Program Prepares Defendants for Return to the Community

Managing people with mental illness in one Florida jail system is now a little less tangled thanks to a pilot program that restores defendants’ competency to stand trial and prepares them for return to the community.

Miami-Dade County found itself in crisis in 2006 and 2007. Shrinking public funding, closing of hospital psychiatric units, and reduced access to community treatment pushed more people with mental illness into the criminal justice system, said Miami-Dade County Judge Steven Leifman, J.D. Leifman heads the Judges’ Criminal Justice/Mental Health Leadership Initiative and is a member of the American Psychiatric Foundation’s Board of Directors.

The usual pattern at that time was to send incompetent defendants to a state hospital for restoration treatment, then return them to jail. Too often, however, those prisoners decompensated while awaiting trial and had to be sent back to the hospital, even though one-third of the county’s public mental health dollars was expended in the process. That revolving-door system ultimately ground to a halt.

“The state finally ran out of forensic beds, and the head of the Department of Health and Human Services was held in contempt by the courts,” said Leifman in an interview with Psychiatric News. “So we needed an alternative system for competency. We persuaded Jackson Memorial Hospital to fund a forensic psychiatry fellowship and the state to fund a competency restoration center.”

And so the Miami-Dade Forensic Alternative Center opened as a unit within Jackson in 2009.

“The goal was to provide safe, effective, and cost-efficient alternative placement options for defendants ruled incompetent to stand trial and who faced less-serious offenses, had no histories of violence, and were less likely to face additional prison time if convicted,” said Regina Carney, M.D., an assistant professor of psychiatry at the University of Miami Miller School of Medicine. Carney was named chief psychiatrist at the center after she completed the forensic fellowship at Jackson in 2012.

“We are unique in assuring that the patients receive not just medications and competency training here, but also begin the process of recovery,” said Carney in an interview.

“Most competency restoration programs have as their goal to get incompetent defendants restored to stand trial so they can go to court,” said Peter Ash, M.D., an associate professor of psychiatry and director of the Psychiatry and Law Service at Emory University. “The Florida program also appears to aim to get people released to the community with treatment.”

In short, the program serves a diversion function, like mental health courts do, but with a difference, said Ash, who is not affiliated with the Miami-Dade center, in an interview. Even a nondangerous defendant who is incompetent to stand trial can’t legally reach an agreement in mental health court to accept treatment and other services in exchange for release.

At the Forensic Alternative Center, defendants remain in the criminal court system. Prisoners undergo a psychiatric screening on intake at the county jail and then can be referred for a competency assessment. If a judge then rules them incompetent, they either can be committed to a state mental hospital for treatment and restoration of competency—which was the only option prior to 2009—or, now, to the Forensic Alternative Center.

The unit has 16 beds. The staff includes nurses, a case manager, and competency instructors, as well as the psychiatrist. Patients spend an average of 97 days there in treatment, learning life skills and taking competency classes to improve their understanding of who does what in the courtroom and how to work with their lawyers on their case. Peer counselors offer support on the unit and after release.

“We also help them recognize and react to emotional states without acting instinctively, to improve their functioning in the community,” said Carney.

“We needed a hybrid model that fell between community restoration and the state forensic system,” said Leifman. “The Forensic Alternative Center uses a sophisticated medical model to treat the individual’s illness and prepare them to go back to the community.”

Following restoration, defendants return to court where they may receive probation, charges may be dropped, or they may choose to have a trial. Recidivism rates so far have been “almost nonexistent,” said Leifman.

Other states have competency restoration programs, but the Forensic Alternative Center’s approach may herald another approach, one that may someday expand to the rest of the state, he said.

“The Florida program expands the goal of competency restoration from simply a one-size-fits-all model—going to jail and then to court—to a more comprehensive model that considers ultimate disposition,” said Ash.