Integrating the criminal justice system into mental health service delivery: the worcester diversion experience

The Cal-DSH diversion guidelines

The Cal-DSH Diversion Guidelines provide 10 general guidelines that jurisdictions should consider when developing diversion programs for individuals with a serious mental illness (SMI) who become involved in the criminal justice system. Screening for SMI in a jail setting is reviewed. In addition, important treatment interventions for SMI and substance use disorders are highlighted with the need to address criminogenic risk factors highlighted.

Police-initiated diversion for youth to prevent future delinquent behavior: a systematic review

This Campbell systematic review examines the effects police-initiated diversion programs on delinquent behavior, compared to traditional system processing. The review summarizes evidence from nineteen high-quality studies, including 13 randomized controlled trials and six quasi-experimental studies. This review includes studies that evaluated the effects of police-led diversionary practices compared to traditional processing for youth under 18 years of age. We identified a total of 14 manuscripts representing 19 evaluations. Of these 19 evaluations, 13 used randomized controlled designs (random assignment to conditions) and 6 used quasi-experimental designs (no random assignment to conditions). Many of these designs included two or more diversionary conditions compared to a common control (traditional processing) producing 31 treatment-comparison contrasts for analysis. These studies were conducted between 1973 and 2011, inclusively. Most were conducted in the USA (11) with the remaining conducted in Canada (4), Australia (2), and the UK (2). The general pattern of evidence is positive, suggesting that police-led diversion reduces the future delinquent behavior of low-risk youth relative to traditional processing. Assuming a 50 percent reoffending rate for the traditional processing condition, the results suggest a reoffending rate of roughly 44 percent for the diverted youth. This overall benefit of diversion holds for the random assignment studies judged to be free from any obvious risks of bias. No meaningful differences were found across types of diversionary programs. Furthermore, we found no evidence to suggest these findings suffer from publication selection bias.

Plain language summary

Police-led diversion of low-risk youth reduces their future contact with the justice system: Police-led diversion of low-risk youth who come into contact with the justice system is more effective in reducing a youth's future contact with the justice system compared to traditional processing.What is this review about?: Youth misconduct and misbehavior is a normal part of adolescence and that misbehavior sometimes crosses the line from disruptive or problematic to delinquent. Nationally representative surveys of youth in the USA have indicated that minor delinquent behavior is normative, particularly for boys. The normative nature of minor delinquent behavior raises the question of how police should respond to minor delinquent behavior in a way that is corrective, but also avoids involving the youth in the criminal justice system beyond what will be effective in reducing future misbehavior.Police diversion schemes are a collection of strategies police can apply as an alternative to court processing of youth. Diversion as an option is popular among law enforcement officers, as it provides an option between ignoring youth engaged in minor wrongdoing and formally charging such youth with a crime. Police-led diversion has the potential to reduce reoffending by limiting the exposure of low-risk youth to potentially harmful effects of engagement with the criminal justice system.What are the main findings of this review?: This review includes studies that evaluated the effects of police-led diversionary practices compared to traditional processing for youth under 18 years of age. We identified a total of 14 manuscripts representing 19 evaluations. Of these 19 evaluations, 13 used randomized controlled designs (random assignment to conditions) and 6 used quasi-experimental designs (no random assignment to conditions). Many of these designs included two or more diversionary conditions compared to a common control (traditional processing) producing 31 treatment-comparison contrasts for analysis. These studies were conducted between 1973 and 2011, inclusively. Most were conducted in the USA (11) with the remaining conducted in Canada (4), Australia (2), and the UK (2).The general pattern of evidence is positive, suggesting that police-led diversion reduces the future delinquent behavior of low-risk youth relative to traditional processing. Assuming a 50 percent reoffending rate for the traditional processing condition, the results suggest a reoffending rate of roughly 44 percent for the diverted youth. This overall benefit of diversion holds for the random assignment studies judged to be free from any obvious risks of bias. No meaningful differences were found across types of diversionary programs. Furthermore, we found no evidence to suggest these findings suffer from publication selection bias.What do the findings of this review mean?: The findings from this systematic review support the use of police-led diversion for low-risk youth with limited or no prior involvement with the juvenile justice system. Thus, police departments and policy-makers should consider diversionary programs as part of the mix of solutions for addressing youth crime.Many of the studies included in the review were conducted in the 1970s and 1980s. Newer high quality studies are needed to ensure that the findings still hold for contemporary juvenile justice contexts. Additional studies are also needed outside of the USA for this same reason. Finally, we recommend that research explore the usefulness of diversion for low-risk adult offenders.How up-to-date is this review?: The search for eligible studies was completed in January of 2017, so only studies identifiable through January 2017 were included. This Campbell systematic review was published in May 2018.

Executive summary/Abstract

Background: Overly punitive responses to youth misconduct may have the unintended consequence of increasing the likelihood of future delinquency; yet, overly lenient responses may fail to serve as a corrective for the misbehavior. Police diversion schemes are a collection of strategies police can apply as an alternative to court processing of youth. Police-initiated diversion schemes aim to reduce reoffending by steering youth away from deeper penetration into the criminal justice system and by providing an alternative intervention that can help youth address psychosocial development or other needs that contribute to their problem behavior.Objectives: The objective of this review was to synthesize the evidence on the effectiveness of pre-court interventions involving police warning or counseling and release, and cautioning schemes in reducing delinquent behavior.Search methods: A combination of 26 databases and websites were searched. References of relevant reviews were also scanned to identify studies. We also consulted with experts in the field. Searches were executed by two reviewers and conducted between August 2016 and January 2017.Selection criteria: Only experimental and quasi-experimental designs were eligible for this review. All quasi-experimental designs must have had a comparison group similar to the police diversion intervention group with respect to demographic characteristics and prior involvement in delinquent behavior (i.e., at similar risk for future delinquent behavior). Additionally, studies must have included youth participants between 12 and 17 years of age who either underwent traditional system processing or were diverted from court processing through a police-led diversion program. Studies were also eligible if delinquency-related outcomes, including official and non-official (self-report or third-party reporting) measures of delinquency were reported.Data collection and analysis: This study used meta-analysis to synthesize results across studies. This method involved systematic coding of study features and conversion of study findings into effect sizes reflecting the direction and magnitude of any police-led diversion effect. There were 19 independent evaluations across the 14 primary documents coded for this review. From this, we coded 67 effect sizes of delinquent behavior post diversion across 31 diversion-traditional processing comparisons. We analyzed these comparisons using two approaches. The first approach selected a single effect size per comparison based on a decision rule and the second used all 67 effect sizes, nesting these within comparison condition and evaluation design.Results: The general pattern of evidence is positive, suggesting that police-led diversion modestly reduces future delinquent behavior of low-risk youth relative to traditional processing.Authors' conclusions: The findings from this systematic review support the use of police-led diversion for low-risk youth with limited or no prior involvement with the juvenile justice system. Thus, police departments and policy-makers should consider diversionary programs as part of the mix of solutions for addressing youth crime.

Interagency collaboration models for people with mental ill health in contact with the police: a systematic scoping review

OBJECTIVE

To identify existing evidence on interagency collaboration between law enforcement, emergency services, statutory services and third sector agencies regarding people with mental ill health.

DESIGN

Systematic scoping review. Scoping reviews map particular research areas to identify research gaps.

DATA SOURCES AND ELIGIBILITY

ASSIA, CENTRAL, the Cochrane Library databases, Criminal Justice Abstracts, ERIC, Embase, MEDLINE, PsycINFO, PROSPERO and Social Care Online and Social Sciences Citation Index were searched up to 2017, as were grey literature and hand searches. Eligible articles were empirical evaluations or descriptions of models of interagency collaboration between the police and other agencies.

STUDY APPRAISAL AND SYNTHESIS

Screening and data extraction were undertaken independently by two researchers. Arksey's framework was used to collate and map included studies.

RESULTS

One hundred and twenty-five studies were included. The majority of articles were of descriptions of models (28%), mixed methods evaluations of models (18%) and single service evaluations (14%). The most frequently reported outcomes (52%) were 'organisational or service level outcomes' (eg, arrest rates). Most articles (53%) focused on adults with mental ill health, whereas others focused on adult offenders with mental ill health (17.4%). Thirteen models of interagency collaboration were described, each involving between 2 and 13 agencies. Frequently reported models were 'prearrest diversion' of people with mental ill health (34%), 'coresponse' involving joint response by police officers paired with mental health professionals (28.6%) and 'jail diversion' following arrest (23.8%).

CONCLUSIONS

We identified 13 different interagency collaboration models catering for a range of mental health-related interactions. All but one of these models involved the police and mental health services or professionals. Several models have sufficient literature to warrant full systematic reviews of their effectiveness, whereas others need robust evaluation, by randomised controlled trial where appropriate. Future evaluations should focus on health-related outcomes and the impact on key stakeholders.

Organizational capacity for service integration in community-based addiction health services

OBJECTIVES

We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs.

METHODS

We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14 379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program.

RESULTS

Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing.

CONCLUSIONS

These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care.

Facilitating knowledge exchange between health-care sectors, organisations and professions: a longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality

Background

Relatively little is known about how people and groups who function in boundary-spanning positions between different sectors, organisations and professions contribute to improved quality of health care and clinical outcomes.

Objectives

To explore whether or not boundary-spanning processes stimulate the creation and exchange of knowledge between sectors, organisations and professions and whether or not this leads, through better integration of services, to improvements in the quality of care.

Design

A 2-year longitudinal nested case study design using mixed methods.

Setting

An inner-city area in England (‘Coxford’) comprising 26 general practices in ‘Westpark’ and a comparative sample of 57 practices.

Participants

Health-care and non-health-care practitioners representing the range of staff participating in the Westpark Initiative (WI) and patients.

Interventions

The WI sought to improve services through facilitating knowledge exchange and collaboration between general practitioners, community services, voluntary groups and acute specialists during the period late 2009 to early 2012. We investigated the impact of the four WI boundary-spanning teams on services and the processes through which they produced their effects.

Main outcome measures

(1) Quality-of-care indicators during the period 2008–11; (2) diabetes admissions data from April 2006 to December 2011, adjusted for deprivation scores; and (3) referrals to psychological therapies from January 2010 to March 2012.

Data sources

Data sources included 42 semistructured staff interviews, 361 hours of non-participant observation, 36 online diaries, 103 respondents to a staff survey, two patient focus groups and a secondary analyses of local and national data sets.

Results

The four teams varied in their ability to, first, exchange knowledge across boundaries and, second, implement changes to improve the integration of services. The study setting experienced conditions of flux and uncertainty in which known horizontal and vertical structures underwent considerable change and the WI did not run its course as originally planned. Although knowledge exchanges did occur across sectoral, organisational and professional boundaries, in the case of child and family health services, early efforts to improve the integration of services were not sustained. In the case of dementia, team leadership and membership were undermined by external reorganisations. The anxiety and depression in black and minority ethnic populations team succeeded in reaching its self-defined goal of increasing referrals from Westpark practices to the local well-being service. From October to December 2010 onwards, referrals have been generally higher in the six practices with a link worker than in those without, but the performance of Westpark and Coxford practices did not differ significantly on three national quality indicators. General practices in a WI diabetes ‘cluster’ performed better on three of 17 Quality and Outcomes Framework (QOF) indicators than practices in the remainder of Westpark and in the wider Coxford primary care trust. Surprisingly, practices in Westpark, but not in the diabetes cluster, performed better on one indicator. No statistically significant differences were found on the remaining 13 QOF indicators. The time profiles differed significantly between the three groups for elective and emergency admissions and bed-days.

Conclusions

Boundary spanning is a potential solution to the challenge of integrating health-care services and we explored how such processes perform in an ‘extreme case’ context of uncertainty. Although the WI may have been a necessary intervention to enable knowledge exchange across a range of boundaries, it was not alone sufficient. Even in the face of substantial challenges, one of the four teams was able to adapt and build resilience. Implications for future boundary-spanning interventions are identified. Future research should evaluate the direct, measurable and sustained impact of boundary-spanning processes on patient care outcomes (and experiences), as well as further empirically based critiques and reconceptualisations of the socialisation → externalisation → combination → internalisation (SECI) model, so that the implications can be translated into practical ideas developed in partnership with NHS managers.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Herpes simplex virus type 2 serological testing at a community court: predictors of test acceptance and seropositivity among female defendants

Despite the high prevalence of herpes simplex virus type 2 (HSV-2), testing for asymptomatic infections is uncommon. One population for whom targeted interventions may be prioritized include individuals involved with the correctional system. Here we describe the acceptability of a novel HSV-2 screening program, implemented in a court setting, as a possible intervention for corrections-involved women. Female defendants completed an interviewer administered survey assessing factors associated with uptake/refusal of free point-of-care HSV-2 serologic testing and HSV-2 seropositivity. Participants included 143 women, 18-62 years old (mean 32.85) with diverse ethnicities. The majority (65.7%) accepted testing and 62.4% tested HSV-2 seropositive. Factors independently associated with test acceptance included higher perceived susceptibility to genital herpes infection and not receiving a preventative health screen. Women who were seropositive tended to be older, Black, report having previous STI, and be arrested on a prostitution charge. Findings suggest point-of-care testing in a court setting is acceptable to women and can be implemented to improve case finding of STI.

Fetal alcohol spectrum disorder: can diminished responsibility diminish criminal behaviour?

This text examines how current scientific knowledge has the potential of fulfilling one of the major functions of the criminal justice system. Scientific knowledge should be used to ensure that the criminal justice system's functioning results in maximizing societal protection and crime reduction. Abnormal states of the mind contribute to criminal behaviour and are considered in exculpatory defences. The failure of the long standing insanity defence and its utility among cognitively impaired offenders, provided impetus to this work. In estimating the success rates (or lack thereof) of raised defences for the cases of the 'invisible disorder', fetal alcohol spectrum disorder (FASD), coming before the Canadian Courts, we sought to expound on the reasons, from knowledge and pragmatic perspectives. We propose that a diminished responsibility defence and verdict that recognizes the 'grey zone' between 'knowing' and 'not knowing' based on neurocognitive disparities in FASD serves the individual, legal system and the society better than the current practice.

Integrated services plus drug treatment as a system alternative to crime control and parole

Integrated services have the potential to facilitate recovery in drug offenders as well as reduce criminal recidivism. This is significant given that prison overcrowding has led many drug offenders to be released from custody into society via the "reentry movement." Offenders incarcerated for many years often return to society with medical, mental health, behavioral, and drug abuse issues. These issues have been found in similar populations, including those with severe mental illness and the homeless, for which integrated services has shown to have a significant impact on improving functioning. Thus the argument of this article is that because integrated services have shown to be effective with somewhat similar populations, integrated services can be effective in treating paroled drug offenders. These benefits are expected to be to a greater degree than that achieved by current system policy regarding paroled drug offenders being supervised by parole officers rather than case managers facilitating integrated services.

Promising practices for delivery of court-supervised substance abuse treatment: perspectives from six high-performing California counties operating Proposition 36

Operative for nearly a decade, California's voter-initiated Proposition 36 program offers many offenders community-based substance abuse treatment in lieu of likely incarceration. Research has documented program successes and plans for replication have proliferated, yet very little is known about how the Proposition 36 program works or practices for achieving optimal program outcomes. In this article, we identify policies and practices that key stakeholders perceive to be most responsible for the successful delivery of court-supervised substance abuse treatment to offenders under Proposition 36. Data was collected via focus groups conducted with 59 county stakeholders in six high-performing counties during 2009. Discussion was informed by seven empirical indicators of program performance and outcomes and was focused on identifying and describing elements contributing to success. Program success was primarily attributed to four strategies, those that: (1) fostered program engagement, monitored participant progress, and sustained cooperation among participants; (2) cultivated buy-in among key stakeholders; (3) capitalized on the role of the court and the judge; and (4) created a setting which promoted a high-quality treatment system, utilization of existing resources, and broad financial and political support for the program. Goals and practices for implementing each strategy are discussed. Findings provide a "promising practices" resource for Proposition 36 program evaluation and improvement and inform the design and study of other similar types of collaborative justice treatment efforts.

[Mental Health courts: therapeutic jurisprudence in action]

In Québec, as elsewhere in North America, psychiatric deinstitutionalization, lack of community mental health resources as well as legislative changes to civil and criminal codes have led to an increased probability that individuals with a mental illness come into contact with the criminal justice system. Based on the principle of therapeutic jurisprudence, mental health courts constitute emerging diversion programs, taking place within the court, implemented to offer an alternative to incarceration for individuals with a mental illness. This article offers a critical synthesis of the scientific literature on the topic. The authors first present the context in which mental health courts were developed ; describe their objectives and functioning ; and introduce the Montreal Mental Health Court pilot project, renamed PAJ-SM (Plan d'Accompagnement Justice et Santé) the first of its kind in Québec. The paper examines the research on mental health courts and tackles some of the stakes of diversion programs. The challenges and limits inherent to specialized courts are discussed as well as methodological obstacles related to the study of these complex intervention programs. The authors conclude that mental health courts offer promising intervention venues, but that they do not constitute a panacea to resolving all issues related to the contact of mentally ill individuals with the justice system. Mental health courts must be accompanied by other intervention strategies for persons with mental health problems at all stages of the criminal justice process.

Measuring collaboration and integration activities in criminal justice and substance abuse treatment agencies

Individuals with substance abuse problems who are involved in the criminal justice system frequently need community-based drug and alcohol abuse treatment and other services. To reduce the risk of relapse to illicit drugs and criminal recidivism, criminal justice agencies may need to establish collaborations with substance abuse treatment and other community-based service providers. Although there are many variations of interorganizational relationships, the nature of these interagency collaborations among justice agencies and treatment providers has received little systematic study. As a first step,we present an instrument to measure interagency collaboration and integration activities using items in the National Criminal Justice Treatment Practices Surveys conducted as part of the Criminal Justice Drug Abuse Treatment Studies(CJ-DATS). Collaboration and integration activities related to drug-involved offenders were examined between substance abuse treatment providers, correctional agencies, and the judiciary. The measurement scale reliably identified two levels of collaboration: less structured, informal networking and coordination and more structured and formalized levels of cooperation and collaboration. An illustration of the use of the systems integration tool is presented.

Organizational factors and collaboration and integration activities in criminal justice and drug abuse treatment agencies

Despite strong interest in improving collaborations between correctional and substance abuse treatment organizations, there is a lack of empirical data describing the existing practices. The current study used a national survey of correctional administrators to examine organizational factors related to cross-agency collaboration and integration activities between corrections and substance abuse treatment organizations. Using a measure of collaboration that scaled cross-agency activities from less structured, informal networking and coordination to more structured and formalized levels of cooperation and collaboration, we found that different correctional settings (e.g., community corrections, jails, prisons) differed significantly in terms of their collaborative activities with substance abuse treatment agencies. We also found that the organizational characteristics that were associated with different levels of collaboration and integration differed across the correctional settings. Further research is needed to better understand how and why correctional agencies decide to formalize collaborative arrangements with treatment agencies and whether these efforts lead to more favorable outcomes.

Court outcomes for clients referred to a community mental health court liaison service

Court liaison and diversion services come in a variety of forms, but the similarities and differences between these services are not well characterized. Findings from a six-year audit of the Newcastle (Australia) Mental Health Court Liaison (MHCL) service are reported, including client characteristics, offence and service contact profiles, court outcomes, and interrelationships among these variables. During the audit period, there were 2383 service episodes by 1858 clients (1478 males, 380 females). Drug and alcohol disorders (40.9%) and psychotic disorders (17.0%) were the most prevalent mental health problems, while assault (23.1%), theft (23.1%), offences against justice procedures (15.4%), driving offences (13.4%) and malicious damage to property (8.3%) were the most frequently recorded charges. Among service episodes with a finalized court outcome, 70.0% involved a punishment (bond: 49.5%; jail term: 29.7%). Females were less likely to be punished, but more likely to have their case dismissed under sections of the relevant Act that required further assessment and monitoring. Being married, or having an adjustment or drug and alcohol disorder, were also associated with an increased likelihood of punishment, while clients with a psychotic or bipolar disorder were less likely to be punished. Among clients who were punished, those referred from inpatient mental health services were more likely to receive a non-jail punishment, while unemployed clients were more likely to be jailed. A substantial proportion of clients had court outcomes that required an ongoing involvement with local mental health services. By being part of community mental health services, our MHCL service is able to work efficiently and effectively with the criminal justice system, while facilitating ready access to existing mental health services and continuation of care.

Impact of court-mandated substance abuse treatment on clinical decision making

California's Proposition 36 offers nonviolent drug offenders community-based treatment as an alternative to incarceration or probation without treatment. The study objective was to examine how substance abuse treatment providers perceive the impact of Proposition 36 on their clinical decision making. Program surveys were completed by 115 treatment programs in five California counties to assess the impact of the law on clinical decision making, and five focus groups were conducted with 37 treatment providers to better understand their perspectives. Compared to residential programs, outpatient programs reported that the policy impacted them to a greater extent in terms of drug testing, reporting to criminal justice personnel, and determining client discharge. Providers in the focus groups particularly highlighted their changing roles in assessing clients' treatment needs and determining the best routes of care for them. The findings indicate that alternate strategies for determining treatment placement and continuing care should be developed.

Mental health legislation in the commonwealth

PURPOSE OF REVIEW

Mental health law is changing in some common law jurisdictions. Questions are being asked about whether special legislation is still needed, whether it is a health or a legal issue, and how this part of the law relates to cognate laws about patient consent to healthcare and determinations about competence. The role of tribunal or court adjudication of the need for admission is also debated, along with the capacity of the law to harness resources or manage care. It is therefore timely to review these debates.

RECENT FINDINGS

Renewed support is evident in the literature for subsuming mental healthcare within the general laws governing consent to care or determinations of competence. Socio-legal and interdisciplinary research suggests that health perspectives are already quite dominant in mental health law, while involuntary detention may correlate poorly with levels of need. The mesh between the law and service systems remains problematic, and there is little evidence that law has yet developed a significant capacity for leveraging treatment resources.

SUMMARY

This review suggests that the priority for future research lies in exploring the factors which enhance treatment access and outcomes for the mentally ill rather than debating the shape or content of mental health law.

The development and introduction of an in-patient student law services for persons with serious mental illness: a case study

There is a need to provide legal assistance to persons who suffer with serious mental illness for legal problems over and above problems associated with mental illness. This paper describes a single-case study of the development and introduction of a pilot of a hospital-based, legal service, in partnership with The University of Western Ontario Faculty of Law. The data sources included direct observation and documentation. Law students provide legal services reflecting the application of a therapeutic jurisprudence approach. Interprofessional education and training occurs with law, medical, nursing and other students, and professionals on the principles and scholarship of therapeutic jurisprudence, mental illness and legal rights. A programmatic organizational template, the program logic model, was used to conceptualize the activities, and process, short-term, long-term and ultimate objectives, and indicators. The four core activities were: (1) patient access point to law students; (2) supervision of law students at the London Health Sciences Centre; (3) intake and access to other services, and (4) teaching and additional training of law and other students, physicians and other health caregivers. The development, issues and challenges of the introduction of an in-patient student law service is described.

Intensive case management as a jail diversion program for people with a serious mental illness: a review of the literature

This article reviews the research on intensive case management (ICM) programs as a jail diversion intervention for people with a serious mental illness (SMI). The review includes two types of ICM programs: (a) general ICM programs that included an assessment of arrests and incarceration rates for people with an SMI and (b) ICM programs specifically implemented as a component of a jail diversion intervention for people with an SMI. Results indicate that general ICM programs (19) rarely led to reductions in jail or arrest rates over time, and these rates were similar to those found in standard mental health services. General ICM programs that included an integrated addiction treatment component (8) had mixed results but a trend toward reductions in rates of arrests and incarceration over time for individuals with an SMI and a co-occurring substance use disorder. Results were mixed for jail diversion interventions with an ICM program, but most ICM programs (8) led to significant reductions in arrests and incarcerations over time. Specific elements of effective ICM jail diversion programs are discussed.

Involuntary outpatient treatment as "desintitutionalized coercion": the net-widening concerns

In American jurisprudence, two justifications have traditionally been put forth to support the government's social control of persons with mental illness: police power and parens patriae. As public mental hospitals became less available as loci in which to exercise these functions, governments sought alternative means to achieve the same ends. One prominent but quite controversial means is involuntary outpatient treatment (IOT). While the concerns about IOT have been myriad, one often alluded to but never documented is that of "net-widening." That is, once IOT became available, it would be applied to an ever greater number of individuals, progressively expanding the margins of the designated population to whom it is applied, despite the formal standard for its application remaining constant. We tested the net-widening belief in a naturalistic experiment in Massachusetts. We found that net-widening did not occur, despite an environment strongly conducive to that expansion. At this time, whatever the arguments against IOT might be, net-widening should not be one of them.

Variations in mental health courts: challenges, opportunities, and a call for caution

Mental health courts have quickly proliferated in the United States and represent an attempt to expand legal leverage and enhanced treatment access to select persons with severe mental illness who are also involved in the criminal justice system. A national survey of mental health courts has begun to elucidate the procedural, clinical, and operational aspects of these courts and the defendants they adjudicate. A secondary analysis of survey data was performed to determine the similarities and differences among these courts. Results revealed large variability among existing mental health courts across multiple domains. The implications of this variability are discussed in terms benefits and limitations.