BARTOW — The largest mental health facility in Polk County isn’t the traditional places that people associate with in-patient care, like Lakeland Regional Health Medical Center or Peace River Center.
In fact, the organization that houses the most mentally ill people here is the Polk County Jail, which has 140 beds for mentally ill inmates, while Lakeland Regional has 68 in-patient beds and Peace River has 50 beds.
Polk County is not alone.
“In every county in the United States with both a county jail and a county psychiatric facility, more seriously mentally ill individuals are incarcerated than hospitalized,” states a 2016 report for the Treatment Advocacy Center — “Serious Mental Illness Prevalence in Jails and Prisons.” “Serious mental illness has become so prevalent in the U.S. corrections system that jails and prisons are now commonly called ‘the new asylums.’ In point of fact, the Los Angeles County Jail, Chicago’s Cook County Jail, or New York’s Riker’s Island Jail each hold more mentally ill inmates than any remaining psychiatric hospital in the United States.”
The TAC is based in Arlington, Virginia, and was founded in 1998 to help reform laws throughout the country regarding the mentally ill.
The TAC report states that before the development of psychotropic medication in the 1950s to successfully treat major mental illnesses like schizophrenia, “conditions for patients in state mental hospitals were often abysmal…and provided a major impetus” for releasing hundreds of thousands of patients from asylums and closing down those institutions.
“However, by shifting the venue of these mentally ill individuals from the hospitals to prisons and jails, we have succeeded in replicating the abysmal conditions of the past but in a nonclinical setting whose fundamental purpose is not medical in nature,” the TAC report states.
The United States has the highest rate of incarceration than any other country in the world, according to a 2020 report by The Commonwealth Fund. In December 2018, almost 1.5 million individuals were in state or federal prisons, while another 10.6 million are admitted to jail each year.
According to the National Association of Counties, about 3,000 county and local jails across the United States admit nearly 11 million people each year, including:
• 64 percent with a major mental health illness
• 53 percent with drug dependency or abuse
• 49 percent with co-existing mental health and substance abuse conditions.
“As a nation, we have abandoned the health care needs of our most vulnerable residents. By making 911 a hotline for those in need of mental health services, we send people experiencing a behavioral health crisis to jail at a time when we should instead be providing them with resources and care in the community,” said National Association of Counties Commissioner Mary Ann Borgeson. “We are assured better health outcomes when the burden of care is not placed on local law enforcement.”
In Florida, the Miami-Dade County Jail houses more psychiatric patients than any other facility in the state. According to Florida Health Justice, people with mental illnesses remain incarcerated in the Miami-Dade County jail for eight times as long as people without mental illness for the same charge, and at seven times the cost.
According to a report by Alison Yager of Florida Health Justice, inadequate access to appropriate mental health care has led to Floridians with severe mental illness at increased risk of constant entanglement with incarceration and the criminal justice system.
“Because of systematic disinvestment in our state public health system and mental health hospitals, and because of the outsized number of uninsured and medically disenfranchised in Florida, the Miami-Dade County jail currently serves as the largest psychiatric facility in the State of Florida,” Yager wrote in a June 2020 report. “Lacking access to appropriate care and treatment outside of jail or prison, many individuals cycle through the system for the majority of their adult lives. This may help to explain why Florida incarcerates more adults per capita than 40 of our sister states.”
Polk County Sheriff Grady Judd said his team at the jail works to identify people entering the facility who are significantly mentally ill, including keeping medical records on repeat offenders.
“Once we identify them, we immediately put them back on medication because the vast majority of them – the overwhelming majority of them — have decompensated,” Judd said. “They have quit taking their medication. They are self-medicating with illegal drugs or alcohol and, many times, that’s added to or created the reason they’re in jail.”
Judd said he wants the mental health unit of the jail to “look as much as possible like a mental health facility,” connecting with experts to make sure the walls are painted the right color, what protocols should be followed, and ensure that the medical professionals treat mentally ill inmates appropriately — “as far as is reasonable in a detention environment.”
Capt. Michael Allen, Polk County Sheriff’s Office chief of the jail, said when patients come in, they are asked if they currently want to self-harm, if they have tried in the past to harm themselves, if they are on psychotropic medication used to treat psychosis, if they are currently taking prescription medication, and if they have ever been involuntarily committed (Baker Acted) for a mental health evaluation.
“Kind of just determining where they’re at right now,” Allen said. “We know that when people come to jail, you know, sometimes that can be a very trying time for them and sometimes we don’t see them at their best. Certainly, they’re upset about being incarcerated and we kind of use that screening tool to help us determine who’s going to need help beyond just, you know, I’m excited or upset about being arrested.”
Allen said that they have to determine if a mentally ill inmate needs to be held in their mental health unit or can be held in general population, but medicated, at one of two facilities the Central County Jail in Bartow or the South County Jail in Frostproof.
Inmates in the Polk County Jail identified as requiring behavioral health care are housed in one of two cell blocks: In one, inmates agree to medication management and are otherwise able to share a cell with two other people. The other cell block houses inmates not willing to comply with medication management or are acute enough to require a one-person cell, according to a report by Polk Vision.
A U.S. District Court of Appeals ruling in 1983 upheld that patients do not have to take anti-psychotic medication. However, in 1990 the U.S. Supreme Court upheld that in state prisons, treatment over objection can be accomplished administratively and 31 states utilize a treatment review committee to administer medication.
“Even though this treatment mechanism is authorized in those states, it is often grossly underutilized,” a Treatment Advocacy Center study states. “In state prisons in the other 18 states and the District of Columbia, treatment over objection requires a judicial review or transfer to a state psychiatric hospital, making such treatment much more difficult to carry out. Arkansas was the only state that refused to provide information for the survey.”
The TAC report states that Florida requires judicial review for involuntary treatment. It allows a warden of a Florida Department of Corrections institution containing a mental health treatment facility to petition a local circuit court to seek an order granting nonemergency use of medication. The court will order nonemergency involuntary medication if it determines the inmate is mentally ill and the requested treatment is essential to the care of the inmate. The court must consider:
• The inmate’s expressed preference regarding treatment;
• The probability of adverse side effects;
• The prognosis for the inmate without treatment;
• And the prognosis for the inmate with treatment.
But in county and city jails, the procedures for treating seriously mentally ill inmates over objection vary from county to county and town to town.
“Many jails require the inmate to be transferred to a state psychiatric hospital for treatment,” the report states. “Since such hospitals are almost always full, such treatment does not take place in most cases.”
After evaluating an inmate, a non-treating psychiatrist prepares an affidavit stating that medication is necessary to prevent the inmate from harming self or others, and the inmate’s care and treatment are in jeopardy without such medication. The court then determines whether to issue an order for nonemergency administration of medication.
Polk County Sheriff’s officials said the Polk County Jail has a criminal stabilization unit for treatment or inmates can be taken to Peace River.
The TAC report says the process is “used in extreme situations only. According to people who have experience with the process, the process has become more difficult in recent years as a result of opposition from public defenders. In some cases, an attorney’s opposition may be related to trial strategy. A public defender may be concerned about the effect treatment will have on trial competency, particularly when it is in question. In other cases, public defender objections may be strictly ideological, based on a belief that those with mental illness have an absolute civil right to refuse treatment.”
The Polk Vision report notes that, locally, “inmates requiring behavioral health care – not to mention general population inmates who would benefit from care – receive no (or minimal) counseling services.”
On Sept. 20, there were 2,964 inmates in the Central and South County Jail facilities. Of those, 92 were housed in the mental health units, which has a capacity of 140.
For those 2,964 inmates, the Polk County Jail employs one on-call psychiatrist, one full-time psychiatric advanced registered nurse practitioner, three mental health counselors and two as-needed nurse interns.
A 2014 study on the mental health of prisoners published in the American Journal of Public Health surveyed 18,185 inmates. More than half – 52% – of state prisoners received medication while incarcerated, while 42% of federal prisoners took medication. Fewer than half of both groups — 46% of state prisoners and 41% of federal prisoners — saw a counselor while they were behind bars.
In September, nearly 3,000 inmates were housed at the Polk County Jail, with 604 of them being treated with mental health drugs — about 20% of the inmates.
Judd and Lakeland Regional Health Medical Center’s director of behavioral services Alice Nuttall agree that most inmates are at the jail for an average of 30 days and not much can be done for them psychologically in that timeframe.
“People book in and book out. We don’t — with the exceptions — we don’t deal with long-term people,” Judd said. “We put them on medications immediately, but most take more than that to kick in.”
The TAC report shows that in the nearby Orange County, Florida Jail, the average stay for all inmates is 26 days, in New York’s Riker’s Island, it’s 42 days. Judd said the average stay in the Polk County Jail is 28 to 34 days.
But the mentally ill remain in jails much longer than their mentally healthy counterparts. In Orange County, the mentally ill stay twice as long — 51 days — while in Riker’s Island, it’s five times as long — 215 days. The report states that it is harder for the mentally ill to understand and follow jail and prison rules and thus, more likely to be charged with facility rules violations.
The number of inmates statewide with mental illness has grown continually over nearly 25 years, according to the Florida Health Justice Project, going from 6,777 in 1996 to a projected 30,170 in 2023. It’s expected to climb to 40,000 in 2028.
According to the TAC study, “approximately 20% of inmates in jails and 15% of inmates in state prisons are now estimated to have a serious mental illness. Based on the total inmate population, this means approximately 383,200 individuals with severe psychiatric disease were behind bars in the United States in 2014 — or nearly 10 times the number of patients – 38,000 – remaining in the nation’s state hospitals.”
The TAC report shows that Americans diagnosed with a serious mental disorder like bipolar, major depression or schizophrenia — a psychological disorder that produces visual and auditory hallucinations, delusions, movement disorders, and confused thought or speech — are 10 times more likely to be in a jail or prison than a hospital bed.
TAC states that 2.8 million Americans have schizophrenia — or 1.1 percent of the U.S. population — and 383,000 inmates in the U.S. have been diagnosed with schizophrenia or bipolar disorder. But, the study notes, federal prisons fail to classify serious mental illnesses in prisoners and only require treatment in 3% of inmates.
“But the reality is that approximately 20% of incarcerated Americans are seriously mentally ill. Lack of treatment causes many inmates with schizophrenia to experience heightened negative symptoms which, without treatment, drove some inmates to attempt suicide,” a 2019 Virginia Tech study on inmates with schizophrenia reads. “Administering antipsychotic drugs providing counseling, and offering emotional therapy to people with schizophrenia reduces their negative symptoms, which would help current inmates, and keep non-incarcerated people with schizophrenia out of prison. The United States, compared to other countries, lacks in treating inmates with schizophrenia, thus reform is needed to fix this problem.”
The TAC study shows that it is also more costly to house inmates with mental illnesses. In the Broward County Jail, it costs an average of $80 a day to house a healthy inmate, compared to $130 to house a mentally ill inmate. The study cites increased staffing and additional medications as adding to the costs.
A recent grand jury called Florida’s mental health system a “sad state” and the TAC reports that “most of the mentally ill individuals in prisons and jails would have been treated in the state psychiatric hospitals in the years before the deinstitutionalization movement led to the closing of the hospitals, a trend that continues even today.”
The TAC studied the mentally ill in the nation’s jails and prisons in 2014, stating that, “Sheriffs, jail administrators, and others who were interviewed for the survey expressed compassion for inmates with mental illness and frustration with the mental health system that is failing them.”
The study shows that most jails and prisons are neither equipped nor trained to house hundreds of thousands of seriously mentally ill inmates. In many cases, they are unable to provide them with psychiatric medications. Problems association with incarcerating mentally ill persons include:
• Jail/prison overcrowding resulting from mentally ill prisoners remaining behind bars longer than other prisoners;
• Behavioral issues disturbing to other prisoners and correctional staff;
• Physical attacks on correctional staff and other prisoners;
• Victimization of prisoners with mental illness in disproportionate numbers;
• Deterioration in the psychiatric condition of inmates with mental illness as they go without treatment;
• Relegation in grossly disproportionate numbers to solitary confinement, which worsens symptoms of mental illness;
• Jail/prison suicides in disproportionate numbers;
• Increased taxpayer costs;
• And disproportionate rates of recidivism;
Lakeland Regional’s Nuttall co-chaired a team that helped to produce Polk Vision’s comprehensive study on mental health care in Central Florida, which was released in August.
The report states that “jail inmates are a highly acute population” and are placed into a highly stressful environment that can exacerbate behavioral health issues. “Inmates are more than five times more likely to experience mental health problems than the general public.”
In addition, it notes that recidivism rates are high, with the Florida Department of Corrections estimating that one-third of male prisoners who require ongoing mental health treatment at the time of release return to prison within three years.
The Polk County Jail contracts with Corizon Correctional Healthcare to provide health services at both of its facilities – Central County Jail and South County Jail – including mental health counseling.
“I’m not privy to what happens in those sessions, but I know they have meetings with (inmates),” Allen said. “It’s not a group session, it’s an individual thing where they come in and counsel them concerning how they’re feeling and medication – if it’s working and so forth. As you said, it’s a short-term time that we have and so it doesn’t lend itself to these year-long and two-year long programs.”
The Polk Vision report states that “Inmates identified in jail as needing behavioral health care often ‘fall through the cracks’ (I.e. do not receive ongoing behavioral health – including substance use disorder – care upon release). This notably contributes to the likelihood of a return to unhealthy behaviors and, possibly incarceration.”
According to the Polk Vision report, the percentage of Polk County residents dealing with both mental health and substance abuse issues is 43.9%.
For inmates coming into the county jail who are addicts, there is not a designated unit for them. Instead, drug and alcohol step-downs or detoxifications are conducted in the jail’s medical unit.
Judd and Allen said the jail has provided Alcoholics Anonymous and Narcotics Anonymous meetings, but the COVID-19 crisis has put those meetings on hold because they are conducted by outside volunteers who are currently reluctant to meet with groups, either inside the jail or outside of it.
“We have an active program, but of course we would like to see it more active and hopefully, as COVID kind of goes to the wayside and we can recover from this, we’ll see more and more people coming down here,” Allen said. “It takes them coming in here and working with us to get that done today.
Allen said some inmates are required to stay for six months or a year and, when that happens, they can work with them.
“If they can do without it for that period of time, there’s a good likelihood that if we can kind of change that pattern of behavior, when they get out maybe they won’t use it again,” Allen said.
When asked if he would be willing to hold daily AA and NA meetings, even though most stays are short term, the sheriff said he is open to ideas.
“How many people have addicted themselves to drugs and there’s a psychosis as a result of that? I am a firm believer in AA and NA, but, once again, we live under this illusion that we keep people long enough to deal with their issues and we don’t,” Judd said. “A jail is a short-term facility. But if I can plant the seed in a county jail environment, I’m all for it. I would support that.”
Judd said that many inmates are mentally ill and self-medicating on drugs or alcohol. The daily list of people making their first appearance in court bears that out, with the overwhelming majority arrested on drug charges or violating their parole on drug charges. Many also resist arrest, some violently.
“We’ve got an absolute crisis on our hands and we’re exacerbating that with the suggestion, ‘Well, since we can’t stop the drug importation and use, we’ll just legalize it,’” Judd said. “Whether they acknowledge it or not or are in denial or not, it’s all tied together.”
Judd said there isn’t one wing or one cellblock at the jail dedicated to recovery.
“Let me predicate this by saying I’m not against any new ideas,” Judd said. “But when you look at a significant portion of that jail, they’re all in there for drug crimes or drug-related crimes. So, it’s not like you pick out a wing or a floor or a pod. So, understand I’m not giving you excuses because I’m always ready to do better and learn and do.”
There are a few things that are working in Polk County.
The jail and Tri-County Human Services partner to provide a program called Jail Alternative to Substance Abuse.
“It kind of takes some components over AA and NA, but this is something the inmates can participate in through the courts and, upon completion of the program, there’s a possibility that their sentence could be reduced if they complete the program,” Allen said. “We’ve had that relationship with Tri-County for a long time here, both for males and females.”
Another program that people throughout the county and state applaud is Helping HANDS, or “Healthcare: Access, Navigation, Delivery and Support.” It is funded through the Board of County Commissioners and run in partnership between the Polk County Sheriff’s Office, Polk County Fire Rescue, Polk Health and Human Services, jail healthcare providers and behavioral health providers.
Helping HANDS provides support to people after they leave the jail to ensure they can go to the doctor’s for follow-up visits, obtain their medications, and take their medications
Judd said the program was the brainchild of the late Dr. Thomas McMicken, who was chairman of an advisory committee on the half-cent sales tax for medical services, and was also on the sheriff’s advisory council, in addition to being Judd’s personal physician.
“He says, ‘But we’ve got some money left over and I’m on your sheriff’s advisory council and we can do more with mental health with this money,’” Judd recalled. “I said, ‘I’m in.’”
McMicken passed away in 2017 just shy of his 80th birthday after seeing Helping HANDS instituted throughout the county.
“When they leave and go home, they leave with medication, they leave with a paramedic or EMT that goes by their house, checks on them,” Judd said. “So what we do is we hand them back off to the community. And the goal is that if we keep them on the medication and keep them in the appropriate counseling, they’ll live a healthier life, they’ll live a happier life. They will hopefully live a crime-free life.”
Nutall called it a “crown jewel in Polk County,” one that could be expanded.
“There’s something we need to really be proud of and I think we need to grow it because it’s been very successful,” Nuttall said.
Another program that works is Behavioral Health Court, which steers hand-picked defendants to a special judge who meets with them weekly. They also undergo weekly drug screening and mentors help to guide them to already-existing social services to help them kick substances abuse issues and receive counseling.
The U.S. Department of Justice estimates that the annual cost of corrections to U.S. taxpayers is just over $80 billion, although many experts believe that to be an underestimate.
Incarcerating the mentally ill in Florida’s prisons and forensic treatment facilities costs the state approximately $625 million dollars annually, according to the Florida Health Justice report “Mental Illness and Criminal Justice in Florida: The Case for Medicaid Expansion.” It costs an additional $400 million to house them in county and city jails.
“Over the next decade, state expenditures are projected to increase by as much as a billion dollars annually if present trends continue,” the report states.
One problem that is recognized across the board from national officials to local providers was a failure to bridge the immediate funding gap for inmates transitioning back into society. Some will not have medication and no way to obtain it until their Medicaid kicks back in — it gets terminated when they are incarcerated and they must re-enroll when they leave jail or prison, a process that can take weeks or months after they walk out of jail or prison.
According to a report from The Commonwealth Fund, Medicaid’s role for people behind bars is limited. By law, Medicaid cannot cover services provided to people while they are in jail or prison, with the exception of inpatient hospital stays provided outside of carceral settings.
“This prohibition, known as the inmate exclusion policy, was established in 1965, when Congress first authorized Medicaid, to prevent cost-shifting from state and local governments to the federal government,” the report states. “As a result, states and local governments are solely responsible for financing health care delivered to incarcerated people who qualified for Medicaid before they were in prison or jail.”
For inmates with serious behavioral and public health conditions, the current federal policy of terminating or suspending Medicaid for these individuals results in poorer health outcomes, ultimately driving up recidivism (re-arrest) rates and overall public sector costs, according to the National Association of Counties.
In 2014, many states added inmates who are nonviolent offenders with mental illness or chemical addiction to Medicaid rolls.
“Currently, states and localities bear almost all the healthcare costs incurred within the criminal justice system,” a 2012 article in the magazine “American Jails” stated.
But that didn’t materialize in Florida, which opted out of expanded Medicaid funding programs under the Affordable Care Act .
The Florida Health Justice report states that if Florida were to expand Medicaid to include those incarcerated, the state could see a projected savings of up to $57.5 million for the inpatient hospital care of those currently incarcerated instead.
According to a 2015 Kaiser Family Foundation Study, under a Florida state statute, all Medicaid enrollees who become incarcerated in a state, county, or municipal correctional facility remain eligible for Medicaid, but not enrolled and generally cannot receive services through Medicaid.
Florida requires Medicaid managed care plans to “make every effort…to provide medically necessary community-based services for Health Plan enrollees who have justice system involvement.” Among other things, plans must:
• Provide psychiatric services to enrollees and likely enrollees within 24 hours after release from a correctional facility;
• Ensure that enrollees are linked to services and receive routine care within seven days after release;
• Conduct outreach to populations of enrollees “at risk of justice system involvement, as well as those Health Plan enrollees currently involved in this system, to assure that services are accessible and provided when necessary.”
In addition, plans must work to develop agreements with correctional facilities that will enable the plans to anticipate the release of individuals who were enrolled prior to incarceration.
Nuttall said inmates or former inmates receiving medication and treatment should be everyone’s concern.
“When you think about it like, oh well that’s just, you know, the jail’s problem or oh that’s just the criminal justice (system),” Nuttall said. “These people are our neighbors, these are our friends, these are our community members and there’s a lot of opportunity to be able to care for them and then vice versa.”
Ledger reporter Kimberly C. Moore can be reached at email@example.com or 863-802-7514. Follow her on Twitter at @KMooreTheLedger.
Polk County’s Peace River Center offers a 24-Hour Emotional Support and Crisis Line: 863-519-3744 or toll-free at 800-627-5906.
From the Treatment Advocacy Center Report “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey”
What is it like to be seriously mentally ill and in prison or jail?
There are many adverse aspects of incarceration for an individual with serious mental illness. Such individuals are often raped or otherwise victimized, disproportionately held in solitary confinement, and frequently attempt suicide. Because treatment of mental illness is often not available behind bars, symptoms often get worse, sometimes leading to self-mutilation.
Prior to the introduction of effective medication in the 1950s, conditions for patients in state mental hospitals were often abysmal. Exposés of these conditions provided a major impetus for the deinstitutionalization of the patients and the closings of hospitals. However, by shifting the venue of these mentally ill individuals from the hospitals to prisons and jails, we have succeeded in replicating the abysmal conditions of the past but in a nonclinical setting whose fundamental purpose is not medical in nature.
• In New York, a man with schizophrenia was in prison for 15 years, 13 years of which were spent in solitary confinement.
• In a Minnesota county jail, a man with schizophrenia blinded himself with a pencil while “standing naked in his cell, standing in his own feces, screaming gibberish.”
• In a Mississippi prison specially designed for mentally ill inmates, “rats climb over the prisoners’ beds, and some prisoners capture the rats, put them on makeshift leashes, and sell them as pets to other inmates.”
This survey found that the administrators of many prisons and jails have undertaken impressive efforts to provide appropriate psychiatric treatment. Treating mentally ill inmates who are aware of their illness and will voluntarily accept treatment is comparatively easy. The real problems come from mentally ill inmates who refuse treatment because they believe they have no awareness of their illness and believe they are not sick, which is called anosognosia.
Mental Health: Polk County Jail is home to more mentally ill people than hospitals or treatment centers – The Ledger
BARTOW — The largest mental health facility in Polk County isn’t the traditional places that people associate with in-patient care, like Lakeland Regional Health Medical Center or Peace River Center.