Running head: INCARCERATED MENTAL HEALTH

The Cycle of Mental Health Treatment and Incarceration in Hillsborough County

Shawn Hekkanen
University of South Florida College of Nursing

The Cycle of Mental Health Treatment and Incarceration in Hillsborough County

Incarceration should not be a defining catchment for treating persons with mental health
and substance abuse. With systemic failure to recognize treatment needs in any community,
arrests can reveal unmet treatment needs that reached acute crisis, which increases danger to
officers, persons with mental illness, and the community. Among all states, Florida ranks 49 in
funding level for mental health issues. Compromising to provide limited treatment during
incarceration is biased towards respite and de-escalation, and rather minimally applicable to life
experiences while not incarcerated. For mental health treatment performed under best practice,
patients return to the counselor for validating new coping skill performance, receive feedback to
continue goal-oriented planning, and increasingly build more complex skills (Hirshbein, 2003).
However, incarceration is missing real life stressors and experiences to challenge the learned
skills. After incarceration, routine access to the same therapist is no longer possible and

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transition to community-based care is difficult to both initiate and maintain relevancy for the
patient. New trusting therapeutic relationships must be formed amidst many other needs, such as
food, clothes, shelter, and safety, which form the prioritized steps of Maslows hierarchy of needs
(Hirshbein, 2003). In most circumstances, community treatment is not funded by Florida
Department of Corrections or Hillsborough County (Braga, Cormier, & Anton, 2015). Repeated
incarcerations also create delays in access to care due to needing to restart application process for
health insurances, as well as lengthy intake processes at community mental health centers that
require an intake appointment several weeks before a psychiatric appointment (Braga et al.
2015). At most, the subcontracting provider of the jail will only discharge a patient with several
days of psychotropic or medical medications (Braga et al., 2015). In action, incarceration mental
health treatment seems only to create a model inmate, not a stable citizen perhaps capable of
being in a less restricted environment.
Hillsborough County is located in Midwest Florida and was formed by dividing Alachua
and Monroe counties in 1834 (Hillsborough County Government, 2014). Since then,
Hillsborough boundaries have moved inward with the addition of eight more counties that were
partially formed from old Hillsborough County land. The current total county area is 1,266
square miles, which is approximately 19.4% water and 158 miles of shoreline along the Gulf of
Mexico and affiliated waterways. Hillsborough is the fourth largest county in Florida by
population with over 1,316,298 residents, which is 96% urban and 4% rural (Florida Department
of Health, 2015). Residents are 53.7% Caucasian, 15.6% African American, and 3.4% Asian.
24.9% of residents identify as Hispanic ethnicity. 1.9% identify with more than one race. The
median age of residents is 36 years old. Overall, private companies account for 75% of
employment and the government accounts for 7%, with 18% claiming self-employment. The top
five private employers with local employees are Bay Care Health Systems, Publix, Home

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Shopping Network, University of South Florida, and Tech Data Corp. From the public sector, the
Hillsborough County School Board has the largest amount of employees. This reveals that
education, healthcare, healthy food, and commerce are very important to the vibrancy and
continued growth of Hillsborough County. Bay Care is the largest healthcare system that owns
several treatment facilities. Tampa General Hospital is the largest independent hospital in the
area with 6,700 employees.
The median household income in Florida is $47,212, while Hillsborough County exceeded
the state median with $50,122 (Florida Department of Health, 2015). 16.8% of Hillsborough
County residents live within poverty under guidelines compared to all Florida residents at 16.5%.
The Hillsborough population of high school graduates age 25 years or older make up 87.1% of
residents compared to a Florida-wide value of 86.5%. The Hillsborough population older than
five years old that speaks a primary language other than English is 27.2% of children compared
to Florida-wide 27.8%.
Hillsborough County has several strengths. The median household income of
Hillsborough and Florida in 2000 was $40,663 and $38,819, respectively (Florida Department of
Health, 2015). Data in 2014 indicates a 23.3% increase in median household income data to
$50,122 in Hillsborough, compared to 21.6% increase statewide. Overall, this is thirteenth
highest median income in the state. The household median income is an important marker for
continued growth. Another strength is the amount of kids under 4 enrolled in nursery school is
29%, keeping pace with the rest of the state of Florida at 28.9%. An educated population is more
tolerant of diversity and integrative (Hirshbein, 2003). Hillsborough also has an increasing
amount of people educated with bachelors degrees with 29.8% of the population, compared to
Florida at 26.8%. This is a big increase in educated population from Hillsborough in 1990 at
20.2% of the population with bachelors degrees. As the population percentage of people that are

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educated increases so also tends to increase incomes, tolerance of diversity, infrastructure

investment, recreation investment, and residents engagement in the community (Hirshbein,
2003). Such a community may be more willing to allow more of the incarcerated population to
be eligible for mental health diversion, as compared to the tough on crime approach in the
1990s (Braga et al. 2015). The homicide rate in 2000 was 6.6 per 100,000 people in
Hillsborough compared to a statewide rate of 6.2 per 100,000 people (Florida Department of
Health, 2015). While Hillsborough experienced a drop in 2014 to 5.4 homicide rate, the
statewide rate increased to 6.3. This places Hillsborough in the middle of all county homicide
rates. A population that feels safer also may be willing to enjoy recreation, thus increasing
commerce and sense of community. Overall, safety, continued growth, continued increase in
high school graduations and higher education, and families willing to settle allow progressive
policies towards incarceration to be politically argued (Wilde, Meiser, Mitchell, & Schofield,
2009).
Areas for improvement in Hillsborough County include an overall death rate that
outpaces the rest of the state with 735.8 per 100,000 people compared to 682 statewide (Florida
Department of Health, 2015). Also, the rate of suicide has vacillated from 11.1 per 100,000
people in 2005 to 14.7 in 2006. In 2014, the suicide rate is at 13.7 with 185 confirmed suicides
in Hillsborough compared to 13.9 rate in Florida. This is the fifth highest suicide count of all
Florida counties, but ranked twenty-three in suicide rate, a more accurate measure, though the
media will have more examples to sway public perception. Any person diagnosable with a
severe mental health issue is at increased risk of suicide and substances abuse (Thomas &
Torrone, 2008). Hillsborough has a long history of prosecution for drug cases, and currently
ranks highest of all counties at 7.2% (Braga et al. 2015).

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Hillsborough ranks fifth highest in the daily share of overall Florida incarcerated
population (Braga et al. 2015). If every arrest in Hillsborough sought trial, the backlog of cases
would already collapse the system under the right to a speedy trial. Overburdening
Hillsboroughs criminal system is most evident with persons who are being evaluated for legal
competency to stand trial due to mental illness, under Chapter 916 of Florida law (Braga et al.
2015). These defendants are incarcerated based upon an arrest that cannot be tried in court nor
plea-bargained until the defendant passes a legal competency test. Legal competency has six
defined factors, primarily including appreciating the definitions of the charges, understanding
possible penalties, and understanding courtroom roles of prosecutor versus defense with judge as
referee (Braga et al. 2015). Competency also includes the abilities to maintain courtroom
etiquette, disclose relevant facts to counsel, and testify with relevancy. Annually, two million
arrested people have a related mental health issue (National Alliance on Mental Illness, 2016).
Serious mental illness in local jails occurs in 15% of men and 30% of women. Approximately
70% of persons incarcerated in Hillsborough jail are pre-trial. Half of defendants legally
incompetent to proceed wait longer than two months to be transferred to treatment facilities
known as state hospitals, which specialize in psychiatric treatment and counseling alongside
legal competency training (Braga et al. 2015). The Hillsborough jail subcontracts all medical
services, including mental health treatment, to an independent provider called NaphCare, who
prescribes a limited list of psychotropic medications, thus limited ability to become legally
competent during exhibition of mental health symptoms (Florida Department of Health, 2015).
This statewide integration of counties to attain legal competency for defendants costs the Florida
taxpayer $53,000 per incompetent person with an overall $50,000,000 spent on legally
incompetent nonviolent defendants (Braga et al. 2015).

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Mental health arrests are affected by various determinants. Biologically, severe mental
illness is often manifested by abnormalities in brain structure and neurotransmitter function
(Wilde at al., 2009). Abnormalities are treated primarily by psychotropic medications and
supplemented with therapy to train functional behaviors and thinking patterns, as well as reduce
stress effects that may threaten stability (Wilde et al., 2009). Over time, psychiatric prescriptions
are continuously adjusted to maintain therapeutic drug levels and reduce emergent symptoms.
There is a large genetic component to many diagnosable mental illnesses, as shown in twin
studies, and certain ages make a person more at risk, especially 18 to 25 years of age (Hirshbein,
2003). Within the health system, minorities have a history of being diagnosed differently than
Caucasians for the same symptoms or behaviors, likely due to cultural bias and other factors (de
Freitas, 2015). As diagnosis is the stage before planning treatment, prescriptions may differ
significantly and be inappropriate. Also, persons entering incarceration often lapse health
insurance coverage, whether public or private, creating re-application delays to fund care (Braga
et al. 2015). Environmentally, psychosocial stressors create negative feelings of danger, loss,
grief, and anxiety (de Freitas, 2015). Any history of a severe or chronic trauma, such as child
abuse, being a crime victim, or natural disaster, may become so intense as to create a trigger for
altered brain function and mentally ill thought patterns or behaviors (Hirshbein, 2003). Persons
charged with crimes have a greater likelihood of history of also being a crime victim. Genetic
vulnerabilities or mechanical traumas create specific vulnerabilities towards a particular mental
illness. Lifestyles that have abrupt transitions are more prone to mental illness (de Freitas,
2015). Other examples besides incarceration include moving to college, constantly moving
homes, sudden lack of finances and nutrition access, and lacking a consistent caregiver, each

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may benefit from counseling or other mental health treatment interventions to limit possibility of
diagnosable thoughts or behaviors (Hirshbein, 2003).
The priority health issue for Hillsborough County is incarcerated persons with mental
health diagnosis at risk for increased spectrum and severity of relative symptoms related to
inadequate access to care surrounding an extended incarceration, as evidenced by over half of
criminally incompetent defendants delayed an average of two months or more for adequate
treatment through state hospital.
Primary prevention regards the community for prevention of incarceration of persons
exhibiting acute signs of mental illness that have lead to a potentially criminal act. Preventing
incarceration can be helped by training all officers to recognize potential mental health issues
and perform specialized de-escalation of crisis events. Also, law enforcement should be
encouraged to access non-law enforcement crisis intervention teams run by local mental health
agencies, as well as provide referrals for hotlines for crisis and social service information.
Officers trained as part of Crisis Intervention Teams (CIT) are approximately 80% less likely to
sustain injury on mental health crisis calls (CIT International, 2016). Stakeholders include
mentally ill persons and families, local mental health centers, local law enforcement, judges,
state attorney office, public defender office, state hospitals, state legislators, local legislators, and
first responders. Funding is minimal to train officers for Crisis Intervention Teams, as existing
officers are trained (CIT International, 2016). Certified trainers are supplied as a partnership
between nonprofit CIT International, the sheriff, and local public officials. Officers need to be
encouraged through employee evaluations, promotions, recognition, and awards to perform CIT
interventions. The mental health community health nurse will be essential in forming trusted
relationships with law enforcement to prevent crisis interventions through maintaining treatment.

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Severely mentally ill persons may be eligible for injectable psychotropic medications and nurses
may make house calls to administer medications.
Secondary prevention is focused on the individual that has been arrested and transported
to jail. Stationing licensed counselors inside jail provides familiarity with manifestations of
mental illness, as well as unbiased assessment by non-authority figures. The Mini International
Neuropsychiatric Interview may be the most simple screening tool to briefly screen admits (de
Azevedo Marques & Zuardi, 2008). Early after arrest, assessment and identification of mental
illness provides for saving money and time, increased safety by awareness of active mental
health issues, and opportunity to limit of stress by the arrested person. The licensed counselor
should be placed as near to booking department process as safety allows. Not all persons would
be identifiable early in the arresting process, so reassessment should be performed.
Reassessment would be on the basis of unlicensed staff observations, medical staff observations,
and requests by incarcerated persons who have a verifiable treatment history. Persons with
nonviolent criminal charges should be diverted to acute crisis inpatient units with mandatory
community supervision for follow-up treatment that would allow charges to be dropped with
reported compliance to the court. Persons who are deemed legally incompetent should receive
mental health case management while inside the state hospital that would continue upon
discharge back to jail and local community in order to reduce the treatment gaps that cause
cycling between jail and state hospital. After gaining legal competency, defendants transferred
back to jail waited an average of three months before criminal case resolution, and 20% relapsed
back to state hospital before resolution (Braga et al. 2015). Mental health case management can
help plan with state hospital to provide medications and support that is accessible upon discharge
back to local community. Stakeholders include the local sheriff, court system, families and
mentally ill persons, public officials, and health care providers. Funding concerns include

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psychotropic medications, counseling costs, social services, basic needs, staff for supervision,
and transportation. Funding would need to be provided by costs savings for not having to
supervise people 24-7 inside the jail at $53,000 per incompetent defendant (Braga et al. 2015).
The community health nurse would collaborate with the patient during treatment appointments to
advocate for choices in treatment in order to increase likelihood that patient will continue
treatment. The mental health nurse would also recommend re-evaluations of current treatments,
assess success of adaptation to treatment, and assess for crisis referral.
Tertiary prevention would focus on long-term community reorientation for the individual,
including joining mental health support groups, vocational rehabilitation, attending treatment
appointments and long- term case management to manage access to health care, housing, social
services, transportation, and benefits. The treatment team would continuously evaluate
effectiveness of all wrap-around services. Different members of the treatment team would
attempt to make contact to restart treatment. The patient would be called regularly called to
assess for acute crisis intervention by local mental health center crisis team to prevent hostile law
enforcement interaction. The community health nurse would discuss the long-term side effects of
psychotropic medications, and how to manage diet, activity, and other lifestyle components to
limit side effects. These interventions support positive behavioral patterns, when paired with
routine checkup from trained case managers become an effective means towards limiting
potential crisis events, which are related to law enforcement interactions (Braga et al. 2015).
Stakeholders include local mental health centers, law enforcement, local public officials,
families, and persons with mental illness.
Adequate access to care after incarceration starts with early identification using the
primary level of prevention. Hillsborough policy needs to reflect the uncertain timetables of
moving persons through the criminal justice system and potentially referred to a more

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appropriate treatment system. Diverting people prior to incarceration is the most effective means
of advancing towards the mental health system, as mental health treatment is often compelled
unsuccessfully solely by the threat of incarceration (Braga et al. 2015). If training CIT officers is
successful, they will be less likely to aggravate a situation into further criminal actions during the
potentially criminal event. Altered officer engagement methods may include recognition of
overstimulation, providing options, having brief and simple vocabulary before seeking response,
partnering with licensed mental health teams on certain crisis deployments, being knowledgeable
about process of initiating mental health treatment, and transporting people to acute crisis
inpatient units rather than jails. The health system benefits by prevention of crisis via
uninterrupted mental health treatment, as crisis has the greatest cost. Supporters of the policy
will include the sheriff, families of mentally ill persons, local mental health centers, and local
public officials. Positive media stories are helpful to treatment agencies for funding, and also to
public officials for re-election. Families may be more likely to call law enforcement as crisis
approaches preventing the use of lethal force. One in four deaths by police firearm are related to
acute exhibition of mental illness (National Alliance on Mental Illness, 2016). Forces possibly
opposed to the policy will be public officials seeking a tough on crime approach and crime
victims. CIT International has an application program through its website to apply for training.
The Sheriff and mayor should be approached first. A press conference should be held with CIT
trainers, local public officials, the sheriff, and several male and female officers to be trained.
CIT training hopefully will reduce the amount of suicides, overall death rate, increase visibility
of persons seeking mental health treatment, and create a partnership between law enforcement
and community treatment centers. Hillsborough penal system would be less burdened by
incarcerated people that judges cannot expedite through the judicial process.

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Nursing is consistently noted among trustworthy professions. Nurses will often be the
handoff agents for people diverted from crisis, as initial assessments must include medical and
mental health issues. As I begin my nursing career, it is paramount that I am working towards
equality of treatment to promote community wellness, as all parts of the community interrelate to
increase individual health. Persons with mental health issues require added treatment but can
find meaningful lives if allowed to live in least restrictive environments.
References
CIT International. (2016). CIT: Facts and benefits. Retrieved April 7, 2016, from
http://www.citinternational.org/cit-overview/131-cit-facts-and-benefits.html
de Azevedo Marques, J., & Zuardi, A. (2008). Validity and applicability of the Mini
International Neuropsychiatric Interview administered by family medicine residents in
primary health care in Brazil. General Hospital Psychiatry, 30(4), 303-310 8p.
de Freitas, C. (2015). Aiming for inclusion: a case study of motivations for involvement in
mental health-care governance by ethnic minority users. Health Expectations, 18(5),
1093-1104 12p. doi:10.1111/hex.12082
Braga, M., Cormier, A., & Anton, L. (2015). Definition of Insanity. Retrieved April 7, 2016, from
http://www.tampabay.com/projects/2015/investigations/florida-mental-health
hospitals/competency/
Florida Department of Health Division of Public Health Statistics and Performance Management.
(2015). Florida Charts. Retrieved April 7, 2016, from
http://www.floridacharts.com/charts/OtherIndicators/NonVitalIndRateOnlyDataViewer.as
px?cid=0293
Hillsborough County Government. (2014). Hillsborough County History. Retrieved April 7,
2016, from http://www.hillsboroughcounty.org/index.aspx?NID=2578
Hirshbein, L. (2003). Biology and mental illness: a historical perspective. Journal Of The
American Medical Women's Association, 58(2), 89-94 6p.
National Alliance on Mental Illness. (2016). Law Enforcement and Mental Health. Retrieved
April 7, 2016, from https://www.nami.org/Get-Involved/Law-Enforcement-and-MentalHealth#sthash.D2ANADnZ.dpuf
Thomas, J., & Torrone, E. (2008). Incarceration as forced migration: effects on selected
community health outcomes. American Journal Of Public Health, 98S181-4 1p.
doi:10.2105/AJPH.98.Supplement_1.S181
Truglilo-Londrigan, M., & Lewenson, S. (2013). Public health nursing: Practicing populationbased care. Burlington, MA: Jones & Bartlett.

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Wilde, A., Meiser, B., Mitchell, P., & Schofield, P. (2009). Community attitudes towards mental
health interventions for healthy people on the basis of genetic susceptibility. Australian &
New Zealand Journal Of Psychiatry, 43(11), 1070-1076 7p.
doi:10.3109/00048670903179152