Insane. Invisible. In danger. ‘Definition of insanity’ Florida spends millions making sure the mentally ill go to court — and gets nothing for it.

Laura Mallia smokes her last cigarette after waking up on the sidewalk near the Salvation Army in Sarasota. Chronically homeless and mentally ill, Mallia has been sent to mental hospitals four times — costing taxpayers about $143,000.

Every year, Florida courts send hundreds of people accused of minor crimes to high security mental hospitals. Forced to live among violent offenders, they get medication to stabilize their symptoms, but little therapy or long-term support to help them manage their illnesses. Instead, the hospitals run patients through drills, day after day, to teach them how a courtroom works. “What is a bailiff?” “What is the role of a judge?”

The singular goal: to get them deemed legally competent so they can return to face their charges. The average cost to Florida taxpayers is $53,000 per defendant. But the moment a patient is declared mentally fit, the state cuts off care and sends them back to jail. Without medication, some fall apart so quickly they are hallucinating again before their first court hearing and must be returned to a mental hospital to start the process all over again. By the time many make it to court, they are told they’ve already spent more time locked away than their crime deserves. “It’s the definition of insanity,” said George Sheldon, who oversaw Florida’s state-funded mental hospitals from 2008 to 2010, when he was secretary of the state Department of Children and Families. “The majority of defendants are picked up for crimes that escalate from a misdemeanor. They get released, then they go off their meds and rotate right back into the system.” As part of a yearlong investigation into Florida’s mental hospitals, the Sarasota Herald-Tribune and Tampa Bay Times reviewed court case files and criminal records for thousands of defendants deemed incompetent to stand trial over the past decade. The records show that, every year, Florida spends at least $50 million restoring the competency of defendants whose nonviolent crimes are so minor they never spend a day in prison. Many spend more time confined to mental hospitals being prepared for court than they would have spent in jail had they simply pleaded guilty to their charges. One patient is still being held eight months after he was caught sleeping in the back of someone’s car. He had taken 97 cents from the dashboard. Another has been committed to a state hospital since July after shoplifting three shirts from a Burlington Coat Factory outlet in Sarasota. After paying for months of “competency training,” the state makes it easy for patients who get out to relapse in just a few days. It releases many of them with no place to live and no support — not even enough medication to last the 30 days experts say it typically takes to schedule a doctor’s appointment to get more. Every year, about 200 defendants get out of mental hospitals only to wind up back there again within 12 months. As criminal defendants cycle in and out of state institutions, thousands of Florida families desperate for mental health services go without. Florida ranks 49th in the nation when it comes to overall funding for mental health. Only five other states have fewer psychiatric beds per capita, according to a 2014 study by the American College of Emergency Physicians, a Texas-based organization that advocates on behalf of doctors across the country. So many treatment beds are taken up by criminal defendants being prepared for trial that there aren’t enough for law-abiding residents who need help. As a result, more than half of those seeking placement at a state hospital wait more than two months for a bed. “Rather than appropriating additional funding to keep up with this growth in demand, Florida simply shifted resources from the civil system to pay for the forensic system,” said Steve Leifman, a Miami-Dade County judge who has led a 15-year crusade to reform Florida’s mental health system. “The result has been fewer services available to those outside of the criminal justice system, which has consequently led to more justice system involvement.”

Miami-Dade County Judge Steve Leifman stands near a shattered window in an abandoned mental hospital. Here, Leifman wants to open a diversion program to keep nonviolent mental patients out of the state's six psychiatric institutions.

If Florida dismissed nonviolent charges against the mentally ill, the state could save enough in mental hospital costs alone to fund more than 600 beds in residential treatment facilities across the state. “The way we spend money now is ludicrous,” Leifman said. “Our emphasis should be on recovery and community reintegration rather than memorizing facts about the justice system.” Experts say no state has figured out how to solve all the challenges associated with treating the mentally ill. But there are lessons to be learned from cities across the country, including some in Florida, that have found ways to provide more meaningful treatment at less cost. In San Antonio, Texas, in 2010, state and local officials worked with private donors to open a treatment center designed as a cheaper alternative to hospitals and jails. It saves the city $10 million each year. Courts in New York City can place mentally ill defendants into a program that keeps them out of jail if they take medication. Officials say the program has cut the cost of treating frequent offenders in half. In Gainesville, defendants can go through competency training in the local jail. The program costs $125 a day — 60 percent less than a state hospital. But the Florida Legislature has been reluctant to expand programs like these. In Miami, a program paid for by the state provides a secure place to house nonviolent offenders for 20 percent less than the cost of one of the state’s mental hospitals. It was started in 2009 and has been heralded as a cheaper, more effective alternative. Today it has 16 beds — six more than when the program was started. This year, the Department of Children and Families has asked for $19 million that could expand treatment options designed to keep people out of jails and make their transition from hospitals to the community easier. State lawmakers will decide whether to approve the money as part of the budget process next year. They also are expected to vote on a bill that would expand jail diversion programs and other treatment options around the state. “What we’re doing now makes no sense,” said Rep. Charles McBurney, the Jacksonville Republican who co-sponsored the bill. “It makes no sense from a criminal justice standpoint. It makes no sense from a budgetary standpoint, and it’s not the humane thing to do.”

65 arrests

Laura Mallia is no stranger to the way Florida handles the mentally ill. Chronically homeless and struggling with a crack cocaine addiction, she has been arrested 65 times in and around downtown Sarasota and Palmetto. She was banned from 7-Eleven for stealing coffee, from Starbucks for walking out with napkins and condiments, and from St. Martha Catholic Church for disrupting a Mass.

How one woman’s care cost Florida $143,000 and solved nothing LAURA LEE MALLIA, 59, has spent a total of 443 days in mental hospitals at a cost to taxpayers of $142,664. PAUL ALEXANDER, MARTIN FROBISHER AND CONNIE HUMBURG | Times

Her mother tried to help. But Mallia was left on her own when she developed Alzheimer’s disease and died in 2014. “Laura has had mental problems since she was a young teenager,” Mallia’s sister, Catherine Orobello, wrote in a 2013 letter to the court. “She has been in and out of mental hospitals and has been diagnosed with paranoid schizophrenia and bipolar disorder. She is a menace to society and a danger to herself.” Four times in the past decade, judges sent Mallia to one of Florida’s mental hospitals so that she could be made competent enough to face her charges. In 2005, she hit and spat at a jail guard. In 2009, she promised an undercover officer oral sex for $20. In 2011, she yelled at someone who refused to give her money at Publix and spat all over the inside of the responding officer’s squad car. In October 2014, she was caught with an $8 lump of crack cocaine. For these four offenses, she spent a total of 15 months in Florida mental hospitals. It cost Florida taxpayers $143,000. In each case, as soon as she could pass a competency examination, she pleaded no contest and was sentenced to time served, meaning she got no prison time for her crimes. Each time, she went back to life on the streets. “You might as well take the money you spent on her, put it in a pile and burn it,” said Larry Eger, Sarasota’s elected public defender. There are cases like Mallia’s all over the state, costing Florida taxpayers millions of dollars each year. The Times/Herald-Tribune used computer programs to analyze a database of more than 16 million criminal court cases over a decade in Florida. The data, collected by the state courts administrator, show that defendants were deemed incompetent to stand trial 30,000 times from 2004 to 2013. The charges in 18,840 of those cases — 63 percent — were for nonviolent offenses. Many others were for minor scuffles with police. Waleska Marie Rivera-Berrios attempted to hug a police officer in a Tampa parking lot in September 2011 and ended up slapping him in the face. Charged with battery on a law enforcement officer and obstruction of justice, she was sent to Florida State Hospital in Chattahoochee for three months and was sentenced to probation a month after her return. Kendall Shane Mitchell was confined to North Florida Evaluation and Treatment Center in Gainesville for a year after he stole $7.19 worth of oranges and vitamin drinks from a Tampa store. When he was deemed competent and sent back to court, a judge sentenced him to probation for petit theft. In Pinellas County in 2009, Louis McShay twisted a policeman’s wrist and attempted a feeble punch. He spent 17 months being trained in court etiquette at Florida State Hospital only to be immediately released after pleading no contest to battery on a law enforcement officer.

Since 1978, Louis McShay has been arrested 50 times within 10 blocks of the St. Petersburg Health Department. Florida spent $160,000 getting him ready for court after a 2009 arrest — only to see him plead no contest and be immediately released back out onto the street.

Eger, the Sarasota public defender, said no one benefits from sending people like Laura Mallia to state hospitals time after time. Taxpayers spend tens of thousands of dollars and the patients get no lasting help, he said. Today, after four stints in a mental hospital, Mallia is once again living on the streets of downtown Sarasota. Last year she was arrested 15 times.

No treatment

Defendants who get sent to a Florida mental hospital for treatment spend up to two hours each day learning how to navigate a courtroom. They watch videos designed to help them understand how the court system works. Sometimes they participate in mock trials, reading scripts that simulate what they can expect to see during their own hearings. There are also hours of quizzes, including courtroom versions of game shows like Wheel of Fortune, where patients spin the wheel to get questions about courtroom functions and etiquette. A typical question: “What is the maximum penalty for a life felony?” A state training video created in 2007 shows the competency training in detail, with actors playing the parts of game show host and mental patient. When one “patient” answers two questions correctly, the host says excitedly: “Congratulations, Mrs. Faust, you are now considered competent to return to court and face your charges!” Patients are tested on their knowledge 30 days, 90 days and 180 days after they arrive at the hospital. If they understand the charges against them, show improvement in their mental conditions and have not had major behavior problems, they are sent back to jail to face trial. The bar for being deemed competent is not high, experts say. “It’s enough for them to know their lawyers are on their side and that they’ll get punished if found guilty,” said Melinda Blostein, a Broward County public defender.

Mental hospital workers use quizzes, game shows and posters like this one to restore patients' competence and help them get ready for their trial.

In the not-too-distant past, patients also got one-on-one therapy, anger management and substance abuse counseling. There was time for vocational training, sports and art. But as the Times/Herald-Tribune reported previously in this series, the state has cut nearly $100 million from mental hospital budgets since 2008. Hospitals eliminated a third of their employees, leaving patients with less supervision and fewer counseling programs. Today at Florida State Hospital, the state’s largest mental facility, patients spend 20 hours a month on therapeutic activities, down from 48 hours in 2008. In comparison, they spend as much as 38 hours each month drilling on courtroom procedure. At South Florida Evaluation and Treatment Center in Florida City, former counselor Gretchen Rovira said she never saw patients spend time with a psychologist for counseling. “There was no one-on-one or talking therapy, at least not while I was there,” said Rovira, who worked at the hospital for several months in 2014 and 2015. “For safety reasons, patients were not able to participate in other events or activities like basketball and art therapy.” What patients need, experts say, are programs that allow them to acquire skills and help them function. “If someone is hearing voices, he should learn how to have those voices disrupt him less,” said Joel Dvoskin, chairman of the Nevada Behavioral Health and Wellness Council. “He should learn that he doesn’t need to listen to what the voices say. He should learn how to make or keep a friend, how to stay housed and treated so that he is less impaired and stays out of jail.”

Futile spending

For years, Florida mental hospitals have focused largely on training criminal defendants to become competent to face their charges. Today, one-fifth of everything the state spends on mental health goes toward that single purpose. But Florida does little to make sure patients who are successfully treated stay competent — not even long enough to face their day in court. It doesn’t matter how serious the crime.

Bobby Lane McGee was convicted of killing his wife, Helene, in 1998. It took prosecutors nearly two decades to bring McGee to trial because of his mental illness. Handout photo

Take Bobby Lane McGee. Back in 1998 he was accused of stabbing his wife, Helene, to death at their Dunedin home. Helene had previously tried to get a restraining order. She reported that McGee sexually assaulted her, burned her belongings and insisted she change her name to Celene “because Helene is from hell and must be destroyed.” McGee later confessed in letters to a judge that he felt he “was being attacked by all kinds of demons” and “started stabbing and swinging out of control.” Prosecutors demanded the death penalty. But it took more than 17 years to bring McGee to trial.

Taxpayers spent about $1.3 million and sent Bobby Lane McGee to mental hospitals six different times to have his competency restored so he could stand trial for the murder of his wife in Dunedin.

Diagnosed with schizophrenia and bipolar disorder, he has been sent to state mental hospitals to have his competency restored at least six times since 2000 — at an estimated cost of more than $1.3 million. Each time, treatment teams controlled his symptoms with psychotropic drugs and sent him back to jail to await trial. Each time, he stopped taking the medications and reverted to a delusional state before his trial could start. Florida law requires defendants awaiting trial in jail to be sent to a mental hospital within 15 days of being found incompetent. But once they have been deemed competent, they don’t remain in the hospital awaiting trial. Instead, they are returned to jail, where there is no limit on how long they can wait for their case to be heard. During this time, there is no guarantee defendants will continue taking the medication that stabilized them. “It’s a travesty,” said Christopher Slabogin, a psychiatry professor and director of the Criminal Justice Program at Vanderbilt Law School. “It’s unethical to put someone on medication and let them off, and it’s incredibly damaging to the individual.” It’s also a significant waste of resources, Slabogin added. As long as defendants are not overly tranquilized, states should find ways to keep them on their medications while awaiting trial, he said. In 2007, state lawmakers introduced a bill that would have allowed jails to petition the court for permission to forcefully medicate a patient for up to 180 days. The bill failed. There is intense debate over whether and how the government should be allowed to force medication on people who are mentally ill. Advocates generally have argued that patients have the right to turn down medical care, and the U.S. Supreme Court has affirmed that right. But there are ways to increase the chances that patients who get competency training don’t relapse before a court hearing can be held. In McGee’s case, prosecutors finally brought him to trial in October after working out a deal to house him at a state mental hospital in Gainesville until he was needed in court. Upon his departure, he was given a shot of Haldol designed to last four to six weeks, enough time to complete his case. He was convicted and sentenced to life in prison without parole. “It’s the only time it’s ever been done in Pinellas County,” said Richard Ripplinger, the assistant state attorney who tried the case. “I think it’s also been done a few times in South Florida.” Alachua County officials use another strategy. They provide competency training and mental treatment in the local jail, speeding up the court process and providing continuous care. In Miami, an innovative program houses nonviolent offenders in a lock-down treatment facility just across the street from the courthouse. Patients remain there throughout their court case. But the vast majority of Florida counties have no such programs, leaving many stabilized defendants to deteriorate in jail. To gauge how long a typical patient waits to get through their case after returning from a mental hospital, the Times/Herald-Tribune examined court records on mentally incompetent defendants in two counties — Sarasota and Hillsborough — where records were easily available. On average, defendants deemed competent in a state hospital waited three months in jail to have their case resolved. Almost 20 percent of them relapsed to the point they had to go back to a mental hospital before their case could be heard.

Small successes

Experts say one way to reduce the high cost of housing nonviolent defendants in mental hospitals is to keep them out of the criminal justice system in the first place. That involves providing other mental health care options — everything from crisis stabilization units and residential treatment facilities to homeless shelters and sobering centers to help people detox. “If you dramatically increase the number of crisis options, police will be less likely to arrest,” said Dvoskin, who served as commissioner of Mental Health for the state of New York. “And if police don’t arrest, patients won’t have to do competency training.” In Nevada, where Dvoskin now serves as chairman of the state’s Behavioral Health and Wellness Council, the Republican governor and Republican dominated legislature agreed to expand Medicaid under the Affordable Care Act last year. That allowed childless adults to get insurance coverage for the first time. Knowing they could get paid through Medicaid, private hospitals immediately added more psychiatric beds. In Florida, Gov. Rick Scott and the House blocked efforts to expand Medicaid earlier this year. As a result, more than 240,000 Floridians suffering from mental illness remain uninsured and there has been no rush to try to serve them. Dvoskin also pointed to a novel program in New York City, where people in emotional crisis can stay overnight at one of four “respite centers.” The program has served about 1,600 people since it began in 2013. New York’s Department of Health and Mental Hygiene says it has saved the state more than $20 million by keeping patients out of hospitals. Among Florida counties, Miami-Dade is the most aggressive in steering people with mental illnesses away from the court system. Every law enforcement agency in the county trains its officers to recognize someone in crisis and keep them out of jail whenever possible. Over the past five years, officers have responded to nearly 50,000 mental health calls and have arrested only 109 people, according to Leifman, the Miami judge. Instead of jail, police diverted most of them to crisis stabilization centers and other health care facilities. The dramatic reduction in arrests permitted Miami-Dade to shut down one of its five jails in 2014. Miami-Dade also has a state-funded program managed by Jackson Behavioral Health Hospital that provides 16 beds to defendants accused of lower-level felonies and found incompetent to stand trial. Patients residing in this lockdown facility must be willing to take their medications and attend group activities. Violent offenders are screened out.

Jackson Behavioral Health Hospital in Miami-Dade County has a diversion program that could be a model for others across Florida. Here, nonviolent mental patients get more intense counseling, not just the “competency training” offered at state mental hospitals.

Staffing ratios are higher and patients get much more intense treatment than they would at state hospitals. They learn basic life skills to help them socialize with others, find an apartment, set up a bank account and manage their illnesses when they get out. They spend five to six hours a day on these activities and only an hour on competency training. Yet the center costs 20 percent less per day than state hospitals because it does not require such high security. And the average defendant spends about 97 days at the center compared to about 220 days at state mental hospitals. The facility also tracks patients and supports them for at least a year after they get out. That’s a critical difference between state hospitals and the Miami program, Leifman said. “It’s not like they’re cured,” he said. “They suffer from serious, chronic illnesses. Without appropriate treatment, many would reoffend and come right back in.” Computer-assisted reporting specialist Connie Humburg and Times researcher Caryn Baird contributed to this report. Times reporter Leonora LaPeter Anton can be reached at [email protected] or 727-893-8640. Times reporter Anthony Cormier can be reached at [email protected]. Herald-Tribune reporter Michael Braga can be reached at [email protected].