A Court of Refuge Read online

  The consent decree I had been hired to monitor focused on the discharge planning process. As plaintiff’s monitor, I spent my days at the state hospital meeting with class members, reviewing care plans, and attending discharge planning meetings. Each day when I arrived, the first thing I did was check to see if anyone had been added to the discharge planning list. If so, I would visit that person to introduce myself, review the person’s rights under the consent decree, and begin to engage in that individual’s care plan and discharge planning process. My other key duties involved following clients into the community upon their discharge from the state hospital to evaluate the quality or the lack of quality of the discharge plans and then report back to senior counsel at Southern Legal Counsel, Alice K. Nelson.

  The suit sought relief from the court for civil rights violations. Allegations included the type of maltreatment and indignities shown in films such as the 1948 film The Snake Pit and in Life magazine’s groundbreaking exposé on the abuse of psychiatric patients, “Bedlam 1946—Most US Mental Hospitals Are a Shame and Disgrace.” This article documented the beatings and murders of more than 400,000 psychiatric patients who were confined in 180 psychiatric state hospitals throughout the United States.2 Sanbourne v. Chiles contained allegations of wide-ranging abuse and neglect at the South Florida State Hospital. These allegations included “a lack of rehabilitation and complete lack of privacy and control over the most basic and routine aspects of life.”3 More specifically, plaintiffs cited group nakedness and a failure to provide personal clothing; instead, “communal clothing” was distributed by staff daily.4 Additional allegations included that the conditions of the physical plant of the hospital were intolerable, staff abuse was rampant, and a lack of basic dental care consigned the plaintiffs to a considerable amount of unnecessary discomfort.5 Susan Curran, a hospital surveyor who testified on behalf of the Advocacy Center for Persons with Disabilities, was quoted in the Palm Beach Post as saying, “We broke down and cried at what we saw.”6

  When it came to Seth, I don’t know which specific conditions he experienced in the state hospital. He entered the system as an adolescent, and despite the love and support of his family, who tried to make the experience as positive as it could be, he struggled. I can only imagine what life inside the state hospital must have been like. His unit was one among many on a campus consisting of military-style barracks and minimal landscaping. Inside these residential barracks, long, winding corridors amplified noise. Seth’s days, in his unit, would have been filled with the sounds of screams from other unit tenants in an unchanging landscape of gray. He never attended a typical school, went to a prom or homecoming dance, played sports, or joined a debate team. He never learned to drive.

  Even with the loving support of his family, Seth experienced a kind of life that I cannot imagine.

  When I joined the Advocacy Center, the parties had already been working for several years to improve conditions at the state hospital. These negotiations were in accordance with the earlier ruling of the US District Court, Southern District, Miami, to work toward resolving the problems and settling the lawsuit. The negotiations involved the court’s 1991 ruling on the plaintiff’s motion for summary judgment.7 At the same time, members of the Florida legislature moved to close the state hospital, in order to limit the liability of the state for the maltreatment uncovered by the suit.8

  The conflation of these events led the state to make significant improvements at the state hospital and to undertake efforts to move reforms toward a community-based system of care. In exchange for a consent decree between parties settled in 1993 the state pledged to infuse the state hospital catchment areas with substantial funding to enhance community-based resources for mental health.

  This left two questions for class members and the community: Would legislative funding be sufficient to drive transformational change of South Florida’s beleaguered mental health system? And what would happen to Sanbourne class members in the meantime?

  On February 5, 1963, President John F. Kennedy addressed Congress in support of what would be a series of legislative measures known as the Community Mental Health Act.9 In a special message to the Congress, President Kennedy shared his transformative vision to shift the nation away from its reliance upon an antiquated and dangerous system of state institutions and hospitals to care for and house those with mental illness.10 At the time, nearly eight hundred thousand patients were confined in mental hospitals, six hundred thousand for mental health problems and two hundred thousand for mental retardation. These were people with disabilities who, in Kennedy’s words, “have been kept out of sight and forgotten.”11 Kennedy had a special interest in ushering in a new era in mental health having had a sister, Rosemary, who had intellectual disabilities and lived in a private institution for much of her adult life.

  President Kennedy spoke of a “troubled national conscience” and a moral urgency for Congress to address this public health crisis.12 While Kennedy expressed appreciation for states’ efforts to improve the conditions of state institutions, he recognized the need for the federal government to bring its resources and energies to bear on the problem. He called for all levels of government and the private sector to share in taking responsibility to improve health in the areas of mental health and mental retardation.

  Citing research findings pertaining to the need to develop a new systemic approach to healthcare, Kennedy relied upon a study by the Joint Commission on Mental Illness and Health and its final report, which appeared in 1961.13 He noted key facts illustrating the urgent need for Congress to support his proposals:

  Nearly one-fifth of the 279 state mental institutions are fire hazards; three-quarters of them were built prior to World War I.

  Nearly half of the 530,000 patients in our state mental hospitals are in institutions with over 3,000 patients, where individual care is virtually impossible.

  Many of the institutions have less than half the professional staff required—less than 1 psychiatrist for every 360 patients.

  Forty-five percent of the inmates have been hospitalized continuously for ten years or more.

  The president referred to the positive research and recommendations of the commission, which pointed to a new trend in mental health care and rehabilitation: the use of new drugs and “a growing public awareness” about mental illness and community-based care.14

  Kennedy’s visionary blueprint was consistent with the recommendations of the commission, which envisioned a mental-health-care system focused on prevention that would include a broad range of treatment and restorative programmatic services such as community mental health centers, psychiatric beds, day-care respite centers, crisis services, and other community facilities to provide treatment and rehabilitative services in the “open warmth of community.”15 The president’s goal was to shift patients into local mental health centers, reduce the state hospitals’ population by 50 percent, and ultimately eliminate the need for most state hospitals.16 On October 31, 1963, Kennedy signed into law the Mental Retardation and Community Mental Health Centers Construction Act, more commonly known as the Community Mental Health Act.17 It would his last legislative action before his death.

  By the 1990s, the failings of the deinstitutionalization movement were evident. The Florida legislature pledged a significant infusion of funds, about $25 million, for community-based services to support the downsizing of the state hospital. Yet for Seth and thousands of residents residing in state hospitals across the nation, the hospital that was failing them was the only home they knew.18

  My duties as plaintiff’s monitor were complex and often contentious, as my role pitted me against the State of Florida. I advocated on behalf of my clients who had been discharged from the state hospital to the community. My jurisdiction was six feeder counties across the southern half of the state. Soon after I was appointed to the position, I started to question the effectiveness of my advocacy. The more I built positive relationships with state hospital employees, the more
tensions with the state seemed to intensify. On the positive side, the state legislature allocated about $20 million to the provision of community resources for mental health patients, which led to the development of Florida’s first assertive community treatment teams (interdisciplinary teams of case managers and psychiatric clinical staff), a mobile crisis unit, the first consumer drop-in centers, and other community-based resources. But supportive housing and residential programming were still in short supply. Class members may have been linked to psychosocial programs, but housing options were limited and marginal. Many Sanbourne class members were discharged to non-therapeutic group homes and assisted-living facilities.

  In time, I decided that I might be more effective in a judicial role and left my position as plaintiff’s monitor to run for an open judicial seat. I was elected in 1996.

  Seth had burned many bridges while a patient at the state hospital. He was constantly “redirected” by staff, meaning that they attempted to manage his behavior from inappropriate to appropriate through various therapeutic strategies. He obsessively repeated various self-injurious behaviors, so it was difficult for Seth to make advances in his rehabilitation. No one at the time could imagine that Seth would one day inspire “the Seth line,” an alternative to a crisis line, staffed by trained consumers who listen to callers’ concerns and provide support and advice on a peer-to-peer basis.

  As I began to deal with Seth’s case, I speculated that he was probably one of the last residents to be discharged from the state hospital in the 1990s. He had been institutionalized as an adolescent in the early to mid-seventies, when his intellectual disabilities and behavioral disorders became severe enough to require constant supervision. Hospital staff had significant concerns regarding his capacity for self-harm. His deep behavioral problems led to many staffing issues, as frustration on his unit ran high.

  Yet here he was in court, a middle-aged man now, looking much more mature and different then I remembered him.

  “Judge Ginger,” Seth called out happily, “it’s good to see you!” Seth was always so excited to come to court: here, he had conversations with people, and he was asked about his life. It was a stark difference from what he experienced in the hospital. Yet after a moment, his jubilant smile faded. Perhaps thinking he had said too much or was too enthusiastic, his face now reflected anxiety as he began to stammer, “I’m sorry—I’m sorry,” repeating this in an anxious, high tone.

  “It’s OK, Seth,” I replied. “I’m happy to see you, too.”

  Standing next to him, looking more like a protective big brother than a mental health advocate, was Jack Kuhn, his former case manager at the Henderson Behavioral Health Center. Today, Jack would serve as Seth’s housing coach and residential administrator.

  Jack was one of my mentors when I began my position as plaintiff’s monitor with the Advocacy Center. He was the first community case manager I met at the state hospital. Our initial conversation back then, which occurred as we stood next to a large round garbage can in the hospital courtyard, led to years of friendship.

  Jack came from a large family in Nashville, Tennessee. He was smart and could have chosen any profession, but he wanted to be a social worker. It was a vocation that, he said, “my father did not appreciate or support.”

  Jack retired from Henderson after the death of his father, a Nashville businessman, who profited from the sale of his family’s Big K chain of discount stores to Sam Walton of Walmart.19 Turning to philanthropy, Jack fulfilled his lifelong dream when he launched Simple Dreams, a foundation whose mission was to provide housing for mental health consumers.

  At the time, Jack was an intensive community case manager, and I was new to the job of plaintiff’s monitor. There were so many facets to this role, but the first order of business for me was to understand the fundamentals of discharge planning from a community level. Jack generously offered to allow me to shadow him during community visits. This experience was profoundly important because Jack taught me the essential principles of person-centered psychiatric rehabilitation based on data-driven research from Boston University’s Center for Psychiatric Rehabilitation. These principles were being applied at South Florida State Hospital and in the community to foster a person-centered and psychosocial culture across Broward County’s system of mental health care.20 Working with Jack, I learned how important it is to develop positive relationships with community-based case managers and hospital-based discharge planners when collaborating and negotiating for scarce resources on behalf of your clients, people like Seth, who wanted to experience his “simple dream” of residing in the warmth of the community.

  “Judge, I wanted to let you know that Seth is doing very well,” Jack said.

  Jack knew Seth and his parents, Chuck and Gayle Staumbach, a delightful couple who have been mental health advocates in Broward County since the mid-1970s, when Seth had been committed to South Florida State Hospital as a teenager. Warm and eager to support other families, the Staumbachs worked closely with the Mental Health Association of Southeast Florida. A local Broward affiliate of Mental Health America, the Mental Health Association of Southeast Florida was chartered in 1957 and is still dedicated to promoting mental health through education, prevention, research, and advocacy.

  I now learned the reason for Seth’s appearance in my courtroom. Apparently, he had been arrested for stealing some snacks from a local convenience store, an incident that, Jack stated, “he was already on top of.”

  “I want you to know what steps Seth and I have taken to ensure that something like this does not happen again,” Jack said.

  In a conventional criminal court setting, I would not permit an attorney or any person to discuss the facts of a case. As the presiding judge, I advise defendants not to comment about their cases. This advice is meant to protect their constitutional right to remain silent and to prevent them from saying anything that could be used against them, should their case proceed to trial. Because I knew that there was no reasonable likelihood that Seth’s case would proceed to trial, I allowed Jack’s comments. Further, I recognized that Jack was speaking about psychiatric rehabilitative strategies, which Seth had already agreed to. I agreed that sharing these steps with the court would be therapeutic for Seth and put him more at ease with court process.

  “Go on, Mr. Kuhn,” I said, now intrigued about what kind of creative steps Jack had implemented to keep Seth safe to and prevent further behaviors that could get Seth arrested again.

  “Well, Judge,” Jack began, “I realize that although Seth spent many years at the hospital, he likes people and enjoys being independent.” He spoke like a college professor delivering a lecture to a class of social work students. He continued: “Seth has opened a small bank account, and I am working with him to establish a weekly budget. Seth receives a certain amount of money each month, and this experience has taught him how much money he has allocated for food and snacks. In fact, we took a walk to the community store where this situation occurred to meet with the manager.”

  Jack continued, with a giant grin on his face, knowing full well that I would be impressed with the new and improved case management plan that had already been implemented. “Seth and I had a meeting with the general manager and we discussed Seth’s goals to become more independent in the community. I gave the store manager my card and let him know that Seth is only permitted to come to the store with a shopping buddy who will ensure he has the correct amount of money with him.”

  “That sounds like a sensible and responsible plan,” I said.

  The state attorney, who had been listening silently, chimed in. “Judge, I agree with you that Mr. Kuhn sounds like he is overseeing his client very well, but I suggest we follow Mr. Staumbach in the court, to ensure he is following his case management plan.” This meant that the court would monitor Seth through a series of review hearings in order to monitor his case management plan and his compliance to treatment and its effectiveness, to troubleshoot problems proactively, and to oversee
the accountability of his community-based treatment provider.

  Janis agreed that given Seth’s history of behavioral challenges it would be helpful for him to be followed by the court. “It would bolster his behavioral plan in the community and give him more opportunity to socialize and be around people,” she said.

  Janis had spoken with Jack prior to the hearing and was advised that Seth was not interested in attending a day treatment program focused on mental health. Janis did not want Seth to become isolated. “He needs to connect with people,” she said.

  Seth agreed. “I would like to stay in the court—and my parents wanted me to say hello because they could not come with me today.” Seth’s participation in the mental health court was voluntary, and he was stating his desire to continue his participation.

  I smiled at him, accepting the greeting Seth had relayed to me. “You know, Seth,” I said, “in a few months the court is holding its fifth anniversary celebration and ‘Triumph Awards’ luncheon. I would love to have you as one of our honorees.”

  Attorney General Janet Reno would be our special guest. I wasn’t sure Seth knew who Janet Reno was, but it was a great honor to have her there. During her time as US attorney general Reno dispatched several high-ranking members of her office to observe the Broward County Mental Health Court. The following year, Attorney General Reno identified Broward’s court as an emerging best practice.21 As a former Miami-Dade County state attorney, Janet Reno pioneered the first drug court in 1989.22 She was a great advocate of court innovation and problem-solving treatment courts.

  Janet Reno took office as Miami-Dade County state attorney in 1978. While speaking to an audience of drug court professionals, nearly a decade after Miami launched America’s first drug court, Reno described how she watched as the criminal justice system in Miami-Dade County became “swamped” by cases involving people being arrested for possessing “small amounts” of drugs and then larger amounts of drugs, where first-time offenders entered a revolving door of arrests due to drug addiction.23 She realized that alternatives to incarceration must include drug treatment, but saw a system that offered no interventions. On March 24, 1998, at a conference in Washington, DC, Reno stated, “When I first took office, in 1978, people did not believe in treatment. And I could not understand why. But I quickly learned that unless we made treatment an effective alternative to incarceration, we were never going to build our way out of the problem.”24