Tag Archives: Zelia Baugh

Letter from Bazelon: Alabama’s Mental Health Funding Crisis

Interesting letter to Governor Bentley from the Bazelon people.  This is the law firm involved in the Wyatt vs. Stickney case– if you don’t know about that, there is some good background on it by Dr. Fuller Torrey’s group.  It is the lawsuit that resulted in the tragic consequences of deinstitutionalization in prior decades– the burgeoning population of homeless mentally ill, the dumping of sick people into prisons, and the loss of sick persons to suicide.  It was intended by some involved to force hospitals into better standards of treatment, not to abandon patients entirely– but the consequences were disastrous.

The letter is a clear threat that if Alabama doesn’t fund our mental health, we are about to get sued– again.  Bazelon says Bentley should apply all the funds initially intended for Bryce to use for transitional planning and they seem to think this will be enough.  I am uncertain of that– we need not only funds for transition, including capital costs and training of new personnel, but also for the ongoing expenses of our current and future services.  Using one-time funds may not cut it– we won’t know until DMH releases a clear plan and estimated expense.

Bazelon’s insistance on closing all the hospitals may be misguided– the Olmstead decision says that we should place people in the least restrictive setting possible, and to integrate them into the community if it can be done.  Some people are too sick to make it in the community, no matter how hard we try, until we have a real cure.  More will be intermittently very sick, since relapses happen even while on previously effective medicine, and they must have a secure, safe place to get treatment.  It is possible we could replace the hospital with local crisis stabilization units– we should be open-minded– but they would have to have capacity to keep people until they are REALLY ready for a lower level of care.  Here’s a brief breakdown of what Olmstead requires and does not require, from Iowa– note that it does NOT require all hospitals to be closed!  It just says that people can’t be kept in the hospital longer than they need to be there, if it is possible to serve them in a community setting.  The pitfalls of over-reliance on community settings are severe.  Bazelon is hurting us by over-interpreting Olmstead.

Bazelon has an ulterior motive that conflicts with reality.  They do not believe in commitment, even to outpatient care– they think all patients with mental illness should be left to their own devices unless they are right about to kill someone.  The reality this conflicts with?  There is a well-studied phenomenon in serious mental illness called anosognosia.  People who have this are incapable of understanding that they are sick or need treatment, the same way as some people after a stroke will not be able to believe they have a left arm.  It is part of the illness itself.  Real advocates for loved ones with mental illness have a more realistic approach.  We are definitely not in favor of restrictive setttings when they are unneeded, and we fight for the inclusion of patients in making their treatment decisions whenever possible.  We want our loved ones to be as independent as they can be and to have fulfilling lives.  None of that is possible if they die from suicide or undergo permanent brain damage as a result of inadequately treated illness.

Torrey’s site has a good explanation of why we need approximately 50 hospital beds for each 100,000 population (same as my prior estimate of 140 beds needed for Madison County alone) and a list of capacities per state– notice Alabama is far short.

Bentley and Baugh have promised that they will not close the hospitals until local infrastructure is ready.  If they keep that promise, the transition could go well.  The reason many of us are not reassured by their words is many-fold.  There have been multiple and rapidly changing plans issued from DMH since February, so we are uncertain anything they say is going to remain in place.  They have not yet told us how they will pay for it or how they will apply the 2012 proration to DMH without hurting outpatient services.  At our regional meeting last week, we were told that DMH couldn’t guarantee a timeline because it depended on funding– which is in direct conflict with saying the timeline depends on having infrastructure prepared.

The threat of lawsuit may be the only thing that saves our mental health system.  Will Bazelon be just as ready to sue on behalf of those who become homeless or commit suicide because they have inadequate care as they are to sue for what they consider excessively restrictive care?  Don’t hold your breath.

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Filed under Alabama legislative session 2012, mental health, Uncategorized

Notes from Region I DMH Meeting

Notes from Region I DMH meeting, March 23, 2012, Huntsville Main Public Library, 10 am to 1 pm

 (This may be of interest to those of you who are preparing for mental health cuts, but I am mainly posting it here so local Alabama advocates can review.  DMH= Alabama Department of Mental Health, NARH is North Alabama Regional Hospital.  As I’ve posted previously, the state is preparing to close all the large regional psychiatric hospitals except for criminally committed and geriatric, and move care into the communities.  However, the communities are not ready.   This was the last in a series of regional meetings around the state between DMH representatives and what they call “stakeholders”– family members, consumers, service providers, law enforcement, etc.  It was a LONG meeting).

My general impression/opinion:  DMH came planning to reassure us and give some broad platitudes.  Long on “philosophy” and short on facts.  Peacock told the press she expected us to leave feeling “more open-minded”.  We quickly uncovered that they have NO IDEA what they are going to do—not reassuring at all.  They do not even have an estimated cost analysis or desired timeline.  They are saying that the regional facilities won’t close until local capacity is in place, but in the next breath, they can’t give a timeline because it depends on proration.  So the truth is, they don’t even know if they will be ready before they are forced to close the hospitals because they can’t pay to run them.


Lots of use of “I agree” and “I feel your frustration” but the group was not taken in by these therapy tactics.  I suspected the questioners were more well-informed than they expected.


I do not think it is DMH’s fault that the legislature is not funding adequately, but I am very frustrated that they are not following the example of other state agencies and being clear that they can’t cover services without $.  They owe us the duty of presenting a clear budget need to the Legislature and a clear time-frame for transition, whether the government provides that needed money or not.  They need to be clear in saying what the consequences of inadequate funding will be. It is unacceptable for them to be so passive in this circumstance.


Fortunately, the press did read the release and talking points I sent in advance and were quite pointed in their reporting—they could definitely tell that DMH was not providing the answers we requested.  We also did a 1 hr sign protest in the pouring rain beforehand—made for some great TV footage.



Dr. Tammy Peacock began with introductory remarks/ background.  Said Commissioner Zelia Baugh had planned to come but was in a finance meeting discussing plans to deal with proration.  They do not know how they are going to deal with the 10.6 proration (21.2% cut in next 6 months). Discussed anticipated 29 million dollar cut in DMH budget for 2013.  Said hospital budgets had already been cut as far as possible and that even closing only 2 of them would not be enough to cover a 29 million $ gap.  Said other reason to close hospitals is that the Department of Justice is enforcing Olmstead ruling, which says that individuals with mental illness have the right to live in the most integrated setting they are capable of.


Peacock said no one had been comfortable with the October 1 timeline.  They are still not certain of where funding to create the new community infrastructure will come from.  They plan to overlay mobile crisis teams onto local MHC services, work toward tele-psychiatry 24-7, and leverage more federal dollars.  They are not sure of plans for long term care of the most seriously mentally ill.  They are currently talking to other states and federal agencies to get ideas.  It is “not our intention to shift the financial responsibility to the local level.”


Peacock said the timeline is extended but they don’t know by how much.   She then opened the floor to questions.


Questions/ Comments from floor (my occasionally snarky editorial comments in italics, and interchanges that seemed particularly significant to me in bold– I may have missed some, was writing furiously—please fill in if you notice a gap):



Q:  If consumers were required to clean their facilities themselves, how much money would that save?  (Really, someone said this—I almost fell out of my chair. Fortunately, it got better)

A:  Consumers would need to be compensated fairly for any work they did


Q: Isn’t it a short-term solution to become dependent on federal $?  And the questioner can’t tell when her relative with SMI is stopping meds—he would be capable of killing somebody if off them.

A: Most consumers would be able to live in their homes but some could go to supported housing.  They have been in meetings with HUD.  They will need ACT teams and PACT teams (a larger team) for the most seriously ill.  (Did not answer the question about federal $).


F/U Q: But if my relative refuses treatment the PACT team can’t force him, right?

A: No, they can’t


Comment: HUD housing is in bad neighborhoods where people prey on mentally ill.

A: This is not about us saving money—reality is that we have 29 million less to spend. (not an answer)


Comment:  Concern that outpatient commitment law has no teeth and needs to be revamped. 

A: There will be inpatient care through “different means”.  Alabama just hasn’t been sued “yet” because of restrictive care. (doesn’t seem like an answer)


Q: Is the state prepared to help local hospitals become designated facilities?

A: Contact your local MHC


Comment (mine):  I disagree that we have too many people in restrictive care and are at risk under Olmstead.  For Madison County alone, if 1.1% of adults over 18 have schizophrenia, national statistics say 5% should be in the hospital at a given time.  That would be 140 at NARH for our county alone, just for schizophrenia.  We have fewer served by the hospital and group homes than should be there, not more—what we need is MORE community services in addition to crisis and group home services.  Told briefly about son’s experience with commitments and difficulty getting community services.  Said that without adequate services at every level, people would cycle through repeatedly and each time they had a bad relapse, they could suffer permanent damage.

Answer:  I agree but we don’t have the money  (that was all she said.  To me, that says she knows good and well that this Olmstead bit is blowing smoke.)


Q: Can you elaborate on the timeline for hospital closings?

A:  The Commissioner is working with the Governor and hopes to announce next week.  We are not going to close the hospitals until communities have identified local beds.  Says there has never been a July deadline at NARH (for stopping new civil commitment admissions) and doesn’t know where we heard that.


Comment:  A son has been committed 4x for mania but in between is fine.  Risk of being hurt/ arrested when manic.  Takes 3 to 4 weeks before safe out of a confined place.


Comment: Our Place (drop in center in Huntsville) needs more $ for peer-led services


Q: If Judge says a person is committed to the hospital, where will they go if no hospital?

A: No closings until we have local beds

Q: Where is the funding for new facilities coming from?

A: We aren’t going to put the bulk of our money into bricks and mortar.  There will be “repurposing” of existing structures.  We can’t do it without bridge $. (basically, they don’t know)


Comment:  The cost of renovation is high—must do expensive items like replacing window glass, etc, not cheap

A: I agree


Comment:  “It sounds like you’ve decided to sell us out”

A: That’s not my perspective


Comment:  We need more research and funding to find early treatment for SMI


Comment:  Concern about consumers who will be discharged too soon because they have learned what to say—doesn’t think ACT/ PACT teams maintain outpatient control without offending constitutional rights


Comment:  the community is uneasy because of how the information was released.  People don’t have enough info, being given conflicting information, changing info–  DMH should have given better/ more complete info

A: I agree.  Hard to be definitive when we don’t know


Q: Why didn’t DMH prepare for this earlier—they knew the budget situation was coming long before now

A: “It isn’t cost-cutting—nobody has $” (how is this an answer?)


Comment from consumer:  NARH helped me tremendously

A: Closure is on hold until access at community level


Q: What is the probable time of hospital closure?

A: We don’t know—it depends on proration and funding.   MHC’s have been asked to give a plan for what they need.  There is a philosophical change to move to community care. (Philosophy, Shmilosophy… give us some facts)


Q (me): How much time and money do you actually NEED to do this right?

A: Can’t answer—“we can’t control the process”  “we don’t make a wish budget”


Q: Is there a 5 year plan for how to evaluate/ monitor this transition?

A:  Didn’t answer.  Just said they would get feedback from MHC’s.


Q: Is there a plan to meet individually with MHC’s?

A: We have been meeting collectively, and some individual meetings are in process


Q: Can local hospitals serve as crisis stabilization and will $ be available to them?

A: talk to your MHC


Comment:  Georgia did a similar transition to community care, and it was fine until patients decompensated and they did not have enough places to send them.  Became a revolving door system.

A: Isn’t it already a revolving door system? (Wow—she really said that.  How is that a helpful answer?)


Q: Have you pressured the fed govt for $?

A: Commissioner hasn’t asked yet, doesn’t know how many housing vouchers needed, “a lot of data hasn’t been gathered”


Comment: Real stakeholders have not been brought into this process.  Crisis houses have failed in other states

A: They have applied for housing grants (first, doesn’t answer the question—second, seems to conflict with answer above but I may be misunderstanding)


Comment:  Illinois closed a hospital in one area to rely on community services, then closed community services, and now churches are doing a rotation to care for the mentally ill (I have not seen this in print)


Q: Have you coordinated with the Sherrif’s Depts, State Police to find out needs?

A: Not sure.  Did meet with Probate Court committee


Q: What about Deaf?  Are interpreters in plan?  Commenter noted that her local hospital was often not staffed to assist her 24-7.

A:   Possible regional capacity. Haven’t figured it out (Note—there was a Sign interpreter present)


Q:  The responsibilities of the Community Mental Health centers are increasing—how will we fund all this?

A: Never underestimate the power of your vote.  (By this point, I think she realized we were serious)


Q: How will the MHC’s handle the 10.6% proration and handle new administrative responsibilities to develop these plans? 

A: “No one has told the MHC’s they will have a 10.6% cut”.  (umm… you said earlier that the hospitals could not be cut further at 25% cut—this will be a 21.6% cut over the rest of the fiscal year—how could it NOT come down on the MHC’s? Is there some secret department we don’t know about?)


Comment:  You can’t answer our questions and can’t give us a plan.  You haven’t done a cost-benefit analysis.

A: I understand your frustration


Comment:  State has been trying to get out of hospital business for years.  ECM (Eliza Coffee Memorial) hospital is limited to short term only.  Communities have trouble keeping psychiatrists to staff local hospitals.  How many on the planning committee are probate judges, family and consumers? 90% of commitments are recycled. (I didn’t hear the answer, sorry)


Comment: People get bumped from group homes to communities and then their families bear the burden.


Comment:  It doesn’t just take resources to begin this project but resources to sustain it.


We broke into groups and discussed our needs, then reported back.  I could not see the written lists of the other groups, but the verbal reports were very general—just basically needing peer support, law enforcement training/ support, more community capacity.


Madison County MHC group requested a long list of items by process of brainstorming, which I have because I was in that group.  Note that Brian Davis, who has spoken to us about his own perspective previously, gave us a chance to tell HIM what we think we need.  Thanks, Brian!  I don’t know if the other groups did it that way.


1) 60 additional group home beds in addition to present capacity

2) 100 more supervised apartments and $ for setup/ furniture, etc

3) Ability to use larger than 3 bed homes if necessary for economy of scale

4) Private rooms in the group homes, for consumers who relapse from stress of no privacy

5) A mobile psychiatrist available 24-7

6) More peer support, another drop-in center

7) Young adult Peer Support and transitional support

8) Maintain current services at Huntsville Hospital

9) Consumer classes for communication skills/ assertiveness

10) A crisis stabilization unit ready before NARH closes

11) More timely access to appointments at MHC

12) Recruit/ hire more psychiatrists

13) Try to get some of the oil money for infrastructure

14) Respite beds for short term care, if family needs to be out of town or are ill

15) Flexibility in policies about who needs therapy and med monitoring

16) Mixed opinions on tele-psychiatry—some in favor, some worried about pinning too many hopes on it

17) More services for autism/ Asperger’s

18) DMH needs to tell the Governor and Legislature how much $ they NEED and not just take what they get

19) Transportation for consumers

20) More family members involved at DMH level in planning

21) More local planning sessions/ communication.  Don’t call the meetings “stakeholder” meetings—should be town hall/ forums and should be well-publicized.  The whole community is affected

22) More commitment from local government to be involved

23) Increase the skill level of MHC therapists

24) Some remaining capacity in the state for long-term hospitalization


Filed under Alabama legislative session 2012, mental health

Alabama’s Budget Canary: Funding the Department of Mental Health

As you know, our state is woefully short of the amount it takes to carry out our basic functions, and legislators have been acting like teenagers about it—shrugging their shoulders, rolling their eyes and saying “oh well!”’.  Many of the shortfalls will not show up in immediate damage.  Inadequately funded schools will result in a poorly prepared workforce, and proration to universities will eventually limit quality to the point our students invest tuition money elsewhere.  Loss of support for Medicaid and AllKids could result in poorer child health (and yes, even death from conditions not treated in time), but this could take months to show up.


The delayed nature of these consequences allows legislators to get away with it, for awhile.  One program on their hit list, the Department of Mental Health (DMH), could prove the exception to that rule. 


Our DMH funds three basic divisions—Developmental Disabilities (formerly called mental retardation), Substance Abuse, and Mental Illness.  In the planned budget, mental illnesses will take the entire cut to the department.  I am told that this is likely because the opposition to cuts for developmental disabilities would be too heavy, in the form of service mandates, lobbying groups, and potential lawsuits.  Addiction treatment is so minimally funded that there is nothing left to cut anyway.  So that leaves mental illness.


I would not want to be Zelia Baugh, our state’s mental health commissioner.  She has an impossible task.  The DMH pays out funds two ways, for operations, including at state owned facilities serving those who are committed by probate courts or criminally committed, and for contracted services by county mental health centers (MHCs).  The MHC’s also bring in money from private insurance payments and sliding scale payments by patients, but they are heavily dependent on the DMH money.


Baugh had a choice between cutting payment to the MHCs, already running on less than they need, and cutting payment to the state facilities, also underfunded, or both.  If she had cut MHC money, the centers would have had to let large numbers of staff go.  Patients would have to wait significantly longer than they already do, and for some of the most fragile patients who had barely been managing in the outpatient setting, the loss of access would have caused rapid increase of hospitalization and civil commitment.


The state facilities probably could not have been funded less and still stayed in operation.  So Baugh, under the gun, decided the only option was to close the state facilities almost completely.  The patients formerly at Taylor Hardin, for the criminally committed, will move to the new Bryce.  Mary Starke Harper in Tuscaloosa, the hospital for geriatric patients, will remain open because it is funded with Medicare money.  Everything else will close.


DMH plans to transfer care of committed patients to local facilities, as part of an overall strategy to integrate persons with SMI into their communities.  This could be a great plan for many patients, but for some it is unrealistic—I’ll cover the “philosophy” aspect in a later post.  So where are these local facilities?


Ah, there’s the rub!  There are no such creatures.  All over the state, MHC’s are scrambling to figure out what to do.  I am the secretary of our Huntsville chapter of NAMI (National Alliance on Mental Illness)—NAMI is an advocacy and support organization for families of persons with SMI.  We are not opposed to more community care.  We just want to be sure it gets done correctly.

 I met with Brian Davis, the director of the Madison County MHC, along with several NAMI members and board members, this past Thursday evening.  Brian kindly spent 1.5 hours answering our questions and explaining what our MHC is trying to do.  I’ll cover other community services later, but for patients newly committed to hospital care, he has asked for funding to run a 16 bed crisis unit (more than 16 beds would disqualify them from billing Medicaid).  If the adjacent counties also get the beds they’ve requested, there will be an equal or greater capacity than we previously had at NARH for our area.


He has submitted a budget request to DMH, but unfortunately he will not have any real idea of the planned funding for several weeks.  The state hospital in our area, North Alabama Regional Hospital, is projected to close along with the others at the end of September (because of the fiscal year), and that would be hard enough—but NARH plans to close to new civil commitments as of July 1.  That means he must locate a suitable building, renovate it, staff it, and be ready to go in less than 4 months.  He can’t start until he knows about the money, so make that less than 3 months.


To compound matters, he expects DMH money to only apply to operations for the crisis unit—it won’t cover capital.  So he will have to get a loan for our MHC.  He will have to locate a suitable building (not time to actually do new construction), purchase it in the face of the usual NIMBY outcry, and do extensive renovations.  Patients aren’t committed here unless they are considered a real threat to themselves or others—that means he will have to replace all the window glass and install “crash bars.”  He will have to get safe furnishings.  Even details like the showers have to be right—otherwise patients could hang themselves on the shower bars.


Are you getting the picture?  Do you think there is any way in heck all these tasks can be completed by July 1, or even September 30?  I sure don’t.


I asked Brian what it would take to do this right.  He told us he would need twice the expected money and three times the time.  If he had that, he said, he could do a GOOD job for us, and the outcome would be improved services for persons with SMI.  Money buys time, so that’s our first priority.


Back to the consequences of failing to be ready for this transition.  It might help to look at other states that cut services.  It is a grim picture.  Most mentally ill patients who kill or hurt people target themselves, not others—we can expect an immediate increase in death by suicide.  For those who do attack others, it is usually a care-giving family member who gets hurt or killed—the same family members struggling desperately to make up the gap in state services.  Speaking as one of these family members, I can tell you I am more afraid of what the state would likely do to my loved one—execution—than I am of dying myself.  But given the high frequency of SMI, we should also anticipate the rarer public violence to increase. 


We will pay, one way or the other—in money or in death.


I know I’ve asked for a lot of action on your part this year.  I hate to constantly have to tell you the sky is about to fall or that the alert level is red!  But it’s just that way.  You, my friends, are holding up our sky. 


Many of our fellow Alabamians with SMI can do well with proper treatment, but their mental health is very, very fragile.  A disruption in service can send an apparently stable person over the edge in a matter of days.  We will see disaster not in years, as for education, or months, as for Medicaid, but DAYS.  I’m not saying we should pass the planned cuts to those other programs—we should not.  We should tell our legislators to do their jobs and come up with the money, no matter what campaign pledges they have to break.  Otherwise Alabama will go down like the Titanic, with our statehouse playing the no-taxes violin on deck while we prepare to drown.


Your efforts so far have been productive.  The sneaky planned privatization of Medicaid, initially termed a “done deal”, has at least for now been slowed down.  The attack on women’s health services in the form of SB 12 has been met with such loud public outcry that the bill sponsor is backing down.  Keep pressure on—it works!  Tell our legislature to give the MHC’s money so they can buy time to do this right.  I’ll post a separate list of talking points for my county—please help NAMI Alabama add to it by investigating plans in your area.


Efforts are already in place by NAMI chapters in our state and NAMI Alabama, but family members burdened with providing in-the-trenches care to their loved ones can’t do it alone.  We are all affected by the mental health of our state.  Get in there and fight with us, shoulder to shoulder! 


Filed under Alabama legislative session 2012, citizen responsibility, mental health