That same day Luis Nunez was freed from four-point restraints -- which bound him by the wrists and ankles, spread-eagled on a bare metal slab -- after a change in medication helped him to stop smashing his head against the wall until he bled. And he was better for a while. When I was there, he was on his feet and yelling, "Where are my shoes?!" But last week he was back in full restraints.
As sick as they are, Portelles and Nunez are not in a psychiatric facility. Where they should be.
Instead they are prisoners in the Miami-Dade County Jail, two of more than 325 men charged with felonies and even misdemeanors who are being heavily medicated and warehoused in small, cold, overcrowded and filthy cells in what has become the largest psychiatric facility in the state of Florida. And some have been there for up to two years.
Portelles, who is 40 years old, and Nunez, who is 38, were being held on C-Wing of the ninth floor, the maximum security section of the psych ward, where up to 40 inmates identified as acutely ill and extremely violent are held in 24-hour lockdown. If deemed suicidal, the men are kept in the nude, given only a paper gown or an indestructible nylon vest called a Ferguson garment -- too thick and unwieldy to use as a means of hanging themselves -- for cover. They are permitted no books, no pencil, not a stitch of clothing, nothing that could be fashioned into a weapon or a noose. Visitors are not allowed. The inmates are not taken out for exercise. They have no access to a telephone, nor to any window with a view of the outside world.
At times three and four men are jammed into a four-by-eight-foot cell that has one metal cot bolted to the wall. So some prisoners sleep on the floor. They sleep huddled together. Or sometimes they don't sleep; they babble, they pace, they pull out their hair, they bang their heads. Some spend the day shaking in withdrawal from the drugs they used on the street.
In each cell the overhead neon light is always on. The single bunk has no mattress or sheets. Food comes in Styrofoam boxes shoved through a slot in the steel door. Offered a shower three times a week, prisoners often refuse it. When the stench grows unbearable, guards pull uncooperative inmates out of their cells and slosh them down with a green garden hose.
It wasn't supposed to be this way. But with state hospitals closing, and few community-based health services available for mentally ill criminals considered a danger to themselves and others, three floors of the fifty-year-old jail at 1321 NW 13th St. now serve as the asylum of the new millennium. Thanks to psychotropic drugs that can sedate even the most disturbed prisoner, the jail isn't exactly bedlam. Outbursts of screaming and wailing, bouts of self-mutilation, and psychotic breakdowns where prisoners eat or throw their own feces are frequent but not constant. But even on the best of days, the jail's psych ward is a gloomy, forbidding madhouse.
To get off the elevator and walk into C-Wing is to journey backward, to take a trip to a dark age when mental illness was called lunacy, and lunatics were kept out of sight. The walls are painted bright blue, but there is no cheer. In the center of the tier is a glassed-in command center, where white-shirted medical technicians sit at computers as jacketed guards patrol the cell block, making notations on the condition of the suicidals every fifteen minutes: "Awake, asleep, agitated ..."
The metal doors and Plexiglas cell windows are dotted with the splatter of blood and other fluids. The odor of disinfectant barely rises over the smell of human despair. The stale air is cooled to just above frost, to keep the violence down.
In the cells the inmates curl in fetal balls. Or stare into space. Or at the visitors, blankly.
"It's hell, it truly is," says forensic psychologist Merry Haber. "Medieval. If you saw this in any other country you'd call it a human rights abuse."
Even the jail's staff admits that conditions are horrible, especially for the one-fourth of the jail's 1750 inmates suffering from mental illness. "It's a shocking environment: old, barbaric, archaic," sighs Joseph Poitier, the jail's chief psychiatrist for the past eight years. "Primarily we practice triage, and then it's management by medication. The jail environment is not conducive to traditional treatment. We do the best we can."
How bad is it? "You wouldn't treat your dog this way," says County Judge Steven Leifman, co-chairman of the mental health committee of Florida's 11th Judicial Circuit. For the past two years, Leifman, who is 43 years old, has spent the majority of his time trying to focus public attention on what he calls the "criminalization of mental illness and the crisis on the streets."
Indeed, according to the state's Department of Children and Families (DCF), there are three times more mentally ill people on the streets of Miami-Dade County, per capita, than in any other major metropolitan area in the U.S. That translates to 200,000 county residents, or nine percent of the population, who have been diagnosed with severe and persistent mental illness, including schizophrenia and bipolar disorder.
Why so many here? Leifman cites two reasons: Miami's warm weather, which makes the city a transient mecca, and the legacy of Mariel, the 1980 exodus from Cuba that included several hundred mental patients.
With only a few receiving treatment, that leaves the majority on the street for the police to deal with. And that means many end up in jail.
Most police officers have no specialized training in how to handle the mentally ill. And aggression, which can work in defusing situations involving most people, often turns encounters with the mentally ill from a misdemeanor into a felony. Or worse. In the past three years, police have shot and killed nine mentally ill suspects.
To cut down on the number of shootings, and to keep the insane out of jail on felony charges, Leifman promotes Crisis Intervention Training, a program run through Jackson Memorial Hospital in which cops are taught how to respond to suspects who may be disturbed. So far Miami and Miami Beach police have sent selected officers through the program, and, says Leifman, results are encouraging. Miami-Dade police have so far declined to take part, but chief Carlos Alvarez says his officers are receiving similar training.
Leifman also wants to reform Florida's Mental Health Act -- the so-called Baker Act -- so that courts can order outpatient treatment. Created 30 years ago, the Baker Act permits police to take into custody those considered a danger to themselves or others, but empowers courts to order only inpatient care.
And the judge has promoted some changes locally. Under a November 2000 agreement signed by Miami and Miami Beach police, the county prosecutor's office, and the DCF, mentally ill persons picked up for misdemeanor offenses are moved within 48 hours of their arrest from the county jail to one of six cooperating community treatment centers for evaluation. From there criminal charges can often be avoided or dropped.
But there is no such diversion program for accused felons, or for those charged with minor offenses who are potentially dangerous.
"They are ugly, people are scared of them, and they have few advocates," says Leifman.
They are also expensive to care for. The county annually spends $15 million to manage more than 600 psych patients that on an average day are held in the county jail, the women's detention center at 1401 NW 7th Ave., and the Turner Guilford Knight detention center at 7000 NW 41st St. That figure includes $4 million a year in overtime for corrections officers and $1 million just for drugs.
In yet another measure of the cost of mental illness to taxpayers, Leifman looked at the 31 misdemeanor defendants who were most often Baker Acted or who showed up in the diversion program last year; he found they used up $540,321 in services. That figure includes the cost of 1955 days in jail, and some $310,000 in emergency medical services.
To move the mentally ill out of county jail, local officials must have a place to send them. And for convicted and accused felons, there are no places. The shift away from large state-run psychiatric hospitals began with a 1950s Supreme Court decision calling for patients to be removed from impersonal institutions and treated in smaller settings closer to home. But Florida, like many states, failed to fund and build those community treatment centers. Now only three state hospitals for mentally ill criminals remain -- at Miami's South Florida Evaluation and Treatment Center, outside of Tallahassee, and in Gainesville -- with a designated total capacity of 880 patients, including 105 women. In county jails all over Florida, there is a backlog of forensic patients waiting to get in.
Partners in Crisis is a coalition of Florida judges, law enforcement and corrections officers, and medical professionals that has proposed to legislators spending $100 million to redesign the mental health delivery system. That redesign would include creating Florida Assertive Community Treatment teams, which under contract to DCF manage up to 100 patients struggling to rebuild lives outside of institutions. Two such FACT teams now operate in Miami, at an annual cost of $1 million each.
"People will get involved," says Leifman, "when mental health becomes a public safety issue, not a social issue."
And jail psychiatrist Poitier acknowledges that "nobody wants their hard-earned tax dollars to go towards criminals. That's the bottom line. Nobody wants mental health facilities for chronically mentally ill in their neighborhood. Add in the fact that they are criminals, lower socio-econ classes, minorities -- and you don't have a population that anybody's going to advocate for."
That leaves Poitier, who is 47 years old, to do what he can with new antipsychotic drugs such as Risperdal, Cyprexa, and Seroquel, and Leifman to campaign for help by inviting politicians, bureaucrats, and the news media in for a look. Celeste Putnam, director of mental health programs for the state's DCF, walked through the psych ward recently and almost passed out, reports the judge.
Miami-Dade County commissioners Katy Sorenson, Barbara Carey-Shuler and Natacha Seijas were also shaken. Sorenson compared what she saw to scenes in a 1948 movie called The Snake Pit, set in a mental institution. Carey-Shuler said she is still having nightmares. "Horrendous, absolutely mind-boggling to know we allow people to exist in those conditions. My heart just broke," she says. "I don't need to see that ever again. It's indelible on my brain. But others need to see it."
Portelles and Nunez, meanwhile, are still on C-Wing. Portelles, picked up in May for driving without a license, is being held on a fugitive warrant from Broward County, where he faces charges of grand theft, drug possession, and battery. He was to be in court Friday.
Arrested in December, Nunez several weeks ago was judged competent and allowed to plead guilty to misdemeanor assault, and sentenced to 364 days in county jail. So he is doing his time -- in four-point restraints. But where does Nunez go when he completes his sentence?
"Good question," says Leifman.
