One of the facilities in which I consult treats patients who have been found incompetent to stand trial or not guilty by reason of insanity. Sooner or later, most of those patients are ready for discharge to the community (except for those who return to jail for eventual trial). In Texas, that means transferring their involuntary care to community mental health center, by means of a court hearing.

It is often difficult to get these folks back into their communities once clinical evaluation indicates that they no longer need inpatient care for either safety or intensity of treatment. The first choice is the community from which they came originally. There are three main barriers: (1) The local judges are reluctant to have troublesome people back in their counties; (2) the community MH center does not want the expense of intensive care and monitoring of a previously dangerous (or perhaps just troublesome) patient (they are responsible for funding the care, with state and federal dollars); and/or (3) there is no appropriate residential placement available in the area (e.g., a group home) with the ability and willingness to closely monitor a patient who has a history of violence or sexual assault).

I'd be very interested in hearing from others who might have some creative suggestions, or who work in systems that make it easier to "step down" these difficult-to-place patients.