From Shoddy Hospitals to Shoddy Houses!

The main reason why I wrote CRAZY was to expose how thousands of persons with severe mental illnesses are being locked-up in jails and prisons because of inadequate community services and laws that require a person to be dangerous before they can be helped.

To me, the incarceration of persons whose only real crime is that they have become ill is a national scandal.

Of course, not everyone with a severe mental disorder in Miami, where I did my research, ended up in jail. When I did my investigation, there were 4,500 persons with severe mental disorders living in 650 boarding homes, called Assisted Living Facilities.  At one time, most of these folks would have confined in state hospitals. Now they are in the community — which is wonderful.

Wonderful, that is,  until you explore the conditions under which many of them are living today.

Of the 650 boarding homes that existed when I did my research — 400 could not pass the state’s minimum standards for operating as licensed ALFs. They were granted special waivers. What that means is Florida waived important safeguards that it normally required because it was desperate for somewhere to house persons with mental disorders.

I remember walking into one ALF in Miami and discovering a hole in the roof that rain poured through, psychotropic medications were scattered across a kitchen table, the ALF’s caretaker only spoke Spanish, none of the tenants spoke Spanish. Meals were rice and beans. There was no serious case management, no therapy, no recreation, no jobs, no crafts, there was nothing for tenants to do but sit around smoking cigarettes and watching television.

After my book was published, an owner of an ALF complained. He pointed out that he received $29.90 per day from local, state and federal resources for each tenant. That $29.90 had to cover all of a person’s food, clothing, medication — everything.

That complaint caused me to call my local animal kennel and I discovered that it charged $34 per day to take care of a dog. In other words, pet owners were paying $4 more per day to take care of their dogs than what we were paying AFL owners to care for persons with severe mental disorders.

It irritates me when mental health advocates push for the wholesale closing of all state facilities but then turn a blind eye to the horrific community facilities where persons with severe illnesses are being sent. I’m not claiming that our old hospital system was better. What I am saying is that simply moving a person into a community doesn’t guarantee that he/she will get any better care.

Because of my book and the tireless efforts of Miami-Dade Mental Health Court Judge Steve Leifman to improve conditions in Miami Dade County, I assumed that most of the problems that I witnessed at ALF facilities would get resolved.

But The Miami Hearld posted an expose last week that documented the same sort of conditions that I observed six years ago. If anything, it appears conditions have gotten worse!

“It’s a cheap, easy, unregulated system of care,” Judge Leifman told the Herald. Leifman has been so disgusted by conditions at ALF’s that he has refused to send some persons with mental illnesses from jail into ALF housing. Some of the ALF’s are more dangerous than the jail!

The Herald reporters found that reports of abuse filed with the Agency for Health Care Administration, which is entrusted with overseeing the facilites, were routinely ignored, leaving residents at the mercy of shoddy operators.

The newspaper found ALF residents were nearly twice as likely to be beaten, sexually abused, or molested as someone without a mental illness in an ALF.

Regulators caught nearly 100 homes using illegal restraints, including doping residents with tranquilizers without doctor’s approval, tying them with ropes in beds and chairs, and locking them in isolation rooms.

Caretakers were routingly caught intoxicated, asleep and even abandoning their posts entirely, often with severe consequences to residents. At one ALF, fellow residents called the police when one of the other residents was dying from a drug overdose. The caretaker had locked the office door and was taking a nap at the time.

Where is the outrage from the mental health lawyers who were so critical of state hospitals? Where are the protection and advocacy investigators whose jobs were created by Congress to protect consumers back when they were being housed in state hospitals?

I am grateful to the Herald reporters! I hope other newspapers follow the Herald’s  example because what is happening in Florida with ALFs is happening in other states as well.

In these incidents, we are have not improved the lives of persons with severe mental illnesses by taking them out of state hospitals. We are just hiding them better in our communities.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.


  1. Thank you for calling attention to this horrific situation. But, we should point out that there are outstanding ALF’s too. We work with several group home operators who actually come into appointments, worry about proper diet and that medications are given appropriately and that the residents have intellectually and socially stimulating activities. They genuinely care about the people in their homes. We value them and work closely with them. Wish they all could be like that but for now we positively reinforce the folks who are doing the right thing by recognizing them for awards, etc, and we also call attention to the people who are not doing the right thing by reporting them to the housing authorities. It takes all of us in the mental health field, advocates, family members, everyone who can to speak up.

  2. Thanks Pete. And sadly we won’t invest, or we can’t as we pay for the war-complex machine, and that brings home even more people who need services.

  3. Thank you for that information as I struggle to arrange the best situation for my son. Defining the problem is great. We all agree we need more quality places for our family members. Now, what can we do about it?

  4. Mhalligan83 says

    This is not a new issue, been around for year. The more noise we make, hopefully, change follows, but it doesn’t seem that way with congress right now.

  5. concerned mom says

    As the parent of a severely autistic child, this is infuriating and so heartbreaking. I think the last forty years have consisted of a game of “hot potato.’ Some of the institutions and many policies of indiscriminate institutionalization were dreadful, but it is too much trouble, it seems, to improve anything rather than just dissolve it. I want my child to stay with me as long as humanly possible because of situations like these. But, it is a sad comment on our society that there is no humane place for the most vulnerable among us..

  6. I agree – it is not much better to dump someone in inadequate community care, then to dump someone in inadequate institutions. As a consumer, however, I still believe people recover better in community settings that fit their needs than any long-term, involuntary hospital detainment. We, as a country and people, need to advocate and work towards better group homes (which should have a goal of eventual discharge, and lower levels of supervision – not forced or pressured; but it should be a goal), housing, and a wide array of community services. The ones of good quality already in existence needs to be encouraged, and there needs to be some system to let consumers and their families know how to find and access it. A good facility needs to not just meet state requirements, they need to actually step up and care for people. There needs to be quality psychiatrists, social workers, psychologists, staff and, ideally, practitioners of what would be considered “alternative treatment” (anything from acupuncturists, Chinese traditional, vitamin/mineral supplements – that’s not an anti-medication statement, people just need options, especially when a combination is involved); there needs to be illness-specific group-therapies, meditation, yoga, and other therapeutic groups; there needs to be recreation, vocational training and a wide range of expressive therapies (art, psychodrama, etc); for the spiritual, there needs to be religious access, preferably out in the community; and, of course, the basics on Maslow’s scale need to be well met (food, shelter, water – the necessities). This should be what we demand. And the thing is, this is not such an out-there goal. The money is there – in prisons, in horrible group homes, it’s there. I wonder, as well, where those lawyers who claimed to care went.


  7.   There are facilities that are not the very best, however, the difficult part is looking at those that live there, and options that follow.  Operated by the state some of these people have this home and nowhere else to go.  This is a delicate issue, but a much needed topic of discussion.  I am glad that you  brought up this idea.