How Psychiatry Has Displaced Clinical Therapy in LA County's Criminal Justice System

There is a strange contradiction sitting in the middle of America's criminal justice system: we have become increasingly sophisticated at recognizing that people involved in the courts may have psychological and behavioral health needs, yet we still tend to organize those needs around the machinery of the criminal case rather than around the human being experiencing them. In Los Angeles County, that contradiction becomes especially important because the county operates one of the largest criminal justice systems in the country while simultaneously dealing with an enormous behavioral-health population. The question is not whether psychiatric services belong in the criminal justice system. Of course they do. The more interesting question is whether psychiatry has been asked to carry too much of the responsibility for problems that could sometimes be addressed earlier, differently, and more humanely through clinical therapy, counseling, rehabilitation, and other forms of psychological care.

This distinction matters because psychiatry and clinical therapy are not interchangeable. Psychiatry is a medical specialty. Psychiatrists can diagnose mental disorders, evaluate competency, prescribe medication, manage acute psychiatric conditions, and address situations in which a person's medical condition requires psychiatric intervention. Clinical psychologists, therapists, counselors, and social workers operate through different professional disciplines and may provide psychotherapy, behavioral interventions, assessment, coping strategies, trauma-informed treatment, relationship work, cognitive-behavioral interventions, rehabilitation, and other forms of psychological support. None of this means one profession is superior to another. It means that different problems require different tools.

Imagine taking your car to a mechanic and explaining that the transmission is acting strangely. The mechanic's job is not necessarily to replace the entire engine because the transmission is difficult to diagnose. Likewise, the existence of a mental-health concern does not automatically mean that the most appropriate response is medication, psychiatric hospitalization, competency proceedings, or confinement in a forensic facility. Sometimes the person needs medical psychiatric intervention. Sometimes the person needs intensive therapy. Sometimes the person needs substance-use treatment. Sometimes the person needs stable housing, sleep, family support, occupational structure, or trauma counseling. Sometimes they need several of those things simultaneously.

The criminal justice system has historically had difficulty making those distinctions because the court asks a very particular question: Can this person participate meaningfully in the legal proceeding? California Penal Code section 1367 defines incompetence in terms of whether, because of a mental health disorder or developmental disability, a defendant is unable to understand the nature of the criminal proceedings or assist counsel in the conduct of a defense in a rational manner. That is a legal standard. It is not a general declaration that a person is incapable of living, learning, reasoning, receiving therapy, making decisions, or functioning in society.

That distinction is enormously important.

Competency proceedings are designed to answer a legal question, not to become a universal substitute for mental-health treatment. The California Legislative Analyst's Office has explicitly recognized that competency-restoration treatment differs from general mental-health treatment. The objective of competency restoration is to treat a felony defendant until the person is competent enough to face the criminal charge, rather than necessarily provide comprehensive treatment for the person's underlying mental-health condition.

That sentence should make everybody involved in the system stop for a moment.

If a person has a psychological problem, but the system's principal objective becomes making that person legally competent enough to continue a prosecution, the system may successfully accomplish its immediate legal objective while leaving the underlying human problem substantially unresolved. It is possible to restore somebody sufficiently for court without actually restoring the person's life.

And that is where clinical therapy deserves a much larger seat at the table.

Therapy is sometimes treated as though it were the soft cousin of “real” mental-health treatment. That is an unfortunate misunderstanding. Clinical psychotherapy is a legitimate professional discipline grounded in established psychological science. Cognitive behavioral therapy, dialectical behavior therapy, trauma-focused therapies, motivational interviewing, family therapy, behavioral interventions, and other evidence-based approaches are not motivational posters taped to a refrigerator. They are structured interventions delivered by trained professionals.

A criminal defendant is still a human being before, during, and after the courtroom process. The same is true of victims, witnesses, family members, attorneys, judges, prosecutors, public defenders, correctional officers, clinicians, and even jurors. A criminal case can place enormous psychological pressure on every person connected to it. The longer a case remains unresolved, the greater the potential human toll can become.

That means the question should not simply be, “How do we get this defendant competent enough to proceed?”

It should also be, “What happened to this human being, what does this human being need, and what combination of services gives this person the best realistic chance of functioning successfully without returning to the criminal justice system?”

Those are not the same question.

Los Angeles County has actually demonstrated that it understands the value of treatment models that extend beyond traditional jail psychiatry. The county's Rapid Diversion Program, for example, combines justice-system agencies with clinical providers and was specifically designed to divert people with behavioral-health or substance-use disorders away from jail and into treatment. A RAND evaluation reported that 91 percent of people who successfully completed the program avoided having a new criminal court case filed.

That is not a small detail.

It is evidence that the criminal justice system does not have to choose between public safety and humane treatment. Sometimes treatment is part of public safety.

The county has also expanded community treatment capacity. In August 2025, Los Angeles County reported that it had expanded community treatment beds and surpassed its Fiscal Year 2024–25 goal with 4,697 treatment placements across three programs operated through the Office of Diversion and Reentry. The county also reported substantial compliance with requirements concerning acute mental-health treatment beds in its jails.

These developments are encouraging, but they also reveal something else: the problem is sufficiently large that the government has had to build an increasingly elaborate infrastructure just to keep the system from collapsing under the weight of its own mental-health population.

California has spent hundreds of millions of dollars addressing competency restoration and the broader mental-health crisis associated with criminal justice. The Legislative Analyst's Office reported that California's felony incompetent-to-stand-trial system alone involved substantial state expenditures, including $59.8 million in General Fund support for jail-based competency treatment and $15.6 million for community-based restoration programs in 2018–19. Later budget proposals contemplated hundreds of millions more for expanding competency-restoration capacity.

The historical numbers are even more revealing. A Legislative Analyst's Office analysis estimated that California was spending approximately $170 million annually on incompetent-to-stand-trial patients based on an average daily population of approximately 1,000 people and an estimated cost of roughly $450 per patient per day.

Those numbers are old, but that is precisely the point. The financial burden of competency and forensic mental-health services is not a new phenomenon. California has been spending extraordinary sums for years trying to manage the intersection between mental illness and criminal prosecution.

And the bill does not stop at the treatment facility.

There are court hearings. Attorneys must litigate competency. Experts must evaluate defendants. Correctional personnel must transport and supervise people. Courts must schedule hearings. Prosecutors and defense attorneys must devote resources to cases that may remain unresolved for months or years. State hospitals and county facilities require staff, security, medical personnel, administrative systems, and physical infrastructure. When treatment beds are unavailable, people can remain in jails awaiting transfer to a treatment setting.

California's own budget analysts have documented the consequences of inadequate capacity. The felony IST waitlist historically reached levels exceeding 1,700 people, with average waits exceeding 100 days during the pandemic-era crisis.

That is not simply an accounting problem.

That is a human problem wearing an accounting costume.

Every number represents an individual.

And every individual exists within a family.

A person sitting in a jail cell waiting for competency treatment is not merely “an IST.” Someone's son is sitting there. Someone's daughter. Someone's parent. Someone's sibling. Someone's friend. Perhaps someone who was working, raising children, attending school, creating music, running a business, or simply trying to survive before becoming entangled in the criminal justice system.

Likewise, the family members are not spectators. They experience the uncertainty, expense, shame, frustration, fear, and helplessness associated with a loved one's criminal case.

Attorneys experience it too. Public defenders routinely carry enormous caseloads and must make difficult decisions under extraordinary time constraints. Prosecutors have obligations to victims and the public. Judges must manage crowded calendars while protecting constitutional rights and maintaining the integrity of proceedings. Correctional officers are placed in environments where they are expected to manage people experiencing serious behavioral-health crises despite not being mental-health professionals.

The system therefore has a psychological cost that is difficult to capture on a spreadsheet.

This is why clinical therapy deserves consideration as part of criminal justice infrastructure rather than merely something a person receives after the criminal case is over.

There is an enormous difference between treating a person as a psychiatric emergency and treating a person as a human being who may require sustained psychological care.

One approach tends to ask, “What is wrong with you?”

The other can ask, “What happened to you, what are you experiencing now, and what can we do to help you function better?”

Those questions are not mutually exclusive. In many cases, the best system would ask both.

The danger emerges when a competency framework becomes the doorway through which virtually every serious behavioral-health question must pass. A legal competency evaluation has a defined purpose. It should not become a generalized psychological assessment of whether a defendant is agreeable, compliant, socially conventional, emotionally regulated, or easy for an attorney to work with.

This distinction becomes particularly important because disagreement between a defendant and an attorney is not automatically evidence of incompetence. A defendant can disagree with strategy. A defendant can be difficult. A defendant can distrust the system. A defendant can insist on arguments that counsel believes are legally weak. A defendant can misunderstand portions of the case. None of those facts, standing alone, necessarily establishes legal incompetence.

That is precisely why the competency inquiry has to remain tied to the legal standard.

The criminal courtroom is an adversarial environment by design. Defendants are allowed to disagree with the government. They are allowed to challenge evidence. They are allowed to question their lawyers. They are allowed to have unpopular beliefs. They are allowed to be angry. They are allowed to make mistakes. They are allowed to be inconvenient.

A functioning constitutional system cannot quietly redefine “competent” to mean “cooperative.”

That would be an extraordinarily dangerous transformation.

The better approach is to distinguish between a defendant who genuinely lacks the functional abilities required by the competency standard and a defendant who simply presents challenges for the people attempting to manage the case.

Those are not necessarily the same person.

This is where clinical therapy could potentially serve as a preventative and stabilizing layer before problems become courtroom crises. A person experiencing anxiety, trauma, depression, anger, grief, substance-use problems, family instability, distrust, or chronic stress may benefit from regular therapeutic intervention without needing to become a psychiatric patient. Therapy can provide a structured environment in which a person learns communication skills, emotional regulation, cognitive restructuring, problem-solving, conflict resolution, and strategies for dealing with the enormous pressure associated with criminal proceedings.

And perhaps most importantly, therapy does not have to be framed as punishment.

That matters.

If the only time the government offers a person psychological intervention is after a criminal case has deteriorated to the point of competency litigation, the system has waited until the fire department is standing outside the burning building.

Why not install smoke detectors?

Los Angeles County has already moved toward this philosophy in various diversion programs. The county's own behavioral-health infrastructure includes community services, crisis intervention, referrals, treatment programs, and justice-involved mental-health resources. The county Department of Mental Health maintains a 24/7 behavioral-health access system, demonstrating that a substantial clinical infrastructure already exists outside the courtroom.

The challenge is integrating that infrastructure with criminal justice without turning every therapist into an arm of prosecution or every therapy session into potential courtroom evidence.

That requires careful boundaries.

Therapy works partly because people can speak honestly. If every therapeutic disclosure is perceived as potentially becoming ammunition in a criminal case, people may stop talking. If defendants believe that admitting emotional difficulties automatically places them on a path toward competency proceedings, they may avoid treatment entirely.

That would be counterproductive.

A holistic system therefore needs meaningful separation between therapeutic treatment and forensic evaluation. The purposes are different. A therapist's job may be to help a person function better. A forensic evaluator's job may be to answer a specific legal question. Confusing those roles undermines both.

There should also be meaningful access to non-forensic clinical therapy for people involved in criminal cases. Not every service should be conditioned upon a judicial finding of incompetence. Not every defendant needs psychiatric medication. Not every psychological problem requires hospitalization. Not every behavioral-health concern requires a competency proceeding.

Sometimes a person needs someone to talk to.

Sometimes they need someone trained to challenge destructive thought patterns.

Sometimes they need trauma treatment.

Sometimes they need substance-use treatment.

Sometimes they need medication.

Sometimes they need all of the above.

The point is that the system should be capable of recognizing the difference.

There is also a fiscal argument for this approach. California's experience demonstrates that forensic mental-health care is expensive. The state's 2025–26 spending plan allocated approximately $2.9 billion in General Fund spending to the Department of State Hospitals, while also identifying hundreds of millions of dollars in reductions and adjustments associated with incompetent-to-stand-trial waitlist programs. The same budget documents show that California has had to devote substantial resources to maintaining competency-restoration capacity and community-based alternatives.

Nobody should interpret those figures as proof that competency statutes themselves are fraudulent or that every competency proceeding is unnecessary. That conclusion would go beyond the evidence.

But the numbers do establish something important: the consequences of the competency system are enormous enough that California has a legitimate public interest in preventing avoidable escalation into the forensic system.

That is the more defensible argument.

If early clinical intervention can prevent even a fraction of people from deteriorating into jail-based psychiatric crises, competency proceedings, prolonged detention, or expensive restoration programs, the potential savings could be substantial. More importantly, the benefit would not merely be financial.

It would be human.

The state would spend less money managing deterioration and more money preventing deterioration.

That is a fundamentally different philosophy.

Instead of waiting for somebody to become sufficiently impaired to trigger a legal intervention, the system could build a continuum of care that begins much earlier. Screening could identify behavioral-health needs. Clinical therapy could provide ongoing support. Psychiatric services could address medical conditions when necessary. Substance-use treatment could address addiction. Housing could stabilize people whose psychiatric symptoms are aggravated by homelessness. Family services could repair support networks. Educational and vocational services could rebuild structure. Peer support could reduce isolation. Legal services could help defendants understand their cases without converting every disagreement into a psychological diagnosis.

That is what “holistic” should mean.

It should not mean giving everybody every service imaginable.

It should mean giving people the right service for the problem they actually have.

There is another reason this matters: public safety.

It is sometimes assumed that a therapeutic approach is inherently soft on crime. That assumption is difficult to defend when treatment actually reduces recidivism. The purpose of a criminal justice system should not merely be to process people through punishment. It should be to protect the public, administer justice, hold offenders accountable where appropriate, and reduce the likelihood that future victims will be created.

A person who receives effective treatment and does not return to court is a public-safety success.

A person who cycles through jail, psychiatric crisis, competency proceedings, hospitalization, release, and rearrest is not necessarily evidence that the system is working.

Sometimes the most expensive form of justice is the justice system that keeps meeting the same person under different circumstances.

Los Angeles County's own experience with diversion illustrates the potential. The RAND evaluation of the county's Rapid Diversion Program found that 91 percent of successful completers avoided a new criminal court case. That does not prove that therapy solves every criminal justice problem. It does demonstrate why treatment-based alternatives deserve serious attention rather than being treated as sentimental accessories to “real” criminal justice.

The larger lesson is that psychiatry and clinical therapy should not be enemies.

They should be teammates.

Psychiatrists should be available when medical psychiatric intervention is appropriate. Psychologists and therapists should be available when psychotherapy is appropriate. Social workers should address social conditions. Substance-use professionals should address addiction. Physicians should address medical conditions. Attorneys should address legal rights. Courts should determine legal questions. And correctional personnel should not be expected to function as substitute mental-health professionals simply because somebody happens to be incarcerated.

That is what a functional system looks like.

The alternative is specialization without coordination.

And specialization without coordination can become fragmentation.

Los Angeles County has already spent years responding to lawsuits, court orders, federal oversight, jail conditions, competency backlogs, staffing shortages, treatment-bed shortages, and the growing population of people with significant mental-health needs. The county reported in 2025 that it had made substantial progress in several areas of jail mental-health care, while also acknowledging continuing challenges involving people entering the jail system with significant medical conditions, substance-use disorders, and mental-health needs.

That acknowledgment should lead to the next question.

What happens before the jail?

What happens before the competency hearing?

What happens before the psychiatric emergency?

What happens before a family calls law enforcement because nobody else knows what to do?

That is where Los Angeles County—and jurisdictions across the country—have an opportunity to rethink the architecture of justice.

A truly modern criminal justice mental-health system should not measure success solely by how quickly it can identify incompetence, restore competency, medicate a crisis, transfer somebody to a hospital, or move a case back onto the court calendar.

It should measure success by whether people become healthier, safer, more stable, more capable of functioning, and less likely to become involved with the criminal justice system again.

That is a much higher standard.

It is also a much more rational one.

Clinical therapy should therefore be recognized as part of the infrastructure of justice, not merely an afterthought for people who have already survived the system. Defendants should have access to appropriate psychological services without automatically being treated as psychiatric cases. Inmates should have meaningful opportunities for therapeutic treatment rather than having mental health reduced to medication management. Families should have pathways to support. Attorneys should have access to multidisciplinary resources when behavioral-health problems complicate representation. Courts should have access to appropriately differentiated clinical and forensic expertise. And policymakers should track whether these services actually reduce recidivism, hospitalization, competency referrals, jail utilization, and long-term public expenditures.

The goal should not be to eliminate psychiatry from criminal justice.

The goal should be to stop pretending that psychiatry is the entire mental-health system.

There is a person underneath every diagnosis, a family underneath every case number, and a taxpayer underneath every government expenditure.

When those three realities are ignored, the system becomes expensive, adversarial, and reactive.

When they are considered together, something different becomes possible.

Justice can still be justice.

Accountability can still be accountability.

Competency can still mean competency.

But treatment can finally mean treatment.

And perhaps the most important reform Los Angeles County could make is not another specialized courtroom, another institutional bed, or another emergency response program.

It could be building a system capable of asking the simplest question first:

What does this person actually need?

Sometimes the answer will be psychiatry.

Sometimes it will be therapy.

Sometimes it will be both.

Sometimes it will be neither.

But a justice system that cannot tell the difference will continue paying the price—in dollars, in court time, in institutional capacity, and most importantly, in human lives.