Article
The ROC Program: Accelerated Restoration of Competency in a Jail Setting
Journal of Correctional Health Care 2014, Vol 20(1) 59-69 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345813505067 jcx.sagepub.com
Kevin Rice, LCSW1,2, and Jerry L. Jennings, PhD2
Abstract In 29 months of operation, the restoration of competency (ROC) program provided treatment services to 192 incompetent to stand trial patients in a jail setting. The ROC restored competency for 55% of the patients in an average of 57 days compared to the state hospital average of 180 days. The average cost of treatment/restoration per admission was $15,568 compared to the state hospital average of $81,000. The ROC model accelerates needed treatment for mentally ill defendants, cuts demand for costly state hospital forensic beds, and assists jails in better managing inmates with severe psychiatric disorders—yielding major cost savings and improved care. In addition to preventing readmissions and negative behavioral episodes, the ROC improved the broader forensic system by eliminating the state hospital waiting list, accelerating access to psychiatric services, promoting local access for lawyers and family, and gaining stakeholder satisfaction. Keywords restoration of competency, jails, mental illness, psychiatric treatment, forensic patients In the past 15 years, severe reductions in public mental health services have caused increasingly high numbers of people with severe and persistent mental illness to land in the criminal justice system (Lamb & Weinberger, 2005; Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010). Budget cuts to state hospital systems and community-based mental health resources have shifted the cost and services burden to local emergency rooms, county jails, and law enforcement agencies. Even before the dramatic cuts precipitated by the economic recession of 2008, Wortzel, Binswanger, Martinez, Filley, and Anderson (2007) decried the common practice of jailing persons with severe mental illness who are incompetent to stand trial (IST), often for long periods of time, and often without adequate psychiatric treatment, because there are not enough forensic beds available in state hospital systems.
1 2
California ROC Program, West Valley Detention Center, Rancho Cucamonga, CA, USA Liberty Healthcare Corporation, Bala Cynwyd, PA, USA
Corresponding Author: Jerry L. Jennings, PhD, Liberty Healthcare Corporation, 820 E. City Ave., Suite 820, Bala Cynwyd, PA 19004 USA. Email: [email protected]
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Hundreds of patients with severe mental illness deemed incompetent to proceed are languishing in jails around the nation, unable to access meaningful psychiatric care and not moving forward in the legal process as they await admission to grossly undersized and understaffed state hospitals . . . The combination of inadequate psychiatric care, the stress of incarceration, and the long waits involved have yielded nightmarish results . . . . (Wortzel et al., 2007, p. 357)
A variety of interventions and approaches have been developed to address this national IST crisis, but they have shown mixed results (Jennings & Bell, 2012; Justice Policy Institute, 2011). Assisted outpatient, involuntary outpatient commitment, and court-to-community programs have had some success in removing mentally ill defendants from jails, but cannot be used for those charged with violent and dangerous crimes (Gilbert et al., 2010; Lawlor, Grudzinskas, Geller, & Genovese, 2007; Loveland & Boyle, 2007; Swartz, Swanson, Kim, & Petrila, 2006). In particular, mental health courts have multiplied across the country to divert mentally ill defendants and substance abusers from incarceration and toward appropriate treatment (Redlich, Steadman, Clark-Robbins, & Swanson, 2006; Watson, Hanrahan, Luchins, & Lurigio, 2001). Mental health courts entail a range of features, including nonadversarial process, training judges in mental health, and collaborative interagency teams (Wortzel et al., 2007). Jail diversion programs, which include a variety of prebooking, postbooking, and pretrial diversion as well as deferred prosecution strategies, attempt to divert patients into community-based treatment (Watson et al., 2001) and some appear to reduce rates of rearrest and jail days (Case, Steadman, Dupuis, & Morris, 2009). Nontreatment interventions, such as housing programs and long-term residential services, have also been tried (Robbins, Petrila, LeMelle, & Monahan, 2006). These strategies can help prevent recurrent relapses and reoffending, especially for homeless persons with severe mental illness, but cannot be exercised immediately to avert hospitalizations or detention (Miller, 2003; Trudel & Lesage, 2006). In short, although many approaches have been tried, the problem of holding IST patients in jails for extended periods of time persists and appears to be worsening.
The Restoration of Competency (ROC) Model The jail-based ROC model offers an innovative and cost-effective method to evaluate, treat, and stabilize persons with severe mental illness when they are first arrested and detained—and restore them to competency in the jail setting—rather than waiting indefinitely for long periods of time for available state hospital forensic beds. The ROC program was first piloted in Virginia in a successful 5year program in the late 1990s (Bell, 2003; Jennings & Bell, 2012). The ROC model has numerous advantages for state mental health systems, local courts and jails, and patients. ROC Advantages for State Hospital Systems. 1. Reduces demand for limited state hospital forensic beds for competency evaluation and restoration services, including large and lengthy waiting lists for admission to state forensic hospital beds. 2. Reduces length of stay for restoration through earlier intervention and targeted treatment that keeps symptoms of mental illness from worsening in the stressful, nontreatment setting of a typical jail. 3. Maximizes resources by distinguishing patients who can be restored in a short-term program while conserving state hospital beds for patients who require long-term or indefinite treatment. 4. Forestalls admissions to the state hospital for persons who are malingering to get out of the harsher confinement of a jail or prison.
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5. Helps to maintain competency to stand trial and averts relapse and rehospitalizations through seamless transition from the ROC program back to the court and jail. ROC Advantages for Local Jails and Law Enforcement. 1. The local county/jail saves money by reducing the time spent in jail by mentally ill inmates, who cost significantly more than ordinary inmates. 2. Jail can potentially gain revenue to cover the expenses already incurred by holding mentally ill inmates. (In California, the jail receives a per diem from the state Department of State Hospitals for hosting the service.) 3. Eliminates the time and cost of escort and transport between state hospitals and jails. 4. Reduces disruptions to jail operations caused by psychotic and disordered behavior. 5. Reduces risk of suicide, violence, injury, and litigation by providing extended hours of treatment-oriented attention and support in a more therapeutic setting within the jail. ROC Advantages for Local Courts and Patients. 1. Improves convenient access for local courts, defense attorneys, prosecutors, law enforcement, and family support. 2. Reduces the length of time that patients would otherwise wait for transfer to the state hospital for forensic evaluation and restoration and initiates restorative treatment more quickly. ROC Program Description. For the past 2½ years, the jail-based ROC model has been used in California with promising results. Patients and program space. The main program is a traditional male residential pod within a county jail with 20 beds and dayroom space for group programming. Given the small number of females (10% of the referrals), services are delivered to females individually without any treatment or activity groups. ROC referral process. The following is a simplified summary of the typical steps in the process of referral and admission to the ROC program. Following arrest, the individual with mental illness is held in the local jail until arraignment within 48 hours. A public defender is typically assigned at this time and preliminary hearings are scheduled. The preliminary hearing determines if there is enough evidence to go ahead with the trial and, if so, a pretrial court hearing is scheduled in about a week. If there is doubt about competency to stand trial, the judge suspends all criminal proceedings and orders an independent psychiatric forensic evaluation (which can entail one to three different evaluators depending on the case and usually takes 1 month per evaluation). If the defendant is determined incompetent, all criminal proceedings remain suspended until he is considered to be competent to stand trial. Within 15 days, another placement evaluation is performed by the California Conditional Release Program to determine if restoration will require secure confinement or community treatment. If confinement is required (as it is in 90% of the cases), the inmate is committed to the ROC (or the state psychiatric hospital) for restoration. The committing court asks for a progress report 90 days after commitment and then every 6 months. If competency cannot be restored in the near future in the ROC, the individual is typically referred to the state hospital for restoration. Following restoration and discharge from the ROC, the patient is typically placed in specialty housing (in the same housing pod where the ROC is operated), but about 10% are placed in the general inmate population. Admission/assessment and treatment planning. Treatment begins with the intake assessment. The clinical team evaluates the person’s psychological functioning, suicide and behavioral risk, current level of trial competency, and likelihood of malingering. A standard battery of psychological tests is
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used to evaluate cognitive abilities, social and psychological functioning, psychiatric symptoms, and potential malingering. As needed, the ROC psychologist has other tests/screenings available for specific targeted areas of deficit. Assessment continues through the course of the admission to measure response to treatment and identify new problems to target for ROC. The Competency-related Abilities Rating Scale is used to monitor the individual’s progress (Hazelwood & Rice, 2010). Based on the assessments, the treatment plan is individualized and geared toward one of two curriculums for lower and higher functioning patients. But treatment planning continues to be flexible and vigorous. It is common for the treatment team to discuss the treatment plan informally on a daily basis and to formally discuss treatment issues at least once a week. Approach to competency restoration. The ROC program uses a recovery model that focuses on individual strengths and targets abilities that are related to competency, including remediation of deficits and alleviation of acute symptoms. The primary goal for most IST patients is to resolve the psychosis, when present, to enable the patient to regain general thinking abilities. The second goal is to educate the patient in the legal/court process such that he is able to cooperate with his counsel in mounting a defense. If there is a failure to achieve either of these goals, the third goal is to compile documentation to credibly opine that the patient is unrestorable to competency. The ROC team combines the proactive use of psychiatric medications, motivation to participate in rehabilitative activities, and multimodal cognitive, social, and physical activities that address competency in a holistic fashion. Interdisciplinary treatment team. The interdisciplinary ROC treatment team is like that of a traditional forensic psychiatric unit, including a forensic psychiatrist, forensic psychologist, psychiatric nurse, social worker, rehabilitation therapist, and clerk to coordinate scheduling, court dates, transports, and forensic reports. The direct care staff are specially trained security officers who are dually trained in security and treatment functions. Security personnel understand that clinical information is confidential and available on a need-to-know basis only. They do not have access to medical records. The designated ROC deputy attends treatment team meetings and is the only security officer who is privy to clinical information. Daily rehabilitative schedule and coordination of medical care. Individuals in the program typically meet with a treatment professional one-on-one at least twice daily about issues related to regaining their mental health and/or competency. They are also engaged in 3.5 to 5.5 hours of group-based psychosocial rehabilitative activities each weekday depending on the individual’s current capacities. (Experience showed that the lower functioning patients could not tolerate more than 3 to 4 hours of focused work per day.) Treatment activities are structured and delivered across four domains: ROC, mental illness and medication management, mental/social stimulation, and physical/social stimulation. Basic residential and health care, including all medical care and medications, are provided on-site through a service agreement with the county jail to use its existing pharmacy, medical records, and medical service delivery system. Modules/groups at two cognitive levels. Many patients with active psychosis or low intellectual functioning can be easily confused and overwhelmed by too much education about competency and the legal process. Likewise, their abstract reasoning is impaired, so it is important to keep the legal information specific to their individual case. They can be confused by videos and scenarios and roleplays that apply to other patients’ legal cases. The primary distinction of the lower functioning group is its de-emphasis of cognitive concepts and the use of simple language, simple learning strategies, and familiar constructs or icons. The classes are kept to a very small size to allow for individualized attention. Repetition and multisensory learning helps group members better retain content. Videos are used to concretely demonstrate and facilitate discussion of relevant topics.
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Conversely, many higher functioning patients do not need basic legal education and can go directly to the second-level competency education groups. The higher-functioning group modules entail applying and practicing legal knowledge and skills, often using more experiential modalities like role-plays and video discussions. The higher level competency groups can focus more on advanced discussion and problem solving specific to their individual situations. No involuntary medication. Although allowed by the California Penal Code, the ROC program does not currently deliver involuntary medications. Instead, the ROC treatment team addresses this common problem by working closely with the individual and delivering incentives that facilitate voluntary agreement to medication. The success of this approach is reflected in the fact that 92% of all patients have been prescribed medications and 85% have been fully compliant (see ROC Outcomes). In the few cases in which informed consent still cannot be obtained and medication is deemed necessary to restore competency, the patient is typically recommended for transfer to the state hospital, where involuntary medications can be provided.
ROC Outcomes Improving the Legal Forensic System. The implementation of the ROC program encountered some unexpected challenges and had an unexpected positive impact on the local legal forensic system. Removing negative incentives. The California system is slow, cumbersome, and expensive. Defendants may wait months in jail before restoration treatment can begin in earnest. Systemic delays in the competency evaluation process also created two negative incentives. First, the expected delays could potentially be used to the advantage of the defense to the degree that witnesses might withdraw or their memories of the crime may decline in accuracy over time. Second, if the defendant is facing a likely sentence, the system potentially creates an incentive for malingering because the state hospital is a nicer place to serve time than a jail. Developing a better system. The process of educating and familiarizing the many stakeholders in the court system about the new ROC program was complex and took a few months because of the sheer number of judges, public defenders, prosecuting attorneys, conditional release representatives, and clerical/administrative personnel. Moreover, as the largest county in size in the United States, San Bernardino County has nine county courts. By making it a practice to routinely attend court hearings, the ROC program earned the confidence of the courts and attorneys and facilitated the process by answering any questions about the ROC program and providing information to guide the judge’s recommendation. Initially, some stakeholders were skeptical that the jail-based program could provide restorative treatment that was equivalent to the state hospital and entailed a shorter time frame. During the initial months of ROC, they were concerned that patients might return to court with only marginal restoration and might relapse into acute illness. Ninety-eight percent of the certifications of competency issued by the ROC have been upheld by the court, which speaks to the maintenance of competency after discharge.
ROC Outcomes Utilization and Clinical Data Demographic data. To date, the ROC program has admitted 192 forensic patients. The population is 43% Caucasian, 27% Hispanic, 25% African American, and 5% Other. With ages ranging from 19 to 68, the average age is 37.1 years. Program census. The ROC program was originally designed for a maximum capacity of 20 forensic patients, but the census has grown steadily as the referring courts have gained familiarity and
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Figure 1. Average daily census. Table 1. Outcomes by Primary Diagnosis.
Psychotic thought disorders Schizophrenia, paranoid Schizophrenia, undifferentiated Schizophrenia, disorganized Schizoaffective disorder Psychotic disorder NOS Delusional disorder Subtotal All other diagnoses Bipolar disorder Mood disorder NOS Major depressive episode Organic brain disorder Substance induced/related Unknown/deferred Malingering Subtotal Total
Total
Restored in ROC
Transferred to State Hospital
16 33 16 13 46 2 126
6 (38%) 17 (52%) 3 (19%) 7 (54%) 23 (50%) 1 (50%) 57
10 16 13 6 23 1 69
12 2 2 3 9 2 12 42 168
8 (67%) 1 (50%) 2 (100%) 2 (66%) 8 (89%) 2 (100%) 12 (100%) 35 92
4 1 0 1 1 0 0 7 76
Note. ROC ¼ restoration of competency; NOS ¼ not otherwise specified.
confidence in the program. The daily census averaged about 12.1 patients in the first year, 18.0 in the second year, and 20.2 for the first 5 months of the current year (see Figure 1). Primary diagnosis. Table 1 displays the frequency of primary diagnosis at admission and the outcomes achieved. The two largest diagnostic categories were the schizophrenias (46% of all admissions) and psychotic disorder not otherwise specified (NOS; 27%). All psychotic thought disorders combined accounted for 75% of all admissions; 7% were diagnosed and restored as malingering. Length of stay for restoration. Of the 192 persons admitted to the program thus far, 168 have reportable outcomes. Ninety-two (55%) were fully restored in the jail in an average of 57.4 days and 76 were transferred to the state hospital after an average of 86.9 days because they could not be restored within 90 days (see Table 2). Two individuals were discharged from ROC because foreign language
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Table 2. Restoration Statistics. Restored in ROC Rate of Restoration All discharges (n ¼ 168)
55% (92 of 168)
Psychotic versus nonpsychotic disorders Thought disorders 45% (57 of 126) All other diagnoses
77% (23 of 30)
Malingering
100% (12 of 12)
Two largest diagnostic groups Schizophrenias
Psychotic Disorders NOS
Gender Males
Females
42% (33 of 78) 50% (23 of 46)
51% (77 of 151) 88% (15 of 17)
Length of Treatment
Transferred to State Hospital (Not Yet Restored) Rate of Transfer
Length of Treatment
Avg: 57.4 SD: 24.4 Median: 54.0 Range: 16–150
45% (76 of 168)
Avg: 86.9 SD: 42.7 Median: 94.5 Range: 13–198
Avg: 62.9 SD: 26.5 Median: 61.5 Range: 18–150 Avg: 49.0 SD: 19.9 Median: 47.0 Range: 16–90 Avg: 50.3 SD: 19.5 Median: 51.0 Range: 20–91
55% (69 of 126)
Avg: 81.4 SD: 39.4 Median: 92.0 Range: 13–198 Avg: 140.9 SD: 39.1 Median: 144.0 Range: 64–188 NA
Avg: 64.1 SD: 27.8 Median: 56.0 Range: 20–150 Avg: 63.1 SD: 23.7 Median: 65.5 Range: 18–106
58% (45 of 78)
Avg: 59.2 SD: 25.3 Median: 55.0 Range: 18–150 Avg: 48.8 SD: 17.6 Median: 46.0 Range: 16–73
23% (7 of 30) NA
50% (23 of 46)
49% (74 of 151) 12% (2 of 17)
Avg: 87.6 SD: 38.2 Median: 95.0 Range: 22–198 Avg: 67.8 SD: 39.4 Median: 68.0 Range: 13–125 Avg: 97.0 SD: 42.3 Median: 97.0 Range: 13–198 NA
Note. ROC ¼ restoration of competency; NOS ¼ not otherwise specified.
services were not available and 22 are presently in treatment. The length of treatment is the number of days from admission to ROC to the date that the program submits a certification of restoration, which indicates readiness for discharge (not the actual date of discharge from ROC). In terms of gender, 88% of the females were restored compared to 51% of the males and in a shorter average time (48.8 days compared to 59.2). Comparative cost of treatment. In January 2012, the California Legislative Analyst’s Office (LAO) conducted a study of the entire state forensic mental health system, including an objective analysis of cost and effectiveness of this new jail-based ROC pilot program of felon ISTs. The report concluded that treatment could be initiated much sooner, was completed more quickly, showed lasting effectiveness, and saved an average of more than $70,000 for each patient admission. ‘‘The combined savings to both the state and the county bring the total public sector savings from the pilot project to approximately $1.4 million for this group—more than $70,000 in savings being achieved for each IST patient directed to [the ROC program]’’ (California LAO, 2012, p. 12). The LAO study reported a cost differential of $278 per day for a ROC bed compared to $450 per day for a state hospital bed.
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Table 3. Comparison of ROC Program Outcomes. ROC California Forensic services offered
Restoration of ISTs Only
Percentage restored Average length of stay
55% n ¼ 92 57 days
ROC Virginia Restoration of ISTs 83% n ¼ 482 77 days
Forensic Evaluations
Acute Stabilization
n ¼ 298 32 days
n ¼ 573 21 days
Note. ROC ¼ restoration of competency; IST ¼ incompetent to stand trial.
Figure 2. Hours of treatment services and census.
Comparison to original ROC program outcomes. Although there are differences in the size and scope of work for the original Virginia ROC pilot program (35 beds and three types of forensic services) and this California ROC program (20 beds and IST services only), it is worthwhile to compare outcomes (see Table 3). The Virginia ROC achieved a higher percentage of restorations (83% compared to 55%), but the California ROC restored competency in an average of 20 fewer days. Differences between the two sites are presented in the discussion section to help explain these different outcomes. Treatment activities. On average, the patients in the ROC program attended 3.1 groups and received 2.7 hours of group treatment and 1.6 individual contacts each day. The average time needed to complete an individual comprehensive admissions assessment was 4.1 hours. Figure 2 shows that the level of daily treatment provision has remained consistent across years, although the average unit census of the program has nearly doubled from an average of 12.1 in the first year to 20.2 in the third year. Medication compliance. On average, the ROC psychiatrists prescribe psychotropic medications to 92% of the patients. On average, 85% (149 of the 179 patients) were fully compliant with their medications, while 2% showed intermittent compliance and 13% refused medications. In a program that does not force medications, a monthly average of 31% of those refusing were incentivized to comply with medications using simple rewards like candy bars, chips, and soup.
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Behavioral episodes and injuries. In 29 months of operation, the program experienced 11 acts of inmate-on-inmate assault, none of which resulted in serious injuries (roughly one assault every 3 months). There have been no assaults on staff and only one injury from a patient fall. There has been no use of restraints or seclusion and one episode involving physical intervention. In the event that an inmate-patient displays inappropriate behavior that may disrupt a group activity, the procedure calls for a security officer to gently remove the patient from the group activity and escort him to his cell for a ‘‘time-out.’’ The group activity continues.
Discussion and Conclusion The national trend toward jailing more and more persons with severe and persistent mental illness and co-occurring disorders is expected to continue to rise. State hospital systems are overloaded and unable to provide a reasonably timely response to the rising demands for forensic psychiatric treatment and ROC. Local and regional jails and prisons have become de facto holding hospitals for persons with mental illness who become involved with the criminal justice system and await forensic treatment. There clearly is a continuing IST crisis in America as economic factors continue to strain public health budgets. It is a time for innovative approaches like the jail-based ROC model, which can deliver critical forensic services at reduced cost without sacrificing effectiveness, timeliness, or quality of care. Based on the success of a previous pilot study with jail-based ROC in Virginia (Jennings & Bell, 2012), there was confidence that the ROC model could be replicated in California and other states. In 29 months of operation, this second ROC has demonstrated its effectiveness and cost efficiency. When implemented properly by well-trained staff, the ROC model can establish an adequate therapeutic milieu inside a jail, conduct assessments to distinguish those patients who can be restored within a 70-day time frame, and initiate and complete restorations of competency in less time and for a fraction of the cost of traditional inpatient psychiatric hospitalization. Like any new program coming into an already established forensic mental health system, it was essential for the ROC program to establish positive working relationships with the many stakeholders. In particular, it needed to work very closely with jail custody staff to maintain an appropriate balance of security and therapeutics. The model itself is lean and aggressive to achieve the goal of ROC (Restoration Of Competency) in the least time possible. The ROC model is lean in that all assessments and treatment interventions are aimed at the single objective of restoring competency through psychiatric stability. The ROC is aggressive in terms of the pace of treatment, which is expected to restore competency in less than 70 days. This rapid time frame is built into the model and guides treatment decisions. Those ROC patients who are found to be likely to require long-term treatment (i.e., those who do not show potential for recovery within 70 to 90 days) are reviewed for possible transfer to more extended inpatient care at the state hospital. Thus, the model requires frequent reassessment by the treatment team to evaluate each individual’s progress toward goals and what remains to be completed for this person to gain competency. Taken at face value, the current ROC model can be questioned for its apparently modest restoration rate of 55%. This is significantly lower than the 86% rate of restoration achieved in the Virginia ROC pilot program. The most obvious explanation for this discrepancy is the difference in the average length of stay to restore competency. The Virginia program had an average stay of 77 days compared to the California ROC average of 57 days. One key difference was that the Virginia ROC had no time limit on the length of stay to restore competency. Thus, patients stayed as long as necessary to restore competency or to conclude that the patient could not be restored. In fact, the restoration time frame of 70 days for the California ROC model was based on the presumption that restorations could be achieved within the 77-day average of the Virginia ROC model by distinguishing and transferring patients who would require long-term or indefinite treatment.
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More importantly, however, the large differences in the rates of restoration (31% fewer) and length of stay (20 days shorter) reflect the evolution of the ROC model itself, which now accommodates the expectation that a large percentage of forensic patients will require substantially longer time, even years, to be restored to competency. The new ROC model is actually designed to distinguish those patients who will need long-term treatment in order to move them to the psychiatric hospital setting as soon as possible. This includes transferring patients who continue to refuse or who cannot give informed consent to medication that is deemed necessary to restore competency (because the ROC model does not use involuntary medication). This two-pronged approach conserves the use of ROC beds for those who can be effectively treated and restored in a short-term setting and conserves the use of state hospital beds for those who need long-term care. In both cases, the model provides better care and treatment for the most seriously ill and impaired individuals by moving them out of the jail setting at the earliest date possible. In short, the ‘‘new’’ ROC model is fully consistent with its objectives of minimizing the days that defendants with severe mental illness will spend in local jails and accelerating access to restoration services. Critics could also argue that jail-based restoration could contribute to reducing overall services for the mentally ill because it allows state hospital systems to provide less of what would be expected to be a superior and preferable level of hospital service. While there is no question that jails are not designed for mental health, there is much that can be done within a jail setting to provide an enriched, humane, and safe therapeutic environment with a skilled treatment team. Alternatively, the ROC model can potentially improve traditional forensic systems by facilitating a two-track approach that can distinguish and refer IST patients to shorter and longer term settings for restoration and treatment according to their presenting needs. In this way, the majority of IST patients can be therapeutically restored in an immediate, short-term jail-based program, while state hospital treatment is conserved for those who need longer term hospital-level care. It is also worthwhile to consider some of the ways that the restrictions of a jail-based unit could have potential therapeutic advantages. First, the intensified level of supervision and control of movement and contraband can help to make the ROC a safer place than most state hospitals, which adds to the inmate-patient’s sense of personal safety and is conducive to treatment. Second, to the degree that the jail-based unit can be used exclusively for IST patients and treatment-oriented activities, it can reduce noise, movement, and distractions, which makes it easier for mentally ill inmates to maintain attention and concentration in therapeutic groups. Participation in groups and activities can also provide a more appealing way to escape boredom. Finally, the less comfortable jail environment can be motivating factor for patients who desire to get out as soon as possible and they may work harder to meet their treatment goals sooner. As the ROC program continues into its third year of operation, research will continue to evaluate ongoing program effectiveness. In addition, a new program site has recently opened in neighboring Riverside County, which will allow for cross-validation of the effectiveness of the model across sites. As the number of patients increases over time, it may become possible to discern more reliable differences in the rates and speed of restorability by diagnosis and diagnostic groupings and/or to improve assessments to better predict the time frame for restorability (or not) of newly admitted patients. Acknowledgments The authors acknowledge the California Department of State Hospitals for its support of this innovative pilot project and the West Valley Detention Center, San Bernardino County Sheriff’s Department for its willingness to establish the ROC in the facility and ongoing collaboration in maintaining its success.
Declaration of Conflicting Interests The authors disclosed no conflicts of interest with respect to the authorship and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
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Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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The ROC Program: Accelerated Restoration of Competency in a Jail Setting
Journal of Correctional Health Care 2014, Vol 20(1) 59-69 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345813505067 jcx.sagepub.com
Kevin Rice, LCSW1,2, and Jerry L. Jennings, PhD2
Abstract In 29 months of operation, the restoration of competency (ROC) program provided treatment services to 192 incompetent to stand trial patients in a jail setting. The ROC restored competency for 55% of the patients in an average of 57 days compared to the state hospital average of 180 days. The average cost of treatment/restoration per admission was $15,568 compared to the state hospital average of $81,000. The ROC model accelerates needed treatment for mentally ill defendants, cuts demand for costly state hospital forensic beds, and assists jails in better managing inmates with severe psychiatric disorders—yielding major cost savings and improved care. In addition to preventing readmissions and negative behavioral episodes, the ROC improved the broader forensic system by eliminating the state hospital waiting list, accelerating access to psychiatric services, promoting local access for lawyers and family, and gaining stakeholder satisfaction. Keywords restoration of competency, jails, mental illness, psychiatric treatment, forensic patients In the past 15 years, severe reductions in public mental health services have caused increasingly high numbers of people with severe and persistent mental illness to land in the criminal justice system (Lamb & Weinberger, 2005; Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010). Budget cuts to state hospital systems and community-based mental health resources have shifted the cost and services burden to local emergency rooms, county jails, and law enforcement agencies. Even before the dramatic cuts precipitated by the economic recession of 2008, Wortzel, Binswanger, Martinez, Filley, and Anderson (2007) decried the common practice of jailing persons with severe mental illness who are incompetent to stand trial (IST), often for long periods of time, and often without adequate psychiatric treatment, because there are not enough forensic beds available in state hospital systems.
1 2
California ROC Program, West Valley Detention Center, Rancho Cucamonga, CA, USA Liberty Healthcare Corporation, Bala Cynwyd, PA, USA
Corresponding Author: Jerry L. Jennings, PhD, Liberty Healthcare Corporation, 820 E. City Ave., Suite 820, Bala Cynwyd, PA 19004 USA. Email: [email protected]
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Hundreds of patients with severe mental illness deemed incompetent to proceed are languishing in jails around the nation, unable to access meaningful psychiatric care and not moving forward in the legal process as they await admission to grossly undersized and understaffed state hospitals . . . The combination of inadequate psychiatric care, the stress of incarceration, and the long waits involved have yielded nightmarish results . . . . (Wortzel et al., 2007, p. 357)
A variety of interventions and approaches have been developed to address this national IST crisis, but they have shown mixed results (Jennings & Bell, 2012; Justice Policy Institute, 2011). Assisted outpatient, involuntary outpatient commitment, and court-to-community programs have had some success in removing mentally ill defendants from jails, but cannot be used for those charged with violent and dangerous crimes (Gilbert et al., 2010; Lawlor, Grudzinskas, Geller, & Genovese, 2007; Loveland & Boyle, 2007; Swartz, Swanson, Kim, & Petrila, 2006). In particular, mental health courts have multiplied across the country to divert mentally ill defendants and substance abusers from incarceration and toward appropriate treatment (Redlich, Steadman, Clark-Robbins, & Swanson, 2006; Watson, Hanrahan, Luchins, & Lurigio, 2001). Mental health courts entail a range of features, including nonadversarial process, training judges in mental health, and collaborative interagency teams (Wortzel et al., 2007). Jail diversion programs, which include a variety of prebooking, postbooking, and pretrial diversion as well as deferred prosecution strategies, attempt to divert patients into community-based treatment (Watson et al., 2001) and some appear to reduce rates of rearrest and jail days (Case, Steadman, Dupuis, & Morris, 2009). Nontreatment interventions, such as housing programs and long-term residential services, have also been tried (Robbins, Petrila, LeMelle, & Monahan, 2006). These strategies can help prevent recurrent relapses and reoffending, especially for homeless persons with severe mental illness, but cannot be exercised immediately to avert hospitalizations or detention (Miller, 2003; Trudel & Lesage, 2006). In short, although many approaches have been tried, the problem of holding IST patients in jails for extended periods of time persists and appears to be worsening.
The Restoration of Competency (ROC) Model The jail-based ROC model offers an innovative and cost-effective method to evaluate, treat, and stabilize persons with severe mental illness when they are first arrested and detained—and restore them to competency in the jail setting—rather than waiting indefinitely for long periods of time for available state hospital forensic beds. The ROC program was first piloted in Virginia in a successful 5year program in the late 1990s (Bell, 2003; Jennings & Bell, 2012). The ROC model has numerous advantages for state mental health systems, local courts and jails, and patients. ROC Advantages for State Hospital Systems. 1. Reduces demand for limited state hospital forensic beds for competency evaluation and restoration services, including large and lengthy waiting lists for admission to state forensic hospital beds. 2. Reduces length of stay for restoration through earlier intervention and targeted treatment that keeps symptoms of mental illness from worsening in the stressful, nontreatment setting of a typical jail. 3. Maximizes resources by distinguishing patients who can be restored in a short-term program while conserving state hospital beds for patients who require long-term or indefinite treatment. 4. Forestalls admissions to the state hospital for persons who are malingering to get out of the harsher confinement of a jail or prison.
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5. Helps to maintain competency to stand trial and averts relapse and rehospitalizations through seamless transition from the ROC program back to the court and jail. ROC Advantages for Local Jails and Law Enforcement. 1. The local county/jail saves money by reducing the time spent in jail by mentally ill inmates, who cost significantly more than ordinary inmates. 2. Jail can potentially gain revenue to cover the expenses already incurred by holding mentally ill inmates. (In California, the jail receives a per diem from the state Department of State Hospitals for hosting the service.) 3. Eliminates the time and cost of escort and transport between state hospitals and jails. 4. Reduces disruptions to jail operations caused by psychotic and disordered behavior. 5. Reduces risk of suicide, violence, injury, and litigation by providing extended hours of treatment-oriented attention and support in a more therapeutic setting within the jail. ROC Advantages for Local Courts and Patients. 1. Improves convenient access for local courts, defense attorneys, prosecutors, law enforcement, and family support. 2. Reduces the length of time that patients would otherwise wait for transfer to the state hospital for forensic evaluation and restoration and initiates restorative treatment more quickly. ROC Program Description. For the past 2½ years, the jail-based ROC model has been used in California with promising results. Patients and program space. The main program is a traditional male residential pod within a county jail with 20 beds and dayroom space for group programming. Given the small number of females (10% of the referrals), services are delivered to females individually without any treatment or activity groups. ROC referral process. The following is a simplified summary of the typical steps in the process of referral and admission to the ROC program. Following arrest, the individual with mental illness is held in the local jail until arraignment within 48 hours. A public defender is typically assigned at this time and preliminary hearings are scheduled. The preliminary hearing determines if there is enough evidence to go ahead with the trial and, if so, a pretrial court hearing is scheduled in about a week. If there is doubt about competency to stand trial, the judge suspends all criminal proceedings and orders an independent psychiatric forensic evaluation (which can entail one to three different evaluators depending on the case and usually takes 1 month per evaluation). If the defendant is determined incompetent, all criminal proceedings remain suspended until he is considered to be competent to stand trial. Within 15 days, another placement evaluation is performed by the California Conditional Release Program to determine if restoration will require secure confinement or community treatment. If confinement is required (as it is in 90% of the cases), the inmate is committed to the ROC (or the state psychiatric hospital) for restoration. The committing court asks for a progress report 90 days after commitment and then every 6 months. If competency cannot be restored in the near future in the ROC, the individual is typically referred to the state hospital for restoration. Following restoration and discharge from the ROC, the patient is typically placed in specialty housing (in the same housing pod where the ROC is operated), but about 10% are placed in the general inmate population. Admission/assessment and treatment planning. Treatment begins with the intake assessment. The clinical team evaluates the person’s psychological functioning, suicide and behavioral risk, current level of trial competency, and likelihood of malingering. A standard battery of psychological tests is
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used to evaluate cognitive abilities, social and psychological functioning, psychiatric symptoms, and potential malingering. As needed, the ROC psychologist has other tests/screenings available for specific targeted areas of deficit. Assessment continues through the course of the admission to measure response to treatment and identify new problems to target for ROC. The Competency-related Abilities Rating Scale is used to monitor the individual’s progress (Hazelwood & Rice, 2010). Based on the assessments, the treatment plan is individualized and geared toward one of two curriculums for lower and higher functioning patients. But treatment planning continues to be flexible and vigorous. It is common for the treatment team to discuss the treatment plan informally on a daily basis and to formally discuss treatment issues at least once a week. Approach to competency restoration. The ROC program uses a recovery model that focuses on individual strengths and targets abilities that are related to competency, including remediation of deficits and alleviation of acute symptoms. The primary goal for most IST patients is to resolve the psychosis, when present, to enable the patient to regain general thinking abilities. The second goal is to educate the patient in the legal/court process such that he is able to cooperate with his counsel in mounting a defense. If there is a failure to achieve either of these goals, the third goal is to compile documentation to credibly opine that the patient is unrestorable to competency. The ROC team combines the proactive use of psychiatric medications, motivation to participate in rehabilitative activities, and multimodal cognitive, social, and physical activities that address competency in a holistic fashion. Interdisciplinary treatment team. The interdisciplinary ROC treatment team is like that of a traditional forensic psychiatric unit, including a forensic psychiatrist, forensic psychologist, psychiatric nurse, social worker, rehabilitation therapist, and clerk to coordinate scheduling, court dates, transports, and forensic reports. The direct care staff are specially trained security officers who are dually trained in security and treatment functions. Security personnel understand that clinical information is confidential and available on a need-to-know basis only. They do not have access to medical records. The designated ROC deputy attends treatment team meetings and is the only security officer who is privy to clinical information. Daily rehabilitative schedule and coordination of medical care. Individuals in the program typically meet with a treatment professional one-on-one at least twice daily about issues related to regaining their mental health and/or competency. They are also engaged in 3.5 to 5.5 hours of group-based psychosocial rehabilitative activities each weekday depending on the individual’s current capacities. (Experience showed that the lower functioning patients could not tolerate more than 3 to 4 hours of focused work per day.) Treatment activities are structured and delivered across four domains: ROC, mental illness and medication management, mental/social stimulation, and physical/social stimulation. Basic residential and health care, including all medical care and medications, are provided on-site through a service agreement with the county jail to use its existing pharmacy, medical records, and medical service delivery system. Modules/groups at two cognitive levels. Many patients with active psychosis or low intellectual functioning can be easily confused and overwhelmed by too much education about competency and the legal process. Likewise, their abstract reasoning is impaired, so it is important to keep the legal information specific to their individual case. They can be confused by videos and scenarios and roleplays that apply to other patients’ legal cases. The primary distinction of the lower functioning group is its de-emphasis of cognitive concepts and the use of simple language, simple learning strategies, and familiar constructs or icons. The classes are kept to a very small size to allow for individualized attention. Repetition and multisensory learning helps group members better retain content. Videos are used to concretely demonstrate and facilitate discussion of relevant topics.
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Conversely, many higher functioning patients do not need basic legal education and can go directly to the second-level competency education groups. The higher-functioning group modules entail applying and practicing legal knowledge and skills, often using more experiential modalities like role-plays and video discussions. The higher level competency groups can focus more on advanced discussion and problem solving specific to their individual situations. No involuntary medication. Although allowed by the California Penal Code, the ROC program does not currently deliver involuntary medications. Instead, the ROC treatment team addresses this common problem by working closely with the individual and delivering incentives that facilitate voluntary agreement to medication. The success of this approach is reflected in the fact that 92% of all patients have been prescribed medications and 85% have been fully compliant (see ROC Outcomes). In the few cases in which informed consent still cannot be obtained and medication is deemed necessary to restore competency, the patient is typically recommended for transfer to the state hospital, where involuntary medications can be provided.
ROC Outcomes Improving the Legal Forensic System. The implementation of the ROC program encountered some unexpected challenges and had an unexpected positive impact on the local legal forensic system. Removing negative incentives. The California system is slow, cumbersome, and expensive. Defendants may wait months in jail before restoration treatment can begin in earnest. Systemic delays in the competency evaluation process also created two negative incentives. First, the expected delays could potentially be used to the advantage of the defense to the degree that witnesses might withdraw or their memories of the crime may decline in accuracy over time. Second, if the defendant is facing a likely sentence, the system potentially creates an incentive for malingering because the state hospital is a nicer place to serve time than a jail. Developing a better system. The process of educating and familiarizing the many stakeholders in the court system about the new ROC program was complex and took a few months because of the sheer number of judges, public defenders, prosecuting attorneys, conditional release representatives, and clerical/administrative personnel. Moreover, as the largest county in size in the United States, San Bernardino County has nine county courts. By making it a practice to routinely attend court hearings, the ROC program earned the confidence of the courts and attorneys and facilitated the process by answering any questions about the ROC program and providing information to guide the judge’s recommendation. Initially, some stakeholders were skeptical that the jail-based program could provide restorative treatment that was equivalent to the state hospital and entailed a shorter time frame. During the initial months of ROC, they were concerned that patients might return to court with only marginal restoration and might relapse into acute illness. Ninety-eight percent of the certifications of competency issued by the ROC have been upheld by the court, which speaks to the maintenance of competency after discharge.
ROC Outcomes Utilization and Clinical Data Demographic data. To date, the ROC program has admitted 192 forensic patients. The population is 43% Caucasian, 27% Hispanic, 25% African American, and 5% Other. With ages ranging from 19 to 68, the average age is 37.1 years. Program census. The ROC program was originally designed for a maximum capacity of 20 forensic patients, but the census has grown steadily as the referring courts have gained familiarity and
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Figure 1. Average daily census. Table 1. Outcomes by Primary Diagnosis.
Psychotic thought disorders Schizophrenia, paranoid Schizophrenia, undifferentiated Schizophrenia, disorganized Schizoaffective disorder Psychotic disorder NOS Delusional disorder Subtotal All other diagnoses Bipolar disorder Mood disorder NOS Major depressive episode Organic brain disorder Substance induced/related Unknown/deferred Malingering Subtotal Total
Total
Restored in ROC
Transferred to State Hospital
16 33 16 13 46 2 126
6 (38%) 17 (52%) 3 (19%) 7 (54%) 23 (50%) 1 (50%) 57
10 16 13 6 23 1 69
12 2 2 3 9 2 12 42 168
8 (67%) 1 (50%) 2 (100%) 2 (66%) 8 (89%) 2 (100%) 12 (100%) 35 92
4 1 0 1 1 0 0 7 76
Note. ROC ¼ restoration of competency; NOS ¼ not otherwise specified.
confidence in the program. The daily census averaged about 12.1 patients in the first year, 18.0 in the second year, and 20.2 for the first 5 months of the current year (see Figure 1). Primary diagnosis. Table 1 displays the frequency of primary diagnosis at admission and the outcomes achieved. The two largest diagnostic categories were the schizophrenias (46% of all admissions) and psychotic disorder not otherwise specified (NOS; 27%). All psychotic thought disorders combined accounted for 75% of all admissions; 7% were diagnosed and restored as malingering. Length of stay for restoration. Of the 192 persons admitted to the program thus far, 168 have reportable outcomes. Ninety-two (55%) were fully restored in the jail in an average of 57.4 days and 76 were transferred to the state hospital after an average of 86.9 days because they could not be restored within 90 days (see Table 2). Two individuals were discharged from ROC because foreign language
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Table 2. Restoration Statistics. Restored in ROC Rate of Restoration All discharges (n ¼ 168)
55% (92 of 168)
Psychotic versus nonpsychotic disorders Thought disorders 45% (57 of 126) All other diagnoses
77% (23 of 30)
Malingering
100% (12 of 12)
Two largest diagnostic groups Schizophrenias
Psychotic Disorders NOS
Gender Males
Females
42% (33 of 78) 50% (23 of 46)
51% (77 of 151) 88% (15 of 17)
Length of Treatment
Transferred to State Hospital (Not Yet Restored) Rate of Transfer
Length of Treatment
Avg: 57.4 SD: 24.4 Median: 54.0 Range: 16–150
45% (76 of 168)
Avg: 86.9 SD: 42.7 Median: 94.5 Range: 13–198
Avg: 62.9 SD: 26.5 Median: 61.5 Range: 18–150 Avg: 49.0 SD: 19.9 Median: 47.0 Range: 16–90 Avg: 50.3 SD: 19.5 Median: 51.0 Range: 20–91
55% (69 of 126)
Avg: 81.4 SD: 39.4 Median: 92.0 Range: 13–198 Avg: 140.9 SD: 39.1 Median: 144.0 Range: 64–188 NA
Avg: 64.1 SD: 27.8 Median: 56.0 Range: 20–150 Avg: 63.1 SD: 23.7 Median: 65.5 Range: 18–106
58% (45 of 78)
Avg: 59.2 SD: 25.3 Median: 55.0 Range: 18–150 Avg: 48.8 SD: 17.6 Median: 46.0 Range: 16–73
23% (7 of 30) NA
50% (23 of 46)
49% (74 of 151) 12% (2 of 17)
Avg: 87.6 SD: 38.2 Median: 95.0 Range: 22–198 Avg: 67.8 SD: 39.4 Median: 68.0 Range: 13–125 Avg: 97.0 SD: 42.3 Median: 97.0 Range: 13–198 NA
Note. ROC ¼ restoration of competency; NOS ¼ not otherwise specified.
services were not available and 22 are presently in treatment. The length of treatment is the number of days from admission to ROC to the date that the program submits a certification of restoration, which indicates readiness for discharge (not the actual date of discharge from ROC). In terms of gender, 88% of the females were restored compared to 51% of the males and in a shorter average time (48.8 days compared to 59.2). Comparative cost of treatment. In January 2012, the California Legislative Analyst’s Office (LAO) conducted a study of the entire state forensic mental health system, including an objective analysis of cost and effectiveness of this new jail-based ROC pilot program of felon ISTs. The report concluded that treatment could be initiated much sooner, was completed more quickly, showed lasting effectiveness, and saved an average of more than $70,000 for each patient admission. ‘‘The combined savings to both the state and the county bring the total public sector savings from the pilot project to approximately $1.4 million for this group—more than $70,000 in savings being achieved for each IST patient directed to [the ROC program]’’ (California LAO, 2012, p. 12). The LAO study reported a cost differential of $278 per day for a ROC bed compared to $450 per day for a state hospital bed.
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Table 3. Comparison of ROC Program Outcomes. ROC California Forensic services offered
Restoration of ISTs Only
Percentage restored Average length of stay
55% n ¼ 92 57 days
ROC Virginia Restoration of ISTs 83% n ¼ 482 77 days
Forensic Evaluations
Acute Stabilization
n ¼ 298 32 days
n ¼ 573 21 days
Note. ROC ¼ restoration of competency; IST ¼ incompetent to stand trial.
Figure 2. Hours of treatment services and census.
Comparison to original ROC program outcomes. Although there are differences in the size and scope of work for the original Virginia ROC pilot program (35 beds and three types of forensic services) and this California ROC program (20 beds and IST services only), it is worthwhile to compare outcomes (see Table 3). The Virginia ROC achieved a higher percentage of restorations (83% compared to 55%), but the California ROC restored competency in an average of 20 fewer days. Differences between the two sites are presented in the discussion section to help explain these different outcomes. Treatment activities. On average, the patients in the ROC program attended 3.1 groups and received 2.7 hours of group treatment and 1.6 individual contacts each day. The average time needed to complete an individual comprehensive admissions assessment was 4.1 hours. Figure 2 shows that the level of daily treatment provision has remained consistent across years, although the average unit census of the program has nearly doubled from an average of 12.1 in the first year to 20.2 in the third year. Medication compliance. On average, the ROC psychiatrists prescribe psychotropic medications to 92% of the patients. On average, 85% (149 of the 179 patients) were fully compliant with their medications, while 2% showed intermittent compliance and 13% refused medications. In a program that does not force medications, a monthly average of 31% of those refusing were incentivized to comply with medications using simple rewards like candy bars, chips, and soup.
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Behavioral episodes and injuries. In 29 months of operation, the program experienced 11 acts of inmate-on-inmate assault, none of which resulted in serious injuries (roughly one assault every 3 months). There have been no assaults on staff and only one injury from a patient fall. There has been no use of restraints or seclusion and one episode involving physical intervention. In the event that an inmate-patient displays inappropriate behavior that may disrupt a group activity, the procedure calls for a security officer to gently remove the patient from the group activity and escort him to his cell for a ‘‘time-out.’’ The group activity continues.
Discussion and Conclusion The national trend toward jailing more and more persons with severe and persistent mental illness and co-occurring disorders is expected to continue to rise. State hospital systems are overloaded and unable to provide a reasonably timely response to the rising demands for forensic psychiatric treatment and ROC. Local and regional jails and prisons have become de facto holding hospitals for persons with mental illness who become involved with the criminal justice system and await forensic treatment. There clearly is a continuing IST crisis in America as economic factors continue to strain public health budgets. It is a time for innovative approaches like the jail-based ROC model, which can deliver critical forensic services at reduced cost without sacrificing effectiveness, timeliness, or quality of care. Based on the success of a previous pilot study with jail-based ROC in Virginia (Jennings & Bell, 2012), there was confidence that the ROC model could be replicated in California and other states. In 29 months of operation, this second ROC has demonstrated its effectiveness and cost efficiency. When implemented properly by well-trained staff, the ROC model can establish an adequate therapeutic milieu inside a jail, conduct assessments to distinguish those patients who can be restored within a 70-day time frame, and initiate and complete restorations of competency in less time and for a fraction of the cost of traditional inpatient psychiatric hospitalization. Like any new program coming into an already established forensic mental health system, it was essential for the ROC program to establish positive working relationships with the many stakeholders. In particular, it needed to work very closely with jail custody staff to maintain an appropriate balance of security and therapeutics. The model itself is lean and aggressive to achieve the goal of ROC (Restoration Of Competency) in the least time possible. The ROC model is lean in that all assessments and treatment interventions are aimed at the single objective of restoring competency through psychiatric stability. The ROC is aggressive in terms of the pace of treatment, which is expected to restore competency in less than 70 days. This rapid time frame is built into the model and guides treatment decisions. Those ROC patients who are found to be likely to require long-term treatment (i.e., those who do not show potential for recovery within 70 to 90 days) are reviewed for possible transfer to more extended inpatient care at the state hospital. Thus, the model requires frequent reassessment by the treatment team to evaluate each individual’s progress toward goals and what remains to be completed for this person to gain competency. Taken at face value, the current ROC model can be questioned for its apparently modest restoration rate of 55%. This is significantly lower than the 86% rate of restoration achieved in the Virginia ROC pilot program. The most obvious explanation for this discrepancy is the difference in the average length of stay to restore competency. The Virginia program had an average stay of 77 days compared to the California ROC average of 57 days. One key difference was that the Virginia ROC had no time limit on the length of stay to restore competency. Thus, patients stayed as long as necessary to restore competency or to conclude that the patient could not be restored. In fact, the restoration time frame of 70 days for the California ROC model was based on the presumption that restorations could be achieved within the 77-day average of the Virginia ROC model by distinguishing and transferring patients who would require long-term or indefinite treatment.
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More importantly, however, the large differences in the rates of restoration (31% fewer) and length of stay (20 days shorter) reflect the evolution of the ROC model itself, which now accommodates the expectation that a large percentage of forensic patients will require substantially longer time, even years, to be restored to competency. The new ROC model is actually designed to distinguish those patients who will need long-term treatment in order to move them to the psychiatric hospital setting as soon as possible. This includes transferring patients who continue to refuse or who cannot give informed consent to medication that is deemed necessary to restore competency (because the ROC model does not use involuntary medication). This two-pronged approach conserves the use of ROC beds for those who can be effectively treated and restored in a short-term setting and conserves the use of state hospital beds for those who need long-term care. In both cases, the model provides better care and treatment for the most seriously ill and impaired individuals by moving them out of the jail setting at the earliest date possible. In short, the ‘‘new’’ ROC model is fully consistent with its objectives of minimizing the days that defendants with severe mental illness will spend in local jails and accelerating access to restoration services. Critics could also argue that jail-based restoration could contribute to reducing overall services for the mentally ill because it allows state hospital systems to provide less of what would be expected to be a superior and preferable level of hospital service. While there is no question that jails are not designed for mental health, there is much that can be done within a jail setting to provide an enriched, humane, and safe therapeutic environment with a skilled treatment team. Alternatively, the ROC model can potentially improve traditional forensic systems by facilitating a two-track approach that can distinguish and refer IST patients to shorter and longer term settings for restoration and treatment according to their presenting needs. In this way, the majority of IST patients can be therapeutically restored in an immediate, short-term jail-based program, while state hospital treatment is conserved for those who need longer term hospital-level care. It is also worthwhile to consider some of the ways that the restrictions of a jail-based unit could have potential therapeutic advantages. First, the intensified level of supervision and control of movement and contraband can help to make the ROC a safer place than most state hospitals, which adds to the inmate-patient’s sense of personal safety and is conducive to treatment. Second, to the degree that the jail-based unit can be used exclusively for IST patients and treatment-oriented activities, it can reduce noise, movement, and distractions, which makes it easier for mentally ill inmates to maintain attention and concentration in therapeutic groups. Participation in groups and activities can also provide a more appealing way to escape boredom. Finally, the less comfortable jail environment can be motivating factor for patients who desire to get out as soon as possible and they may work harder to meet their treatment goals sooner. As the ROC program continues into its third year of operation, research will continue to evaluate ongoing program effectiveness. In addition, a new program site has recently opened in neighboring Riverside County, which will allow for cross-validation of the effectiveness of the model across sites. As the number of patients increases over time, it may become possible to discern more reliable differences in the rates and speed of restorability by diagnosis and diagnostic groupings and/or to improve assessments to better predict the time frame for restorability (or not) of newly admitted patients. Acknowledgments The authors acknowledge the California Department of State Hospitals for its support of this innovative pilot project and the West Valley Detention Center, San Bernardino County Sheriff’s Department for its willingness to establish the ROC in the facility and ongoing collaboration in maintaining its success.
Declaration of Conflicting Interests The authors disclosed no conflicts of interest with respect to the authorship and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
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Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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