Examining Mental Health Courts in the Justice System

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Mental health courts (MHC) are relatively new approaches to the problems of the mentally ill caught in the criminal justice system. (Almquist & Dodd, 2009, p. 2) The number of these individuals has surged in the decades following deinstitutionalization. (Torrey, 2005) Although there is no definitive model of a mental health court, research indicates successes have been achieved in lowering recidivism rates, increasing access to mental healthcare services and reducing court and incarceration costs. Despite recent legislation funding research, resources and grants, many planners and policymakers see MHCs as temporary or experimental in nature; economic and political factors may derail the efforts of local communities to establish or retain mental health courts. (Acquaviva, 2006, pp. 994-996)

Keywords: Mental health court, deinstitutionalization

Mental health courts (MHC) offer relatively new approaches to the problems of the mentally ill caught in the criminal justice system. (Almquist & Dodd, 2009, p. 2) The number of these individuals has surged in the decades following deinstitutionalization. (Torrey, 2005) Although there is no definitive model of a mental health court, research indicates successes have been achieved in lowering recidivism rates, increasing access to mental healthcare services and reducing court and incarceration costs. Despite recent legislation funding research, resources and grants, many planners and policymakers see MHCs as temporary or experimental in nature; economic and political factors may derail the efforts of local communities to establish or retain mental health courts. (Acquaviva, 2006, pp. 994-996)

History of Deinstitutionalization

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Torrey (2005) defines deinstitutionalization as the policy of moving severely mentally ill people out of large state institutions and then closing part or all of those institutions. The policy was not without its problems. Regarding the policy, Dr. Torrey states, "The former affects people who are already mentally ill. The latter affects those who become ill after the policy has gone into effect and for the indefinite future because hospital beds have been permanently eliminated." (Torrey, 2005)

An effort in the 1950s began throughout the United States to remove long-term patients from psychiatric facilities and place them in community-based treatment programs. Deinstitutionalization policy was influenced by several social forces, including an interest in the civil rights of individuals, fiscal concerns and the discovery of a new drug. (Hott Productions, Inc., 2005)

Firstly, psychiatrists were optimistic about effectively treating mental disorders outside of the hospital after successfully treating soldiers traumatized during World War II. (Hott Productions, Inc., 2005)

Secondly, there became a focus on the civil rights of institutionalized people. It was felt that the abusive conditions and long-term institutionalization in state psychiatric hospitals might be as harmful as the mental illnesses suffered by the patients. (Hott Productions, Inc., 2005)

Thirdly, the cost of caring for these patients in large institutions was a concern for fiscal conservatives at that time. (Hott Productions, Inc., 2005)

Fourthly, the discovery of the first effective anti-psychotic medication in 1954, chlorpromazine, allowed effective treatment of many patients outside the hospital setting. (Hott Productions, Inc., 2005)

And finally, the enactment of federal Medicaid and Medicare in the 1960s had a major impact on deinstitutionalization nationally. (Torrey, 2005)

The effects of changes to admission and discharge practices at state and county psychiatric hospitals have been notable: In 1955, 559,000 patients were living in state and county psychiatric hospitals throughout the country. In 1980, only 138,000 people were living in such facilities. (Hott Productions, Inc., 2005) It should be said that this type of data oversimplifies the numbers since it doesn't account for the significant increase in the U.S. population since 1955. (Torrey, 2005)

President Jimmy Carter's Commission on Mental Health based the principle of deinstitutionalization and patients being treated in the least restrictive setting on this ideology: "The objective of maintaining the greatest degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while he or she participates in treatment or receives services." (Torrey, 2005)

According to Torrey (2005):

For a substantial minority, however, deinstitutionalization has been a psychiatric Titanic. Their lives are virtually devoid of "dignity" or "integrity of body, mind, and spirit." "Self-determination" often means merely that the person has a choice of soup kitchens. The "least restrictive setting" frequently turns out to be a cardboard box, a jail cell, or a terror-filled existence plagued by both real and imaginary enemies.

Mental Health Court Movement

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Mental illness has been criminalized in our society since deinstitutionalization. The criminal justice system has become responsible for providing avenues for basic mental healthcare services. Simplistically, mental health courts are attempting to apply rehabilitative solutions to otherwise criminally sanctioned behavior. (Schneider, 2008) These courts were introduced as a response to over-crowded jails and high recidivism rates. (Almquist & Dodd, 2009, p. 2) The number of MHCs has grown from one or two in 1997 (Mental Health Courts Appear to Shorten Jail Time, Reduce Re-Arrest for Those With Psychiatric Illness, 2010) to about 280 nationwide. (Balassone, 2010)

Mental health courts grew out of so-called problem-solving drug courts that began in the 1980s. (Balassone, 2010) MHCs divert mentally ill offenders away from jail and into long-term community mental health treatment. (Acquaviva, 2006, p. 971) The South Carolina Department of Mental Health website (2006) defines its mental health courts as:

Adult criminal specialty courts with a separate docket dedicated to the diversion of non-violent pretrial felony and misdemeanor offenders with mental illness from the criminal justice system to appropriate community treatment services and resources.  The program is voluntary and the individual's charges are held in abeyance until the individual completes the treatment course as directed by the court. 

Mental health courts generally share the following goals: reduce criminal recidivism; improve public safety; provide effective treatment to people with mental illness; increase access to treatment; and reduce costs of related to incarceration (Almquist & Dodd, 2009, p. 2)

Funding and Resources

The large number of individuals with mental illnesses involved in the criminal justice system is strongly influencing policy changes across the country within the criminal justice and mental health systems. (Almquist & Dodd, 2009, p. v) The response to state government officials' requests for recommended improvements to assisting people with mental illness within the criminal justice was the creation of The Justice and Mental Health Collaboration Program (JMHCP) through the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 (Public Law 108-414). The Office of Justice Programs website (2010) states that "the purpose of the program is to increase public safety by facilitating collaboration among the criminal justice, juvenile justice, mental health treatment, and substance abuse systems to increase access to treatment for this unique group of offenders." The Justice and Mental Health Collaboration Program is funded through the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 (MIOTCRA) (Public Law 108-414) and the Mentally Ill Offender Treatment and Crime Reduction Reauthorization and Improvement Act of 2008 (Pub. L. 110-416). Funding in FY 2010 was $12 million. (Office of Justice Programs, 2010)

The Criminal Justice/Mental Health Consensus Project is a national effort to help local, state, and federal policymakers and criminal justice and mental health professionals improve the response to people with mental illnesses who come into contact with the criminal justice system. It is coordinated by the Council of State Governments Justice Center. (Justice Center, 2011)

The landmark 2002 Consensus Project Report was written by Justice Center staff and representatives of leading criminal justice and mental health organizations. The report led to the "implementation of practical, flexible criminal justice/mental health strategies through on-site technical assistance; the dissemination of information about programs, research, and policy developments in the field; continued development of policy recommendations; and educational presentations." (Justice Center, 2011)

Statistics and Research Findings

Almquist & Dodd (2009) report the prevalence of serious mental illnesses among all people entering jails is estimated to be 16.9 percent (14.5 percent of men and 31 percent of women). Courtrooms, jails and prisons do not have the resources to provide needed services to those people with mental illnesses who often cycle repeatedly through the system. (p. v)

That percentage has not changed since a Bureau of Justice Statistics 1999 report. While approximately 5 percent of the U.S. population has a serious mental illness, the statistics for prison and jail populations remains at approximately 16 percent. In 1997, at least 700,000 of the 10 million people in U.S. jails had a serious mental illness. Substance abuse was a co-occuring disorder for approximately three-quarters of those individuals. A study completed by the National Center for Mental Health and Juvenile Justice concluded that an alarming two-thirds of detained male youth and three-quarters of detained female youth have at least one mental health disorder. (Office of Justice Programs, 2010)

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A sampling of data from numerous studies shows mental health court successes. Almquist & Dodd (2009) point out that "the body of research on mental health courts is quite limited at this stage, both in terms of the number of studies and their scope." (p. v) Because of the varying models of mental health courts, the studies conducted to date have measured and reported different outcomes. (Almquist & Dodd, 2009, p. v)

A 2007 study by the RAND Corporation, the first to look at the cost-effectiveness of mental health courts, found that a Pennsylvania mental health court saved taxpayers $3.5 million over a two-year period. (Reuters, 2010)

In a study published June 18, 2010, about 72 percent of those who completed the program in a North Carolina mental health court were not rearrested within two years, compared with 37 percent of those who chose to leave. (Balassone, 2010)

After five years of operation, the recidivism rate is less than 10% in a Tennessee Metro Mental Health Court. (Acquaviva, 2006, p. 992)

In the year prior to MHC participation in Reno, Nevada, forty participants averaged 528 days in the hospital. After completing the court-mandated program, the same forty participants only spent ninety-three days collectively in the hospital. (Acquaviva, 2006, p. 992)

In Clark County, Illinois, 85% of participants had not been arrested on new charges since participating in MHC. (Acquaviva, 2006, p. 992)

Following successful completion of prescribed treatment, charges were dismissed against 95% of participants in St. Louis County Municipal MHC. (Acquaviva, 2006, p. 992)

The methodologies used in the available research vary widely; however, there is enough information accumulated to support the following according to Schneider (2008): "Mental health courts do indeed reduce recidivism rates; are associated with longer time without any new criminal charges, or charges for violent crimes; reduce the probability of future arrests; improve access to care; save the taxpayers money by keeping mentally ill individuals out of prison; reduce drug abuse; and improve overall levels of functioning." ( p. 2)

Schneider (2008) summarizes, "However, while the early data is encouraging, there is still a great need for further study regarding the efficacy of mental health courts. In particular, there remain questions about who is likely to benefit from participation in mental health courts, of what sort, and under what circumstances. (p. 1)

Mental Health Court Pilot Model

Despite early successes, MSCs are established as pilot programs whose future existence relies on several factors, i.e., fiscal, political, societal. Planners and policymakers often refuse to acknowledge the need for MHCs to hold a permanent place in the judicial system. MHCs are usually funded solely or predominantly with grant money and are perennially at risk of being eliminated. Stability and the future of a MHC at the conclusion of its pilot period are often tied to budgetary constraints. (Acquaviva, 2006, pp. 994-996) Some feel planners and policy makers should look to the available research and no longer fund MHCs as "pilot programs". (Schneider, 2008, p. 2)

Summary

Research clearly indicates that mental health courts are an alternative to the current criminal judicial system in place for the mentally ill. The several decades of deinstitutionalization without an effective mental healthcare system in place has resulted in the criminalization of the mentally ill. For many, jail is the only alternative to living on the streets or obtaining the necessary care that is not available in the present day healthcare system. The growth of mental health courts in the United States in the past decade and the limited studies completed to date show positive outcomes for both participants and the public. Further research is needed to determine why some mental health court models work better than others. Research results can help analyze cost effectiveness, define target participants, and identify services to increase the likelihood of success. In areas without a mental health court, good practices can be implemented in traditional courts to improve services to individuals with mental illness. (Almquist & Dodd, 2009, p. 29)