The major current issues facing state and local forensic mental health programs are presented in this paper. Debates over forensic patients' rights and the insanity defense are discussed, together with many administrative problems such as the pros and cons of correctional versus mental health system program control and payment incentives for treatment. The authors cite the differing goals of correctional and mental health systems, i.e., security and treatment, as reasons for difficulties in developing needed collaboration. Guidelines are suggested to address such important issues as mixing civil with criminal patients, developing units for special populations, defining patients who can respond to treatment, and follow-up after discharge.