A Guide to

Mental Health Court

Design and Implementation

BJAmental

health

courts

program
The Council of State Governments (CSG) is a nonprofit, 

nonpartisan organization that serves all three branches of 

state government. Founded in 1933, CSG has a long history 

of providing state leaders with the resources to develop and 

implement effective public policy and programs. Owing to 

its regional structure and its constituency—which includes 

state legislators, judges, and executive branch officials—

CSG is a unique organization. Comparable associations operate only on a national level and target one branch of state 

government exclusively.

 The development of this guide was overseen by staff of 

the Criminal Justice Program of CSG’s Eastern Office, which 

also coordinates the Criminal Justice/Mental Health Consensus Project.

About the Council of State Governments

Coordinated by the Council of State Governments (CSG), 

the Criminal Justice/Mental Health Consensus Project is an 

unprecedented national effort to improve the response to 

people with mental illnesses who become involved in, or are 

at risk of involvement in, the criminal justice system. The 

landmark Consensus Project Report, which was authored 

by CSG and representatives of leading criminal justice and 

mental health organizations, was released in June 2002. 

Since then, the Consensus Project has continued to promote 

practical, flexible approaches to this issue through presentations, technical assistance, and information dissemination. 

This includes providing technical assistance to the Bureau of 

Justice Assistance Mental Health Courts Program.

About the Criminal Justice/Mental Health Consensus Project 

The Office of Justice Programs, US. Department of Justice, 

was created in 1984 to provide federal leadership in developing the nation’s capacity to prevent and control crime, 

administer justice, and assist crime victims. OJP carries out 

this mission by forming partnerships with other federal, 

state, and local agencies, as well as national and communitybased organizations. OJP is dedicated to comprehensive 

approaches that empower communities to address crime, 

break the cycle of substance abuse and crime, combat family 

violence, address youth crime, hold offenders accountable, 

protect and support crime victims, enhance law enforcement initiatives, and support advancements in adjudication. 

OJP also works to reduce crime in Indian Country, enhance 

technology’s use within the criminal and juvenile justice systems, and support state and local efforts through technical 

assistance and training. www.ojp.usdoj.gov

About the Office of Justice Programs (OJP) 

The Bureau of Justice Assistance (BJA), Office of Justice 

Programs, U.S. Department of Justice, supports law enforcement, courts, corrections, treatment, victim services, 

technology, and prevention initiatives that strengthen the 

nation’s criminal justice system. BJA provides leadership, services, and funding to America’s communities by emphasizing 

local control; building relationships in the field; developing 

collaborations and partnerships; promoting capacity building through planning; streamlining the administration of 

grants; increasing training and technical assistance; creating 

accountability of projects; encouraging innovation; and

ultimately communicating the value of justice efforts to

decisionmakers at every level. www.ojp.usdoj.gov/BJA/

About the Bureau of Justice Assistance (BJA) 

A Guide to Mental Health Court

Design and Implementation

A publication of the Council of State Governments,

prepared for the Bureau of Justice Assistance
A Guide to

Mental Health Court 

Design and Implementation

The Council of State Governments

May 2005
Several authors contributed to the content of this guide. 

Alan Henry developed an early draft, Daniel Souweine made 

substantial additions, and Kelly Dedel Johnson offered constructive revisions and managed the editing and process. 

In addition to the authors, many people and organizations helped make this guide possible. CSG thanks the Bureau of Justice Assistance for its support, and recognizes the 

guidance and input of Michael Guerriere, Senior Policy Advisor for Substance Abuse and Mental Health, who served as 

the grant manager for this project. CSG is continually grateful 

for the ongoing leadership of Representative Michael Lawlor 

(Connecticut) and Senator Robert Thompson (Pennsylvania), 

co-chairs of the Criminal Justice/Mental Health Consensus 

Project, who have guided CSG’s work in this field. 

CSG also thanks the representatives of mental health 

courts across the country, particularly those that received 

BJA funding. These courts graciously provided information 

about their activities, accommodated site visits, and shared 

their insights. Their experience and expertise added depth 

and dimension to this guide.

CSG used a peer review process to ensure the relevance 

and usefulness of this guide. Vicki Downing, Barry Mahoney, 

E.J. Maldonado, Judge Stephanie Rhoades, and Dr. Erik Roskes contributed valuable time, proposed text, recommended 

resources, and offered suggestions on matters of format and 

style. Their input resulted in substantive improvements to 

the final product.

Amanda Katz copy edited the guide and Dave Williams 

designed its layout.

CSG would like to thank Daniel Souweine, who, using 

extensive knowledge developed through his visits and meetings with numerous mental health court professionals and 

lengthy conversations with a broad array of experts in the 

field, wrote much of this document. Over a 3-year period, 

Daniel’s contributions and leadership were crucial to the 

success of the Consensus Project. CSG is especially grateful 

for Daniel’s commitment to seeing this document through 

to its completion by serving as a consultant to the Consensus 

Project team after his tenure at CSG ended.

Acknowledgements

suggested citation:

Council of State Governments. A Guide to Mental Health Court Design and Implementation.

New York, NY: Council of State Governments, 2005. 

This guide was prepared by the Council of State Governments 

under grant number 2003-DD-BX-K007, awarded by the

Bureau of Justice Assistance, Office of Justice Programs,

U.S. Department of Justice. 

The opinions, findings, and conclusions or recommendations expressed in this guide are those of the authors and 

do not represent the official position or policies of the U.S. 

Department of Justice.
| iii

Contents

iv Executive Summary

xi Introduction

1 STEP I. Understanding the Mental Health Court Concept

9 STEP II. Determining if a Mental Health Court Is Appropriate

22 STEP III. Considering Elements of Mental Health Court Design 

and Implementation

25 1. Goals 

28 2. Target Population

37 3. Confidentiality 

38 4. Terms of Participation 

43 5. Informed and Voluntary Choice

46 6. Participant Identification

52 7. Integration of Treatment and Community Supports

63 8. The Court Team 

67 9. Monitoring Adherence to Court Conditions

77 10. Sustainability 

82 Conclusion

84 Appendices

84 A. 2002–2003 BJA Mental Health Court Program grantees

86 B. Conference of Chief Justices/Conference of State Court Administrators

 Resolution in Support of Problem-Solving Courts

89 C. Sample referral form 

90 D. Sample information release form

91 E. Sample contract for participation

93 References
iv |

Executive Summary

the last five years have witnessed a boom in the development of mental 

health courts. From only a handful of such courts in the late 1990s, there are now 

more than 100 nationwide. With this recent surge, mental health courts are quickly 

becoming the most popular strategy across the country to address the overrepresentation of people with mental illnesses in the criminal justice system. 

Even in their infancy, much has already been written about mental health courts, 

including evaluations of individual courts, analyses of practices across courts, and 

commentaries on the merits of the mental health court concept. This guide attempts 

to build on that substantial body of work by providing a roadmap, based largely on 

the experience of existing mental health courts, for those interested in establishing a 

mental health court in their jurisdiction. 

The guide is organized according to the three basic steps, described below, that 

should be followed by any community considering the establishment a mental health 

court: 

1. Understanding the mental health court concept.

2. Determining whether a mental health court is appropriate 

3. Considering elements of mental health court design and implementation

STEP ONE: UNDERSTANDING THE MENTAL HEALTH COURT CONCEPT

Mental health courts are part of the growing problem-solving court movement, which 

includes drug courts, community courts, domestic violence courts, reentry courts, 

and others. These specialized court dockets replace the traditional adversarial process 

with a focus on addressing the underlying problems that lead to criminal justice involvement. While mental health courts share much in common with other problemsolving courts, important differences have already emerged. For example, despite the 

significant overlap of their target populations (75 percent of offenders with mental 

illnesses have a co-occurring substance abuse disorder) mental health courts and 
| v

drug courts differ in terms of charges accepted, monitoring practices, responses to 

violations, and modes of service delivery. 

Their recent popularity notwithstanding, mental health courts are not the only 

strategy that court systems use to better respond to defendants with mental illnesses. 

In fact, mental health courts are closely related to specialized pretrial release programs, court-based diversion programs, and dedicated probation caseloads for people 

with mental illnesses. What differentiates mental health courts from these other approaches are their use of a specialized docket and their regular, judicially supervised, 

team-based approach to monitoring participants’ treatment and adherence to court 

conditions. This difference is not trivial—there are important philosophical and practical distinctions between mental health courts and the other court-based strategies 

mentioned above. Nevertheless, much in this guide is relevant to court-based efforts 

that do not fit the description of a mental health court. 

Among programs that share the “mental health court” label, diversity is the rule. 

The more than 100 mental health courts nationwide differ widely in terms of their 

eligibility criteria, case processing, treatment options, how they dispose of cases upon 

program completion, and in many other ways. Understanding the mental health 

court concept means recognizing that not only are multiple options available for improving the court’s response to defendants with mental illnesses, but also that there 

are numerous ways to design and implement a mental health court. 

Program planners should also be aware of the limited evidence base for mental 

health courts. While these programs show great promise, their long-term viability 

depends on empirically documented results. More research is needed to better understand mental health court processes, to identify the specific categories of defendants 

who benefit the most from a mental health court, and to isolate the components of 

the mental health court model most responsible for its effectiveness. 

STEP TWO: DETERMINING IF A MENTAL HEALTH COURT

IS APPROPRIATE

If understanding the mental health court concept means a step forward, the question 

of whether to establish a mental health court requires a step back. Because mental 

health courts are just one response to the involvement of people with mental illnesses 

in the criminal justice system, key stakeholders in a jurisdiction should analyze the 

dynamics of that problem, and the needs and attributes of their community, before 

determining the appropriateness of a specialized docket. 
vi |

Regardless of where the proposal for a mental health court comes from—a charismatic judge, a mental health advocate, a state legislator, or elsewhere—the full array 

of policymakers and practitioners affected by the involvement of people with mental 

illnesses in the criminal justice system should discuss its viability. This discussion 

should include representatives of criminal justice agencies, mental health and substance abuse treatment providers, mental health and victims’ advocates, and housing and benefits officials, among others. Ideally, this dialogue would be chaired by 

a member of the judiciary, who carries the neutrality of the court and possesses the 

ability to moderate discussions among parties with differing viewpoints and priorities. 

Rather than simply weighing the pros and cons of a mental health court, the 

stakeholder group should consider the full range of problems that occur when people 

with mental illnesses enter the criminal justice system. This assessment should include step-by-step mapping of the way in which individuals with mental illnesses are 

processed, how decisions are made, and how they might be improved. The discussion should be informed by empirical data, which can pinpoint the imperatives of the 

local population and establish baseline measures needed to evaluate the effectiveness 

of whatever response is developed. Stakeholders should also take the time to discuss 

their different priorities, goals, duties, funding mechanisms, and core concerns. 

Establishing common ground in these areas is essential for building the collaboration 

that must underlie any response to the problems at the intersection of the mental 

health and criminal justice systems. 

Through this process, stakeholders in a jurisdiction should answer the following 

questions, among others that arise, before deciding to establish a mental health court. 

• Where on the criminal justice continuum will the community focus?

• If the focus is on a court-based intervention, is a specialized docket the right 

strategy? 

• Is a mental health court the only court-based strategy that will be employed? 

Whatever the answers to these questions, a mental health court will not be a panacea, and should be considered one aspect of a systemic strategy to improve the response to people with mental illnesses across the criminal justice and mental health 

systems, from before arrest to after reentry. 
| vii

STEP THREE: CONSIDERING ELEMENTS OF MENTAL HEALTH COURT

DESIGN AND IMPLEMENTATION

To aid communities that do decide to establish a mental health court, this guide highlights ten elements of mental health court design and implementation. With limited 

research knowledge, and the youth of the mental health court field, it is impossible to 

suggest that there is universal agreement on, or an evidence base to confirm, the importance of these elements. Rather, the guide identifies them as aspects of a mental 

health court that should be considered carefully throughout the planning and operation of the program. The guide does not offer prescriptions about how jurisdictions 

should structure these elements, but rather describes the virtues and drawbacks of 

different approaches to each one. 

To help readers understand the information contained in the guide, the table on 

the following pages identifies the ten elements and some of the questions that the 

guide can help program planners to answer. Ultimately, the path for a particular jurisdiction will be dictated by the characteristics of the local population, the priorities of 

the stakeholders involved, and the available community resources.
viii |

Section

Number

Mental Health 

Court Element Key Questions

1 Goals What are the specific goals for the mental health court: increased public safety, 

increased treatment engagement, improved quality of life, and/or more effective 

use of resources?

How will progress towards these goals be measured? 

2 Target 

Population

Will the court accept defendants charged with misdemeanors, felonies, or both?

Must a relationship between defendants’ mental illnesses and their charges be 

demonstrated? If so, how will that relationship be established?

Will those accused of violent crimes or with a history of violence be eligible for the 

program?

Will the court establish eligibility criteria related to defendants’ criminal histories?

What kind of diagnostic criteria will the court establish?

How will the court coordinate with other programs (such as the drug court)?

3 Confidentiality How will prospective participants be asked to consent to the release of information, and to whom will it be released? 

How will clinical information be handled in open court?

How will federal regulations related to the sharing of mental health and substance 

abuse treatment information affect program design? 

4 Terms of 

Participation

What kind of plea arrangement will the court establish for program participants? 

Will a guilty plea be required? 

How will cases be disposed when participants successfully complete the program? 

What about when participants are unsuccessful?

How often will participants report to the court for status hearings?

How long will the court program last? Will it vary for each individual? If so, what 

will be the basis?

5 Informed and 

Voluntary 

Choice

How will the court ensure prompt assessment of legal competency?

How will the court ensure that defendants are fully informed about the program 

before opting into the court? 

How will the court encourage participant input into treatment plans and other 

conditions?
| ix

Section

Number

Mental Health 

Court Element Key Questions

6 Participant 

Identification

From which agencies or individuals will the court accept referrals?

How will high rates of inappropriate referrals be avoided? 

Who will screen referrals for legal and clinical eligibility?

How will information required for treatment planning be gathered? 

How will the final determination of eligibility be made? Who will have ultimate 

authority to accept participants?

What speed of processing targets will the court set?

7 Integration of 

Treatment and 

Community 

Supports

How will the court determine what kinds of mental health treatment are available 

in the community? How will the court respond to gaps in treatment?

How will the court address the treatment needs of participants with co-occurring 

psychiatric and substance abuse disorders?

How will the court ensure that treatment for court participants does not reduce 

treatment availability for non-court participants?

How will the court make use of peer support services?

How will the court account for the specific treatment needs of women and

minorities? 

How will the court transition participants from court supervision to unsupervised 

treatment? 

8 The Court Team Who will compose the court team? 

How will team members be selected?

What kind of training, both initial and ongoing, will be provided to team members?

How long will staff be assigned to the mental health court program?

9 Monitoring 

Adherence 

to Court 

Conditions

Who will monitor or supervise participants in the community? Will these staff 

have a mental health background (e.g., case managers), a criminal justice background (e.g., probation officers), or will a team approach be used?

Who will manage information about participants’ adherence to court conditions?

Who will attend case staffing meetings during which participants’ progress is 

discussed?

What kind of rewards and incentives will be provided to encourage compliance?
x |

Section

Number

Mental Health 

Court Element Key Questions

continued

9

How will the court determine when to adjust treatment plans and when to apply 

sanctions in response to non-adherence? 

What kinds of sanctions will be applied? When, if at all, will jail be used as a

sanction? 

How will the court resolve differences of opinion about how to best respond to 

violations of court conditions? 

10 Sustainability From what sources will the court obtain long-term funding or resources to

operate? 

When will the court develop written policies and procedures?

Which outcome data will be collected and who will collect them?

How will the court respond to program failures, such as well-publicized new 

crimes committed by program participants?

How will the court educate other agencies and community members about the 

goals and processes of the court?

With the aid of this guide, readers will better understand how mental health courts 

across the country have negotiated the questions above, and will be better prepared to 

develop answers in their own jurisdictions. As with the decision of whether to establish a mental health court, answers to these questions should be based on the input 

of stakeholders throughout the criminal justice, mental health, substance abuse, and 

related systems. Without a strong collaborative base, no mental health court, or any 

program to address the involvement of people with mental illnesses in the criminal 

justice system, can be successful. But by working together, practitioners and policymakers from across these systems have the opportunity to improve the lives of 

individuals with mental illnesses, the functioning of the criminal justice and mental 

health systems, and the health and safety of communities across the country. 

Monitoring 

Adherence

to Court 

Conditions
Introduction

people with mental illnesses are familiar faces in courtrooms across the 

country. Some act strangely, muttering to themselves or to invisible companions; others are distant, eyes cast to the floor, hardly aware of the proceedings taking place before them. Many are disheveled and possibly homeless, with few apparent ties to the 

community. And some appear no different from other defendants, their symptoms 

undetectable during the cursory court process. Most have been booked on low-level 

crimes, often no more than public manifestations of their untreated mental illnesses. 

If the court becomes aware of a defendant’s mental illness, it may evaluate his or 

her legal competency. Beyond the question of competency, most people with mental 

illnesses cycle through the nation’s court systems with little attention paid to their 

conditions. Many will serve short sentences in jail, where the stress of crowding, isolation, and the threat of violence may cause further decompensation. Release to the 

community rarely involves the comprehensive planning needed to ensure connection 

with community treatment providers. All too often, defendants with mental illnesses 

are back before the court shortly after their release. 

Few courts are capable of interceding in this vicious cycle. In cases where community treatment might be preferable to incarceration, the court lacks sufficient information, time, or resources to develop appropriate treatment plans. Further, judges 

diverse people, diverse terminology

Many different terms are used to describe people involved with the mental health system and the criminal 

justice system. In this guide, we have chosen to use 

the following:

• Individual with a mental illness — someone 

with a mental illness.

• Consumer—someone receiving mental health 

treatment.

• Defendant—someone appearing in court after 

being charged with a criminal offense.

• Participant—someone who is participating in a 

mental health court program.

| xi
xii |

and prosecutors, rightfully concerned about public safety, are wary of transferring 

responsibility for these defendants to the mental health system, which appears to 

have had difficulty engaging these people in the first place. 

But in select communities across the country, court officials, mental health advocates, treatment providers, representatives of other criminal justice agencies, and 

consumers have sought to develop court processes and procedures that are more responsive to the needs of defendants with mental illnesses, while continuing to protect 

public safety and ensure the integrity of the court process. Some communities have 

developed court-based diversion programs that do not entail a separate docket; other 

jurisdictions have infused traditional court processes with relevant information about 

the mental health needs of defendants without developing a separate program. And 

some jurisdictions—more than 100 nationwide—have developed specialized dockets, 

or mental health courts, which are the focus of this guide. 

ABOUT THIS GUIDE

This guide helps readers determine whether a mental health court is right for their 

communities, and explains how to design and implement a mental health court that 

both responds to local needs and reflects the knowledge gained from existing mental 

health courts. It is intended for the diverse array of policymakers and practitioners 

who are interested in mental health courts, including judges, mental health advocates, prosecutors, consumers of mental health services, defense attorneys, mental 

health and substance abuse treatment providers, pretrial services administrators, and 

many others. 

The guide is organized according to the three basic steps that should be followed 

by any community considering the establishment a mental health court. Step I—

“Understanding the Mental Health Court Concept”—provides a working definition 

of a mental health court and helps readers understand the origins of mental health 

courts and the status of their development across the country. Step II—“Determining 

if a Mental Health Court is Appropriate”—guides readers in deciding whether or not 

to establish a mental health court in their community. The third and most important 

step—“Considering Elements of Mental Health Court Design and Implementation”— identifies ten key aspects of mental health courts that can help guide planners 

and administrators when establishing a specialized mental health docket. Throughout steps II and III are examples from various jurisdictions around the country. 
| xiii

These examples are included to offer concrete illustrations of how courts have operationalized these elements and put various ideas into practice, and are not intended as 

recommendations or models of “best practices.”

The Council of State Governments (CSG), which provides technical assistance 

to the Mental Health Courts Program of the Bureau of Justice Assistance (BJA), 

published this guide along with three other documents, which are referenced often 

throughout: 

• What Is a Mental Health Court?

• Navigating the Mental Health Maze: A Guide for Court Practitioners

• A Guide to Collecting Mental Health Court Outcome Data 

The first is a basic primer on mental health courts, while the second and third 

documents provide in-depth elaboration on topics of particular concern to mental 

health court practitioners. Readers from the courts or other criminal justice agencies are particularly encouraged to consult Navigating the Mental Health Maze, and to 

work with local mental health providers and advocates to understand the complicated 

dynamics of mental illnesses and their treatment. Mental health courts represent 

an intersection of the criminal justice and mental health systems; as this guide often 

points out, representatives of these systems must understand the nature of each others’ goals, methods, and concerns in order to be effective partners.*

METHODOLOGY

In addition to using reviews of recent research and analysis of mental health courts, 

CSG also relied heavily on information from BJA Mental Health Court Program 

grantees and other mental health courts in the development of this guide. Telephone 

interviews with representatives of each of the 37 BJA grantee courts elicited comprehensive information about the courts’ organization and operation, including the 

number of clients served, composition of the courtroom team, length of the program, 

and plans for sustainability. In addition, CSG responded to requests from grantee 

and non-grantee courts for targeted technical assistance. During the course of these 

responses, CSG staff and consultants obtained first-hand views of the many varieties 

of mental health courts and the complex issues with which they must contend. CSG 

staff and consultants also had the opportunity to visit several mental health courts 

that were not BJA grantees. 

*Mental health 

professionals should 

consider consulting 

a similar publication 

from the TAPA Center 

for Jail Diversion: 

Working with People 

with Mental Illness 

Involved in the Criminal 

Justice System: What 

Mental Health Service 

Providers Need to Know,

which is available 

at: http://www.

gainsctr.com/pdfs/

tapa/Massaro.pdf
xiv |

In January 2002, on behalf of BJA, CSG convened a national meeting of representatives of all 37 BJA grantees, which included approximately 130 mental health court 

practitioners. During the two-day meeting, in a series of interactive workshops, grantees discussed the barriers they faced and strategies for overcoming them. Workshop 

topics included identifying and screening clients, monitoring adherence to court 

conditions, integrating community treatment, and sustaining court operations. These 

sessions helped CSG to understand the variety of ways these issues are managed and 

to identify innovative practices developed by individual courts. 

Given that research on mental health court operation and outcomes remains limited, the experience of existing courts is perhaps the best source of guidance for jurisdictions interested in launching such programs. Those experiences have substantially 

informed what follows.
| 1

mental health courts are one response to a broad systemic problem that has 

evolved over the past several decades: the overrepresentation of people with mental 

illnesses in the criminal justice system. The magnitude of this problem is startling. 

According to a 1999 U.S. Department of Justice study, the prevalence of mental 

illness is three to four times higher among inmates in jail and prison than in the 

general population.1 Almost half of inmates with mental illnesses are incarcerated 

for non-violent crimes.2 The Los Angeles County Jail and New York City’s Riker’s 

Island Jail each house more people with mental illnesses than any public or private 

mental health institution in the country.3

 Though statistics on the prevalence of 

mental illness are most easily obtained from correctional institutions, the impact on 

law enforcement and the courts has also been well documented.4 Simply put, for too 

many people with mental illnesses, the criminal justice system has become a neverending revolving door. 

A WORKING DEFINITION

If observers of mental health courts agree on anything, it is that there is not yet a 

universally agreed upon definition of a mental health court. In fact, the only existing 

nationwide survey of mental health courts offers no descriptive model, relying instead 

on jurisdictions to identify themselves as having mental health courts.5 The more 

Understanding the Mental Health Court Concept

STEP

I
2 |

step i. understanding the mental health court concept

than 100 courts identified by this survey differ widely in the types of cases and defendants they accept, the manner in which those cases are processed, the treatment to 

which participants are connected, and the manner in which those cases are resolved 

when a participant completes the term of supervised treatment. The medley of existing approaches reflects the grassroots nature of mental health courts’ development. 

But while their variability is undeniable, most mental health courts have similar basic 

characteristics.

In general, the term “mental health court” describes: 

A specialized court docket for certain defendants with 

mental illnesses that substitutes a problem-solving 

model for traditional court processing. Participants 

are identified through specialized screening and as- sessments, and voluntarily participate in a judicially 

supervised treatment plan developed jointly by a 

team of court staff and mental health professionals. 

Incentives reward adherence to the treatment plan 

and other court conditions, non-adherence may be 

sanctioned, and success or graduation is defined ac- cording to specific criteria.6 

This description summarizes the components that are common to the majority 

of mental health court programs across the country. As mentioned previously, within 

this general description mental health courts vary widely in terms of target population, plea arrangement, intensity of supervision, program duration, and types of treatment available. Furthermore, research is not yet able to explain how changes in the 

arrangement of these components affect outcomes. But when a jurisdiction says it is 

launching a mental health court, the program almost always fits the above description. 

There are many court-based efforts to improve the response to defendants with 

mental illnesses that share components of this definition. For example, some pretrial 

services agencies have implemented specialized screening and assessments for defendants with mental illnesses; specialized mental health probation programs regularly 

apply sanctions and incentives geared toward people with mental illnesses. What differentiates mental health courts from these other approaches are their 1) designation 

of a specialized court docket for some portion of criminal cases involving defendants 

with mental illnesses, and their 2) team-based monitoring of participants that includes regular judicial supervision. Nevertheless, there is much in this guide relevant 

to court-based strategies that does not fit the description of a mental health court. 

2 |
| 3

A BRIEF HISTORY OF MENTAL HEALTH COURTS

Mental health courts have emerged alongside numerous other collaborative strategies to improve the response to people with mental illnesses in the criminal justice 

system. Over the past two decades, state and local criminal justice and mental health 

agencies have enhanced training for law enforcement officers, developed programs 

to divert certain offenders with mental illnesses from jail, established specialized 

probation and parole caseloads, and improved transition planning from correctional 

facilities. 

These parallel efforts have coalesced into a national, bi-partisan consensus on 

the need to improve the criminal justice and mental health systems’ response to this 

population. In 2002, the Council of State Governments released the Criminal Justice/ 

Mental Health Consensus Project Report, which reflected the input of more than 100 

leading practitioners and policymakers from across the criminal justice and mental 

health systems. The report contained recommendations on improving the response 

to people with mental illnesses throughout the criminal justice continuum, from 

before their involvement with law enforcement to after their release from prison or 

jail. The comprehensive recommendations were a testament to the broad agreement 

among criminal justice, mental health, substance abuse, and other policymakers and 

practitioners about what should, and could, be done to address this complex issue.

Federal leadership has been instrumental in supporting these state and local activities. Congress has provided grant funding for jail diversion programs through the 

Substance Abuse and Mental Health Services Administration (SAMHSA). Additionally, America’s Law Enforcement and Mental Health Project of 2000 (P.L. 106-515), 

sponsored by Sen. Mike DeWine (R-OH) and Representative Ted Strickland (D-OH), 

established the Mental Health Courts Program, administered by the Bureau of Justice 

Assistance (BJA) of the Office of Justice Programs, U.S. Department of Justice. Building on these programs, the Mentally Ill Offender Treatment and Crime Reduction 

Act of 2003, just recently signed into law by the President, authorizes $50 million in 

funding for collaborative efforts between criminal justice and mental health agencies. 

| 3

People with mental illnesses are falling through 

the cracks of this country’s social safety net and 

are landing in the criminal justice system at an 

alarming rate.

Criminal Justice /Mental Health Consensus Project Report

“

”
The impact of the considerable local, state, and federal efforts described above is 

difficult to gauge empirically, but the last ten years have clearly witnessed a surge of 

activity intended to reverse the overrepresentation of people with mental illnesses in 

the criminal justice system. Mental health courts are one of the best-known components of this emerging movement. In the late 1990s, only a few mental health courts 

were accepting cases.*8 Since then, mental health court development has boomed, 

with more than 100 additional courts either established or in the planning phase.

Just as mental health courts are one link in a chain of strategies across the criminal justice system to better respond to people with mental illnesses, they also share 

common ground with other efforts to drastically reconfigure the court processing of 

certain defendants. 

PROBLEM-SOLVING COURTS

As has been explained at length elsewhere, in the late 1980s and 1990s, many court 

systems began to look beyond the simple determination of guilt and innocence and 

toward the underlying causes of crime. This expanded outlook led to the development 

of problem-solving courts, of which mental health courts are one example. 

Most scholars agree that the modern problem-solving court movement originated 

with a drug treatment court established in Miami in 1989. Since then, drug courts 

have proliferated rapidly, and other problem-solving models have emerged, including 

part I. understanding mental illness and its symptoms

the Bureau of Justice Assistance (BJA)

Mental Health Courts Program

As of 2004, BJA’s Mental Health Courts Program provided support to 37 mental health courts in 24 states. 

The goal of the program is to decrease the frequency 

of contact between people with mental illnesses and 

the criminal justice system. BJA-funded projects, as 

with all mental health courts, vary considerably, but 

all involve continuing judicial supervision of participants who have mental illnesses, mental retardation, 

or co-occurring mental illnesses and substance abuse 

disorders, and who are charged with misdemeanors or 

nonviolent offenses.7 A list of BJA Mental Health Court 

Program grantees appears in Appendix A. 

The Mental Health Courts Program is coordinated 

closely with the SAMHSA Targeted Capacity Expansion 

Jail Diversion Program, and the technical assistance

providers for the two programs—the Council of State

Governments and the TAPA Center for Jail Diversion—

work together to ensure that their activities are complementary.

4 |

*The mental health 

courts in Broward 

County (Florida), 

King County 

(Washington), 

Anchorage (Alaska), 

and San Bernardino 

(California) are recognized as the “first 

judge-supervised, 

court-based innovations designed to 

address the problems 

of mentally ill defendants and offenders 

in the criminal caseload in the United 

States.”— “Emerging 

Judicial Strategies for 

the Mentally Ill in the 

Criminal Caseload” 

by John Goldkamp 

and Cheryl IronsGuynn.
| 5

community courts, domestic violence courts, and reentry courts.9 As one study put 

it, these courts were “developed in response to frustration by both the court system 

and the public to the large numbers of cases that seemed to be disposed repeatedly 

but not resolved.”10 Problem-solving courts, as their name suggests, seek to unite the 

legal system with other social service agencies to solve the problems that bring people 

before the court. In 2000, the Conference of Chief Justices and Conference of State 

Court Administrators adopted a resolution titling these initiatives “problem-solving 

courts,” encouraging their careful study, and, perhaps most importantly, promoting the integration of their core concepts into the general administration of justice. 

A subsequent resolution in 2004 reaffirmed their commitment to the 2000 action 

items and to increased curriculum development, expanded educational opportunities, 

the identification of best practices, and expansion of resources available to problemsolving courts. (A copy of the most recent resolution appears in Appendix B.) 

Within the field of problem-solving courts, some use an even more specific rubric to describe the underlying concepts of interventions like mental health courts: 

therapeutic jurisprudence. In fact, this concept has its roots in the analysis of developments in mental health law. One of the leading architects of this concept, David 

Wexler, describes it as “the study of the role of the law as a therapeutic agent.”11 In 

practice, the application of therapeutic jurisprudence means incorporating both legal 

and therapeutic goals in response to violations of the law. Treatment is not prioritized 

over the requirements of the legal system, but rather integrated into its very processes. Thus, mental health courts are a prime example of therapeutic jurisprudence in 

action. 

Of the various problem-solving court models, drug courts are the closest relative 

of mental health courts.* Drug courts respond to substance-abusing offenders with 

comprehensive supervision, drug testing, and treatment services to address the addictions that led to their criminal justice involvement.12 The overlap between drug court 

and mental health court target populations is substantial: three out of four people 

with mental illnesses who become involved in the criminal justice system have a

co-occurring substance abuse disorder.13 

In fact, some of the earliest mental health courts were created when drug court 

practitioners recognized that people with serious mental illnesses did not fare well 

in drug court programs.14 The implications of the substantial number of defendants 

with co-occurring disorders for drug courts and mental health courts will be discussed at greater length later in this guide (see Step III, Element 7, Integration of 

Treatment and Community Supports). 

*Those interested 

in more detailed 

information about 

drug courts should 

consult the National 

Drug Court Institute 

(www.ndci.org), the 

National Association 

of Drug Court Professionals (www.nadcp.

org), and the Bureau 

of Justice Assistance 

(www.ojp.usdoj.

gov/BJA/).
6 |

step i. understanding the mental health court concept

Not surprisingly, mental health courts have numerous features in common with 

drug courts. Both have special court “teams” that largely eschew the adversarial 

process; both include “outsiders” in the court process, i.e. mental health or addiction 

professionals; and both use sanctions and incentives to encourage adherence. Despite 

these similarities, the two types of courts have important differences. While serious 

mental illness and drug addiction can both lead to criminal justice system involvement, they are different types of disorder with distinct treatment methods and 

relationships to the criminal justice system. As one researcher has pointed out, 

“mental illness, in contrast to [the possession or purchase of illegal substances], is not 

itself a crime, nor is there an equivalent to the urine screen as a monitoring device.”15 

Though comparative research on mental health courts and drug courts is only beginning, initial observations indicate a number of differences between drug court and 

mental health court operations (see table). These early observations are evidence that 

jurisdictions interested in developing a mental health court based on an existing drug 

court will need to significantly adapt the drug court model to effectively serve people 

with mental illnesses.

RESEARCH AND ANALYSIS TO DATE

Scholars and practitioners have written extensively about the mental health court 

concept and the operation of specific programs. In addition to reviewing the information in this guide, those interested in mental health courts should also refer to these 

analyses: 

• Emerging Judicial Strategies for the Mentally Ill in the Criminal Caseload: Mental Health Courts in Fort Lauderdale, Seattle, San Bernardino, and Anchorage.

U.S. Department of Justice, April 2000. John Goldkamp and Cheryl IronsGuynn.

• The Use of Criminal Charges and Sanctions in Mental Health Courts.

Patricia A. Griffin, Henry J. Steadman, and John Petrila. Psychiatric Services 53, 

October 2002.

• Law and Psychiatry: Mental Health Courts: Their Promise and Unanswered 

Questions. Henry J. Steadman, Susan Davidson, and Collie Brown. Psychiatric 

Services, April 2001. 

• Criminalization of People with Mental Illnesses: The Role of Mental Health 

Courts in System Reform. Judge David L. Bazelon Center for Mental Health Law,

January 2003.
Program 

Component Drug Courts... Mental Health Courts...

Charges 

accepted

Focus on offenders charged with drugor alcohol-motivated crimes. 

Include a wider array of charges because mental 

illness itself is not a crime. 

Monitoring Rely on urinalysis or other types of drug 

testing to monitor adherence. 

Do not have an equivalent test available to determine whether a person with a mental illness is 

adhering to treatment conditions.

Response to 

violations

Apply behavior management grid that includes incentives and sanctions for compliance / noncompliance. Graduated sanctions culminate in brief jail sentences. 

Adjust treatment plans and apply sanctions in 

response to non-adherence; rely more heavily on 

incentives; use jail less frequently.

Role of 

advocates

Feature only minimal involvement from 

substance abuse advocacy community, 

which is generally not as large or well 

organized as the mental health advocacy 

community.

Have been promoted heavily by some mental 

health advocates, who are often involved in the 

operation of specific programs; other mental 

health advocates have raised concerns about mental health courts, either in general, or in terms of 

how they are designed.

Service

delivery 

Often establish independent treatment 

programs for their participants.

Usually contract with community agencies;

require more resources to coordinate services

for participants.

Expectations 

of 

participants

Require sobriety, education, employment, 

self-sufficiency, payment of court fees, and 

stabilization of co-occurring disorders; 

some charge participation fees. 

Recognize that even in recovery, participants are 

often unable to work or take classes and require 

ongoing case management and multiple supports; few charge a fee for participation.

key differences between drug courts and mental health courts

| 7
8 |

step i. understanding the mental health court concept

• Broward Mental Health Court: Process, Outcomes, and Service Utilization.

Roger A. Boothroyd, Norman G. Poythress, Annette McGaha, and John Petrila. 

International Journal of Law and Psychiatry 26, January–February 2003.

• The Effectiveness of the Broward Mental Health Court: An Evaluation.

John Petrila. November 2002. A policy brief derived from the International

Journal of Law and Psychiatry, Evaluation and Program Planning, Court Review,

and Psychiatric Services articles.

• Evaluation of the Santa Barbara County Mental Health Treatment Court With 

Intensive Case Management. Merith Cosden et al. Funded by the California 

Mentally Ill Offender Crime Reduction Program. 2004.

• The Second Generation of Mental Health Courts. Allison D. Redlich & Henry J. 

Steadman, et. al. In Press, Psychology, Public Policy, and the Law. 2004

• From Referral to Disposition: Case Processing in Seven Mental Health Courts.

Henry J. Steadman and Allison D. Redlich, et. al. In press, Behavioral Sciences 

and the Law. 2004.

It is far too early in the development of mental health courts to identify a validated 

model, a set of “best practices,” or the most effective arrangement of components. 

Nevertheless, this guide is intended to help communities consider some of the 

important issues related to mental health court design and implementation. As will 

be discussed later, expectations about the impact of a mental health court should be 

realistic. No mental health court, no matter how carefully planned, will be the sole answer to all the issues that arise at the nexus of the criminal justice and mental health 

systems. In fact, a separate mental health court may not even be appropriate in some 

jurisdictions. Furthermore, in communities that do implement a mental health court, 

many cases will not be eligible for the specialized docket and will require some other 

response to their mental health needs. 

With those caveats in mind, the next part of this guide is designed to help readers decide whether a mental health court is a viable solution to the specific problems 

observed in their jurisdictions.
| 9

the impetus for starting a mental health court can come from a variety of 

sources. Communities may consider mental health courts in response to jail crowding, following a high-profile tragedy involving an offender with mental illness and 

law enforcement, or based on a recommendation from an outside observer. It might 

first be proposed by an advocacy organization or mental health administrator, or it 

might be the brainchild of a judge, defense attorney, or drug court coordinator. No 

matter who first proposes the idea, a diverse group of stakeholders must determine 

whether a mental health court makes sense in a particular jurisdiction. Policymakers 

and practitioners affected by the overrepresentation of people with mental illnesses in 

the criminal justice system should be engaged in a conversation about this problem 

and the ways in which a mental health court may or may not resolve it.

INVOLVING KEY STAKEHOLDERS

The forum for discussing a mental health court should include input from the many 

officials and agencies whose participation and support will be essential to the success of the court. The venue for such discussions will vary widely. Some communities have formed criminal justice coordinating councils or commissions, which often 

involve representatives of mental health, substance abuse, housing, and other social 

service agencies. 

Determining if a Mental Health Court

Is Appropriate

STEP

II
10 |

step ii. determining if a mental health court is appropriate

example: Anchorage Court Coordinated Research Project (Alaska)

The Anchorage CRP (the official title for the specialized mental health docket in that jurisdiction) 

emerged as a recommendation from the 1997 Alaska Criminal Justice Assessment Commission. 

The Commission was established by the National Institute of Corrections’ Criminal Justice System Project. Through that commission, representatives from the Alaska Department of Corrections, the Alaska Department of Health and Social Services, and the Alaska Court System, along 

with members of other agencies, participated in a statewide cross-systems effort to develop 

more cost-effective and cooperative systems of criminal justice sanctions.16 

In other jurisdictions, ad hoc or formal groups have been formed to respond to the 

diverse problems related to mental illness in the criminal justice system. Elsewhere, 

task forces have been established specifically to examine the possibility of launching a 

mental health court. If an appropriate vehicle is not already available, those interested 

in developing a mental health court should consider how to create one.

example: Summit County Criminal Justice Forum (Ohio)

In 2000, in response to a recommendation from the National GAINS Center for People with 

Co-Occurring Disorders in the Criminal Justice System, stakeholders in Summit County, Ohio, 

formed a Criminal Justice Forum. The forum comprises representatives from criminal justice, 

mental health, and substance abuse treatment agencies and includes working groups to investigate specific issues including training, reentry, cross-systems communication, and the viability 

of a mental health court. The mental health court working group spawned the Akron Municipal 

Mental Health Court. The forum now meets quarterly to decide on major priorities, hear reports 

from working groups, and ensure communication among participating agencies. 

Though the initial push for a mental health court may come from a variety of 

sources, the ensuing discussions are likely to be most effective if convened and 

overseen by a judge. Judges carry with them the neutrality of the court in the criminal 

process and they are well-positioned to moderate discussions between parties (prosecutors, defense attorneys, mental health providers, advocacy organizations, etc.) with 

different priorities and attitudes toward a mental health court and its appropriate organization. Just as importantly, if a respected judge convenes a meeting to explore the 

potential for a mental health court, other stakeholders, regardless of their opinions 

about such a strategy, are more likely to attend.

example: King County District Court Mental Health Court (Washington) 

In response to the murder of a Fire Department Captain by a person with a mental illness, the King 

County chief executive formed a task force to examine the involvement of people with mental 

illnesses in the criminal justice system. The “Mentally Ill Offenders Task Force” was chaired by the 

former chief justice of the Washington State Supreme Court and made numerous recommendations, one of which called for the establishment of a pilot mental health court. 
| 11

Ideally, the presiding or chief judge chairs such an effort. If not, the judge who 

takes the lead should seek to gain the support of the chief or presiding judge and, if 

possible, the full bench. For some chief judges, mental health courts (or any specialized docket) may not be viable, and putting significant effort into examining the potential for a mental health court could be a waste of energy. Even when a chief judge 

is receptive to specialized dockets, a mental health court has implications for staffing, 

case scheduling, and resource allocation. Garnering the support of the chief judge for 

initial discussions helps ensure that these issues are considered early and are ultimately incorporated into the proposal to implement a mental health court.

The key stakeholders who should be involved in any discussions about launching 

a mental health court include:

• Judges

• Prosecutors

• Defense counsel

• Probation

• Court administrators

• Jail administrators

• Jail medical and mental health staff 

• Pretrial services

• Community mental health treatment providers 

• Community substance abuse treatment providers 

• Consumers

When I was a public defender trying to address 

this problem, I called a meeting of all the key 

stakeholders, and no one came. When I became 

a judge I called the same meeting. Everyone was 

five minutes early.

Judge Steven Leifman, Associate Administrative Judge, Miami-Dade County, 

Florida, 11th Judicial Circuit

“

”
12 |

step ii. determining if a mental health court is appropriate

• Law enforcement officials

• Crime victims and advocates

• Family members and advocates for people with mental illnesses 

• Housing providers/shelters

• Emergency room (psychological and medical) administrators

• Public guardians/conservators

• Adult protective services

SYSTEMS MAPPING

The group tasked with discussing the advantages and disadvantages of a mental 

health court should not begin by simply weighing the viability of a specialized docket. 

Rather, it should identify and assess the problems that occur when people with 

mental illnesses enter the criminal justice system and discuss the merits of a variety 

of strategies for resolving these problems. Depending on the nature of the problems 

identified, a mental health court may not be the best, and certainly not the only, way 

to address them.

To guide the initial discussions, the committee should examine, step-by-step, 

how people with mental illnesses are processed through the criminal justice system, 

a method referred to by some as “systems mapping.”17 What happens when police 

respond to a call involving a person with mental illness? What options are available to 

the officer besides jail? When these arrestees enter the court, what approach is taken 

by the judiciary, the defense counsel, and the prosecutor? At the defendant’s first appearance in court, what resources are available to the judicial officer if the defendant’s 

mental health is in question? The committee should examine each step in the system, 

from arrest to re-entry into society. At each step, the committee should ask the following questions: 

• What decision is being made, and how does it affect people with mental illness? 

• Who makes the decision? 

• What information is available to the decision maker?

• What options are available to the decision maker? 

• Are the available information and options sufficient to make the best possible 

decision?
| 13

The Criminal Justice/Mental Health Consensus Project Report can help guide this 

process. The report identifies 23 decision points on the criminal justice continuum 

and provides a policy statement about how the response to people with mental illnesses could be improved at each point, along with recommendations for implementing the policy statement. (See flowchart on following page.) Recognizing that each 

jurisdiction is organized differently, the report does not propose specific programmatic models, but rather suggests overarching strategies for making informed decisions 

regarding people with mental illnesses in the criminal justice system. Some jurisdictions have used the report’s policy statements as a tool for evaluating their current 

systems and for devising strategies for moving forward. 

example: Jefferson County Criminal Justice Strategic Planning Committee (Colorado) 

The Jefferson County Criminal Justice Strategic Planning Committee, formed in 1995, established a Criminal Justice / Mental Health Subcommittee in 2003. The subcommittee used the 

policy statements of the Consensus Project Report to analyze the movement of people with mental illnesses through the Jefferson County criminal justice system. The subcommittee identified 

local strengths and weaknesses related to each policy statement, and assigned priorities for the 

coming year.

Another useful framework for this discussion is the “sequential intercept model,” 

developed by consultants from the GAINS Center for People with Co-Occurring 

Disorders in the Criminal Justice System.18 (See diagram on page 15.) This model 

proposes five points on the criminal justice continuum at which people with severe 

mental illnesses and co-occurring disorders can be “intercepted”:

1. Law Enforcement/Emergency Services 

2. Initial Detention/Initial Court Hearings

3. Jails, Courts, Forensic Evaluations, and Hospitalization

4. Re-entry

5. Community Corrections and Community Support

The model suggests that at each intercept point, procedures should be developed 

to ensure: 

• Prompt access to treatment

• Opportunities for diversion

• Timely movement through the criminal justice system

• Linkage to community treatment providers
a person with mental illness in the criminal justice system: 

a flowchart of select events

1. Involvement with the Mental Health System

2. Request for Police Service

3. On-Scene Assessment

4. On-Scene Response

6. Police Response Evaluation

7. Appointment 

of Counsel

8. Consultation

with Victim

9. Prosecutorial Review of Charges

(including decision whether to divert)

10. Modification of Pretrial 

Diversion Conditions Diversion Violation of Pretrial 

Diversion Conditions

Violation of Pretrial 

Diversion Conditions

Rearrest; Subject 

Proceeds to 13 Pretrial Release 11. Pretrial Release/

Detention Hearing

12. Modification of Pretrial 

Release Conditions

13. Intake at County/

Municipal Detention Facility 14. Adjudication

Conviction Not Guilty / Acquittal Charges Dismissed

14 |

Crime / Incident

22. Modification of Conditions 

of Supervised Release Release

17. Receiving and Intake of Sentenced Inmates

18. Development of Treatment Plans, Assignment to Programs, and Classification/Housing Decisions

21. Development of Transition Plan

20. Release Decision

19. Subsequent Referral for Screening and Mental Health Evaluation

23. Maintaining Contact Between Individual and Mental Health System

Arrest 5. Incident Documentation Diversion

Rearrest; Subject 

Proceeds to 13

16. Modification of Conditions of 

Probation/Supervised Release Probation/

Supervised Release 15. Sentencing

Violation of 

Conditions of Probation/

Supervised Resease

Community–Based 

Supervision

Violation of Conditions of 

Supervised Resease Rearrest; Subject 

Proceeds to 13

involvement with the

mental health system

contact with

law enforcement

pretrial

issues,

adjudication, 

and

sentencing

incarceration 

and reentry

continued involvement with 

the mental health system
| 15

sequential intercept model 

Initial Contact 

with Law 

Enforcement

Initial

Detention

Citation Arrest

Jail —

Pre-trial

Jail — 

Sentenced

State

Prison

Release without 

Conditions

Completion of 

Sentence

Conditional 

Release Probation Parole

Initial

Appearance

Court

State Hospital —

Forensic Unit

State Hospital —

Civil Unit

Not Guilty

by Reason of 

Insanity

Not

Guilty / Guilty

Guilty but

Mentally Ill

Dispositional 

Court

Incompetent

to

Stand Trial

Bond

Release on Own 

Recognizance 

Bond

Release with 

Supervision Bond

Charges Dropped

law enforcement / 

emergency services

initial detention / 

initial hearings

jail, courts, forensic 

evaluation, & 

hospitalization

re-entry

community 

corrections & 

supports
16 |

step ii. determining if a mental health court is appropriate

Obviously, the first three intercept points are most relevant to the mental health 

court discussion. But the broader point is that discussions concerning the viability 

of a mental health court should also consider the movement of people with mental 

illnesses throughout the entire criminal justice system. The many strategies jurisdictions employ at the different “decision” or “intercept” points have been documented 

elsewhere and are beyond the scope of this guide.*

COLLECTING AND USING DATA

In addition to a map of system flow, the discussion about whether to launch a mental 

health court should be informed by as much hard data as possible. These data must 

go beyond experience, anecdotes, or “best guess” estimates. While estimates can be 

helpful in understanding how the criminal justice and mental health systems function generally, they are often distorted by the estimator’s own perceptions and should 

not be relied upon when planning systemic change. Instead, deliberations about 

how to better respond to people with mental illnesses in the criminal justice system 

should be based on accurate statistics compiled from a variety of sources. 

Generating local data is critical for two reasons. First, planning efforts, no matter 

the scope, must be driven by the imperatives of the local population. For example, 

policymakers may be interested in reducing the number of misdemeanants with 

mental illnesses housed in the jail. Before developing an intervention to accomplish 

this goal, the dimensions of the problem must be fully analyzed: how many misdemeanants are in the jail on any given day? What is their average length of stay? What 

proportion of these inmates have mental illnesses and how does their average length 

of stay differ? Such an analysis may reveal that, contrary to general perceptions, the 

vast majority of inmates with mental illnesses are booked on felony charges. If the 

planning committee bypassed the data collection and analysis phase, the resulting 

intervention would likely fall short of the desired impact.

Second, collecting relevant data at the outset of program planning is the only 

way to evaluate the impact of the changes resulting from the intervention. Without 

accepted baseline data, decision makers cannot assess whether a program or policy 

change accomplished its intended goals. 

Collecting data on people with mental illnesses in the criminal justice system can 

be extremely difficult. Data on this population is maintained by multiple agencies 

in both systems. Even within particular agencies, information technology may be 

*For more information on strategies for 

responding to people 

with mental illnesses 

in the criminal 

justice system (aside 

from mental health 

courts), interested 

readers should consult the Consensus 

Project Report, the 

Consensus Project 

Web site (www.consensusproject.org), 

or contact the GAINS 

Center for EvidenceBased Practices 

(www.gainsctr.com) 

and the TAPA Center 

for Jail Diversion 

(www.tapacenter.

org), a branch of the 

GAINS Center.
outdated or ill-equipped to provide specific information related to people with mental 

illnesses who become involved in the criminal justice system. Because of these obstacles, sufficient data may not be available to answer the full range of questions that 

a planning committee would want to consider. For example, the jail may track the 

number of inmates receiving psychotropic medication, but may not have aggregate 

data on inmate diagnoses. Ultimately, data-driven answers to a more limited set of 

questions are preferable to anecdotal responses to a broader range of questions. 

useful data for planning purposes

The following statistics will be useful for jurisdictions 

considering the development of a mental health court. 

Because the availability of data varies widely across 

jurisdictions, jurisdictions should focus on data that is 

already available, or relatively easy to obtain. 

• Percentage of law enforcement calls for service 

that involve an individual with mental illness 

• Dispositions of law enforcement calls for service 

involving people with mental illnesses (e.g., how 

many are arrested, taken to the emergency room, 

diverted to other community resources?) 

• Percentage of current jail inmates with mental 

illnesses

• Percentage of jail inmates with mental illnesses 

in past years 

• Percentage of jail inmates receiving mental 

health treatment or psychotropic medications

in jail 

• Percentage of jail inmates with mental illnesses 

who have been involved in treatment 

• Specific diagnoses of jail inmates receiving mental health treatment or psychotropic medications 

in jail 

• Average length of stay for inmates with mental illnesses compared to that of the general 

population

• Types of charges of jail inmates with mental illnesses compared to those of the general population (e.g., what percentage are felony or misdemeanor, violent or non-violent)

• Percentage of all current jail inmates who have 

five or more prior bookings

• Percentage of jail inmates with mental illnesses 

who have five or more prior bookings

• Costs resulting from the 25 to 50 heaviest users of jail, detoxification, psychiatric hospital, 

emergency room, and community-based mental 

health services 

• Average length of time required for competency 

evaluations

| 17
OVERCOMING DIFFERENCES

Representatives of the criminal justice and behavioral health systems often speak 

different languages, but the gaps between these systems are more than linguistic. 

They may also have different (and sometimes opposing) goals, methods, and underlying assumptions. In fact, even within each system, different actors have diverse and 

sometimes competing priorities. Within the criminal justice system, prosecutors are 

charged with public safety, defense counsel protect the rights and interests of their 

clients, judges are responsible for maintaining the fairness of the court process, and 

probation officers must ensure compliance with release conditions. These players 

have different interests to protect when contemplating the role of a mental health 

court and its impact on their responsibilities. 

Any substantial, cross-system dialogue must provide an opportunity to uncover 

and discuss these differing perspectives. Representatives from both systems should 

be offered the opportunity to explain their duties, clients, funding mechanisms, agency goals, and core concerns with regard to people with mental illnesses who become 

involved in the criminal justice system. During this process, assumptions, stereotypes, and personal beliefs about the target population can be discussed and, in some 

instances, corrected. Though these discussions may seem off-topic or unproductive, 

they can lead to common ground on which to begin deliberations about starting a 

how much does a mental health court cost?

The question of cost will be an important factor for 

many jurisdictions considering a mental health court. 

As with all aspects of mental health courts, the answer 

to this question varies, depending on the design of the 

court and the available community resources. Some 

courts have been started with no new resources, literally run during lunch hours or after other court business has been concluded. Others have required the 

development of one or multiple new staff positions, 

and have apportioned resources to purchase treatment services for court participants. The question

of cost is further complicated by the lack of

concrete information about cost savings or shifting. While the potential for mental health courts to 

improve treatment engagement and reduce criminal 

justice involvement suggests that they will result in a 

net savings, current data is equivocal, and savings may 

not be realized to the agency that absorbs the cost of 

operating the court. Determining how much a mental 

health court would cost requires the consideration 

of different program designs, identification of available staff resources, evaluation of community treatment capacity, investigation of potential new funding 

sources, and a host of other issues.

18 |

step ii. determining if a mental health court is appropriate
| 19

mental health court. Without a collaborative and cooperative foundation in which 

participants feel free to express their views, the success of a mental health court—

or any initiative in this area—is in jeopardy before it starts. 

Of course, wide-ranging discussions about people with mental illnesses who 

become involved in the criminal justice system can be difficult and exhausting. A 

comprehensive analysis of the system’s components can expose a plethora of issues, 

not all of which can be addressed at once. Collecting data can be time consuming and 

frustrating. At some point, priorities must be set, direction must be established, and 

action must be taken. Among others, a community should try to answer the following 

questions before moving ahead:

1. Where on the criminal justice continuum will the community focus?

As discussed above, there are numerous points (or intercepts) on the criminal justice 

continuum at which the response to people with mental illnesses can be improved. 

Addressing each of these points should be a long-term goal for any community, but 

targeting the entire criminal justice process simultaneously can overwhelm even the 

most organized collaborative effort. A limited number of priorities should be identified for initial action. If the priorities include improving the way in which people with 

mental illnesses are processed through the courts, launching a mental health court 

may be appropriate. But after substantial discussion, a jurisdiction may choose instead to focus on issues related to law enforcement, jail booking, jail reentry, or other 

decision points, and postpone considering the viability of a mental health court. 

The single most significant common denominator 

shared among communities that have successfully 

improved the criminal justice and mental health 

systems’ response to people with mental illnesses 

is that each started with some degree of coopera- tion between at least two key stakeholders—

one from the criminal justice system and the

other from the mental health system.

Criminal Justice/Mental Health Consensus Project Report

“

”
20 |

step ii. determining if a mental health court is appropriate

2. If the focus is on a court-based intervention, is a specialized docket the 

right strategy? 

Many communities have decided to improve their court system’s response to people 

with mental illnesses without starting a mental health court. Their reasons for eschewing mental health courts varied. Some communities felt that judicial resources 

were insufficient to devote time to a specialized court. Others were doubtful that a 

mental health court would result in better outcomes. Still others had concerns about 

establishing a specialized docket based on people’s mental conditions rather than the 

types of crimes they committed. Nevertheless, these communities sought to infuse 

many of the core principles of mental health courts—early identification of defendants with mental illnesses, treatment in lieu of incarceration, and monitoring or 

community treatment—into their traditional court processes. 

For example, a recent monograph—Non-specialty First Appearance Court Models for 

Diverting Persons with Mental Illness—profiled twelve jurisdictions that have incorporated screening for mental illness into their pretrial release decision-making process, 

providing information about a defendant’s mental illness, pretrial release recommendations, and needed treatment services to judicial officers at the first appearance in 

court.19 Other jurisdictions have established programs to divert people with mental 

illnesses at subsequent points in the criminal justice process without establishing a 

separate docket to streamline that process and supervise people while they are in the 

community. 

These examples are not intended to suggest that other strategies are more or less 

effective than a mental health court. In fact, research in this area is at such an early 

stage that arguing convincingly for or against a specialized mental health court based 

on outcomes is nearly impossible. These examples are offered simply as a reminder 

that a variety of options, including, but not limited to, a mental health court, are available to improve the response of the courts to people with mental illnesses.*

3. Is a mental health court the only court-based strategy that will be 

employed? 

Establishing a mental health court is a serious endeavor requiring collaboration 

among numerous entities. Nevertheless, a mental health court will serve only a fraction of the people with mental illnesses who become involved in the court system. 

Prior to launching a mental health court, communities should discuss other courtbased strategies that might be employed, either immediately or later on, to address 

other aspects of this systemic problem. 

*Jurisdictions interested in strategies 

other than mental 

health courts should 

contact the Consensus Project (www.

consensusproject.

org/212-482-2320)

or the GAINS Center 

for Evidence Based 

Practices and the 

TAPA Center for Jail 

Diversion

(www.gainsctr.com/ 

800-311-GAIN).
| 21

For jurisdictions that undertake the difficult process of cross-system dialogue and 

determine that a mental health court fits their needs and goals, the remainder of 

this guide provides direction for the numerous and difficult issues they will need to 

resolve.
like deciding to establish a mental health court in the first place, designing 

a mental health court requires considering complex issues and soliciting input from 

a diverse group of stakeholders. While each mental health court must be adapted to 

local concerns and imperatives, there is much to be learned from the experiences of 

other jurisdictions. Based on the structure and operation of existing courts and the 

substantial literature that has accompanied their development, this guide identifies 

ten elements of mental health court design and implementation and offers guidance 

on addressing each of them. 

Considering Elements of Mental Health Court 

Design and Implementation

This list of elements is inspired by “Defining Drug 

Courts: 10 Key Components,” published by the National Association of Drug Court Professionals, but 

should not be considered a direct counterpart to that 

document. The initial list of elements was developed 

by CSG and presented at the BJA Mental Health Court 

Program conference in January 2004. The list was then 

revised based on commentary from conference attendees. During 2005-2006, CSG plans to coordinate a 

process to determine which of these elements should 

be considered essential to a mental health court 

program, and to establish benchmarks by which the 

presence of these elements can be measured. 

elements explained

22 |

STEP

III
| 23

The intent is not to suggest that a mental health court should be designed or operated in a particular way, but rather that these issues should be considered before the 

mental health court is established and should be revisited throughout its operation. 

When designing a mental health court, communities should rely on a planning 

and implementation model similar to the one recommended for deliberating whether 

to launch one. Discussions should include all the people and agencies that will be 

involved in or affected by the operation of the court, including: 

• Judges

• Prosecutors

• Defense counsel

• Probation officers

• Jail administrators

• Jail medical and mental health staff 

• Pretrial services

• Mental health providers 

• Substance abuse treatment providers 

• Consumers

• Law enforcement officials

• Crime victims and advocates

• Family members and advocates for people with mental illnesses 

• Housing providers/shelters

• Emergency room (psychological and medical) administrators

• Public guardians/conservators

• Adult protective services 

To facilitate cross-system dialogue, many communities have formed a mental 

health court task force, either as a subcommittee of a larger group or as a stand-alone 

body. Relying on a task force helps ensure a program design that reflects the input 

of all stakeholders. Furthermore, such a group can help monitor the progress of the 

court program and inform strategic decision-making as it moves forward. Whatever 

the mechanism, the planning and oversight for the court should mirror the interdisciplinary, cross-system nature of its operation. 

Of course, even after careful and comprehensive planning, the court’s operation 

will uncover additional complexities. A successful mental health court requires more 
than just a thoughtful design; it demands effective leadership, dedicated court staff, 

and a willingness to continually reexamine the functioning of the court. For this reason, the elements described below can be used not only to steer the planning process, 

but also to guide periodic reviews of the design of the court.

Elements of Mental Health Court Design and Implementation

1. Goals 

2. Target Population

3. Confidentiality 

4. Terms of Participation 

5. Informed and Voluntary Choice

6. Participant Identification

7. Integration of Treatment and Community Supports

8. The Court Team 

9. Monitoring Adherence to Court Conditions

10. Sustainability 

determining the need for changes in law or policy

Many mental health courts have been successfully 

implemented with no explicit law, rule, or policy 

changes. Some mental health court planning groups 

discover, however, that a change in law or court policy 

is required to launch a mental health court in their 

jurisdiction. Such changes may be necessary in order 

to identify a lead agency responsible for the court’s operation, transfer jurisdiction to the specialized docket, 

define eligibility for the court, gain legislative or policymaker interest in the pilot program, or gain formal 

approval from the court administrator or chief judge. 

Planning groups should familiarize themselves with 

relevant state statutes and court administrative procedures and, once a basic program has been designed, 

identify any changes that should be proposed. 

example: Oklahoma 22 O.S. § 47220

The “Anna McBride Act” of 2002 permitted any district 

or municipal court to establish a mental health court 

pilot program subject to the availability of funds. The 

Department of Mental Health and Substance Abuse 

Services was named the primary agency to assist in 

program development; eligible charges and criminal 

history were outlined and the district attorney’s office 

was given discretion over defendant participation. 

New Hampshire: Senate Bill 435, 200221 

New Hampshire Senate Bill 435 ordered the establishment of a mental health court in the Keene District 

Court to serve misdemeanor offenders, and provided 

for a legislative oversight committee to study the program and make recommendations on its continuation, funding, and expansion to other counties. 

24 |

step iii. considering elements of mental health court design and implementation
| 25

1. GOALS

The broad goal of all problem-solving courts, including mental health courts, is to address the issues underlying people’s repeat contacts with the criminal justice system 

so they will not return, or not return as frequently. Such an overarching goal provides 

important context, but it is not sufficient to guide the operation and measure the 

impact of a mental health court program. The stakeholders involved in planning a 

mental health court should agree on a limited number of specific goals that are both 

realistic and measurable.*

In general, goals for mental health courts can be grouped into the following categories: 1) Increased public safety; 2) increased treatment engagement; 3) improved 

quality of life; and 4) more effective use of resources. Within each category, jurisdictions should determine the precise goals for their courts, clearly specifying how progress toward those goals will be assessed. In doing so, court planners should consider 

the following issues: 

Increased public safety 

Mental health courts have the potential to positively impact public safety by reducing 

criminal justice involvement among program participants, which means fewer crime 

victims in the community. Mental health court planners should remember that many 

participants will have extensive criminal histories and complicating social factors 

(e.g., homelessness, poverty, lack of family connections), along with chronic and potentially disabling mental health conditions. A mental health court cannot solve these 

numerous problems by itself, and eradicating all future criminal justice involvement 

for program participants is not a realistic goal. Rather, mental health courts should, 

for example, pursue incremental reductions in the number of law enforcement contacts, jail days, probation violations, or new charges for program participants. 

While mental health court planners will naturally focus on the period of court supervision, they should also set goals for when supervision ends. If the mental health 

court cannot reduce criminal justice involvement for participants once the oversight 

of the court is stopped, important questions will (and should) be raised about the 

ultimate value of the intervention. 

Increased treatment engagement 

Many mental health court participants have long histories of inconsistent treatment 

engagement. They may have experienced repeated crises and have, at some point, 

*For more on measuring the impact 

of a mental health 

court, readers should 

review A Guide to Collecting Mental Health 

Court Outcome Data, a 

companion piece to 

this guide.
26 |

step iii. considering elements of mental health court design and implementation

been hospitalized involuntarily. For too many consumers, especially those who 

become involved in the criminal justice system, treatment has not been a positive 

experience. Likewise, mental health providers may view them as their most difficultto-serve clients, and see them as unmotivated or beyond help. For this reason, most 

mental health courts identify improved consumer engagement as a primary goal. 

At times, treatment engagement is equated solely with medication adherence, but 

mental health courts should consider a wider range of treatment issues when setting 

goals. For example, goals related to the venue for receiving treatment (e.g., emergency 

facilities vs. outpatient clinics), the types of treatment provided (e.g., integrated treatment for co-occurring substance abuse disorders), and the level of consumer satisfaction all offer a more powerful assessment of the court’s impact on treatment engagement. Further, the extent to which engagement is maintained beyond the period of 

supervision provides a measure of the court’s ability to effect long-term change. 

Improved quality of life 

At its heart, a mental health court is designed to improve the lives of its participants. 

Engaging in treatment and avoiding criminal justice contact are usually correlated 

with such improvements, but mental health courts should also consider establishing 

other goals related to quality of life. Along with self-perceived quality of life, measures 

of stable housing, family and peer relationships, employment and education status, 

drug and alcohol use, and victimization are also important indicators of the extent 

to which mental health court participation has brought about tangible changes in its 

participants’ daily lives. Quality of life is also affected by the extent to which participants are able to manage the symptoms of their mental illnesses and any physical 

ailments. Given the racial and ethnic diversity of mental health court participants, 

mental health courts should employ culturally sensitive and bias-free instruments 

when measuring progress.

More effective use of resources

Many mental health courts cite cost savings as one of the central objectives of the 

court, and a key justification for long-term funding. While the goal of making better use of limited criminal justice and mental health resources is laudable, mental 

health courts should be careful about establishing cost-related goals. Cost data are 

very difficult to gather correctly, and some studies suggest that mental health courts 

and related programs result in an initial net cost increase and that savings may not be 
realized for several years.22 In addition, even if “per-person” savings are realized and 

can be tracked successfully, these savings may not actually accrue to any particular 

agency. For example, although a mental health court may reduce the consumption 

of jail bed days for its participants, the overall cost of operating the jail will remain 

the same. Accordingly, caution is warranted when making promises about decreased 

expenditures resulting from the mental health court. 

This should not dissuade mental health courts from setting goals related to 

resource use. In addition to their chronic entanglement with the criminal justice 

system, many mental health court participants cycle repeatedly through other social 

service systems (psychiatric hospitals, detoxification facilities, emergency rooms) and 

may fit the profile of “high utilizers” described in the sidebar below. Reducing the 

consumption of these limited resources among program participants is both realistic 

and measurable. For example, courts such as Anchorage, Alaska, have demonstrated 

reduced consumption of jail and hospital bed days among program participants.23 

Mental health courts should consider the specific resources they hope to impact

and devise systems by which the use of these resources by court participants can

be monitored. 

Producing substantial reductions in jail overcrowding is another goal that mental health court planners should be wary of adopting. Compared to the number of 

inmates admitted to a local jail, the number of participants accepted by mental health 

courts is relatively small; thus, the decreased utilization of jail resources by court

participants is not likely to have a measurable impact on the overall jail census. However, jail inmates with mental illnesses require significant staff resources to manage, 

protect from harm, and treat, and the cost of providing psychotropic medications can 

tracking service usage of “high utilizers”

Several jurisdictions have collected data on the group 

of people with mental illnesses who cycle repeatedly 

through the criminal justice and other social service 

systems. During 2000, King County, Washington 

spent more than $1.1 million on mental health treatment, drug and alcohol acute services, and criminal 

justice resources for just 20 people. In Summit County, 

Ohio, during 2001, services for a similar group of 20 

people cost taxpayers $1.3 million. These calculations 

included neither the time invested by law enforcement or the court, nor the costs of transportation to 

different facilities. Perhaps most disturbing, despite 

these considerable expenditures, the level of functioning and quality of life did not improve for the majority 

of these people.24

| 27
28 |

step iii. considering elements of mental health court design and implementation

be staggering. For these reasons, preventing the return to jail of only a few mental 

health court participants could be very significant to the jail administrator.

example: King County Mental Health Court 

The King County Mental Health Task Force outlined the following goals for its mental health 

court:25

1. Reduce the number of future criminal justice contacts among offenders with mental illnesses; 

2. Reduce the inappropriate institutionalization of people with mental illnesses; 

3. Improve the mental health and well-being of defendants who come in contact with the Mental 

Health Court; 

4. Improve linkages between the criminal justice system and the mental health system; 

5. Expedite case processing; 

6. Protect public safety; 

7. Establish linkages with other County agencies and programs that target people with mental 

illnesses in order to maximize the delivery of services. 

Jurisdictions seeking to establish a mental health court should give great care to 

the wording of their goals for the court.* Clearly identified goals become the benchmarks against which the court’s effectiveness can be measured. Not only must the 

goals be both realistic and measurable, but the processes for obtaining or tracking the 

necessary data should also be developed and implemented along with the court’s operation. (For more on data collection in mental health courts, readers should consult 

the Guide to Collecting Mental Health Court Outcome Data, a companion to this guide.) 

2. TARGET POPULATION

Most existing mental health courts have established basic eligibility criteria across 

four main categories: current charges, violence, diagnosis, and prior criminal record. 

The target population for mental health courts must be carefully defined; the court’s 

inherent specialization requires a focus on a subset of defendants with mental illnesses who come through the court system. Communities should be judicious in 

determining the segment of the population likely to be best served by this limited 

resource. 

Setting eligibility criteria raises important political, ethical, and operational issues. For example, stakeholders may disagree vehemently about the types of charges 

to authorize for admission. Likewise, only defendants with certain diagnoses will be 

*The process of 

mental health court 

goal setting can be 

easily adapted to 

other interventions 

for people with serious mental illnesses 

in the courts, not 

just those involving a 

specialized docket.
| 29

eligible. The choice of eligible diagnoses will, in turn, determine the types of treatment resources the court will need to secure. The process of selection also involves 

exclusion, leading to ethical questions about who may not have access to treatment. 

Mental health court planners must wrestle with the consequences, implications, and 

trade-offs of these important decisions. 

Current charges

There are two major components of criminal charges that most mental health courts 

consider in their criteria for eligibility: the severity of the charge and the relationship 

to a person’s mental illness. The second of these components is difficult to determine. 

There is no recognized measure to assess the degree to which an alleged offense was 

“caused by” a person’s illness, and courts vary widely in how they apply this standard, 

if at all. Those that do require some link between a defendant’s illness and charge 

should rely on the input of a mental health professional to determine whether the 

type of behavior with which the defendant is charged could be related to his or her 

diagnosis. 

Many of the earliest mental health courts denied admission to people charged 

with felonies, often in response to public safety concerns from judges or prosecutors. 

Since mental health courts are a form of diversion from traditional criminal justice 

processing, prosecutors, judges, and victim advocates, among others, may be concerned that allowing people to participate in treatment in lieu of incarceration may 

jeopardize public safety, or send the wrong message about offender accountability. 

example: Jackson County Mental Health Court (Missouri) 

Because of public safety concerns and the high volume of low-level offenders with mental illnesses, the planning commission for the Jackson County Mental Health Court decided to target 

people charged with misdemeanors, particularly ordinance violations such as trespassing and 

public urination. Many court participants have a history of multiple misdemeanor offenses, 

though first-time offenders are eligible. The only participants charged with felonies are referred 

from the local drug court. The mental health court currently operates in two municipal court systems within the county, and is considering expansion into several more. 

On the other hand, recent research suggests that mental health courts are increasingly accepting defendants charged with felonies. A 2002 study of eight mental 

health courts found that seven focused on defendants charged with misdemeanors, 

and only two accepted felony defendants.26 When these courts were surveyed again 

two years later, all but two accepted defendants with felony charges.27 In addition, in 

a recent study of seven mental health courts (all of which received grants from the 
30 |

step iii. considering elements of mental health court design and implementation

Bureau of Justice Assistance), all seven accepted felony-level defendants, and three 

dealt exclusively with defendants charged with felonies.28 

example: Monroe County Mental Health Court (New York) 

The majority of the participants accepted into the Monroe County Mental Health Court are 

charged with felonies. A defendant charged with a misdemeanor may be accepted if his or her 

original felony charge was subsequently reduced to a misdemeanor or if he or she has a history of 

felony charges. The decision to focus on defendants charged with felonies ensured the buy-in of 

the public defender and allowed for the development of a longer program duration, which court 

planners felt would improve the likelihood of effective treatment.

The reasons underlying the shift toward accepting those charged with felonies 

are not certain, and this guide does not recommend that new courts follow this trend 

blindly. But mental health court planners should recognize that, in developing their 

target population, the line between misdemeanors and felonies can be blurry. While 

many people who commit felonies do so after committing a series of misdemeanors, many misdemeanants may also have prior felony convictions. Furthermore, the 

considerable discretion in charging decisions means that similar offenses can end 

up in different charge categories depending on the circumstances of the case. From 

the treatment perspective, a person with schizophrenia who commits a misdemeanor 

and a person with schizophrenia who commits a felony have the same disorder and 

will likely have similar treatment needs.

Upon close analysis, the decision about whether to accept defendants charged 

with misdemeanors, felonies, or both has little to do with a particular individual’s 

likelihood of success in mental health court. Rather, charge-related eligibility criteria 

amount to political and strategic decisions that should be assessed periodically for 

their effect on the court’s ability to achieve its goals. Along this line, there are several 

issues related to the question of charges that warrant further consideration. 

First, as discussed in Step II: Determining if a Mental Health Court is Appropriate, mental health courts should be only one of a variety of strategies employed to 

address the overrepresentation of people with mental illnesses in the criminal justice 

system. Interventions occurring earlier on the criminal justice continuum—such as 

police-based diversion programs or diversion mechanisms that do not include ongoing judicial supervision—could serve offenders who commit less serious crimes, thus 

making the mental health court more appropriate for felony offenders. 

Second, potential reductions in the number of jail days consumed by court participants depend in large part on the seriousness of charges deemed eligible. A court 

accepting only defendants charged with misdemeanors, given their shorter sentences, 
has less potential to demonstrate jail bed savings, particularly in states with presumptive sentences for felony crimes. 

Third, people charged with misdemeanors may be less inclined to opt for mental 

health court participation, which is likely to extend for a significant time, in lieu of 

a jail sentence that is likely to be very short. For this reason, defense attorneys may 

advise clients charged with misdemeanors that the mental health court is not in their 

best interests. 

Courts that do target defendants charged with misdemeanors should consider 

establishing treatment plans and other conditions that are the least restrictive as 

possible while still ensuring public safety. Highly restrictive conditions increase the 

likelihood that violations will be detected, which can intensify the involvement of 

participants in the criminal justice system as compared to the normal court process. 

This scenario would run counter to a core goal of mental health courts, which is to 

lessen criminal justice involvement for their participants. Research from the drug 

court context supports this concept: several studies suggest that lower-level offenders fare worse in programs that require more frequent status hearings and intensive 

supervision.29 

 Less restrictive conditions, when complemented by firm partnerships with treatment providers, also encourage participants to turn to the mental health system for 

support in times of crisis, thus lessening the likelihood of future criminal justice 

involvement. Lastly, having less restrictive conditions lessens the frequency of court 

hearings and other supervision requirements that may be sources of considerable 

stress for participants. 

Along with decisions about the severity of the charge, mental health court planners must also consider whether they will accept people who have already been 

sentenced in another courtroom or court program. For example, some mental health 

matching charges to court jurisdiction

The decision of which charges to accept will affect the 

court system in which the mental health court can be 

established. In most communities, a limited jurisdiction court based in a single county or municipality 

deals with misdemeanors (and sometimes ordinance 

violations) only, and a general jurisdiction court that 

may involve multiple counties takes all felony cases. 

Several mental health courts have decided to accept 

defendants charged with both felonies and misdemeanors and, as a result, have established two separate dockets in two separate court systems to account 

for jurisdictional limitations. 

| 31
courts accept offenders who have violated the terms of their probation and are referred by a judge or probation officer who believes the probationer may benefit from 

the involvement of the judge and regular status hearings. 

example: Mental Health Probation Violation Court (Maricopa County, Arizona) 

The Mental Health Probation Violation Court in Maricopa County, Arizona, targets people on the 

specialized mental health probation caseload. A probationer can be brought before the court after 

a violation, or if their probation officer determines them to be at risk of violation. If the probationer admits to a violation, he or she can be terminated and returned to the Department of Corrections, but in most cases the probationer is sanctioned and then remains on probation. Thereafter 

the court works with the probationer, probation officer, and treatment providers to determine 

the obstacles to successful adherence to court conditions. Participants return for status hearings 

at which sanctions and incentives are applied until the difficulties that brought them before the 

court are resolved, after which they resume their probation. In this way, the program serves as 

an alternative response to probation violations that usually avoids re-incarceration, thus saving 

costly prison beds and helping maintain continuity of treatment and community tenure for probationers with mental illnesses. 

Violence

Most mental health courts exclude people charged with violent offenses or who are 

charged with driving while intoxicated. Of the 37 BJA grantee courts, more than 75 

percent automatically deny admission to those charged with violent offenses, while 

the other 25 percent consider defendants with violent charges on a case-by-case

basis.32 The reasons for these exclusions are obvious: diverting people who have

committed violent offenses from jail to the community is a public safety risk few 

court officials are willing to accept. 

mental illnesses and violence

Many popular beliefs about violence and mental 

illness are not based in fact. Recently, several largescale research projects found only a weak statistical 

association between mental disorders and violence. 

Serious violence by people with major mental disorders is concentrated in a small fraction of the total 

population, particularly among those who use alcohol 

and other drugs and those without access to effective 

services.30 The vast majority of people with mental 

illnesses are not violent; in fact, they are more likely to 

be victims than perpetrators.31

 Because the majority 

(75 percent) of defendants with mental illnesses have 

co-occurring substance abuse disorders, this research 

makes clear the necessity of making effective substance abuse treatment a priority for mental health 

court participants.

32 |

step iii. considering elements of mental health court design and implementation
| 33

Some charges involving violence may, however, be more complicated than they 

first appear. For example, some cases of assault on police officers by people with 

mental illnesses may result from officers’ lack of awareness about mental illnesses or 

insufficient training to properly deescalate a situation. In these instances, a trespass

-

ing violation can quickly deteriorate into a shoving match, and a charge involving vio-

lence.33 Similarly, domestic violence cases involving defendants with mental illnesses 

can result from minimal behaviors like pushing, shoving, and agitation against 

parents, siblings, caretakers, or co-residents in housing facilities. These cases differ 

significantly from the documented cycle and endemic risk factors of ongoing spousal 

domestic violence. Mental health courts should consider potential participants based 

on the facts and circumstances underlying the charges to account for these situations. 

Diagnosis

Diagnosis-related eligibility criteria should be established in consultation with mental 

health treatment providers, giving careful consideration to the community’s capac

-

ity for treatment and the most effective use of existing resources. As with criteria 

related to charges and violence, diagnosis-related eligibility criteria vary widely across 

mental health courts. Of the 37 BJA grantee courts, more than half have very specific 

criteria, such as requiring an Axis I diagnosis, “serious and persistent mental illness” 

as defined by state law, or an Axis I and co-occurring substance abuse disorder. The 

other courts have much broader criteria and include defendants with brain injuries, 

developmental disabilities, and less serious mental illnesses. 

Decisions related to eligible diagnoses will have perhaps the greatest impact on 

the success of court participants. As discussed later in this guide, the key intervention 

provided by mental health courts is not identifying and processing defendants, but 

connecting them to treatment. Accordingly, whichever diagnoses the court decides 

to include, it must consider whether the corresponding treatment is available in the 

community, and how that treatment will be accessed. When discussing the complex 

issues related to the different types of mental illness and how they are treated, court 

officials should look to local mental health providers and administrators for guidance, 

and may also want to refer to Navigating the Mental Health Maze: A Guide for Court 

Practitioners, a companion to this guide. 
coordination with drug courts

The prevalence of co-occurring psychiatric and substance abuse disorders suggests that mental health 

courts would be wise to consider mechanisms for 

coordinating with the local drug court. More than 

1,100 drug courts operate across the country, and are 

present in most of the communities considering or operating a mental health court. Because of the significant overlap in the target populations for these related 

programs, mental health court planners should work 

with the administrators of their local drug court to 

ensure that all participants are connected to the most 

appropriate interventions. While there are no hard 

and fast rules for this coordination, a recent monograph on co-occurring disorders and specialty courts 

suggests that, in cases where criminal charges are not 

the deciding factor in court referral, people with more 

serious mental health problems (and less serious substance abuse problems) should be referred to mental 

health courts, and people with more serious substance abuse problems (and less serious mental health 

problems) should be referred to drug courts. Special 

programming should be developed for people with 

severe mental health and substance abuse disorders.34

Traditional diversion programs

(no intensive treatment

programming)

Drug court

Specialized co-occurring disorder 

programs, or enhancement of

existing specialty court programs 

to create unique “tracks” for

co-occurring disorders

Mental health court

program type

[ Low Severity ] mental illness [ High Severity ]

substance abuse [ Low ] [ High ]

34 |
| 35

Criminal history

Finally, a jurisdiction may want to limit eligibility based on criminal history. For 

example, many courts exclude defendants with prior convictions for violent crimes, 

even if the defendant’s current offense is nonviolent. Screening out people previously 

convicted of sex offenses is also a common practice among existing mental health 

courts. While issues of community safety will always be primary considerations, other 

criminal record issues—such as failure to appear in court—may be directly related 

to a person’s mental illness, and should not necessarily be cause for exclusion. Accordingly, many courts refuse to exclude defendants automatically based on criminal 

record information, choosing to determine eligibility on a case-by-case basis. Mental 

health court planners will also have to decide whether to accept cases involving graduates who have re-offended and whether to take post-sentence cases involving probation violations. 

Criminal history can also be a reason for inclusion. Some courts specifically 

target defendants with extensive criminal records—the proverbial “revolving-door” 

defendants for whom traditional court processing appears to have been consistently 

ineffective. 

example: Eighth Judicial District Mental Health Court (Clark County, Nevada)

In order to realize the greatest savings of criminal justice resources, the Eighth Judicial District 

Mental Health Court in Nevada targets defendants with at least five jail bookings in the previous five years. This strategy, along with the decision to include defendants charged with gross 

misdemeanors and felonies, allows the court to maximize the number of jail and prison beds for 

court participants. 

With little comparative research on the impact of mental health courts on different 

types of defendants, courts will need to set criminal history-related eligibility criteria 

based on their established goals and the collective perception of how the court can 

have the greatest impact. 

Setting eligibility criteria to establish a target population requires weighing the 

political climate of the jurisdiction, the available resources, and the specific objectives 

of the mental health court. This process leads to different results across communities. As one judge said, “Our philosophy is if someone has a mental illness, there’s 

no such thing as ‘inappropriate for mental health court.’ Even if they’re tough to deal 

with, locking them up is good for nobody.”35

 But another jurisdiction has resolved to 

focus on certain kinds of defendants with mental illnesses. As the judge there put it, 

“We have to triage to determine who will do well in the program, who we can actually 
juvenile mental health courts

Mental illness in the juvenile justice system is as 

prevalent, if not more so, than in the adult criminal 

justice system. Nearly two-thirds of boys and nearly 

three-quarters of girls in juvenile detention facilities 

have at least one psychiatric disorder, far exceeding 

the 15 percent among the general population.36

Recently, this issue has received attention from Congressional lawmakers in the form of a report prepared 

for Rep. Henry Waxman (D-California) and Senator 

Susan Collins (R-Maine) titled, “Incarceration of Youth 

Who Are Waiting for Community Mental Health Services in the United States,” which chronicles the trend 

of youth with serious mental disorders being detained 

without criminal charges, or being eligible for release 

but remaining in detention because of insufficient 

surface slots.37

Only a handful of jurisdictions (including Santa 

Clara, San Diego, and Los Angeles, California, and Cincinnati, Ohio) have adapted the mental health court 

concept to the juvenile justice system, so even less is 

known about their operation and effectiveness than 

is known about adult mental health courts. Juvenile 

mental health courts do appear to confront many of 

the same operational issues as those for adults, but 

because of their participants’ status as minors, juvenile mental health courts must also address a separate 

range of issues, including:

• Involving parents and guardians. Juvenile 

mental health courts must focus even more than 

adult courts on developing services that address 

the psychosocial needs of the family, as well as 

those of the youth.38

• Linking with the foster care system. Upon 

arrest, children in foster care are more likely to 

be sent to juvenile detention centers than back 

home.39 This can exacerbate mental health issues 

and result in a child’s losing his place in the foster 

care or group home. Juvenile mental health 

courts may include child welfare representatives 

to protect the stability of the youth’s living arrangement. 

• Reporting child abuse. Many youth in the 

juvenile justice system have been neglected or 

physically or sexually abused. Mandatory reporting laws require that all social service professionals, including those in the mental health court, 

report a suspicion of child abuse to their state’s 

child protective services agency. 

• Working with schools. When a youth’s mental 

illness interferes with her learning and ability to 

progress in the regular school curriculum, she 

may be eligible for special education services. 

These services can support court-ordered treatment by providing a structured environment that 

responds to the unique needs of each youth.40 

• Recognizing developmental issues. Most youth 

with mental illnesses experience the same developmental issues as healthy adolescents. Juvenile 

mental health courts must design interventions 

in a manner that responds to these unique developmental needs. 

36 |
| 37

help.”41 The ideals of inclusiveness and triage can often be at odds, and communities 

must resolve these and other conflicts as they solidify their courts’ target populations. 

3. CONFIDENTIALITY

Mental health court processes require that considerable information about participants be collected and shared at all points of the court process, from the initial 

screening to the eligibility determination and throughout the entire period of judicial 

supervision. The need to share information raises important and difficult concerns 

related to confidentiality, requiring mental health court planners to consult all relevant state and federal regulations. Within these statutory limits, participants’ medical, 

mental health, and substance abuse treatment information must be safeguarded, and 

participants must be allowed to specify with whom information can be shared, all the 

while maximizing collaboration between agencies that are sharing information. 

Any discussion of confidentiality issues immediately raises the specter of the 

Health Insurance Portability and Accountability Act of 1996 (HIPAA) that protects 

patients from the unauthorized release of their medical information. This law has 

created some confusion about what information can be exchanged within and across 

criminal justice and mental health settings, and has significant implications for mental health courts. Fully resolving this confusion is, unfortunately, beyond the scope of 

this guide. However, the safest way to comply with HIPAA requirements is to assure 

that mental health court participants provide their written consent to release information on a form that specifically identifies what information will be released and the 

parties to whom it will be released. 

example: Buffalo Mental Health Court (New York) 

Participants who enter the Buffalo Mental Health Court sign a series of releases of information 

for collecting medical and mental health information. The information included in those releases 

is then entered into a database that mental health court personnel can review. The database indicates which staff members are authorized to speak to which treatment providers, what kind of 

information can be shared, and the dates when releases expire. This process protects the participant’s confidentiality by preventing inappropriate accidental communications between unauthorized court personnel and treatment providers. (A copy of this release form is in Appendix D.) 

Courts can also address confidentiality issues by instituting rules for excluding clinical information from the public record of the court, or by simply allowing such information to be discussed only in sidebar or chamber conversations. 
Information-sharing protocols should also take into account the potential impact of 

clinical information on the regular processing of defendants’ criminal cases if they 

are not accepted into, or do not successfully complete, the mental health court program. Defense attorneys have an important role here; their position as client advocates should include concern for privileged information about their clients’ mental 

health conditions.42 

 With such a large percentage of mental health court participants suffering 

from co-occurring substance abuse disorders, federal regulations related to substance 

abuse treatment information also deserve careful attention.* The relevant federal 

regulations for substance abuse treatment information are 290dd-2 of Title 42 of 

the United States Code, which applies to all drug treatment programs, and 42 C.F.R. 

§ 2.20, which explains how federal and state laws interact when their confidentiality provisions differ. As with HIPAA, a defendant’s written consent to the release of 

information can overcome most information-sharing restrictions in these federal 

regulations. 

4. TERMS OF PARTICIPATION

Mental health court planners must consider a number of issues when establishing 

the terms of program participation, including the plea participants are required to 

enter, the duration of the program, the conditions of supervision, and the impact of 

program completion. These general terms should be adapted to the specific conditions of each defendant, who should have the opportunity to consider the terms with 

the advice of defense counsel before agreeing to enter the court program.

*For more information on the 

confidentiality of 

substance abuse 

treatment information, readers should 

consult “Federal 

Confidentiality Laws 

and How They Affect 

Drug Court Practitioners,” available at 

http://www.ndci.

org/admin/docs/

confid.pdf. Much of 

the guidance in that 

document is directly 

applicable to mental 

health courts.

prevalence of required guilty pleas in mental health courts

An examination of eight selected mental health courts 

undertaken in 2002 found that five of eight required 

a guilty plea for program entry.43 In a subsequent 

examination of some twenty mental health courts, 

The Bazelon Center for Mental Health Law found that 

approximately half required a guilty or no contest 

plea for program entry.44 Approximately 40 percent of 

the 37 BJA grantee courts require a guilty plea for all

participants, though the percentage requiring a guilty 

plea for some participants (e.g., those charged with 

felonies) is somewhat higher.45

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step iii. considering elements of mental health court design and implementation
| 39

Plea

Determining the type of plea a program participant will be required to enter is one of 

the most contentious operational decisions. While there are nuances related to different plea options in different states, the core issue is whether the court will require the 

participant to enter a guilty plea. Powerful arguments support both sides of this issue, 

and practices in the field follow suit.

From the prosecutor’s standpoint, a guilty plea is desirable in case the person fails 

in the mental health court and is returned to the regular court process. Without a 

guilty plea, the prosecution will have to remain vigilant about the defendant’s consti

-

tutional right to a speedy trial and will have to reopen the case if it is returned to regu-

lar court. The definition of speedy trial varies across states, but when the time limit is 

reached and a case has not been disposed of, the case is generally dismissed. This is a 

distinct possibility when a mental health court participant leaves the program, either 

of his or her own volition or because of non-adherence to court conditions. Accord

-

ingly, mental health courts that choose not to require a guilty plea should consider the 

development of a form through which participants waive their right to a speedy trial. 

If the case does return to regular court, the prosecution’s task will be complicated. 

The offense might have occurred months—or even years—in the past; witnesses may 

no longer be available and evidence may be lost. 

From the defense’s point of view, requiring a guilty plea leaves a client virtually 

unprotected if he or she fails in the mental health court. The client will have given up 

all the rights afforded to an innocent person, and the sole issue on which the defense 

would have input would be sentencing. In a similar vein, advocates have argued that 

requiring a guilty plea unfairly stigmatizes defendants with mental illnesses, leav-

ing them with a black mark on their records that will hamper their ability to get a 

job, find housing, and receive treatment.46 These concerns are important, as many 

people with serious mental illnesses have histories of minor offenses. A guilty plea 

entered in mental health court may also affect how the criminal justice system treats 

subsequent crimes. For example, a recently passed Florida law requires a mandatory 

minimum six-month jail sentence for persons convicted for the fifth time of a mis

-

demeanor offense. Other jurisdictions have legislated habitual offender statutes that 

make it a felony offense to commit a misdemeanor crime more than twice. 

Mental health courts have devised a variety of strategies to weigh the interests of 

the prosecution, defense counsel, and the defendant in establishing the plea arrange-

ments for their programs. Some courts accept a conditional guilty plea: charges are 

dismissed if the defendant is successful in the mental health court. Others hold 
40 |

step iii. considering elements of mental health court design and implementation

charges in abeyance or defer prosecution during the period of judicially supervised 

treatment. Still others vary the plea arrangement depending on the severity of the 

charge (e.g., misdemeanor vs. felony). And in some mental health courts, the prosecutor extends two plea offers: a more favorable one, which applies if the prospective 

participant graduates from the mental health court (such as a dismissal or a no jail 

time offer), and a second offer, which applies if the prospective participant decides to 

return to the regular court or is returned for non-adherence. The second offer is the 

offer that a defendant would typically receive in the regular court. Whichever plea arrangement a mental health court decides to adopt, prospective participants must fully 

understand the implications of the plea, especially if they are not able to complete the 

terms of participation outlined by the court. 

Mental health court planners should also consider establishing a protocol for 

accepting people who have already been sentenced in another court (e.g., probation 

violators), and for resolving outstanding charges or conditions prior to program participation. Some defendants may come to the mental health court with another case 

pending or with an existing probation order. In these situations, the conditions that 

the original court placed on the defendant may contradict the mental health court 

conditions. Likewise, the staff member responsible for monitoring the potential participant, such as a probation officer, will have no mandate to coordinate their supervision with the mental health court. 

Duration

Mental health court planners must also decide how long participants will—or 

might—remain under the auspices of the court. This issue is more difficult to resolve 

in the context of a mental health court than in a traditional court setting. Mental 

health courts are designed to help participants avoid future criminal justice involvement, which depends on many factors specific to an individual’s situation. Simply 

matching certain offenses with set program durations is not likely to serve this 

broader goal. For this reason, many mental health courts establish minimum and 

maximum periods of participation, but vary the specific length of judicially supervised treatment for each participant. Most programs last between one and two years, 

but some are as short as six months or as long as three years (or more). 

example: Orleans District Mental Health Court (Louisiana)

All participants in the Orleans District Mental Health Court, whether charged with a misdemeanor or a felony, are in the program for a minimum of one year. The maximum period of judicially 

supervised treatment is equivalent to the maximum length of probation (two years for misdemeanors, five years for felonies). Within this range, the program duration is individualized. The 
| 41

court team determines specific goals that a participant must meet to move through the three 

phases of supervision intensity and to graduate from the program. Because of the diversity of participants’ functioning and abilities, no two participants have the exact same expectations placed 

upon them. In some cases, participants will graduate much earlier than their maximum period 

of probation. 

With the existing variability in the length of court programs, clear guidelines 

for establishing program duration are difficult to identify. Some suggest limiting 

the length of time the participant is under the court’s jurisdiction to the maximum 

penalty the defendant could receive if found guilty of the instant charge or charges in 

the traditional court process. This simple concept has merit—mental health courts 

should not serve as mechanisms to extend a person’s involvement with the criminal 

justice system—but the calculus is actually quite complicated. 

The modern criminal justice system relies on a system of plea-bargaining that 

makes it highly unusual for any individual to receive the maximum sentence for the 

crime with which he or she is charged, particularly for low-level, non-violent offenses. 

Accordingly, the maximum penalty someone could have received is almost never 

commensurate with the penalty they would have received in practice, were they not to 

enter a mental health court. But some low-level offenders will have the most complicated treatment needs, and would require a considerable period of court-supervised 

treatment to achieve stability in the community, which would be totally disproportionate to the severity of the charges against them.

On the other hand, mental health courts do provide significant benefits to participants that may justify a term of supervision longer than the jail term that they would 

have received in traditional court. Mental health courts provide resources to assist 

participants in obtaining treatment in a fragmented, difficult-to-access service system. 

Some participants may see the requirements of treatment, status hearings, and other 

conditions as a greater restriction on their freedom than a brief jail term, but from 

the point of view of the criminal justice system, a respite from jail is a reasonable 

trade-off for a significant period of community treatment. 

These difficult and conflicting concerns reaffirm the importance of informed 

choice, the next element discussed. Whatever duration a mental health court team 

sets, prospective participants should have the opportunity to consider the mental 

health court option carefully, with the advice of defense counsel and treatment 

providers, before deciding to enter the program. Ensuring the voluntariness of this 

decision is the best way to match program duration to the needs and interests of the 

participants. 
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step iii. considering elements of mental health court design and implementation

Supervision

Court planners should also develop standards for the frequency of court appearances 

and other scheduled meetings participants will be expected to attend, such as reporting to probation, pretrial services or other court agencies. Unlike the plea arrangement, which is established firmly when a participant enters the court, the terms of 

supervision and status hearings are usually adjusted according to the participants’ 

progress in treatment and adherence to court conditions. In fact, many courts have 

divided the program into phases with differing levels of supervision and reporting requirements. The mechanics of supervision, status hearings, and monitoring 

adherence to court conditions are discussed in more depth in Element 9 (Monitoring 

Adherence to Court Conditions). 

Treatment 

The terms of an individual’s treatment are the most important yet also the most difficult to determine. Unlike plea arrangements or the duration of program participation, treatment plans must be highly individualized, and therefore, general standards 

are not particularly useful. In addition, treatment plans often change, sometimes 

multiple times, based on a participant’s response to treatment. Treatment conditions should be determined with input from mental health professionals, and the 

procedures for integrating treatment providers into the court process are discussed 

in more depth later in this guide (see Element 7, Integration of Treatment and Community Supports). In addition, court practitioners interested in learning more about 

mental illnesses and their treatments should consult Navigating the Mental Health 

Maze: A Guide for Court Practitioners, a companion to this guide. 

In any diversion program, including a mental 

health court, the intervention is not the process 

by which the person is being diverted—it is the 

treatment that they receive. The success or failure 

of the program depends on linking participants to 

effective treatment in the community. 47

Henry J. Steadman, President, Policy Research Associates 

”

“
Impact of program completion on charges

Finally, court planners will have to decide the impact of program completion—both 

favorable and unfavorable—on participants’ cases. This component of the program 

is linked closely to the plea arrangement, in that the impact of program completion is 

usually (and should be) determined prior to entry. Mental health courts usually vary 

the impact of successful program completion based on the severity of the charges; 

many courts dismiss misdemeanor charges, while those that accept felony charges 

may reduce them or place participants on probation after program completion. 

The impact of unsuccessful program completion depends largely on the plea arrangement. Courts that require a guilty plea usually agree upon a sentence up front 

that would be applied if the participant does not complete the program. Mental health 

courts that do not require a guilty plea typically send the participant back to the original court of jurisdiction. In structuring these arrangements, court planners should 

strive to ensure that participants who voluntarily leave the program do not have

negative repercussions in their case that stem from leaving the program, and are

not related to the original criminal charge. 

5. INFORMED AND VOLUNTARY CHOICE

Like any diversion program or sentencing alternative, all mental health courts are 

voluntary, and defendants must not face negative repercussions if they decline to 

participate. But voluntariness in the mental health court context is more complicated 

than simply presenting the option of participation to defendants. Mental health 

courts must establish procedures to ensure that defendants are legally competent and 

that they fully understand what participation in the court involves prior to accepting 

admission. Attention should also be paid to the experience of court participants after 

they have decided to enter the program. 

legal competency defined

The definition of competency for legal proceedings 

varies among states, but in general, a defendant is 

considered legally competent when he or she can understand the legal situation and the proceedings and 

can also assist his or her attorney in the defense.48 If a 

person is not competent to stand trial, he or she is not 

competent to decide to enter a mental health court 

program.

| 43
44 |

step iii. considering elements of mental health court design and implementation

The question of legal competency must be addressed prior to considering any 

defendant for participation in the mental health court (see sidebar on previous page). 

If a defendant is not competent to aid in his or her defense, he or she is certainly not 

competent to volunteer for participation in a mental health court program. Some 

mental health courts rely on existing mechanisms to determine competency. However, these processes are often time-consuming, which is particularly problematic in 

misdemeanor cases, for which the time to determine competency often exceeds the 

maximum likely jail time for the offense. In response to this obstacle, some mental 

health courts have developed expedited processes for determining competency. 

example: Anchorage Court Coordinated Resources Project (Alaska)

The Anchorage CCRP (the title for the mental health court there) identified the need for expedited 

competency evaluations as a way to speed resolution of misdemeanor cases and reduce unnecessary periods of incarceration while awaiting evaluation for competence. With assistance from the 

Alaska Mental Health Trust Authority, CCRP achieved an agreement with the relevant state agencies to expand capacity for competency evaluations by dedicating a full-time, doctorate-level clinician to performing forensic examinations. This clinician is able to complete competency evaluations in misdemeanor cases within one week—often within one day of the order—significantly 

decreasing the time for resolution of criminal cases and avoidable periods of incarceration.

Other courts have established unique relationships with the competency determination and restoration process, targeting defendants who have been referred for competency evaluations and providing an alternative to traditional criminal processing for 

those whose competency is restored. 

example: Broward County Felony Mental Health Court (Florida)

When competency issues are raised in a felony case in Broward County, the case is transferred 

to the mental health court for monitoring while the defendant’s competency is restored. If the 

defendant’s competency is restored, the case remains with the mental health court, which, in 

exchange for a guilty plea, can downwardly adjust the sentence and place the defendant on felony 

mental health probation instead of sending him or her to prison.

Once competency is established, defense counsel play a critical role in making 

sure defendants understand the implications of all of their available options, including entering the mental health court. Defense counsel should discuss with their 

clients the requirements of program participation and the consequences for failing 

to abide by court conditions, and should help them weigh the mental health court 

option against traditional criminal case processing. In courts where a guilty plea is 

required for participation, the implications of that plea should also be explained. 
| 45

Recent research indicates that ensuring that court participants are fully aware of 

their ability to opt in or out of mental health court is difficult: a study of the original 

Broward County Mental Health Court, which targets defendants charged with misdemeanors, found that about one-third of study participants were unaware of their ability to choose between mental health court and regular misdemeanor court.49 For this 

reason, many courts have wisely listed all the court terms in a written, formal contract 

that is concrete, easy-to-read, and free of legalese and other jargon. Defendants have 

the opportunity to review the contract with their defense attorneys before signing and 

accepting entry into the court. 

example: Oklahoma County Mental Health Court (Oklahoma)

The Oklahoma County Mental Health Court provides participants with a comprehensive handbook. The handbook includes information on terms of participation, transition from the court 

back to the community, contact information for relevant court agencies, confidentiality protections, and a performance contract. The contract is individualized for each participant; it includes 

agreements to make appointments, acknowledgement of the possibility of sanctions for nonadherence, and rules for courtroom behavior. After careful review with the team, the participant, 

the judge, the defense attorney, and the DA all sign the contract. (A copy of this contract is included in Appendix E.) 

The question of voluntariness does not end with entry into the court program. 

Mental health court planners should also consider how the development of treatment 

plans, the structure of status hearings, and other program components contribute to 

participants’ perceptions of the court, particularly the extent to which they experience 

the process as coercive. The relationship between coercion (either actual or perceived) 

and the effectiveness of mental health treatment is empirically unclear, but there is 

reason to think that a participant who perceives the mental health court process as 

fair, respectful, and open to his or her input will be more likely to adhere to the treatment plan and other court conditions and to respond positively to requests from the 

courtroom team.50 

The experience of participants should be considered in all aspects of the court process: Are participants offered options as to where they will receive treatment? Do they 

have the opportunity to request changes in their treatment plans or explain their reasons for non-adherence? Are court team members familiar with the details of participants’ personal interests? Do court team members use stigmatizing language? Many 

mental health court practitioners take considerable steps to address these issues, and 

it is not surprising that some participants describe the mental health court team as 

a positive support structure or even part of their family. Attention to the subjective 
experience of court participants is another aspect of ensuring voluntariness, and may 

help improve the success of court participants. 

6. PARTICIPANT IDENTIFICATION

The prompt identification of potential participants and quick determination of their 

eligibility for the court is essential. Efficient and effective participant identification 

requires the development of processes for:

• Receiving referrals

• Screening referrals for eligibility

• Gathering further information about those who screen positive

• Making final eligibility determinations

Each court accomplishes these tasks differently, based on the organization of

its criminal justice system and its staffing complement. The guide describes these 

four processes as separate events in order to highlight the various components of 

screening defined

In this section, the term screening refers to the 

process by which a mental health court determines 

whether a defendant is eligible for the program according to the legal and clinical criteria established. A 

positive screen does not mean that the defendant will 

ultimately be admitted into the program, just that 

they fit within the target population, and that more 

information should be gathered to determine their appropriateness for the mental health court. 

The term screening has a distinct meaning in correctional institutions. In general, screening in jails 

and prisons is divided into two segments.51 

• Receiving Mental Health Screening. 

Mental health information and observations, 

particularly risk of suicide, gathered about every 

new inmate or detainee when they arrive at an 

institution, usually based on a standard screening form. 

• Intake Mental Health Screening. A more comprehensive screening performed within 14 days of 

arrival at an institution, which usually includes 

a review of the receiving screening, behavior 

observations, and an inquiry into mental health 

treatment history.

Inmates who screen positive at either juncture 

are usually referred for a more comprehensive mental 

health assessment.

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step iii. considering elements of mental health court design and implementation
| 47

participant identification. However, some mental health courts accomplish multiple 

tasks simultaneously (e.g., screening and gathering further information). 

Referrals

Information that an arrestee may have a mental illness can come from a number of 

different sources, including police, jail staff, probation officers, judicial officers, drug 

court programs, pretrial services staff, prosecutors, defense attorneys, mental health 

or substance abuse treatment providers, family, friends, or defendants themselves. 

Almost all mental health courts accept referrals from a combination of these sources, 

helping to ensure the identification of appropriate participants. But casting a wide net 

carries with it complications: ultimately many people are found to be ineligible, either 

because of their legal charges, their diagnoses, or their decision not to participate. 

These negative screenings mean that significant court staff time is devoted to people 

who will not participate in the program.*

For this reason, court planners should consider identifying primary and secondary 

referring agents (e.g., the public defender’s office, the jail) from which they receive 

most of their referrals.52 A recent study of seven mental health courts revealed that 

four of the courts received more than 40 percent of their referrals from one office 

or program (e.g., the public defender’s office).53 Pretrial services programs, which 

interview people shortly after arrest to gather information to be used by the court at a 

bail-setting hearing, are particularly well-positioned to identify and refer people to the 

mental health court. 

example: Hamilton County Pretrial Services Program (Ohio)

In Hamilton County, the pretrial services program added questions to its standard interview to 

identify mental health issues. When issues are discovered, pretrial staff immediately schedule 

an assessment by an in-house psychiatrist. As a result, at the defendant’s first appearance, the 

pretrial report contains information related to defendants’ mental health status and, where appropriate, a recommendation from the court psychiatrist as to appropriate conditions of release. 

The report may also suggest a referral to the mental health court for eligible defendants.

Courts should also consider educating potential referral sources about the mental 

health court’s eligibility criteria to reduce time spent processing improper referrals. 

example: Allegheny County Mental Health Court (Pennsylvania)

Allegheny County Mental Health Court staff distribute referral forms to any member of the community upon request. To improve the quality and reliability of referrals, the court conducts training for staff from systems likely to supply referrals, including law enforcement officers, judges, 

public defenders, prosecutors, service providers, and consumer advocates. Initially, court staff 

*“Negative” screenings for mental 

health courts represent an opportunity 

that mental health 

court staff should not 

neglect. People who 

have mental health 

problems but are not 

legally eligible for the 

mental health court 

can and should be 

referred to community mental health 

services.
48 |

step iii. considering elements of mental health court design and implementation

used trainings to provide an overview of mental illness and mental health court policy and procedure. After identifying a high rate of inappropriate referrals, court staff decided to focus training on eligibility requirements. Since this change in emphasis, the rate of accepted referrals has 

increased. (A copy of the referral form used in Allegheny County is in Appendix C.)

Screening for eligibility 

Once referrals are received, mental health courts need to screen them for legal and 

clinical eligibility for the program. Across mental health courts, screening mechanisms differ substantially as does the person responsible for this task. Most commonly, courts identify a single staff member, usually one with a mental health background, to manage this function. This helps ensure consistency in applying screening 

instruments and in analyzing eligibility criteria. In some courts, this screener makes 

recommendations to the court regarding eligibility of the defendants and may even 

propose a treatment plan. In other courts, screened participants undergo a more 

comprehensive assessment before a treatment plan is developed. 

example: San Bernardino Mental Health Court (California)

In San Bernardino County, prospective mental health court participants are screened by the district attorney, public defender, and mental health staff, each of whom have veto power over admission. Before a clinical assessment is preformed, the district attorney and the public defender 

assigned to the mental health court review the defendants’ legal histories and current charges. 

The district attorney essentially sets the upper limit or “legal ceiling” for potential participants: 

defendants with histories of violence or crimes of a sexual nature are disqualified. The public defender sets the lower limit or “legal floor” for acceptable charges, usually vetoing admission for 

defendants with limited criminal histories and low level misdemeanor charges. If both the district attorney and public defender agree to recommend a defendant for participation, a licensed 

clinician assesses the defendant for mental health history and current mental status. Individuals 

with serious and persistent mental disorders who meet the legal criteria are recommended for 

admission to the court.

Because of the high frequency of co-occurring disorders among the target population, mental health court screening protocols should include information on both 

mental health and substance abuse needs. 

Gathering information 

After the initial screening, more comprehensive information about potential participants is required, both to confirm the initial positive screen and to develop a treatment plan which will be presented to the participant and the court team. As with 
the screening, the information gathering process is usually centralized in the hands 

of one or two staff members, who work with staff representing the different components of the criminal justice and mental health systems to gather the necessary 

background information. 

Information about potential participants must be drawn from a variety of sources. 

Most offenders with mental illnesses have had multiple contacts with the mental 

health and criminal justice systems, and these agencies can provide information relevant to eligibility and treatment needs. Accessing pre-existing information controls 

costs by keeping new evaluations to a minimum and also ensures continuity of care. 

Furthermore, mental health and criminal justice agencies may be able to contribute 

relevant facts that the defendant is unable or unwilling to provide, such as past offenses, employment history, family contacts, medical insurance and benefits information. As discussed previously, information sharing must comply with all privacy laws 

and regulations; obtaining a defendant’s written consent to release information is the 

surest way to adhere to these regulations. 

example: Muscogee County Mental Health Court (Georgia)

The Muscogee County Mental Health Court operates two separate dockets: state court for misdemeanors and superior court for felonies. Referrals for both dockets are sent to the mental health 

court program director or the case manager, both employees of New Horizons, a communitybased mental health treatment agency. The New Horizon employees visit prospective participants individually in the jail clinic (if they are still being detained) or at the New Horizons office (if 

they have been bonded out) to discuss mental health court programs and to have interested people sign a HIPAA-compliant release of information form. Prospective participants consult with 

mental health assessments

Many mental health courts have a full mental health 

assessment for each defendant completed prior to 

making a final determination of eligibility. An assessment (which may also be called an evaluation) requires a mental health professional to examine health 

records, observe behavior, and administer mental 

status exams. Proper assessment also requires careful 

attention and adequate time to rule out medical conditions or substance use that could account for abnormal mood, behavior, or thinking. Often, multiple assessments are needed to sort out diagnoses, duration, 

and disability. For this reason, some mental health 

practitioners argue that an assessment is not a discrete event but rather a continuous process of evaluating a consumer’s illness and progress. In some courts, 

the assessment is completed by a clinician employed 

by the court, and in others the task is assigned to an 

outside mental health provider. The timing for assessments also varies: some courts require a completed assessment before eligibility is determined, while some 

wait until after the participant has volunteered for 

and been granted entry into the program.

| 49
50 |

step iii. considering elements of mental health court design and implementation

defense counsel either prior to meeting the New Horizon employees or soon thereafter. Some 

prospective participants are met several times before the information release form is signed to 

ensure that consent is fully informed. Once the release form is signed, the New Horizon employees compile any past treatment history with the agency, speak with family members, and then 

prepare a treatment plan. The plan is presented to the court team at the case staffing before the 

next mental health court session, at which point final eligibility is determined by the prosecutor 

and the judge. 

Final eligibility decision

Once defendants are screened, legal and clinical eligibility is reviewed, and information is gathered about the participant, a final decision must be made to accept or 

reject a defendant for participation in the mental health court. Court planners should 

ensure that all team members have input into this decision. While it is not uncommon for the prosecutor and or the judge to have veto power over all potential participants, efforts to maximize the collaborative nature of the final eligibility decision will 

serve the team well in the long run. 

As noted in the sidebar on assessments (previous page), some courts make a final 

decision about eligibility and accept a defendant into the court before a full mental 

health assessment has been completed and before a treatment plan is developed. In 

these cases, a subsequent hearing may be held to determine the precise treatment 

and other conditions to which the participant will adhere. 

example: Anchorage Court Coordinated Research Project (Alaska)

Participation in the Anchorage CCRP is determined during an initial opt-in hearing and a second, 

formal opt-in hearing. At the initial opt-in hearing, which occurs about a week after the individual 

is screened, defendants sign a waiver of their speedy trial rights and an information release form, 

after which they are released to the supervision of a mental health case coordinator. The case 

coordinator develops the treatment plan in conjunction with the defendant, and subsequently 

shares the plan with the defense attorney. If the defendant and his or her attorney approve the 

plan, it is shared with the prosecutor and the judge. Upon agreeing to the plan, the defendant 

returns for a formal opt-in hearing, which occurs, on average, one month after the initial opt-in 

hearing. Along with ensuring speedy release to the community for potential participants, this 

process helps to ensure the confidentiality of mental health information, as the defendant, with 

advice of counsel, has the opportunity to review the plan before it is shared with the prosecution 

or judge. 

As mental health court teams develop systems for identifying and accepting 

participants, benchmarks for the speed with which defendants will be processed 
| 51

through these systems should be established. Time limits are especially important for 

misdemeanor cases, in which defendants could spend more time in jail waiting for 

a treatment plan to be developed than they might otherwise serve if their cases were 

processed through the regular court. In such situations, one of the core goals of most 

mental health courts—reducing jail time for program participants—could be compromised. On the other hand, identifying appropriate treatment resources is difficult, 

especially for defendants with more significant needs and more serious charges. The 

need to balance the goals of timeliness, appropriate treatment, and public safety leads 

to wide variety in processing time across court programs: some mental health courts 

screen, gather information, and determine eligibility in less than one week, while others take months. 

example: Tempe Municipal Mental Health Court (Arizona) 

Because the Tempe Municipal Mental Health Court targets only people who have an existing case 

manager with the local mental health system, the court is able to identify most participants and 

confirm their participation within less than a week of their arrest. Most participants are identified by the prosecutor at pretrial conference, at which they are offered the opportunity to participate in the court program. Interested defendants sign a preliminary contract and release of 

information form, after which the mental health court liaison works with their case manager to 

identify the problems that led to their criminal justice involvement and to develop a revised treatment plan. Defendants then appear at the next weekly mental health court hearing, at which 

point they can decide (with the advice of defense counsel) either to participate or to return to 

regular court. Even after they have agreed to participate, defendants can opt out of the program 

at any time with no negative repercussions for their case. Defendants who remain in the court 

program generally report for status hearings on a monthly basis. 

example: Bronx Mental Health Court (New York)

The Bronx Mental Health Court targets defendants with mental illnesses who are charged with 

felony offenses or persistent misdemeanors. A majority of the defendants who are accepted also 

have co-occurring substance use, trauma histories, and personality disorders. One-third of the 

participants accepted for diversion are residing in the community following their initial hearing, 

and are facing jail and prison incarceration; two-thirds of participants, who are typically facing 

a minimum of two years in prison, are evaluated for diversion while detained in jail. Due to their 

serious charges, significant service needs, supervision requirements, and lack of community ties, 

this group stays in jail an average of three months awaiting placement. The Bronx Mental Health 

Court addresses service gaps by supplementing community resources with intensive direct clinical case management, psychiatric consultation liaison services to the community providers, and 

with court monitoring.
52 |

step iii. considering elements of mental health court design and implementation

Either way, ambitious but realistic targets will help the court reduce the time spent 

in jail for people with mental illnesses who can be supervised safely and effectively in 

the community.

7. INTEGRATION OF TREATMENT AND COMMUNITY SUPPORTS

A mental health court’s success is predicated on its participants receiving comprehensive treatment in the community. Unfortunately, this is not as simple as assessing a 

participant, making a diagnosis, and setting up an appointment for services. People 

with serious mental illnesses, particularly those who become involved in the criminal 

justice system, have extensive and complicated needs. Typically, they have co-occurring substance abuse disorders and complicating medical conditions. They are more 

likely than the general population to be homeless and may lack resources to pay for 

treatment and other basic needs. 

A mental health court that has effectively defined its goals, established a target 

population, assured voluntariness and confidentiality, developed terms of participation, and identified eligible participants—in other words, a court that has addressed 

all of the elements discussed thus far—has achieved only the precursors to program 

success; it has yet to actually apply the intervention designed to produce positive 

outcomes. This section provides guidance on integrating treatment and related 

supports into the court process, including identifying the treatment needs of court 

participants, developing treatment plans, contending with the high prevalence of cooccurring disorders, and planning for the transition of participants out of the mental 

health court program. 

 To address these issues, court practitioners will need to understand basic information about mental illnesses and their treatment, subjects which are beyond the 

scope of this guide. For this reason, CSG has published Navigating the Mental Health 

Maze: A Guide for Court Practitioners as a companion to this document. Navigating 

the Mental Health Maze provides detailed information about the mental health service 

system, the types of mental illnesses that court participants have, how those illnesses 

are diagnosed, and the kinds of treatment and supports that participants require. 

Representatives of criminal justice agencies participating in mental health court programs are strongly encouraged to consult that guide. 
| 53

Identifying treatment needs

Developing strategies to meet the treatment needs of mental health court participants 

requires in-depth discussions to answer questions such as the following: 

• What are the expected treatment needs of the participants?

• Who is able to provide each type of treatment? 

• How much will these services cost?

• How will treatment providers be compensated? 

Obviously, these questions can only be answered with criminal justice and mental 

health representatives at the table together. Courts cannot simply expect treatment to 

be made available to their participants without the buy-in of community-based treatment providers. As many court officials have learned, this often requires reaching out 

to an array of agencies. For example, more than 75 community-based agencies have 

provided services to participants in the Brooklyn Mental Health Court.54 In other 

jurisdictions, such as in the example below, service slots may be somewhat easier to 

identify. 

example: Bonneville County Mental Health Court (Idaho)

The Bonneville County Mental Health Court relies on an existing Assertive Community Treatment (ACT) team to serve all court participants. Because of the low client-to-staff ratio of ACT 

programs, the mental health court accepts no more than 20 clients at any given time. The court 

chose to rely on an ACT Team to ensure public safety and to overcome the inherent difficulty of accessing treatment in a rural setting. 

Recognizing the current gaps in the service system, some courts have secured resources and contracted with providers for a pre-determined number of beds or treatment slots. While this strategy may improve access to treatment for mental health 

court participants, it raises important philosophical and practical issues. One of the 

most trenchant criticisms of mental health courts is that they prioritize treatment 

for court-involved consumers above treatment for those who have not committed a 

crime.* Isolating treatment slots for mental health court participants contributes to 

the perception, and in some cases the reality, that becoming involved in the criminal 

justice system makes it easier to obtain services. In response to this criticism, mental 

health court planners should establish clear arrangements with mental health treatment providers that ensure treatment access for mental health court participants 

without jeopardizing treatment availability for the general public.

*“Criminalization of

People with Mental 

Illnesses: The Role 

of Mental Health 

Courts in System Reform,” by The Bazelon 

Center for Mental 

Health Law, offers a 

thorough discussion 

of this concern.

Available at:

www.bazelon.org/

issues/

criminalization/

publications/

mentalhealthcourts/.
As discussed later in this section, mental health court participants are likely to 

require care long after judicially supervised treatment has ended and, as a result, 

are best served by linkages with community-based providers who are prepared to 

treat consumers regardless of their court status. When defendants receive services 

from one agency while under court supervision and from a separate agency after the 

program ends, continuity of care is hampered. One exception to this view is courtbased case management. Court-based case managers perform essential planning and 

monitoring functions of court-ordered treatment and support and this function can 

be readily transferred to a community-based case manager upon program completion 

without disrupting the flow of treatment.

The mental health court planning committee should identify all available services, 

particularly those previously unknown to the court, and ensure that these programs 

are willing and able to accept court referrals. Estimated capacity needs for the various 

types of treatment should be informed by local data on the projected size of the target 

population and the types of diagnoses anticipated among court participants. As mentioned above, a complete discussion of the likely treatment needs of mental health 

court participants is included in Navigating the Mental Health Maze: A Guide for Court 

Practitioners. These needs include: 

• Psychiatric hospitalization

• Inpatient mental health treatment (crisis stabilization)

• Outpatient mental health treatment

paying for services and supports: the role of benefits programs

Practitioners working at the intersection of the 

criminal justice and mental health systems, including those in mental health courts, are increasingly 

paying attention to the importance of federal benefit programs such as Medicaid and Social Security 

Insurance as funding sources for treatment and other 

supports. In general, federal funds cannot be accessed 

for people who are incarcerated, but steps can be 

taken to accelerate the reinstatement of benefits after 

incarceration, including the establishment of policies 

to suspend, rather than terminate, Medicaid benefits, 

and the development of prerelease application procedures with local, state, and federal benefit agencies. 

Mental health courts should take steps to ensure that 

eligible participants are connected as quickly as possible to federal benefit programs, and consult guides 

such as the Bazelon Center for Mental Health Law’s 

“Arrested? What Happens to Your Benefits If You Go to 

Jail or Prison,” and case studies recently developed by 

the Council of State Governments about efforts in four 

states to address these issues.55

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step iii. considering elements of mental health court design and implementation
• Substance abuse treatment 

• Medication and symptoms management

• Housing (including supported housing)

• Benefits (e.g., Medicaid, SSI, SSDI, veterans)

• Transportation

• Supported employment

Some mental health providers may be reluctant or even unwilling to accept clients 

referred by the criminal justice system, especially those charged with felonies. Court 

officials should respect these concerns and provide information and consultation to 

mental health providers to help alleviate them. For example, courts can provide data 

to mental health providers demonstrating that many of their existing clients have 

been involved in the criminal justice system at some point in their lives. Emphasizing 

that the clinical requirements are comparable regardless of criminal justice involvement may make mental health treatment providers more amenable to serving court 

participants. Treatment providers can also be reminded that the addition of court 

peer supports

One of the emerging practices in mental health treatment is the use of consumers to provide support to 

their peers to aid recovery. Some mental health courts 

are adapting this strategy to their programs. Consumers, whether or not they have been involved with the 

criminal justice system, are ideally suited to support 

mental health court participants because of their 

unique insight into the dynamics of recovery. Peer 

supports can be important components in helping 

mental health court participants remain in treatment 

and develop adaptive, crime-free lifestyles.

example: St. Louis County Mental Health Court 

(Missouri) 

The St. Louis County Mental Health Court makes 

available a peer support specialist for all participants. 

This specialist provides one-on-one consultation, 

facilitates group meetings, introduces participants 

to consumer education, and provides other supports 

as needed. For some participants, the peer support 

specialist serves as an intermediary with his or her 

mental health treatment providers to ensure a collaborative treatment environment. The peer support 

specialist also provides trainings on the use of public 

transportation, household management, budgeting, and social networking, among other issues. The 

peer support specialist is not a full-time employee but 

receives a stipend to cover costs associated with this 

work.

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step iii. considering elements of mental health court design and implementation

leverage to a treatment regimen often creates better overall outcomes for both the 

treatment and criminal justice systems. 

Developing treatment plans

Treatment plans provide the framework for services delivered to consumers; particularly when treatment is delivered by multiple providers and supervised by yet another 

agency, treatment plans are essential to ensure treatment integrity. The various court 

and mental health professionals involved with the participant should be involved in 

formulating the treatment plan, along with the participant himself, family and significant others, and other community supports (e.g., Alcoholics Anonymous sponsor, 

mentor). While language conventions and philosophical approaches will vary across 

providers, the end product should provide a framework for how the consumer will 

manage his or her issues and identify specific steps toward recovery. Treatment plans 

must be responsive to each consumer’s individual needs, and should also provide 

specific benchmarks for progress. Treatment planning involves five basic steps:56

1. Identifying the Problem: clinicians must identify the most significant problems 

interfering with the consumer’s functioning. Having a smaller, more manageable number of problems keeps the treatment plan focused.

2. Defining the Problem: the way in which the problems are manifested in terms 

of the consumer’s behavior should be clearly articulated.

3. Setting Goals: broad, long-term goals should describe how the targeted problems will be resolved.

4. Specifying Objectives: specific and measurable steps for attaining each treatment goal should be listed, along with expected dates of completion. When 

appropriate, this section may also be used to discuss signs of relapse and to 

provide the consumer with specific strategies for resisting common triggers. 

5. Identifying Interventions: specific interventions will vary according to the 

consumer’s needs and the clinician’s expertise, but will generally include a 

combination of cognitive, psychodynamic, behavioral, pharmacological, and 

family-oriented therapies; medical care; assistance with housing, employment, 

or education; peer-based supports; and concrete supports such as transportation 

and child-care. The people responsible for providing the various interventions 

should be clearly identified. 
gender-specific and trauma-informed services

Women with mental illnesses involved in the criminal 

justice system have particular needs to which mental 

health courts should attend. For example, most women who are arrested have one or more children in their 

custody; maintaining custody and ensuring that their 

children are appropriately cared for may be primary 

concerns for female defendants. In addition, histories 

of trauma are considered the norm for women in the 

criminal justice system: 94 percent of incarcerated 

women report violence or sexual assault by intimates 

over the course of their lifetime. Mental health courts 

that do not consider these issues may inappropriately 

exclude some women (because of inaccurate diagnoses), apply sanctions ineffectively, or otherwise 

hamper the ability of female participants to adhere to 

court conditions. A recent monograph, Special Needs

of Women with Co-Occurring Disorders Diverted from the

Criminal Justice System, recommends that mental

health courts and other diversion programs take 

the following steps to develop “gender-specific” and 

“trauma-informed” programs:57 

• Examine policies and procedures—to ensure 

that gender and trauma issues are considered, 

particularly in staff training. 

• Adapt screening and assessment—to account 

for histories of trauma and abuse and to determine whether female defendants have children

in their custody.

• Develop treatment plans—that respond to 

the specific needs of women and their children, 

including trauma-specific services, parenting 

classes, sexual assault and domestic violence 

groups, and children’s health care. 

• Link women to long-term services—to ensure 

that women’s involvement in treatment continues past their term of judicial supervision.

ensuring cultural competency

Mental health court planners must also take steps to 

ensure the cultural competence of their programs, 

particularly in light of the racial disparities in the 

criminal justice system. Consensus panels convened 

by the Substance Abuse and Mental Health Services 

Administration (SAMHSA) have defined cultural

competency as: “An acceptance and respect for

difference, a continuing self-assessment regarding 

culture, a regard for and attention to the dynamics 

of difference, engagement in ongoing development 

of cultural knowledge, and resources and flexibility 

within service models to work towards better meeting the needs of minority populations.” Examples of 

culturally competent program adaptations are the use 

of peer counselors and the availability of interpreters. 

Consumers can provide particularly valuable input on 

how courts can address these issues.

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step iii. considering elements of mental health court design and implementation

Treatment plans are not intended to be static documents, but rather living instruments that are reviewed and updated periodically. As court staff and treatment providers learn more about the participants and their strengths and resources, plans may be 

made more specific. Not only should the plan be used to track consumer progress or 

lack thereof, but also to hold court and treatment partners accountable for their commitments to provide services. 

Co-occurring substance abuse disorders 

Among mental health court participants, co-occurring psychiatric and substance 

abuse disorders are the rule, not the exception, a fact that must be considered in all 

aspects of the court’s operation. Recent research on managing co-occurring disorders 

in the context of a specialty court (particularly drug courts) offers the following recommendations to enhance the quality of care:*

• Screen and assess potential participants for both mental health and substance 

abuse problems.

• Educate participants about both mental health and substance abuse disorders.

• Ensure access to both medication monitoring and drug testing.

• Work closely with both community mental health and substance abuse treatment providers.

• Include conditions, goals, and objectives related to mental health treatment and 

substance abuse treatment in treatment plans for all participants with co-occurring disorders.58 

Of all the actions that mental health courts can take to ensure the success of 

participants with co-occurring disorders, perhaps the most important is identifying 

and promoting integrated treatment. Integrated treatment involves the simultaneous 

and coordinated treatment of both mental health and substance abuse disorders, as 

opposed to the sequential or parallel treatment strategies, which are common in most 

communities. Research has consistently demonstrated that integrated treatment 

leads to superior outcomes among people with co-occurring disorders.59 In general, 

integrated treatment combines interventions targeting both the psychiatric and the 

substance abuse disorders within the same context, ideally delivered by cross-trained 

staff (see sidebar on next page). 

*Co-Occurring Disorders and Specialty 

Courts was published 

by the National 

GAINS Center for 

People with Cooccurring Disorders 

in the Criminal 

Justice System and 

the TAPA Center for 

Jail Diversion, and is 

available at: http://

www.gainsctr.

com/pdfs/CoOccurringSpecialty04.pdf.
example: The Substance Abuse and Mental Illness (SAMI) Court Program

(Butler County, Ohio)

The SAMI Court Program in Butler County is based on the New Hampshire-Dartmouth Dual Disorder Integrated Treatment (DDIT) model.60 As its name suggests, the program serves persons with 

serious mental health and substance abuse disorders. Only defendants charged with felonies are 

eligible. All participants receive integrated treatment from a specially trained, dedicated team 

that includes an alcohol and drug abuse specialist, a psychiatrist, a case manager, and a probation officer. Integrated treatment is not generally available in Butler County, so the court has also 

conducted trainings on integrated treatment for mental health and substance abuse treatment 

providers across the county.

modes of treatment for co-occurring disorders

Sequential Treatment—the consumer with cooccurring disorders is not eligible for treatment for 

one disorder until the other problem is resolved or 

suitably stabilized.

Parallel Treatment—the consumer has both disorders treated simultaneously, but by different providers 

who have no formal relationship or shared treatment 

planning.

Integrated Treatment—the consumer has both disorders treated simultaneously by providers who develop 

a single treatment plan addressing both conditions.

High-quality Integrated Treatment Programs: 

• Utilize a multidisciplinary team.

• Deliver treatment in sequential stages that correspond to the client’s readiness (engagement, 

motivation, action, relapse prevention).

• Provide access to residential treatment, supported employment, family psychoeducation, 

illness management and recovery, and assertive 

community treatment. 

• Deliver treatment over a long period, modifying 

intensity based on the client’s degree of recovery.

• Provide information and offer practical assistance to the client during outreach.

• Use motivational interviewing techniques to 

express empathy and empower the client.

• Focus on relapse prevention strategies in

counseling.

• Address both disorders in group treatment.

• Involve family members.

• Require clients to participate in self-help groups 

(e.g., AA or NA).

• Use psychotropic medications to address psychiatric symptoms.

• Target the full range of physical, social, and behavioral effects of substance abuse in counseling.

• Make secondary interventions available for those 

who do not respond to treatment initially.

source: SAMHSA. Co-Occurring Disorders: Integrated Dual Diagnosis

Treatment Fidelity Scale. Washington, DC, SAMHSA, 2003. Available at 

http://media.shs.net/ken/pdf/toolkits/cooccurring/

IDDTFidelityScaleAJ1_04.pdf

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step iii. considering elements of mental health court design and implementation

Creating broad access to integrated treatment presents a significant challenge; 

integrated treatment is not widely available in most communities, and in some, not 

at all. The reasons for the dearth of integrated treatment slots are complex, relating to 

funding requirements, standard practices, and systemic inertia. While mental health 

courts cannot solve these problems on their own, they can become vocal advocates 

for expanding access to integrated treatment, both for court participants and for the 

community at large.

Transition Planning 

As mental health courts mature and participants begin to successfully complete their 

term of treatment, the following scenario has become increasingly common. After a 

year of judicially supervised treatment during which several setbacks were overcome, 

a participant gets “back on her feet” and graduates from the court. Her life appears to 

be headed in a positive direction and the mental health court strategy appears vindicated. Six months later, she is back in the mental health court, having committed 

a crime similar to the one that precipitated her initial involvement. Even if this only 

happens to a few participants, the psychological impact on the court team’s morale 

(not to mention that of the participants) can be significant, as the return of the participant to the court suggests that all the hard work of the consumer and those supporting her was for naught. Though frustrating, these situations offer valuable lessons. 

The return to court of some proportion of “successful” graduates is inevitable. 

Serious mental illness is a lifelong ailment, and even with the good intentions and 

collaborative efforts of numerous people, psychiatric disorders often lead to behavior 

that brings people into repeated contact with the criminal justice system. Accepting 

this fact is an important step toward establishing realistic expectations at the outset of 

a mental health court project and toward deciding whether to re-accept graduates on 

new offenses.

Much can be learned from the mental health system’s experience in this area. 

“Discharge planning begins on admission” is the mantra of inpatient psychiatric 

services, and should be adopted by mental health courts. In the early phases of participation, the court is appropriately focused on engaging the individual and ensuring 

that he or she understands the court’s expectations. Mental health court practitioners 

must also recognize from the outset that the mental health court intervention is timelimited, while the individual’s mental health problems may be chronic and ongoing. 

Mental health and court staff must attend to the inevitable end of judicial supervision 
| 61

from the date of admission and be prepared to address the client’s concern, anxiety, 

or outright decompensation as graduation approaches.

One of the best ways to help people navigate this transition is to acknowledge, 

collectively, its potential difficulty. Reciprocal engagement between the consumer and 

treatment providers should be the focus; that is, the court participant must be engaged with her treatment providers, and the treatment providers must be prepared to 

continue working with the individual after the court mandate has been lifted.

For many participants, the structure provided by the mental health court is itself a 

clinical intervention; the clear expectations communicated by the court can be therapeutic. In some cases, the structure of the mental health court should be replaced 

by another structured intervention (e.g., day treatment, intensive case management, 

Assertive Community Treatment, etc.). For others, the increased intensity of courtbrokered services during the transitional period may suffice. In addition, court and 

mental health providers should ensure that all participants have adequate housing 

and resources to pay for needed services, including access to Medicaid, cash and food 

stamps benefits, and SSI. Above all else, strong, collaborative relationships between 

court staff and the entire spectrum of community-based service providers is the best 

way to ensure that success in the mental health court breeds success in the community, over both the short and long term. 

example: Washoe County Mental Health Court (Nevada)

The Washoe County Mental Health Court has taken steps to ensure a smooth transition for program participants ending their period of judicially supervised treatment. The court team is developing a system through which court participants maintain the same case manager, doctor, 

comprehensive service plan, and amount of contact after leaving the court program. This allows 

the treatment provider to mirror the structure and supervision provided by the court. The team is 

also identifying potential graduates three months in advance and working with the participants 

and mental health treatment providers to develop aftercare plans, to identify issues for concern 

during the transition period, and to promote continuity of care and engagement. 

Collaborative advocacy

Even courts with strong mental health partnerships struggle to rectify the chronic 

limitations of the community treatment system. The inadequacies and fragmentation of the mental health system have been well documented in several recent major 

reports, most notably the report of the President’s New Freedom Commission on 

Mental Health.61 In the radical shift from a system of large, centrally-managed
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step iii. considering elements of mental health court design and implementation

institutions to a community-based system of care, numerous agencies, including 

agencies within the criminal justice system, assumed some responsibility for the 

treatment and support of people with serious mental illnesses. This fragmentation 

presents enormous challenges for the effective delivery of services. But in the context 

of mental health courts it may also present opportunities.

Developing a mental health court brings with it a new investment of the court in 

the availability of treatment. If certain treatment options are unavailable, court and 

other criminal justice officials should collaborate with policymakers and providers 

from the mental health and other systems to address these gaps, both for mental 

health court participants and for all consumers of mental health services. Many 

people’s involvement in the criminal justice system is precipitated by their inability 

to access adequate mental health treatment in the community. Making community 

treatment more accessible and affordable can help prevent this involvement in the 

first place. Partnerships developed for the initial purpose of developing mental health 

courts or related programs are also powerful political coalitions that can be used in 

the service of improving the quality and availability of mental health care.

example: Florida Partners in Crisis

Florida Partners in Crisis (PIC) is an advocacy and educational organization committed to promoting access to quality services and treatment for people with mental illnesses and substance 

abuse disorders. Partners comprise traditional and non-traditional advocates, including judges, 

law enforcement and corrections officers, prosecutors and public defenders, service providers, 

hospital administrators, people with mental illnesses and substance abuse disorders, and family 

members. PIC primarily targets legislators to advocate increased funding and resources to the 

community mental health and substance abuse treatment systems and to advocate on specific 

policy issues related to this population. Overseen by a state director, state coordinator, and steering committee, PIC produces a brochure, editorials, billboard campaigns, legislative packets, 

meeting materials, and public service announcements, as well as holding press conferences. PIC 

leaders have met with the Governor and other key legislative leaders such as the Speaker of the 

House and the Senate President. 

Having a chief judge and sheriff testify against 

cuts to the mental health budget has a much

bigger impact than any mental health official 

could ever have.

Assemblywoman Sheila Leslie (D-NV)

“

”
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8. THE MENTAL HEALTH COURT TEAM

No matter how sophisticated the planning, the ability of the mental health court to 

engender change among participants depends on the composition of the courtroom 

team—those who work in the court on a daily basis. As one mental health court judge 

remarked to a new participant, the courtroom team is the “group of people whose job 

it is to make sure you are successful in this program.”62 Analyzing the dynamics of 

a mental health court team is complicated by the variability in how such teams are 

structured. All court teams include a judicial officer and a treatment provider or case 

manager (either a court employee or staff from a program providing direct services to 

court participants). In addition, many also include a single prosecutor and defense attorney, although those positions change in some courts on a case-by-case basis. Some 

court teams also include a court supervision agent, such as a probation or pretrial 

services officer. Lastly, many courts employ a court coordinator or project manager, 

who serves as a liaison between the various court and mental health professionals. 

Regardless of the team arrangement in a particular jurisdiction, selecting appropriate 

team members and providing sufficient training opportunities are challenges that all 

courts face. 

Selecting team members

Mental health courts require team members to rethink and expand their professional 

roles. Shifting away from the adversarial model, the mental health court team works 

together to achieve the best outcome for the defendant. Setting aside these traditional 

conventions can be difficult: prosecutors are trained to uphold public safety, not work 

in the best interest of the defendant; defense attorneys want to limit the penetration 

of their client in the criminal justice system, not extend the period of their supervision; and judges are impartial arbiters of fact, not probation officers or social workers. 

Mental health court planners should select team members who are willing to 

adapt to this non-traditional setting. Judges, prosecutors, defense counsel, and probation or pretrial services officers who have demonstrated an interest in mental health 

issues or a willingness to entertain alternative strategies in responding to defendants 

with mental health issues make ideal candidates. On the other hand, a prosecutor or 

probation officer who is determined to respond to all probation violations with punitive sanctions and incarceration will quickly clash with mental health practitioners 

who favor adjusting treatment plans in response to non-adherence to court orders. 
Likewise, mental health providers with experience or expressed interest in the 

criminal justice system will make good additions to the project, while treatment professionals who are unprepared to appreciate the public safety concerns of the court 

will not. Mental health providers who refuse to accept even the occasional use of 

punitive sanctions will make effective teamwork nearly impossible. 

No matter their professional affiliation, team members often struggle with the unfamiliar court process and may find that their peers are not supportive or view them 

in a different light. One defense attorney noted the contradictory roles: “You want to 

be part of the team, but you’ve always got to guard against ‘going along,’ and make 

sure it’s the best thing for your client.”63 Said one judge, “My brethren on the bench 

said, ‘If you want to do that, fine, but you’re going to have to fit it into your regular 

calendar.’”64 A probation officer who successfully applied for the new position in a 

mental health court talked about how his peers were both curious and jealous. As he 

put it, “I have a smaller caseload, but it’s a harder one to work.”65 

Many mental health court practitioners prefer team membership to remain fixed 

over time. Some courts assign team members for a year or two, while others have 

indefinite terms of membership, terminated at staff’s own request. Such longevity contributes to trusting professional relationships, smooth teamwork, familiarity 

with the unique processes of the mental health court, a sense of consistency for the 

participants, and an improved ability to assess the progress of individual participants 

during their time in the court program. Clearly, to achieve optimum functioning, a 

team needs time to gel. 

However, some courts have also offered persuasive arguments against indefinite 

or lengthy assignments to mental health court teams. Mental health consumers are 

the role of victim advocates and victims’

services providers in mental health courts

Mental health court planners should work closely with 

court-based victim advocates and community based 

victims’ services providers to address the needs and 

interests of crime victims. These include providing 

victims with input on the entry of defendants into 

the program, providing updates to victims about the 

status of defendants’ cases, and connecting crime 

victims to counseling and other services. Crime 

victims issues are particularly important in light of 

the increasing willingness of mental health courts to 

accept defendants charged with more serious crimes. 

Courts should also consider the needs of the many 

family members who are both caretakers and victims 

of crime.

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step iii. considering elements of mental health court design and implementation
some of the court’s most difficult-to-serve clients, and some staff may become burned 

out after multiple years of working in a mental health court. Even if some team members would prefer to remain in the mental health court indefinitely, such an arrangement prevents other interested staff members from participating in the program. 

Perhaps most importantly, rotating staff on the mental health court team can prevent 

the isolation of the mental health court and enhance awareness throughout the legal 

system about mental illness generally and the mental health court in particular. Staff 

who have served in the mental health court at one time will be well-positioned to help 

the traditional court process better respond to the many defendants with mental illnesses who will not participate in the mental health court.

Courts should strive to balance the virtues of a fixed mental health court team 

with the importance of involving multiple staff members in the mental health court, 

and above all recognize that some turnover among court team members is inevitable. 

rural mental health courts

Several rural jurisdictions, including communities in 

West Virginia and South Carolina, have recognized 

that the mental health court concept must be adapted 

to account for their smaller case volume and less comprehensive service systems. Examples of these adaptations include the following: 

Smaller Case Volume

The West Virginia Supreme Court of Appeals established a multi-jurisdictional mental health court 

for Hancock, Brooke, Ohio, and Marshall Counties. 

Spreading the court across four counties ensures sufficient volume to justify the development of a specialized program. The cases for the mental health court 

are distributed across the dockets of four magistrates 

and two judges. Case staffing is held in a central 

location, but hearings are held in all four counties, to 

which the court team travels on a regular basis.

In Marlboro County, South Carolina, the social 

worker assigned to the mental health court also provides an array of services for people in criminal or civil 

court who are not eligible for the mental health court. 

This includes counseling for jail detainees and providing input on commitment hearings. 

Service gaps 

Court planners in West Virginia have worked to augment the existing services by seeking support from 

local foundations and federal agencies, and by adapting criminal justice services to respond to people 

with mental illnesses. For example, the probation 

department has added mental health and co-occurring disorder treatment capacity to its day reporting 

center, and has submitted a grant to develop housing 

dedicated to probationers (including mental health 

court participants) with mental illnesses. 

In Marlboro County, South Carolina, there is no 

soup kitchen, no homeless shelter, no alcohol and 

drug treatment program, and limited self-help groups 

for people with substance abuse problems. In response to this shortage, the social worker assigned 

to the mental health court there has begun to receive 

training on substance abuse treatment in order to 

provide those services to court participants.

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step iii. considering elements of mental health court design and implementation

Staff changes should be preceded by a period of training, exposure to the policies 

and procedures of the court, and on-the-job mentoring by the outgoing team member when possible. These efforts ensure ongoing fidelity to court goals as well as 

operational consistency. A project manager or court coordinator can be of particular 

use here, serving as the team member that institutionalizes orientation and training 

materials, ensures that all team members understand their roles, and maintains high 

levels of intra-team communication.

(Cross) Training

Even with the selection of high-quality team members, training is required to bridge 

the gaps between the often disparate perspectives of mental health and criminal justice, and to help team members grow accustomed to their new roles. A mental health 

court judge must learn to be a counselor, cheerleader, moderator, and team leader, 

along with serving in the traditional role of final arbiter. Mental health professionals 

will need to familiarize themselves with legal terminology and develop expertise in 

the workings of the criminal justice system. Courts should identify education and 

training resources, both inside and outside of the court, to help judges, other court 

officials, and treatment providers learn and adapt to their new positions. If possible, 

training should be extended beyond the mental health court practitioners to allow 

staff from throughout the criminal justice, mental health, and substance abuse treatment systems to improve their knowledge and ability to collaborate. 

example: Hennepin County Mental Health Court (Minnesota)

The Hennepin County Mental Health Court has conducted trainings for mental health and criminal justice personnel. The court has held five training sessions for mental health case managers 

on the operation of and interaction with the criminal justice system. The court has also held focus 

groups with probation officers to inform training materials on mental health issues for criminal 

justice personnel. Coordinating these sessions with the training department of the relevant target agencies has allowed the mental health court to reach the broadest possible audience. 

example: Summit County Cross-Training (Ohio)

The Summit County Criminal Justice Forum, which comprises representatives from criminal 

justice, mental health, and substance abuse treatment agencies, has instituted biannual crosstraining sessions for practitioners from all three systems. The two-day training sessions involve 

staff from specialized programs such as the Akron Municipal Mental Health Court as well as nonspecialty practitioners. The first day of training features break-out sessions on the criminal justice system, mental health system, and substance abuse treatment system, which are typically 

attended by staff from other systems (i.e., criminal justice practitioners learn about the mental health or substance abuse systems, and vice versa). The second day provides opportunities 
| 67

for dialogue about core assumptions, current problems, and potential improvements to crosssystems collaboration. Faculty are drawn from local participating agencies.

example: National Judicial College Training Courses

The National Judicial College offers courses of relevance to mental health court judges or any 

judges interested in mental health issues. The Managing Cases Involving Persons with Mental 

Disabilities course covers mental health issues that affect and are affected by the justice system 

and provides judicial strategies to respond to defendants with mental disorders. The Co-Occurring Mental and Substance Abuse Disorders course provides information on the physiological and 

pharmacological aspects of substance abuse and major mental disorders, appropriate judicial 

strategies and tools for treatment and monitoring, and the implementation of systems or ideas 

to address co-occurring disorders.66 

9. MONITORING ADHERENCE TO COURT CONDITIONS

In the effort to distinguish mental health courts from other diversion strategies, the 

phrase “judicially supervised treatment” is often applied. In reality, the judge is the 

final link of a supervision chain that relies first on mental health and criminal justice 

staff who meet regularly with participants to monitor their adherence to court conditions. As with all other aspects of mental health court design and operation, different 

courts rely on different processes to accomplish this task. In some cases, the same 

staff who perform the initial screening and develop the treatment plan are responsible for monitoring the participants’ behavior in the community. In other courts, 

supervision is the purview of a particular team member. 

Whoever the mental health court designates to monitor participants in the community, the overall objective is to ensure that court orders are being followed, to 

reward adherence, to adjust treatment plans as necessary, and to sanction non-adherence. This section provides guidance on different supervision strategies, and on the 

use of regular status hearings to review each participant’s progress and to determine 

whether incentives or sanctions will be imposed. 

Supervision strategies

Courts have three basic options for monitoring participants during their involvement 

with the program, each with its own advantages and disadvantages. The use of these 

strategies may vary depending on the type of offense a participant is charged with, or 

other case-specific criteria. 
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step iii. considering elements of mental health court design and implementation

Supervision by mental health providers

Some courts rely on mental health treatment providers, usually case managers, to 

report on the participant’s adherence to court conditions. This case manager may be 

an employee of the court or may be employed by a partnering community agency. In 

smaller courts, one case manager may supervise all participants, while a larger court 

may split the caseload between two or more case managers. Regardless of the employing agency, the essential component of this strategy is that the supervising agent 

has a mental health background and is actively involved in facilitating the participants’ linkage to community treatment. 

One obvious benefit of this strategy is efficiency: a single point of contact is responsible for coordinating and monitoring all aspects of the court participant’s progress, making it easier for other team members (e.g., the judge, prosecutor, defense 

counsel) to obtain updates and streamlining the process of collecting information to 

prepare for team meetings and status hearings. Furthermore, the case manager is 

well-positioned to identify potential causes for non-adherence and to propose changes 

to the treatment plan or court conditions to address those underlying issues. 

On the other hand, this arrangement creates the potential for role conflicts, as the 

case managers find themselves as both facilitators of the participant’s support structure and as potentially punitive extensions of the legal system. This dual role may 

impede the development of a trusting relationship with the participant. In addition, 

some judges and prosecutors are uncomfortable assigning the responsibility for 

supervision to someone with a non-criminal justice background. Thus, with this approach, coordination with other team members is critical to best manage this role.

example: Orange County Community Resource Court Program (North Carolina)

Most of the participants in the Orange County Community Resource Court Program are accepted pre-plea and supervised by a community-based mental health case manager: either the case 

manager dedicated to the mental health court program or a case manager from one of two local Assertive Community Treatment (ACT) teams. Case managers report on the progress of each 

participant, including adherence to treatment plans and other court conditions, during monthly 

case staffing meetings. The court team decides jointly how to respond to any violations, with the 

judge as the arbiter of any disagreements. The court partners have worked to ease the role confusion of relying on mental health-based supervision by having the judge stress to participants the 

team nature of all court decisions, thus lessening the connection between the case manager and 

any sanctions that are applied. 
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Supervision by criminal justice staff 

Some courts assign the monitoring role to criminal justice staff, usually a probation 

officer, or sometimes the mental health court coordinator or a pretrial services officer. 

As with the mental health-based supervision strategy described above, the criminal 

justice agent may be permanently assigned to the court, supervising all of its participants, or may be based in another agency (e.g., probation) and involved only in 

certain cases. In this arrangement, the probation officer meets with the defendants 

on a regular basis, consults family, coworkers, and employers, and receives detailed 

reports from treatment providers about attendance and progress toward established 

goals. Rather than being the person responsible for communicating with the court, 

the treatment provider becomes one of multiple sources of information on the success with which the defendant is adjusting in the community. 

 Courts assigning responsibility for supervision to a criminal justice staff member 

may do so because of concerns about public safety, particularly when the court serves 

defendants charged with felonies. On the other hand, a criminal justice agent may 

not be as well versed in identifying treatment-based solutions in response to nonadherence to court orders. Courts employing this strategy should ensure that mental 

health staff have input into the responses to supervision violations. 

example: Orange County Dual Diagnosis Court (California) 

A probation officer is assigned full time to the Orange County Dual Diagnosis Court to supervise 

all program participants. Court participants are monitored more closely than other probationers, although the frequency and form of monitoring varies with their level of progression through 

the program. At the outset, participants report twice weekly to the probation office for review 

of progress and for drug and alcohol testing. As participants successfully progress through the 

program, their supervision is adjusted so that they can report by phone, at the probation office, 

or via home visits, and drug and alcohol testing becomes less frequent. Violations of court conditions result in an immediate sanction, which may include time in custody (usually one to three 

days), community service, essay writing, journaling, or increased probation monitoring. The 

Dual Diagnosis Court team makes all sanction recommendations. 

Joint supervision by criminal justice and mental health staff

Finally, some courts employ a combination of the two strategies above, with a mental 

health provider and criminal justice officer working together to monitor adherence. 

This strategy helps maintain clarity between treatment and supervision roles, but increases the need for close collaboration between the two supervising staff members. 

In addition, with two staff members serving a single function, per-participant costs 

increase. 
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step iii. considering elements of mental health court design and implementation

example: Court Coordinated Services (Yamhill County, Oregon) 

The Yamhill County Mental Health Court varies supervision arrangements depending on whether 

a participant is accepted pre-plea or post-plea. For pre-plea participants, the treatment court 

coordinator, who has a mental health background and is an employee of the court, acts as the 

liaison between the judge and the treatment provider, assessing a client’s engagement with the 

treatment plan and reporting to the judge. Most participants who are accepted post-plea are 

placed under probation, and supervised jointly by a probation officer and the treatment court 

coordinator. 

Comparative research has not demonstrated the superiority of one strategy over 

the others in terms of ensuring adherence to court orders and encouraging treatment engagement among participants. Accordingly, court planners must devise a 

supervision strategy by weighing public safety, efficiency, coordination, and resource

concerns. 

Case staffing 

Most mental health courts hold a separate meeting of the court team prior to when 

mental health court actually convenes. In this meeting, often referred to as “case 

staffing” or a “pre-meeting,” the court team discusses all the cases on the calendar for 

that day, including potential new participants and existing participants appearing for 

status hearings. For new participants, the court coordinator or mental health provider 

presents the team with basic information about each individual in terms of his or her 

characteristics across each of the eligibility criteria. Team members discuss the case 

and make a determination on the defendant’s appropriateness for the program. For 

existing participants appearing for status hearings, the team member or members 

responsible for monitoring the participant report each participant’s progress and offer 

suggestions for how the judge should respond (e.g., praise, changes to the participant’s treatment plan, or sanctions). 

Case staffing can be a time-consuming and difficult process. Differences of 

opinion about managing participants, both practical and philosophical, will surface. 

Effective teams engage in a productive give-and-take that results in compromises. 

Where collaboration and teamwork are less developed, case staffing discussions may 

be contentious and difficult to resolve. At the very least, the basic ground rules for 

these discussions should be set at the outset of court operations. Important questions 

include: 

• Who is authorized to attend these meetings based on confidentiality concerns?
| 71

• Who is responsible for managing information about court participants? 

• Who presents status reports during case staffing?

• Who has final authority to grant admission to the court program? 

• How will the court resolve differences of opinion about how to respond to violations of court conditions? 

Status hearings 

Judicial involvement in the supervision of mental health court participants occurs 

during the status hearings that all courts employ. Participants are required to appear 

before the judge on a regular basis (e.g., weekly, bi-weekly, monthly, depending on 

individual circumstances) to discuss their progress. In some courts, the judge is the 

primary spokesperson for the court during these hearings, commenting on information provided by other team members during the case staffing discussions. Other 

courts rely on a team approach, wherein case managers or probation officers offer 

brief reports on the participant’s progress, followed by a discussion of key issues 

among the case manager or probation officer, defendant, and the judge. 

Because most mental health courts maintain a non-adversarial atmosphere, and 

because status hearings do not have a natural counterpart in the traditional court 

process, some courts make the presence of defense counsel at status hearings optional. This practice may help control costs and ease scheduling conflicts, but it raises 

significant concerns. Despite their distinctness from traditional court processing, 

regular status hearings still represent a function of the criminal justice system, and 

as such present the opportunity for court participants to put themselves in further 

jeopardy. For example, participants may appear at status hearings after having been 

recently booked on new crimes, or may volunteer information to the court that puts 

them in violation of their court conditions and thus eligible for jail time. The role of 

defense counsel is to advise their clients throughout their involvement in the criminal 

justice system, not just prior to entry into the mental health court program, and the 

preceding scenarios illustrate the difficulties that can arise when defense counsel are 

absent from status hearings. 

The principal purpose of status hearings is to formally dispense rewards and 

sanctions, which are discussed below. But court personnel should also pay attention to how status hearings are conducted. Is the courtroom structured in a way that 

participants feel intimidated? Are participants offered an opportunity to discuss their 

successes or explain the reasons why difficulties may have arisen? Do court team 
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step iii. considering elements of mental health court design and implementation

members show interest in participants as individuals? These intangibles may significantly affect how participants experience the mental health court, and, by extension, 

their adherence to court conditions and the ultimate success of the program. 

Rewarding adherence

Mental health courts are based on the premise that treatment engagement will lead to 

improved health and public safety outcomes for program participants. It is appropriate, then, for mental health court planners to focus first and foremost on developing 

ways to offer positive reinforcement to participants who adhere to their treatment 

plan and other court conditions. Mental health courts employ an array of strategies 

for rewarding participants who are engaged in treatment and making good-faith efforts to adhere to all conditions of supervision. Given the complexity of the tasks facing program participants, small, incremental achievements should be recognized and 

rewarded along with long-term treatment goals. Rewards that mental health courts 

employ include:

• Priority position in the order of cases called

• Praise from the judge 

• Applause in court 

• Increased time between status hearings

• Certificates for completion of treatment 

• Food items or gift certificates from local businesses

• Birthday and special occasion cards 

• Reduced fees for probation supervision or drug testing 

• Special seating while participants are in court 

A mental health court may be the first time some 

participants have heard a kind word from anyone 

in their life, let alone a criminal justice official.

Judge Winston P. Bethel, Chief Magistrate, Dekalb County, Georgia

“

”
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• Extended privileges (i.e., where people are allowed to live, whom they may visit) 

• Graduation ceremonies 

example: Youngstown Municipal Mental Health Court (Ohio)

The Youngstown Municipal Mental Health Court offers several rewards to participants who are 

adhering closely to the court’s conditions: verbal praise from the judge; less frequent status hearings (e.g., every other week instead of every week); gift certificates from local businesses; and 

modifications to treatment plans (e.g., less stringent requirements to attend groups or other 

treatment components). The judge decides which rewards to offer, with input from the entire 

team, prior to each court session. 

Mental health court planners should also consider, as many courts have, dividing the program into a set of phases that mark the progress of participants. These 

phases may be tied to changes in court conditions (e.g., frequency of status hearings, 

intensity of supervision, extension of privileges), but they can also serve to formally 

recognize the accomplishments of program participants throughout their time in the 

court. 

example: Brooklyn Mental Health Court (New York) 

The Brooklyn Mental Health Court program is divided into four phases, described in treatment 

plans as “Adjustment,” “Engagement in treatment,” “Progress in treatment,” and “Continued 

progress in treatment and successful completion of the mandate.” To move from phase to phase, 

participants must comply with all terms of their participation. When a phase is completed, the 

defendant receives a certificate from the judge, which has proved a powerful motivator for many 

participants. Completing a phase may result in less intensive supervision or less frequent status 

hearings. A defendant can graduate from the court after completing all the phases and remaining 

in treatment for 12 to 24 months. Upon graduation, charges may be dismissed or reduced to a 

misdemeanor (with a sentence of either probation or a conditional discharge) depending on the 

nature of the charges and the defendant’s criminal history.”68

Adjusting treatment plans

At some point during their tenure in the court program, most mental health court 

participants will miss a treatment appointment, test positive for drug use, or otherwise have difficulty adhering to all of the court’s conditions. Responses to such 

violations should balance the court’s need for accountability with the recognition 

that relapse is an expected component of recovery. Some violations (such as committing a new crime) are serious and require an immediate and significant punitive 

response. But for most violations, especially those related to treatment adherence, 
the appropriateness of the treatment plan should be assessed prior to the application 

of any sanction. In response to a violation, the mental health court team should ask 

questions such as: 

• Has the participant been taking his or her medication? 

• If not, why not? Are side effects an issue? Should the type of medication,

the dosage, or the manner of administration be reexamined? 

• Has the participant been attending treatment sessions? 

• If not, why not? Does the participant have sufficient transportation and

childcare?

• Where does the participant live? Is the living situation conducive to treatment 

engagement? 

The responses to these questions will be different in every case, as will the appropriate response. Court teams will need to analyze the seriousness of the violation 

and the underlying causes before determining the response. In many cases, the appropriate response will be an adjustment or intensification of treatment. If the court 

team decides to intensify treatment in response to a condition violation, this change 

should not be described as a sanction. The team should remember that increasing 

long-term treatment engagement entails, in part, encouraging participants to view 

treatment services as beneficial, supportive aspects of their life, not as punishment. 

How the court explains its decisions regarding participants’ treatment conditions may 

mental health court graduation

Because of their highly individualized nature, their 

small caseloads, and their relative youth, mental 

health court programs do not often have multiple 

participants completing the program simultaneously. 

Nevertheless, most courts formally recognize program 

completion, either by taking time out of the normal 

court process, or by reconvening a group of participants who have recently “graduated” for a special 

ceremony. There is general agreement among mental 

health court practitioners that program completion should be lauded. But some have cautioned that 

courts should not equate program completion with 

treatment completion, as most participants will have 

chronic conditions that require ongoing support. For 

this reason, some courts avoid the term “graduate” altogether, feeling that it suggests a false finality to the 

broader goals of ongoing treatment engagement and 

avoidance of future criminal justice involvement.

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step iii. considering elements of mental health court design and implementation
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have significant consequences for their attitude toward treatment in general, particularly after the period of court supervision is over. 

Applying sanctions

Of course, some violations of the court’s orders are not easily justified or explained 

by the participant’s illness and are clearly volitional. In these situations, a punitive 

sanction may be appropriate. Many mental health courts have turned to the example 

of drug courts for guidance in this area. Over the years, drug courts have come to rely 

on a series of “graduated sanctions” to respond to violations (such as positive drug 

tests); each subsequent violation results in a more serious sanction, usually culminating in a short jail sentence. Research on drug court sanctions emphasizes the need 

for immediate and consistent application of sanctions that are of sufficient intensity 

and are targeted to the specific violation and individual.69 

The applicability of drug court sanctions within the mental health court context 

has not yet been empirically determined. However, anecdotal reports from mental 

health court practitioners suggest that the drug court model may not translate well 

for many mental health court participants. Given their unique diagnoses, differing 

functional abilities, and individualized treatment plans, a formulaic application of a 

sanctioning grid may not address the root causes of a violation. Many mental health 

court judges underscore that mental health consumers do not respond as well, or at 

all, to punitive actions from the court. Because no research base exists to guide the 

application of mental health court sanctions, court teams should tailor sanctions 

to the specific violation and participant, and should maintain internal data on the 

effectiveness of these sanctions in encouraging adherence. General rules for the application of sanctions will be helpful, but they cannot replace the evaluation of each 

violation on a case-by-base basis. Sanctions could include: 

• Judicial reprimands

• Journal assignments

• Increased frequency of status hearings

• Increased supervision intensity (e.g., meetings with a probation officer or case 

manager, drug testing)

• Restriction of privileges (e.g., curfew, travel)

• Community service
• Jail

• Expulsion from the program 

example: Oklahoma County Mental Health Court (Oklahoma)

The Oklahoma County Mental Health Court employs a variety of sanctions to respond to nonadherence to court conditions. These include written assignments, increased supervision, more 

frequent court appearances, more frequent drug testing, curfews, demotion to a lower level of 

court status, community service, and jail time. Sanctions are targeted to the specific behavior 

and graduated in severity upon recurrence of the unacceptable behavior. Sanctions are applied 

with the goal of assisting participants in making progress toward treatment goals, and eventually succeeding in the program. Participants may be expelled from the program for repeated 

non-adherence to their court requirements or after available graduated sanctions have been exhausted without correction of the identified problematic behavior. The team must inform the 

participant that he is at risk for expulsion with enough notice to allow the participant to correct 

the problematic behavior. A new offense is immediate grounds for expulsion. 

More than the specific responses to individual violations, some mental health 

court practitioners feel that the key to successfully engaging court participants is 

continued interaction with the courtroom team. As one court coordinator noted, 

“Lectures aren’t useful if there’s just one contact. But if you’re there through ups and 

downs, people will respond. They’ll show up even when they screw up, because they 

jail as a sanction

One sanction worthy of substantial discussion on its 

own is jail. The diverse practices among courts indicate the variety of opinions on this issue. Some courts 

rarely, if ever, use jail in response to non-adherence, 

citing the belief that while jail may satisfy the desire 

to punish, it does little to actually improve a participant’s long-term ability to comply with treatment. 

(Practitioners in these courts note that incarceration, 

through the disruption of a participant’s mediation, 

treatment regime, housing, and other stability factors 

can cause a person to decompensate.) Some practitioners also doubt the deterrence potential of incarceration, suggesting that some court participants may 

welcome time in jail because of the stability it can 

afford. Other courts use jail more liberally: when they 

feel that community safety is at risk, to “shake-up” a 

participant, to stabilize someone in crisis, or as a form 

of detoxification. 

Recent research suggests that as courts begin to 

accept more defendants charged with felony offenses, 

they are relying increasingly on jail, usually for public 

safety reasons.70 Absent evidence from research, mental health courts must develop a policy relying only 

on anecdotal observation, politics, and philosophical 

approaches. This policy should identify the conditions 

under which jail may be ordered and establish mechanisms to evaluate its effectiveness over time.

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step iii. considering elements of mental health court design and implementation
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feel it’s part of the relationship or process. Sometimes people will come to court even 

when it’s not their week because it’s a positive place to go.”71

Whatever the sanctions employed, a complete list should be compiled for the 

benefit of the court team and the participants. In some courts, defense counsel have 

requested such a list to ensure that the consequences of a violation are clear to their 

clients before they enter the program. 

10. SUSTAINABILITY

Mental health courts, like all pilot strategies, have to contend all too quickly with the 

challenge of sustainability. Postponing the consideration of this issue until the court 

becomes well established is a common and understandable approach. With the considerable work required to design and implement the court, finding the time to plan 

for subsequent years of operation may seem to be a low priority. Courts must resist 

this temptation and begin planning for long-term sustainability early in their operation. This includes developing written policies and procedures, collecting outcome 

data, securing funding, responding to failures, effectively reaching out to the community at large, and eventually coordinating the activities of multiple courts in a particular state. 

Developing written policies and procedures

Mental health court policies and procedures should quickly be institutionalized in 

writing, particularly if the court’s creation relied heavily on the interest or impetus of 

one team member, such as a judge. Courts early in the implementation phase may 

prefer to postpone developing written materials until after the program design is 

well established; but revising outdated program documents is far easier than creating them after key staff have left the court. Written materials related to all the issues 

described in this guide should be developed, including:

• Project history and partners

• Project goals and objectives

• Eligibility criteria

• Information sharing protocols 

• Referral and screening procedures

• Treatment resources 
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step iii. considering elements of mental health court design and implementation

• Case staffing and status hearing procedures 

• Sanctions and incentives 

• Advocacy efforts

Partner agencies should also strongly consider developing a memorandum of 

understanding (MOU). These documents can solidify agreements between agencies 

that will outlast the participation of specific people who made verbal agreements to 

collaborate. Along with standardizing court practices, written policies and procedures 

and agreements between agencies are useful when submitting reports to funders or 

when applying for continued financial support. 

Outcome data

A court’s most important ally in the pursuit of long-term funding is empirical data. 

As one noted researcher has pointed out, mental health courts are funded for the 

first time on promises; they are funded after that based on results.72 Data on the 

individual- and system-level impacts of the court should be collected and maintained 

from the first day of operation. As discussed in element 1 (goals), the specific data 

targeted for collection should be guided by the stated goals of the court. For example, 

if the court was launched, in part, to reduce the number of jail bed days consumed by 

people with mental illnesses, the court must be able to demonstrate whether program 

participants spent fewer days in jail compared to a period prior to court participation, 

or compared to a similarly-situated group of people who did not participate in the 

mental health court. 

Most mental health courts have little, if any, time and resources budgeted for data 

collection and evaluation, which severely limits their ability to measure their success, and possibly, to sustain their programs. To provide guidance for courts in this 

situation, CSG has published a companion to this guide, A Guide to Collecting Mental 

Health Court Outcome Data. This guide offers practical advice about the types of data 

courts should collect, methods for compiling data, common data collection challenges, and strategies for overcoming them. For that reason, those issues will not be 

addressed here, except to recommend (as that guide does) that courts enact data collection strategies as early as possible, seek resources and allies in the community, and 

set realistic data collection goals that match their staffing capacity and budget. 
| 79

Funding 

Mental health courts have turned to a number of different sources for funding: 

federal grant programs, local foundations, county agencies, and state legislatures 

among them. Just as with the other aspects of mental health court design, no one 

size fits all, but the experience of existing courts provides some useful lessons. First, 

long-term funding must be contemplated early in the court’s planning. Potential 

funding sources should be identified and cultivated from the start. Second, the value 

of personal experience with the court cannot be overestimated. Observing a mental 

health court session (particularly a graduation ceremony) during which a formerly 

homeless individual with serious mental illness receives glowing praise from a judge 

is a powerful experience. While such anecdotal evidence should not and cannot stand 

in for empirical documentation, interested state legislators, county commissioners, 

foundation officials, and other potential funders should be offered the opportunity to 

see the mental health court in action. 

Lastly, mental health court team members should be both clear and realistic in 

their claims about the mental health court’s potential accomplishments. Is the court 

designed to reduce the consumption of jail bed days? Is the court being pitched as a 

money-saving strategy? Is its core goal to connect people to treatment and improve 

their quality of life? Each court will have different answers to these questions, but 

when pursuing funding, the answers must be consistent and must be supported by 

reliable data. 

Responding to failures

Hopefully, collecting and analyzing outcome data will provide empirical verification 

of the positive impact of the mental health court. However, courts must also prepare 

for the possibility that a participant will commit a serious and violent crime while 

under court supervision. Such an incident can easily attract unfavorable press and 

jeopardize the sustainability of the court, even if it is the one exception to an otherwise stalwart record. Many high-profile crimes catalyze significant (and sometimes 

appropriate) county-wide or statewide changes in criminal justice policy or practice; 

mental health courts are not immune from this phenomenon. 

The various agencies involved with the court should establish a plan, in advance, 

to respond to incidents that attract negative publicity, in order to ensure that pres

-

sure to react quickly does not result in finger-pointing. This plan should include an 

agreement on how to respond to inquiries from the legislature, other state or local 

governing bodies, the media, and attorneys. Because a high profile crime committed 

by a program participant will raise significant public safety concerns, the court team 
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step iii. considering elements of mental health court design and implementation

would be wise to have a judge or prosecutor be the lead spokesperson for the court in 

these situations. While an emergency plan is helpful, the ultimate ability to weather 

the storm of negative publicity will depend on the depth of collaboration among the 

various agencies, which reaffirms the importance of cross-system dialogue, crosstraining, and other strategies discussed throughout this guide. 

Community outreach

In addition to preparing for the worst-case scenario, collaborating agencies should 

also publicize the activities and successes of the mental health court. The overrepresentation of people with mental illnesses in the criminal justice system is a community problem, and the community—including related agencies and community 

members in general—should be aware of the innovative solution being undertaken 

to address this problem. When making information available, representatives of the 

court should make clear the underlying reasons why the mental health court was 

started, and its potential impact on the community, while taking care not to reinforce 

common stereotypes about people with mental illnesses (e.g., that they are inherently 

violent or unable to live successfully in the community). Members of criminal justice and mental health agencies who may not be directly involved in the operation of 

the court should be made aware of its existence as a new component of the criminal 

justice and mental health systems, and should be educated about its key features and 

about how its philosophy differs from normal court processing. 

example: West Virginia’s Mental Health Court

(Hancock, Brooke, Ohio, and Marshall Counties, West Virginia) 

The multi-jurisdictional mental health court in West Virginia has energetically publicized its program across the four participating counties. Court staff members have held information sessions 

for attorneys, other court personnel, law enforcement officers, civic groups and churches, and the 

community at large. These sessions have explained the national, state, and local dynamics of the 

involvement of people with mental illnesses in the criminal justice system, the goals and design 

of the mental health court program, and procedures for referring potential participants. 

Local newspapers are increasingly showing interest in innovative responses to the 

overrepresentation of people with mental illnesses in the criminal justice system, 

and many courts have obtained favorable news coverage and even editorial support. 

Funding sources also like to promote the promise of their initiatives, and mental 

health courts should consider developing brief, clear, easy-to-read reports for funders, 

whether they are required or not. Finally, mental health court teams should select an 
| 81

individual to represent the court at public hearings or other meetings at which the 

court will be discussed. 

Ongoing input of stakeholders

Mental health court administrators must be careful not to let the day-to-day administration of the court program prevent opportunities for the ongoing input of the 

stakeholders who participated in the decision to establish a court. Regular meetings 

should be convened with lead officials from relevant criminal justice, mental health, 

substance abuse, advocacy, and other agencies to review the progress of the program. 

Such meetings do more than just keep various stakeholders abreast of program activity; they also help to ensure that the mental health court adheres to the original goals 

outlined by the agencies that signed on to its development, and improves the likelihood that representatives of those agencies will take steps to ensure the long-term 

sustainability of the program. 

Coordination across courts

As more mental health courts are launched, it becomes increasingly likely that two or 

more will exist in a particular state. Some of these courts have recognized that coordination across jurisdictions can help gain the interest and support of the legislature or 

relevant statewide agencies, along with providing an opportunity to share strategies 

and discuss common challenges. Such coordination may entail developing common 

goals, program designs, or data collection strategies. 

example: Nevada Mental Health Courts

The mental health courts in Clark County (Las Vegas) and Washoe County (Reno) are developing 

a plan to collect common outcome data. This will ensure that the report to the Legislature about 

the courts’ progress will be based on consistent measures and will offer a clear understanding 

of the impact of the two programs. The court planners will also work to ensure that subsequent 

courts in the state use the same outcome measures. 

example: New York State Unified Court System 

Five mental health courts, each designed according to the unique needs of their communities, 

currently operate in New York State: Bronx, Brooklyn, Buffalo, Monroe County, and Niagara Falls. 

The New York State Unified Court System, through its partnership with the Center for Court Innovation, sponsored a meeting with representatives of each court to share and collect knowledge 

and to begin developing guiding principles for the establishment and operation of courts within 

the state, without insisting on a single “model” for all localities.
Conclusion

the proliferation of mental health courts has been driven by collaboration 

between criminal justice and mental health staff at the local level, responding to the 

numerous challenges presented by people with mental illnesses who enter the court 

system.73 Fueled by individual success stories, the popularity of problem-solving 

courts in general, and the desire to respond to an intractable social problem, jurisdictions will likely continue to establish mental health courts in the coming years. Their 

efforts should be applauded. In the face of overwhelming numbers of defendants 

with mental illnesses, many of whom appear repeatedly before the court, the development of new, creative solutions is admirable. Further, the limited available research 

and the experience of jurisdictions across the country both suggest that mental health 

courts show great promise. 

But the expansion of mental health courts must be matched by rigorous efforts 

to assess their impact. More research is needed to better understand mental health 

court processes (i.e., how participants are identified and supervised), to identify the 

specific categories of defendants who benefit most from mental health court intervention, and to isolate the components of the “mental health court model” most responsible for its effectiveness. Such evaluations will be used not only to refine the design 

of current and future mental health courts, but also to advocate for their long-term 

sustainability. If the mental health court concept is to be supported over time, its 

effectiveness must be documented empirically. Individual courts can contribute to 

the development of this knowledge by collecting data about their own operation and 

outcomes. 

Until that research emerges, the best guide for communities interested in implementing a mental health court is the experience of other jurisdictions, and the goal 

of this guide is to compile those experiences in a format useful to interested parties 

across the criminal justice, mental health, and related systems. With the enormous 

diversity in mental health courts across the country and insufficient evidence/base for 

them, prescriptions for structuring a mental health court are inappropriate, and this 

guide has attempted to avoid hard and fast rules. Nevertheless, readers will, hopefully, 

82 |
develop a sense of how other courts have negotiated the complex issues related to the 

design and implementation of a mental health court, and which options may be best 

suited to their jurisdictions. 

Regardless of their ultimate effectiveness, mental health courts—by definition 

intensive, specialized programs—lack the capability to respond fully to the vast numbers of people with mental illnesses who enter the criminal justice system. Accordingly, mental health court planners, court systems generally, and all criminal justice 

and mental health policymakers should consider how mental health courts may fit 

into a larger strategy for reversing the overrepresentation of people with mental illnesses in the criminal justice system. Toward that end, mental health courts should 

be closely coordinated with related programs, such as police-based and post-booking 

jail diversion programs, drug courts, and specialized probation caseloads for people 

with mental illnesses. Court administrators should also investigate the extent to 

which strategies at the core of mental health courts can be integrated into the general 

court system. Finally, criminal justice and mental health policymakers must ensure 

that the criminal justice system generally—and mental health courts in particular—

do not become the preferred route to access mental health services. 

Overcoming these broad challenges, and the practical difficulties of establishing 

effective mental health courts, will require the collective energy of numerous dedicated professionals, advocates, and consumers. Together, their efforts play an important role in a growing, nationwide effort to improve the lives of people with mental 

illnesses, the functioning of the criminal justice and mental health systems, and the 

health and safety of communities across the country.

| 83
84 |

Appendix A 2002-2003 BJA Mental Health Court Program grantees

Program name State Phone number

Allegheny County Mental Health Court PA (412) 350-7337

Athens County Mental Health Court Project OH (740) 594-8302

Bonneville County Mental Health Court ID (208) 356-6880

Boone County Mental Health Court MO (573) 886-4000

Bronx County Mental Health Court NY (718) 590-6954

Brooklyn Mental Health Court NY (718) 643-5603

Broward County Mental Health Court FL

Cheshire County Mental Health Court Project NH (603) 352-8215

Chittenden County Mental Health Court VT (802) 865-6179

Clackamas County Mental Health Court OR (503) 722-686

Court Coordinated Services

(Yamhill County)

OR (503) 434-7523

Court Transition Project (Pasadena) CA (626) 403-4370

Eighth Judicial District Mental Health Court 

(Las Vegas)

NV (702) 455-6188

Franklin County Mental Health/

SAMI Court

OH (614) 222-3724

Hennepin County Mental Health Court MN (612) 348-3876

Jackson County Mental Health Court MO (816) 221-5000

King County Mental Health Court WA

Lane County Mental Health Court OR

Mahoning County Mental Health Court OH

Marlboro County Mental Health Court SC (843) 454-0841
| 85

Program name State Phone number

Santa Ana Mental Health Court CA (714) 834-2956

Mental Health Enhanced Supervision Project 

(Louisville)

KY (502) 574-6336

Mental Health Treatment Court of

Santa Clara

CA (408) 491-4772

Missoula Mental Health Court MT (406) 258-4728

Multi-Jurisdictional Mental Health Court 

(Washoe County)

NV (775) 325-6769

Muscogee County Mental Health Court GA (706) 596-5510

Buffalo Mental Health Court NY (716) 851-4157

Oklahoma County Mental Health Court 

Program

OK (405) 522-8117

Orange County Community Resource Court 

Program 

NC (919) 913-4237

Orleans District Mental Health Court LA (504) 827-3470

Richland County Mental Health Court SC (803) 576-1964

St. Louis County Mental Health Court MO (314) 615-4772

Statewide Mental Health Court Program DE (302) 577-2711

Tarrant County Mental Health Court TX (817) 884-3218

Tempe Municipal Mental Health Court AZ (602) 506-3916

West Virginia’s Mental Health Court

(Brooke, Hancock, Marshall, and

Ohio Counties) 

WV (304) 558-0145

Yavapai-Apache Mental Health Court AZ (928) 567-1033
86 |

Appendix B Conference of Chief Justices/ 

Conference of State Court Administrators 

Resolution in Support of Problem-Solving Courts

WHEREAS, the Conference of Chief Justices and the Conference of State Court Administrators appointed a Joint Task Force to consider the policy and administrative implications of the courts and special calendars that utilize the principles of 

therapeutic jurisprudence and to advance strategies, policies and recommendations on the future of these courts; and

WHEREAS, these courts and special calendars have been referred to by various 

names, including problem-solving, accountability, behavior justice, therapeutic, 

problem-oriented, collaborative justice, outcome-oriented and constructive intervention courts; and

WHEREAS, the findings of the Joint Task Force include the following:

• The public and other branches of government are looking to courts to address 

certain complex social issues and problems, such as recidivism, that they feel 

are not most effectively addressed by the traditional legal process;

• A set of procedures and processes is required to address these issues and 

problems that are distinct from traditional civil and criminal adjudication;

• A focus on remedies is required to address these issues and problems in

addition to the determination of fact and issues of law;

CCJ Resolution 22

COSCA Resolution 4
| 87

• The unique nature of the procedures and processes encourages the establishment of dedicated court calendars;

• There has been a rapid proliferation of drug courts and calendars throughout 

most of the various states;

• There is now evidence of broad community and political support and increasing state and local government funding for these initiatives;

• There are principles and methods grounded in therapeutic jurisprudence, 

including integration of treatment services with judicial case processing, 

ongoing judicial intervention, close monitoring of and immediate response to 

behavior, multidisciplinary involvement, and collaboration with communitybased and government organizations. These principles and methods are now 

being employed in these newly arising courts and calendars, and they advance 

the application of the trial court performance standards and the public trust 

and confidence initiative; and

• Well-functioning drug courts represent the best practice of these principles 

and methods;

NOW, THEREFORE, BE IT RESOLVED that the Conference of Chief Justices and the 

Conference of State Court Administrators hereby agree to:

1. Call these new courts and calendars “Problem-Solving Courts,” recognizing 

that courts have always been involved in attempting to resolve disputes and 

problems in society, but understanding that the collaborative nature of these 

new efforts deserves recognition.

2. Take steps, nationally and locally, to expand the principles and methods of 

well-functioning drug courts into ongoing court operations.

3. Advance the careful study and evaluation of the principles and methods 

employed in problem-solving courts and their application to other significant 

issues facing state courts.

4. Encourage, where appropriate, the broad integration over the next decade 

of the principles and methods employed in the problem-solving courts into 

the administration of justice to improve court processes and outcomes while 
88 |

preserving the rule of law, enhancing judicial effectiveness, and meeting the 

needs and expectations of litigants, victims and the community.

5. Support national and local education and training on the principles and 

methods employed in problem-solving courts and on collaboration with other 

community and government agencies and organizations.

6. Advocate for the resources necessary to advance and apply the principles and 

methods of problem-solving courts in the general court systems of the various 

states.

7. Establish a National Agenda consistent with this resolution that includes the 

following actions;

a. Request that the CCJ/COSCA Government Affairs Committee work with 

the Department of Health and Human Services to direct treatment funds 

to the state courts.

b. Request that the National Center for State Courts initiate with other organizations and associations a collaborative process to develop principles 

and methods for other types of courts and calendars similar to the 10 Key 

Drug Court Components, published by the Drug Courts Program Office, 

which defines effective drug courts.

c. Encourage the National Center for State Courts Best Practices Institute 

to examine the principles and methods of these problem-solving courts.

d. Convene a national conference or regional conferences to educate the 

Conference of Chief Justices and Conference of State Court Administrators and, if appropriate, other policy leaders on the issues raised by the 

growing problem-solving court movement.

e. Continue a Task Force to oversee and advise on the implementation of 

this resolution, suggest action steps, and model the collaborative process 

by including other associations and interested groups.
| 89

Appendix C Sample referral form 
90 |

Appendix D Sample information release form
| 91

Appendix E Sample contract for participation
92 |
| 93

1. Ditton, Paula M. Bureau of Justice Statistics 

Special Report: Mental Health and Treatment of 

Inmates and Probationers. Washington, DC: U.S. 

Department of Justice, Office of Justice Programs, 

Bureau of Justice Statistics, 1999.

2. Ditton, Mental Health and Treatment. 

3. “Treatment Not Jail: A Plan to Rebuild Community Mental Health.” Sacramento Bee. March 17, 

1999, Section B, p. 6.

4. Council of State Governments. Criminal Justice/Mental Health Consensus Project. New York: 

Council of State Governments, 2002.

5. Council of State Governments, National 

GAINS Center, TAPA Center for Jail Diversion, 

and NAMI. “Mental Health Courts Survey.” 2003. 

Available at: http://www.mentalhealthcourtsurvey.

com/

6. This definition is consistent with what researchers have identified as the eight elements 

that the vast majority of existing mental health 

courts have in common, collectively known as the 

“paradigmatic mental health court.” Steadman, 

Henry J. Personal communication. December 2, 

2004.

7. For more on the BJA Mental Health Courts 

Program, see the BJA Web site at: http://www.ojp.

usdoj.gov/BJA/grant/mentalhealth.html

8. Goldkamp, John and Cheryl Irons-Guynn 

(2000). “Emerging Judicial Strategies for the Mentally Ill in the Criminal Caseload: Mental Health 

Courts in Fort Lauderdale, Seattle, San Bernardino, and Anchorage.” Washington, DC: U.S. 

Department of Justice, Office of Justice Programs, 

Bureau of Justice Assistance.

9. For a recent discussion of drug courts and 

other problem-solving courts see: Huddleston, 

C. West, Karen Freeman-Wilson, and Donna L. 

Boone. Painting the Current Picture: A National Report Card on Drug Courts and Other Problem Solving 

Court Programs. Alexandria, VA: National Drug 

Court Institute, May 2004. 

10. Casey, Pamela M. and David Rottman (2003). 

Problem Solving Courts: Models and Trends.

National Center for State Courts. Available at:

http://www.ncsconline.org/WC/Publications/

COMM_SpeProProbSolvCtsPub.pdf 

11. Wexler, David and Bruce J. Winick. Judging in a 

Therapeutic Key. Durham, North Carolina: Carolina 

Academic Press, 2003. 

12. National Association of Drug Court Professionals. www.nadcp.org/whatis 

13. Teplin, Linda and Karen Abram (1991).

“Co-Occurring Disorders among Mentally Ill

Jail Detainees: Implications for Public Policy.” 

American Psychologist 46 (10): 1036–45. 

References
94 |

14. Goldkamp and Irons-Guynn. “Emerging Judicial Strategies.” 

15. Petrila, John, Norman G. Poythress, Annette 

McGaha, and Roger A. Boothroyd (2001). “Preliminary Observations from an Evaluation of the 

Broward County Mental Health Court.” Court 

Review (Winter, 2001): 14–22. 

16. Goldkamp and Irons-Guynn. “Emerging Judicial Strategies.” 

17. Griffin, Patricia, David Wertheimer, and Mark 

Munetz. “Mapping Strategies for Change: Using 

Systems Maps to Enhance Local Criminal Justice 

and Treatment System Interfaces.” Presentation at 

the 2004 National GAINS Center conference. Las 

Vegas, Nevada: May 12, 2004.

18. Ibid. 

19. Clark, John. Non-specialty First Appearance 

Models for Diverting Persons with Mental Illness: 

Alternatives to Mental Health Courts. Delmar, NY: 

Technical Assistance and Policy Analysis Center 

for Jail Diversion, 2004.

20. Full text of the statute is available at:

http://www.oscn.net/applications/oscn/

deliverdocument.asp?citeID=436031 

21. Full text of the statute is available at:

http://gencourt.state.nh.us/legislation/2002/

SB0435.html 

22. Cosden, Merith, Jeffrey Schnell, & Yasmeen 

Yamini-Diouf. “Evaluation of the Santa Barbara 

County Mental Health Treatment Court With

Intensive Case Management.” Santa Barbara:

University of California, Santa Barbara Press, 

2004. 

23. Hamilton, Steven L. and Christopher Hamilton. Jail Alternative Service Program Evaluation: 

July 1, 1998–June 30, 2003. Anchorage, Alaska: 

C&S Management Associates, 2004. Available at: 

http://trustgroups.infoinsights.com/word/

JAS_2003_FinalReport.doc 

24. Unpublished statistics courtesy of Patrick 

Vanzo, Administrator, Cross Systems Integration 

Efforts, Department of Community and Human 

Services, King County, WA, and Mark Munetz, 

Clinical Director, ADAMH Board, Summit County, Ohio. 

25. Goldkamp and Irons-Guynn. “Emerging Judicial Strategies.”

26. Griffin, Patricia, Henry J. Steadman, and John 

Petrila (2002). “The Use of Criminal Charges and 

Sanctions in Mental Health Courts.” Psychiatric 

Services 53: 1285–1289.

27. CSG, et al. “Mental Health court Survey.” 

Available at: http://www.mentalhealthcourtsurvey.

com

28. Redlich, A., H. Steadman, J. Monahan, J. Petrila, P. Griffin. “The Second Generation of Mental 

Health Courts.” Psychology, Public Policy and the 

Law, in press.

29. Marlowe, Douglas, David S. Festinger, and Patricia A. Lee (2004). “The Judge is a Key Component of Drug Court.” National Drug Court Review

IV (2): 1–34. 

30. Steadman, H., E. Mulvey, J. Monahan, P 

Robbins, P. Applebaum, T. Grisso, L. Roth, and 

E. Silver (1998). “Violence by People Discharged 

From Acute Psychiatric Inpatient Facilities and by 

Others in the Same Neighborhoods.” Archives of 
| 95

General Psychiatry 55: 393–401. See also Meuser, 

K.T., et al. (1998). “Trauma and Post-Traumatic 

Stress Disorder in Severe Mental Illness.” Journal 

of Consulting and Clinical Psychology 66 (3):

493–99.

31. Hiday, Virginia, Marvin S. Swartz, Jeffery W. 

Swanson, Randy Borum, and H. Ryan Wagner 

(1998). “Criminal Victimization of Persons with 

Severe Mental Illness.” Psychiatric Services 50:

62–68. 

32. Council of State Governments. Unpublished 

survey of BJA Mental Health Court Program 

Grantees, 2003.

33. Council of State Governments. Observations 

made on a technical assistance site visit to Orange 

County, Florida.

34. Peters, Roger, and Osher, F. (2004).

Co-Occurring Disorders and Specialty Courts. (2nd 

ed.). Delmar, NY: The National GAINS Center.

35. BJA Mental Health Court Program grantee 

conference participant. Comment during conference workshop. January 22, 2004. 

36. Teplin, L., K. Abram, G. McClelland, M. Dulcan, and A. Mericle (2002). Psychiatric Disorders 

in Youth in Juvenile Detention. Archives of General 

Psychiatry 59: 1133–1143.

37. Full text of the report is available at:

http://www.house.gov/reform/min/pdfs_108_2/

pdfs_inves/pdf_health_mental_health_youth_

incarceration_july_2004_rep.pdf 

38. Arredondo, D., K. Kumli, L. Soto, E. Colin, J. 

Ornellas, R. Davilla, L. Edwards, and E. Hyman 

(2001). “Juvenile Mental Health Court: Rationale 

and Protocols.” Juvenile and Family Court Journal

Fall: 1–19.

39. Conger, D. and T. Ross (2001). Reducing the 

Foster Care Bias in Juvenile Detention Decisions.

New York, NY: Vera Institute of Justice.

40. Coolidge, S. “Mental Health Court Helping 

Kids.” The Cincinnati Enquirer. July 6, 2004. 

41. BJA Mental Health Court Program grantee 

conference participant. Comment during conference workshop. January 22, 2004. 

42. Judge David L. Bazelon Center for Mental 

Health Law (2003). “Criminalization of People 

with Mental Illnesses: The Role of Mental Health 

Courts in System Reform.” Washington, D.C.: 

Bazelon Center. 

43. Griffin, et al. “The Use of Criminal Charges 

and Sanctions in Mental Health Courts.”

44. Bazelon Center. “Criminalization of People 

with Mental Illnesses.”

45. Council of State Governments. Unpublished 

survey of BJA Mental Health Court Program 

Grantees, 2003.

46. See Barr, Heather. “Mental Health Courts: An 

Advocate’s Perspective.” Available at: http://www.

urbanjustice.org/publications/pdfs/mentalhealth/

MentalHealthCourts.pdf. Also, National Mental 

Health Association. NMHA Position Statement—

Mental Health Courts. Available at: http://www.

nmha.org/position/mentalhealthcourts.cfm. Also, 

Bazelon Center, “Criminalization of People with 

Mental Illnesses,” 2003. 
96 |

47. Presentation at BJA Mental Health Courts 

Program conference in Cincinnati, Ohio, January 

22, 2004. 

48. This standard is derived from the Supreme 

Court cases of Dusky v. U.S. 362 U.S. 402, 80 

S.Ct. 788 (1960) and Drope v. Missouri, 420 U.S. 

162, 171 (1975).

49. Poythress, Norman G., John Petrila, Annette 

McGaha, and Roger Boothroyd (2002). “Perceived 

coercion and procedural justice in the Broward 

mental health court.” International Journal of Law 

and Psychiatry 25: 517–533. 

50. Poythress, Norman G., et. al. “Perceived coercion,” p. 530. 

51. Council of State Governments. Criminal 

Justice/Mental Health Consensus Project. New York: 

Council of State Governments, 2002.

52. Steadman, Henry J., Allison D. Redlich, 

Patricia Griffin, John Petrila, and John Monahan. 

“From Referral to Disposition: Case Processing in 

Seven Mental Health Courts.” Behavioral Sciences 

and the Law, in press. 

53. Ibid. 

54. Center for Court Innovation. Unpublished 

description of five mental health court programs 

in New York State.

55. Koyanagi, Chris. “Arrested? What Happens to 

Your Benefits If You Go to Jail or Prison?” Washington, D.C.: Bazelon Center for Mental Health 

Law, 2004. See also http://www.consensusproject.

org/projects/benefits/ 

56. Jongsma, A. and L.M. Peterson. The Complete 

Adult Psychotherapy Treatment Planner. Third Edition. New York, NY: Wiley, 2003. 

57. Hills, H. (2004). The Special Needs of Women 

with Co-Occurring Disorders Diverted from the 

Criminal Justice System. Delmar, NY: The National 

GAINS Center. 

58. Peters, R., and F. Osher. “Co-Occurring Disorders and Specialty Courts.” 

59. Drake, Robert E., Susan M. Essock, Andrew 

Shaner, Kate B. Carey, Kenneth Minkoff, Lenore 

Kola, David Lynde, Fred C. Osher, Robin E. Clark, 

and Lawrence Rickards (2001). “Implementing 

Dual Diagnosis Services for Clients with Severe 

Mental Illness.” Psychiatric Services 52: 469–76.

60. Mueser, Kim T., Douglas L. Noordsy, Robert 

E. Drake and Lindy Fox. Integrated Treatment for 

Duals Disorders: A Guide to Effective Practice. New 

York, NY: Guilford Publications, 2003. 

61. New Freedom Commission on Mental Health. 

Achieving the Promise: Transforming Mental Health 

Care in America. Final Report. DHHS Pub. No. 

SMA-03-3832. Rockville, MD: 2003.

62. McGroarty, Judge John S. Remarks heard 

by CSG staff at session of Clark County Mental 

Health Court, April 13, 2004. 

63. BJA Mental Health Court Program grantee 

conference participant. Comment during conference workshop. January 22, 2004. 

64. Chow, Judge Mark. Personal communication. 

Aug. 19, 2004.
| 97

65. Remarks from roundtable discussion at King 

County Mental Health Court, August 20, 2004. 

66. More information on the National Judicial 

College project supported with funding from the 

Bureau of Justice Assistance, is available at:

http://www.judges.org/ 

67. Gonnerman, J. “Where Justice and Mercy 

Meet.” Village Voice. July 24, 2004. Available at: 

http://www.villagevoice.com/issues/0430/

gonnerman.php 

68. Ibid.

69. Marlowe, Douglas B. and Kimberly C. Kirby 

(Summer 1999). “Effective Use of Sanctions in 

Drug Courts: Lessons From Behavioral Research. 

National Drug Court Institute.” National Drug 

Court Institute Review II. 

70. Redlich, Allison D., Henry J. Steadman, John 

Monahan, John Petrila, and Patricia A. Griffin. “The Second Generation of Mental Health 

Courts.” Psychology, Public Policy and the Law,

in press.

71. Remarks from participant at BJA Mental 

Health Courts Program conference, January 23, 

2004. 

72. Steadman, Henry J. Personal communication. 

December 2, 2004. 

73. Steadman, et al. “From Referral to Disposition: Case Processing in Seven Mental Health 

Courts.”
A Guide to Mental Health Court Design and Implementation provides detailed guidance 

on critical issues such as determining whether to establish a mental health court, selecting the 

target population, ensuring confidentiality, sustaining the court, and many others. Examples 

from existing mental health courts illustrate key points.

this guide:

What Is a Mental Health Court?

introduces the mental health court 

concept, including the reasons why 

communities establish such courts, 

how they differ from drug courts, 

recent research, and concerns that 

these courts have raised.

Navigating the Mental Health 

Maze: A Guide for Court Practitioners offers a basic overview of 

mental illnesses, including their 

symptoms, diagnosis, and treatment, and discusses the coordination of treatment and court-based 

services.

A Guide to Collecting Mental 

Health Court Outcome Data 

provides practical strategies to 

both well-established and newly 

operating courts for deciding which 

data to collect; obtaining, evaluating, and comparing the data; and 

overcoming common challenges.

other guides in the series:

The Bureau of Justice Assistance administers the Mental Health Courts Program (MHCP), which has awarded grants to 37 

mental health court projects nationwide since 2002. The MHCP funds projects that seek to improve the response to adult 

and juvenile offenders with mental illnesses through continuing judicial supervision and the coordinated delivery of mental 

health and related services. www.ojp.usdoj.gov/BJA/grant/mentalhealth.html 

The program also provides technical assistance, coordinated by the Council of State Governments (CSG), to grantee 

courts and other jurisdictions. As part of its technical assistance effort CSG has developed four publications to aid communities considering or implementing a mental health court:

About the Mental Health Courts Program

The Bureau of Justice Assistance (BJA), Office of Justice 

Programs, U.S. Department of Justice, supports law enforcement, courts, corrections, treatment, victim services, 

technology, and prevention initiatives that strengthen the 

nation’s criminal justice system. BJA provides leadership, 

services, and funding to America’s communities by emphasizing local control; building relationships in the field; developing collaborations and partnerships; promoting capacity 

building through planning; streamlining the administration 

of grants; increasing training and technical assistance; 

creating accountability of projects; encouraging innovation; 

and ultimately communicating the value of justice efforts to 

decisionmakers at every level.

810 Seventh Street, NW

Fourth Floor

Washington, DC 20531

Tel: (202) 616-6500 | Fax: (202) 305-1367

www.ojp.usdoj.gov/BJA/

The Council of State Governments (CSG) is a nonpartisan, 

public, nonprofit organization 

that provides information, 

research, and training to state 

officials in all three branches of 

government in every state and 

U.S. Territory. 

40 Broad Street

Suite 2050

New York, NY 10004

Tel: (212) 482-2320

Fax: (212) 482-2344

www.csgeast.org

The Criminal Justice/Mental 

Health Consensus Project is 

an unprecedented national 

effort to improve the response 

to people with mental illnesses 

who become involved in, or are 

at risk of involvement in, the 

criminal justice system.

For more information 

please contact

editors@consensusproject.org

www.consensusproject.org/

mhcourts/