When mental illness drops charges, patients are often discharged

For seven years, Timothy J. Fowler alternated between prison, forced psychiatric hospitalization, and freedom.

In 2014, a Great Falls, Montana, man was charged with assaulting two detention officers while in jail on burglary charges. A mental health evaluation concluded that Fowler, who has been diagnosed with schizophrenia, was incompetent to stand trial, according to court documents. After Fowler received psychiatric treatment for several months, a judge ruled that he was unlikely to be competent anytime soon. His case was dismissed, and he was released after a stay in a state-run psychiatric hospital.

About eight months after his dismissal, Fowler was arrested again, accused of beating a stranger with a metal pipe. As before, he was found incompetent to stand trial, the charges were dropped, and he was eventually released.

At least five times from 2014 to 2021, Fowler went through the same cycle: He was charged with serious charges, disqualified by mental health professionals, and his case was dismissed. Fowler declined to be interviewed for this article. As of July, he had not faced any criminal charges in more than a year.

In the United States, criminal proceedings are dismissed if a defendant is determined to be incompetent. What happens after that varies from state to state. No one is tracking how often criminal charges are dismissed because defendants’ mental illness prevents them from understanding the court process to aid their defense.

Some states have a policy of transferring hospitalized patients to liberty after their criminal charges are dropped. But in others, such as Montana, there are few landing spots for such patients outside of prisons or hospitals to help make that transition. Health professionals, county attorneys and criminal defendants say people declared incompetent to stand trial can spend a short time in a mental hospital before being released without additional supervision.

Most people with chronic mental illness are not violent and are much more likely to be victims of crime than the general population. Also, health professionals say most defendants who are determined to be incompetent become stable enough through treatment to continue their cases.

Some never do. The criminal justice system has long been a revolving door for defendants with mental illness. The National Nonprofit Treatment Advocacy Center, which advocates for making treatment for serious mental illness more accessible, found that as of 2017, 21 states had made little effort to create programs that treat those defendants. This failure leaves individuals without stability and some end up harming themselves or others.

“They’re only getting emergency care, then no care at all,” said Lisa Dailey, the center’s executive director. He added that people don’t get treated until they face new charges: “You’re creating a system that requires a victim.”

Dr. Karen B. Rosenbaum, a forensic psychiatrist and vice president of the American Academy of Psychiatry and the Law, said experiences like Fowler’s show a system that fails people released from psychiatric care. “There are a lot of steps that should be taken before you go back into the community,” Rosenbaum said.

Some states have developed such measures. Colorado has a team of navigators who coordinate care for people deemed incompetent to stand trial and a recovery program to provide treatment to patients closer to home. In Oregon, a psychiatric review board works with state hospitals to supervise incompetent individuals to reduce the risk of future dangerous behavior.

But even in states with programs to stabilize people with serious mental illness, treatment is often not warranted because of the limited availability of psychiatric services.

Minnesota has a process for identifying, treating, and managing the risk of individuals determined to be “mentally ill and dangerous.” However, maintaining appropriate staffing levels in treatment facilities has been an issue, as there have been insufficient community-based options for people who need the higher level of care that typical group homes can offer. Last year, a KARE 11 statewide investigation found dozens of cases where people accused of serious crimes — including assault, rape and murder — were deemed mentally incompetent and released without regular treatment or supervision. As a result, more people were injured, according to the investigation.

Forcing someone into psychiatric treatment is controversial, creating tensions between autonomy and public safety. For decades, mental health advocates have pushed for local services, such as intensive outpatient treatment programs and transitional placements. But as psychiatric hospitals are underfunded, local alternatives often lack the resources to meet the need.

In Montana, when cases are dropped because defendants are found incompetent, local officials must file a petition for a judge’s order to admit them into psychiatric care. People may need to attend outpatient treatment options, though attorneys and state officials say those services often don’t exist or are spread too thin. Often, people are admitted to understaffed state-run psychiatric hospitals, which lost federal funding earlier this year due to unsafe conditions and patient deaths.

Montana courts and state officials say cases are dismissed because a defendant is incompetent. However, the state has no way to track when this happens or how many people receive additional treatment in those situations.

Lewis and Clark County Attorney Leo Gallagher said people are sometimes released with their cases dismissed. An involuntary commitment to a mental illness requires the person to be an imminent threat to themselves or others. Gallagher says that’s a high bar to meet.

After a motion for commitment goes to a judge after being found not likely to be fit to stand trial, the defendant may be jailed or hospitalized for months. That deadline makes it difficult to prove an imminent threat remains, Gallagher said, and a judge is likely to deny the commitment.

“There’s a loophole in the system,” he said, adding that he filed the motion knowing they would be dismissed because he couldn’t meet the burden of proof.

Delon Martin, a Great Falls defense attorney, said that if clients whose charges were dropped due to an illness are hospitalized, their discharge is often the end of their care. “People come back into the community expecting to take their medication,” Martin said. “There needs to be a good transition.”

State-run hospitals have long waiting lists. Dr. Virginia Hill, a recently retired psychiatrist who worked at Montana State Hospital for more than 35 years, told lawmakers this spring that a typical stay is two to four weeks, “when you’re charged with a very serious crime, a short commitment to a big plan. done.” He said a patient usually leaves hospital with medication in hand and a local appointment is booked but the patient then exits the system.

“It’s our revolving door population,” Hill said. “The charges were dismissed, and they left. And they’re usually pretty sick.”

He asked lawmakers to consider a way to define in state law who people are unlikely to qualify. To understand what the problem is, Hill said he wants to see more information about who the state hospital treats, whether they receive care elsewhere and outcomes.

Montana lawmakers have drafted a proposal for next year’s legislative session aimed at increasing treatment coordination for people released from psychiatric treatment after being convicted of a crime. Matt Koontz, executive director of the Montana chapter of the National Alliance on Mental Illness, is pleased to see the proposal but said it does not include people whose complaints are dismissed on merits issues.

“Sometimes people would rather let the status quo continue,” Kuntz said, “even if there’s something that’s clearly not working.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides health information to the nation.

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