Mental Health Court Study the

¶ … Mental Health Court Study The study examines the outcomes of mental health courts in the treatment of mentally challenged people in the criminal justice system. The study is looks at the particular outcomes of cases which the Court has diverted from the criminal justice system to various social services agencies and institutions. It measures outcomes based on the rate of Criminal Recidivism and Quality of Life, but also yields important conclusions about overall program quality. Mental health courts are alternative courts for mentally disordered individuals charged with committing a crime.

They allow a judge the option of ordering punishment through the criminal justice system or treatment through the behavioral health system. Mental health courts are needed because criminal offenders with mental health problems are traditionally "alienated by both the justice system and the increasingly debilitated and diluted mental healthcare system.

According to the Alaska Mental Health Trust Authority, a "1997 study indicated that up to 37% of persons in custody or under supervision of the Department of Corrections suffers from a mental illness -- 12% with major psychiatric disorders." Mental health courts are relatively new and occupy a very important position at the junction of mental health treatment and criminal justice. The growth and expansion of mental health court programs has spawned a great deal of interest among policy makers and community stakeholders.

The costs of treating mental health-related crime for the State of Alaska is The stakeholders here are the mental health patients, their families, the general public, taxpayers, and the various state institutions and social services agencies. These institutions include the court system, correctional facilities and public health care facilities. The agencies include social service agencies and substance abuse programs. Today, the broader and sustained impact of these programs on the criminal justice system and on the individuals participating in these programs is just starting to be explored.

This study is one such exploration, and its results will reveal much about alternative responses to mental health-related crime. Background The study used four different techniques for gathering data. These included both quantitative and qualitative techniques. It also obtained information from several different sources. Interviews with Program Participants In-depth, semi-structured interviews with former participants of the Anchorage Coordinated Resources Project (ACRP). In addition, a retrospective, pre-post design was employed in a number of interviews that were conducted with former CRP participants so as to gather various quality-of-life outcomes.

Interviews with former participants also included a number of questions about their experience with the program, recommendations for improvement and their insights into reasons behind successful and unsuccessful outcomes. In all, a total of 29 people were interviewed, of which three were excluded because they had no recollection of ever being involved in the ACRP, or the court itself. Interviews with Program Stakeholders An extensive array of interviews conducted with key stakeholders both directly and indirectly involved with the program.

Responses from 40 key stakeholder interviews provided the study with insight into how the ACRP works within the general context of the criminal justice and behavioral health systems. These interviews yielded recommendations for ACRP improvement and provided additional perspective in interpreting outcomes. The observational methodology employed to document the overall content and organization of the ACRP rounds out the series of methods employed in the study. In all, HZA observed a total of seven ACRP status hearings with each of the two ACRP judges presiding.

Structured Observations of Program Operations The study relied on observations of program operations both to obtain general background information about the program as well as to compare the program with similar programs around the country. The ACRP shares important basic similarities with other mental health courts.

These include 1) a specialized court docket employing a therapeutic approach to criminal case processing for people who experience mental illness; 2) voluntary participation requirements and freedom to withdraw; 3) individually tailored community-based treatment plans; 4) follow-up care and hearings with each participant at which time his or her treatment plan and other conditions of participation are reviewed; 5) incentives and sanctions based on participant progress; and, 6) some termination point at which a participant will either successfully complete the program and graduate or withdraw from the program and return to the regular court for traditional criminal case processing.

Mental health courts, though, tend to vary in regards to their operations. This is because mental health courts are fairly new and their operations have not yet been standardized by any regulatory body. However, the Bureau of Justice Assistance has developed best-practice guidelines for mental health court programs. This study analyzed the operations of the ACRP according to the Bureau of Justice Assistance guidelines contained in the publication entitled: Improving Responses to People with Mental Illnesses: The Essential Elements of a Mental Health Court.

Data Analysis The study analyzed administrative data from various criminal justice health and human services agencies to determine the level of Criminal Recidivism, a key benchmark of program effectiveness. It obtained data from a number of relevant departments. The study used two different quasi-experimental techniques are to assess the effectiveness of the ACRP from the sources of administrative data mentioned above.

The first technique involved a pre-post design where differences in clinical and criminal recidivism outcomes are compared for four groups of people exiting the ACRP at various stages or levels of involvement (referral, initial opt-in, formal opt-in and graduates). The second technique involved a matched-pair design where both criminal and clinical recidivism outcomes are compared between a sample of 218 ACRP discharged participants (e.g., graduates, formal opt-outs) with an equivalent group of people with mental illness who were not referred to the ACRP.

The comparison group was constructed using the abovementioned data sources and matched on a number of variables including date of exit, correctional institution status, gender, mental health diagnosis, age and race. Results Criminal Recidivism Of particular interest to criminal justice institutions and for public safety are the study's findings that participants in the ACRP had reduced levels of Criminal Recidivism as compared to non-participants.

The one year post-discharge recidivism rate for all ACRP participants formally opting into the program is 39%, which compares very favorably against a matched comparison group of similarly-situated offenders who were not referred to the ACRP (47%). Among those discharged from the ACRP, program graduates were least likely to re-offend overall (30%). Among those who did engage in new criminal conduct, ACRP participants were less likely to commit new felonies, violent or drug related crimes.

Hence, diversion of people with mental illness from incarceration into the ACRP poses less of a risk to public safety than traditional adjudication.

Of particular interest to mental health court judges are the study's findings that "There is a significantly higher rate of program completion for participants in the ACRP Jail Alternative Services (JAS) Program track compared to participants in the Alaska Alcohol Safety Action Program track (ASAP)." Cost-Effectiveness of Program The study found that the "fewer incarcerations, psychiatric hospital visits and reductions in the length of stay between both institutional settings "generated a net savings for the ACRP both over time as well as against a comparison group ($97,685)." For the State of Alaska as a whole, the "combined institutional savings generated by the ACRP ($705,390) is estimated to be almost two and one-half times the annual operational costs of the program ($293,000)." General Program Quality Case Coordinators The study found that ACRP was lacking sufficient case coordinators, who are responsible for assisting the ACRP in determining a defendant's clinical eligibility and developing individualized treatment plans.

Over the past year, the number of ACRP participants assigned to both case coordinators was either at or exceeding the stated operational capacity of the program. Also, interviews with participants, key stakeholders as well as observations of ACRP operations revealed the need for an additional case coordinator so as to both reduce caseloads and expand the overall operational capacity of the program.

Catchment Area The study found that the catchment area in the municipality of Anchorage, with 280,000 had a comparable rate of violent crime, a lower rate of property crime, and a higher rate of sexual assaults. Intended Target Population The study assessed whether or not the ACRP is meeting its intended target population by comparing the clinical characteristics among those who were referred to the ACRP with others who matriculated through the program at various other levels of programmatic involvement (e.g., initial opt-in, formal opt-in, graduates).

Another indication that the program is enrolling its intended target population is to examine those with only substance-related disorders. These are defendants who may be more appropriately served by the Anchorage Wellness Court which offers a specialized track for misdemeanor defendants whose primary problem is substance abuse as opposed to mental illness. In sum, while the ACRP is meeting its intended target population, it is returning to regular court a high volume of participants with co-occurring disorders.

While admirable, the program is taking on some very difficult cases whose service needs likely extend beyond that which the ACRP is able to provide, given the resources that currently exist in the community. Nonetheless, people who received some level of ACRP intervention had a lower rate of criminal recidivism than people who received no intervention at all. System Flow The study found that the case flow through the ACRP was a little slow. The amount of time between the Initial Opt-In Hearing and the Formal Opt-In Hearing averaged 74 days.

While there are no hard and fast rules governing how long this process should take, the study found that that "the ACRP is performing rather well on the front-end of the admissions process (up to the initial opt-in stage) but that more could be done to work on the back end (time between the Initial Opt-In Hearing and the Formal Opt-In Hearing)." Status Hearings The study found that the incentives and sanctions used by ACRP judges to promote compliance at status hearings, though standardized, were not tailored to correspond to participant progress.

Also, the sanctions appeared to be somewhat arbitrary, depending on the judges' personality a times.

The study stated that "Although difficult to quantify, anecdotally, one appeared more reserved whereas the other seemed more charismatic; one tended to be more punitive, the other a little more assertive." Cross-Systems Integration The goal of any mental health court is move along a continuum from basic implementation (requiring judicial leadership) to integration (forging partnerships) with the criminal justice, behavioral health and service delivery systems, and finally to institutionalization (interwoven into the fabric of a community).

The study found that, long this continuum, the ACRP is not quite there yet but it has come a long way since its inception. It has made significant strides in forging partnerships and building relationships with a vast array of key stakeholders in the Anchorage community who have an important impact on the program as well as the people it serves. Analysis Critique Qualitative data, such as interviews with participants, is highly valuable in obtaining data for Quality of Life outcomes.

Quality of Life is highly subjective and hard to measure. The most common, and perhaps reasonable, method is to ask the subject about its Quality of Life. Although in most cases, the only way to determine Quality of Life outcomes is to ask the subject itself, the nature of the subject matter with mental health patients presents certain difficulties. There is always some risk of unreliability with data gained from self-reporting. Here, those risks are exacerbated.

First, mental health patients are more likely than the average person to misperceive his or her own mental states, emotions, or condition. Second, these mental health patients are or were at risk of re-institutionalization if their progress does not meet treatment program standards. Thus, they might have misrepresented their progress and general Quality of Life as more positive than it actually was. Although interviews with stakeholders do not reveal much about the two major outcomes, Quality of Life and Criminal Recidivism, but were valuable for determining overall program health.

The participants have expertise in the field and incentive to providing helpful information. Thus, the participant's responses were effective for determining overall institutional health and for obtaining suggestions and recommendations for improvement. The data gained from interviews with stakeholders about.