This chapter is a guide to taking on a first consultant post in forensic psychiatry, a guide to supervising trainee doctors in forensic psychiatry and an overview of advice from a group of senior clinical directors in forensic psychiatry across multiple jurisdictions. It is designed to offer informal advice to consultant forensic psychiatrists on a wide range of issues that pertain to clinical practice and management that is rarely contained in textbooks.

Nearly three times as many people detained in a jail have a serious mental illness (SMI) when compared to community samples. Once an individual with SMI gets involved in the criminal justice system, they are more likely than the general population to stay in the system, face repeated incarcerations, and return to prison more quickly when compared to their nonmentally ill counterparts.

State psychiatric hospitals face increasing referrals for the evaluation and restoration of individuals whose mental health symptoms render them incompetent to stand trial (IST). As referrals can overwhelm capacity for admission, state hospitals at times are unable to admit IST patients in a timely fashion. The resulting use of “waitlists” have the undesirable consequence of forcing symptomatic individuals to endure long waits (while jailed) for admission to a psychiatric hospital. These long wait times have been determined to be unconstitutional, resulting in litigation against the responsible state mental health authorities. Unfortunately, available options to expedite hospital admission of these IST patients can have significant clinical and economic consequences.

The history of serious mental illness (SMI) is grim, from a cultural as well as a treatment perspective. The conditions of individuals with psychotic disorders have swung, like a pendulum, from institutional neglect to community neglect and back again over the past several hundred years. At the core of treatment failure is a failure in mental health policy and funding, with the result usually framed as the degree of human institutionalization in jails, prisons and asylums. In the middle of the nineteenth century, institutions designed to deliver moral treatment were considered the humane answer to care properly for the SMI population. By the mid-twentieth century, those same, now overcrowded, institutions were blamed for the horrible conditions of mistreatment of individuals with SMI.

Have you ever walked down the street and seen someone with mental illness, agitated and yelling, or lying on the sidewalk, and wondered why? Have you ever wondered why, despite myriad reforms from bold thinkers and progressive governments over centuries, does this still occur? Why, despite miraculous technology, comfort, and opportunity for the majority of the Western population, do people living with serious mental illness continue to miss out on a good life? Or even a humane one?

Have you ever walked down the street and seen someone with mental illness, agitated and yelling, or lying on the sidewalk, and wondered why? Have you ever wondered why, despite myriad reforms from bold thinkers and progressive governments over centuries, does this still occur? Why, despite miraculous technology, comfort, and opportunity for the majority of the Western population, do people living with serious mental illness continue to miss out on a good life? Or even a humane one?

U.S. health care costs are staggering, with spending at $3.5 trillion dollars in 2017. Additionally, criminal justice system expenditures are estimated at $270 billion dollars. Our nation’s most at-risk individuals are falling through the cracks and entering a vicious cycle of incarceration and temporary institutionalization, which only exacerbates these costs.

Forensic populations in the United States are increasing, driven largely by a rise in individuals determined to be incompetent to stand trial (IST). According to the California Department of State Hospitals’ 2017 Annual Report, the most common type of commitment (22% of all commitments) was defendants adjudicated IST. While just five years ago, 343 mentally ill inmates were awaiting placement for competency restoration services, as of 2018, that number has increased to a staggering 819. As defined by the Dusky v. United States (1960) standard, a competent defendant must have the capacity to understand the legal proceedings, which includes an understanding of the various participants in the justice process. Defendants must also be able to function within the legal system by consulting with their attorneys.

Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred as incompetent to stand trial (IST). The surge in referrals for the evaluation and restoration of patients found IST is taxing state hospital systems, as well as the jails that must care for these patients when state hospitals are unable to accommodate the increased referrals. Many state mental health authorities are facing litigation pressure to admit IST patients more quickly, raising concerns about overcrowding and reinstitutionalization. Little is known about these national trends of increasing IST populations, and even less is known about what is driving them. This survey was intended to broaden the understanding of IST population trends on a national level.

According to the US Supreme Court, all individuals charged with a crime must be competent to stand trial (CST). As defined in Dusky v. US, competency requires that defendants have the ability to consult with their attorney with a reasonable degree of rationality and possess a rational as well as factual understanding of the legal proceedings. The precise number of CST evaluations conducted each year is unknown. The oft-reported figure of 60,000 provided by Bonnie and Grisso is an estimate based on the number of felony indictments coupled with the estimated percentage of referrals for competency evaluations made by the courts in the 1990s. Later work has suggested a much higher number.