Developing and implementing a statewide plan for forensic services
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- 537 9 1994 Human Sciences Press, Inc. 538 Administration and Policy in Mental Health 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 recommenda- tions for improving the consistency and timeliness of pretrial evaluations: the estab- lishment of uniform content guidelines for evaluation reports and an increase in the number of certified forensic examiners. The Task Force developed a uniform format for all pretrial evaluations, which was included in the Forensic Plan. Implementation of the format began immediately after its release, and informal reviews of the reports sug- gested a high rate of compliance. To evalu- ate compliance in a more systematic man- ner, adherence to the format became a statewide quality assurance indicator at the beginning of FY92. Initial results indicated a 90% compliance rate by certified forensic examiners with the new format. As to the timeliness of reports, the Task Force concluded that increasing the number of forensic examiners would improve the timeliness of reports, although it acknowl- edged that other factors can have a major 540 Administration and Policy in Mental Health impact on timeliness, such as length of time it takes to receive court orders, police re- ports, or medical records. When the Foren- sic Plan was published in July 1990, 19 indi- viduals were certified by DMH to conduct pretrial evaluations. As of January 1993, the number of examiners has increased to 22. This figure is somewhat deceptive in that only three examiners conduct evaluations on a full-time basis. The other examiners have administrative or clinical duties and may complete one evaluation or less each month. It has not been determined if the amount of time devoted to pretrial evaluations by certi- fied forensic examiners actually increased with the addition of the two examiners. Though the number of examiners expanded, the timeliness of reports decreased from a 50% compliance rate at the time the Task Force met to a current rate of about 40 %. In order to gain more information on why the reports continue to be late, the timeliness of the submission of pretrial reports is another statewide quality assurance indicator. While Forensic Services was unable to im- prove the timeliness of evaluation reports, it was successful in decreasing the number of inpatient pretrial evaluations. During FY91, 15% of the pretrial evaluations were con- ducted on an inpatient basis compared to 36% in both FY85 and FY86. Also, during FY91 only 6% of the evaluations were sec- ond or more requests for the same defen- dant. Although formal data were not avail- able when the Task Force met, it was the opinion of forensic examiners that multiple evaluation requests were excessive. RESTORATION OF COMPETENCY The Task Force conducted an examina- tion of the treatment approaches used in each inpatient facility for restoration of com- petency and found a lack of uniformity in the content of the competency education curric- ulum. In addition, for those individuals found permanently incompetent to proceed under the statute, uniform standards across facilities were not being applied in determin- ing the need for a legal guardian and assess- ing the most appropriate living arrangement for those clients. In response to the lack of uniformity in competency treatment and education, the Task Force established and standardized procedures applicable to the treatment and discharge of clients found incompetent to proceed and refined a competency education course. The Forensic Plan includes both the procedures and the course outline. A recent review of the two areas indicates a high rate of compliance. While the content of compe- tency education training is uniform among facilities, variance exists in the methods by which information is imparted, which allows flexibility to adapt training methods to the individual needs of the clients and to the type and number of staff available to conduct the competency training. The competency edu- cation package developed by the Task Force is now extended to MR/DD clients deter- mined to be incompetent to proceed and be- ing served in MR/DD habilitation centers. TREATMENT OF NGRI CLIENTS Given that most clients committed as NGRI will eventually be released from inpa- tient facilities and return to the community, assisting clients to conform their behavior to the requirements of the law is a primary treatment goal. To accomplish this, the Task Force strongly believed that both the pri- mary mental illness and any underlying problems must be addressed in the inpatient treatment setting. The Task Force identified seven areas that warrant specialized treat- ment: acute mental illness; severe and per- sistent mental illness; antisocial personality and related behavior disorders; substance abuse; sexual offenses; organic impairments; and mental retardation. While no facility has a comprehensive range of specialized programs for all the above areas, some progress has been achieved in program development. Selected facilities are implementing pilot projects and are subsequently providing training to other P. Ann Dirks-Linhorst and Donald M. Linhorst 541 facilities. For example, one facility estab- lished a comprehensive treatment approach known as responsibility therapy for clients with antisocial personality disorders, while another facility initiated a substance abuse inpatient treatment program. Information about the programs and the technical assis- tance necessary to initiate them have been made available to other facilities. Forensic Services also worked with MR/DD to apply forensic policies and procedures to their fo- rensic population currently served in habili- tation centers and community locations. In addition to the specialized treatment programs for NGRI inpatient clients, an- other important aspect of treatment is the gradual reintroduction of NGRI clients into the community. The Task Force reviewed the pass system used by each facility and found the need existed for uniform, objective criteria on which to determine appropriate- ness for passes on or off hospital grounds. A survey of each facility indicated that the issu- ing of passes was more a function of the philosophy of the particular facility rather than the clinical state of the clients. In re- sponse, the Task Force developed the Risk Rating Form, which provides a more struc- tured and systematic means for determining the readiness of clients for passes and whether clients should reside on open or locked wards. The Risk Rating Form is now used by treatment teams throughout the state for de- termining appropriateness for passes. In the few instances when clients were improperly released after the institution of the Risk Rat- ing system, one of two problems occurred. First, selected clinicians disagreed with the outcome of the rating and chose not to use established procedures when approving the passes. In other cases, the treatment teams did not incorporate changes in the condition of the clients into their Risk Ratings. Over- all, the Risk Rating has been successfully implemented because it provides treatment teams with a structured means to assist in the assessment of the readiness of clients for passes and adds another safeguard that they will not be inappropriately released. Some inpatient facilities have found it to be so useful that they are expanding its use to nonforensic clients. THE AFTERCARE PROCESS The Task Force closely reviewed two as- pects of the process by which NGRI clients are released from inpatient facilities and su- pervised in the community. First, they ex- amined the performance of forensic review committees, which are independent three member panels located at each facility that are responsible for reviewing and approving all requests for trial, conditional, and uncon- ditional releases. The Task Force found that methods used by forensic review committees in determining the readiness of clients for release were often subjective and varied among facilities. To increase the objectivity and uniformity of decision making by forensic review com- mittees, the Task Force developed a release review form, which incorporates pertinent factors that may affect readiness for release including the presence of psychiatric symp- toms; current and past behavior, partic- ularly dangerous actions; the course of treat- ment; involvement with drugs or alcohol; an assessment of the current living situation; and the proposed release plan. All review committees currently use the form. While somewhat time consuming to complete, both treatment teams and review committees have found it to be a useful assessment tool, since it offers a more objective and compre- hensive means of determining readiness for discharge and provides a measure of assur- ance to prosecuting attorneys and judges, who ultimately grant all releases, that treat- ment teams are considering all relevant fac- tors when recommending cIients for release into the community. The other aspect of aftercare examined by the Task Force was the process by which NGRI conditional release clients are mon- itored in the community. Missouri statute mandates that forensic case monitors are to have monthly contact with all conditionally 542 Administration and Policy in Mental Health released NGRI clients to determine if they are adhering to the conditions of their re- lease. If violations occur, it may be necessary to revoke the release and involuntarily re- turn the client to the hospital. The Task Force identified the revocation procedure as particularly problematic and consequently established uniform revocation procedures. The procedures eliminated most of the con- fusion surrounding revocations, and all facil- ities are currently using them. COMMUNITY PLACEMENT The Supported Community Living Pro- gram (SCLP), a component of CPS, pro- vides funding for housing for persons with a mental illness , as well as placement and monitoring services. At the time of the devel- opment of the Forensic Plan, over 9,000 SCLP slots existed in a variety of settings, including apartments, group homes, board- ing homes, residential care facilities, and nursing homes. The Forensic Task Force expressed concern about the underutilization of SCLP facilities by forensic patients. Fo- rensic clients occupied less than 2 % of the 9,000 SCLP beds. This significantly under- represents the current inpatient population in which over 50% of the adult beds are occupied by forensic patients. While state- wide SCLP usage is well below expectations, variation exists among regional SCLP offices as to their willingness to work with forensic clients. Several factors appear to account for the low usage: lack of training for commu- nity providers; difficulty in placing clients with certain offense patterns, such as assaul- tive behavior or arson; exclusive placement criteria; and the lack of an adequate history provided by inpatient units. In response to these concerns, the Task Force proposed several recommendations. First, a commitment by DMH to provide housing to forensic clients must be made. Second, training of SCLP staff, community vendors, and inpatient treatment teams is necessary to begin to break down the stigma surrounding forensic clients, to provide edu- cation regarding the forensic system, and to improve the general flow of communication between systems. Next, specification of the expectations of Forensic Services and the re- sponsibility of providers to forensic clients should be specified in contracts for services. Also, social work positions should be created at each regional office that could serve as liaisons between the inpatient programs and SCLP. Finally, criteria for acceptance to SCLP should be modified to include those forensic clients who may not meet the diag- nostic criteria but yet are committed to DMH as NGRI. The Director of Forensic Services and fo- rensic case monitors provided training to the administrative agents who are responsible for arranging community services for DMH clients. The training took place at seven sites around the state and attracted over 150 par- ticipants and is now repeated on an annum basis. The training curriculum was an ab- breviated version of that used with DMH inpatient staff. In addition, service area plans, which act as contracts and set forth the duties and responsibilities of administra- tive agents, now incorporate specific expec- tations concerning forensic clients, such as services to be offered and court testimony requirements. DMH has also made a com- mitment to housing, and a pilot project was initiated in one region of the state to provide supported housing for forensic clients. TRAINING The Task Force surveyed all facilities and learned that no facility had a training pack- age directed exclusively toward forensic is- sues. In response, a Task Force subcommit- tee, which included facility staff development officers, designed a compre- hensive forensic training curriculum to be administered at each facility. The Task Force identified several critical areas for training at facilities: public safety; attitudes toward forensic clients; legislation and statu- tory mandates; court orders; standards for assessment and documentation of progress; evaluation of dangerousness; court testi- mony; diagnosis and treatment offered; se- P. Ann Dirks-Linhorst and Donald M. Linhorst 543 curity issues of both clients and staff; client rights; and individualized treatment plan- ning. The training was completed at six different sites in 12 months. The content was divided into two components with each taking ap- proximately two eight-hour days to complete. Training was mandatory for all direct service staff working with forensic clients. Staff de- velopment videotaped the training so that staff employed after the training was held could benefit, although not all new staff are routinely reviewing the tape. Several factors made the training more difficult to conduct than anticipated, including coordinating staff development resources, adjusting staffing patterns at the facilities to maximize partici- pation, and arranging the schedules of the Director of Forensic Services and the forensic psychiatric consultant. DATA COLLECTION The Task Force identified the need for state- wide data collection that could be available to staffin a timely manner. During the formation of the Forensic Plan, DMH was in the process of developing a statewide information system. If implemented as planned, this system may have met most of the information needs of Fo- rensic Services. To date, the system is not op- erational in the manner originally designed but remains a long-term option. In the absence of a statewide mental health information system, Forensic Services instituted several internal means of data col- lection. First, a one page questionnaire is completed on each pretrial evaluation con- ducted within the state, the results of which are compiled annually. A second source of data is the annual inpatient forensic survey. Inpatient treatment staff complete question- naires on all forensic inpatient clients on a given date. While this survey does not yield data on all inpatient clients served during the year, it provides a cross-sectional view of the inpatient population, and it has been a valu- able source of information. The question- naire was updated in 1992 to provide addi- tional information. Another aspect of data collection includes quality assurance. Forensic Services recently began collecting quality assurance data in three areas: compliance with the established format of social service assessments and pre- trial psychiatric evaluations; compliance with the 60 day timeline for the submission of pretrial reports to the courts; and the in- clusion of substance abuse treatment in the Individual Treatment Rehabilitation Plan of those clients with an identified substance abuse problem. Given other demands on time, most facilities are tardy in the submis- sion of the quality assurance data. However, this remains a priority, and efforts are ongo- ing to assure the review of areas targeted for quality assurance examination. LEGISLATION The Task Force identified two issues to be addressed in the legislative process. First, it recommended that the number of pretrial evaluations be statutorily limited to one, al- though this would apply only to those eval- uations conducted by certified forensic ex- aminers of Forensic Services. This limitation could be effective in decreasing response time to the courts and in reducing inpatient length of stay. DMH was not successful in obtaining this statutory change. Instead of being proactive in seeking legislative changes, DMH has had to respond to legisla- tive attempts to further restrict the condi- tional release process. Next, Forensic Services submitted bud- getary requests to the legislature for an in- crease in the number of forensic case moni- tors, the staff responsible for monitoring the conditions of release of NGRI clients living in the community. When these positions were created by statute in 1985, seven were funded to monitor 250 clients living in the community. While an additional 162 clients have been released to the community since then, the number of forensic case monitors has remained at seven. A request for four more positions was made in FY91 and FY92, and two positions were formally granted in September 1992. 544 Administration and Policy in Mental Health CONCLUSION States attempting to develop statewide plans must address a number of issues. First, who should participate in the planning pro- cess? The development of the Statewide Plan for Forensic Services incorporated all the major actors in the implementation process, including representatives from both the criminal justice and mental health systems. Broad based representation increases the chances that all pertinent issues will be ad- dressed and that obstacles to implementation are identified and discussed. Second, to what extent should local facili- ties be allowed to develop and implement their own policies and programs, in contrast to uniform statewide policies? The Forensic Plan standardized those aspects of the Plan with which Forensic Services already had considerable experience and could make a judgment about the effectiveness of each of the regional policies, such as criteria for passes and for discharge. The Plan allows for flexibility at the local level in new policy and treatment areas, such as working with sub- stance abuse and personality disordered cli- ents. As local programs are implemented and evaluated, Forensic Services will con- sider their implementation on a statewide basis. Third, who controls the resources neces- sary for implementation of the statewide plan? Forensic Services has been most suc- cessful in implementing those components of the Plan under its complete jurisdiction, such as training and the modification of in- ternal policies and procedures. Forensic Ser- vices was less able to implement those parts of the Plan requiring changes in legislation, additional financial resources, or coopera- tion from other departments or systems. In developing aspects of statewide plans that require external involvement, it should be recognized that implementation may pro- ceed at a slower pace and may require addi- tional resources. Finally, to what extent are feedback mech- anisms incorporated into the statewide plan- ning and implementation process? Planning should be a dynamic process, and Forensic Services has developed a mechanism to an- alyze system changes and correct policy fail- ures. In order to provide ongoing feedback, Forensic Coordinators from across the state meet with the Director of Forensic Services on a quarterly basis to discuss implementa- tion of the various components of the Foren- sic Plan, to identify new problems, and to offer solutions. The Director also visits each of the four inpatient facilities on at least a quarterly basis to meet with the staff. Ob- taining feedback on an ongoing basis is nec- essary to modify plans when new issues arise and to ensure that existing plans are address- ing the relevant issues in an effective man- ner. REFERENCES Bloom, J. D., Williams, M. H., & Bigelow, D. A. (1991). Monitored conditional release of per- sons found not guilty by reason of insanity. American Journal of Psychiatry, 148, 444-448. Bowman, A. O'M., & Kearney, R. D. (1986). The resurgence of the states. Englewood Cliffs, NJ: Prentice-Hall. Nelson, S. H., & Berger, V. F. (1988). Current issues in state mental health forensic programs. Bulletin of the American Academy of Psychiatry and the Law, 16, 67-75. Peterson, P. D. (1987). State mental health plan- ning: New opportunities. Administration in Men- tal Health, 15, 29-35. Petrila, J. (1982). The insanity defense and other mental health disposition in Missouri. 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