Administration and Policy in Mental Health Vol. 21, No. 6, July 1994
DEVELOPING AND IMPLEMENTING A STATEWIDE PLAN FOR FORENSIC SERVICES
P. Ann Dirks-Linhorst, J.D., and Donald M. Linhorst, M.S.W., M.A.
Although in recent years states have gener- ally improved their ability to effectively ad- minister programs (Bowman & Kearney, 1986), state mental health planning con- tinues to be limited (Peterson, 1987). In par- ticular, little has been written about the ef- forts of states to develop and implement statewide plans for evaluation and treatment of forensic clients. The literature instead fo- cuses on administering components of foren- sic systems, such as pretrial evaluations (Poythress, Otto, & Heilbrun , 1991) or the monitoring and treatment of outpatient in- sanity acquittees (Bloom, Williams, & Big- elow, 1991; Scott, Zonana, & Getz, 1990; Silver & Tellefsen, 1991). In July t990, Fo- rensic Services, a program of the Missouri Department of Mental Health (DMH), re- leased a comprehensive statewide plan for forensic services. This article examines the
P. Ann Dirks-Linhorst is Director of Forensic Ser- vices, and is Assistant General Counsel, of the Missouri Department of Mental Health. Donald Linhorst is Program Director of St. Louis State Hospital. Address for correspondence: P. Ann Dirks-Linhorst, Missouri Department of Mental Health, 1706 E. Elm St., P.O. Box 687, Jefferson City, MO 65102.
development and content of the Forensic Plan, as well as its implementation status almost three years after its introduction.
THE MISSOURI FORENSIC SYSTEM
The Missouri Department of Mental Health has three components: the Division of Comprehensive Psychiatric Services (CPS), the Division of Mental Retardation and Developmental Disabilities (MR/DD), and the Division of Alcohol and Drug Abuse. Most forensic clients are evaluated and treated in mental health inpatient and outpatient facilities operated by CPS, al- though a limited number proceed through MR/DD.
Chapter 552, Revised Statutes of Missouri (RSMo), defines forensic clients as defen- dants either (1) court-ordered to DMH for pretrial psychiatric evaluations to determine, among other questions, competency to stand trial and/or responsibility at the time of the offense; (2) incompetent to proceed to trial, and committed to DMH for inpatient treat- ment for up to one year; (3) committed to an inpatient facility as not guilty by reason of mental disease or defect (NGRI) for an in-
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definite period of time; or (4) found NGRI and then granted court-ordered conditional releases that allow a return to the community under specific conditions including DMH supervision.
Evaluation and treatment of forensic cli- ents are provided primarily through four in- patient and seven outpatient CPS facilities. Five hundred and forty forensic clients cur- rently reside in inpatient facilities, which ac- count for greater than 50% of all adult inpa- tient beds operated by CPS. Forensic Services also monitors the progress of 412 NGRI clients living in the community. In addition, Certified Forensic Examiners of Forensic Services completed 643 pretrial psychiatric evaluations during Fiscal Year 1992 (FY92) ending June 30, 1992.
DEVELOPMENT OF THE STATEWIDE FORENSIC PLAN
The state forensic population increased by 54% between 1985 and 1989. This dramatic expansion was not accompanied by the de- velopment of a systematic plan to address the needs of the growing forensic population. Two community incidents prompted a re- view of the forensic program. In late 1988, a client court-ordered for a pretrial evaluation eloped from one of DMH's mental health centers. Shortly thereafter, an NGRI client eloped from the same mental health center during movement of inpatient clients from one ward to another. DMH initiated an in- vestigation, which highlighted the need for uniform policies and for the identification of treatment modalities specific to this popula- tion. Though a Forensic Task Force was convened prior to this, the occurrence of the two incidents and the naming of a new state Director of Forensic Services in June 1989 drove the Task Force to produce the Foren- sic Plan.
DMH mandated that the Task Force de- fine the target population, establish a clear mission, identify problems, and recommend solutions. The Task Force consisted of the Director of Forensic Services, the psychiatric
consultant to Forensic Services, and repre- sentatives from DMH facility staff, the Mis- souri Department of Corrections, the Attor- ney General's Office, and the judicial system. Members were chosen from each of the key components of the mental health and criminal justice systems to assure that the Plan was comprehensive and contained prac- tical, workable solutions to the identified problems.
The Task Force initially made two deci- sions regarding the development of the Plan: its information needs and the extent to which the Plan should contain uniform, stan- dardized policies and procedures in contrast to allowing facilities to establish their own policies and programs. The Task Force chose not to conduct a literature search to review forensic services in other states, nor did they utilize consultants from other foren- sic programs. The Task Force believed its members possessed the experience and ex- pertise necessary to develop a Plan appropri- ate to Missouri's mental health and criminal justice systems and to the needs of its foren- sic clients.
In addition to the expertise of its mem- bers, the Task Force utilized existing data and conducted a survey of the DMH facili- ties working with forensic clients. Little data useful for planning was available to the Task Force. A comprehensive quantitative anal- ysis of the forensic population had not been conducted since 1979 (Petrila, 1982; Petrila, Selle, Fouse, Evans, & Moore, 1981). A statewide data collection system did not exist to provide ongoing client information. Con- sequently, the Task Force had little informa- tion other than documentation of the grow- ing number of forensic clients. The only data collected specifically by the Task Force was a comprehensive survey of each DMH facility providing services to forensic clients, which included their policies and procedures and an assessment of their effectiveness.
In addition to assessing information needs, the Task Force decided to standardize most policies and procedures. The four inpa- tient and seven outpatient DMH facilities had been operating under their individual
P. Ann Dirks-Linhorst and Donald M, Linhorsl 539
policies and procedures for a considerable length of time. The Task Force intended to learn from the experiences of the facilities and to extract those local policies and pro- cedures that were most effective in order to establish the best possible system for the en- tire state. Consequently, the implementation of the Plan was directed toward compliance with the uniform statewide policies and pro- cedures established in the Plan. The Plan still allows flexibility to individual facilities in developing treatment programs unique to special populations, such as clients with per- sonality disorders or with substance abuse problems. As the effectiveness of these local programs is demonstrated, consideration will be given to expand them to other facili- ties.
In order to guide the decision-making pro- cess, the Task Force developed a mission statement that incorporated the dual roles of the forensic system, treatment and public safety. According to the Task Force, the mis- sion of Forensic Services is to evaluate and/ or treat mentally ill criminally committed clients so that they will be capable of commu- nity reintegration without posing a danger to themselves or others. The Task Force also defined its philosophy of service delivery to forensic clients. Treatment is to be provided regardless of legal status. Forensic clients re- quire a seamless system of care to maintain public safety and accountability and, like other mental health clients, they should be provided with individualized services in the least restrictive, clinically appropriate set- ting.
The Task Force proceeded to identify six major content areas that provided the struc- ture for the development of the Forensic Plan: evaluation and treatment, the after- care process, community placement, train- ing, data collection, and legislation. These areas reflect most of the issues identified as being current to state mental health pro- grams (Nelson & Berger, 1988). The re- mainder of this article examines the six con- tent areas and the implementation status of the recommendations developed in the Fo- rensic Plan. For increased clarity, the eval-
uation and treatment section is divided into its three subcomponents, pretrial psychiatric evaluations, restoration of competency, and treatment of clients found NGRI.
PRETRIAL PSYCHIATRIC EVALUATIONS
The primary concern of the Task Force regarding pretrial evaluations was the lack of consistency and thoroughness of the evalua- tion reports and delays in submission to the courts. As a result of these deficiencies, inpa- tient evaluations and second evaluations were sometimes requested when they may not have been otherwise necessary. Also, de- lays in the submission of inpatient reports unnecessarily extended hospital length of stay. At the time of the development of the Forensic Plan, over 50% of the reports did not meet the 60 day statutory timeline for completion. In addition, during both FY85 and FY86, the most recent data available to the Task Force, Forensic Services conducted 36 % of the pretrial evaluations on an inpa- tient basis.
The Task Force offered two re