Advocates push for Arizona State Hospital reform at Joint Legislative Psychiatric Hospital Review Council hearing


Hannah Saunders


Members of the Joint Legislative Psychiatric Hospital Review Council focused on the governance of Arizona State Hospital (ASH) at a January 4th meeting, where they adopted a list of recommendations made in 2022. 

Operated by the Arizona Department of Health Services (ADHS), the ASH is the state’s only publicly operated psychiatric hospital. Numerous complaints alleging insufficient oversight from ADHS have spurred efforts to enact leadership reform at the institution.

The Council acts as an interim legislative committee that makes recommendations regarding psychiatric hospital capacity in Arizona, and will be operational through 2026. After hearing testimony alleging insufficient oversight and operations at ASH, Council members will consider acting on calls to establish an independent oversight board.


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Sommer Mutter, who is the guardian of her brother, Darren, discussed how he was court-ordered to ASH for treatment for autism spectrum disorder in March of 2021. When he first entered ASH, he was told he was a star patient and would be released in a few months, but shortly after, his medication was changed.

“After this, Darren’s behavior started escalating. He started to become aggressive and agitated,” Mutter said.

Mutter mentioned how she pleaded with the treatment team to put him back on the medication he was originally taking for his disorder, but her pleas went unrecognized.

“I even went as far as meeting with the chief medical officer, Dr. Katharine Woods, begging her to put Darren back on his medications. I was met with her harsh and cruel answer of, ‘We supersede your guardianship, and we make all the decisions now,’” Mutter said.

Darren was transferred to the Iron Wood unit, which is where ASH holds their problematic patients, according to Mutter, who also stated how ASH staff undiagnosed his autism spectrum disorder. On December 15th of 2022, Darren was arrested at ASH and taken to jail, where he remains today. He is facing charges of alleged aggravated assault of a healthcare worker, said Mutter. 

“When a patient is sent to jail from ASH, all meds are abruptly stopped and or flipped,” Mutter said. “This is exactly what happened to Darren.”

Because he was without his medications for three days, Darren suffered a psychotic break and was taken to a hospital for severe mental impairment. While he remains imprisoned, Mutter said her brother is doing much better there than he was at ASH.

Council discussions continued to focus on ASH, and the importance of fixing the conflict of interest concerning ADHS’s authority to both operate and regulate the facility. 

In December of 2021, the Council published a report of their findings, which included recommendations for how to improve psychiatric care within the state. Two bills were passed during last year’s legislative session as a result of the report. 

Senate Bill 1444 prohibits ADHS leadership from retaliating against patients for family participation in ASH Independent Oversight Committee meetings. The bill also requires the superintendent and chief medical officer at ASH to attend and fully participate in Council meetings. 

Under SB 1444, ASH must develop and report evidence-based clinical improvement plans, human resources improvement plans, and budgets by September 1st, 2023, for implementation no later than January 1st, 2025. ASH must also identify necessary enhancements for services, facilities, and staff to provide statutorily mandated treatment, including autism spectrum disorder, substance use disorder, personality disorders, and developmental disorders. 

SB 1444 says ASH must also identify optimum acuity-based staffing levels with full time employees and the minimal use of contracted staff, and have forensically trained staff at both management and staff levels to reduce the waiting list and waiting times for admission. SB1444 requires ASH to develop an emergency response plan to prevent complete closures, to develop transition services to move patients to less restrictive community treatment settings, and to identify an out-of-state third party to investigate complaints filed by patients and their families.

Senate Bill 1651 was also passed last year, and requires the Arizona Health Care Cost Containment System (AHCCCS) to report fiscal records on expenses in the behavioral health system to the Joint Legislative Budget Committee each year. Under SB 1651, $25 million in the state budget was designated to develop secure behavioral health residential facilities for individuals with serious mental illness diagnoses who are chronically resistant to treatment. 

Last July a former ASH patient, Isaac Contreras, filed a lawsuit against the facility with allegations that he was unlawfully isolated for over 600 days, as reported by ABC 15. Contreras has a severe mental illness and was held in isolation from July 2020 to May 2022. 

Following the meeting, the Council is requiring ASH to provide an explanation as to why it is not providing statutorily required services to those with intellectual or developmental disabilities.

Going forward, Council priorities for ASH include assessing the high levels of violence, the chronic staffing shortages, the use of registry staff, clinical care for developmental disabilities and autism spectrum disorder, and governance and accountability to the legislature.