Law & psychiatry: mental health courts: their promise and unanswered questions

"You feed and water a rose bush and eventually it blossoms": Constructions of self-transformation among mental health court defendants

This study qualitatively examined adaptive responses to mental health court mandates through individual interviews with defendants in a mental health court (n = 31). Thematic analysis of interview data revealed that defendants engaged in meaning-making to comprehend and adapt to the perceived programmatic demands of mental health court. Programmatic burdens, court-enforced accountability, and intrinsic rewards were themes that converged to form a distinct adaptive response: construction of self-transformation narratives. Defendants in this study tended to interpret the intense burdens of participation as intrinsically rewarding and meaningful, leading them to see the expectations of mental health court as an opportunity to better themselves. The findings help to differentiate between compliance versus full treatment engagement among defendants with serious mental illness (SMI). This study's findings have important implications for how individuals with serious mental illness engage with court diversion programs and mandated treatment, and how these defendants may be best served in specialized mental health court programs.

Individual factors associated with recidivism among mental health court program clients

There is growing evidence that diversion to a mental health court program (MHC) can reduce recidivism rates and improve the quality of life of clients. However, there is less known about MHC client characteristics and factors associated with recidivism. Yet, this information would be useful to increase the effectiveness of these programs. Cross-sectional quantitative data were collected on MHC clients in three consecutive years. Of the 155 program clients that were successfully interviewed, only 154 were included in the analysis due to one non-consent to collect further data from their case manager. The purpose of this secondary analysis was to examine "What individual factors are associated with recidivism among MHC program clients?" This analysis specifically explored the association of sex, age, low functional ability, homelessness, court site, and criminal history. From the multiple logistic regression results, the increased risk of recidivism was found to be significantly associated with younger clients and a prior criminal history. The results of this study suggest programs tailored to young adults and repeat offenders may be areas that MHCs could potentially focus on to increase their effectiveness.

The impact of mental health court: A Sacramento case study

Mental health courts (MHCs) use a collaborative justice approach to provide a therapeutic alternative to the traditional justice process for defendants with mental illnesses directly relevant to their alleged criminal offenses. MHCs have proliferated in recent years, in light of early research reports documenting their successes. The aim of this paper is to provide further evaluation of the effects of MHCs by evaluating the impact of the Sacramento County MHC in California. We analyzed quantitative data and conducted interviews with stakeholders and MHC participants to understand how the MHC influenced individual participants' recidivism rates, mental health, and quality of life. Results from the quantitative data analysis indicate that defendants had a lower rate of recidivism after the MHC program than before it. Moreover, graduates were less likely to be rearrested and rehospitalized than non-graduates. Qualitative analyses revealed several core themes regarding participants' views on facilitators and barriers related to the MHC's success. These findings provide further insights into the effectiveness of MHCs.

Integrating a Co-occurring Disorders Intervention in Drug Courts: An Open Pilot Trial

Little research has focused on systematically integrating clinical treatment within existing drug court procedures. This could be particularly useful for clients with substance use disorders, who comprise those on court dockets and often have co-existing mental health issues. This article reports on the preliminary outcomes of integrating MISSION-Criminal Justice (MISSION-CJ), a co-occurring mental health and substance use wraparound intervention, within two Massachusetts drug courts. In this open pilot, clients completed intake and 6-month follow-up assessments. The participants were primarily Caucasian (86%), male (82%), had at least 2 prior arrests, and received outpatient treatment for mental health (54%), alcohol use (51%), or drug use (88%) prior to enrolling in MISSION-CJ. Six-month follow-up data suggested that participants showed statistically significant reductions in average number of nights spent in jail, alcohol use, and drug use, as well as an increase in full time employment.

Life After: Examining the Relationship Between Sociobehavioral Factors and Mental Health Among African American Ex-Offenders

Mental health problems are 3 times higher among prisoners than the general population. After release, reentry barriers and other factors can exacerbate mental problems. This study of 250 African American ex-offenders examines the relationship between sociobehavioral factors and mental health. Independent variables included self-reported health, alcohol use, employment, and history of mental problems before prison. Covariates included the number of immediate family with mental problems and the number of serious conflicts with family members or friends. Analyses revealed that men who had serious conflicts, used alcohol more often, reported less than excellent health, and not employed were more likely to report being troubled by mental problems. Family mental health history was not statistically significant. The current study adds to the literature by identifying selected factors associated with the mental health of African American male, ex-offenders. Findings from this study can inform interventions to address mental health issues and reduce recidivism.

Forensic Assertive Community Treatment: A Review of the Literature

An extensive body of literature provides evidence supporting the effectiveness of assertive community treatment (ACT) with regard to non-forensic outcome measures, such as number of hospital admissions and length of stay. However, research findings on the effectiveness of ACT for forensic outcome measures, such as rearrests or detentions, is much less clear. The present review, therefore, focuses on the application of ACT in forensic populations, combining key elements of ACT with elements of forensic rehabilitation models. Specifically, a review of the literature was conducted using a systematic methodology in an attempt to combine evidence-based elements of 40 years of research on regular ACT with elements of forensic rehabilitation models. Results reveal limited yet promising evidence in support of the effectiveness of forensic ACT for forensic outcome measures. Implications for future research and clinical practice are discussed.

Psychiatric symptoms and mental health court engagement

People with mental illnesses are overrepresented in the criminal justice system. Many interventions have been implemented to treat the underlying causes of criminal justice involvement and prevent people with mental illnesses from recidivating. Mental health courts (MHC) are one of these programs. This analysis examines the relationship between psychiatric symptoms and MHC engagement. Eighty MHC participants from two Midwestern MHCs were interviewed. Symptom severity was assessed at baseline using the Brief Psychiatric Rating Scale. MHC engagement was estimated by treatment adherence, substance use, days spent in jail, probation violations, and MHC retention during a six month follow-up period. Using nonparametric statistical tests and logistic regression, results indicate symptoms of depression, anxiety, and guilt are more severe at baseline for those people who are incarcerated during the follow-up period. Symptoms of anxiety are more severe for people who are terminated or went missing during the follow-up period. Further research is needed to determine the directionality and causality of these relationships. MHCs professionals should be aware of the relationship between symptom severity and MHC engagement and attempt to connect participants with treatment and services as early as possible and individualize treatment plans based on current symptoms and need.

What Happens to Mental Health Court Noncompleters?

Mental health court (MHC) research consistently finds that defendants who successfully complete and graduate from the court are less likely to recidivate than those who do not. However, research has not assessed what happens to these noncompleters once they are sent back to traditional court. Using follow-up data on six years of noncompleters from pre-adjudication MHC, we examine what happens to these defendants in traditional court. Findings suggest that 63.7% of defendants' charges were dismissed, 21.0% received probation, and 15.3% were sentenced to incarceration. We examine the time to disposition and differences in defendant characteristics and disposition outcome as well as the relationship between disposition and subsequent recidivism. Results suggest that more severe punishments in traditional court are associated with recidivism. Logistic regression analysis shows that defendants whose charges were dismissed in traditional court were less likely to recidivate than those who were sentenced to probation or incarceration. Our findings highlight the need for future MHC evaluations to consider traditional court outcomes and support trends towards post-adjudication courts.

Why do mental health courts work? A confluence of treatment, support & adroit judicial supervision

The article contributes to the understanding of 'what works' in mental health courts (MHCs). There are now almost 400 MHCs in the US and more worldwide. A substantial body of evidence demonstrates that MHCs can succeed in reducing recidivism among offenders who suffer mental disorders. This article argues that MHCs succeed when they have achieved the right confluence of essential elements, including providing evidence-based treatment and psychosocial supports and using adroit judge-craft. After a brief review of some of the studies demonstrating MHC success, this article discusses the research into the necessary foundations of rehabilitation programs. It is argued that, although treatment and psychosocial services should be supplied within an evidence-based framework, neither of the two leading conceptual models - Risk-Needs-Responsivity and the Good Lives Model - are empirically proven with offenders who suffer from mental disorders. Despite the absence of proof, the Good Lives Model is argued to be appropriate for MHCs because it is normatively consonant with therapeutic jurisprudence. The MHC judge is another essential element. The judicial role is assayed to elucidate how it functions to promote the rehabilitation of offenders with mental disorders. It is argued that the role of the MHC judge during supervisory status hearings is to establish a therapeutic alliance and practice motivational psychology with each MHC participant.

The impact of judge-defendant communication on mental health court outcomes

Previous research has shown that mental health courts have been successful in reducing the rates of recidivism among mentally ill offenders. However, none of these studies, to date, have examined exactly what aspects of the courts reduce these rates of recidivism and what makes them successful. The current study utilized a sample of 291 mentally ill criminal offenders participating in a mental health court to examine whether those participants who were addressed by and communicated with the judge had a reduction in recidivism rates and the severity of new charges in comparison to those who did not. The hypotheses regarding greater judge-defendant communication and recidivism were not supported. This suggests that communication in and of itself is not sufficient to reduce recidivism. Future research of a qualitative nature is essential to identify if the frequency, tone, and valence of the communication results in improved outcomes. In addition, these results may indicate a necessity for more stringent training and guidelines for the maintenance of Mental Health Courts. Results of the current study suggested differences between genders, such that females were spoken to by the judge more frequently than were men.

The impact on taxpayer costs of a jail diversion program for people with serious mental illness

Mental illness is prevalent among those incarcerated. Jail diversion is one means by which people with mental illness are treated in the community - often with some criminal justice system oversight - instead of being incarcerated. Jail diversion may lead to immediate reductions in taxpayer costs because the person is no longer significantly engaged with the criminal justice system. It may also lead to longer term reductions in costs because effective treatment may ameliorate symptoms, reduce the number of future offenses, and thus subsequent arrests and incarceration. This study estimates the impact on taxpayer costs of a model jail diversion program for people with serious mental illness. Administrative data on criminal justice and treatment events were combined with primary and secondary data on the costs of each event. Propensity score methods and a quasi-experimental design were used to compare treatment and criminal justice costs for a group of people who were diverted to a group of people who were not diverted. Diversion was associated with approximately $2800 lower taxpayer costs per person 2 years after the point of diversion (p<.05). Reductions in criminal justice costs drove this result. Jail diversion for people with mental illness may thus be justified fiscally.

Integrating the American criminal justice and mental health service systems to focus on victimization

Although most research and policy in the mental health and criminal justice arenas have operated independently of one another, there is a growing consensus suggesting the need for an integration of these two disparate, yet complementary systems. Furthermore, in light of the adverse mental health consequences that often accompany victimization experiences, it is apparent that these two systems should develop and foster overlapping services for crime victims. The research reviewed herein provides an examination of issues such as these, identifies some of the barriers that stand in the way of a successful integration of the two systems, and attempts to provide some guidance and direction for future integrated mental health and criminal justice system approaches. An outline of research gaps and directions for future study are offered for the integration of criminal justice and mental health systems, as such collaborations are likely to alleviate some of the deleterious mental health outcomes evident among crime victims and at the same time reduce the occurrence of repeat victimization.

Recognition and understanding of goals and roles: The key internal features of mental health court teams

The increasing involvement of people with mental illness in the criminal justice system has led to the formation of specialty programs such as mental health courts (hereafter MHCs). We discuss MHCs and the teams serving these courts. Specifically, we examine team members' perceptions of MHC goals and their own and others' roles on the MHC team. Using a semi-structured interview instrument, we conducted 59 face-to-face interviews with criminal justice and mental health treatment personnel representing 11 Ohio MHCs. Findings from our qualitative data analyses reveal that MHC personnel understand individuals' roles within the teams, recognize and appreciate the importance of different roles, and share common goals. MHCs could foster this level of understanding and agreement by working to recruit and retain individuals with experience in or willingness to learn about both the criminal justice and mental health systems. Future research should explore the impact of MHC team functioning on client outcomes.

Citizenship, mental illness, and the criminal justice system

The concept of citizenship in regard to persons with mental illness has gained increasing attention in recent years, but little empirical research has been conducted on this topic. In addition, little research or conceptual writing has been done on the topic of criminal justice in regard to citizenship for people with mental illness, in spite of the high incidence of criminal charges and incarceration among this group. We review our work on an applied theoretical framework of citizenship, including its origins in mental health outreach work to people who are homeless and in a jail diversion program. We then suggest the contribution the framework can make to the intersecting issues of mental illness, its criminalization in the U.S., and the goal of community integration for people with mental illness.

Program planning and staff competencies for forensic assertive community treatment: ACT-eligible versus FACT-eligible consumers

PURPOSE

Forensic assertive community treatment (FACT) is a recent adaptation of the assertive community treatment (ACT) model; however, more information is needed about how FACT and ACT consumers differ and how FACT should be modified to accommodate these differences.

METHOD

Linked, multisystem administrative data from King County, Washington, were used to compare the demographic, clinical, and criminal justice characteristics of ACT- and FACT-eligible consumers.

RESULTS

FACT consumers were more likely to be male, persons of color, and had more complex clinical profiles. Also, some FACT consumers were incarcerated for sex offenses, and more than half had violent offenses.

CONCLUSIONS

Traditionally, ACT teams avoid serving consumers with personality disorders, violent consumers, and sex offenders; however, given increased use of mandated outpatient treatment and mental health courts, FACT teams may have less discretion to choose whom they serve. The addition of clinical interventions and other modifications may be particularly important for FACT teams.

A testable theory of problem solving courts: Avoiding past empirical and legal failures

Recent years have seen a proliferation of problem solving courts designed to rehabilitate certain classes of offenders and thereby resolve the underlying problems that led to their court involvement in the first place. Some commentators have reacted positively to these courts, considering them an extension of the philosophy and logic of Therapeutic Jurisprudence, but others show concern that the discourse surrounding these specialty courts has not examined their process or outcomes critically enough. This paper examines that criticism from historical and social scientific perspectives. The analysis culminates in a model that describes how offenders are likely to respond to the process as they engage in problem solving court programs and the ways in which those courts might impact subsequent offender conduct. This Therapeutic Jurisprudence model of problem solving courts draws heavily on social cognitive psychology and more specifically on theories of procedural justice, motivation, and anticipated emotion to offer an explanation of how offenders respond to these programs. We offer this model as a lens through which social scientists can begin to address the concern that there is not enough critical analysis of the process and outcome of these courts. Applying this model to specialty courts constitutes an important step in critically examining the contribution of problem solving courts.

Dealing with mentally ill domestic violence perpetrators: A therapeutic jurisprudence judicial model

People suffering from mental illness are increasingly referred to the domestic violence court. Yet the typical diversion programs available, including batterer's intervention programs, are inappropriate for those with serious mental illness. As a result, the Miami-Dade Domestic Violence Court has developed a new approach for dealing with this population that applies mental health court techniques in domestic violence court. This article will describe and discuss this pioneering model. It also will situate this model within the context of other problem-solving courts and discuss how the court uses principles and approaches of therapeutic jurisprudence. The paper presents some preliminary data that describe the social and legal characteristics of 20 defendants in the Domestic Violence Mental Health Court followed over a two year period between 2005 and 2007.

Categorizing temporal patterns of arrest in a cohort of adults with serious mental illness

Temporal patterns of arrest among mental health systems' clientele have not been well explored. This study uses "trajectory analysis," a methodology widely employed by criminologists exploring patterns of desistence in offending, to examine patterns of criminal justice involvement in a cohort of mental health service recipients. Data for this study are from a statewide cohort of individuals who received services from the Massachusetts Department of Mental Health in 1991 (N = 13,876) and whose arrests were followed for roughly 10 years. Zero-inflated Poisson trajectory analysis applied to cohort members having two or more arrests identified five trajectories with widely varying arrest patterns. Analysis of differences in the composition of the five trajectory-based groups revealed few between-group differences in members' demographic and service use characteristics, while certain offense types were disproportionately prevalent among particular trajectory-based groups. The implications of these findings for understanding criminal justice involvement in this population and the utility of the trajectory model for system planning are discussed.

Stakeholder views of a mental health court

To reduce criminal justice involvement of persons with mental disorders, many communities have created mental health courts. Early mental health courts were restricted to persons charged with nonviolent misdemeanors. Recently mental health courts have begun to accept persons charged with felonies and violent crimes. To our knowledge, this is the first study to examine the process and outcomes of a mental health court that accepts persons charged with more serious offenses from the perspective of stakeholders in the court. Data come from semi-structured interviews with 43 professionals involved with the mental health court, including judges, attorneys, probation officers, case managers, mental health professionals, and agency administrators. The stakeholders endorsed mental health court compared to traditional court for reducing criminal justice involvement of individuals with mental disorders with a history of repeated arrests. The observations of stakeholders revealed important themes to consider in research evaluating mental health courts, including selection mechanisms, supervision processes, treatment access, use of sanctions, competency, indicators of effectiveness, participant characteristics associated with better or worse outcomes, and mechanisms of change.

Diversion down under - Programs for offenders with mental illnesses in Australia

This article provides an overview of mental health courts and diversion programs operating for offenders with mental illnesses in Australia. Methods of diversion that have been established in Australia include Magistrates courts diversion programs, psychiatric court liaison services and legislative powers of diversion. Some of the problems associated with diversionary options are discussed and recommendations for reform made. It is argued that no matter what form diversionary programs take, detailed consideration must be given to how the court or program will be evaluated and that sufficient funding be allocated for ongoing evaluation.

Problem-solving courts in Canada: A review and a call for empirically-based evaluation methods

While problem-solving courts may soon become permanent fixtures within the criminal justice system in Canada, little is actually known of their effectiveness in dealing with crime. The current paper will review the fundamental basis for these court models, with special attention on their arrival in Canada. The focus will be on three particular forms of problem-solving courts - mental health court, drug treatment court and community court - due in large part to the availability of literature. Existing evaluations, both process and outcome, of both the Canadian and American models will be discussed and their inadequacies addressed. It is hoped that this article will serve to dispel myths surrounding the ethical application of random assignment when evaluating these court systems. Through the application of experimental methodology, evaluations may finally be able to address the issue of whether these court systems are effective alternatives to the traditional criminal justice stream.

[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.

Implementing the essential elements of a mental health court: the experiences of a large multijurisdictional suburban county

Mental health courts developed in the USA in the late 1990s as one means to reduce the involvement of people with mental illness in the criminal justice system. In response to the growth in number of mental health courts, the Council of State Governments led an initiative to identify essential elements of mental health courts to guide their development and implementation. This paper applies these essential elements to a municipal mental health court in a multijurisdictional, suburban county. While this court met most essential elements, they faced a number of challenges. The primary ones included not being able to advance from hearing municipal cases only to state misdemeanor and felonies, not having the resources to expand program capacity for municipal cases, and participants not being able to always access needed mental health treatment, rehabilitation, and support services. The paper concludes with implications for behavioral health administrators and direct service staff in implementing the essential elements of mental health courts.

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers

OBJECTIVE

Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients.

METHODS

The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined.

RESULTS

About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types.

CONCLUSIONS

The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.

Mental health court outcomes: a comparison of re-arrest and re-arrest severity between mental health court and traditional court participants

Mental health courts have been proliferating across the country since their establishment in the late 1990's. Although numerous advocates have proclaimed their merit, only few empirical studies have evaluated their outcomes. This paper evaluates the effect of one mental health court on criminal justice outcomes by examining arrests and offense severity from one year before to one year after entry into the court, and by comparing mental health court participants to comparable traditional criminal court defendants on these measures. Multivariate models support the prediction that mental health courts reduce the number of new arrests and the severity of such re-arrests among mentally ill offenders. Similar analysis of mental health court completers and non-completers supports the prediction that a "full dose" of mental health treatment and court monitoring produce even fewer re-arrests.

Patient inducement, provider priorities, and resource allocation in public mental health systems

Public mental health systems are increasingly facing demands from the criminal justice system and social services agencies to provide services and support in cases in which mental illness contributes to crime, homelessness, or poverty. In this article we analyze how policies from outside public mental health systems affect resource allocation within these systems, using examples from criminal justice. These policies use two types of mechanisms: inducing patients to consume treatment (by offering rewards or imposing penalties) and inducing clinicians to provide treatment (by creating priorities). We propose a classification of these social policies based on whether they affect demand through rewards or penalties or supply through priorities. We then relate the classification to data on patients treated in public systems to evaluate the current prevalence and potential for growth in these outside demands. These inducements impose a set of nonobvious costs on other patients who are not targeted by the policies. Furthermore, they create incentives for both patients and providers to modify their behavior in order to take advantage of rewards, avoid penalties, or better compete for resources with prioritized patients. We consider some policy implications for avoiding unintended consequences of these policies.

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers

OBJECTIVE

Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients.

METHODS

The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined.

RESULTS

About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types.

CONCLUSIONS

The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.

Beyond criminalization: toward a criminologically informed framework for mental health policy and services research

The problems posed by persons with mental illness involved with the criminal justice system are vexing ones that have received attention at the local, state and national levels. The conceptual model currently guiding research and social action around these problems is shaped by the "criminalization" perspective and the associated belief that reconnecting individuals with mental health services will by itself reduce risk for arrest. This paper argues that such efforts are necessary but possibly not sufficient to achieve that reduction. Arguing for the need to develop a services research framework that identifies a broader range of risk factors for arrest, we describe three potentially useful criminological frameworks-the "life course," "local life circumstances" and "routine activities" perspectives. Their utility as platforms for research in a population of persons with mental illness is discussed and suggestions are provided with regard to how services research guided by these perspectives might inform the development of community-based services aimed at reducing risk of arrest.

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.

Transitions between the public mental health system and jail for persons with severe mental illness: a Markov analysis

Proposed changes to the mental health care system are usually debated in terms of either health benefits or costs savings. However, because of the extensive intersection between the mental health system and the criminal justice system, changes in the organization and financing of mental health services may change the jail detention rate. We analyze jail incarcerations for felonies and non-felonies following the start of a public managed mental health care program in King County, Washington (including Seattle). We analyze unique data that tracks individuals in and out of the public mental health, Medicaid, and criminal justice systems for 1993-1998. In this manuscript we examine individuals with severe mental illness who were enrolled in the Washington state Medicaid program. The final sample size has monthly observations on 6766 unique individuals aged 18-64. We estimate Markov models of the monthly transition probabilities among living in the community with no public mental health treatment, receiving inpatient or outpatient mental health or substance abuse services, or being in jail for either a felony or non-felony charge. The transition probabilities are adjusted for demographics and policy changes that occurred during our study period. There is little evidence of any change in the jail detention rate for severely mentally ill users of the county mental health system in contrast with other SMI individuals following the public managed care program.

Court diversion in perspective

Court diversion schemes have been running for a decade in New Zealand and are increasing in number in Australia. This paper aims to give an international and historical context to these developments, by reference to psychiatric initiatives at courts in the US and in England and Wales. From a review of the specialist literature, an account is given of three forms of psychiatric intervention in courts over the last 90 years: court psychiatric clinics and mental health courts in the US, and court diversion schemes in England and Wales. High levels of psychiatric morbidity among prisoners, coupled with a continuing increase in prisoner numbers, demonstrate the need for systems for dealing with mentally ill people who come before the courts. Court diversion in England and Wales developed as part of a system where the mentally ill who are found guilty are sent to hospital in lieu of any other sentence. Its focus is on a form of psychiatric triage, and its ethos is the health of the patient. Court psychiatric clinics in the US grew up as an alternative to assessment in prison. Their focus has been on full psychiatric evaluation in an insanity and incompetence jurisdiction. The ethos has been that of serving the court. Mental health courts are heavily influenced by ideas of therapeutic jurisprudence, and their emphasis has been on a judge holding minor offenders in community care through the threat of judicial sanction. Experience in England and Wales has shown that court diversion can be a powerful and effective intervention. In order for it to function properly, those running court schemes need direct admission rights to psychiatric beds, both open and locked. Court diversion schemes are best as part of a spectrum of services to police stations, courts and prisons, which involved both general and forensic psychiatrists.

Patterns of practice in mental health courts: A national survey

Mental health courts (MHCs) represent an important new development at the interface of the criminal justice and mental health systems. MHCs are criminal courts for persons with mental illness that were in part created to divert this population from jail/prison into community treatment. MHCs are proliferating rapidly despite limited knowledge regarding their characteristics or their efficacy. We surveyed the entire population of adult MHCs in the United States, n = 90. In the past 8 years, MHCs have been created in 34 states, with an aggregate current caseload of 7,560 clients in MHCs nationally. Most courts (92%) reported using jail as a sanction for noncompliance, if only rarely. Further, jail sanction use was significantly predicted by increased judicial supervision and number of felons in the court. Implications for MHCs and social monitoring are discussed.

From coercion to contract: reframing the debate on mandated community treatment for people with mental disorders

Approximately half the people receiving treatment in the public sector for mental disorder have experienced some form of "leverage" in which deprivations such as jail or hospitalization have been avoided, or rewards such as money or housing have been obtained, contingent on treatment adherence. We argue in this essay that framing the legal debate on mandated community treatment primarily in terms of "coercion" has become counterproductive and that the debate should be re-framed in terms of "contract." Language derived from the law of contract often yields a more accurate account of the current state of the law governing mandated community treatment, is more likely to be translated into a useful descriptive vocabulary for empirical research, and is more likely to clarify the policy issues at stake than the currently stalemated form of argumentation based on putative rights. Our hope is that adopting the language of contract may help to identify those types and features of mandated community treatment that are genuinely problematic, rather than perpetuating the unhelpful and misleading assumption that all types of leverage amount to "coercion."

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

The substantial number of persons with mental illness encountered in many sectors of the criminal justice system has spurred actors from various agencies within that system to take actions aimed at reducing the growth of this population. These actions have included the development of specialty police units, jail diversion programs, and other mechanisms for channeling persons with mental illness out of the criminal justice system and into mental health treatment. The courts, too, have become involved in this effort with the recent development of the "mental health court," the latest of the "specialty" or "problem solving courts." These courts have not been without their critics, however, nor are they the only feasible approach to court-based diversion. This paper identifies and explores a range of options for structuring the relationship between criminal courts and local mental health systems. Beginning with a discussion of the rationale motivating the development of mental health courts, two alternatives to this specialty court model are discussed. One involves judges dealing with defendants having mental illness and substance abuse on a case-by-case basis. The other takes advantages of linkages that may already exist between most courts and the mental health providers who conduct their forensic assessments, expanding the role of these providers to serve as boundary spanners between courts and the components of local mental health systems. Regardless of the model adopted, however, appropriate linkages must exist between the courts and relevant providers. A case study is provided that demonstrates how the status of a locale's linkages can be evaluated and how the information derived from such evaluation can be used to improve the linkages between police, courts, and health and human services agencies.

Family violence among adults with severe mental illness: a neglected area of research

Violence against family caregivers by their adult relatives with severe mental illness is a taboo area of public discourse and scientific research because of fears of further stigmatizing this population. Yet, these families experience violence at a rate estimated to be between 10% and 40%, which is considerably higher than the general population. This article reviews the limited research on violence of adults with severe mental illness against their family caregivers and proposes a conceptual framework that can further stimulate study in an area that has been neglected too long by both mental health and family violence investigators. Research on this topic is essential in developing effective policy and practice interventions.

Evaluating the efficiency and community safety goals of the Broward County Mental Health Court

Mental health courts have developed as one response to persons with mental illness who are involved with the criminal justice system. This study investigated the efficiency and safety goals of one such court in Broward County, FL. Mental health court (MHC) clients spent significantly fewer days in jail for the index arrest associated with study enrollment than a comparison group. MHC clients had similar survival time to re-arrest up to one year after study enrollment. MHC clients did not significantly differ from the comparison group in self-reported aggressive acts over an 8 month follow-up period, while they did self-report significantly fewer acts of violence than the comparison group at the 8 month follow-up. These findings suggest that some of the benefits associated with the MHC reported in prior studies were not achieved at the expense of efficiency and safety.

From referral to disposition: case processing in seven mental health courts

The number of mental health courts in the United States is rapidly increasing, from one in 1997 to nearly 100 in 2004. However, to date there is comparatively little research regarding these specialty courts. The present study reports data on the referral and disposition decision-making processes of seven mental health courts. Information on all referrals to the seven courts over a three-month period was gathered. Results show that, in comparison with individuals involved in the criminal justice system, mental health court clients are more likely to be older, White, and women than individuals in the general criminal justice system. Furthermore, this over-representation occurs at the point of referral, rather than at the point of the court's decision to accept or reject a referral. In addition, the length of time from referral to diversion is much longer in these mental health courts than in other types of diversion programs. Implications of these findings are discussed.

Efficacy of a Mental Health Treatment Court with assertive community treatment

This study examined the efficacy of a Mental Health Treatment Court (MHTC) with diversion to treatment supported by an assertive community treatment (ACT) model of case management. A total of 235 participants were randomly assigned to either MHTC or treatment as usual (TAU) and assessed over a 2 year period. It was hypothesized that participants in the MHTC would decrease their criminal activity and improve their psychosocial functioning relative to participants receiving TAU. While there were offenders for whom neither treatment was effective, a majority in both groups decreased jail days and improved psychosocial functioning, with MHTC participants demonstrating greater gains in most areas. The impact of implementing the MHTC on community practices, and the value of integrating criminal justice and mental health systems, is discussed.

Effects of legal mechanisms on perceived coercion and treatment adherence among persons with severe mental illness

This study takes preliminary steps to examine the effects of 2 legal mechanisms-outpatient commitment (OPC) and representative payeeship (rep payee)-on perceived coercion and treatment adherence in persons with severe mental illness (SMI). Data were collected in structured interviews from 258 involuntarily-admitted inpatients with SMI who were followed for 1 year after discharge. Subjects' clinicians and family members were also interviewed. The analyses show that subjects with both OPC and a rep payee perceived their mental health treatment to be significantly more coercive than subjects who did not receive these legal interventions. Duration of OPC and having a newly-appointed rep payee were both significantly associated with increased treatment adherence over the course of 1 year. For treatment-adherent subjects, neither form of legal mechanism was associated with perceived coercion in treatment, whereas subjects who were nonadherent perceived legal mechanisms as significantly more coercive. The data suggest that these legal tools both affect adherence to treatment, but when used together significantly increase the perceived coerciveness of treatment. Questions remain concerning the underlying mechanism of these effects.