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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.