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William Reid July 31st, 2004 01:22 PM

Moving Forensic Patients from Institution to Community
One of the facilities in which I consult treats patients who have been found incompetent to stand trial or not guilty by reason of insanity. Sooner or later, most of those patients are ready for discharge to the community (except for those who return to jail for eventual trial). In Texas, that means transferring their involuntary care to community mental health center, by means of a court hearing.

It is often difficult to get these folks back into their communities once clinical evaluation indicates that they no longer need inpatient care for either safety or intensity of treatment. The first choice is the community from which they came originally. There are three main barriers: (1) The local judges are reluctant to have troublesome people back in their counties; (2) the community MH center does not want the expense of intensive care and monitoring of a previously dangerous (or perhaps just troublesome) patient (they are responsible for funding the care, with state and federal dollars); and/or (3) there is no appropriate residential placement available in the area (e.g., a group home) with the ability and willingness to closely monitor a patient who has a history of violence or sexual assault).

I'd be very interested in hearing from others who might have some creative suggestions, or who work in systems that make it easier to "step down" these difficult-to-place patients.

phyllis berman August 28th, 2005 11:19 AM

Re: Moving Forensic Patients from Institution to Community
It sounds like a very dangerous situation. In the mid to late seventies a law was passed to allow any mental health/mental retardation individual to be placed in what was referred to as "the leaset restrictived environmrnt." At that time the plan was to build 350 thousand mental health centes across the country. Only 35,000 were built. When I worked in community mental health, the case managers had 300 people on their caseload. Of course, there was no way to get to 300 people.

I have heard the statement that 70 to 75% of the homeless are from this population.

I believe that one of the forensic teams responsibilities is to determine if the individual is "not guilty by reason of insanity." The message, of course, is that if the individual is determined to be insane, I agree there is absolutely no where for them to go. If they are not insane, then the individual should be returned to their home county to await the trial.

In either case it could be very dangerous to release either one into the community.

As an individual I see in counseling who is a nurse on the forensic unit at our state hospitals states "Do you think I am going to argue with someone who just killed his mother, father, wife and children over whether he can have more than one cigarette an hour. In my opinion, he can have the whole carton!"

William Reid August 29th, 2005 03:58 PM

Re: Moving Forensic Patients from Institution to Community
The issue is one of both the patient's clinical eligibility for discharge and his or her right to live outside an institution. You may be misunderstanding the concept of "not guilty by reason of insanity" (NGRI). That's not something a forensic team determines; it's determined at a criminal trial, by a jury or (sometimes) a judge. Once adjudicated NGRI, people don't go back to court for any "trial" related to the alleged criminal activity, though a court may (or may not) retain jurisdiction over whether or not they can be released from the hospital.

You may be thinking of trial competence. People found legally incompetent to stand trial by a court (never by a forensic team, although such a team may recommend such a finding to the court) may indeed be returned to court for trial. Some remain in institutions indefinitely (if they are civilly commitable), some are discharged (if they remain incompetent for trial but are not civilly commitable), and some regain competence and are sent back to court for trial. Of the last group, some are found guilty, some not guilty, some NGRI, and some, while waiting in jail for their trials to begin, again become incompetent to stand trial.

I am concerned about the role -- appropriate or not -- of nonclinical entities such as courts and prosecutors in preventing the appropriate release of patients for whom there is apparently no legal or clinical reason to stay in the hospital. I understand that the community may be fearful of or angry at, the patient, and that there is always some level of risk when discharging any patient, but if no patients are ever discharged, then (1) justice is often poorly served; (2) some patients' rights are violated; and (3) hospitals would have to grow and grow and grow (and grow).


phyllis berman February 11th, 2006 08:24 PM

Re: Moving Forensic Patients from Institution to Community
I agree with everything you said. However, in reality, at least in this state, there is very limited, if any, support. The Community Mental Health Centers are being reduced and downsized. I agree that non-professionals should not be making these decisions.

A violent individual was recently released to a group home in this area. He murdered the only attendant on duty. I cannot understand why a group home would provide only one attendant but, unfortunately, they do. It is an extremely low paying job, barely minimum wage. The hours are long and the staff may be left alone with 15 people. There is a professional on duty at all times but, in this case, there was no one who could call.

The individual is back in the state hospital.

Another concern I have is that in this state there is a mental retardation bill of rights. The people who work in this part of the local state hospital are not allowed to restrain and not allowed to use medication. I see one person who had her finger bit off. Another had her teeth knocked out and her hair pulled out.

The people I see in therapy tolderate this because the job pays more than anything else available in this area. Plus, they have great benefits.

I would like to hear your thoughts on this! Thanks!

William Reid February 12th, 2006 01:11 PM

Re: Moving Forensic Patients from Institution to Community
Wow. I understand the problems you mention in institutional care, whether of the mentally retarded or the severely mentally ill. What state are you referring to?

People who are simply mentally retarded are not usually "violent" or abusive to others; however, there are some folks who have multiple problems (often called "dually diagnosed") or have behavior problems in addition to their mental retardation or developmental disability. It seems logical when you think about it: Even "normal" people come in a variety of personalities, mentally disabled people may have brain-defect reasons for things like aggression, poor judgement, or impulsivity, and it must be extremely frustrating to live life as a severely disabled person.

I am a very strong advocate for three things relevant to your comments: caregiver safety, proper care, and access to & encouragement for appropriate residential settings.

(1) Caregivers' safety. Caregivers who are following the rules and trying to do a good job deserve extensive protection from injury or abuse. Those who are injured because of ill-conceived agency limitations on their safety should, in my view, be talking to their lawyers, union leaders, and legislators.

(2) Proper medical and psychological care for patients/residents. Misunderstanding or misapplication of many of the "rights" you describe actually keep lots of patients and residents from getting better. I've had a lot of experience with this (e.g., as former medical director for a large state department of mental health and mental retardation). Of course people's rights and preventing abuse are important, but those concepts are sometimes stretched to an unhealthily politically-correct extent, usually by people who don't understand the issues and/or are more interested in media coverage than good, individualized care. I have seen, literally, more than one patient "die with her rights on" because a consumer organization (such as a federally-funded protection & advocacy organization which is supposed to work for patients' interests) or a pseudoscientific group blocked necessary care.

Readers of this forum can help by loudly advocating for patients' rights to good care, not just the "right" of mentally disabled patients to "choose" to be left alone by clinicians, and thus to suffer when help is otherwise easily available.

(3) Easy access to care and social encouragement for residential settings/care. Two things -- the misunderstood "rights" mentioned above and state & local financing for the mentally disabled -- prevent many people from getting hospital, institutional, or intensive community care. A shocking number of mentally disabled people who could be helped, or at least safely maintained in humane surroundings, are allowed to suffer (and sometimes die) without such help.

The decades-old idea that hospitals & institutions are bad places, or places of last resort, is simply untrue for hundreds of thousands of mentally disabled people. Of course unwarranted hospitalization is a bad idea, but that's not what I'm talking about. In the over 4 decades since the so-called deinstitutionalization movement began, we should have learned that it only works if (a) the community provides adequate clinical and social supports and (b) the community understands that deinstitutionalization doesn't work for everyone. I can't think of a single state or community in the U.S. that routinely provides acceptable intensive community care for patients who need it, appropriate lengths of hospital stay for patients who need inpatient care, and protected residential settings for people who need something in between hospitals and community supports in order to live reasonable lives.

That's my rant for the day. It's not limited to the forensic pateints referred to in the title of this thread; the issue is far larger.

If readers want to hear more, and/or get in on the beginning of a movement my wife and I call "Real Help," they are welcome to send an email to me at (type the words "Real Help" in the subject line).

William H. Reid, M.D.

phyllis berman March 4th, 2006 06:51 PM

Re: Moving Forensic Patients from Institution to Community
I live in Ohio. The state has something they call "The Mentally Retarded Bill of Rights." This does not allow for any restraint except what is referred to as "the basket hold."

I will certainly subscribe to your post. Sadly, I have felt so powerless in this situation. I am not a state employee. When I briefly worked for the state, there were 1600 residents in this hoispital and 1200 staff. Now, there is less than 100. The rest, as you know, have been put in "the least restricted environment."

Sadly, the people who are left are the people who could no funtion in any community. In one of the group homes in the area a staff member was killed. (Why they would staff this facility with only one person especially at night bewilders me.)

As you know there is power in numbers so I will gladly join in any effort you make toward resolving this situation! Thank you!

sk8rgrl23 March 5th, 2006 12:36 AM

Re: Moving Forensic Patients from Institution to Community
From reading your post and subsequent threads, it sounds like there's no easy answers. I think the initial idea behind deinstitutionalization is good, and I have to say that in our county, it works pretty well when the available services are in place. We have a relatively new program called ACT, Assertive Community Treatment, and high maintenance clients receive basically wrap-around services. Some of these clients have criminal records, some with violence of the disorganized type, though none as serious of histories as what you describe. Unfortunately research and plenty of anecdotal evidence suggests that sexual predators are extremely likely to reoffend no matter what treatment is provided. Witness the recent Dateline project where they lured men into a camera-filled kitchen by making htem think they were in a chatroom conversation with a 14-year old girl. One man had gotten out of jail for a sex offense only hours earlier.

Unfortunately it looks like public mental health is going the way of the public education system, more and more unfunded mandates with ever decreasing resources. Add to that the shrinking availability of living-wage jobs and you have the makings for a community losing stability, and this is what our kids are growing up with, and no wonder we're bound to produce a new generation of people unable to live functionally.

All this while an administration spends considerable time and money on emergency court hearings over a comatose woman, trying to damage-control the Katrina ineptitude and debating the merits of intelligent design. We need a better set of priorities is all I can say.

William Reid March 5th, 2006 05:05 PM

Re: Moving Forensic Patients from Institution to Community
Thanks for your comments. The common explanation that deinstitutionalization works well when there are adequate community services (and access to those services) sounds good on paper, but works poorly in practice. Community services, access, and resources are highly variable, with most being inadequate (usually because of a combination of resource problems, unfortunate priorities, poor services, access limitations related to inadequate case finding or follow-up, and/or access problems related to misguided focus on the "rights" of patients to be miserable).

ACT programs (Assertive/Aggressive Community Treatment) tend to be very good, but they are only available to a tiny fraction of the patients who need them. Almost all community mental health (and mental reardation) service centers have heard of the concept, which has been around for over a decade, and many have tried it. The outcome studies are virtually unanimous that the programs work, both for patients themselves and for saving dollars. Nevertheless, once the newness wears off, attention wanes and funding dries up (or does not expand to meet the need), as legislators and community leaders tend to divert the dollars to something else that has garnered the public's (or media's) attention.

One last thing: I am amazed at the number of very smart people who think the operative phrase is "least restrictive setting." It's not. The complete phrase is "least restrictive clinically appropriate setting." Those two extra words make all the difference between real help and mindless political correctness.

William Reid November 23rd, 2007 11:52 AM

Re: Moving Forensic Patients from Institution to Community
Thanks for reading this thread! The Law, Ethics and Psychotherapy Forum gets a lot of readers, but few new posts. You are invited to contribute statements, comments or questions to keep the forum alive. Pick something you like, or something you don't like, but don't let the threads go stagnant! All I ask is that we avoid personal questions from patients (we can't do clinical work or second-guess therapists here, but we can have professional discussions among clinicians about ethics or forensic scenarios). We also avoid personal attacks.

The possibilities are endless. You can simply reply to a post in an existing thread, or start a new one. Do you have questions or experiences that involve the ethics or legal aspects of training? clinical work? termination? malpractice or malpractice lawsuits? forensic careers? criminal matters related to mental health? boundaries? work with courts or lawyers? work in correctional institutions? work with parolees or probationers? clinician impairment? laws affecting practice?

Choose something you're familiar with or something you want to know more about. If you want suggestions, you're welcome to check out my website at

Bill Reid, Forum Administrator

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