NAMIGrading the States: A Report on America's Health Care System for Serious Mental Illness
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Grading the States 206: Alabama - Narrative

Alabama is a state trying very hard to move in the right direction, but poverty and historical bureaucratic inertia make progress slow. In the words of one advocate: "We are the 'make me' state. We do what you inspect, not what you expect."

The current status of services for people with serious mental illnesses in Alabama is inextricably linked to the case of Wyatt v. Sawyer, a class action lawsuit originally filed in 1972 that was finally settled in 2000 - more than 30 years later. As if the long, tortured history of the lawsuit isn't enough, problems facing the state also are symbolized by the fact that the majority of probate judges who hear civil commitment cases in Alabama are not lawyers and have little or no mental health training.

Aimed originally at improving conditions in Alabama state hospitals for people with mental illnesses and mental retardation, the Wyatt case also addressed community-based services. In the end, the Alabama Department of Mental Health and Mental Retardation (DMH/MR), after many years of contentiousness as the defendant in Wyatt,"committed to sustain and improve the reforms" stimulated by the decision.

Unfortunately, the settlement in Wyatt has not led to an infusion of new dollars into recovery-oriented community-based services. Thus, each county has been vested with responsibility for serving people released from the state's hospitals without additional resources to provide these services. The result has been a mixed bag at best. Left to their own resources, some counties have done well, others have not. In many parts of the state, recovery-oriented services such as employment, housing, and psychiatric rehabilitation services are non-existent.

Overall funding for mental health services has increased in recent years. However, per capita spending by the DMH/MR remains very low relative to other states, and significant gaps exist in many areas, particularly rural parts of the state.

Although conditions in Alabama's state hospitals have improved significantly, extended care and long-term care units in these hospitals are still overcrowded. These problems are compounded by the loss of an estimated 500 psychiatric beds in community hospitals.

Lack of community housing options is also a major problem. This in turn contributes to the shortage of acute and long-term inpatient beds for those who need them - because people occupying beds who are ready to move into less restrictive settings have no place to go.

To its credit, DMH/MR is engaging in efforts to increase supportive housing options. Working with the Alabama Housing Finance Authority and other housing agencies and advocates, they have developed and implemented a plan for 454 new units of housing statewide - 369 of which have already been completed. Most will be occupied by DMH/MR clients.

DMH/MR is also working with the Alabama Rural Coalition for the Homeless (CRCH) on strategies to leverage federal HUD funds to provide housing for people with serious mental illnesses and others in rural areas who are homeless—or at imminent risk of homelessness.

Despite these efforts, grave concerns exist about substandard housing conditions, particularly in unlicensed boarding homes. The county public health boards are ultimately responsible for licensing the facilities, but they report that they do not have the funding to license or conduct inspections adequately. There are also concerns about the exploitation of vulnerable consumers who are enticed to sign over monthly SSI or SSDI checks in exchange for a bed in overcrowded, substandard living quarters.

In Alabama, criminalization of people with serious mental illnesses has reached epidemic proportions. From 1992 to 2000, the Alabama Department of Corrections (ADOC) was a defendant in a class action lawsuit, Bradley v. Hightower, which revealed inhumane and unconstitutional conditions of confinement and lack of appropriate treatment for inmates with serious mental illnesses confined in adult correctional facilities. To its credit, ADOC has since invested additional staff and financial resources into more effectively and humanely addressing inmate treatment needs. However, prisons are never optimally therapeutic environments for people with serious mental illnesses. 

A multi-stakeholder effort that includes DMH/MR and NAMI Alabama is engaged in efforts to promote jail diversion and more effective community re-entry services for people with serious mental illnesses leaving prisons. Three statewide criminal justice/mental health consensus conferences have been held in recent years. A number of jail diversion programs have been established or are in the planning phase, including CIT programs in Tuscaloosa and Birmingham and mental health courts in Birmingham and Montgomery. The police department in the rural Northern Alabama community of Florence employs a community service officer who has received extensive training about mental illness and is the second responder to most calls received involving mental illness.

The state has taken positive steps in certain psychiatric treatment facilities to reduce the use of restraints and seclusion. Remarkably, the Taylor Hardin Secure Medical Facility, which serves exclusively forensic patients, has been so successful in training its staff on crisis de-escalation techniques that the use of restraints and seclusion has been virtually eliminated - so much so that in 2004, NAMI's National Consumer Council gave a special award to the facility and its director, Mr. James Reddoch, J.D., for exemplary leadership in reducing the use of restraints and seclusion and humane treatment of residents.

DMH/MR has also reached out in a progressive way to the deaf community, including training a number of interpreters on how to respond effectively to individuals with serious mental illness who are deaf. The agency also is pursuing JCAHO accreditation of all seven of Alabama's state psychiatric hospitals.

Alabama is a state with good intentions, and there are a number of positive initiatives underway to improve services for people with serious mental illnesses. However, the recent settlement of the Wyatt case is just a start towards the goal of developing a comprehensive community-based system for people with serious mental illnesses. Resources must be increased and good will translated into good practices if this goal is to be attained.

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