The role of state-operated public psychiatric hospitals as changed in the era of the deinstitutionalization f mental health services. No longer are these hospitals the hub of psychiatric services in most states (Pepper & Ryglewicz, 1985). Instead, their function is being redefined, and they are becoming providers of primarily long-term psychiatric hospitalization. There is a growing recognition that in spite of the availability of a range of community psychiatric services, a small number of people will need inpatient psychiatric hospitalization for extended periods because of the severity and persistence of a serious mental illness or because of behaviors that are unmanageable in the community (Belcher & DeForge, 1997; Lamb, 1997; Lamb & Shaner, 1993). In addition, public psychiatric hospitals are dedicating increased resources to the care, custody, and treatment of forensic patients (Scott, 1997).
Although definitions vary across states and types of mental health settings, the term forensic typically refers to a legal status whereby a person has a mental illness and is involved with the criminal justice system. Types of forensic patients may include defendants referred for court-ordered pretrial psychiatric evaluations, defendants found by the courts to be incompetent to stand trial, defendants acquitted as not guilty by reason of insanity (NGRI), defendants convicted as guilty but mentally ill, and some convicted defendants who committed sex crimes.
The role of public psychiatric hospitals in the treatment of forensic patients has expanded in recent years as some states' public psychiatric hospitals have experienced a dramatic increase in the number of forensic patients they serve. As a result, the care and treatment of forensic patients is consuming a large percentage of the resources of those hospitals. For example, Lamb and Shaner (1993) reported that forensic patients occupy 41 percent of public psychiatric hospital beds in California. In their study of Oregon's forensic system, Bloom and Williams (1994) indicated that the state had to open new public psychiatric hospital beds to serve the increasingly large number of NGRI forensic patients committed for inpatient treatment. In Missouri the percentage of long-term public psychiatric hospital beds occupied by forensic patients increased from 14 percent in 1981 to 61 percent in 1995 (Linhorst, 1995a). The greater percentage of public psychiatric hospital beds occupied by forensic patients results in part from a combination of an increasing number of hospitalized forensic patients and a decreasing number of public psychiatric hospital beds, which has occurred as a result of the deinstitutionalization of psychiatric services.
Historically, analyses have found the treatment of forensic patients in public psychiatric hospitals to be inadequate. Ladds (1997) argued that forensic psychiatry has focused on the evaluation of forensic patients rather than their treatment. Ogloff, Roberts, and Roesch (1993) reported that the use of medication is the most common form of treatment for forensic patients and that psychotherapy for forensic patients is often unavailable. Similarly Heilbrun, Nunez, Deitchman, Gustafson, and Krull (1992) found that relevant treatments (for example, cognitive-behavioral interventions) usually were not provided even when clinically appropriate. Contributing to poor treatment is the failure to consider the treatment needs of forensic patients when designing services for this group. Steadman (1985) contended that minimizing costs and using available buildings and other resources dominate planning.
In spite of the increasing role of public psychiatric hospitals in the treatment of forensic patients, research in this area has been meager (Heilbrun et al., 1992). To address this research void, the study discussed in this article examined patients residing in Missouri's four long-term public psychiatric hospitals, which treat both forensic and voluntary patients. …