since then.
In the end, an unlikely and dangerous liaison between fiscal conservatives and well-meaning humanitarians all but emptied the nation's mental hospitals. In the 1950s, according to federal government estimates, about 500,000 people were housed for indeterminate lengths of time in state mental hospitals.
Today, that number is about 50,000, and all but the very sickest may get an opportunity for release at some point.
Earley — who was motivated to write his book after his son had a schizophrenic breakdown in his early 20s — warns that even with social services, mental illness can be difficult to diagnose, treat, and continue to treat.
And it can be hard for parents or other people close to the ill person to recognize trouble in the first place.
"Most of these illnesses, including schizophrenia, surface in late adolescent and early college years, and so it's sometimes difficult for a parent to see what is a serious mental illness and what is a kid getting his own identity," Earley says.
That is not to say there haven't been improvements across the board — from educating parents to creating programs. Many seriously mentally ill people are able to lead quiet and productive lives, but usually only if they receive the right medical care and social assistance — which is no small task in Arizona, where libertarians too often overrule do-gooders.
Enter Charles "Chick" Arnold.
The Phoenix attorney has been on the frontlines of the mental-health conundrum for more than 30 years. In 1981, when Arizona ranked dead last in the nation for per-capita spending on mental-health services, Arnold was serving as the Maricopa County Public Fiduciary.
That year, he became the plaintiff on behalf of seriously mentally ill clients in a groundbreaking lawsuit filed by the Arizona Center for Law in the Public Interest against the state health department, state hospital, and his own bosses, the county Board of Supervisors.
Arnold prevailed, and increased funding from the Arizona Legislature later allowed the paltry services to improve, though not anywhere near the level that he and like-minded advocates wanted. To this day, his practice continues to focus on mental-health law, an admittedly frustrating line of work.
Yet Arnold has been instrumental in helping to craft an enlightened body of law involving civil commitments, the legal process in which a judge decides whether a troubled person should be ordered into a psychiatric hospital or forced to accept other mental-health treatment.
"While our system sucks, our statutes are the best in the country," Arnold says, a sentiment echoed by many but not all of those interviewed for this story (state officials bristle at the notion that Arizona's mental-health system "sucks").
As for Arnold vs. Sarn — the official name of the class-action lawsuit that a young Chick Arnold initiated three decades ago — the case still is alive, at least technically.
After years of bickering with the state of Arizona, and untold hundreds of thousands of dollars spent on legal fees and negotiations, both sides agreed last June to table the suit for two years because of the current economic climate.
The hard-hearted attitude of Governor Jan Brewer didn't help any.
The best advocates in any aspect of social welfare often are those hit close to home, and Brewer is no exception.
Rather, she was no exception.
A staunch conservative for years in the Legislature, Brewer nevertheless routinely pushed to fund mental-health programs, often citing her own seriously mentally ill son.
Ronald Brewer has been held at the state mental hospital for much of the time since 1990, when a judge found him not guilty by reason of insanity under a now-defunct law for sexually assaulting and kidnapping a Phoenix woman.
As a legislator and even later as a county supervisor, Brewer gained a reputation among lobbyists and lawmakers as steadfast on the issue, which is why many have been surprised by her change of tune since she became governor.
Brewer was not, at first, elected to that office. From county supervisor, she'd gone on to become Arizona's Secretary of State and, in early 2009, ascended when Janet Napolitano left the governor's seat to become secretary of the U.S. Department of Homeland Security under President Barack Obama.
Within months, Brewer announced that her administration was going to slash funding for mental healthcare.
The governor's former mental-health allies had clung to the hope that her son's condition would sway her to find a way to avoid doing that.
But Governor Brewer no longer was talking about her son and his story. In fact, she took great measures to hide his scary criminal record from the public during her successful 2010 gubernatorial campaign.
Chick Arnold has a simple explanation for Brewer's switch in attitude: "I think when she decided to run for election a year ago, she had to throw the human-services community under the bus. And did."
Laura Nelson, acting deputy director of the Behavioral Health Services division of the state health department, bristles at Arnold's words. She says she doesn't think mental healthcare in Arizona is abysmal. To the contrary, the psychiatrist says she's proud of how street-level providers have responded to ensure that care is available.
"Actually, things have been very stable statewide," says Nelson, noting that her agency been tracking the numbers of calls to crisis hotlines (and the disposition of those calls), and the admission rates to in-patient settings, emergency rooms, psychiatric urgent-care centers, and jails.
"It's definitely been going as well as anyone anticipated with what we've been facing, and, in part, that's because of the enormous creativity from our peer-run agencies and advocacy groups."
But even Nelson had to suck wind when she learned — right in the middle of her interview with New Times — that the governor's budget proposal had been made public.
The news caught her off-guard, she admits; she's been busy fielding calls about Tucson and Loughner.
The whole thing is shortsighted, says Bob Bohanske, chief of clinical services and clinical training at Southwest Behavioral Health Services, a direct service provider in Maricopa County. He explains that in 2014, the federal healthcare law takes effect — and, on paper, stands to improve services to Arizona's mentally ill.
"Here we are in this two-year hiatus before all kinds of changes happen, and so the state of Arizona has decided to balance its budget on the backs of the least capable and least powerful."
One of the reasons the state's Laura Nelson hasn't seen a huge spike in problems following recent budget cuts is because law enforcement has stepped in to avert crisis in many cases.
Mental-health advocates warn this is an expensive, dangerous way to do business — although they are grateful to people like Nick Margiotta, a veteran Phoenix police officer who is that agency's coordinator for the Crisis Intervention Training program.
Margiotta trains officers to avoid escalating situations with the mentally ill and to discern when it is appropriate to divert people from jail and instead take them to an urgent-psychiatric-care facility. He estimates that Phoenix police have performed about 12,000 such diversions in the past decade, though he can't say for sure that every individual would have ended up behind bars.
Margiotta notes, "For our program to have any real positive effect, a community needs a comprehensive and responsive behavioral-health and human-services system. That last part is forgotten in most parts of this country."
Margiotta says he was very concerned about the hits last July but says Maricopa County's crisis system has picked up some of the slack.
"We knew there would be a bunch of people not doing as well as they used to when they had fuller services," he says, "and we knew that the last thing needed right now is for people [to show] up in droves at emergency rooms, which are not places for someone going through a rough spot mentally."
If you're not getting services, he adds, "you're truly out there by yourself these days. And, diagnosed or undiagnosed, it's endemic out there right now."
And the danger, for the most part, is not to others. It's to the mentally ill.
The vast majority of mentally ill people won't kill anyone, says Anne Ronan, an attorney with the Arizona Center for Disability Law who has worked on mental-health issues for years, even if they don't get the right help.
"They'll just have horrible lives with no jobs and no support and no love," she says.
Adds Dr. Jack Potts, a Phoenix psychiatrist, "Far, far more people who are [seriously mentally ill] are victims, not perpetrators. They become victims of others and victims, in a sense, of themselves."
The dust is settling in Tucson. The president has come and gone, folks are setting up for the annual international gem show in a couple weeks.
Not H. Clarke Romans. The longtime head of the southern Arizona office of the National Alliance for the Mentally Ill, in Tucson, has his work cut out for him, fighting the governor's latest "cost-saving" measure. Even before she'd announced her budget last week, he had his sound bites ready. By phone, he sounds like the gentlest man you'd ever hope to meet — and the angriest.
"The money's cut on a piece of paper in Phoenix, and people pound their chests about it," Romans says. "Later, down in the towns, the police and the . . . insurance companies and the hospitals and the [families] pay the price."
The cuts are hitting Pima County hard. Romans estimates that thousands of people with substance abuse and what is described as "general" mental-health problems lost services in January 2010.
But the worst, he says, came last July, when more than 3,000 seriously mentally ill people who have no more than $11,000 a year in income (that's the cutoff for qualifying for Medicaid) lost almost all their services. And this was just in Pima County.
These people still do get medical care but have no case management, meaning that no one in the system keeps track of them to ensure (as best can be done) that they are taking their medication — which is vital.
And even though many people respond well mentally only to specific brand-name medications, the state now pays only for cheaper, generic versions. If there's no generic version of your prescribed drug, tough luck.
Romans tells of a 55-year-old seriously mentally ill woman who lost her case manager last July and then fell apart. The woman "became unhinged," Romans says, when the state removed the caseworkers from the mental-health equation. He says she's been hospitalized in Tucson for 36 days, at a cost to taxpayers of about $1,200 a day.
Romans recalls the case of Joseph Molina, the paranoid schizophrenic who died on the streets of Tucson after going on a rampage that could have had a far worse end than just one death — Molina's.
Romans learned about the case after the fact.
"He'd had any number of encounters with the police years ago," Romans says, "and he eventually was sent to prison. And then when he was let out of prison, he was brought down to Tucson and told, 'See ya.'"
Yes, he says, a judge held a hearing in Molina's case, "but nobody in the public mental-health system said anything or did anything to suggest that [Molina] should maybe remain in jail or be treated or whatever. So the judge just let him go about his business."
Romans calls this the "silo treatment."
Each entity within the criminal-justice and mental-health systems, he says, is its own "silo," not really connecting with each other to try to ensure continuity of services — or even so much as keeping an eye on a troubled soul.
"I think Mr. Loughner's problem is not that dissimilar," Romans adds. "The silo of the community college, the silo of the family, the silo of the community at large — once he was out the door [suspended from Pima Community College], it was like, 'Hey, not my problem. Not my responsibility.'"
One reason, Romans says, is the continued community stigma, even today, about mental illness.
"Fifty, 60 years ago, people never said the 'C' word," he says, referring to cancer. "Now, women are running down the street throwing their bras off [in support of breast-cancer research]. With mental illness, people don't want to talk about it."
Or pay for it. Romans says his National Alliance for the Mentally Ill chapter has a program that trains teachers in elementary and middle schools to recognize the signs of mental illness in students.
But many schools refuse to sign on, he says, not wanting to pay the costs associated with implementation.
"Students with special needs [cost more] money," Romans says. "And principals — not social workers in schools, not school counselors, but the people who have to pay the bills — really do not encourage teachers to tell parents, 'I think your child has a mental illness.'"
Here's something else to consider in this already disheartening milieu:
Neal Cash is the CEO of Community Partnership-Arizona, the organization that contracts with the state to provide public mental-health services in southern Arizona. Like Romans, he's been busy talking to media from across the country, patiently explaining the need for good mental-health services.
Unlike Romans (but like the state's Laura Nelson, whose office contracts with Cash's group for services) Cash argues that there are currently enough resources. The mentally ill in Pima County are okay, he said last week. But Cash admitted he was worried about the potential that the governor would propose exactly what she proposed. He did raise doubt that the federal government would approve the waiver she'll need to make the plan financially feasible.
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Cash has worked in the mental-health field in Tucson for decades. He knows Gabby Giffords and many of her staff well. He, too, was hit hard by the tragedy, and went to see the president speak. Isn't he glad, at least, that there is finally some attention getting paid to mental-health issues?
Sure, he says. But he sees a definite downside.
"I think we can meet the demand that we currently have," Cash says. "When people start becoming more aware, that's when there's a problem."