This article is published as part of the Mental Health Parity Collaborative, a national partnership between AZCIR and The Carter Center’s Rosalynn Carter Fellowships for Mental Health Journalism and other newsrooms throughout the U.S.
Larry Bootsma was 23 years old when he experienced psychosis for the first time.
His parents still remember the phone call from his apartment. He was panicking, saying bugs were crawling out of the vents. He was later diagnosed with schizophrenia.
Larry exhausted nearly every level of Arizona’s behavioral health system over the next 25 years, including its most intensive public services for people with serious mental illness, or SMI. He was ordered by a judge to receive treatment, assigned to work with a specialized team of psychiatrists, nurses and case managers, and eventually given a court-appointed public guardian.
Despite those interventions, Larry never found lasting stability. He lived on the streets and cycled in and out of hospitals and treatment centers, occasionally landing in jail as his illness worsened. And then, on the morning of Sept. 24, 2025, the 47-year-old, known to his family as “Larry Bear,” was found dead at a bus stop in Phoenix, just outside of the mental health clinic where he received treatment.
The medical examiner said he died of a drug overdose.
“All this didn’t have to end like this. That’s the hard part for me,” said Helen Bootsma, Larry’s mom. “He could have gotten better.”
The cycle of failed treatment that preceded Larry’s death reflects a gap that Arizona has recognized for years: The state has no appropriate treatment options for people with mental illnesses too severe to be managed in the community but who don’t qualify for long-term hospitalization.
Advocates estimate that up to 3% of the roughly 63,000 Arizonans with serious mental illness—nearly 2,000 people—could fall into that gap.
Lawmakers tried to address the problem in 2019 when they authorized secure behavioral health residential facilities, small group homes where patients could receive longer-term, court-ordered treatment in a secure setting.
AZCIR found that in the seven years that followed, the effort repeatedly faltered amid contractor failures, funding gaps, legal complications and provider challenges.
Sign up. Get engaged.
Get AZCIR’s latest investigations and updates delivered straight into your inbox.
It wasn’t until April 2026 that the Arizona Health Care Cost Containment System, the state’s Medicaid agency, began seeking providers to operate the long-promised facilities. Even then, it could not say when they would be up and running.
In the meantime, some of Arizona’s sickest psychiatric patients are left rotating through costly, short-term interventions that experts say repeatedly fail to produce meaningful recovery.
Two days before Larry died, Helen received a message from his treatment team at Terros Health. Larry had picked up his medications and was compliant with his court order.
By the state’s own standards, the system was doing what it was designed to do.
But the team also mentioned that Larry was mixing methamphetamine with fentanyl and following it with alcohol. His daily use had increased substantially since his detox a week earlier.
The message ended with an explanation that his parents had gotten countless times before: “Terros policy is to meet the client where they are. We will continue to encourage Larry to seek assistance for his substance use when and if he is ready. Of course, substance use is never a reason to psychiatrically hospitalize someone, so Larry’s increased use is not a legitimate reason to amend his (court-ordered treatment).”
His treatment team could encourage care, monitor his condition and respond when he was in crisis. But unless his illness put him in immediate danger or left him unable to care for himself, they had few options to keep him in treatment.
Most of Arizona’s behavioral health system is built around this kind of voluntary model. And a lot of the time, it works.
But Larry, like many people with the most severe forms of SMI, had anosognosia, a neurological condition that left him unable to recognize he was ill. It is a primary reason people with schizophrenia or bipolar disorder refuse medication, walk out of treatment and experience repeated relapses. One in four adults with serious mental illness also has a substance use disorder, which can worsen the symptoms of mental illness and make long-term recovery that much harder.
For people who can’t voluntarily engage in treatment, a few days or weeks of care is rarely enough to stabilize them, said Josh Mozell, a mental health attorney and president of the Association for the Chronically Mentally Ill.
“They cycle through things like (group homes) and homelessness and crisis centers and interactions with police and fire. All the while getting sicker and sicker and sicker—and almost irredeemable.”
josh mozell
“They cycle through things like (group homes) and homelessness and crisis centers and interactions with police and fire,” Mozell said. “All the while getting sicker and sicker and sicker—and almost irredeemable.”
That cycle defined Larry’s adult life.
In the five years before he died, Larry was hospitalized at least 26 times for a total of 280 days, according to a timeline compiled by his parents. Between hospitalizations, he was placed in behavioral health residential facilities at least 10 times.
The group homes provide around-the-clock care but patients can leave whenever they want. Each of Larry’s stays was followed by another crisis and another hospitalization.
“What a waste for him to be admitted in each one of these situations and then not have a positive outcome,” said Helen, who is also an advocate with Arizona Mad Moms, an organization that supports families of people with serious mental illness. “Each one of these would have been—could have been—an opportunity for wellness.”
According to an AHCCCS report, nearly half of the roughly 8,000 people with serious mental illness discharged from unlocked residential facilities in fiscal year 2025 were hospitalized within a year.
In the same report to the governor, the agency acknowledged that conditions such as anosognosia mean some patients are “unable to engage voluntarily in interventions, including antipsychotic medication and community support,” and that court-ordered treatment “may be necessary for stabilization.”
That’s why lawmakers authorized secure residential treatment seven years ago.
Unlike traditional residential facilities, patients could not simply walk out, giving them time to stabilize on medication, gain insight into their illness and ideally transition to a less restrictive setting. The homes, each capped at 16 beds, are meant for individuals under court-ordered treatment whose repeated hospitalizations, homelessness or arrests show they have been unsuccessful in less restrictive settings. Judges could authorize placements ranging from three to 12 months.
Under those criteria, Larry would have qualified for a placement. And his parents believe it could have made all the difference.
“In a secure environment and taking his meds,” Helen said, Larry “was a different boy.”
His parents saw that version of him one last time in the weeks before he died. During his final hospital stay at Aurora Behavioral Health, he was on clozapine, an antipsychotic medication primarily used for treatment-resistant schizophrenia. Larry was like his old self, they said—cracking jokes and discussing football, Carl’s Jr. and music.
“We talked about things that a normal couple of guys would talk about,” his dad, Elvern, said.
A week later, he was gone.
Public records and interviews show Arizona’s effort to build secure facilities stalled after a series of setbacks.
AHCCCS awarded grant funding to a provider in 2020, but the project ran into delays finding properties, rising construction costs and budget constraints. After the provider failed to meet the terms of its agreement, AHCCCS halted the project and ended the contract in 2022.
Lawmakers approved $25 million for the construction of five secure facilities that same year, but the funding was pulled from the state budget after AHCCCS was unable to move the project forward. Attempts to restore that funding failed two years in a row. Instead, lawmakers approved a $5 million appropriation in 2025 for AHCCCS to restart the effort.
“We thought we could pass the law, and the agencies would get the rest done,” Mozell said. “That’s just not the truth. If you’re going to get something done that actually builds a level of care in the system … you have to hold these agencies’ hands.”
The project hit another roadblock after county attorneys identified a pathway in the law that allowed people charged with a dangerous crime—and found mentally unfit to stand trial—to be placed in secure facilities alongside civil psychiatric patients. Mozell said providers were unwilling to participate until lawmakers passed a measure separating the two populations in 2025—a fix that cost the project another year.
Disability rights and civil liberties organizations have also long raised concerns that expanding secure or involuntary treatment could come at the expense of patients’ rights and due process.
“People with disabilities have the right to receive services in the least restrictive setting that’s appropriate for their needs,” said Asim Dietrich, a supervisory attorney at Disability Rights Arizona.
Support AZCIR
Help AZCIR do more to keep you informed.
Prefer to send a check? Mail it to AZCIR: PO Box 3665, Phoenix, AZ 85030
Citing shortages of community treatment teams and overburdened case managers, he contended that “if more resources were focused on home and community-based services, we likely wouldn’t need the (secure facilities).”
Supporters of secure treatment say the due process concerns, while valid, mischaracterize how the facilities would actually work. By the time someone qualifies for placement, a judge has already determined that less restrictive options have failed and the legal standard for involuntary care has been met.
“More than any other place in the behavioral health system, there’s going to be due process,” Mozell said during a 2019 legislative hearing, as lawmakers considered creating the facilities.
Leslie Carpenter of the national Treatment Advocacy Center, which has long advocated for expanding involuntary treatment options for people with severe mental illness, thinks the debate has become too polarized. Both sides agree that community-based services need strengthening, she said, but for the sickest patients, secure treatment fills a gap that community care alone cannot close.
“A secure setting does not automatically have to be a bad setting,” said Carpenter, the center’s senior legislative advocacy manager. “I would propose that the number of people we’re seeing in our prisons, in our jails, homeless and untreated, and in our graveyards—that’s much more carceral … than to be in a state facility that is meant to meet their needs.”
Without secure residential facilities available, many of Arizona’s sickest mental health patients are trapped in a loop of emergency room visits, psychiatric hospitalizations and crisis care—a pattern that comes at a steep cost to the state.
Last year alone, AHCCCS spent more than $1.2 billion on behavioral health services for members with serious mental illness: about $20,000 per member, on average. A 2024 paper authored by Mozell and other mental health experts said those who would qualify for secure treatment visit emergency rooms five times more often than the general population and, when hospitalized, stay four times as long.
They said “it would be less costly, more therapeutic, and more humane for the person to spend this time in a secure, home-like setting.”
Experts say secure residential facilities could also help relieve a longstanding bottleneck at the Arizona State Hospital, the state’s highest level of long-term psychiatric treatment.
“There are people at … that highest, most secure level of treatment, that are ready for discharge if there was a place to put them,” said Will Humble, executive director of the Arizona Public Health Association.
Patients at the Arizona State Hospital stay an average of more than four years. In just the first month of the current fiscal year, discharge delays kept beds occupied for a combined 482 days by patients who no longer needed to be there. Those delays are especially significant in Arizona, which had the lowest rate of state-operated psychiatric beds for civilly committed patients in the nation as of 2023.
In April, seven years after Arizona authorized secure behavioral health facilities for people with serious mental illness, AHCCCS formally began its search for providers to build and operate them. But the agency still could not say when the facilities would open. AHCCCS told AZCIR that providers have to be selected and facilities must be developed, licensed and staffed before services can begin.
The progress came too late for Larry. He died before Arizona established the kind of care his family believes could have helped him.
His parents hold onto the memory of the son they knew—affectionate, fiercely competitive and always reaching for a guitar. Their “Larry Bear.”
On June 26, what would have been Larry’s 48th birthday, Helen brushed aside blades of grass from his headstone before laying a single red rose across the top. She rested her hand there for a moment, then reached up to take her husband’s.
“He’s safe now,” Elvern told her. “He’s OK.”
This article is published as part of the Mental Health Parity Collaborative, a national partnership between AZCIR and The Carter Center’s Rosalynn Carter Fellowships for Mental Health Journalism and other newsrooms throughout the U.S.
RELATED
Treatment Interrupted
Clozapine is widely considered the most effective treatment for patients with severe schizophrenia. But across the U.S., people were repeatedly denied access to it because of a federal monitoring system that could block prescriptions over missed or delayed blood tests. Despite recent reforms, decades of stigma and a fragmented mental health system continue to reinforce the medication’s status as a drug of last resort.
