A Call to Evaluate Our Forensic Treatments

• forensic hospital treatment
• forensic treatment research
• quality improvement

Since its inception, forensic psychiatry in the United States has primarily focused on the use of psychiatric skills to conduct evaluations for legal matters, including courts and other third parties. Early literature in the field largely shared that focus on forensic evaluations. Over the last three decades, the field has begun to shift, with growing attention to the care and management of forensic populations in correctional, state hospital, and community settings. In kind, educational organizations have recognized this shift, underscored by the need to include a care component in fellowship training as part of the formal Accreditation Council for Graduate Medical Education (ACGME) accreditation process and, more recently, the creation of a correctional track at the American Academy of Psychiatry and the Law (AAPL) annual meeting. The literature has started to evolve in this direction as well; however, when considering scholarship on the quality and efficacy of care within forensic psychiatry settings, efforts continue to lag. As recently as the 2024 AAPL Presidential Address, retiring president Dike identified the ongoing limited focus on treatment and advocated for increased emphasis on treatment in ethics discussions and fellowship training, among other things.¹

When exploring variability or quality improvement within forensic evaluations, readers may find many published works in this and other journals. Conversely, although there have been calls for research efforts focused on treatment and recommended elements to evaluate,² substantially less has been published on care- and treatment-focused efforts in forensic hospitals or for forensic populations. For example, several reviews of evidence-based care of forensic populations in the last decade have noted the relative lack of literature on treatment for forensic populations.^3,4 Hillbrand detailed the barriers to research in state hospitals and the imbalance between research focusing on problems versus treatment in an editorial nearly two decades ago.⁵ Lindqvist and Skipworth found the imbalance stark enough at the turn of the millennium to admonish, “The profession of forensic psychiatry should not restrict itself to being an entrepreneurial risk assessment industry without ties to the traditional roles of medicine: to treat and to care. Thus, treatment and rehabilitation need to occupy a central position in forensic mental health” (Ref. 6, p 320).

Although there is some literature examining specific outcomes within forensic populations (e.g., length of stay), the primary focus of such work is typically on individual patient characteristics rather than treatment interventions.⁷ Recent reviews have found limited evidence for most medication and therapeutic interventions in forensic populations.^3,4,8,9 Most of the studies cited were completed outside the United States, typically with different care systems and legal frameworks.^3,8,9 For example, MacInnes and Masino completed a review of randomized control trials looking at evidence for psychological and psychosocial interventions offered to forensic inpatients, and none of the nine studies meeting their criteria were completed in the United States.⁹ The authors noted some positive findings for cognitive behavioral therapy (CBT) and psychoeducation as effective interventions for symptom reduction, and some promising results for dialectical behavioral therapy (DBT) regarding violence risk reduction, but overall found a lack of consistent significant differences between groups and limited evidence for current practices. Notably, The Journal recently published a quasi-experimental study by Marshall and colleagues showing positive results for DBT interventions in a Michigan forensic population.¹⁰ Howner and colleagues also completed a review of controlled trials of medications in forensic psychiatric care.⁸ Most of their 10 included studies were retrospective and nonrandomized, and several had high risk of bias. Only two were from the United States. Others have described plans to complete more comprehensive reviews of forensic care systems, but again, mostly outside of the United States.^11,12

Further, although there has been some promising research in correctional populations on programming to reduce recidivism (including the Risk-Needs-Responsivity model and Good Lives Model), there are limited data on the adaptation and application in other forensic settings.¹³ In The Journal, although there is increasing interest in treatment, only eight of the 42 total regular articles and Analysis and Commentary articles over the last year focused primarily on treatment for forensic populations (September 2023 to June 2024), compared with 14 focused on evaluations, including two articles counting as both treatment and evaluation. Others have previously identified similar gaps in the focus of forensic publishing and presentations.¹⁴

Although we can learn much from the work of our international colleagues, we cannot rely solely on applying practices in the United States that were evaluated in different systems with diverse resources and regulations. We owe our patients more. Given the paucity of scholarship systematically exploring ways to improve the quality of care in U.S. forensic settings, it is imperative that we increase our collective attention on this area and ensure we are providing our patients the best possible care. To maximize the benefit of our dwindling state hospital beds^15,16 and have an effective way to address the risks identified in our assessments, we need to increase our focus on improving treatment and rehabilitation in our forensic settings. Only by identifying effective treatment programs can we appropriately balance the inherent tensions in forensic institutions: individual liberty and care needs with the safety of the public.

We recognize there are many barriers to research on treatment within forensic mental health settings. There are larger regulatory and ethics barriers, including the protective rules for studies in forensic settings, special ethics considerations,¹⁷ and administrative barriers to Institutional Review Board (IRB) approval.⁵ Nicholls and Goossens note variable implementation of risk assessment tools upon which to make treatment decisions and reflect on the challenges inherent in the shift from focusing on risk assessment and monitoring as the basis of care to more active treatment.¹⁸ There are also barriers to applying research from a single institution to other settings given the significant interstate (and international) variability in the forensic population, local statutes and regulations, and available resources. Further, forensic mental health patients are typically complex, and treatment and quality improvement efforts must address both mental health and criminogenic needs.^4,19 Treatment and release decisions may also be influenced by social and political considerations.²⁰ Similarly, measuring postdischarge outcomes is complicated and time-consuming, especially when the base rates of the most readily identifiable outcomes (e.g., recidivism) may be low.^21,22 Similar barriers exist in correctional settings. Looking to outpatient settings, additional barriers include variable programming targeting forensic populations. In some areas, forensic outpatients (whether insanity acquittees or individuals on some form of community supervision or monitoring) are even more difficult to capture as they are served in public health clinics for individuals with severe mental illness without tailored programming for forensic needs.

Similar to Dike’s reflections on ethics, in a recent systematic review of literature on competency restoration, Candilis and Parker reflect on the impact of forensic focus on evaluations, reports, and testimony as the primary elements of forensic practice, with the ensuing impacts on fellowship training, focus of research during and after fellowship, and material presented at Academy meetings.²³ We note the same focus may negatively affect fellows’ experience of forensic care, interest in treatment-focused careers, and experience and interest in treatment-related research. Although Candilis and Parker’s priority was primarily on improving the quality of research related to competency restoration, both they and Kolla advocate for improved quality of research in forensic psychiatry.^23,24 We agree but also emphasize the special need for increased attention to research in the United States that prioritizes the quality and effectiveness of care.

Given the traditional focus on evaluations, it is not surprising that, unlike international experiences,¹⁴ state hospital positions have often been considered less desirable or less regularly sought out by forensically trained psychiatrists or other high-quality applicants. In our experience, medical directors struggle with high rates of turnover and reliance on locum tenens psychiatrists, which presents a barrier to interest, expertise, and continuity required for research and may also negatively affect the continuity and quality of care. There are similar recruitment and retention challenges in correctional settings, with many sites reporting high turnover and difficulty filling positions.²⁵

Existing literature includes reasonable recommendations for improving the current dearth of evidence. For example, authors have recommended larger structural changes, such as developing academic partnerships and a tiered system of centers of excellence similar to the model in oncology.²⁶ Others have suggested expanding the literature looking at patient outcomes reflecting on the characteristics of care and expanding outcomes measured.^6,7 These efforts would represent important first steps to help our field develop a uniform language for meaningful metrics specific to forensic populations. We also recommend clinicians and researchers consider the diversity, equity, and inclusion implications of their work (consider the comprehensive overview of elements described by Chatterjee and colleagues²⁷ and framing of survey questions as noted by Candilis,²⁸ for example).

Although improvement of care through larger systemic changes and coordination between levels of care is ideal,^13,26 smaller, local quality improvement (QI) efforts may represent a crucial first step and may seed collaborations and larger study efforts. For example, writing about quality improvement (QI) efforts in forensic settings may help clinicians and medical directors model and implement their own QI projects based on previously published programs. Over the last two decades, QI efforts in health care have focused on improving the safety, equity, effectiveness, efficiency, timeliness, and patient centeredness of health care.²⁹ These are all important elements in forensic care, with nuances specific to concerns about violence, safety, legal requirements, and dwindling resources. There are many more general resources available on implementing the Plan-Do-Study-Act QI cycle.^30,31

In the past, QI efforts may have represented a lower barrier to IRB approval or exemption, but at our institutions, IRBs have become more rigorous when reviewing these projects, especially if there is any possibility of publication. Still, QI projects may represent a more accessible point of entry for clinicians working in forensic sites and inspired to try to address gaps in their own system but with less formal research background. Similarly, at least a part of a QI project may be more accessible in scope to fellows or other trainees, providing greater hope that we might train and inspire a new generation of researchers and clinicians in forensic care. Although all forensic sites of care, including correctional and outpatient settings, would benefit from additional research on effective treatment and rehabilitation efforts, forensic inpatient settings may represent an easier point of entry, given that they are primarily health care settings (versus a secondary service in a carceral system) and include clearly defined and accessible populations (versus some outpatient settings). Potential projects might include examining the impact of implementing various trainings for staff to enhance the quality of care, rolling out new treatment modalities (e.g., CBT for psychosis or elements from the Risks-Needs-Responsivity (RNR) model), development or implementation of new milieu management models, impact of new services on treatment outcomes, or alternatives to restraint and seclusion to reduce rates of aggression and untoward events.

The task is daunting. We hope to inspire medical directors, forensic psychiatrists, and other professionals working in forensic mental health settings to examine their practices, identify QI initiatives or other research projects based in their own practice, and write about their experiences. Over time, as we develop this foundation of interest and expertise, our literature can move toward more robust, prospective research of larger populations as described, for example, by Candilis and Parker.²¹ We also echo Hillbrand’s recommendations to involve all stakeholders (including patients) in advocacy regarding research, balancing risks in forensic research with risks inherent with lack of research, and incorporating research as intrinsic to state mental hospital systems’ missions.⁵ Finally, we hope that state hospital systems and academic institutions will continue to scale up partnerships to facilitate sharing of research expertise and support and to attract individuals with academic interests to the state hospital systems.^32,33

• © 2026 American Academy of Psychiatry and the Law