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Service Delivery Innovation Profile

Mental Health Court Links Eligible Offenders With Treatment and Monitoring, Reducing Recidivism, and Improving Outcomes


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Snapshot

Summary

The Brooklyn Mental Health Court links eligible defendants to long-term treatment and monitoring of their mental health problems as an alternative to incarceration. The goal of these new model courts is to move beyond punishment to address the underlying problems that are leading to criminal behavior, thus reducing the chance of repeat offenses. Early evidence suggests that the program has been successful in reducing recidivism, homelessness, psychiatric hospitalizations, alcohol use, and substance abuse, although not all of these declines reached the level of statistical significance.

Evidence Rating (What is this?)

Moderate: The evidence primarily consists of a comparison of key outcomes for the 12 months before and after participation in the program by 37 users of the system.
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Developing Organizations

Center for Court Innovation; New York State Office of Mental Health; New York State Unified Court System
New York, NYend do

Use By Other Organizations

  • The Council of State Governments Justice Center estimates that there are approximately 275 to 300 mental health courts in approximately 40 states as of early 2012, with more in the planning stages. There were 26 mental health courts in New York State as of early 2012.
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Patient Population

Vulnerable Populations > Mentally ill; Prisonersend pp

Problem Addressed

People with mental illness often do not fare well under the current criminal justice system, leading to the potential for repeat crimes. Because their underlying mental health problems are typically not addressed through standard punishments (e.g., probation, incarceration), people with mental illness often find themselves in a "revolving door" situation in which they commit crimes, serve their sentence, and then commit repeat offenses. Statistics show that individuals with mental health problems are disproportionately represented in U.S. jails and prisons; in New York, moreover, the average prison stay for those with mental illness is much longer (215 days vs. 42 days) than for the typical prisoner.1

What They Did

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Description of the Innovative Activity

The Brooklyn Mental Health Court offers mental health treatment to eligible defendants coupled with judicial monitoring as an alternative to incarceration. Key elements of the program are described below:
  • Eligibility: Eligible defendants must have a "serious and persistent" mental illness for which there is a known treatment, such as schizophrenia, bipolar disorder, major depression, or schizoaffective disorder. Those with less severe mental illness and those with illnesses that are more difficult to treat effectively are not eligible. The program was initially open only to those charged with felony, nonviolent offenses, or those repeatedly charged with misdemeanor offenses. (Those charged with first-time misdemeanors were excluded, because most individuals charged with misdemeanors in Brooklyn are sentenced to little or no jail time.) Over time, however, a significant number of individuals charged with violent felony offenses were referred to the program, and these individuals are evaluated on a case-by-case basis. Overall, approximately 40 percent of program participants are violent offenders, while 15 percent are repeat misdemeanor offenders. 
  • Identification and referral process: Individuals can be referred to the program through a variety of sources, including defense attorneys (who referred 55 percent of cases), competency proceedings (15 percent), the district attorney (25 percent), and other judges (5 percent). The following protocols were developed:
    • Referrals from competency proceedings: People whose competence to stand trial has been put into question can be referred to the court after having been found competent, or having been treated and deemed to be competent, in a competency proceeding. Defendants found to be fit or restored to fitness with appropriate charges can be put on the court's calendar for assessment (to determine eligibility for the program) by the clerk’s office, without the need for approval from the judge.
    • Referrals from judges, defense attorneys, and other court parties: For cases in another part of the court, the judge, defense attorney, or prosecutor can refer the case to the court for screening and assessment.
  • Screening and review: All nonviolent felony and misdemeanor cases that are referred to the mental health court are evaluated for eligibility; in violent felony cases, the assistant district attorney has the right to "veto" this initial evaluation and prevent the case from going to the court. For all cases that are referred for evaluation of eligibility, a thorough mental health assessment is conducted as a part of the determination of clinical eligibility for the program, as outlined below:
    • Defendant consent to evaluation: All defendants must formally consent to being evaluated.
    • Psychosocial evaluation: A psychosocial evaluation is conducted by a court social worker.
    • Psychiatric evaluation: A psychiatric evaluation is conducted by a psychiatrist under contract with the court.
    • Summaries: Written summaries of each part of the evaluation are provided to the court judge, the prosecutor, and the defense attorney.
    • Unilateral right to reject: To protect public safety, the court judge and the prosecutor (assistant district attorney) each has the unilateral right to reject any case, even if the individual is deemed to be eligible for the mental health court.
    • Defendant consent to participation in the court: All defendants who are approved for the program must formally consent to participate. This consent is given after the program's requirements are fully explained to the defendant, including the treatment and monitoring protocols and the consequences associated with noncompliance with court requirements.
  • Enrollment: Overall, roughly one-half of the individuals who are referred to the court for evaluation ultimately enroll as participants in the program. As of December 2011, the median number of days from first court appearance to eligibility determination for all applicants was 28 days, with a mean of 40 days. Determinations for those found to be ineligible for the program are often quicker than for those found to be eligible, because many ineligible individuals quickly express a lack of interest in the program, have mental health conditions that exclude them from qualifying, and/or have other relatively easily identifiable issues that preclude participation.
  • Pleas and treatment: As a condition of participation, all participants agree to plead guilty to the charges against them and to remain under court supervision for a specified period of time as an alternative to incarceration: 12 to 18 months for first-time felony offenders, 18 to 24 months for predicate felony offenders (those with at least one prior felony conviction), and 12 months for misdemeanor offenders. During this time, participants are linked to community-based services based on individualized treatment plans that may include mental health treatment, substance abuse treatment (or integrated treatment) for those with co-occurring mental health and substance abuse disorders, case management services, and housing support services. There are four phases to each treatment regimen—adjustment, treatment, progress, and continued progress/preparing to graduate. The first phase lasts 3 months, with other phases lasting 3 months or longer as appropriate for the treatment regimen being used. Certificates are awarded at the completion of each phase as a positive reinforcement to participants. 
  • Ongoing clinical and judicial monitoring: All participants are monitored regularly by the court judge and a dedicated clinical team. Once a defendant becomes a participant, the mental health clinical team meets with him or her on a regular basis (including after court appearances) and also receives weekly updates from providers. The team may also be in contact with participants and providers via telephone, onsite visits, and/or courtroom visits on an as-needed basis, including nights and weekends. The clinical director makes recommendations to the judge related to responses, including the issuance of phase certificates, to progress and problems in treatment engagement. The participants appear in court before the judge every week for the first 2 to 3 months of the program, then monthly thereafter (unless a different time interval is required by the judge). During these sessions, the judge inquires about treatment progress and setbacks, family, hobbies, and goals. The judge praises participants who demonstrate a commitment to engage in treatment and make progress toward a stable, law-abiding life, while admonishes those who do not comply with the requirements of the court program. Changes in the treatment plan are made as necessary to meet participants' clinical needs and improve engagement in services. 
  • Graduation: Those individuals who successfully comply with their individualized treatment plans for the period they are under court supervision are eligible to "graduate" from the program. To graduate, a participant must successfully pass through all phases of treatment and should not commit any additional offenses (although committing an offense is not automatically grounds for termination; the judge decides whether to terminate based on the nature and severity of the offense and other considerations). All charges against misdemeanor and nonviolent felony offenders are dropped; felony charges for violent first-time offenders and repeat offenders are reduced to a misdemeanor. Those who do not complete the program are terminated from it and sentenced to a predetermined amount of time in jail or prison. As of December 2011, 483 of the first 788 participants had graduated, whereas 127 had failed to graduate and were sentenced to jail time.

Context of the Innovation

The impetus for the court began with a year-long study undertaken by the Center for Court Innovation, a public–private partnership sponsored by the New York State Unified Court System and the Fund for the City of New York. This study examined the challenges faced by offenders with mental illness, current court-based approaches to overcoming these challenges, and areas of concern regarding mental health courts. The report laid out a framework for the planning team involved in developing the mental health court.

Did It Work?

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Results

Brooklyn Mental Health Court Results
Preliminary evidence suggests that the court has been successful in reducing recidivism, homelessness, psychiatric hospitalizations, and frequency and current use of alcohol and drugs, although not all of these findings are statistically significant. During the first few years of operation, the court handled roughly 45 cases per year. The volume is now up to 90 to 100 new participants per year. An outcome analysis of the first 37 participants has found that the program has had a generally positive impact on outcomes1:
  • Reduced recidivism: Twenty-seven percent of participants were arrested at least once in the 12 months before enrollment, compared with 16 percent being arrested in the first 12 months of program participation. Although suggestive of an improvement, this finding was not statistically significant.
  • Reduced homelessness: Sixteen percent of participants were homeless in the 12 months before participating in the program, compared with 11 percent who were homeless in the first 12 months of participation. The number of homeless days declined from 60 to 35 over the same time period. Neither of these findings was statistically significant.
  • Fewer psychiatric hospitalizations: The percentage of individuals hospitalized fell from 50 percent to 19 percent, the percentage visiting a psychiatric emergency room fell from 44 percent to 25 percent, and the average number of psychiatric hospitalizations fell from 0.58 to 0.27. The decline in the percentage of individuals hospitalized was a statistically significant finding.
  • Improved psychosocial functioning: Participants showed statistically significant improvement on scales measuring cognition problems, depressed moods, living conditions, and occupations and activities.
  • Less alcohol and drug use: The percentage of participants who are currently not using drugs or alcohol and the percentage not using them in the previous 6 months increased after participation in the program. These findings were statistically significant.
  • Positive perceptions: Interviews suggest that participants perceive the court experience to be a positive one, that they do not feel coerced into participating, and that they believe the program is fair and just.
  • Further evaluation under way: The Urban Institute is currently conducting a more comprehensive evaluation of the outcomes from the court.
Results From Other Settings
A handful of studies show promising results for mental health court participants as compared with similar individuals not participating in the court, including reductions in recidivism and violence, and improved psychosocial functioning.2-6 A quasi-experimental study of four mental health courts was published in 2010, documenting lower re-arrest rates and fewer days of incarceration for mental health court participants compared to treatment-as-usual controls.7

Evidence Rating (What is this?)

Moderate: The evidence primarily consists of a comparison of key outcomes for the 12 months before and after participation in the program by 37 users of the system.

How They Did It

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Planning and Development Process

Planning for the court began in April 2001 and lasted for roughly a year. Key steps in the process are outlined below:
  • Recruitment of a project director: A project director was hired in April 2001. A lawyer by training, this individual had no formal experience in mental health or the criminal justice system but did have extensive experience in bringing together disparate stakeholders into a collaborative planning process. The project director’s role was a temporary one, designed primarily to get the court up and running. Her main job was to guide multiple stakeholders through a consensus process that resulted in the development of formal protocols related to the court, including eligibility requirements, treatment plans, and judicial and clinical monitoring systems. Once these protocols were established, the role of project director became less important. After the court had been fully operational for a year, the clinical director took over the project director's role (while remaining responsible for all clinical functions of the court).
  • Stakeholder outreach: During the spring of 2001, the project director reached out to key stakeholders to explain the proposed initiative, discuss potential challenges and obstacles, and garner general support. This process relied heavily on one-on-one meetings rather than the formation of an overarching committee. Key stakeholders contacted included, but were not limited to, the following: the King's County District Attorney's Office, the New York State Office of Mental Health, the New York City Department of Health and Mental Health, and public defender agencies.
  • Monthly meetings: The project director met with city and state officials on a monthly basis to discuss eligibility criteria, service utilization, and access to residential treatment services and housing for participants.
  • Multistakeholder planning meetings: Two large planning meetings were held with relevant stakeholders during the 12-month period before the launch of the court.
  • Legal committee: A dedicated committee reviewed and came up with strategies to address the legal issues related to the initiative. This committee met five times, including two training sessions on mental health.
  • The court judge: In the summer of 2001, the Honorable Matthew D'Emic was appointed as the first court judge. This individual had extensive experience with the Brooklyn Felony Domestic Violence Court and was regarded by key stakeholders as being fair and having the appropriate demeanor for the position.
  • Clinical director, provider partnerships: The court hired a full-time clinical director to oversee day-to-day court operations in January 2002. This individual’s first job was to spend several months reaching out to mental health providers in Brooklyn and other boroughs in an effort to introduce the program and garner their support for it. Key issues discussed included housing, case management, substance abuse treatment, and mental health treatment. An evaluation of the planning process found that the providers appreciated the opportunity to meet with the clinical director before receiving referrals from the program.
  • Finalizing eligibility criteria, treatment mandates: In February 2002, key stakeholders forged a consensus on the eligibility and treatment requirements for the program.
  • Development of documents laying out requirements, policies, and procedures: To guard against participants feeling coerced into entering the program, the court staff developed a series of public documents that lay out the responsibilities of participants and the policies and procedures of the court.
  • Cross-training of mental health and criminal justice professionals: The court sponsored "cross-training" programs that were designed to educate those in the mental health community about the basic aspects of the criminal justice system and those in the criminal justice system about relevant aspects of mental illness.
    • Training on criminal justice: Sessions for mental health professionals focused the basic processes related to arrest, arraignment, processing, incarceration, and reentry. The court sponsored an "arrest-to-arraignment" tour and other educational sessions in which mental health professionals learned about navigating the criminal justice system, the workings of the mental health court, and their role in that court.
    • Training on mental health: Judges, lawyers, probation officers, and other court personnel attended several half-day and lunch-and-learn sessions where they learned from psychiatrists and others about mental illness and what it is like for patients and family members to live with mental illness. Sessions focused on those aspects of mental illness that are most relevant for the courts, including what behaviors mentally ill individuals might display in the court room, the prospects for treatment (e.g., what is and is not achievable), the distinctions between managing mental illness (which is a biochemical process) and alcohol/substance abuse addictions, and the role of medications and their side effects.

Resources Used and Skills Needed

  • Staffing: The court has been fortunate to secure funding to support the hiring of a full-time project director/clinical director, social worker, and three full-time forensic coordinators. A part-time psychiatrist (who is under contract) and resource coordinator also support the program, along with the judge, the district attorney, two agencies that provide defense attorneys for most participants, and other court staff. It is important to note, however, that the court represents a "resource-rich" model that need not be replicated by other mental health courts. In fact, other courts have been able to get by with fewer dedicated resources, often "borrowing" resources from other stakeholders who have a vested interest in the court succeeding. For example, in some communities, county governments have reallocated resources and/or funding from the budget for prisons (e.g., reassigning and/or sharing individuals involved in evaluating the mental health of prisoners), with the hope that investing resources in a mental health court will result in fewer first-time incarcerations of mentally ill individuals (who need treatment rather than prison time) and reduced recidivism, thus reducing long-term prison costs.
  • Computer database: A database has been developed to track relevant information on program participants. This database has gone through several iterations to increase its value as a data-collection tool. This data is used to monitor performance indicators and provide activity reports for stakeholders. It is also used to explore questions about categories of candidates and participants that may inform practice and policymaking in the court.
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Funding Sources

U.S. Department of Justice; New York State Office of Mental Health; New York State Unified Court System
  • The New York State Office of Mental Health provided funding both for ongoing operations and for evaluation of both the process and outcomes from the program.
  • The planning and startup phase was supported by the New York City block grant from the Temporary Assistance for Needy Families program and three private foundations—the New York Community Trust, the United Hospital Fund, and the Ittleson Foundation. The Temporary Assistance for Needy Families grant expired in 2004.
  • The New York State Unified Court System provides standard courtroom support, including paying for the judge, court clerk, court officers, court attorney, and a part-time resource coordinator. The Unified Court System also assumed the salaries of the three forensic coordinators when the Temporary Assistance for Needy Families grant expired.
  • After the first year, Brooklyn Mental Health Court received a grant from the U.S. Department of Justice’s Bureau of Justice Assistance Mental Health Courts Program.
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Tools and Other Resources

The Council of State Governments is under contract with the Federal government to provide technical assistance to those involved in developing mental health courts. More information, including a variety of tools and resources, can be found at http://consensusproject.org/resources.

Articles that review the use of mental health courts in other settings are listed below:
  • Mentally Ill Offender Crime Reduction (MIOCR) grant program: Butte County Forensic Resource Team (FOREST) final program report. Gary Bess Associates, 2004.
  • Cosden MC, Ellens J, Schnell J, et al. Efficacy of a mental health treatment court with assertive community treatment. Behav Sci Law. 2005;23(2):199-214. [PubMed]
  • Christy A, Poythress NG, Boothroyd RA, et al. Evaluating the efficiency and community safety goals of the Broward County Mental Health Court. Behav Sci Law. 2005;23(2):227-43. [PubMed]
  • McNeil DE, Binder RL. Effectiveness of a mental health court in reducing criminal recidivism and violence. Am J Psychiatry. 2007;64(9):1395-1403. [PubMed]
  • Moore ME, Hiday VA. Mental health court outcomes: a comparison of re-arrest and re-arrest severity between mental health court and traditional court participants. Law Hum Behav. 2006;30(6):659-74. [PubMed]
  • Trupin E, Richards H. Seattle’s mental health courts: early indicators of effectiveness. Int J Law Psychiatry. 2003;26(1):33-53. [PubMed]
  • Steadman, HJ, Redlich, A, Callahan, L, et al. Effect of mental health courts on arrests and jail days. Archives of General Psychiatry, October 4, 2010. 

Adoption Considerations

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Getting Started with This Innovation

  • Clarify requirements: Make clear to would-be participants the requirements of participation and effects of noncompliance with court requirements, including the consequences of taking a guilty plea and of not adhering to the court's medication, treatment, and monitoring requirements. As noted, the court has developed public documents that outline the court’s requirements, policies, and procedures.
  • Engage stakeholders: Reach out to relevant stakeholders in a collaborative process that is designed to educate them about the potential benefits of a mental health court.
  • Seek funding: Tap relevant stakeholders for funding and/or other resources to support the court. Often, it will be in the financial interest of other departments (e.g., jails and prisons) to support the mental health court, because a well-functioning court can reduce costs elsewhere in the system.

Sustaining This Innovation

  • Leverage experience: Tap into experience and creativity when developing and executing treatment plans. Such skills are necessary given the capacity constraints that often exist within the provider community, particularly for residential-based treatment services.
  • Develop communication pathways: Develop formal means of communication across the mental health court team. Brooklyn Mental Health Court initially relied heavily on key personnel, such as the project director and judge, creating the potential for communication to be stifled if a key individual were to leave the program.
  • Meet on an ongoing basis: Hold periodic meetings between community-based providers and the mental health court team. These meetings can provide an opportunity to thank the providers for their participation and allow them to provide feedback on the program to the Brooklyn Mental Health Court judge and team.
  • Facilitate data collection: Streamline data collection efforts so that team members are not overwhelmed by the documentation requirements. Collecting data on a core group of variables can help to reduce the data collection burden and the amount of missing data.

Use By Other Organizations

  • The Council of State Governments Justice Center estimates that there are approximately 275 to 300 mental health courts in approximately 40 states as of early 2012, with more in the planning stages. There were 26 mental health courts in New York State as of early 2012.

More Information

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Contact the Innovator

Carol Fisler, JD
Director, Mental Health Court Programs
Center for Court Innovation
520 Eighth Avenue
New York, NY 10018
(646) 386-4466
E-mail: fislerc@courtinnovation.org

Innovator Disclosures

Ms. Fisler has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Almquist L, Dodd E. Mental Health Courts: A Guide to Research-Informed Policy and Practice. New York: Council of State Governments Justice Center; 2009.

O'Keefe K. The Brooklyn Mental Health Court Evaluation: planning, implementation, courtroom dynamics, participant outcomes. Center for Court Innovation; September 2006. Available at: http://www.courtinnovation.org/_uploads/documents/BMHCevaluation.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader┬« software External Web Site Policy.)

Fisler C. Building trust and managing risk: a look at a Felony Mental Health Court. Psychology, Public Policy, and Law. 2005;(11):587-604. Available at: http://www.courtinnovation.org/_uploads/documents/buildingtrust.pdf

Christy, A, Poythress, NG, Petrila, J, et al. Evaluating the efficiency and community safety goals of the Broward County mental health court. Behav Sci Law. 2005;23:227-403. [PubMed]

Steadman, HJ, Redlich, A, Callahan, L, et al. Effect of mental health courts on arrests and jail days. Archives of General Psychiatry, October 4, 2010. [PubMed]

Footnotes

1 O'Keefe K. The Brooklyn Mental Health Court Evaluation: planning, implementation, courtroom dynamics, participant outcomes. Center for Court Innovation; September 2006. Available at: http://www.courtinnovation.org/_uploads/documents/BMHCevaluation.pdf
2 Mentally Ill Offender Crime Reduction (MIOCR) grant program: Butte County Forensic Resource Team (FOREST) final program report. Gary Bess Associates; 2004.
3 Cosden, MC, Ellens J, Schnell J, et al. Efficacy of a mental health treatment court with assertive community treatment. Behav Sci Law. 2005;23(2):199-214. [PubMed]
4 McNeil DE, Binder RL. Effectiveness of a mental health court in reducing criminal recidivism and violence. Am J Psychiatry. 2007;164(9):1395-1403. [PubMed]
5 Moore ME, Hiday VA. Mental health court outcomes: a comparison of re-arrest and re-arrest severity between mental health court and traditional court participants. Law Hum Behav. 2006;30(6):659-74. [PubMed]
6 Trupin E, Richards H. Seattle's mental health courts: early indicators of effectiveness. Int J Law Psychiatry. 2003;26(1):33-53. [PubMed]
7 Steadman HJ, Redlich A, Callahan L, et al. Effect of mental health courts on arrests and jail days. Archives of General Psychiatry, October 4, 2010. [PubMed] Available at: http://archpsyc.jamanetwork.com/article.aspx?articleid=211027
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Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 29, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 30, 2012.
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