The criminally insane are feared and reviled. They are kept in overcrowded, understaffed "hospitals" located in rural areas, surrounded by barbed wire, with entry doors easily opened and exit doors always locked. This population has as its members those not fit to stand trial, those acquitted by reason of insanity, transfers from correctional institutions and the "special" offenders who come with labels like "criminal sexual psychopaths." This is the province of forensic psychiatry, long a stepchild of psychiatry and misunderstood by a public that thinks of "Quincy" when the word forensic is mentioned.
Public attention, when given at all, is focused on notorious trials in which the insanity defense is pursued. The outcry which surfaces when a defendant is acquitted on the basis of psychiatric testimony is as predictable as the legislative tinkering with the defense which emerges every few years.
However, there is today a great deal of ferment in forensic psychiatry. This activity is occuring largely out of the public eye. It is concerned primarily not with the clinical or legal aspects of forensic psychiatry (though certainly both are implicated), but rather with the administrative side. For the first time, public departments of mental health and corrections are paying attention to forensic psychiatry as practiced in the public sector.
One visible sign of movement is in the increased numbers of states creating "director of forensic services" positions. These are usually high-level administrative positions located in the department's central office. In most states, the creation of a position like this marks the first time that the particular state has had an individual with system-wide authority who spends all of his or her time working for forensic services.
The creation of these positions has given forensic services much higher visibility within those mental health departments that have them. If there is no such position, the "ranking" forensic administrator may be the head of the state's forensic unit, a position often subordinate to hospital superintendents and department administrators and far removed from the actual locus of administrative authority. Increased visibility in a central administrative capacity means, among other things, an increased voice for forensic service in department debates over the budget. In public psychiatry, where budgets are subject to increasingly cost-conscious state governors and legislators, higher visibility for an advocate for a particular service becomes critical.
Many states are moving away from a system in which one or two maximum security units provide all forensic services. In its place is a forensic system in which it is assumed that both evaluation and treatment will occur initially in the community.
Trend Toward Decentralization
Decentralization has occured for several reasons. First, the community mental health movement has affected more and more types of mental health services and has finally reached the area of forensics. Second, lawsuits have exposed the often inhumane conditions existing in maximum security units and have ordered states to remedy the conditions. In developing remedies, states inevitably consider the alternative of decentralization. Third, a series of lawsuits has developed and validated the "least restrictive environment" doctrine. As a result, some states have studied their forensic populations and determined that not all need a maximum security environment. Fourth, economics have contributed to the trend. Doing out-patient exams in scattered communities is perceived as being both less costly and more efficient than performing forensic exams on an in-patient basis in a unit often located hours from the point of origin.
The impact of decentralization is obvious for community mental health facilities and for the communities they serve. The "criminally insane" will no longer be the sole province of a group of overburdened forensic staff operating in a maximum security unit far removed from the lives of most mental health professionals. …