Jailing the mentally ill
May 23, 2004
Miami Herald - The voices are relentless. They insult him, threaten him, tell him to slit his wrists. Raymond Santos is 30 years old and exhausted, run ragged for most of his life by a biochemical tempest in his mind.
A year ago, he grew so desperate for the voices to shut up that he tried to appease them by taking a large, serrated kitchen knife and digging it four inches into his stomach. Two weeks later, with 31 staples in his abdomen, he landed in Florida's largest psychiatric facility.
The Miami-Dade County Jail.
He was locked up in a wing where psychotic inmates sleep on the tile floor or rusted metal bed frames, without sheets, blankets or mattresses. They stay in their cells for 24 hours a day. No books, no TV, no visitors, no toothbrush, no eating utensils, no clothes.
They screech and cower at unseen demons. They pace furiously and rip their paper gowns off. They urinate on the floor and bathe in the toilet.
The noise never stops, the fluorescent lights mask the passing of days, and the psychiatrist treats patients through a three-inch-wide "chow hatch" in a steel door.
"I don't even try to describe to people what's going on up here," said Dr. Joseph Poitier, the jail psychiatrist. "It's beyond talking about."
The scene is just one consequence of a nationwide failure to care for the severely mentally ill, a situation created over the last 40 years by the closing of psychiatric hospitals in Florida and other states.
Those institutions -- often bleak warehouses for the "insane" -- were supposed to be replaced by local treatment centers that would get patients functioning in the community. But mental health experts widely agree that the new system never received enough funding and has offered fragmented services at best.
With the safety net frayed to threads, untold thousands of people suffering schizophrenia, bipolar disorder or major depression have gone untreated, often homeless and wandering the streets, unable to guide their unruly minds through the straight lines of society.
They trespass, they commit lewd acts, they resist arrest. And many end up in jail over and over.
"Jails and prisons have become, in effect, the country's front-line mental health providers," according to a Human Rights Watch report released last October.
While some other states, like New York, have made significant strides in keeping the mentally ill in treatment -- and out of jail -- Florida has been slow to move.
"This is our biggest failure," said Miami-Dade County Court Judge Steve Leifman. "It's this cycle of despair."
Santos, from Carol City, landed in jail last June on a probation violation for a previous offense; he was too paranoid to report to his officer, he says. He was stripped naked, given a paper gown and locked into the C-wing on the ninth floor.
"You hear people screaming, people laughing," he said. "It is hell. I wouldn't wish the ninth floor on my worst enemy."
In Miami-Dade County, where the percentage of people suffering serious mental illness is between two and three times the national average, the justice system is overloaded with a population it was never meant to care for.
At any given time, an average of 600 inmates have mental illness serious enough for them to be segregated from the general population. Ten years ago, the number was about 300.
"It's a test of your faith," said Officer Clarence Clem, a pastor and officer who has worked on the ninth floor of the jail for 19 years. "There's got to be a better solution than this."
Broward County has had similar problems. On any given day, about 400 people are segregated out of 1,100 inmates -- or 23 percent of the jail system's population -- on psychotropic drugs.
Psychiatric inmates languish in jail eight times longer than other inmates, Judge Leifman says. They wait for court-ordered evaluations. They wait for medication to make them competent to stand trial. They wait for beds in treatment facilities.
Often cut loose from their families and unable to work, they rarely post bail, and when they are released, they have nowhere to go. Many just ride a merry-go-round through a wretched freedom on the streets and oppressive confinement in jail.
Santos did two rounds in jail since his injury. On June 1, 2003, he was arrested for not reporting to his probation officer and released two months later. Without treatment, he was arrested for the same thing in January. This time, he stayed for three months before he even went to court.
"No one is an advocate for these people," said Poitier, the psychiatrist. "They are always at the end of the line . . . always, always, always."
Poitier does rounds every morning, treating up to 100 patients in less than two hours. His only goal is to persuade inmates to take their medication. There is no time for anything else.
Shadowy faces peer out the windows in C-wing, some just gazing, some frantically trying to make eye contact with anyone.
Several inmates are cataleptic, as still as statues. One bangs his head violently and writhes on the floor. Another shouts gloriously, "Thank you, Jesus!"
Poitier, with an unfathomable patience, leans down to the chow hatch of a cell and raises his voice to get the attention of an inmate slumped on the floor.
"Mr. Aviles, do you have any suicidal thoughts?"
The inmate slowly nods no. His eyes are blank. His bare feet are chalky and cracked.
"Do you hear any voices?"
The cell walls are scratched with desperate, fantastical messages.
"Mom, I Miss U," is written in one cell. In the adjacent cell: "I am an alien that not belong here. My place is on the sky."
Poitier comes to a cell with one metal bed rack and three men. On the rack is Jose "Freddie" Jacome. A week before, the 34-year-old man would not move, speak, eat or even shift his eyes.
But on Feb. 6, he agreed to take his medication. Four days later, he was answering the doctor's questions and eating.
Santos was also languishing in jail that day. After several weeks in the C-wing, he was transferred to one of six other psychiatric wings that are less severe. He is allowed to have clothes.
"I was real bad when I came in," he says. "I was talking out loud to myself. . . . It bothers me remembering the things I've gone through. If you could only see what's going through my mind. There's some part of it I can't control."
In jail, Santos was given heavy doses of medication that helped quell the voices but made him slow and groggy, his voice flat.
Santos is as fragile and earnest as a child. His probation officer, the guards and social workers almost dote on him.
"He's just the sweetest kid," says Jill Sperling, a mental health paralegal with the public defender's office.
But his life is a wreck. Santos has been homeless for months at a time, eating out of trash cans. He gets paranoid and thinks his parents are trying to persecute him. He goes on bouts of using crack cocaine.
He once sold the family television set and even stole a necklace off his 7-year-old niece's neck. He was attacked in prison. He has scars from self-inflicted knife wounds all over his body.
"I fight every day in my head," he says. "I don't want to hear voices. Only crazy people hear voices. But I'm not crazy, so why do I hear these voices?"
His family must assure him over and over again that they still love him. "My mom will hug the kids," says his younger sister Dialis Santos, 'and he'll say, `Why don't you hug me, too? I need love, too.' He is a 30-year-old child."
He often tries to call his family, but they don't have the money to accept collect calls from jail pay phones. His disabled father sells avocados on the street corner so Santos can buy cookies and chips from the jail commissary.
Treatment at last
On March 16, Santos was finally sentenced.
The judge granted him a conditional release to the type of in-patient treatment he had wanted, a new program at Bayview Center for Mental Health in Pembroke Pines.
He was lucky to get on the waiting list. There are scant few of these programs and hundreds of people in need.
On April 27, nearly a year after he stabbed himself -- and after more than 165 accumulated days in the county jail -- Santos was finally transferred to treatment.
"They cut down my medication and gave me better therapy," he said last week "I was like a zombie in jail.
"I am alert now. I actually have fun now."