SPECIAL REPORT: FORENSIC PSYCHIATRY
A recent Manhattan Institute report estimated that 20% of jail and 15% of prison populations comprised adults with serious mental illnesses in the US in 2022 (Figures 1 and 2).1 The same report estimated that the number of incarcerated adults with serious mental illness was greater than both the total population of homeless adults and the number of beds in mental health treatment facilities in the United States.
These unfortunate statistics have major implications for the systems in which we work and the individuals we are trying to treat. As psychiatrists working in forensic settings in New York City, we focus primarily on individuals with serious mental illness cycling among limited outpatient psychiatric services, homelessness, civil and forensic psychiatric hospitals, jails, and state prisons.
Patients intertwined with the justice system still require and are entitled to inpatient civil commitment when psychiatrically decompensated. The 1976 Supreme Court case, Estelle v Gamble, established that incarcerated individuals are entitled to adequate medical treatment as per the Eighth Amendment prohibiting cruel and unusual punishment, including “deliberate indifference” to symptoms.2,3
Yet despite these national standards and requirements for care, patients with criminal histories or current legal charges often face biases from health care personnel and officers when they are referred to or request mental health treatment or psychiatric hospitalization. Despite a high percentage of mental health issues and serious mental illness documented in this population, it is not uncommon for justice-involved individuals to receive additional labels and diagnoses such as malingering, personality disorders, or substance use disorders, which can potentially delay or limit the treatment needed for primary mood or psychotic disorders.
Types of psychiatric hospitalizations available for those incarcerated in the US include acute civil hospitalization, forensic hospitalization for competency restoration, and long-term hospitalization for those who require civil commitment upon release from custody. Individuals in custody may be transferred from jail or prison to an inpatient hospital if their psychiatric symptoms become too severe to manage in the carceral setting. Patients may be transferred to a forensic state hospital from jail or an inpatient hospital if the court questions their competency to stand trial, meaning their ability to understand charges or work with their lawyer.
After restoration of competency and symptom improvement, patients are transferred back to jail to resume legal proceedings on their case. Patients who are found not guilty by reason of insanity are typically committed to a forensic or civil hospital, depending upon their level of risk and treatment needs. The Prison Policy Initiative estimates that in 2024, of 1.9 million individuals currently incarcerated nationwide, 25,000 are civilly committed.4
Inpatient Admission to Forensic Units
Generally, conditions in forensic psychiatry inpatient units are not significantly different from general psychiatry civil inpatient units. In forensic units, patients can leave their rooms, watch television, exercise, and have meals together. They are encouraged to participate in individual and group therapy during the day. Forensic hospitals may have correctional officers present or trained mental health security staff. Forensic inpatient units are regulated by national hospital standards for the use of restraints, seclusion, and intramuscular medications for acutely dangerous patients.
Forensic units often have stricter security policies for civilian staff and visitors than general hospitals, as they follow correctional security regulations. For example, in the jail inpatient units at Bellevue Hospital in New York City, civilian staff members must pass through metal detectors and are not permitted to bring mobile phones into the units. In these units, patient property restrictions are consistent with most general inpatient units, but there are additional restrictions to meet Department of Correction (DOC) standards on items such as clothing, personal toiletries, head coverings, and pillows. Substantial overlap exists between patients in forensic and civil units, as many of the patients treated in forensic units have spent time in civil units, and forensic patients may be transferred to civil units if their charges are dropped. This large number of individuals with chronic mental illnesses in the carceral system has been referred to as the “forensification of mental health” or “transinstitutionalization.”4
The Systems
To illustrate the paths of patients with serious mental illness as they move through the complex interface between the legal and the mental health system, we will share the story of “Aaron,” a man with schizophrenia who is arrested as a result of threatening behavior. If the police initially detect signs of mental illness, they may bring Aaron to a local emergency department (ED) for evaluation prior to any legal proceedings. If the officers involved are not concerned about acute mental illness, they will most likely bring him immediately to the precinct and then to the courthouse for booking and arraignment. Then, depending on the charge and the bail the judge sets, he will be released or transferred to jail.
If Aaron is retained in custody and transferred to jail, he will receive a medical and mental health evaluation to determine the level of medical and mental health services required. Patients with more acute psychiatric symptoms may be housed in mental health units if available, which typically involve more frequent clinical encounters by therapists and psychiatric providers.
However, if Aaron is admitted to the hospital from the psychiatric ED after being brought in by police, or his mental illness symptoms become so severe that he cannot be adequately treated in a jail setting, most jurisdictions will transfer him to an inpatient forensic psychiatry unit while he remains in the DOC’s custody. If Aaron no longer meets the criteria for inpatient admission and his charges are not resolved, he will be transferred back to jail.
Restoration of Competency
In addition to acute psychiatric hospitalization, hospitalization for restoration of competency to stand trial is another legal avenue potentially leading to psychiatric hospitalization in the forensic setting. If Aaron is charged with a felony and is found incompetent to stand trial, he will typically be transferred to a state forensic psychiatric facility (such as Kirby Forensic Psychiatric Center, Mid-Hudson Forensic Psychiatric Center, or Central New York Psychiatric Center in the case of New York) to permit him to proceed with his legal case.5 This usually involves both treatment with psychiatric medications and education about the legal process. Currently, a competency crisis exists across the US, in which court orders for competency-to-stand-trial evaluations and the need for restoration services have been increasing faster than states can keep up with.6 If Aaron is found competent to proceed in his case, he will be transferred back to jail to proceed with his legal case. When back in jail, if acute symptoms reemerge, he may be transferred back to the hospital for acute hospitalization, restarting the treatment cycle and likely extending the length of time incarcerated.
Concluding Thoughts
The paths of individuals with severe mental illness through the legal and mental health systems are often complex and fraught with challenges. The frequent movement of a severely mentally ill patient, such as Aaron, between jail, acute inpatient facilities, and state forensic hospitals can limit continuity of care. However, as shown through the sequential intercept model,4 there are several points along this pathway for a justice- involved patient to be intercepted and diverted to mental health treatment.
As forensic psychiatrists, we are passionate about providing adequate and quality treatment to this underserved and neglected population. Yet ultimately, arrest or legal charges should not be the primary avenue for our patients to have access to necessary psychiatric services or receive quality care.
Dr Schoenfeld is a forensic psychiatry fellow at New York University Grossman School of Medicine. Dr Aggarwal is a clinical assistant professor in the Department of Psychiatry at New York University Grossman School of Medicine. She is also an attending forensic psychiatrist at Bellevue Hospital Center. Dr Kushner is a clinical associate professor of psychiatry at New York University Grossman School of Medicine.
References
1. Eide S. How to reform correctional mental health care. Manhattan Institute. March 28, 2024. Accessed October 1, 2024. https://manhattan.institute/article/how-to-reform-correctional-mental-health-care?utm_source=press_release&utm_medium=email
2. Estelle v Gamble, 429 US 97 (1976).
3. Sawyer W, Wagner P. Mass incarceration: the whole pie 2024. Prison Policy Initiative. March 14, 2024. Accessed October 1, 2024. https://www.prisonpolicy.org/reports/pie2024.html
4. Dvoskin JA, Knoll JL, Silva M. A brief history of the criminalization of mental illness. In: Warburton K, Stahl SM, eds. Decriminalizing Mental Illness. Cambridge University Press; 2021.
5. Munetz MR, Griffin PA. Use of the sequential intercept model as an approach to decriminalization of people with serious mental illness. Psychiatr Serv. 2006;57(4):544-549.
6. Murrie DC, Gowensmith WN, Kois LE, Packer IK. Evaluations of competence to stand trial are evolving amid a national “competency crisis.” Behav Sci Law. 2023;41(5):310-325.