RESEARCH WEEKLY: Trade-offs between civil commitment and competency restoration By Elizabeth Sinclair Hancq (September 13, 2023) Across the United States, there has been an increase in the number of individuals with serious mental illness found incompetent to stand trial and court-ordered to a state hospital for competency restoration. This trend is coupled with a decrease of individuals admitted to state hospitals for civil commitment. A new study by Dr. Joe Bloom and colleagues examined the relationship between individuals found in need of competency restoration and civil commitment admissions in Oregon. They found a strong negative correlation between these two admission types, suggesting “neglecting civil commitment may well have contributed to the CST [competency to stand trial] crisis in Oregon.” While correlation does not mean causation, these data are the closest evidence to suggest that the increase in the number of people needing competency restoration, and the subsequent lawsuits requiring speedy admissions to state hospitals, may be inadvertently criminalizing serious mental illness. A deeper dive Civil commitment is a legal process where an individual is court-ordered to receive mental health services because they are found to meet their state’s criteria for needing treatment. Inpatient civil commitment most often occurs in a state hospital. Competency restoration also most often occurs in a state hospital, but the process is different. An individual is found in need of competency restoration if, after being arrested for a crime, they are deemed unable to appropriately participate in their own defense because of their mental illness symptoms, and subsequently, must be restored to competency before standing trial and the legal process can continue. Therefore, to be admitted to a state hospital for competency restoration services, an individual must have been arrested for a crime and be involved in the criminal legal system. The civil commitment process, on the other hand, is separate from the criminal legal system but rather is a way to require someone with mental illness to receive needed mental health treatment when they have significantly decompensated and may not understand their need for treatment. Oregon also has a psychiatric security review board (PSRB) for individuals who have been found, after a court trial, not guilty by reason of insanity. In Oregon, PSRB clients waiting for a hospital bed have the same constitutional rights as those who need competency restoration. In 2003, there was a court decision requiring Oregon to admit individuals waiting in jail for competency restoration to the state hospital within seven days. A further agreement was established in 2019 after the state experienced difficulties in following this order. However, the COVID-19 pandemic resulted in increased strain on the state hospital system, and a series of court proceedings further prioritized the admittance of individuals in need of competency restoration over those for civil commitment. This is further illustrated through the data Bloom and colleagues present on the admissions to Oregon State Hospital average daily population by legal category since 2000: 2000: 52% Civil, 9% CST, 38% PSRB 2010: 30% Civil, 14% CST, 54% PSRB 2021: 3% Civil, 59% CST, 37% PSRB Implications While these data and legal events apply specifically to Oregon, there are many other states in a similar situation. At least 12 states are currently ordered to prioritize admission of people in need of competency restoration due to a lawsuit. “Other states may find Oregon’s limitations and responses, including the longitudinal data on the empirical operation of important mental health statutes to be informative,” the authors note. “Neglecting civil commitment while trying to control a significant rise in criminal confinement was problematic. CST and civil commitment statutes operate in concert with each other but in an inverse manner (when one goes down, the other goes up) … Lower use of civil commitment, driven by many factors over the years, leaves undertreated patients in the community where many will be arrested for various crimes, thereby contributing to criminalization of mental illness.” Reference Hansen, T.E., et al. (September 2023). COVID-19, Mink-Bowman, and court-ordered psychiatric services in Oregon. Journal of the American Academy of Psychiatry & Law. Elizabeth Sinclair Hancq is the director of research at Treatment Advocacy Center. View as Webpage To receive Research Weekly directly in your email inbox on a weekly basis, click here. Questions? Contact us at [email protected] Research Weekly is a summary published as a public service of Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. 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