South Florida's mental health system spirals out of control,
troubled minds are meeting tragic, preventable
By Art Levine
Ronny Morgan could hear voices no one else did. The late-night hosts on television, Jay Leno and David Letterman, had personal messages for him, and in the days before his parents committed the 18-year-old former high school baseball star to a Palm Beach clinic, he would sometimes bring his face near the television set, his eyes darting wildly, to better understand what they were telling him. Everyone, perhaps even Ronny himself, knew he was unraveling. Always rather hyper, by early May, while staying with his mother in Boca Raton, he went into a frenzied state of agitation, playing his gangsta rap tapes extra loud, jabbering at all hours, menacing his uncle Joe, who lived with them. In his notebook of rap poems, he wrote, "I’m afraid I’m getting schizophrenic."
He was right, as it turned out, but he never got the help he needed. On May 25, less than two weeks after he was released by South County Mental Health Center in Delray Beach following a mandatory psychiatric exam — and against the recommendations of two psychiatrists there — he beat his father to death with a red baseball bat while his dad watched TV at his home in Pembroke Pines. The day before the killing, he later told police, he had what he felt was a divinely inspired dream: "My father was gonna go to heaven" — if he would only hit him with a baseball bat.
The killing was one of a series of recent preventable tragedies — suicides, stabbings or shootings of the mentally ill by cops — highlighting a mental health system that is essentially in shambles in South Florida. The state and federal governments fund $58 million worth of adult community mental health services in the four South Florida counties, according to the Department of Children and Families (DCF), but neither patients nor taxpayers are getting much for it. Faced with everything from a stark shortage of crisis beds to relatively low-paid and ill-trained staff, community clinics are, critics say, too often kicking out still-deranged people to the streets or their unprepared families with no effective followup care. Even with much-touted reforms in some counties in recent years, including Broward’s Mental Health Court and assorted outreach teams, the most seriously mentally ill are still largely enmeshed in a revolving-door approach that keeps them bouncing between clinics and the streets and jails. As a result, says Miami-Dade County Court Judge Steven Leifman, "Our jail has become the public psychiatric hospital for our community." In Miami-Dade, Leifman notes, as many as 20 to 30 percent of the jail population have treated or untreated mental illness, with 500 people a day on psychotropic medication.
Too poor or disoriented to navigate a patchwork of limited services, the severely disturbed generally don’t get treatment or vital medicines until they endanger themselves or others. When they’re on medication, people with paranoia or psychosis are no more violent than others. But left untreated, they often end up in jail or, as happened five times in the past 18 months in Miami alone, they’re gunned down by policemen. And once in jail, the mentally ill usually encounter second-rate care, no care at all or, some Palm Beach County families charge, outright brutality; as a result, they can deteriorate further into madness, posing greater risks to guards and, later, to themselves and the public once they’re released.
The saddest part of it all is that these fiascoes don’t have to happen. With the latest medicines, long-term, well-managed outpatient treatment, and housing assistance, most of the severely mentally ill — including those with schizophrenia — could lead functional, even productive, lives. But they’re not getting anything like that, and thanks to shortsighted efforts to keep down spending, we’re all paying the cost in what one advocacy group, the Florida Council of Behavioral Healthcare, calls "human tragedy and a waste of taxpayers’ money." Of course, there doubtless are some dedicated professionals doing their best to help this hard-to-treat population. But as Judge Ginger Lerner-Wren, the presiding judge of the Broward County Mental Health Court, says, "Communities are literally in crisis because public mental health care has never been developed to any effective capacity and is woefully underfunded."
For Rosemarie Morgan, the failures of Palm Beach County’s mental health system have struck home with the death of her ex-husband and a son facing trial for murder once he’s deemed competent to stand trial. "I want to get him proper medication, and a good doctor who deals with mental illness," she still hopes, but that reasonable goal eludes most families in Palm Beach County grappling with serious mental illness, according to local leaders of the family-based advocacy organization the National Alliance for the Mentally Ill (NAMI). "Mental health care in Palm Beach County is such a joke," says Ellie Sikiossy, the president of the local chapter.
As for Rosemarie’s son, Ronny, although he’s been receiving a relatively cheap, outdated anti-psychotic medication, Haldol, since mid-May in the North Broward jail, he’s still almost as delusional as ever. That was amply displayed at his Sept. 7 hearing before Broward Circuit Court Judge Susan Lebow. Wearing an open-necked green jail outfit, the short-haired youth, his left wrist still bandaged from a suicidal attempt to bite himself, sat quietly at first as three psychologists testified that he was genuinely mentally ill and not competent to stand trial. The defense’s expert psychologist, Dr. Phil Heller, pointed out that Morgan was "schizophrenic and extremely delusional," banging his head against the wall, still hearing messages from the TV and insisting on conducting his own defense. Even so, the prosecutor attempted to portray those and other symptoms as still permitting Morgan to be tried.
But when Ronny Morgan spoke up on his own behalf, all the efforts to discredit the psychologists were shown to be as much of a sham as the so-called "treatment" he’s received in jail. Grasping an astrology book, Love Signs, that his mother gave him, he turned in the witness stand to face Judge Lebow, seeking to make her understand him. "Do you believe in astrology?" he asked Lebow, then read aloud from the book: "Pisces vibrates the number seven." He continued, "And that’s my birth date. Also, my job here on Earth was to take care of the lost souls, but I got confused with the music and the TV." His mother stood up to reassure him as he went on, "I’m guilty of my crime. I’m shaking right now. I’m scared. I just don’t want to go to hell."
The judge agreed with the defense attorney, Robert Udell, that Morgan wasn’t ready to stand trial and ordered that he be sent to a secure psychiatric hospital for treatment. The wait for a hospital bed could be as long as six weeks. "He’s going to get good treatment now," his mother said later. But if he does become competent to stand trial, Udell said he would offer an insanity defense. He also plans to sue South County Mental Health Center for what he and Morgan’s mother say was an inappropriately early discharge. "He was clearly psychotic at the time they released him," Udell contends. "He needed treatment, but they kicked him out."
His mother has tried to find decent treatment for Ronny as she watched her son deteriorate over the years. His grades tumbled, he couldn’t stay on the baseball team, he started smoking lots of pot, and by the 10th grade, he dropped out. He visited, briefly, a few therapists, and one psychiatrist he saw told her he was depressed, but the anti-depressant he received didn’t halt his downward slide, and he soon stopped taking it at all. For a while, he managed to pull himself together enough to complete his GED and hold down a job as a bag boy at Publix, but by May all that had started to crumble.
Rosemarie Morgan, a former psychiatric aide, knew her son should be detained under the Baker Act, which allows someone to get an involuntary psychiatric exam at a "crisis stabilization unit" if he’s considered a danger to himself or others. Reluctant to call the police and scared to bring him to a hospital herself, she kept calling her ex-husband, Rick, to help bring Ronny to a nearby community hospital. "I didn’t want to be upstairs with Ronny myself," she recalls about the day he was committed. When Rick Morgan finally arrived, they convinced their son to go to the hospital, where the staff agreed he needed to be committed and arranged for an evaluation at South County Mental Health Center.
After three days there, he was released, against the recommendations of two psychiatrists who believed that he should be kept involuntarily. Dr. Womesh Sahadeo, for instance, wrote that Morgan "posed a real and present threat of potential harm," adding that he was refusing medication and was "responding to internal stimuli, believing that TV is talking about him." Another psychiatrist also noted Ronny’s delusions about the TV, adding, "[He] burned both upper arms with a cigar. Has no understanding of his need for treatment." For reasons of patient confidentiality, South County officials won’t explain why those findings were overruled and Morgan was released.
Under the Baker Act, the mental institution has up to 72 hours to determine if a patient is still likely to be dangerous and petition a court for an involuntary commitment order if clinically necessary. Otherwise, to protect the civil liberties of patients, the institution either can ask the patient to voluntarily commit himself or release him. While at South County, Ronny didn’t take any medication and became angry over being committed ("It pissed me off," he later told police), fueling the homicidal rage that exploded nearly two weeks later.
When Rosemarie visited her son at the facility, he told her, "I’m holding on." She didn’t hear anything about his progress from the clinic until she got a call from a medical staffer telling her that Ronny was going to be released. "Why are you releasing him when he needs medication?" she asked.
"It’s the law," the staffer told her.
"What do we do now?" she wondered aloud, shocked and overwhelmed about the prospect of his early release. He still seemed just as hyper, she remembers, and she wasn’t told anything about how they should deal with him on his release — although educating and involving families has been proven to sharply reduce relapses. Ronny Morgan went to live with his father in Pembroke Pines, in part because Rosemarie couldn’t handle him by herself anymore.
Discharged without even a written prescription or pills to tide him over, Ronny Morgan was given only a fact sheet on bipolar, or manic-depressive, illness, she says. He didn’t obtain a filled prescription for his psychotropic medication until the next week, when his father found a psychiatrist for his son out of an insurance booklet. A few days after that first psychiatric visit, Ronny killed his dad.
It can take at least six weeks, if not more, for some psychiatric medications to have a therapeutic effect. Successfully treating a patient with just the right dosage and medicine can take months, with recovery from a single psychotic episode requiring as long as two years.
At that meeting with the psychiatrist a few days before Ronny killed his father, he threw near-miss punches at his dad right in front of the doctor, Rosemarie Morgan says. But Rick Morgan still thought he could control his son’s behavior. Every few days, she urged Rick to bring his son back to the clinic, but he declined. Neither parent had any real idea on how to handle his illness on their own.
Before Ronny began fitfully using his new anti-psychotic medication, Zyprexa, the vivid dreams about killing his parents had already begun. On his first night home, he told police, he had a dream about killing his mother. He saw his face starting to do strange things in the mirror, and soon, with all his family standing around, "I put her on the ground, and I had my forearm across her throat, and I could feel I was about to crush it, and I woke up." A little over a week later, he had the dream about sending his father to heaven with the baseball bat, following it up the next day by, in fact, killing him, shortly after they played catch together.
The last time Rosemarie spoke to her ex-husband she asked him, "Are things going all right?"
He reluctantly conceded that they weren’t. "If anything’s going to happen, it should happen here in this house," he told her.
"Don’t let anything bad happen," she answered. "We have to Baker Act him." He never got the chance.
She got the call at work from her brother and told him to call the police. Ronny had showed up at her house, his clothes still bloodied, and told his uncle and grandmother, who were shocked by it all, "I killed my father." After washing up at their house and returning from the convenience store with some cigarettes, he was arrested and brought to the Boca Raton police station for questioning.
Why did South County Mental Health Center, a $15 million annual operation, release Ronny Morgan so soon? Mental health officials contend that such facilities have little choice given the requirements of the Baker Act, but reformers and malpractice lawyers say other, cost-saving factors may be at work. In the view of Jeff Lefton, the associate director of South County, patients’ mental status can change during the days they’re being evaluated, leading to cancellations of scheduled court hearings, as in Ronny Morgan’s case. He adds, "If they no longer meet [Baker Act] criteria, then we’ll discharge them — unless they stay on as a voluntary client. It’s difficult: Sometimes, they may not meet criteria, but still may need mental health treatment."
"It’s not against the law to think you’re Napoleon. It’s only a problem if you’re Napoleon and you go to war. The dangerousness issue, that’s the real problem," Laura Leonard, the adult mental health coordinator for the Department of Children and Families in Palm Beach County, told the Sun-Sentinel. Leonard’s agency gives about $5 million a year in state mental health funds to South County. Unfortunately, she tells City Link, families often misunderstand facilities’ obligations under the Baker Act: "They don’t have the legal ability to hold someone if it doesn’t rise to the level of imminent harm to themselves or others. And I can understand how that can be problematic to family members."
Still, a series of dubious discharges and escapes in recent years have underscored troubling questions about local institutions.
In late April, Fort Lauderdale police brought a chronically homeless person, Chris "Cowboy" Kyhl, to Broward General Hospital after he threatened to jump off the City Parking Garage near the downtown library. They talked him down and brought him to the hospital’s psychological unit with the aim of "Baker Acting" him. According to a police report, they met with a nurse and filled her in on his history while an officer started filling out the involuntary examination paperwork — before being told that the medical staff would now handle it. Nine hours later, Kyhl was released and shortly after, the intoxicated "Cowboy" climbed on top of the garage, then had a change of heart while dangling from a seventh-floor railing. A passerby tried to save him, but Kyhl’s sweaty hand slipped and he plunged to his death.
A spokeswoman for Broward General Hospital, Sara Howley, says patient confidentiality bars her from discussing the specifics of the case, but contends, "We have good policies and procedures in place to handle these situations." But at a meeting with hospital staff in June, representatives of the police department’s homeless outreach team and the Homeless Assistance Center met to voice their concerns about the hospital’s discharge policies and to improve communication among the various agencies. According to the civilian member of the police team, R. Courtney, one hospital administrator tried to explain that since Kyhl wasn’t officially Baker Acted — the paperwork wasn’t completed by police — they weren’t obliged to keep him. "That’s bullshit," Courtney recalls telling him. "He was brought to your psych observation room in handcuffs."
The outreach team is now trying to get the hospital staff to pay attention to the police team’s background information on mentally ill individuals when doing their Baker Act evaluations. (Howley insists that the hospital welcomes information about patients from other city agencies.) But Officer Scott Russell says of the hospital’s discharge approach: "Obviously, there’s a cost problem." He adds, "What happens is, if [the mentally ill] really want to commit suicide, they know if they tell the doctor they’re OK, the doctor will release them."
For Christopher Kane, his determination to kill himself wasn’t even foiled when he was kept for observation at South County. Depressed and suicidal, he was admitted briefly to South County in mid-December, after similar stays in previous months, then released by a psychiatrist as no threat to himself or others. But right afterward, on the evening of Dec. 18, Kane flagged down a Palm Beach Sheriff’s officer and told him that he wanted to kill himself. "Without further treatment," the officer wrote on his involuntary exam form, "[patient] will apparently harm himself." Kane was brought back to South County, where he should have been kept under a careful suicide watch. Hospital staffers told police that the next morning, after being refused a cigarette when he awoke, he declined breakfast. About 15 minutes later, the staff reported, they saw him slumped over his bed; he died less than two hours later at the Delray Medical Center from an overdose of drugs — including OxyContin — that he’d smuggled into South County in a pill bottle later found in his clothing.
The family’s attorney, Robert Saylor, is preparing a lawsuit against South County, and says, "There’s a reasonable case that there was negligence," particularly given the history of previous discharges. Associate director Jeff Lefton won’t comment on the case for legal and confidentiality reasons, but says of their suicide prevention policy, "Patients change into a gown, and we go through their belongings, but don’t do a cavity search. We respect the individual’s dignity."
South County’s respect for patient dignity, however, doesn’t always seem to include helping prevent their deaths. Last November, a West Palm Beach jury awarded more than $400,000 to the parents and estate of a mentally ill man who was shot and killed by police hours after jumping the fence at South County. Jair Salazar, 27, was hearing voices and suffering from paranoid schizophrenia when he checked himself into the center. On March 13, 1998, he escaped, and although the center phoned his parents, the center staff didn’t bother to chase him or call the police because, they reasoned, since he’d voluntarily committed himself, his departure wasn’t technically an escape. It was typical of the bureaucratic thinking that afflicts area mental health agencies.
Later that night, Salazar wandered into a parking lot next to the Duncan Conference Center, and police responded to complaints of a man threatening people. He lunged at the officers with a socket wrench and was shot by a policeman, who was later cleared of any wrongdoing. During the trial, the center’s attorney argued, "South County helped him the best they could, but he ran from them."
Unfortunately, the clinics’ best may not be good enough, particularly when there are shortages of beds, or patients encounter indifferent or ill-trained staff. South County, for instance, was cited by state evaluators earlier this year for such flaws as lack of training in both Baker Act procedures and crisis intervention for several staff members, as well as a failure to show a clear followup plan for half their patients. Jeff Lefton says the 16 problem areas, out of 381 studied, mostly involved inadequate documentation of their efforts and are being rectified.
Poorly trained staff, though, can cost lives. For example, in 1995, Brian Mullen, 21, went to the 45th Street Mental Health Center in West Palm Beach after being hospitalized for three days at a nearby hospital following a suicide attempt with drugs. Referred by a psychiatrist at the hospital, he went to 45th Street seeking residential treatment for his depression, but an admissions aide sent him away after a 15-minute meeting as "not suicidal." Subsequently, he hanged himself at home, and attorney Robert Saylor settled with the facility for a large but undisclosed amount on behalf of Mullen’s family. The current medical director, Dr. Suresh Rajpara, won’t comment on an incident that preceded his tenure but says of their Baker Act decisions: "We like to err on the safer side of more monitoring."
Some institutions, however, have a rather limited view of patient and public safety. Last November, Kathryn Jamnicki, a woman with a long history of mental illness who stabbed her mother to death 13 years earlier, knifed a stranger in a Publix in Fort Lauderdale. Three weeks before, the Sun-Sentinel reported, she’d been released from a psychiatric hospital that the DCF won’t name. Her attorney, Ryal Gaudiosi, said it was the ninth release in nine years for Jamnicki. "There is very little in this county for people who are mentally ill," Broward County Chief Assistant Public Defender Howard Finkelstein said at the time of the Publix stabbing.
Apparently, the hospital staff assumed she was no longer a danger to herself or others or, perhaps, they had simply run out of room. The number of inpatient beds has been markedly shrinking since the deinstitutionalization of state hospitals began in earnest in the 1970s. By next April, state hospitals will have lost 3,600 noncriminal inpatient beds since 1979. But the number of criminal beds has more than doubled to 890 since 1980. The community clinics that were supposed to serve patients never filled the gap with either inpatient beds or, in most cases, effective outpatient care. Hence, the revolving door of Baker Act patients cycling in and out of facilities.
Critics say institutions too often narrowly interpret the Baker Act, by either refusing to offer involuntary treatment or kicking out patients before they’re ready. The apparent reason: to make room for other patients or save on costs. One Broward County mother, for example, recalls begging crisis workers from Henderson Mental Health Center to arrange the Baker Acting of her son because his house was in flames from unattended candles. By the time they and the fire department had arrived, though, he was sitting on his front lawn, the house still burning, calmly playing his guitar. "They were standing there while I asked them, ‘Please take him,’ " she says. They refused — on the spurious grounds that he didn’t seem dangerous at that moment. "It’s just a turnstile," she says of the system that’s seen her son Baker Acted 60 times. (Steve Ronick, the CEO of Henderson, said he wasn’t familiar with the alleged incident, but asserts, "We have a track record of responsiveness.")
The clinics, however, seem to have a peculiarly high threshold for judging patient danger. "If they don’t see blood on the floor, they’ll let him go," says Ronny Morgan’s attorney, Robert Udell, a view echoed by Judge Leifman and other advocates for the mentally ill. "They have to have a gun to their own head or someone else," Leifman contends. But he says the law, which also does allow people to be committed if they’re at risk of neglecting themselves, should be applied more broadly to the mentally ill. At the same time, reformers concede that institutions can be held liable if they abuse the process to hold people improperly, as a 1999 state Supreme Court panel reported occurred with the elderly. Still, Leifman believes Florida should amend its law to join the 41 other states that allow judges in civil cases to order outpatient treatment, including medication, for those who don’t recognize the need for treatment.
The facilities’ release of patients who aren’t yet stabilized could be driven by financial need, some observers contend. Dr. Sanford Kaufman, a noted Palm Beach County psychiatrist, says, "There are some institutions that dictate to the physicians how long to keep people, although they’ll deny it." Indeed, Judge Leifman and other mental health advocates say, the state’s own reimbursement policy could be contributing to the problem, because it provides a flat fee to the facilities regardless of how many patients are served. As Angela Vickers, a Jacksonville attorney and state NAMI board member, says, "There’s no accountability: Providers get the same amount of money raining in whether they serve 10 people or 1,000 people, and whether they engage in malpractice or good practice." (DCF’s Laura Leonard strongly disputes that view, contending that the state engages in extensive quality monitoring, and that the facilities’ payments are geared in part to the level of staffing and inpatient beds.)
Whatever the cause of early discharges, a reading of the statute itself shows that virtually all facilities are using it to limit costly involuntary commitments to only those who are, in Leonard’s words, in "imminent harm." But the statute doesn’t even use that term, referring instead to the "substantial likelihood" a person will be dangerous in the "near future" based on "recent behavior causing, attempting or threatening such harm." The families of patients such as Ronny Morgan, Chris Kyhl and Christopher Kane no doubt feel that the law was applied improperly to them.
Clinic leaders resent the charge that they’re kicking Baker Act patients out too soon just to save money. "I don’t think anyone who is a practicing psychiatrist is showing people the door [for financial reasons]," says Jeff Lefton of South County. He adds that the tragedies making headlines are quite rare and at least his facility, with its 20 crisis beds, can’t be blamed: "We don’t have any crystal balls. We look at an individual case and assess clients the best we can. We have 300 Baker Acts a month ... Those [deaths] are things that happen."
Yet even when the mental health system doesn’t leave its victims dead, patients and their families face the daily wounds of fighting to get help for the already devastating mental illnesses crippling them. In the process of dealing with poor or negligent treatment — as well as bureaucratic runarounds — families in South Florida watch with horror as their loved ones continue to disintegrate.
For Bobbie Norris of North Palm Beach, the challenge often has been just to ensure that her son survives both the clinics and jails he’s been placed in since he started to crack up four years ago. Her son — we’ll call him Andy — became isolated and disoriented about the time he turned 20. First admitted to Palm Beach Gardens Hospital, he attacked a nurse there and was Baker Acted to 45th Street, where he vomited, choked and nearly overdosed on the excessive amounts of psychoactive drugs given him, she alleges. "They almost killed him at 45th Street," she says. He was transferred to St. Mary’s ER, apparently for overdose treatment, and then put back in 45th Street. Still hallucinating, he soon was discharged when she went to court seeking an independent medical exam of him, in part to assess a painful lump on his neck the staff at 45th supposedly ignored.
Over the years, although he’d return to 45th Street, he rarely got much better. He used drugs and alcohol, and was arrested a few times for DUI, drug and even assault charges (once against his father). Last year, when he was arrested for cocaine possession and threatening a hotel employee with a baseball bat, he was locked up in the Palm Beach County Jail for six months — and, his mother says, denied both psychiatric medication and medical care he needed for an ear infection. At one point, an administrator with EMSA Correctional Care, the for-profit firm that provides jail health services, allegedly inquired about her schizophrenic son, "Are you sure he’s not faking it?" His parents couldn’t afford bail while he was awaiting trial and court hearings on his competency to stand trial.
Meanwhile, he lost at least 40 pounds while in the jail and became more withdrawn and frightened. His mother also says jail officials told her that he was isolated from other prisoners several times for unruly confrontations with guards. He doesn’t remember that, but he says, "One time, I was lying in my bed, and they came in to search my room and I couldn’t get out of bed. They dragged me out of bed, beat me up, took my clothes off, and I remember this one guy kicked me." On another occasion, he claims, he was beaten up by guards when he stopped for a drink at a water fountain before returning to his cell. The family doesn’t have medical records or other evidence to back up his allegations, however, and they say they haven’t filed lawsuits against either 45th Street or the Palm Beach County Jail because they can’t afford a lawyer.
In Andy’s case, his troubles continued even after he was shipped in December to the North Florida Evaluation and Treatment Center in Gainesville to get him well enough to stand trial. When he was released this past May, he was placed on a form of probation that allowed him to avoid jail if he kept out of trouble for 18 months. But to do that, his parents knew, he needed skilled drug counseling and therapy, along with regular medication. He never got the help he needed, despite entering a new state-funded program, IMPACT, drawing on staff from both 45th Street and South County, that was supposed to offer outpatient drug treatment, "case management," at-home visits and a host of intensive services for the most troubled patients: substance-abusing mentally ill patients with repeated incarcerations. The program’s central mission was to treat these hardcore "dually diagnosed" patients, but even with a caseload of only 30 patients as of June (since expanded), Norris says, "He didn’t get drug counseling or treatment."
At most, his parents say, he’s received only superficial visits lasting about 10 minutes a week to check on his medications. About two weeks ago, after inquiries about the program by City Link, a social worker actually spoke to him for 45 minutes. Ironically, Norris had to fight hard to get her son in the program, overcoming efforts by the supervising psychiatrist to discourage his enrollment. Others never make it past the assorted runarounds placed in their path. One woman, who has asked to remain anonymous, clamored for weeks to enroll her son, but finally couldn’t even get a preliminary appointment for him and gave up. "It was a dead end," she says.
The program costs taxpayers $2.5 million, but it’s not clear what the public or patients are actually receiving.
What is clear is that the results of the treatment program have been a disaster for Andy. He goes on and off his anti-psychotic medications, and, his father says, his thinking has become disordered, his appearance is deteriorating and his face often takes on a hard, angry look. "There’s a storm going on inside his head," his father says. And last month, he was arrested yet again after he got into a dispute with a nightclub bouncer and was booked for trespassing and resisting arrest, thus violating his probation and raising his risk of returning to jail. If jailed, of course, he’ll doubtless deteriorate further, increasing the chances that he’ll be arrested or Baker Acted again after his release.
The IMPACT program was supposed to prevent just such endless recycling through the mental health and criminal justice systems. It’s based on a NAMI-endorsed Assertive Community Treatment (ACT) model that’s succeeded elsewhere in the country and found now in 22 teams around the state. Each 12-person team comprises social workers, nurses and a doctor to offer round-the-clock, wide-ranging support. But local and state NAMI leaders, including the president of the Florida state chapter, Faye Barnette, believe that the Palm Beach County version has, so far, failed to deliver on the promises it offered in its $2.5 million contract. "It’s not working very well," Barnette says.
The local DCF evaluation in June of the program found a variety of problems, noting, for instance, that "substance abuse services are not being addressed." In other words, the centerpiece of the entire multimillion-dollar program didn’t seem to be offered. But DCF’s Leonard insists that critique merely referred to the program’s failure to properly document their drug services. She says that after IMPACT worked out the program’s startup "bugs" and high turnover rates, it is now finally providing all the services the state — and taxpayers — are paying for. "Knock on wood," she adds.
IMPACT leaders, though, don’t seem very willing to explain how they’re applying their funds. When City Link asked one of the IMPACT administrators at 45th Street, Donna Harris, about Bobbie Norris’ struggle to get drug treatment for her son, she said, "I don’t like where this is headed" and ended the interview. Before then, Harris had claimed, "Members are given extensive substance abuse services," and that entry into the program is open to all who qualify.
In Broward County, there appears to be a similar contrast between the claims made for innovative programs and what they actually offer some families in need. For instance, Henderson boasts about its 5-year-old mobile crisis team that’s supposed to be dispatched in a mental health crisis, in part to avoid using the police. "We triage in the order of lethality and danger, and we don’t slip up," says Henderson CEO Ronick. But one mother, who asked not to be identified to protect her son, says that even armed with a written recommendation from a Henderson psychiatrist to Baker Act her psychotic son, she couldn’t get the vaunted mobile crisis team to show up at her house for about a week. As the days passed, he became more unhinged, wallowing in filth in his room and threatening his mother: "If you send me anywhere, God will make you die." Eventually, after pleading with both NAMI and the Henderson psychiatrist, some Henderson staffers arranged for a short-term Baker Act evaluation before he was released again from the clinic. "I don’t know what to do," she complains. "I don’t want him to fall between the cracks."
Perhaps the most striking difference between the official description of services provided and the reality comes at the Palm Beach County Jail. "Mental health and medical treatment is given the highest priority," says Diane Carhart, the spokeswoman for the Palm Beach Sheriff’s Office, which administers the jail. The sheriff’s office has paid since 1993 more than $45 million to EMSA Correctional Care and its affiliated company, Prison Health Services. What are inmates — and taxpayers — getting for all this money? "Inmates staying in our facility receive the best possible medical treatment. They receive the same kind of medical care they would receive on the outside," Carhart says.
That’s not a view shared by the inmates and families who have filed hundreds of lawsuits against EMSA and Prison Health Services around the country. There have been 15 lawsuits in Palm Beach County and five in Broward County filed since 1995, according to a review of local court records by the Sun-Sentinel in March. Here and elsewhere, allegations against the allied firms include wrongful deaths, hiring of a psychiatrist stripped of his license for sexual exploitation of a patient, denying needed psychiatric medications and ignoring repeated complaints by patients of serious medical conditions. "They’re legendary in the legal community for providing second-rate care," says Robert Saylor, who has sued the local EMSA company a few times. "They hire the worst doctors."
In his latest case against them, Saylor won a settlement of $450,000 last year on behalf of Eric Dale. Dale was an inmate who started complaining about extreme pains in his back, then his legs, over a few months until he was virtually paralyzed. The EMSA doctors and staff wrote in his chart that he was just malingering despite his pleas for help. Eventually, when he could barely move, they finally arranged for an MRI at Jackson Memorial Hospital, which found a tumor on his spine.
For parents, it’s particularly galling that EMSA’s psychiatrists appear to have an unwritten policy of denying psychiatric medications, especially to mentally ill patients suspected of being drug abusers. In February, Broward Circuit Judge Susan Lebow, angered by EMSA’s policy of holding mentally ill patients for days without their meds, hauled company officials into the courtroom and threatened to hold them in contempt of court unless they gave patients the needed medication. Denying mentally ill addicts medication is a practice that, Dr. Sanford Kaufman, the former chief of the dual diagnosis unit at Savannas Hospital in St. Lucie County, says is "totally absurd" and violates professional norms. "If you don’t treat both illnesses at the same time, you’re asking for trouble and could precipitate a major psychiatric episode," he says.
EMSA’s approach creates hell for families. One mother recalls, after discovering that her son was languishing in jail without medication, "I brought his prescriptions down there myself and I had to argue with them to accept them." She’s not sure he ever received them, either, because he continued to disintegrate while in jail, occasionally being placed in restraints after violent confrontations with guards. At one point, her son later told her, when he began proclaiming that he was the son of God, a guard amused himself by telling him, "You think you’re the son of God? Well, go hit yourself." A few guards then roughed him up, he claims. But since he is mentally ill and his mother has little in the way of proof, who is going to believe them?
Carhart clearly doubts such claims. "Both Sheriff [Edward] Bieluch and Col. [George] Ottmer [the jail supervisor] will not tolerate any inappropriate behavior by their law enforcement officers in that division, and if there is any, we will fully investigate it," she says. "We hold deputies to the highest standards of professional conduct." She invites any families or inmates concerned about treatment to complain directly to Ottmer or his staff.
While the brutality issue is open to dispute, there’s little doubt that EMSA officials have a unique perspective on medication denial and other allegations about substandard jail health care. Linda O’Rourke, the mental health administrator for EMSA at the Palm Beach jail, said in a written statement, "Medication may be provided when clinically indicated." In an interview with City Link, she denied NAMI members’ charges that medical staff regularly deprived patients of psychiatric medications. "The patient has to agree to take the medications," she says. "It’s a compliance issue: The mom might want them to, but Johnny might not want to." Yet in her written statement, the company’s underlying skepticism about using prescribed meds with dual diagnosis patients is apparent: "Medication-seeking is a serious problem with this population." In other words, mentally ill addicts seemingly should go cold turkey on all drugs.
Despite their unorthodox approach to using psychiatric medication and the flood of lawsuits, corporate representatives contend that their health services have been unfairly maligned. "Any system that depends on humans to deliver care is going to have some mistakes made," says Jean Byasse, the chief legal officer of Prison Health Services, EMSA’s affiliate. "It’s a difficult population to deliver health care to. We’re doing better at it than anyone in the industry." She notes that 74 percent of the cases brought against them are summarily dismissed, and there’s only been a "small percentage" of damage recoveries. The real cause of all the litigation, she argues, is usually the inmates: "This population has a familiarity with the judicial system, has time on their hands and can file pro se [without a lawyer] cases."
Business is booming for the cost-cutting firm, now in more than 400 jails and prisons, but at least one Florida county, Pinellas, did not renew EMSA’s contract in 1997 after an inmate died under the company’s care. Pinellas Sheriff’s Deputy Cal Dennie said earlier this year, "We had several jail deaths out there that came into question, and we had complaints about the care [so] that the sheriff decided to go on his own." The Palm Beach County and Broward Sheriff’s offices, though, are sticking by the controversial company.
But if the criminal justice system — from cops on the street to jail officials — fails to recognize and handle mental illness properly, the results can be tragic. In the past two years, there have been a spate of fatal shootings of the mentally ill as well as at least one murder spree, by a troubled 19-year-old who killed two people and then committed suicide. "The major gap is prevention," Judge Leifman says. "We wait until a crisis to attach someone to services and then it is often too late." On top of that, the courts and jails are ill-equipped to handle mentally ill people. "We’ve criminalized mental illness," Leifman contends. Statewide, there are at least twice as many mentally ill people in county jails as there are in the state’s mental health institutions. All told, of the state’s estimated 252,000 adults with severe and persistent mental illness, 80 percent of them get no treatment of any kind, DCF reports.
And without adequate treatment — including aggressive followup care — a few of the most psychotic can get shot or murder others. Some highlights from Miami:
• In late August, a 22-year-old discharged Navy man, Delvin Williams, had a psychotic episode and was shot by police after threatening officers and civilians in a supermarket parking lot. He’s now in critical condition at Jackson Memorial Hospital. He didn’t follow up on the mental health care suggested to him after he ended his treatment at a Navy medical center in March 2000. If he’d been plugged into an effective ACT team when he returned to Miami — assuming any exist — he might not be hovering near death today.
• In June, a dozen Miami police officers tried to subdue a knife-wielding schizophrenic and Army veteran, Richard Beatty, who was slowly wandering along a city avenue. When they surrounded him, demanding that he drop his knife and spraying him with mace, he lunged at Officer Hector Mendez, who fatally shot him 12 times. He had a long history of living on the streets, going on and off his medications and misdemeanor offenses. An investigation into the incident still is under way.
• Last December, John Eric Carter, 19, went on a rampage in four separate shootings from Miami to Kendall. He had a long record of crimes, including possession of a firearm, and was under house arrest for violating his probation. He’d been examined by psychiatrists who found him stable but not currently suicidal, went to counseling and visited his probation officer nearly 60 times. No one expected him to become a murderer. Yet on Dec. 26, he killed the father of his ex-girlfriend, the Rev. Keith Blakely, and a former friend, Jonathan Scarboto Lott; opened fire on two officers at the county jail; and eight hours later, shot himself in the head. The surviving families have met with Judge Leifman to urge reforms in the way judges decide to place the mentally ill.
In addition, suicidal inmates sometimes kill themselves in jail. The latest apparent suicide — still officially unconfirmed — occurred last week when John Beraglia, 41, beat his head against the wall of his cell in the North Broward Detention Center after he was placed on a suicide watch just two hours earlier.
Almost all of these deaths might have been avoided if patients or inmates had access to decent care.
There are several key reforms that could reclaim and literally save the lives of the mentally ill, but even the most obvious ones — such as training cops to handle the mentally ill — aren’t being adopted quickly enough. Still, there are signs of progress. Working from an approach developed by Memphis police, Miami Beach police have developed Crisis Intervention Teams (CIT) composed of specially trained patrol officers who are dispatched to defuse crisis situations with the mentally ill and avoid violence. Miami-Dade, Fort Lauderdale and Palm Beach County police are planning to start learning the techniques soon. Palm Beach County, though, hasn’t yet developed a system, as in Broward or Miami-Dade, to refer mentally ill misdemeanor defendants to treatment facilities. (Mentally ill felons need a secure treatment facility, too, but they’re not getting it in South Florida.)
Improved community treatment, if it ever happens, likely will come as the result of pressure from groups such as Partners in Crisis, a statewide coalition of criminal justice and mental health leaders seeking to prevent the jails and prisons from being swamped with so many mentally ill people.
But even court-based referrals and monitoring can’t guarantee that community facilities will deliver on the services they promise as long as DCF oversight remains so toothless — regardless of all the paperwork the department generates. Says Florida NAMI president Faye Barnette, "They’re falling short on measuring the mental health providers. Too often, patients are not functioning well enough." One way to improve performance: Use in-depth confidential interviewing of patients and families to determine if clinics are actually helping those they profess to serve — and hold the clinic leadership accountable if they fail to do so.
The usual reformist cry is for more funding, but unless it’s money carefully spent, we’re likely to see more Ronny Morgans, John Eric Carters and Christopher Kanes killing themselves or others. One possible model for change lies in a new plan for the 18-county area in North-Central Florida being served by a state mental hospital, G. Pierce Wood, that’s scheduled to close in April. In its place, with $29 million earmarked by the state Legislature, will be expanded crisis units, modern medications, short-term nurse-assisted housing and other programs designed to break the revolving door cycle that now plagues most of the state, especially South Florida.
It could take nearly $75 million to upgrade the rest of the state’s mental health and drug treatment programs, according to Partners in Crisis. But given Florida’s Third World-country approach to social spending, we’ll probably end up with more horror shows like the ninth-floor of the Miami-Dade County Jail, where the most violent mentally ill felons are housed. Judge Leifman, a buoyant man gripped by a reformer’s zeal, takes visitors there to show the endgame of a system that’s failed. "We’ve reinstitutionalized the mentally ill here," he says, guiding a reporter past a faded blue door to a narrow floor with 21 cells, most with two people inside.
On one side, mostly black and Hispanic men are naked, stripped to prevent suicide and cloaked only in a synthetic blue blanket that can’t be torn. Some are speaking incoherently, a few rock themselves back and forth, while others simply glare at the visitors and guards. Most have refused to take their medication. With lights on 24 hours, they get their fitful sleep on metal beds without sheets or blankets, and for a few, there are no beds at all, just a floor underneath. Outside their ancient, rusting cells are posted warnings about their crimes or jailhouse infractions: murder, aggravated assault, "Use Caution, Officer Assaulter." One violent suspect, a heavyset black man covered in the blue blanket, begins to shout over and over, his face pressed against the bars, "You can’t fool with my voodoo power!"
"You wouldn’t let your dog stay here," Leifman says. Before he leaves, he takes a final glance back at the cells and tells the guards, "I don’t know who’s crazier: the people doing [mental health] policy or these poor folks."