Jail-Based Competency Restoration Services in the United States: The Need, the Controversy, the Impact of COVID-19, and Implications for Future Treatment Delivery

Abstract

Jail-based competency restoration largely emerged as a method to address the backlog at forensic hospitals around the United States, as the number of justice-involved persons in need of restoration outgrew available beds. Jail-based competency restoration units (JBCRUs) appear to be highly effective and cost-saving. However, after the COVID-19 outbreak, services at some JBCRUs were stalled, as providers were forced to either quickly initiate or ramp up technology use to maintain services. The present study describes the course of programming for a JBCRU in Fulton County, Georgia, prior to and after the onset of COVID-19, during which time all treatment shifted to telehealth. A matched comparison group of prepandemic defendants was used to compare in-person versus telehealth services and findings indicated that while defendants’ length of stay remained effectively the same, the restoration rate for telehealth increased remarkably over prepandemic levels (χ² = 10.1, p = .001). Such findings suggest that telehealth services are an effective mode of delivery for competency restoration.

The Supreme Court ruling in Dusky v. United States (1960) transformed the landscape of the American criminal justice system, as it required courts to ensure that justice-involved persons are competent to stand trial (CST) prior to engaging in legal proceedings. Recent studies indicate that approximately 94,000 CST evaluations are conducted annually, which suggests that the number of evaluations each year has likely tripled since the 1960s (Danzer et al., 2019; Morris et al., 2021; Weisman et al., 2020). Felthous and Bloom (2018) mostly attributed deinstitutionalization (i.e., the replacement of long-term psychiatric facilities with community-based mental health programs) to the substantial increase in CST evaluations over the years. They explained that deinstitutionalization ushered in community placement without adequate treatment options for numerous individuals with severe mental illness, and at the same time, justified a decrease in funding for state hospitals. Such an occurrence increased housing instability as well as incarceration in jails and prisons for this group (Felthous & Bloom, 2018). The findings of Danzer and his colleagues (2019) support the aforementioned, as they reported that the most common diagnosis seen among individuals deemed incompetent to stand trial (IST) was psychosis followed by cognitive and affective disorders. In a meta-analysis of 68 studies, Pirelli et al. (2011) found that 27.5% of all CST evaluations resulted in IST opinions and 67% of IST defendants had a diagnosis of psychotic disorder. Many of those individuals, prior to deinstitutionalization, may have been placed in a long-term psychiatric facility for treatment rather than have been subjected to incarceration. It is important to mention, nonetheless, that institutionalization certainly had its drawbacks.

Primary Challenges of Competency Restoration Services

The U.S. Supreme Court decision Jackson v. Indiana (1972) held that individuals must be placed in an “appropriate psychiatric institution” for restoration services, once they are found IST. The frequent use of state hospitals, however, created long waiting lists and backlogs, forcing IST defendants to remain in jail for extended periods (Callahan & Pinals, 2020). Pinals and Fuller (2020) reported that the number of forensic psychiatric beds in state hospitals is insufficient and remains a nationwide concern. Accordingly, several jurisdictions have been involved in litigation regarding delayed waiting periods (Fuller et al., 2017; Kirkorsky et al., 2020).

While legal concerns may have been the impetus for certain jurisdictions to find ways of accelerating or improving competency restoration efforts, it has been found that an extended period without treatment, particularly without psychopharmacological intervention, increases the likelihood that IST defendants will be found nonrestorable (Colwell & Gianesini, 2011). Some jurisdictions have attempted to address treatment access issues by reserving inpatient restoration services for IST defendants with felony crimes and relegating those with misdemeanors to outpatient services. Danzer and colleagues (2019) supported the notion that hospital beds should be used for IST defendants with more serious charges, adding that those with psychotic disorders and medication nonadherence also should be required to participate in inpatient restoration services. This could prove useful in reducing periods of incarceration and hospital admission wait times, as Pinals and Callahan (2020) reported that most IST defendants have misdemeanors or minor felonies. Such a practice, nonetheless, has not been adopted broadly and is dependent upon state laws, which may be slow to change. The quality or effectiveness of outpatient services may also vary by jurisdiction.

Jail-based competency restoration services emerged as a novel solution to problems resulting from extended waits for hospital beds and those stemming from the rising costs of inpatient hospitalization. Such services have been provided in two distinct ways regardless of jurisdiction: One method of jail-based service delivery comprises individual restoration efforts conducted in the general population, wherein IST defendants are provided legal education and psychiatric treatment. Another method has focused on service delivery for IST defendants while they are housed on a segregated unit. Removing these individuals from general population has afforded greater exposure to a number of coordinated services, to include a higher level of monitoring and supervision, psychoeducational groups, legal education, and psychiatric treatment.

The first jail-based competency restoration unit (JBCRU) was established in the state of Virginia in 1997. Since that time, jail-based services in which IST defendants are housed separately from the general population have been offered in at least 13 states (Douglas, 2019). It has been posited that JBCRUs are not only cost-effective but also allow IST defendants to begin services quickly, thereby increasing the likelihood of treatment success while simultaneously reducing the numbers on hospital waiting lists (Ash et al., 2020).

Criticism of JBCRUs

Despite the apparent benefits of JBCRUs, these services have been controversial. Some argue that data for jail-based services are limited, as best practices have not been established for defendant selection and treatment delivery given their relative novelty (Kirkorsky et al., 2020). Nonetheless, Danzer and colleagues (2019) did find that IST defendants in JBCRUs had similar characteristics to those in hospital settings with comparable restoration outcomes. Other treatment concerns raised were the inability to prescribe involuntary medication, the nature of the jail environment (i.e., a security-focused rather than therapeutic approach), and the lack of separation between evaluators and treatment providers (Kirkorsky et al., 2020). These circumstances, however, are jurisdiction- and program-dependent. As an example, recent legislation in the state of California (California Penal Code §2603, 2020) grants providers in jail settings the ability to prescribe medication without consent when medically indicated.

In contrast, while involuntary emergency psychiatric medications are allowed on a very short-term basis at the Fulton County jail, the general procedure is to transport the individual to the county hospital emergency department. The correctional institution, itself, has determined that the issue of administering involuntary medication is rife with problematic scenarios such as the potential appearance of or the reality of abuse of individuals with severe mental illness. As such, many county-run facilities in the state of Georgia avoid involuntary medications entirely. Such policies, admittedly, may serve to disrupt or hinder services on our unit.

Kapoor (2020) contended that any defendant opined not CST is intrinsically “too sick for jail” and correctional detainment should cease until the defendant is restored. Kapoor (2020) also argued that jail-based competency restoration should not be included in treatment offerings because it encumbers correctional mental health systems and implies that it is a preferred mode of delivery. She suggested that instead, it is simply a quick fix to a problem created by a broken system, further indicating that outpatient treatment and inpatient settings are preferred (Kapoor, 2020). However, we argue that treatment success in outpatient competency restoration services may not be feasible with the growing population of defendants facing housing instability, food insecurity, and lack of transportation.

Rules, regulations, and disciplinary practices within the correctional system make this setting less than ideal for any form of mental health treatment. On the contrary, the severity of mental illness in IST defendants is frequently not at the level of severity that would justify inpatient hospitalization in many state hospitals if the defendant were not facing criminal charges. Mental health professionals in correctional settings have provided long-term and acute psychiatric treatment to justice-involved individuals regularly. JBCRUs do not have to disrupt typical services should there be staff hired exclusively for these programs.

Nonetheless, staffing numbers likely vary across JBCRUs depending on the number of IST defendants served and available resources. The issue of dual roles not only presents challenges for treatment and evaluation outcomes but also raises ethical concerns. Adequate staffing in relation to treatment and evaluation referral numbers may greatly diminish fears about dual roles. Still, one must acknowledge that this issue may also exist in the hospital setting and, therefore, such criticism cannot be limited to JBCRUs. Considerable effort is made at our unit to avoid role conflict through successful implementation of system monitoring, which is explained in greater detail later in this article.

JBCRUs and the Onset of COVID-19

Criticisms espoused regarding JBCRUs only gained more traction, or at the very least had the potential of such, after the onset of the COVID-19 pandemic. Similar to the anecdotal experiences of clinicians in other settings, correctional mental health staff in various jurisdictions scrambled to implement technology to ensure safety without compromising service delivery, as nonsecurity staff were often not permitted to enter the facilities. Of note, the use of technology generally refers to the implementation of laptops, smart televisions, or other electronic devices to deliver mental health services. Correctional environments, already dynamic in nature, had to grapple with the enactment of new policies to ensure the health and safety of individuals housed in these facilities and that of staff members. As such, all curricular activities within these facilities, not just nonemergent mental health programming, were affected. Burton et al. (2021) noted that typical correctional activities may include rehabilitative, educational, and occupational programs—all of which ceased for a period. Research detailing such occurrences is scant but likely to emerge in the coming years.

Collica-Cox (2021) did chronicle the experiences of correctional educators at the Westchester County Department of Corrections, which is described as the second largest county jail in the state of New York. Collica-Cox (2021) conveyed the difficulties with using technology in the jail at the onset of the pandemic and emphasized the critical need for coordination with correctional administrators. Qualitatively, she described how educational programs as well as “cognitive behavioral interventions or substance abuse programming” continued successfully with the use of smart televisions and other technologies (Collica-Cox, 2021, p. 37). It is important to acknowledge, however, that the population served by those programs is likely much different in composition when compared with those who require competency restoration services. There also are greater legal and ethical concerns when providing services that may influence the adjudicative process. Still, could the use of technology be equally successful in delivering jail-based competency restoration services?

Research in the domain of adjudicative competence and the use of technology has focused largely on developing best practices regarding evaluation procedures and surveying psychologists to ascertain whether such practices (i.e., using video conferencing or other technologies to conduct competency to stand trial evaluations) are generally accepted in the field. For example, Trupp et al. (2021) reported that a greater number of evaluators used technology after the onset of COVID-19, but held that such practices may be slightly less reliable than an in-person assessment. Such concerns, however, appeared to diminish when evaluators were more familiar with or had prior training in the use of technology (Daffern et al., 2021; Trupp et al., 2021). Batastini et al. (2020) gleaned similar opinions from their survey of forensic evaluators but mentioned that legal professionals, such as judges and attorneys, appeared to be more critical of the use of technology. Their perceptions about using technology to perform evaluations may have implications regarding treatment delivered through similar means.

In the context of technology use and treatment, Batastini and Morgan (2016) conducted a study evaluating the effectiveness of telepsychology with people who are incarcerated placed in administrative segregation housing as a result of violence toward themselves or others. They reported minimal success but cautioned that their findings were limited by technical difficulties while attempting to deliver treatment. Batastini and Morgan (2016) also acknowledged that there were potentially confounding variables, to include therapist characteristics and environmental factors specific to segregated housing. Although the psychological functioning of the individuals in their sample may be more similar to that of IST defendants, it is important to note that the type of services delivered and environmental differences make this study invalid for any prediction about the treatment success of JBCRUs.

Criticisms of JBCRUs, even with the emergence of technology use, have not appeared to be insurmountable. We have argued that there is a myriad of ways in which treatment providers may overcome drawbacks traditionally associated with JBCRUs as well as those that may arise with the use of technology. Because the implementation of in-person JBCRUs, itself, was a comparatively new form of service delivery, we were presented with the unique opportunity to establish best practices while considering ways to address emergent challenges brought on by the COVID-19 pandemic. In this study, we seek to (a) describe a model for the delivery of jail-based competency restoration services; (b) describe the shift from an in-person to telehealth model for the delivery of jail-based competency restoration services in the wake of COVID-19; and (c) compare previous competency restoration rates with preliminary rates since the implementation of telehealth services.

The Fulton County JBCRU

The Fulton County JBCRU, hereafter referred to as the CRU, is located in Atlanta, Georgia. In their paper, Ash and colleagues (2020) describe in detail the CRU’s inception, development, purpose, and cost benefits. Unit operations began in October 2011 (Ash et al., 2020).

Delivery Model for In-Person Services

As a means for service delivery comparison, in-person operations prior to the onset of COVID-19 are briefly described. For those defendants who were opined IST, the CRU evaluator recommended a specific level of competency restoration placement (i.e., outpatient or more intensive services). IST defendants not suitable for outpatient restoration were screened by a different CRU evaluator to determine their appropriateness for the services offered on our unit, which provides treatment for male defendants only.

The CRU treatment team has been interdisciplinary, consisting of two full-time master’s-level mental health clinicians and part-time program and medical directors, a court liaison, fellows in forensic psychiatry, and postdoctoral residents in forensic psychology. Routinely, one or two psychology predoctoral interns, as well as general psychiatry residents may select the CRU as one of their training rotations, and one or two psychology practicum students may also assist in program facilitation. Of note, this allowed for at least one of the three psychiatry fellows to work solely as a CRU forensic evaluator, functioning separate from the treatment team.

Defendants newly admitted to the CRU completed a standardized orientation process. A CRU staff member conducted a brief admission interview and completed paperwork used to inform treatment and case management. Defendants admitted to the CRU immediately engaged in programming. Ideally, within 48 hr of admission, the individual was interviewed by a CRU psychiatrist, a role generally filled by one of the forensic psychiatry fellows. The CRU psychiatrist conducted the initial psychiatric intake. Next, the defendant was assigned to work individually with one of the master’s-level staff members who became familiar with his unique psychiatric and/or cognitive needs as well as relevant competency issues. Forensic psychology postdoctoral residents, predoctoral interns, and practicum students also had a caseload and they provided one-on-one sessions to defendants to focus on individualized needs and instruction. In addition, postdoctoral residents were assigned cases to perform psychological testing to determine baseline intellectual ability, attention and memory capacity, and the recognition of emotional cues—all of which are considered hallmarks of the functional abilities needed for competency.

The CRU treatment schedule, which was essentially adapted from the inpatient competency restoration program at the forensic state hospitals, required clinicians, postdoctoral residents, predoctoral interns, and practicum students to facilitate a total of 35 groups throughout the week. These members of the clinical team also worked closely with CRU-assigned officers. Although the officers were ultimately responsible for safety and security issues, they played an integral role in the milieu. Officers engaged in several tasks that supported components of the program’s goals and objectives, to include actively encouraging defendants to complete their Activities of Daily Living (hygiene, grooming, medication adherence, etc.). Officers also fostered treatment participation in a variety of ways, as they often engaged in group activities or tasks with defendants.

The CRU provided several opportunities for creative expression and community engagement. As examples, individuals created personal cards for various holidays or engaged in discussion to honor significant historical figures or events such as Earth Day, Veterans Day, and Juneteenth. Individual art was hung on the “gallery” (i.e., unit) walls for display and brought warmth and humanity to the CRU environment. Weekly community meetings and large-scale events on the CRU also fostered peer and staff relationships. For instance, an annual talent show was held in which defendants organized, prepared, and officiated the event that included their selected songs, poems, spoken word, readings, or comedy.

Defendants received CRU services for several weeks prior to discharge. To maintain a separation between treatment and forensic evaluation, once the treatment team gathered the necessary evidence to suggest a defendant will likely be restored, an evaluator who was not on the treatment team was assigned to conduct the re-evaluation. If, in the opinion of that evaluator, the defendant was now competent, a report of the re-evaluation was sent to the court. After a defendant was opined competent and was discharged from the CRU, he received follow-up sessions once or twice per month while awaiting a hearing or until the completion of a discharge plan (housing, community-based psychiatric services, etc.) to ensure that competency was maintained.

Shift From In-Person to Telehealth Services

As occurred in many jurisdictions, in response to the pandemic, courts in Fulton County markedly reduced their activity. The number of cases referred on court order to the pretrial competency evaluation program fell from an average of 29 per month in the year preceding March 10, 2020, to 15 per month in the year following. (The referral rate subsequently increased as courts became more active although has not yet, as of November 2021, reached prepandemic levels.) The reduction was greater for evaluations of those charged with misdemeanor offenses compared with felony offenses (66% vs. 36%, respectively) as a result of various efforts made to keep those charged with lesser offenses out of the correctional system to reduce the risk of spreading COVID-19. Mandatory hearings, such as First Appearance and Bond, which are generally held in the Fulton County Jail, were held primarily by utilizing video conferencing. As will be discussed further below, transfers within the Fulton County Jail, including those to and from the CRU, were delayed because of various jail protocols implemented to avoid the spread of COVID-19 among jail people who are incarcerated.

Delivery Model for Telehealth Services

The restrictions brought on by the coronavirus pandemic required CRU staff to adopt the use of technology at warp speed to meet the needs of defendants on the unit. Specifically, they were tasked with developing a telehealth system of delivery that maintained defendants’ level of care in an effort to meet the overall goals of the program. It is important to note that the development of a telehealth system of delivery refers directly to the use of “telemental health,” which Whaibeh and colleagues (2020) define as the “use of information and communications technologies, including videoconferencing (VC), to deliver mental health care remotely, including evaluations, medication management, and psychotherapy” (p. 199).

The CRU staff decided to use Zoom©, a VC platform, stringently vetted and widely adopted by information technology and legal professionals at the Emory University School of Medicine. Furthermore, the CRU’s use of technology was authorized and bolstered by the Fulton County Jail Administration’s and the superior courts’ newly developed system for conducting mandatory jail hearings, as these entities permitted CRU evaluators to schedule use of their laptop devices.

The CRU program director and court liaison worked in tandem to reimagine the therapeutic schedule, assigning primary and ancillary tasks to the master’s-level clinicians. There was a reduced selection of daily activities at the outset, but the schedule quickly ramped up as the ease of technology use improved. Our master’s-level clinicians facilitated the core groups such as factual legal education and its real-world application, medication adherence, cognitive remediation, expressive arts, and structured recreational activities. Other team members (i.e., postdoctoral residents, practicum students, and the two directors) focused on the management of acute behavioral problems exhibited by defendants; CRU systemic issues such as wearing masks, maintaining distance in the Day Area (i.e., the main area outside of the cells where individual and group sessions were held), completing hygiene activities regularly, educating defendants about infection control problems, and monitoring progress of competency restoration goals; and the overall integrity of the program. The CRU forensic psychiatry fellows met with defendants weekly for medication management as well as monitoring of competency status. Of note, all CRU screening and admission procedures were also conducted via video conferencing.

CRU officers were trained to provide technological support and general assistance to defendants when necessary. The officers were essential in maintaining the therapeutic and educational environment that helped CRU telehealth services thrive, as they were the sole staff members on the unit during the height of the pandemic. It is important to note that the officers, already equipped with rudimentary mental health skills, were specifically trained to connect the laptops to large screen televisions and portable microphones placed in the Day Area for individual and group sessions. A postdoctoral resident was assigned to assist officers via phone or email with any troubleshooting at the outset of daily services, but this point-of-contact was used rarely with regard to our specific program needs, as officers handled device-related tasks with ease.

Although the number of group sessions decreased, individual sessions via Zoom were not only more frequent but also more structured and longer in duration. Concentrated effort was placed on legal education in the context of the defendants’ specific needs. The number of defendants in each group was reduced to two or three individuals, rather than the typical number of eight to 12, as a result of the need to maintain adequate distancing from each other for infection control purposes. It should be noted that an officer-led plan was developed for addressing behavioral and risk issues, as well as any technical disruptions. All CRU treatment team members continued to guide officers through the utilization of positive reinforcements to promote treatment participation.

Treatment team meetings were held remotely on a weekly basis, which allowed for in-depth discussion of each defendant’s symptoms and general progress with an increased likelihood for all members to be present. As the CRU treatment team, in its entirety, were not permitted to enter the jail, considerable efforts were made to retain oversight of the CRU program activity, particularly with regard to treatment from other providers.

Collaboration with the private, jail-contracted provider’s medical director, nursing director, and general mental health staff increased significantly. Regular phone calls and remote meetings ensued, bolstering the prepandemic relationships that were previously established. Systemic issues occurring at the outset of telehealth programming, such as remote access to the defendants’ electronic medical records, were resolved through the collaborative efforts of the CRU program director, a forensic psychiatry fellow, and the medical director for the contracted jail provider. Of note, the CRU treatment team was not previously aware that such access was available.

Nursing interventions by the jail-contracted provider continued throughout the time period of COVID-19 restrictions. This included twice-daily contact with defendants for medication administration and health checks. These private providers, along with the multifunctional officers, became the CRU’s “eyes and ears,” in addition to carrying out their primarily roles and responsibilities.

The level of technology required to keep the integrity of the CRU program intact for the better part of a year was daunting at times. In particular, maintaining the laptops, which were paired with large-screen television monitors on rolling carts, as well as frequent troubleshooting of the jail’s Wi-Fi connectivity issues called for great persistence and patience. It afforded, nonetheless, the facilitation of small-group and individual sessions. It also provided the opportunity for CRU team members to attend weekly community meetings with defendants, which was not logistically plausible before the launch of telehealth services. The CRU’s historical “special events” continued, albeit smaller in scale. Still, the defendants planned all aspects of each event and were active participants. The joy seen in their faces was unmatched, as they performed original poetry or sang their favorite songs to a Zoom audience composed of CRU team members and jail administrators. Such programming appeared invaluable to overall buy-in and treatment participation.

Method

Our study utilized a between-participants design examining two independent groups (prepandemic/pandemic) with regard to differences on several outcomes. Of particular importance, we examined differences in final disposition, length of time to restoration of competency, and length of stay. We viewed these outcomes as most critical in determining whether telehealth services could be an effective mode of delivery for jail-based competency restoration.

Data Collection

We routinely gather and store data on each admission with regard to demographic data; type of crime; legal status; previous and current forensic opinions; type of impairment; treatment type and duration, including medications and medication refusal; and disposition. Race is initially entered into the database from referral information from the attorney and police reports. Such information is nonstandardized and the reliability of the information about ethnicity (e.g., Hispanic) is unclear. For purposes of this study, therefore, race was re-coded as White, African American, or Other (a small percentage which included Asian, Pacific Islander, and Native American). Legal status issues were coded from court orders and forensic reports. Impairment refers to the condition(s) that rendered the defendant IST. Impairments were classified as psychosis if the pre-admission court-ordered competency report found a clinical diagnosis of a psychotic disorder and the psychosis contributed to the incompetence. In some cases, such as when the initial diagnosis was unclear or malingering was suspected, the impairment was reclassified after the CRU mental health staff had obtained further information about the defendant’s condition.

Cognitive impairments were coded when the defendant was IST because he did not understand the cognitive factors (such as the roles of trial participants or had an inability to understand plea bargaining). In the prepandemic period, many of the defendants who were thought to have a significant cognitive impairment received psychological testing on the CRU, and for those who were tested, cognitive impairment was coded for those defendants with a Full-Scale Intelligence Quotient (IQ) < 70. Because traditional IQ testing is difficult to conduct virtually in the correctional environment, few pandemic defendants were tested. For those who were not tested, a clinical judgment that the defendant was functioning at an IQ level < 70 was required for a classification of cognitive impairment. A small number of defendants were IST because of other impairments, such as severe depression. Outcome was coded as restored if competence was restored, as diverted if the defendant was released from jail into the community without competence being restored, and as inpatient if the defendant was transferred to the state inpatient forensic unit for further restoration attempts. Transfer to inpatient most often reflected that the defendant was psychotic and refused medication, and the jail by policy would not administer involuntary medication even with a court order for treatment. The time to restoration was measured from the date of admission to the CRU to the date of the forensic interview cited in the follow-up report to the court opining that the defendant was competent.

Sample Selection

The jail implemented COVID-19 precautions on March 10, 2020, and we moved rapidly to telehealth interventions soon after that time. For the purposes of this study, defendants classified as receiving pandemic services were those who were discharged from the unit after April 27, 2020, and before May 31, 2021, so that during the pandemic period they obtained at least 7 weeks of care (or all their care if their length of stay was less than 7 weeks). This pandemic sample consisted of 42 male defendants. The pandemic sample was compared with a sample of all admissions to the CRU who were discharged in the 4 years prior to March 10, 2020 (n = 398) and to a matched subsample of prepandemic defendants. To control for variables that might reflect differing arrest rates and court processing during the pandemic, pandemic participants were compared with a matched comparison group drawn from the list of prepandemic defendants (n = 398) who received services in the 4 years prior to telehealth programming.

For each defendant in the pandemic sample, four prepandemic matches for each pandemic participant were drawn who met the following criteria: A match participant had to be an exact match on the categorical variables of level of crime (misdemeanor/felony), type of impairment (psychosis/cognitive problems/psychosis and cognitive problems/other), and race. From that pool of who matched on categorical variables, four comparison matches were then drawn to maximize age proximity: More than 96% of the matches were of an age within 5 years of the matched pandemic subject. This resulted in a matched comparison group of 168 participants.

Data Analysis

Data were extracted from our database and analyzed using the Statistical Package for the Social Sciences (SPSS), Version 26. In analyzing differences between groups, the data were first examined as to whether they met t-test assumptions by examining boxplots, outliers, and histograms, and if the data did not meet those assumptions, nonparametric statistics were utilized. The data collection, storage, and methods used for research were approved by the Institutional Review Board of Emory University and the Institutional Review Board of the Georgia Department of Public Health.

Results

Baseline characteristics of the samples are shown in Table 1. The prepandemic matched comparison group was matched to the pandemic participants. All the pandemic participants were either White or African American, so no participants from other races were included in the matched comparison group. The matched comparison group was close in age to the pandemic group (matched mean 38.7 years [SD = 13.4], pandemic mean 38.1 years [SD = 13.1]). In the pandemic and matched comparison group, most defendants (81%) had felony charges and the most common impairment was psychosis.

Table 1:

Defendant Characteristics

	Prepandemic (n = 398)	Pandemic (n = 42)
Characteristics	(%)	(%)
Offense type
Felony	84	81
Misdemeanor	16	19
Race
White	8	17
African American	90	83
Other	2	0
Impairment type
Psychosis	72	88
Cognitive	10	7.1
Psychosis and cognitive	13	2.4
Other	4	2.4
Age (mean years)	39.6	38.1

Note. The matched prepandemic group used for analysis (N = 168) matches the pandemic group on all listed variables except that the mean age is 38.7 for the matched sample.

Outcomes are shown in Table 2. The pattern of dispositions in the pandemic sample was significantly different from that of the prepandemic matched comparison group (χ² = 10.4, p = .005). About two thirds (66%) of those treated during the pandemic were restored to competency, a rate that was significantly higher than that of the matched comparison group drawn from the 4-year, prepandemic period (χ² = 10.1, p = .001).

Table 2:

Outcome of CRU Admissions by Type of Disposition

Outcome	Prepandemic (n = 168)a	Pandemic (n = 42)	Test for difference	Sig,	Effect size
Disposition	N (%)	N (%)	χ2	p	Cramer’s V
Restored	66 (39%)	28 (66%)	10.1	.001	.220
Diverted	42 (25%)	7 (17%)	1.3	.253	.079
Inpatient	60 (36%)	7 (17%)	5.6	.018	.163
Overall			10.4	.005	.223
Mean length of stay	Days (SD)	Days (SD)	Mann–Whitney U	p
Restored	91 (48)	133 (82)	2.6	.014
Diverted	118 (88)	104 (78)	0.43	.680
Inpatient	85 (60)	92 (36)	0.46	.650
Total all dispositions	95 (65)	122 (76)	4259	.038
Mean time to restorationb	65 (46)	78 (62)	1.0	.062
Mean admissions/ month	5.7 (1.9)	3.1 (1.5)	90	<.001

^aComparisons were done with the matched prepandemic comparison group. ^b Time to restoration is the time from admission until the defendant was deemed competent to stand trial by an evaluator.

Of the seven defendants who were ultimately transferred to a forensic hospital, six (85%) refused medication during their stay on the CRU (the jail system that housed the CRU, by policy, does not allow involuntary medication, even with a court order). In analyzing the distributions of data regarding length of stay, time to restoration, and number of admissions by examining boxplots, outliers, and histograms, it appeared that the data did not fit t-test assumptions, so differences were assessed utilizing nonparametric methods. The mean length of stay for defendants receiving telehealth services was 122 days, which was considerably longer than the mean length of stay of 96 days in the prepandemic period (Mann–Whitney U = 4259, p = .038). The extended length of stay in part reflected that when a request to transfer a defendant off the CRU was placed during the pandemic period, there was often a significant delay before the jail executed the transfer because of COVID-19 protocols. For those defendants, whose competency was restored, the time from admission until competency re-evaluation increased from 65 days prepandemic to 77 days during the pandemic (Mann–Whitney U = 1, p = .062). While these data reflect a nonsignificant difference, it is still meaningful for our study, as it suggests that the use of telehealth services does not adversely impact a restored defendant’s length of stay. Overall, the number of admissions per month to the CRU decreased during the pandemic reflecting both lengthening of stay and delays in filling empty beds because of transfer delays.

Discussion

Mental health clinicians generally advocate for the least restrictive treatment environment, regardless of the particular set of challenges with which the individual presents. For those who are not justice-involved, the path to treatment is less fettered with the typical issues associated with service delivery in correctional settings (i.e., the provision of both ethical and evidenced-based treatment with regard to the availability of particular treatment providers, environmental restrictions due to limited space, and consistency of services, as all may be affected by security concerns or measures). Justice-involved individuals with an array of treatment needs due to mental illness, cognitive impairment, and other conditions are entitled at the very least to adequate treatment intervention and restorative services available in their respective community.

Despite the apparent criticisms of JBCRUs, a robust cost-benefit analysis for JBCRUs similar to that presented by Ash et al. (2020), in relation to the CRU, may prove beneficial when considering the wide variation of deficits observed among IST defendants. Such analysis may be invaluable in determining appropriate yet cost-effective treatment modalities for competency restoration focused on the defendant’s functional deficits. We seek to describe a model for jail-based services that addresses many of the criticisms found in recent literature. In fact, we argue that the CRU mirrors the treatment model for competency restoration found in most state hospitals, as we adapted many traditional therapeutic activities for success in the jail environment.

The onset of COVID-19 ushered in new challenges, however, as protocols within the jail environment as well as procedures within the court system shifted. Still, we felt confident in the utility of telehealth services, given its necessity, as we had defendants housed on the unit at that time. There is burgeoning evidence that telepsychiatry/telepsychology services are appropriate for use in correctional and forensic settings, and that it can be done in an effective and reliable manner (Antonacci et al., 2008; Luxton & Lexcen, 2018; Luxton & Niemi, 2020). Such findings support the notion that telehealth services are adequate for treatment and evaluation.

Our findings also give credence to the utility of telehealth services. In fact, the CRU’s restoration rate was higher during the implementation of telehealth services when compared with prepandemic programming. Causal reasons for improvement in the restoration rate are unclear and outside the scope of this study. Nonetheless, smaller group sizes, increased time in individual treatment sessions, fewer distractions in individual and smaller groups in the day (common) area, and increased focus during sessions using the Zoom format likely contributed to this observation. It appears, even in the absence of known causes, that competency restoration via a telehealth platform is a viable method of service delivery. However, it is still reasonable to perceive telehealth as less effective as in-person services, given that time to restoration and length of stay were somewhat increased. Criteria for defendant selection were also narrowed.

Still, there were other notable challenges with telehealth implementation. First, the responsibilities of the CRU officers increased remarkably and required hours-long training and coordination. We were fortunate in that we had correctional staff hired solely to carry out CRU operations, as their role was multifunctional in nature, and therefore, we were able to develop and facilitate training sessions for each officer and address issues with technology in real time. If given the opportunity to provide advanced and need-specific officer training, the utility of telehealth services has favorable implications for rural areas and those who have a dearth of professionals qualified to deliver treatment for competency restoration. We must acknowledge, nonetheless, that unpredictable issues with technology and specialized officer training may certainly serve as barriers.

Second, the length of stay for IST defendants was 26 days longer once we began solely offering telehealth services. There was also an observed increase in the number of days between CRU admission and a “competent” opinion for those defendants who were restored. It was previously mentioned that these periods may have been extended as a result of COVID-19 protocols. However, we cannot discount the potential influence of our staff’s physical presence on the CRU, as that could also serve as an impetus to move along defendants’ cases.

The difference in time to restoration also may reflect issues in treatment scheduling related to COVID-19, such as decreased opportunities to provide mobile legal education (i.e., competency restoration sessions) to defendants still housed in general population due to fewer officers being available for escorting, as well as staggered scheduling of staff members utilizing the large television monitor on the CRU for individual and group sessions. It is important to note that the need for staggered scheduling brought into question whether telehealth programming could function sufficiently with a reduced number of clinicians, as there were periods in which staff productivity appeared to lull. Furthermore, the reduction of clinicians may have program cost-related implications.

Finally, despite, or perhaps because of, increased officer presence or usage, there were inherent concerns regarding privacy that arose with telehealth service delivery. Discussion of the defendants’ specific legal situations, in particular, throughout the course of treatment was of keen importance and handled with care. Often such discussions were relegated to individual sessions with their assigned treatment providers via the jail visitation phone, which afforded a greater opportunity for privacy.

Although our preliminary findings appear promising, there are some limitations. First, the matched comparison groups (i.e., prepandemic vs. pandemic) were matched on a limited number of variables and there were numerous differences in the way intervention services were delivered that were not measured. Second, CRU admission and discharge times during the pandemic were affected by jail protocols put in place for health and safety, which likely influenced the average length of stay and perhaps the restoration rate. Probably most significantly, jurisdictional differences and particular practices in our program limit the generalizability of the results to other jurisdictions that utilize different legal procedures and different interventions.

Another limitation was our inability to conduct traditional psychological testing, which precluded us from obtaining an objective estimate of the pandemic defendants’ intellectual abilities. As such, we were limited in directly comparing the IST reason between the prepandemic and pandemic groups, particularly with regard to cognitive impairment. Consequently, it is unclear whether telehealth services are more effective than in-person services, given inherent differences between groups (e.g., smaller groups) and delivery of interventions (e.g., increased time for individual sessions). We were more concerned that service delivery would be hindered or impaired by switching to telehealth. Despite these limitations, however, our findings do suggest that telehealth competency restoration can be an effective method of service delivery with outcomes that are not markedly worse than in-person services.

Conclusions and Implications for Future Research

Telehealth services, as implemented within our program, are likely not appropriate for IST defendants with chronic and treatment-resistant psychotic disorders; rather, restoration success is more likely when IST defendants have the capacity to maintain themselves in front of a screen for distinct periods of time. Telehealth services cannot be delivered to IST defendants with psychotic disorders who are not medication adherent and are too paranoid or distressed to exit their cell. This mode of service delivery may also be contraindicated for IST defendants with communication disorders or who are vision and/or hearing impaired.

Still, it became apparent to us that, rather than being just a temporary method used to overcome challenges brought on by the pandemic, the convenience and cost-saving potential associated with telehealth services will likely be an enduring feature of forensic work in the 21st century. Mulay et al. (2021) corroborate this perspective, as they noted the use of VC for forensic evaluations may be useful in jurisdictions with limited resources and lessen delays in resolving legal cases.

It remains unclear, nonetheless, whether the establishment of a “human connection” between a forensic evaluator or treatment provider and the defendant is better facilitated through in-person services. Does the apparent absence or reduction of such connection affect evaluations as well as treatment outcomes? In a recent meta-analysis, researchers suggested that telepsychology outcomes were greatly similar to in-person outcomes when working with justice-involved individuals (Batastini et al., 2016, 2020). We argue that evaluation and treatment outcomes are likely deficit-dependent, as it seems that certain defendants are more appropriate for telehealth services than others. Future research must be conducted to develop “best practices” or guidelines for screening defendants who might benefit from the use of telehealth platforms.

Similar to early perspectives about using technology to perform competency evaluations, we were initially skeptical about the value of delivering competency restoration services through telehealth programming and viewed in-person delivery as the gold standard for such services. The sudden onset of COVID-19, however, forced us to implement technology use, as no other recourse readily emerged. Because of this, we now recognize how the use of technology for certain aspects of the program has improved training and service delivery, and therefore, we intend to embrace a multidimensional program model for the foreseeable future.

Training

The onset of COVID-19 and consequent rise of telehealth services has caused practitioners and trainees alike to acquire new knowledge and skills. The CRU participates in the advanced forensic training of psychiatry fellows and psychology postdoctoral residents. Direct psychiatric care of defendants on the CRU is provided by fellows in forensic psychiatry under the supervision of faculty forensic psychiatrists. Standards for training forensic psychiatry fellows are set by the Accreditation Council for Graduate Medical Education and those standards include experiences in correctional systems and in competency assessment and restoration (Accreditation Council for Graduate Medical Education, 2020). Regarding the latter, at distinct periods during the training year, each fellow is either assigned as a CRU treatment provider or evaluator, and regardless of assignment, a different fellow is appointed to conduct the follow-up competency evaluation and write a report to the court to avoid dual-agency problems (i.e., conflicts between the roles of treatment provider and evaluator). It is important to note that such practice is not dissimilar to that observed at the state forensic hospitals in Georgia.

Prior to the COVID-19 pandemic, assigned fellows met with defendants in-person for admission workups and then at least weekly for continuing care. When the pandemic began and the Fulton County Jail reported a rising number of COVID-19-positive justice-involved individuals, there was minimal disruption in training. The forensic psychiatry fellows provided individualized, telehealth sessions on the same schedule they had previously. The telehealth interactions went smoothly and were generally well tolerated by the defendants housed on the CRU. This was likely due to the selection policy, under which IST defendants who have severe behavior problems (i.e., overly aggressive toward others or highly resistant to any treatment interventions) are not admitted to the CRU, but instead are directly referred to an inpatient forensic hospital unit.

To meet training objectives as outlined by the commission on accreditation of the American Psychological Association (2018) as well as expectations set forth by The American Board of Forensic Psychology (2022), psychology postdoctoral residents and predoctoral interns conducted pretrial evaluations, in addition to facilitating groups, providing individual sessions, and administering and interpreting psychological testing of IST defendants on the CRU. Psychology postdoctoral residents received at least 3 hr of supervision, consisting of assessment supervision, supervision of jail-based services, and professional development.

Postdoctoral residents supervised the psychology predoctoral intern(s) and practicum student(s). These residents, in particular, offered supervision while on the unit regarding test administration, report writing, group facilitation, administrative management, and site-specific clinical and ethical issues. Prior to the pandemic, supervision was conducted primarily through observation, modeling, shadowing, and feedback around specific forensic-clinical issues.

Once COVID-19 restrictions were imposed, however, postdoctoral residents were given additional responsibilities, as they were instrumental in the CRU’s launch of telehealth services. They were required to learn the technological resources available and determine which staff members were best suited to complete specific tasks. For example, the psychiatry fellows were tasked with gaining remote access to jail medical records, while the postdoctoral residents trained correctional officers to set up the telehealth platform for groups and individual sessions. The latter task required great coordination across an interdisciplinary team with varying levels of knowledge and expertise and could not have been achieved without persistent communication with correctional administrators.

As restrictions continued from the end of one training year through several months of the following year, orientation of incoming psychiatry fellows and postdoctoral residents required significant acclimation to the use of technology through review of literature and observation. Early signs indicate that the use of telehealth platforms may become widespread practice and it is vital that curriculum and training are further developed to address this growing paradigm.

We found that the crystallized structure of supervision afforded through the use of technology was invaluable to forensic supervisors and trainees alike and decided to continue with remote sessions in addition to in-person feedback and supervision. This allowed for more formalized, standing supervision hours, which are often difficult to maintain in the correctional setting.

Service Delivery

We will continue to monitor CRU outcomes closely, as we embrace a multidimensional service model (i.e., using in-person and telehealth programming). While we acknowledge that the potential benefits of a telehealth delivery service model appear promising with regard to competency restoration rates, we also recognize the interpersonal, therapeutic, and operational benefits of the presence of clinicians on the unit. There seems to be intrinsic value in the traditionally functioning therapeutic milieu, as the physical presence of clinicians may positively influence defendants to maintain their treatment plans and look forward to other aspects of their futures. Impromptu interactions with clinicians, for example, could be transformative for some defendants but are essentially lost with services delivered solely through telehealth programming. Finally, we do not view telehealth programming, in which only correctional staff are present on the unit, as ideal or sustainable across most correctional settings.

Maintaining our capacity to render telehealth services, nonetheless, may be useful to defendants with cognitive deficits who could benefit from more concentrated, individual sessions outside of rote programming. Some competency evaluations, particularly those held with defendants on bond, also may continue to be performed via VC, as that mode appears to be more time-efficient for evaluators and preferred by defendants.

In sum, we must express that it was never our desire to create a telehealth competency restoration program. We, like the rest of the world, were faced with a public health crisis, to which our commitment to program participants as well as other stakeholders required a swift and viable response. It is our belief that the COVID-19 pandemic brought on a paradigm shift across disciplines, much like that experienced with the advent and subsequent everyday use of the internet. As such, we view our adoption of a multidimensional program model as a necessary step to attend to a technologically advancing world. It is vital that our field continues to conduct research on psychological service delivery methods holding that in mind.

Biography

Douglas E. Lewis Jr., PsyD, is a clinical and forensic psychologist for the Georgia Department of Corrections as well as an adjunct assistant professor at the Emory University School of Medicine. He holds expertise in diversity, equity, and inclusion and serves as a master facilitator for various group-based trainings. Lewis’ research and professional interests include forensic assessment, diversity considerations for court-ordered evaluations, and history and systems.

Peter Ash, MD, is a professor and director of the Psychiatry and Law Service at the Emory University School of Medicine. He is a past president of several professional organizations, including the American Academy of Psychiatry and the Law, the Georgia Psychiatric Physicians Association, and the Georgia Council on Child and Adolescent Psychiatry. Further information about Ash can be read in a published biography article available online at http://www.jaapl.org/content/39/1/12.full.

Victoria C. Roberts, MEd, LPC, is a consultant, court liaison director, and the former program director for the Emory/DBHDD Jail-Based Competency Restoration Program for the Psychiatry and Law Service at the Emory University School of Medicine in Atlanta, Ga. She is also the past director of forensic services at Georgia Regional Hospital at Atlanta. She is an active member of the 2017 Fulton County Justice and Mental Health Task Force whose mission is the development of cross-system strategies to reduce the number of people with mental illness in jails.

Tomina J. Schwenke, PhD, ABPP, CI, CT, QMHI, is a licensed and board-certified psychologist and nationally certified sign language interpreter. She is an assistant professor in Emory’s Psychiatry and Law Service and serves as the director of Emory’s jail-based competency restoration unit. She was recently awarded the Richard Morrel Community Commitment Award (Emory), the Martin Seligman Research in Psychology and Deafness Award and Outstanding Journal Article Award (ADARA), and the Dennis Brady Service Award (CUNY).

Melvin Pagán-González, PsyD, is a clinical and forensic psychologist in private practice, evaluating persons involved in criminal and civil matters. He completed his predoctoral internship within the federal bureau of prisons and his postdoctoral residency at the Emory University School of Medicine. He has presented at national conferences on topics related to language and culture responsive assessment.

Glenn J. Egan, PhD, is a clinical psychologist and an assistant professor in the Department of Psychiatry and Behavioral Sciences at the Emory University School of Medicine. He specializes in forensic, personality, and neuropsychological assessment. He has been a member of Emory’s Psychiatry and Law Service since 1995 and started a postdoctoral program to train psychologists in the forensic specialty in 2011.