Mental Health Courts

A Primer for Policymakers

and Practitioners
Mental Health Courts

A Primer for Policymakers

and Practitioners

A report prepared by the

Council of State Governments Justice Center

Criminal Justice/Mental Health Consensus Project

New York, New York

for the

Bureau of Justice Assistance

Office of Justice Programs

U.S. Department of Justice
This project was supported by Grant No. 2006-MO-BX-K348 awarded by the Bureau of Justice

Assistance. The Bureau of Justice Assistance is a component of the Office of Justice Programs,

which also includes the Bureau of Justice Statistics, the National Institute of Justice, the

Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime.

Points of view or opinions in this document are those of the author and do not represent the

official position or policies of the United States Department of Justice or the Council of State

Governments’ members.

The Bureau of Justice Assistance reserves the right to reproduce, publish, translate, or

otherwise use and to authorize others to publish and use all or any part of the copyrighted

material contained in this publication.

Council of State Governments Justice Center, New York 10005

© 2008 by the Council of State Governments Justice Center

All rights reserved. Published 2008.

Cover based on design by Nancy Kapp & Company. Cover photo by Peter Comitini,

www.comitini.com. Interior design by David Williams.
Contents

Acknowledgments iv

Introduction 1

Why Mental Health Courts? 2

What Is a Mental Health Court? 4

What Types of Individuals Participate in Mental Health Courts? 5

What Does a Mental Health Court Look Like? 7

What Are the Goals of Mental Health Courts? 8

How Are Mental Health Courts Different from Drug Courts? 9

Are There Any Mental Health Courts for Juveniles? 11

What Does the Research Say about Mental Health Courts? 13

What Issues Should Be Considered When Planning or

Designing a Mental Health Court? 15

What Resources Can Help Communities Develop Mental

Health Courts? 18

Notes 23
iv Mental Health Courts: A Primer for Policymakers and Practitioners

A great many people contributed to the development of this publication.

Daniel Souweine, a Project Director with the Council of State Governments

Criminal Justice Program (now the Justice Center), was the principal author

of early drafts of the guide. Over a three-year period, he drew on the extensive knowledge gained through his visits and meetings with numerous mental health court professionals and lengthy conversations with a broad array of

experts in the field to make this guide a reality.

He was given valuable insights and suggestions by fellow staff member

Denise Tomasini, a Senior Policy Analyst who for many years spearheaded

the Justice Center’s work on courts and mental health. Policy Analyst Lauren

Almquist and Director of Communications Martha Plotkin helped bring the

document to completion by incorporating the views of Dr. Fred Osher, Director of Health Systems and Services Policy, and others to ensure the timeliness and practicality of the primer. Thanks are also due to Elizabeth Hurwit,

who edited the final version of the document.

Subject matter experts Judge Stephanie Rhoades, of the Anchorage District Court; Henry J. Steadman, President of Policy Research Associates; and

Carol Fisler, Director of Mental Health Court Programs at the Center for

Court Innovation, reviewed drafts and provided direction that made this

guide a more useful and informative product. Their contributions are truly

appreciated. Recognition is also owed to the many court practitioners who

hosted visits and engaged in interviews. Any value this guide has in the field

is largely due to their generous contributions of ideas and recommendations.

The Council of State Governments Justice Center board and staff

also thank those individuals at the Bureau of Justice Assistance, U.S. Department of Justice, who have provided guidance and support for this project and

ushered the publication through the many tiers of helpful reviews, particularly Domingo S. Herraiz, Director; A. Elizabeth Griffith, Deputy Director

for Planning; Robert Hendricks, former Acting Senior Policy Advisor for

Substance Abuse and Mental Health; Michael Guerriere, former Senior

Policy Advisor for Substance Abuse and Mental Health; Ruby Qazilbash,

Senior Policy Advisor for Substance Abuse and Mental Health; and Rebecca

Rose, Policy Advisor for Substance Abuse and Mental Health.

Acknowledgments
Mental health courts have spread rapidly across the country in the few years

since their emergence. In the late 1990s only a handful of such courts were

in operation; as of 2007, there were more than 175 in both large and small

jurisdictions.1

If this recent surge in popularity is any indicator, many more communities will consider developing a mental health court in the coming years. This

guide is intended to provide an introductory overview of this approach for

policymakers, practitioners, and advocates, and to link interested readers to

additional resources.

The guide addresses a series of commonly asked questions about mental

health courts:

• Why mental health courts?

• What is a mental health court?

• What types of individuals participate in mental health courts?

• What does a mental health court look like?

• What are the goals of mental health courts?

• How are mental health courts different from drug courts?

• Are there any mental health courts for juveniles?

• What does the research say about mental health courts?

• What issues should be considered when planning or designing a

mental health court?

• What resources can help communities develop mental health courts?

Introduction

Mental Health Courts: A Primer for Policymakers and Practitioners 1
2

Mental health courts are one of many initiatives launched in the past two

decades to address the large numbers of people with mental illnesses

involved in the criminal justice system. While the factors contributing to

this problem are complicated and beyond the scope of this guide, the overrepresentation of people with mental illnesses in the criminal justice system

has been well documented:2

• Prevalence estimates of serious mental illness in jails range from 7 to 16

percent, or rates four times higher for men and eight times higher for

women than found in the general population.3

• A U.S. Department of Justice study from 1999 found that half of the

inmates with mental illnesses reported three or more prior sentences.4

Other research indicates that people with mental illnesses are more likely

to be arrested than those without mental illnesses for similar crimes and

stay in jail and prison longer than other inmates.5

• In 1999, the Los Angeles County Jail and New York’s Rikers Island jail held

more people with mental illnesses than the largest psychiatric inpatient

facilities in the United States.6

• Nearly two-thirds of boys and three-quarters of girls detained in juvenile

facilities were found to have at least one psychiatric disorder, with approximately 25 percent of these juveniles experiencing disorders so severe that

their ability to function was significantly impaired.7

Without adequate treatment while incarcerated or linkage to community

services upon release, many people with mental illnesses may cycle repeatedly through the justice system. This frequent involvement with the criminal

justice system can be devastating for these individuals and their families and

can also impact public safety and government spending. In response, jurisdictions have begun to explore a number of ways to address criminal justice/

mental health issues, including mental health courts, law enforcement–

based specialized response programs, postbooking jail diversion initiatives,

specialized mental health probation and parole caseloads, and improved jail

and prison transition planning protocols. All of these approaches rely on

Why Mental Health

Courts?

Mental Health Courts: A Primer for Policymakers and Practitioners
extensive collaboration among criminal justice, mental health, substance

abuse, and related agencies to ensure public safety and public health goals.

Mental health courts serve a significant role within this collection of

responses to the disproportionate number of people with mental illnesses in

the justice system. Like drug courts and other “problem-solving courts,” after

which they are modeled, mental health courts move beyond the criminal

court’s traditional focus on case processing to address the root causes of

behaviors that bring people before the court.* They work to improve outcomes for all parties, including individuals charged with crimes, victims,

and communities.

Mental Health Courts: A Primer for Policymakers and Practitioners 3

*Drug courts have been particularly instrumental in paving the way for mental health courts. Some of the

earliest mental health courts arose from drug courts seeking a more targeted approach to defendants with

co-occurring substance use and mental health disorders.
4 Mental Health Courts: A Primer for Policymakers and Practitioners

Despite the recent expansion of mental health courts, there are not yet

nationally accepted, specific criteria for what constitutes such a court.

Although some initial research identified commonalities among early mental

health courts, the degree of diversity among programs has made agreement

on a core definition difficult.8 Mental health courts vary widely in several

aspects including target population, charge accepted (for example, misdemeanor versus felony), plea arrangement, intensity of supervision, program

duration, and type of treatment available. Without a common definition,

national surveys developed on mental health courts have relied primarily

on self-reported information to identify existing programs.9

The working definition that follows distills the common characteristics

shared by most mental health courts. The Justice Center worked with leaders

in the field to also develop consensus on what these characteristics should

look like and how they can be achieved, as documented in The Essential Elements of a Mental Health Court.*

What Is a

Mental Health Court?

A Working Definition of a Mental Health Court

A mental health court is a specialized court docket for certain defendants with mental illnesses that substitutes a problem-solving model

for traditional criminal court processing. Participants are identified

through mental health screening and assessments 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 or other court conditions, nonadherence may be sanctioned, and success or graduation is defined according to predetermined criteria.10

*As the commonalities among mental health courts continue to emerge, practitioners, policymakers,

researchers, and others have become interested in developing consensus not only on what a mental health

court is but on what a mental health court should be. The Essential Elements of a Mental Health Court

describes 10 key characteristics that experts and practitioners agree mental health courts should incorporate. Michael Thompson, Fred Osher, and Denise Tomasini-Joshi, Improving Responses to People with Mental Illnesses: The Essential Elements of a Mental Health Court (New York, NY: Council of State Governments

Justice Center, 2008), www.consensusproject.org/mhcp/essential.elements.pdf.
Mental Health Courts: A Primer for Policymakers and Practitioners 5

The majority of mental health court participants suffer from serious mental

illnesses. Mental illness is a general term that includes a range of psychological disorders. A subset of serious mental illnesses is severe and persistent

mental illness. This includes conditions that involve long-term and profound

impairment of functioning—for example, schizophrenia, schizoaffective disorder, bipolar disorder (formerly called manic depression), severe depression,

and anxiety disorders. In addition to describing level of functioning, most

states also use criteria for “severe and persistent” to prioritize access to public

mental health services.

Some mental health courts accept individuals with a broader array of

disabling conditions than mental illness alone. While developmental disabilities, traumatic brain injuries, and dementias are not included in federal

statutory and regulatory definitions of serious mental illness, they may be the

cause of behavioral problems that result in criminal justice contact and may

also co-occur with serious mental illnesses. Each mental health court determines how flexible to be on eligibility requirements and, when screening an

individual who does not precisely fit standard criteria, whether to accept participants on a case-by-case basis. Working with individuals who have needs

that fall outside the typical mental health service continuum requires additional partnerships with other community agencies, and so acceptance decisions are based, in part, on an individual’s ability to benefit from a court

intervention given these clinical and system capacity considerations. All individuals must be competent before agreeing to participate in the program.

Although addictive disorders are considered mental illnesses and are

included in the American Psychiatric Association’s Diagnostic and Statistical

Manual of Mental Disorders, their diagnosis, treatment interventions, and

providers differ from those for nonaddictive mental illnesses. Nevertheless,

the majority of people with mental illnesses involved with the criminal justice system—approximately three out of four—also suffer from a co-occurring

substance use disorder.11 As a result, mental health courts must address this

population and treat both mental health and substance use disorders in a

comprehensive and integrated fashion. The vast majority of mental health

courts accept individuals with co-occurring disorders, and some courts even

seek out this population, but few mental health courts accept defendants

whose only mental disorders are related to substance use.

What Types of Individuals

Participate in Mental

Health Courts?
6 Mental Health Courts: A Primer for Policymakers and Practitioners

The prevailing belief in the scientific community is that mental disorders,

both addictive and nonaddictive, are neurobiological diseases of the brain, outside the willful control of individuals. People with mental illnesses cannot

simply decide to change the functioning of their brain. As with physical illnesses, it is believed that mental disorders are caused by the interplay of biological, psychological, and social factors. This acknowledged lack of control

contributes to the belief that mental health courts, which rely on treatment

and flexible terms of participation rather than the traditional adversarial system, represent a more just way for courts to adjudicate cases involving people

with mental illnesses. Nevertheless, entering a mental health court does not

negate individuals’ responsibility for their actions. Mental health courts promote accountability by helping participants understand their public duties

and by connecting them to their communities.
What Does a Mental Health

Court Look Like?

The enormous variability in mental health court design and operation has

led some observers to note that “if you have seen one mental health court,

you have seen one mental health court.” Nevertheless, while great variety

exists, mental health courts share several core characteristics. What follows is

a description of one mental health court in action that reflects some of these

central features, the “essential elements.”

Every Wednesday afternoon, County Courthouse Room 13 assumes a

mental health docket. The courtroom team (judge, defense attorney, prosecutor, probation officer, court coordinator, and case manager) has already met

for several hours to discuss the people who will be appearing that day.

The first individuals before the bench are those entering the court for

the first time. They have already undergone basic screening for program eligibility, had their mental health needs assessed, and been given a description

of the mental health court program. The judge explains why they have been

offered the opportunity to participate and describes the court’s procedures.

She asks if they want to enter the program and whether they fully understand the terms of participation. Those who agree to participate (the majority) are welcomed into the court.

After the new participants have been admitted, the court proceeds with

status hearings for current program participants. The judge inquires about

their treatment regimens, and publicly congratulates those who received positive reviews from their case managers and probation officers at the staff

meeting. One participant receives a certificate for completing the second of

four phases of the court program. The judge hands down sanctions of varying severity to individuals who have missed treatment appointments—

tailored to the needs of each participant. The judge also informs several participants that certain privileges they had hoped to obtain will be withheld

because of their misconduct over the past two weeks. Throughout the status

hearings, conversation remains informal and individualized, often relaxed.

Observers unfamiliar with mental health court procedures may be uncertain

of what they are witnessing, but they will be sure of one thing: this is not a

typical courtroom.

In the following days, the mental health court team will work to develop

a service plan for each new participant to connect him or her quickly to community-based mental health treatment and other supports. Those individuals

who have declined to participate will return to the original, traditional court

docket.

Mental Health Courts: A Primer for Policymakers and Practitioners 7
8

At their heart, mental health courts represent a response to the influx of people with mental illnesses into the criminal justice system. They seek to use

the authority of the court to encourage defendants with mental illnesses to

engage in treatment and to adhere to medication regimens to avoid violating

conditions of supervision or committing new crimes. Unlike some programs

that divert individuals from the justice system and merely refer them to community service providers, mental health courts can mandate adherence to the

treatment services prescribed, and the prospect of having charges reduced or

dismissed provides participants with additional incentives.

Communities start mental health courts with the hope that effective

treatment will prevent participants’ future involvement in the criminal justice

system and will better serve both the individual and the community than

does traditional criminal case processing. Within this framework, mental

health court planners and staff cite specific program goals, which usually

fall into these categories:

• Increased public safety for communities—by reducing criminal activity

and lowering the high recidivism rates for people with mental illnesses

who become involved in the criminal justice system

• Increased treatment engagement by participants—by brokering comprehensive services and supports, rewarding adherence to treatment plans,

and sanctioning nonadherence

• Improved quality of life for participants—by ensuring that program participants are connected to needed community-based treatments, housing, and

other services that encourage recovery

• More effective use of resources for sponsoring jurisdictions—by reducing

repeated contacts between people with mental illnesses and the criminal

justice system and by providing treatment in the community when

appropriate, where it is more effective and less costly than in correctional

institutions

What Are the Goals

of Mental Health Courts?

Mental Health Courts: A Primer for Policymakers and Practitioners
How Are Mental Health

Courts Different from

Drug Courts?

Mental Health Courts: A Primer for Policymakers and Practitioners 9

Drug courts are the best known and most widespread of the various problem-solving court models and have in many ways served as a prototype from

which mental health courts have evolved. The high rate of co-occurring mental health and substance use disorders among individuals in the criminal justice system also suggests significant overlap in the target populations of

these related court programs. In fact, in some jurisdictions, the inability of

the local drug court to effectively manage individuals with serious mental illnesses precipitated the development of a mental health court.

Important differences remain in the principles and operation of drug

courts and mental health courts; mental health courts are not merely drug

courts for people with mental illnesses.12 Although little research has been

conducted comparing drug courts and mental health courts, it is already

clear that jurisdictions interested in building on the experiences of their drug

courts to develop a mental health court will need to adapt the model in significant ways to accommodate individuals with mental illnesses.

The majority of the differences listed below stem from the fact that mental illness, unlike drug use, is, in and of itself, not a crime; mental health

courts admit participants with a wide range of charges, while drug courts

focus on drug-related offenses. Also, whereas drug courts concentrate on

addiction, mental health courts must accommodate a number of different

mental illnesses, and so there is greater variability among treatment plans

and monitoring requirements for participants than in drug courts.
10 Mental Health Courts: A Primer for Policymakers and Practitioners

PROGRAM

COMPONENT DRUG COURTS . . .

MENTAL HEALTH

COURTS . . .

Charges accepted Focus on offenders

charged with drug-related

crimes

Include a wide array of

charges

Monitoring Rely on urinalysis or other

types of drug testing to

monitor compliance

Do not have an equivalent

test available to determine

whether a person with a

mental illness is adhering

to treatment conditions

Treatment plan Make treatment plans

structured and routinized;

apply sanctioning grid in

response to noncompliance, culminating with

brief jail sentence

Ensure that treatment

plans are individualized

and flexible; adjust treatment plans in response to

nonadherence along with

applying sanctions; rely

more on incentives; use

jail less frequently

Role of advocates Feature only minimal

involvement from 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 their design

Service delivery Often establish independent treatment programs,

within the courts’ jurisdiction, for their participants

Usually contract with

community agencies;

require more resources to

coordinate services for

participants

Expectations of

participants

Require sobriety, education, employment, selfsufficiency, payment of

court fees; 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
Are There Any Mental

Health Courts for

Juveniles?

Mental Health Courts: A Primer for Policymakers and Practitioners 11

The development of mental health courts for juveniles began several years

after the emergence of adult programs. In 2001 Santa Clara, California,

became the first jurisdiction to use this strategy to address the large numbers

of youth with mental health needs involved with the juvenile justice system.13

A number of other juvenile mental health courts have since been catalogued,

and as of 2007 the National Center for Mental Health and Juvenile Justice

(NCMHJJ) had identified 18 juvenile mental health courts in operation. An

additional 20 jurisdictions indicated they were either considering or actively

planning a juvenile mental health court.14 The small number of juvenile

mental health courts does not in any way reflect an infrequency of mental illnesses among youth in the juvenile justice system. In fact, the percentage of

individuals with mental illnesses is just as significant in the juvenile justice

system as in the adult system, if not more so.

Given that the juvenile mental health courts have developed more slowly

than adult mental health courts, less is known about their operation and effectiveness. NCMHJJ’s study of juvenile mental health courts has revealed that

many different models exist; nevertheless, like adult courts, several themes

characterize these courts:

• They work best when part of a larger comprehensive plan that incorporates

other elements, such as diversion and treatment, to address the mental

health needs of these youth.

• The majority use a postadjudication model, although several function at

the preadjudication stage.

• Most juvenile mental health courts accept youth who have committed

either felonies or misdemeanors; however, many have broad discretion in

determining whether to include youth who have committed very serious

felonies.

• They vary on which mental health diagnoses to focus on when identifying

participants, with some accepting youth with any mental health disorder,

others including only youth with certain serious disorders, and still others

concentrating on youth with co-occurring mental health and substance use

disorders.15
12

Juvenile mental health courts offer many of the same benefits as adult

programs. They also confront many of the same operational problems, but

because of their participants’ status as minors, juvenile mental health courts

also must address an additional layer of challenges and tasks. These include

identifying developmental issues that affect cognition, behavior, and the

potential effectiveness of mental health treatment; working with parents and

guardians; and involving a larger number of other systems, including the

education and foster care systems.

Mental Health Courts: A Primer for Policymakers and Practitioners
Research on mental health courts can be divided into two main types: studies

assessing court operations (process evaluations) and studies assessing court

effectiveness (outcome evaluations). Given the short tenure of most mental

health courts, the greatest volume of research examines court operations and

the way in which participants flow through the various programs.

Process evaluations

Process evaluations completed as of 2007 confirm that all mental health

courts have some commonalities, but there are also some important differences. One of the few comparative studies, which looked at seven mental

health courts’ operations, found there were differences between early mental

health courts and more recently developed ones, deemed “second-generation

courts.”16 According to this study, while procedures varied greatly from court

to court, the newer courts were more likely to share these elements:

• They consider defendants charged with felonies, as opposed to only misdemeanors, for acceptance into the program.

• They allow only postplea program enrollment, which means that the time

from jail admission to program enrollment is usually longer.

• They rely more heavily on criminal justice staff, as opposed to community

treatment providers, to monitor and supervise participants.

• They use jail more regularly to sanction nonadherence to court orders.17

These findings were published in 2004, and since then many of the

“first-generation” courts have expanded the charges and pleas they accept. It

is also not uncommon for new courts that would be labeled as second generation to begin as misdemeanor programs. Nevertheless, these general trends

illustrate that as mental health courts become more commonplace and

accepted, planning groups have more opportunities to focus on higher-risk

populations than when mental health courts first emerged.

What Does the Research Say

about Mental Health Courts?

Mental Health Courts: A Primer for Policymakers and Practitioners 13
14

Outcome evaluations

In addition to describing mental health court operations generally, several

studies have evaluated individual mental health courts and their impact

on a range of participant and system outcomes. Their findings suggest the

following:

• Mental health court participation resulted in comparatively fewer new bookings into jail and greater numbers of treatment episodes compared with the

period prior to program participation.18

• Participants were significantly less likely to incur new charges or be

arrested than a comparison group of individuals with mental illnesses

who did not enter the mental health court program.19

• Participation increased the frequency of treatment services, as compared

with involvement in traditional criminal court.20

• Mental health court participants improved their independent functioning and

decreased their substance use compared with individuals who received treatment through the traditional court process.21

• Participants spent fewer days in jail than their counterparts in the traditional court system.22

• Mental health court participants reported more favorable interactions with

the judge and perceived that they were treated with greater fairness and

respect than in traditional court.23

Researchers have also begun to explore the fiscal impact of mental

health courts. A recent study by the RAND Corporation assessed the

Allegheny County Mental Health Court in Pennsylvania.24 The study found

that the program did not result in substantial added costs, at least in the

short term, over traditional court processing for individuals with serious

mental illnesses. The findings also suggested that over the longer term, the

mental health court may actually result in net savings for the government.*

In assessing the impact of mental health courts, it is important to note

that these findings draw on a handful of studies, many of which look at individual programs and so cannot be generalized. Furthermore, research has

not yet explored how changes in a mental health court’s program elements or

procedures affect outcomes. A comparative study of outcomes across different mental health courts has yet to be completed.25

Mental Health Courts: A Primer for Policymakers and Practitioners

*This savings projection is based on an analysis of the anticipated costs associated with incarceration and

utilization of the most expensive mental health treatment (hospitalization) and the expectation that mental

health court participation would reduce both of the above.
Mental Health Courts: A Primer for Policymakers and Practitioners 15

Fueled by emerging data on the utility of mental health courts, the popularity

of problem-solving courts in general, and the desire to respond to a deeprooted social problem, jurisdictions will likely continue to launch mental

health courts in the coming years. Policymakers and practitioners interested

in establishing or enhancing mental health courts should consider some

important issues related to the formation and design of these courts.

Practicality in local context

Mental health courts may be impractical in some jurisdictions, either

because of jurisdiction size and insufficient staff and resources or because of

local resistance to problem-solving courts.26 Accordingly, communities considering the development of a mental health court should also investigate the

array of other court-based strategies being employed across the country,

including postbooking jail diversion programs, specialized dockets within

existing court structures, mental health–specific probation caseloads, and

improved training for court personnel.

Limited data

As the previous section indicates, while only limited research has been completed, the available studies indicate that mental health courts may have

more positive outcomes for people with mental illnesses than traditional

criminal court processing. More research is nevertheless needed to compare

different mental health court practices and evaluate outcomes across programs. Jurisdictions planning a mental health court should build data collection and evaluation into their program operations, so that the court will

eventually be able to conduct its own basic data analyses.

Effect on overall service capacity

Though mental health courts have arisen in part because of the inadequate

treatment services and resources in community mental health systems, implementing a program does not usually result in expanded service capacity.

What Issues Should Be

Considered When Planning

or Designing a Mental

Health Court?
16 Mental Health Courts: A Primer for Policymakers and Practitioners

Instead, mental health court staff works within the existing framework of

local resources and treatment providers. As a result, if mental health courts

are effective in linking their participants with services, they can actually

reduce the availability of treatment options for people with mental illnesses

outside the criminal justice system. To avoid disadvantaging individuals in

the community, therefore, mental health court administrators, other criminal

justice professionals, and mental health and substance use treatment

providers should ensure the availability of services for all people with mental

illnesses and work collaboratively to fill gaps in the treatment system.

Need for a continuum of response strategies

Some communities have developed mental health courts without considering

alternatives across the criminal justice continuum. In these communities

mental health courts might be viewed as the only strategy needed to improve

outcomes for people with mental illnesses in the justice system, when in fact

no single initiative can address the driving factors behind this problem.

Focusing solely on mental health courts can also lead to a lack of coordination with law enforcement–based diversion programs, drug courts, reentry

programs, and other initiatives at the intersection of the criminal justice,

mental health, and substance use systems. Without cooperation among different criminal justice/mental health programs, limited resources cannot be

shared and efforts may be duplicated. To avoid these pitfalls, policymakers

and practitioners should work together to coordinate responses to their

shared clientele.

Integration with traditional case processing

Regardless of their effectiveness, mental health courts alone cannot

respond to the vast numbers of people with mental illnesses who enter the

criminal justice system. Traditional court officials must adopt the principles

and policies at the core of mental health courts to ensure that these

approaches are not limited to the small number of individuals who enter

specially tailored programs. Accordingly, traditional court judges and

administrators should strive toward three goals: making training available

to all court personnel on mental health issues; integrating mental health

information into pretrial and presentence reports and responses to violations of community supervision conditions; and improving collaboration

among all criminal justice agencies and mental health and substance use

treatment systems.

Design considerations

Many complex issues related to mental health court design and implementation deserve greater scrutiny. For example, mental health court practitioners

and observers differ on the types of participants mental health courts should
Mental Health Courts: A Primer for Policymakers and Practitioners 17

accept, the plea agreements courts should offer, appropriate program length,

and how program success should be measured. Readers interested in these

issues should consult this guide’s companion document, A Guide to Mental

Health Court Design and Implementation (www.consensusproject.org/mhcp/

info/mhresources/pubs).
18 Mental Health Courts: A Primer for Policymakers and Practitioners

What Resources Can Help

Communities Develop

Mental Health Courts?

Jurisdictions interested in developing a mental health court can benefit from

a range of resources and documents offering support.

Federal grant support

Although many mental health courts emerged as community-level responses

to locally identified problems, they have also been supported at the federal

level.

• Justice and Mental Health Collaboration Program

In 2004, Congress authorized the creation of the Justice and Mental Health

Collaboration Program (JMHCP).27 This program strives to increase public

safety by facilitating collaboration among the criminal justice, juvenile justice, mental health treatment, and substance use systems and to improve

access to effective treatment for people with mental illnesses involved with

the criminal justice system.

The JMHCP does not exclusively support mental health courts; nevertheless, of the 27 grantees selected in 2006 and the 26 selected in 2007,

approximately one-third have focused on court-related initiatives. Congress

appropriated $5 million for both 2006 and 2007 and increased appropriations to $10 million for the program in 2008.

The JMHCP is administered by the Bureau of Justice Assistance

(BJA).28 At this writing, technical assistance is provided to the grantees by

the Justice Center, as well as the Pretrial Justice Institute and the National

Association of Counties (NACO).29

To learn more about the JMHCP and grantees, see www.consensus

project.org/jmhcp.

• Targeted Capacity Expansion Program

In addition to funds from criminal justice agencies, mental health courts

have also received support from federal health agencies, namely, the Substance Abuse and Mental Health Services Administration (SAMHSA).

Since 2005, SAMHSA has supported several mental health courts

directly through its Targeted Capacity Expansion (TCE) program.30 The
Mental Health Courts: A Primer for Policymakers and Practitioners 19

Technical Assistance and Policy Analysis (TAPA) Center for Jail Diversion

provides technical assistance to TCE grantees.31

State grant support

Several states have developed broad programmatic support to address the

prevalence of people with mental illnesses in the criminal justice system. As

with the JMHCP, these grant dollars can be used for mental health courts.

Such programs can be found in California and Florida, and many states are

considering similar proposals.

• Mentally Ill Offender Crime Reduction Grant Program (California)

The California Mentally Ill Offender Crime Reduction (MIOCR) program

seeks to (1) support the implementation and evaluation of county efforts

to increase access to community-based services and supports, (2) facilitate

successful transitions from incarceration to the community, and (3) reduce

recidivism among both adults and juveniles with mental illnesses involved

with the criminal justice system.

In 2006, 44 grants were awarded to 28 different counties, totaling $44.6

million. Many of these counties have used the funding to plan or improve

mental health court programs. Nearly $30 million was appropriated for

MIOCR in 2007. For more information, see www.cdcr.ca.gov/Divisions_

Boards/CSA/CPP/Grants/MIOCR/MIOCRG.html.

• Criminal Justice, Mental Health, and Substance Abuse Reinvestment

Grant Program (Florida)

In 2007, the Florida Substance Abuse and Mental Health Corporation

announced the availability of $3.8 million under the newly created Criminal Justice, Mental Health, and Substance Abuse Reinvestment Grant Program. In 2008, planning or implementation grants were given to counties

to develop initiatives to improve public safety, avoid an increase in spending on criminal and juvenile justice, and better connect individuals with

mental health or substance use disorders who are involved with the criminal justice system to treatment. More information can be found at

www.samhcorp.org/RFA/index.htm.

In addition to federal and state grants, a number of other resources are

available to jurisdictions interested in planning a mental health court.

BJA mental health court learning sites

Besides its work with the Justice and Mental Health Collaboration Program,

BJA has designated five mental health courts as learning sites to provide a
20 Mental Health Courts: A Primer for Policymakers and Practitioners

peer support network for local and state officials interested in planning a

new—or improving upon an existing—mental health court:

• Akron Municipal Mental Health Court (Ohio)

• Bonneville County Mental Health Court (Idaho)

• Bronx County Mental Health Court (New York)

• Dougherty Superior Court (Georgia)

• Washoe County Mental Health Court (Nevada)

These courts serve as a resource for jurisdictions across the country looking to develop or refine their approach to individuals with mental illnesses.

Since each mental health court has a unique set of policies and procedures,

the learning sites program allows jurisdictions to observe different models

and the flexibility needed to tailor a program to a specific community. The

learning sites also work with the Justice Center, the technical assistance

provider for this program, to assess and improve their own court operations

and to develop tools for the mental health court field.

The five learning sites are indeed representative of the great variability

in mental health court models. For example, the Bronx County Mental

Health Court started with only felony charges and began accepting misdemeanors in 2007, whereas the Akron Municipal Mental Health Court has

continually focused on misdemeanor charges. Similarly, the Bonneville

County Mental Health Court serves a rural jurisdiction and averages approximately 35 participants at a time, whereas the Washoe County Mental Health

Court—located in a more urban area—has an estimated 200 people under its

supervision at a given time. As a dual mental health court and drug court,

the Dougherty Superior Court uses a different program model than all of the

other learning sites. Interested jurisdictions are encouraged to visit the learning site most similar to the program model envisioned or to contact several

or all of the courts to compare their models and processes.32

Policy guides

As part of the Mental Health Court Program and with support from BJA, the

Justice Center has produced a number of practical policy guides to aid mental health courts across the country. The following publications explore in

more depth a number of issues and lessons presented in this primer. They

can be found at www.consensusproject.org/mhcp/info/mhresources/pubs.33

• The Essential Elements of a Mental Health Court

• A Guide to Mental Health Court Design and Implementation

• A Guide to Collecting Mental Health Court Outcome Data

• Navigating the Mental Health Maze
Mental Health Courts: A Primer for Policymakers and Practitioners 21

Web resources

The Consensus Project website, which the Justice Center maintains, is a

helpful place to begin exploring criminal justice/mental health issues or

gathering information on mental health courts. The homepage can be found

at www.consensusproject.org, and the following web pages also provide relevant information.

• Consensus Project Report

The landmark Criminal Justice/Mental Health Consensus Project report, a

comprehensive discussion of the involvement of people with mental illnesses in the criminal justice system, from before arrest to after reentry

from prison or jail, is available at www.consensusproject.org/the_report. A

chapter of the report has been dedicated to issues that must be considered

when looking at possible court-based strategies.

• Mental Health Court Web Page

Within the Consensus Project website, the Justice Center maintains a page

specifically for mental health courts, www.consensusproject.org/mhcp/.

Many of the publications described above can be found on this page, as

well as information on the learning sites and other relevant materials and

websites.

• Criminal Justice/Mental Health Information Network

A number of relevant mental health court resources can be found on the

Criminal Justice/Mental Health Information Network (InfoNet) website,

www.cjmh-infonet.org, an online database that provides a comprehensive

inventory of collaborative criminal justice/mental health activity across the

country and serves as a platform for peer-to-peer networking.

At this writing, the InfoNet contains approximately 175 mental health

court profiles, which are added to the site once a court fills out a survey

about its program. Viewers can sort by type of program (in addition to

courts, the InfoNet contains information on law enforcement, corrections,

and community support programs) or by state to find the mental health

courts closest to them. Users can also get a sense of the type of model these

courts follow, the participants and charges they accept, and how long they

have been up and running. The InfoNet also contains information on mental health court research, as well as relevant media articles.34

• JMHCP Web Page

Grantees and nongrantees alike can find useful resources on the JMHCP

web page, www.consensusproject.org/jmhcp. JMHCP provides access to
22 Mental Health Courts: A Primer for Policymakers and Practitioners

grantee snapshots and technical assistance resources, as well as links to

detailed program profiles for each grantee represented on the InfoNet.

• Center for Court Innovation Website

The Center for Court Innovation, which helps courts and criminal justice

agencies aid victims, reduce crime, and improve public trust in criminal justice, has worked extensively with mental health courts. Relevant publications

are available on its website, www.courtinnovation.org.

• National Center for State Courts Website

The National Center for State Courts (NCSC) strives to improve the administration of justice through leadership and service to state courts and courts

around the world. The NCSC website contains a number of materials for

specialty courts, including mental health courts, which can be found at

www.ncsconline.org.

• National Drug Court Institute Website

Readers interested in learning more about drug courts should visit the website of the National Drug Court Institute (NDCI), www.ndci.org. NDCI promotes education, research, and scholarships for drug court and other

court-based intervention programs.

• National GAINS Center Website

The National GAINS Center works to collect and disseminate information

about effective mental health and substance abuse services for people with

co-occurring disorders involved with the justice system. Within the GAINS

Center, the TAPA Center for Jail Diversion focuses on policies related to jail

diversion, and both GAINS and TAPA resources can be found at www.gains

center.samhsa.gov.
Mental Health Courts: A Primer for Policymakers and Practitioners 23

1. The Justice Center catalogues mental health court programs on its Criminal Justice/Mental

Health Information Network (InfoNet) website: www.cjmh-infonet.org.

2. For a comprehensive discussion, see the Criminal Justice/Mental Health Consensus Project

report (New York, NY: Council of State Governments, 2002).

3. Paula M. Ditton, Special Report: Mental Health and Treatment of Inmates and Probationers

(Washington, DC: U.S. Department of Justice, 1999). The Prevalence of Co-occurring Mental and

Substance Use Disorders in Jails (Delmar, NY: National GAINS Center, 2002). Revised Spring

2004. L. Teplin, K. Abram, and G. McClelland, “Prevalence of Psychiatric Disorders among

Incarcerated Women: Pretrial Jail Detainees,” Archives of General Psychiatry 53 (1996): 505–512.

A study released by the Bureau of Justice Statistics in 2006 (Mental Health Problems of Prison

and Jail Inmates) found that more than half of all prison and jail inmates studied reported

having mental health “problems,” a measure that had not been used previously.

4. Paula M. Ditton, Special Report: Mental Health and Treatment of Inmates and Probationers

(Washington, DC: U.S. Department of Justice, 1999), www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf.

5. Linda Teplin, Keeping the Peace: Police Discretion and Mentally Ill Persons (Washington, DC:

U.S. Department of Justice, 2000). Fox Butterfield, “Asylums behind Bars: A Special Report:

Prisons Replace Hospitals for the Nation’s Mentally Ill,” New York Times, March 5, 1998,

section A, p.1.

6. E. F. Torrey, “Reinventing Mental Health Care,” City Journal 9, no. 4 (1999), www.cityjournal.org/html/9_4_a5.html.

7. L. Teplin, K. Abram, G. McClelland, M. Dulcan, and A. Mericle, “Psychiatric Disorders in

Youth in Juvenile Detention,” Archives of General Psychiatry 59 (2002): 1133–1143. Jennie L.

Shufelt and Joseph J. Cocozza, Youth with Mental Health Disorders in the Juvenile Justice System:

Results from a Multi-state, Multi-system Prevalence Study (Delmar, NY: National Center for Mental Health and Juvenile Justice, 2006).

8. John Goldkamp and Cheryl Irons-Guynn, “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, 2000). Henry J. Steadman,

Susan Davidson, and Collie Brown, “Mental Health Courts: Their Promise and Unanswered

Questions,” Psychiatric Services 52 (2001): 457–458.

9. The Council of State Governments Justice Center, with support from the National Alliance

on Mental Illness and the National GAINS Center, developed three annual surveys on mental

health courts between 2004 and 2006.

10. Adapted by Henry J. Steadman from Henry J. Steadman, Susan Davidson, and Collie

Brown, “Mental Health Courts,” Psychiatric Services 52 (2001): 457–458.

11. Linda Teplin and Karen Abram, “Co-occurring Disorders among Mentally Ill Jail

Detainees: Implications for Public Policy,” American Psychologist 46, no. 10 (1991): 1036–1045.

12. John Petrila, Norman G. Poythress, Annette McGaha, and Roger A. Boothroyd, “Preliminary Observations from an Evaluation of the Broward County Mental Health Court,” Court

Review (Winter 2001): 14–22.

Notes
24 Mental Health Courts: A Primer for Policymakers and Practitioners

13. Joseph J. Cocozza and Jennie L. Shufelt, Juvenile Mental Health Courts: An Emerging

Strategy (Washington, DC: National Center for Mental Health and Juvenile Justice, 2006).

14. Ibid., with updated numbers from personal correspondence with Jennie Shufelt,

September 5, 2007.

15. Ibid.

16. A. Redlich, H. Steadman, J. Monahan, J. Petrila, and P. Griffin, “The Second Generation

of Mental Health Courts,” Psychology, Public Policy, and Law (2004): 527–538.

17. Ibid.

18. E. Trupin, H. Richards, D. Werthheimer, and C. Bruschi, Seattle Municipal Court, Mental

Health Court: Evaluation Report (Seattle, WA: City of Seattle, 2001). M. J. Cosden, J. Ellens, J.

Schnell, and Y. Yamini-Diout, Evaluation of the Santa Barbara County Mental Health Treatment

Court with Intensive Case Management (Santa Barbara, CA: Gevirtz Graduate School of Education, 2004). H. A. Herinckx, S. C. Swart, S. M. Ama, C. D. Dolezal, and S. King, “Rearrest and

Linkage to Mental Health Services among Clients of the Clark County Mental Health Court

Program,” Psychiatric Services 56 (2005): 853–857.

19. Dale E. McNiel and Renee L. Binder, “Effectiveness of a Mental Health Court in Reducing

Criminal Recidivism and Violence,” American Journal of Psychiatry 164 (2007): 1395–1403. M.

Moore and V. Aldige Hiday, “Mental Health Court Outcomes: A Comparison of Re-arrest and

Re-arrest Severity between Mental Health Court and Traditional Court Participants,” Law and

Human Behavior 164 (2006): 1395–1403.

20. R. Boothroyd, N. Poythress, A. McGaha, and J. Petrila, “The Broward Mental Health Court:

Process, Outcomes, and Service Utilization,” International Journal of Law and Psychiatry 26

(2002): 55–71.

21. M. Cosden, J. Ellens, J. Schnell, Y. Yasmeen, and M. Wolfe, “Evaluation of a Mental Health

Treatment Court with Assertive Community Treatment,” Behavioral Sciences and the Law 21

(2003): 415–427.

22. Boothroyd, Poythress, McGaha, and Petrila, “The Broward Mental Health Court.”

23. Ibid.

24. M. Susan Ridgely et al., Justice, Treatment, and Cost: An Evaluation of the Fiscal Impact of

Allegheny County Mental Health Court (Santa Monica, CA: RAND Corporation, 2007).

25. At this writing, Policy Research Associates is working on such a study, which is being

funded by the John D. and Catherine T. MacArthur Foundation and is projected to be published in 2010.

26. For information on how to build political support and assess whether mental health

courts are appropriate for a community, see the Criminal Justice/Mental Health Consensus

Project’s Essential Elements of a Mental Health Court (www.consensusproject.org/mhcp/info/

mhresources/pubs).

27. The Justice and Mental Health Collaboration Program was authorized through the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA). This program replaced

the Mental Health Court Program, which funded 37 mental health court initiatives over the

course of 2002–2004.

28. BJA is a component of the Office of Justice Programs, U.S. Department of Justice, and the

former administrator of the Mental Health Court Program. BJA provides leadership, funding,

training, and technical assistance to states, local governments, and other justice and prevention agencies to reduce crime, violence, and drug abuse and improve the functioning of the

criminal justice system.

29. The Justice Center coordinates the Criminal Justice/Mental Health Consensus Project, a

national effort to help local, state, and federal policymakers and criminal justice and mental

health professionals improve the response to people with mental illnesses involved in the

criminal justice system. Through the Consensus Project, the Justice Center works closely with
Mental Health Courts: A Primer for Policymakers and Practitioners 25

BJA on a number of criminal justice/mental health issues and served as the technical assistance provider for the Mental Health Court Program. For more information on the Consensus

Project and technical assistance opportunities, see www.consensusproject.org. For more information on the Pretrial Justice Institute and NACO, see their respective websites: www.pretrial.org

and www.naco.com.

30. SAMHSA originally coordinated the TCE Jail Diversion Program with BJA’s Mental Health

Court Program and helped to provide technical assistance to the grantees, but mental health

courts were not eligible to apply directly for TCE grants until 2005. The TCE program is

intended to expand the community's ability to provide a comprehensive, integrated response

to substance use treatment capacity issues and to improve the quality of services.

31. For more information on TAPA, see www.gainscenter.samhsa.gov/html/tapa/cmhs/role.asp.

32. For more information on BJA mental health court learning sites, see www.consensus

project.org/mhcp/.

33. Hard copies of all of these policy guides can be requested from the Justice Center.

34. The Justice Center coordinates the InfoNet and developed it with assistance from key partners, namely, the National GAINS Center, the National Alliance on Mental Illness (NAMI),

and the Police Executive Research Forum (PERF). The InfoNet is made possible through the

support of BJA, National Institute of Corrections (NIC), Office for Victims of Crime (OVC),

SAMHSA, the Center for Mental Health Services (CMHS), and the John D. and Catherine T.

MacArthur Foundation.
The Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice, provides leadership training, technical assistance, and

information to local criminal justice agencies to make America’s communities safer. Read more at www.ojp.usdoj.gov/BJA/.

The Council of State Governments Justice Center is a national nonprofit

organization serving policymakers at the local, state, and federal levels

from all branches of government. The Justice Center provides practical,

nonpartisan advice and consensus-driven strategies, informed by available

evidence, to increase public safety and strengthen communities. Read

more at www.justicecenter.csg.org.

The Criminal Justice/Mental Health Consensus Project is an unprecedented

national effort coordinated by the Justice Center to improve responses to

people with mental illnesses who become involved in, or are at risk of

involvement in, the criminal justice system. Read more at www.consensus

project.org.
Notes
Notes
Council of State Governments

Justice Center

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