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Mixed verdict on mental health courts


June 15, 2015
By Dorothy Cotton

There has been a lot of attention in recent years to the issue of police involvement with people with mental illnesses. There are education and training standards, joint response initiatives, and recommendations for de-escalation training. There are also mental health courts—at least in some jurisdictions. Mental health courts (MHCs) are one of a variety of speciality courts whose primary function is problem solving, with a focus on addressing the underlying causes of offending rather than on meting out punishment and assigning guilt—therapeutic jurisdiction, as some call it. Mental health courts vary in some details, but there are many commonalities. Their primary focus is not so much on disputing guilt or innocence. The lead actors including defense and prosecuting attorneys work as a team with judges, criminal justice personnel, and mental health practitioners to arrange treatment and services, and to allot encouragement and sanctions that will address the underlying causes of each participant’s offending while protecting the public (since it seems pretty clear that the door to the cells can start revolving pretty quickly with this population). The assumption is that if you treat the mental illness, the offending will go by the wayside.

Mary Ann Campbell, a Canadian researcher, notes that

It seems to work. The available research suggests that defendants with mental illnesses who go through mental health courts are less likely to offend than they were before they had become involved with the mental health court system. Virginia Aldigé Hiday and her colleagues have had a pretty thorough look at the existing research—as well as conducting some of their own—and have concluded that if people actually “graduate” from mental health court, they are less likely to reoffend, are likely to have less serious charges when they do re-offend and generally spend less time incarcerated than similar folks who did not take the mental health court route. As Goodale, Callahan and Steadman noted in a recent study (2013) the question of “[w]hether MHCs improve justice and treatment outcomes for people with mental disorders who are involved in the criminal justice system appears to be settled: they do.”

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You can always tell that when people start making statements like that, it means we are ready to move on to MHC Research—Part Deux. So MHCs work…but…..

As anyone who has been involved in this kind of initiative knows, there is a big “but.” As noted above, the outcomes are better for people who “graduate.” But alas, there is a high drop out rate. The available studies suggest that somewhere between 19 and 81% of people drop out and do not complete the program. It averages out that about half of people don’t complete MHC programs. I was not able to find any handy explanation for the varying drop out rates but nevertheless, it is worth asking: what predicts failure to complete? If mental health courts are so effective for people who finish, how can we predict—or maybe even increase—the number of people who finish the program?

There are a few studies which have looked at this topic but the results are pretty unclear. Hiday’s study for example suggests that the best predictors of failure to graduate are (duh) failure to show up and noncompliance with court dates. Seems a little circular to me! Testing positive for illegal drug use is also a bad thing. Again, not a big surprize.

Beyond that, there do not seem to be clear answers. Some studies have found differences based on race, of type of offense (in some studies people with drug offenses seemed to fare worse than people who were charged with other types of offenses), on number of previous offences….the list goes on.

One of the hitches of course is that no two mental health courts are exactly the same. There are about 14 mental health courts in Canada and they have different criteria to get in, different things get you pitched out, the services provided are a little variable. So one of the big challenges for the MHC people is to try to figure out how to get people to not only start but also finish the program.

Aside from figuring out what might keep people in the program, it might also be worth having a look at what’s going on in the program itself. Looking at the Canadian situation, Mary Ann Campbell and her colleagues in New Brunswick conducted an interesting study that looked not only at the types of mental health services that their MHC folks got but also the nature and amount of intervention related to criminogenic needs (e.g. those needs that that have an empirically demonstrated association with criminal behavior). With offenders who do not have a mental illness, interventions focus on criminogenic needs. This is bread and butter intervention work with offenders in jails and prisons. Focus on the stuff that actually contributes to re-offending and people might offend less. Another duh. Interestingly, sometimes, with people with mental illnesses, we kind of forget about the criminogenic needs and get all carried away with mental health needs. Campbell and her colleagues noted that the MHC interventions do not always emphasize this part of things as much as they might. Of course we need to look at the mental health services—but perhaps that’s not enough—especially for MHC users who may have a history of more serious offenses.

What’s the take home message from these studies? MHCs do have promise—but we need to find ways of increasing the likelihood that people will stay with the program. And while treating mental illness is a laudable goal and provision of services is essential, we need to remember that it is not simply mental illness that causes people to break the law, because most people with mental illnesses do not break the law.. If we want people with mental illnesses to be less involved in the criminal justice system then we need to focus on the factors that lead people to break the law. The “Central 8” risk/need factors that are linked to criminal behaviour include a history of antisocial behavior, pro-criminal attitudes, antisocial peers/limited prosocial peers, antisocial personality, lack of prosocial leisure activities, lack of education/employment, family/marital problems, and substance abuse. These factors tend to be relevant whether a person has a mental illness or not.

BTW…I have carefully avoided the Elephant in the MHC which relates to the argument about whether MHCs are a good idea at all. There are convincing arguments that they are really just another way of involving people with mental illnesses in the criminal justice system, and that the services available through MHCs would be better placed OUTSIDE the criminal justice system. It’s a valid argument—but one for another day. For today, the fact is we have these courts—so let’s make them work as well as they can.

1 Mary Ann Campbell et al (2105) Multidimensional Evaluation of a Mental Health Court: Adherence to the Risk-Need-Responsivity Model. Law and Human Behavior.
doi: http://dx.doi.org.proxy.queensu.ca/10.1037/lhb0000135

2 Virginia Hiday et al (2014) Predictors of Mental Health Court Graduation. Psychology, Public Policy and Law 20(2) 191-199.

3 Gregg Goodale et al (2013) What can we say about mental health courts today? Psychiatric Services 64:298-300.


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