Lookin’ for beds in all the wrong places: Outpatient competency restoration as a promising approach to modern challenges.

Abstract

In response to consistently increasing numbers of individuals found incompetent to stand trial, some states have identified community-based or "outpatient" competency restoration programs (OCRPs) as a viable alternative to inpatient restoration. This study used a multistep approach to capture information about OCRPs nationwide. We reviewed states' competency statutes to determine which states have provisions that allow for outpatient competency restoration, and we then corroborated this review with a brief preliminary survey that was disseminated to each representative of the Forensic Division of the National Association of State Mental Health Program Directors. We received responses from 48 of 51 U.S. jurisdictions (47 states and the District of Columbia). We conducted in-depth interviews with forensic representatives in those 16 states that identified having operational OCRPS. The current study presents our analysis of state statutes and then compares and contrasts current OCRPs. In summary, OCRPs are a recent but rapidly developing alternative to traditional inpatient restoration. Through a comparison of existing OCRPs, we believe OCRPs show preliminary but promising outcomes in terms of high restoration rates, low program failure rates, and substantial cost savings.

Patient Characteristics and Outcomes Related to Successful Outpatient Competency Restoration

“…The large number of defendants in need of such treatment has led to a significant strain on resources and a log‐jammed forensic system (Wortzel et al, ). Despite an apparent need for outpatient competency restoration treatment, research on such programs remains scarce, and most states seem to be reluctant to utilize them (Gowensmith et al, ; Miller, ). Our goal was to provide a description of one program that has been successfully implemented and to examine the factors related to competency restoration in the civilly committed forensic outpatients it has served.…”

“…The competency restoration rate in the current sample was 54%. That figure fell roughly between the 32% restoration rate reported by Johnson and Candilis () and the national summary statistic of 70% reported by Gowensmith et al () across outpatient programs. Typical restoration rates reported for inpatient programs nationwide approximate 75%, although previous data from Louisiana indicate that the rate found in the present study is comparable with inpatient data (54%; Advokat et al, ).…”

“…Further, the forensic mental health program directors in only three of those states reported that more than 5% of all restorations were done on an outpatient basis (Miller, ). More recent reports indicate that 35 states (plus the District of Columbia) now permit outpatient restoration, but only 16 have functioning formal programs (Gowensmith, Frost, Speelman, & Therson, ; Johnson & Candilis, ). Thus, it is clear that states have been reluctant to allow and to actually utilize outpatient competency restoration programs.…”

“…Most frequently, competency restoration treatment involves addressing an underlying psychiatric disorder, often with psychotropic medication, as well as remediating psycholegal deficits with education and information about the legal process (Gowensmith et al, ; Noffsinger, ; Zapf & Roesch, ). Although those are common practices, very little research has actually evaluated what type of treatment is effective in restoring competency (Mueller & Wylie, ; Noffsinger, ; Scott, ), particularly in the outpatient setting.…”

“…Seventy‐six percent of individuals who were restored achieved competency within the first 45 days of participation, and all of those who were restored achieved competency within 135 days. Gowensmith et al () reviewed available data on outpatient competency restoration programs as of 2014. They found that a majority of these programs had been operating for 10 years or less, and each served about 50 defendants per year.…”