Involuntary Medication Order (IMO) Toolkit
for Justice System Professionals and Treatment Providers

December 2023



  1. What is this Toolkit?

  2. Why was this Toolkit created?

  3. How can counties use this Toolkit?

  4. What is an involuntary medication order (IMO)?

  5. Why do some people with serious mental illness (SMI) refuse treatment with psychotropic medications?

  6. What are the benefits of medication adherence?

  7. Do we have to use force with IMOs?

  8. What are the risks of involuntary medications?

  9. Medication guidance: medication histories, long-acting medication, supratherapeutic dosing, and more

  10. Getting Started with IMOs: Questions to ask

  11. Addressing common barriers and myths to IMO administration in Jails

  12. County checklist for IMO implementation

  13. Tracking Your Jail’s IST Census

  14. Acuity Review Process

  15. Department of State Hospitals (DSH) Support, Resources, Contact info


This Toolkit is a summary of information currently available. Although the Toolkit draws from available scientific literature: 1) there is a need for further research on this topic, 2) this Toolkit is not an exhaustive review of the available literature, and 3) this Toolkit is not a research paper or meta-analysis. This document is written to provide pearls of knowledge drawn from scientific literature, professional multidisciplinary peer consultation, and experience. This Toolkit will be updated periodically based on updated information and feedback from users.

Additionally, this Toolkit does not address all topics related to the treatment of individuals with mental illness in jails. During the development of this document, other subjects that were raised as important but that were beyond the scope of this Toolkit include protocols for observation of individuals after administration of medications, protocols on use of force, documentation of medication administration, guidelines on medication prescribing, and best practices on discharge planning and warm hand-offs from jail to the community. If you want more information on any of these topics, please contact



1. What is this Toolkit?

This Toolkit was created to support treatment for individuals1 with serious mental illness (SMI) in California jails who have been deemed Incompetent to Stand Trial (IST) but can help all individuals with mental illness in jails, regardless of whether they are receiving or waiting to receive treatment in a DSH program.

This Toolkit can be used by anyone who interacts with, advocates for, treats, or is otherwise involved in the care of justice-involved individuals with SMI. This includes but is not limited to jail clinical staff, criminal justice partners, sheriffs, custody staff, court staff and court leadership (district attorneys, public defenders and defense attorneys, judges), community behavioral health providers, county supervisors and county administrators.

Across California’s 58 counties, individuals with SMI are our neighbors, friends, and loved ones and some will come into contact with the criminal justice system. When this occurs, this Toolkit will assist in supporting their mental health treatment.

1: There are many ways to describe the individuals with SMI in jails: patients, prisoners, inmates, incarcerated persons, defendants, and more. For simplicity, we chose the term “individual” unless we are speaking directly about a person interacting with a health care provider, in which case we used the term “patient.”


2. Why was this Toolkit created?

This Toolkit was made in response to a recommendation from the IST Solutions Workgroup2, a statewide work group convened to propose solutions to the challenge of an increasing number of people with SMI in California jails who are being found incompetent to stand trial on felony charges and are waiting to be admitted to DSH for treatment. This Toolkit is intended to help staff navigate the logistical, procedural, and legal requirements to act on involuntary medication orders (IMOs) in the jail.

2: Stiavetti v. Ahlin; Stiavetti vs. Clendenin; California Welfare and Institutions Code 4147

The IST Workgroup convened between August 2021 and November 2021 with several representatives and stakeholders from multiple state agencies, the Judicial Council, local government, and justice system partners, as well as representatives from patients’ rights and family member organizations. Per the statute, the Workgroup identified short-, medium-, and long-term strategies to advance alternatives to placement in DSH restoration of competency programs3. These solutions were detailed in the IST Solutions Report 4.

3: Department of State Hospitals Incompetent to Stand Trial Solutions Proposal, n.d.
4: A Report of Recommended Solutions Presented to the California Health and Human Services Agency and the California Department of Finance in Accordance with Section 4147 of the Welfare and Institutions Code, 2021

This Toolkit was recommended as a short-term strategy (S.3), which specifically states:

By using this Toolkit, counties can increase early treatment engagement of individuals, initiate stabilization, and reduce the symptoms of psychosis such as hallucinations, delusions, and disorganized thinking. A reduction in symptoms and increase in stabilization can provide increased opportunities for placement in Diversion or community-based restoration programs, as well as decrease the length of stay for IST individuals on the pathway to Jail Based Competency Treatment (JBCT) or State Hospital placement.

Prior to the development of this Toolkit, DSH Clinical Operations had been actively providing technical assistance and training, as well as psychopharmacology consultation, to any county partners who requested it. This service will continue to be made available on an as needed basis.


3. How can counties use this Toolkit?

Counties can use this IMO Toolkit to consider, develop, and implement policies and procedures to safely administer medications involuntarily to individuals who are court ordered to take psychotropic medication5. It is important to note that the administration of involuntary medication is used as a last resort when needed to improve an individual’s decompensating mental state. Typically, these individuals are unmedicated, gravely disabled, a danger to themselves others, and have poor insight into the severity and deterioration of their condition. In these instances, good clinical practice including involuntary administration of medications is essential to the safety and wellbeing of the individual, peers, and jail staff.

5: Note that the term “psychotropic medication” is used throughout this document to refer to any medication customarily prescribed for the treatment of symptoms of psychoses and other severe mental and emotional disorders. This is an updated term that is more inclusive than “antipsychotic,” which is still included in the document if there is a direct quote or reference to statute.

California is a large state where custody and medical staffing resources vary by county. This Toolkit will outline recommendations for optimal custody, clinical, and medical processes and procedures necessary for safe involuntary medication administration.

The administration of involuntary medication starts with an order from the court. Occasionally, courts may need guidance and education in the language needed for an IMO to ensure safe and clinically appropriate administration of medication and delineate which entities are authorized to render this service. This Toolkit will provide examples of language courts can consider adding to IMOs to ensure efficient and clear IMO language.

Some suggestions for getting started:



4. What is an involuntary medication order (IMO)?

When a person is arrested, they may be taken to a county jail, where they are held while they are processed by the criminal justice system. During their time in jail, defendants must be offered health care—medical, mental health, and dental—in a manner consistent with the community standard of care. However, defendants who have decision making capacity have a right to refuse any treatment that is offered to them.

Defendants who do not have decision making capacity may not have the right to refuse treatment. If a court has issued an IMO, which is an order granted by a court that requires a person to take psychotropic medication, the county jail has authority to enforce the IMO. It is used in non-emergency situations for people with mental illness who require ongoing administration of medication and have minimal insight into their need for treatment. The medications are always offered in an oral form first and are usually taken with cooperation, but if the person refuses to take the medications, they can be administered involuntarily via an injection.

There are two legal avenues by which a court can order an IMO:

6: See Appendix detailing Statute Code section 1370, subdivision (a)(2)(B)(i)(l)

Note that, in some counties, California Penal Code section 1369.1: Designation as a Treatment Facility was a barrier to implement involuntary medication orders; it was repealed June 30, 2022. Prior to July 1, 2022, a County could designate the county jail as a “treatment facility” with the approval of the County Board of Supervisors, the County Mental Health director, and the County Sheriff, and therefore provide medically approved medication to defendants found to be IST. As of July 1, 2022, designation of the jail is no longer necessary to administer involuntary medication to incompetent defendants. Any jail may administer involuntary medications to incompetent defendants if there is a valid IMO.

Note that for individuals who are not found IST, the dangerousness to self or others does not need to be coupled with a lack of decision-making capacity, but the lack of decision-making capacity does need to be with grave disability.


5. Why do some people with serious mental illness (SMI) refuse treatment with psychotropic medications?

Medication compliance is critical in the management of SMI—including schizophrenia, major depressive disorder, and bipolar disorder. However, medication nonadherence, where a person does not take medication in a manner consistent with recommendations from their health care provider, is very common. In a review of the available data from 20207, 49% of patients with SMI were not adherent to their psychotropic medication, including 56% of people with schizophrenia.

7: Semahegn et al., 2020

Experts agree that persons with schizophrenia are considered medication adherent if they take more than 80% of prescribed medications, and they are partially adherent if they take more than 50% of prescribed medication. Nonadherence is also defined as being off medications for one week8.

8: El-Mallakh & Findlay, 2015

When individuals with SMI in the community disengage from treatment, the symptoms of their disease may lead to actions that result in arrest. Unfortunately, jails nationwide are filled with people who have been arrested secondary to criminal behavior related to untreated mental illness. The Stepping Up Initiative (, a nationwide effort to reduce people with mental illness in jails, was created to help counties address this widespread problem.

The specific reasons people stop taking their psychotropic medication as prescribed vary from person to person. The following are some of the reasons for medication non-adherence:


6. What are the benefits of medication adherence?

The goals in treating SMI are the same as treating any chronic illness: reduce or eliminate the symptoms of disease, prevent progressive deterioration or future episodes of decompensation, preserve functionality, and promote successful community integration and wellbeing. Medication is one important tool available to clinicians to treat patients with SMI. Because mental illness affects the brain, many individuals are unable to think clearly without medications. For this reason, medications can be ordered by the court in select circumstances (see section 4, above).

Treatment with medication reduces morbidity and mortality in patients with SMI. Research shows that antipsychotic use in individuals with schizophrenia reduces mortality from all causes 9. In addition, mood stabilizer treatment reduces self-harm and suicidality in patients with bipolar disorders10.

9: Correll et al., 2022
10: Hayes et al., 2016

Not only are there benefits to medication treatment, such as decreasing the severity of symptoms, but studies have shown that prompt treatment with medication has clear benefits. Psychotropic medication non-adherence can reduce the effectiveness of treatments or leave the individual less responsive to subsequent treatment11. Prompt treatment preserves function (i.e., a person’s long-term ability to think clearly, accurately perceive the world, communicate effectively, and negotiate activities of daily living), decreases the severity of symptoms, and decreases the duration of the decompensation episode.

11: Semahegn et al., 2020

Prompt medication treatment for people with SMI also makes the jail safer by decreasing violent episodes. Poor medication adherence has been shown to be a predictor of violence: in one study, violent crime fell by 45% in individuals receiving psychotropic medication 12. In another study, schizophrenia was associated with violence only in individuals who were untreated13.

12: Fazel et al., 2014
13: Keers et al., 2014

Lastly, prompt medication treatment may shorten the jail length of stay for many individuals. Studies show that mentally ill inmates remain in jail longer than other inmates14. The reasons for this are multifactorial and include (1) the evaluation and restoration of competency to stand trial, (2) difficulty understanding and following jail rules, and (3) increased violent episodes when not treated with medication, which can lead to additional charges. Outside of jail, duration of psychiatric hospitalization, rates of hospital readmission, and suicide attempts are all increased by partial or complete medication nonadherence.4

In summary, there are many advantages to medication treatment for SMI, and significant disadvantages to delays in treatment and medication nonadherence.

14: Serious Mental Illness (SMI) Prevalence in Jails and Prisons, 2016


7. Do we have to use force with IMOs?

If an individual with SMI is in jail and has a court order stating that they shall take medication, jail staff is then responsible for carrying out that order. Sometimes, by the time the order comes from the court, the individual is already taking medication voluntarily, and the court order does not need to be enforced. Other times, if an individual knows the IMO is in place, they will voluntarily comply with their medication regimen. Unfortunately, sometimes the individual continues to refuse medication.

Although the patient has an order from the court requiring that they take medication, they do retain other rights, including access to a mental health patients’ rights advocate. Incarcerated people who are involuntarily medicated should be given information about their rights, including contact information for the local mental health patients’ rights office.

Members of marginalized communities, specifically related to race, ethnicity, sexual orientation, and transgender identities, may be prone to medication non-adherence secondary to distrust of medical providers. There are many steps to take between the individual refusing medication and them being given an injection using a physical or mechanical hold. Use of force should be avoided whenever possible to avoid the potential for re-traumatization, as most justice-involved individuals with SMI have significant trauma histories15. Anecdotally, most individuals who are refusing medications will comply with medications prior to force being necessary if a clear, stepwise approach is used:

15: McQuaid et al., 2018

  1. First, medications must be prescribed by the provider. This may seem obvious but is important to address. When medications are prescribed, providers discuss with the individual the medications that are recommended, including risks and benefits of treatment. This discussion must happen in all cases, even when involuntary medication is ordered by the court. With psychotropic medications, providers often have individuals sign a document indicating that they understand the risks and benefits of treatment and agree to proceed. If the individual is refusing medication, they have usually refused to sign this document as well. The provider must be informed that the court order has eliminated the need for this agreement, and providers must prescribe the medication according to their clinical judgement, even if it is against the individual’s wishes. It is important for the provider to prescribe the medications, even if the individual has stated they won’t take them. This will allow staff to continue to offer it and document any refusals in the medication administration record (MAR).
  2. Second, the medications must be offered to the individual. Sometimes, when the health care staff pass medications to individuals, the individual is unavailable; they could be asleep, showering, in court, in a program, visiting with family or their lawyer, at an appointment, or otherwise not in their housing unit. In these cases, health care staff must try to figure out where the individual is located and offer the medication as soon as is feasible. The individual not being available when the medication was delivered is not the same as the medication being refused.
  3. Work with a trusted entity to encourage the individual to take their medication. For some individuals, a discussion with someone they trust can help alleviate anxiety and lessen distrust of the system, which can lead to medication compliance. This person can be a family member, a peer supporter, a health care staff member, a custody team member, their attorney, or anyone requested by the individual.
  4. Determine the threshold for “noncompliance.” As stated above, medication adherence has been defined as taking more than 80% of prescribed medication. It is common to administer medication involuntarily after 3 days of missed medication. Clarify what the definition of compliance is in your jail. What will you do with partial medication compliance?
  5. Implement a behavioral incentive program. In their Jail Based Competency Treatment programs, DSH has seen great success in limiting the need for forceful administration of medications by using behavioral incentive programs. In fact, some early JBCT programs saw almost complete medication compliance with the use of incentives with their individuals. The use of incentives to modify behavior is often called “contingency management.” In short, desired behaviors—such as taking medications—are reinforced by rewarding the individual with desirable items, such as snacks or music. Incentive programs can vary by institution, but the important principles are that the program is clear, scheduled, and dependable. See below for an example of a jail who implemented a successful behavioral incentive program.
  6. Be patient. In some individuals, it can take many conversations to make inroads into voluntary compliance. Aim for consecutive conversations within a short time frame, each time an individual refuses their medication.
  7. If all attempts at voluntary compliance fail, notify the individual that involuntary administration may be a next step. Many times, an individual who has been nonadherent to their regimen will agree to take medications when they understand that medication administration is unavoidable, and before any force is used. If custody staff activate their use of force protocol to deliver medication involuntarily, often the individual changes their mind and will agree to take the medication. Ensure excellent communication between health care staff and custody staff so that the oral medication is readily available in case the individual decides to voluntarily take their oral medication.
  8. As a last resort, administer involuntary medications with minimum amount of force needed. Administering court-ordered medications using force should only be done when all other actions have been unsuccessful and should always be a planned event. This should not be treated as an emergency. When force is necessary, it is usually only necessary once or few times as the individual learns from the experience and medications reduce the symptoms that cause them to be non-compliant.
  1. Schedule the administration at a time when key staff are available. Staff participating should have a clear plan for how they will work together in administrating the medication. Do a practice run beforehand and educate involved staff that involuntary administration should not be treated as a crisis. It is recommended that the treatment provider is able to alter the course of medication administration should any concerns about the health or safety of the patient arise.
  2. Ensure all medications (by injection and oral options) are available in case the patient agrees to take the medication by mouth. Please note that oral medication should never be given involuntarily because of the risk of choking.
  3. Determine the best place to deliver the medication, preferably in a private setting.
  4. Explain each step being taken during the involuntary administrations, especially those involving physical contact, in a calm and respectful tone.
  5. Monitor the individual after administration.
  6. If a short-acting once-daily medication was given, create a plan for administration the following day, if necessary. (See Medication Section for suggestions around medication choice. Long-acting medications, when used properly, can eliminate the need for force multiple days in a row.)

One jail studied the impact of an incentive program within a specialized housing unit dedicated to treating jail inmates with special needs, including SMI. This incentive program rewarded inmates for maintaining hygiene and cell/common area cleanliness, engaging in programs, complying with medication regimen, attending health care appointments, and associating with peers. Individuals received points for each task completed, and incentive items could be “purchased” with points on a weekly basis. Over the course of a year, the jail saw a decrease of safety cell placement hours by 9.8% and a decrease in jail assaults by 19.4%. In addition, the length of stay in the jail was reduced significantly16.

16: 2020 CSAC Challenge Award San Luis Obispo (SLO) County Sheriff’s Department: Behavioral Health Incentive Program, 2020

Of note, many patients’ rights groups have pushed back against the use of incentives for voluntary treatment because of the concern that using incentives goes against the principles of informed consent. In the context of this Toolkit, behavioral incentive programs are mentioned as a way to encourage medication compliance in patients with involuntary medication orders. However, positive behavioral incentive programs can be successful in facilitating voluntary compliance as well, while maintaining the principles of informed consent.


8. What are the risks of involuntary medications?

All medications have side effects, whether they are given voluntarily or involuntarily. The psychotropic medications used in involuntary medications do not necessarily have more side effects than voluntary medications. Protocols should include an observation period by health care staff to ensure there are no acute adverse effects secondary to allergy or a reaction.

In most cases, individuals will voluntarily take their medication orally when provided a court order, even if they disagree with the order or will agree to take it after a provider takes the time and makes multiple attempts to encourage the individual to take them. However, sometimes enforcement of the order with a medication delivered via intramuscular injection is necessary. The most obvious risk to administering medications involuntarily is the same as the risk with any use of force: injuries to staff or to the individual. The best ways to avoid any injuries are to plan, including creating policies and procedures, and to make sure that the plan is coordinated with and well communicated to key staff. In DSH’s experience, custody leadership takes the lead on organizing these involuntary administrations, working closely with mental health and medical staff.


9. Medication guidance: medication histories, long-acting medication, supratherapeutic dosing, and more

Individuals in the criminal justice system with SMI tend to have complicated disease requiring sophisticated prescribing. Psychiatrists have many choices when it comes to what medication to use to treat individuals’ symptoms. These medications have varying uses, side effects, costs, monitoring requirements, and availability. This Toolkit is not designed to offer specific prescribing guidance for psychiatrists; however, there are some general principles that your team may find helpful:



10. Getting Started with IMOs: Questions to ask

Answering these questions with yes/no/unsure will help you start to identify the resources your county may have around IMOs and will help tailor the assistance DSH can provide. If you need help and would like consultation you begin to answer these questions, reach out to DSH (see contact information, below).


11. Addressing common barriers and myths to IMO administration in jails

Every county jail is different. However, in working with various jails to IMOs, we have identified some common barriers. These are referenced along with some proposed solutions for consideration:

Barrier Category Solution(s)
Need for “Treatment Facility” Designation by Board of Supervisors to administer IMO in Jail (PC 1369.1) Legal No longer required. Senate Bill (SB) 184 repealed Penal Code section 1369.1, effective July 1, 2022. This section had previously required the concurrence of a county’s board of supervisors, the county mental health director, and the county sheriff to designate a county jail as a treatment facility to provide medically approved medications to an IST defendant. This applied to psychotropic medications provided in a county jail pursuant to Penal Code section 1370. With the repeal of section 1369.1, such designation as a treatment facility is no longer required. SB 184 also established in Penal Code section 1370, that an involuntary medication order (IMO) is enforceable in a county jail for psychotropic medications prescribed by the treating psychiatrist.
Court does not typically provide IMO with Penal Code section 1370 commitment order Legal - Outreach to DSH IMO Consultation Team (see below for contact info) - Outreach to judges to identify barriers to issuing IMO - Provide Penal Code section 1369 templates to alienists requiring their clinical opinion regarding the need for an IMO - Ensure that all alienists (both psychiatrists and psychologists) provide opinions related to capacity to consent to medications and dangerousness - DSH IMO Consultation Team can provide consultation in how to obtain an IMO via Penal Code section 2603
Sometimes court does not provide IMO with 1370 order, sometimes it does Legal - Outreach to DSH IMO Consultation Team - Outreach to courts to identify reason for inconsistency
County does not provide “restoration treatment” (language often included in IMO) and therefore cannot administer medications. Legal DSH IMO Consultation Team can meet with County Counsel and stakeholders to clarify
Concern regarding active consent decree and potential scrutiny of this practice Legal IMO implementation is congruent with constitutional-level healthcare
County history of bad outcome using IMO Legal Identify challenges or barriers that led to poor outcome last time and revise policies or practices to support improved outcomes for the future. Seek consultation with DSH IMO Consultation Team
Liability concern: if IMO present in the chart, must it be used if there are documented medication refusals? Legal If an individual is cooperating with medication administration and relevant blood draws, then nothing else is necessary. However, failure to utilize an IMO when medication is medically necessary may create liability for the provider and the institution.
Lack of willingness by Sheriff’s Office (various reasons, including political) Stakeholder position - Outreach to IMO Consultation Team - Provide data on benefits of using IMOs (decreased violence) - Connect Sheriff with peer who has implemented program - Engage with California State Sheriffs’ Association (CSSA)
Advocacy groups opposed to involuntary treatment of inmates Stakeholder position Meet with advocacy groups and hear their concerns. Consider partnering with these groups when developing IMO policies.
Psychiatrist unwilling to order medication involuntarily Stakeholder position - Consult with DSH PRN team - Outreach and education, connect with peers and DSH IMO Consultation Team - Utilize the psychiatrist’s chain of command to establish clinically appropriate behavioral expectations
Stakeholder resistance Stakeholder position Customize education to address group
Some practitioners may feel that once an individual is committed to DSH as an IST the jail may no longer be responsible for providing treatment Stakeholder position - Establish relationships with DSH - DSH IMO Consultation Team can offer support and resources - DSH can provide presentation on IST treatment programs and available funding - Focus on treatment of individuals as a professional duty, ethical responsibility, and Title 15 requirement.
No JBCT program in jail so county unfamiliar with idea or process of IMOs Admin - JBCT is not a pre-requisite for IMO implementation. - DSH IMO Consultation Team can advise on relevant policies, procedures, and templates for the county to consider.
Lack of detailed medical/ mental health procedures including how to offer medications, use of incentives, documenting medication refusals, ordering medications, etc. Admin DSH IMO Consultation Team can provide examples
Lack of detailed custody procedure around use of force in non-emergency Admin - DSH IMO Consultation Team can provide example policies and procedures
Lack of tracking medication refusals to justify involuntary administration Admin - Education and/or training to med pass staff - Education regarding all relevant behaviors (e.g., refusing necessary blood draws, declining necessary medication changes while actively complying with insufficient treatment) - Medication Administration P&P update
Lack of tracking IST list to know who has an order, who is taking meds, who needs IMO Admin - Help develop internal tracking by county - Address privacy considerations in sharing list - Consider Patient Management Unit (PMU) as a resource
Policies in place but not enough custody and/or health care staff to administer IMOs Admin - Demonstrate (using data if available) that more resources are spent on unstable unmedicated individuals - Explore use of long-acting injectable medications to extend medication effects past one day - DSH can provide presentation on IST programs and available funding
Lack of understanding of difference between emergency and non- emergency (court-ordered) involuntary medications Best Practices Education, Training, Presentation, call with DSH, technical assistance
Custody / Sheriff resistance to using force Education Connect with peers, DSH IMO Consultation Team assistance with developing plan, reluctance improves over time, emphasize that this is standard of care
Skepticism around benefits of IMO administration in individuals Education See “Benefits of IMO” section
County lacks connection with DSH for support Education Connect with DSH partners and DSH IMO Consultation Team
Lack of understanding of IMO administration role in big picture (versus offramp, DSH psychiatrist consultation, MH Diversion, JBCT, etc.) Education - This Toolkit can help - Connect with DSH IMO Consultation Team - Connect with DSH Psychopharmacology (PRN) Consult Team


12. County checklist for IMO implementation