When Jails Become Psychiatric Wards: Competency to Stand Trial and the Criminalization of Mental Illness in America

Dr. Douglas E. Lewis, Jr.
19 hours ago
5 min read

Man in gray prison uniform sits on metal bench in cell, head down, hands clasped. Open cell door nearby. Dim, somber atmosphere.

The U.S. criminal justice system has quietly assumed a role it was never designed for: serving as a default mental health provider for tens of thousands of Americans with serious mental illness. Through the lens of competency to stand trial (CST) proceedings, jails and courts have become pressure valves for an underfunded, fragmented mental healthcare system.

Following deinstitutionalization starting in the 1960s, the number of inpatient psychiatric beds in the United States plummeted, from roughly 559,000 in 1955 to far fewer today, due to stricter civil commitment laws and a push toward community-based care that was never adequately funded. At the same time, the number of mentally ill individuals entering the criminal justice system rose sharply. Jails and prisons now house more people with serious mental illness than state psychiatric hospitals.

This shift has driven an explosion in competency evaluations and restoration orders. Estimates suggest 60,000 to over 130,000 CST evaluations occur annually, with many jurisdictions reporting substantial increases in recent years. Forensic systems are overwhelmed, leading to long waits in jail, deteriorating mental health, and lawsuits over delays.

The core issue is not a sudden surge in dangerousness but structural failures: inadequate community mental health, police as de facto first responders, and jails becoming entry points for psychiatric treatment. The competency system has become a pressure valve for failures elsewhere.

What Does “Competent to Stand Trial” Actually Mean?

Competency to stand trial is not about guilt, innocence, sanity at the time of the offense, or even treatability. It is a narrow constitutional safeguard ensuring defendants can meaningfully participate in their own defense.

The foundational standard comes from Dusky v. United States (1960): A defendant must have “sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding” and “a rational as well as factual understanding of the proceedings against him.”

This includes:

Factual understanding: Knowing the charges, roles of courtroom actors (judge, prosecutor, defense attorney, jury), and basic trial procedures.

Rational understanding: Appreciating the seriousness of the situation without delusional distortions (e.g., believing the trial is a divine test rather than a legal process).

Ability to assist counsel: Communicating relevant information, participating in decisions like pleas, and working collaboratively with an attorney.

These requirements protect the dignity of the judicial process, the accuracy of outcomes, and defendants’ autonomy. Historical roots trace back centuries in Anglo-Saxon law, where an incompetent defendant could not enter a plea. Modern U.S. law, influenced by cases like Drope v. Missouri and Indiana v. Edwards, reinforces competency as fundamental to due process.

Forensic psychologists operationalize these standards using structured interviews, tools like the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA), and collateral information. Assessments evaluate not just symptoms but functional capacities.

Why Competency Evaluations Have Exploded in the United States

The surge in competency referrals stems primarily from the failures of deinstitutionalization and community mental health infrastructure, not from more mental illness per se. As psychiatric beds declined, untreated or undertreated individuals with serious mental illness increasingly came into contact with law enforcement, often for low-level offenses linked to homelessness, substance use, or survival behaviors.

Police have become frontline mental health responders due to the lack of crisis services. Jails serve as de facto psychiatric intake centers. Once in the system, mental health issues frequently trigger competency questions, especially for defendants with psychosis. Misdemeanor cases, in particular, show high rates of incompetence findings.

Long waiting lists for forensic beds compound the problem, creating backlogs and extended pretrial detention. This cycle criminalizes mental illness: people who might have been hospitalized in an earlier era are now funneled through courts and jails.

Inside a Competency Evaluation: What Forensic Psychologists Actually Do

Competency evaluations are structured forensic assessments, not casual clinical opinions. They typically involve:

Clinical interviews and mental status exams.
Assessment of cognitive functioning, psychosis, and reality testing.
Review of collateral records (medical, criminal, educational).
Evaluation for malingering (faking incompetence).
Analysis of functional abilities tied to the Dusky criteria.

Evaluators must navigate ethical challenges, such as defendants refusing to participate or the tension between therapeutic rapport and forensic objectivity. Standardized tools enhance reliability, though clinical judgment remains central. Courts agree with evaluator recommendations in the vast majority of cases (around 90%).

Sub-questions include: Yes, malingering is possible and must be assessed. Evaluations can sometimes proceed without a full defendant interview using records and observation, but this is limited. Psychological opinions provide probabilistic insights, not absolute certainty.

The Human Cost of Waiting: Jail Deterioration and Psychiatric Decline

Defendants found incompetent often wait weeks, months, or longer in jail for restoration services. Jails lack therapeutic environments, leading to isolation, symptom escalation, decompensation, and heightened suicide risk. Many deteriorate psychologically while awaiting “restoration,” creating a cruel irony.

The system aims to restore prosecutability, not necessarily holistic recovery. Extended pretrial detention for minor charges can exceed potential sentences, raising questions of fairness and humanity. Restoration typically involves medication, legal education, and therapy, but jail conditions undermine these efforts.

Race, Poverty, and Unequal Exposure to the Competency System

Structural vulnerabilities (e.g., poverty, homelessness, lack of insurance, and over-policing of marginalized communities) disproportionately funnel people into competency proceedings. Serious mental illness overlaps heavily with homelessness and justice involvement. Public defenders often raise competency issues due to limited resources for alternatives.

While direct causal claims require caution, the literature consistently shows higher exposure among poor and unhoused defendants, reflecting broader inequities in treatment access and policing.

Ethical Debates in Modern Forensic Psychology

Competency proceedings raise profound tensions: treatment vs. autonomy, public safety vs. liberty, and punishment vs. care.

Key debates include:

Forced medication (e.g., under Sell v. United States criteria) to restore competency.
Whether defendants are “restored” enough for fair trials but not truly recovered.
Risks of preventive detention disguised as restoration waits.
Whether the system perpetuates criminalization rather than addressing root causes.

A deeper question: Should severe mental illness primarily be routed through criminal courts at all, especially for non-violent or low-level offenses?

Emerging Reforms and Alternatives

Policymakers and researchers increasingly advocate shifting from punitive, jail-centered approaches to therapeutic, community-based models.

Promising reforms include:

Mental health courts and specialized dockets.
Pre- and post-booking diversion programs.
Outpatient competency restoration (effective in several states, with good success rates and cost savings).
Crisis Intervention Teams (CIT) for police.
Expanded community stabilization and supported housing.

These contrast punitive containment with therapeutic intervention, showing potential to reduce backlogs, costs, and recidivism while improving outcomes.

What Competency Law Reveals About American Society

The competency-to-stand-trial system exposes how America manages mental illness through legal and carceral institutions when healthcare and social supports fail. It highlights failures of dignity, autonomy, and compassion, turning treatable conditions into cycles of control and abandonment.

True reform requires reinvesting in community mental health, robust diversion, and viewing severe mental illness primarily as a public health issue rather than a criminal justice one. Until then, jails will continue functioning as psychiatric wards, at great human and societal cost. The blurred line between treatment and control demands we choose dignity over default criminalization.