Mental Health Courts: An Effective Alternative to Incarceration

One way to decrease the number of mentally ill people who are incarcerated is through diversion programs such as collaborative courts where defendants are offered treatment as an alternative to incarceration.

In October, while attending the annual meeting of the American Academy of Psychiatry and the Law, other forensic psychiatrists and I visited the mental health court in Broward County, Fla. Established in 1997, it was one of the first mental health courts in the United States. Judge Ginger Lerner-Wren is a dynamic, energetic judge who has presided over the court since its inception. In the court session I attended, she heard from seven clients who had been arrested for crimes such as disturbing the peace, trespassing, assault on police officers, solicitation for prostitution, and petty theft. All of the clients had a mental disorder diagnosis, and most had a co-occurring substance use disorder.

Although Judge Lerner-Wren wore her black robe, she interacted with her clients in a supportive rather than judgmental manner. She made comments about one client’s new attractive hair color and about the stylish jeans of another. She said she aims to “build trust,” “build self-esteem,” and “restore their personhood.” One of the clients was struggling with maintaining sobriety and had stopped attending her dual-diagnosis program. “I know this whole process is not easy,” Judge Lerner-Wren told her. “I want to appeal to you. Hang in there.” When a client was doing well, everyone in the courtroom applauded.

Mental health courts are an example of a postbooking diversion program that diverts a person with mental illness who has been arrested from jail to treatment programs. Participation is voluntary, in the sense that the individual can decline to participate and choose to remain in the traditional court system. If individuals agree to participate, they are linked to services such as case management, therapy, psychotropic medications, substance abuse treatment, and housing.

Mental health courts take a therapeutically oriented approach. They intervene when mentally ill patients have failed community institutions and services. They use a harm-reduction model and try to facilitate treatment adherence. There are now over 300 mental health courts in the United States and the number continues to grow.

An example of another mental health court is the San Francisco Behavioral Health Court (BHC), established in 2002. In the SF BHC, there is a morning conference with the judge; the district attorney; representatives from the public defender’s office, jail psychiatric services, probation services; case-management services; and community treatment providers. As in Broward County, the courtroom is open, and the judge speaks directly to clients. Eligibility is based on having a mental illness that is connected to the offense. BHC participants follow a judicially supervised treatment plan that is individualized for each client. Participants attend status hearings, in which the judge may apply various incentives and/or sanctions to encourage adherence to the treatment plan. Incentives may include encouragement and praise from the judge, less restrictive treatment, and eventual reduction or dismissal of the original charges upon graduation from BHC. The SF BHC also uses sanctions. These include admonishment or reprimands from the judge, community service work, increased frequency of court appearances or intensity of treatment, and, most significantly, termination of BHC and return to regular criminal court for adjudication.

Does the mental health court model work? My coauthors and I have done several studies evaluating the BHC in San Francisco (see resources listed at the end of this article). In one retrospective study, we found that when compared with other mentally ill inmates, participants in the mental health court reduced their probability of a new criminal charge by 26 percent and reduced the probability of a new violent criminal charge by 55 percent. In a more recent prospective study, we found that during follow-up, 25 percent of the mental health court group perpetrated violence compared with 42 percent of the control group.

Mr. A (a composite case) is an example of a successful outcome. When he entered mental health court, he was a 45-year-old man who had a diagnosis of schizophrenia and crack cocaine dependence. He had been homeless for years and rarely took his psychotropic medications. He had a long history of arrest going back to his teenage years and had been sentenced to three state prison terms and had three extended stays at state hospitals. Mr. A was on probation for a felony and had four open felony drug cases. His treatment plan included participation in mental health and substance abuse treatment, working with a case manager, staying away from substance-abusing peers, and being regularly monitored by the court.

After he became clean and sober and more stable with his antipsychotic medications, he was linked to supportive housing and a supported-employment program. As Mr. A achieved stabilization, he was able to graduate from mental health court. Over time, his charges were dismissed, one by one. Mr. A has not been arrested since entering mental health court three years ago, which is the longest time he has gone without being arrested in decades. In addition, Mr. A has obtained work as a custodian.

There are other specialty courts, including drug courts and veterans courts. The latter link veterans to services within the VA system. These types of courts represent one way of sending people who live with mental illness for treatment instead of to jails and prisons. As Judge Lerner-Wren said, “I want to give a message of hope and support.” ■