AUGUSTA — In the sweltering summer of 1988, five patients died at the Augusta Mental Health Institute, setting off a dramatic chain of events that has not yet reached its conclusion.

First a prolonged legislative inquiry was launched into the patient deaths which were blamed on poor care, poor ventilation, poor sanitation and inadequate air conditioning during one of the century’s worst heat waves.

A federal civil rights investigation was initiated and later closed without any charges.

Besieged by questioning lawmakers, Susan Parker resigned as Gov. John R. McKernan’s commissioner of the Department of Mental Health and Mental Retardation in September 1989.

Finally, after a class-action lawsuit over conditions at AMHI was filed against the state in 1989, the case was settled in 1990 by the AMHI consent decree, a landmark court order that has changed mental health care in Maine ever since.

The heart of the AMHI consent decree, signed by Superior Court Justice Bruce Chandler, requires the state to reduce AMHI’s patient population to 70 nonforensic and 40 forensic patients. While reducing the size of AMHI, the order also requires increased support for mentally ill people to live in the community, including individualized support plans.

Gerald Rodman, formerly an assistant attorney general with the Department of Human Services, was appointed court master for the AMHI consent decree, with broad powers to monitor and enforce the agreement.

Recently, for example, the state ran afoul of one of the agreement’s provisions that all budgets for the AMHI consent decree must be presented first to Rodman, and be approved by him, before they can be presented to the Legislature.

The Legislature cannot be bound by the court to approve a certain spending level, but the agreement stipulates that no budget for the consent decree be presented to the Legislature without Rodman’s approval.

Melodie Peet, commissioner of the Department of Mental Health and Mental Retardation for less than two months, failed to win Rodman’s approval on her plan on April 4. She gave him little time to look at the document and so she was prevented by the court from testifying before the Appropriations Committee on the latest budget.

“It’s sort of like trying to swim with a straitjacket on,” Peet said of living under the court decree. “I respect Gerry Rodman a lot. He and I want the same thing — a safe place in the community for mentally ill people.

“We’re still trying to find the place where we get used to each other’s styles.”

In almost five years since the decree took effect, the state has spent $18 million to begin meeting its terms.

Now Peet has developed a new plan, spending $24 million over the next two years to comply with all the terms of the decree by the court-imposed deadline of June 30, 1997. Peet hopes to get Rodman’s approval of this plan this week.

Unlike a plan unveiled last fall by Peet’s predecessor, Commissioner Susan Davenport, the new plan relies on no “new money,” money that has to be raised outside the budget. Gov. Angus S. King declared in his inaugural address that the state could not afford to put extra money, not already in the budget, into the AMHI consent decree.

Instead, the Peet plan finds $9.9 million by downsizing and cutting various accounts, puts it into community services, generating $9 million in federal Medicaid, takes $4 million from a yet-to-be-approved bond issue, and $1.5 million in federal grant money from the Department of Housing and Urban Development.

Part of the “found” money comes from laying off 225 staff members at AMHI, 185 employees at Pineland Center and 17 employees at Bangor Mental Health Institute.

Peet’s plan departs from Davenport’s by establishing fixed “points of accountability” at the local level and by trying to weave various services throughout the state into a unified system.

Throughout Maine, the department relies on about 70 private, nonprofit agencies to provide services like supported employment and housing in the community.

“What we’ve had up until now is a very fragmented approach,” Peet said. “I’m confident that we have a reasonable shot at complying with the consent decree within existing resources as long as we manage our resources well.”

She admitted that a year from now, it might be necessary to go back to the Legislature and ask for more money for the AMHI consent decree.

Constant reminder

The Maine Insane Hospital, now known as Augusta Mental Health Institute, was built in 1840 on a bluff on the eastern shore of the Kennebec River. The hospital preceded the opening of Bangor Mental Health Institute by about 60 years.

The original granite buildings were attached to newer brick buildings through 1889 and other wards were added in this century.

The oldest buildings at AMHI have a Gothic quality, the perfect setting for a British novel about moors and ghosts. There are towers, spires and decorative ironwork.

The oft-repeated story is that AMHI was placed directly opposite the Maine State House so the legislators and governors could never forget the plight of the mentally ill persons hospitalized there. In the 1800s, they were referred to as “idiots” and “lunatics.”

For much of its life, AMHI was nearly self-sufficient. Patients tended large gardens and a dairy farm, and did ice harvesting on the Kennebec.

In 1982, the original AMHI grounds were put on the National Register of Historic Places.

As AMHI grew, wards were built and filled to capacity. In 1955, AMHI, which originally had been designed for about 300 patients, teemed with 1,850 patients. It continued as an overcrowded asylum until the early 1970s, when the great national wave called deinstitutionalization reached Maine.

More than 1,000 patients were discharged from AMHI between 1970 and 1974. Some of them were found to have spent most of their adult lives at the institution, occasionally for no apparent medical reason.

Today, many state agencies, including the departments of Conservation and Environmental Protec- tion, have taken over renovated former wards of the hospital.

In recent years, with a scaled-down hospital, it has been more difficult for patients to gain admission to AMHI. More and more people in crisis have been treated instead in hospital emergency rooms, small psychiatric wards at local hospitals and short-term community shelters.

In addition, two private psychiatric hospitals opened, Jackson Brook Institute in South Portland and Acadia Hospital in Bangor.

Birth, enforcement of a decree

By 1988, there were fewer than 400 patients at AMHI, but conditions were overcrowded and un- healthful.

Helen Bailey, executive director of Maine Advocacy Services, one of four plaintiffs in the AMHI consent decree case, describes what AMHI was like in 1988.

“AMHI was terribly overcrowded,” she said. “People weren’t getting very good medical attention, the physical plant was dangerous. People were being held longer than clinically necessary. People were dying. There was asbestos and insufficient air conditioning.”

In February 1989, Maine Advocacy Services joined the Maine Civil Liberties Union, Pine Tree Legal Assistance and Legal Services for the Elderly in suing the state over conditions at AMHI on behalf of 11 patients and one former patient.

The suit charged that AMHI patients were denied adequate medical treatment, given too many drugs, locked unnecessarily in restraints and seclusion, did not receive therapy they needed, had inadequate support services in the community and were sometimes discharged before they were ready.

The state settled with the plaintiffs in August 1990 and Justice Bruce Chandler signed the 130-page consent decree, giving it the force of a court order that must be obeyed.

The consent decree applies only to people who were patients at AMHI on Jan. 1, 1988, and afterward, a group that now includes about 3,300 people. This group is among an estimated 10,000 people statewide with serious mental illness and another 10,000 with minor mental illness.

In September 1994, acting on a complaint by the plaintiffs, Chandler found the state in contempt of court for not living up to the terms of the consent decree. He also found the state could not possibly meet its deadline for complying with the decree by Sept. 1, 1995. He extended the compliance deadline to June 30, 1997, but also decreed that if the state didn’t put enough money into funding the consent decree, the court would take money from other programs in the department and apply it to the decree.

State attorneys challenged Chandler’s threat of dictating how state money is spent, in an appeal to the Maine Supreme Judicial Court which has yet to be decided.

Since the decree took effect in 1990, says Helen Bailey, “I have seen improvements and expansion of services in the community. I’ve seen significant changes in adopting a direction for the department. We had to fight some basic battles. I did not want to develop mini-institutions in the community. I wanted them to be able to go out to one place they could call home.”

Of new Commissioner Melodie Peet, Bailey says, “I like her direction. I like her ideas. I like her philosophy. I’d like to think her plans and values will work.”

But she adds, “It is a massive octopus of a system that has been very difficult to budge. It has been an enormous task and it has been extraordinarily slow. … We’re in for some hard times. I want to be cooperative. I want things to happen.”

`A long way to go’

Jamie Morrill, who has been associate commissioner under both Susan Davenport and Melodie Peet, sees some positive benefits to the consent decree.

“It shifts the focus to a consumer-based mental health system,” said Morrill. “What the state needed to do was erect a comprehensive system of mental health care. In that light, we think it’s a great blueprint for what mental health care should look like in this state.

“It has moved to a more community-based system. I think we have a more comprehensive system. It’s less institutional, closer to people’s homes.”

As he and Peet prepared a new budget for Rodman, Morrill said, “We’re looking at every account we have in this department and every opportunity to get Medicaid funds to put to the consent decree.”

Ironically, when the budget was done earlier this month, Morrill found he would be out of a job by June 30, so that his salary and benefits could be put toward the decree. But he said he was going to try to find another position in the department.

Gerald Rodman has what appears to be a lonely job. Since 1990, he has been court master for the AMHI consent decree with broad powers to approve budgets and plans for carrying out the decree.

Rodman’s small office sits deep inside one of AMHI’s oldest buildings.

“Basically, I’m a one-person office. I do get out into the community and hold forums,” the 50-year- old Litchfield resident said.

Although Rodman is viewed as a stern taskmaster upholding the decree, he says there have been some improvements since it took effect.

“I think AMHI is distinctly a better hospital than when the consent decree was entered into,” he said. “In the community, it’s still extremely spotty. Services are still fragmented, not coordinated. People see things as dysfunctional.

“In communities, people don’t see a full array of services that support them. Overall, it’s very clear that we have a long way to go. We need lots of housing. People either don’t have housing or they live in substandard housing.”

Rodman said the overall goal of the consent decree in improving the lives of the mentally ill is to provide “basic services which give the person the opportunity to lead the fullest possible life.”

Narrow focus, funding risks

Rep. Michael Fitzpatrick, D-Durham, is House chairman of the Human Resources Committee and executive director of the Alliance for the Mentally Ill of Maine.

He is a critic of the AMHI consent decree, arguing that by focusing on a relatively small group of AMHI patients and former patients, it drains away needed funding from the rest of the state.

“All you need to do is look at the per-capita funding,” said Fitzpatrick, citing the historically greater funding for mental health in southern Maine than northern Maine. “Where you find the greatest impact is in Greater Bangor.”

Aroostook County historically does better than some other rural counties in gaining mental health funding, Fitzpatrick said.

Fitzpatrick also said there’s a risk that the consent decree will force the state to shrink the size of its psychiatric hospitals too rapidly, and that he thinks that Peet’s current budget proposal may depend too heavily on Medicaid.

“Decrees generally are a very difficult way to do public policy, particularly if there is disagreement between plaintiffs and defendants,” Fitzpatrick said. “It’s really been a push and tug to get agreements.”

Fitzpatrick said lawmakers also may be reluctant to lay off as many institutional workers as quickly as the department wants.

Roger Griffith, executive director of Together Place in Bangor, says he worries about the possibility the consent decree may divert needed funds from northern Maine to southern Maine, especially if the court is allowed to move funds around without legislative approval.

“I’m concerned,” said Griffith. “There’s the potential for that, but we haven’t seen that yet. In fact we’re providing more services now than we did a year ago. We’ve been pretty aggressive in chasing new money.”

Together Place offers mentally ill people a social club, supported employment, a program called Community Connections, a three-bed crisis station and a new, 24-hour mobile crisis team.

As for Commissioner Peet, Griffith said, “I’m very enthusiastic about her attitude about putting more money into the community. Maine has got further to go than the other New England states.”