Integrating the criminal justice system into mental health service delivery: the worcester diversion experience

The substantial number of persons with mental illness encountered in many sectors of the criminal justice system has spurred actors from various agencies within that system to take actions aimed at reducing the growth of this population. These actions have included the development of specialty police units, jail diversion programs, and other mechanisms for channeling persons with mental illness out of the criminal justice system and into mental health treatment. The courts, too, have become involved in this effort with the recent development of the "mental health court," the latest of the "specialty" or "problem solving courts." These courts have not been without their critics, however, nor are they the only feasible approach to court-based diversion. This paper identifies and explores a range of options for structuring the relationship between criminal courts and local mental health systems. Beginning with a discussion of the rationale motivating the development of mental health courts, two alternatives to this specialty court model are discussed. One involves judges dealing with defendants having mental illness and substance abuse on a case-by-case basis. The other takes advantages of linkages that may already exist between most courts and the mental health providers who conduct their forensic assessments, expanding the role of these providers to serve as boundary spanners between courts and the components of local mental health systems. Regardless of the model adopted, however, appropriate linkages must exist between the courts and relevant providers. A case study is provided that demonstrates how the status of a locale's linkages can be evaluated and how the information derived from such evaluation can be used to improve the linkages between police, courts, and health and human services agencies.     

Effects of diversion on adults with co-occurring mental illness and substance use: outcomes from a national multi-site study

This quasi-experimental non-equivalent comparison group study examines outcomes for participants in eight programs conducting criminal justice diversion for people with co-occurring serious mental illness and substance use disorders compared with jail detainees eligible for diversion, but who were processed through standard criminal justice methods without diversion. Nearly 2000 participants were interviewed at baseline, and 1500 at 3 month and 1300 at 12 month follow-up to baseline. In these interviews, outcome measures of re-arrest, mental health functioning, substance abuse, quality of life, and service utilization were obtained. Those diverted were more likely to have received mental health counseling, mental health medication, and mental health hospitalization than those not enrolled in a diversion program, but were equally likely to have received substance abuse counseling. Overall, the differences in proportions receiving services between the two groups were small, even when these differences were statistically significant. The effect associated with diversion differed somewhat across the individual sites. However, overall cross-site pooled analyses revealed no outcome differences between groups on measures of mental health symptoms, substance use, criminal justice recidivism, or quality of life. Although the immediate benefit of diversion as an access mechanism to community treatment is indicated in pooled cross-site results, such access was driven by more coercive (pre-booking and court) models and results suggest that effecting substantially greater access to services or services use did not occur. The findings also suggest that mental health, substance abuse, and criminal justice outcomes remain dependent on the treatment intervention received, perhaps moderated by type of diversion intervention, rather than on a generic and initial diversion event.     

The role of competency to stand trial in mental health courts

Concerns have been raised in the literature about the competency to stand trial and competency to make treatment decisions of defendants referred to mental health courts. However, there is little information reported about the evaluation and prevalence of incompetence, characteristics of incompetent mental health court defendants, and disposition of mentally ill defendants too disturbed to be diverted from the criminal justice system through mental health courts. This study reports on the 85 potential mental health court defendants referred for trial competency evaluations during the first three years of operation of the Akron Ohio Mental Health Court. Of the 80 defendants who could be located for evaluation, 77.5% were found incompetent, and 53% of the incompetent defendants were not restored to competence even after an average of 49 days of treatment in a state psychiatric hospital. The implications of these findings in terms of the diversion potential of mental health courts for the severely mentally ill are discussed.     

An analysis of post-booking jail diversion programming for persons with co-occurring disorders

For persons with co-occurring disorders, interaction with criminal justice systems is a frequent occurrence. As a result, a variety of diversionary programs have been developed nationwide. In this study, a total of 248 individuals with co-occurring disorders of serious mental illness and substance use disorders who had been arrested and booked on misdemeanor charges participated in a post-booking jail diversion program in two urban communities. A quasi-experimental design was used with individuals assigned to diversion or non-diversion status based upon the decision processes of the mental health-criminal justice systems. The effectiveness of the jail diversion program was evaluated from a variety of sources, including structured interviews, behavioral health service utilization patterns, and criminal justice recidivism patterns. Analyses revealed general main effects for time on many of the outcome variables, with few main effects or interaction effects detected on the basis of diversion status (diverted versus non-diverted). Across all measures assessing mental health and substance abuse, study participants displayed improvements over time, irrespective of their diversion status or program location. Participants generally displayed no significant changes in their rates of accessibility to, or frequency of use of, the various mental health, substance abuse, and other services, and few changes for diversion status were detected with regard to service utilization. Although a number of indicators of criminality and violence were reduced over time, these reductions were statistically insignificant, with changes for diversionary status or time identified at follow-up. These results are discussed in light of their implications for jail diversion programming and future research in this area.     

Mental Health Identification Practices of Jails: The Unmet Needs of the “Silent” Population

The overrepresentation of individuals with mental illness in the criminal/legal system is well documented. While professional associations urge diversion towards treatment, little is known about the practices these institutions use to identify this population. One understudied space in the criminal/legal continuum is jails. This exploratory study compares two types of mental health identification at jail booking to assess jail‐ and community‐based service outcomes by identification type (N = 2956): (a) staff observation and (b) a standardized screening instrument. Individuals identified through staff observation were significantly more likely to receive jail‐ and community‐based services, even though current symptomology and substance misuse were both significantly higher for individuals identified only by the screening instrument. These findings point to the importance of jails in providing stabilizing services during incarceration, but further, show the impact that identification practices have on individuals as they transition to the community. Community context showed varied rates of jail staff observations of mental illness, showing greater risks for individuals in rural communities. Implications include a need for system‐level changes by instituting evidence‐based identification practices in jails, and improving professional collaboration practices between mental health and criminal/legal practitioners as individuals enter and exit jails.     

Transitioning Between Systems of Care: Missed Opportunities for Engaging Adults with Serious Mental Illness and Criminal Justice Involvement

Individuals with serious mental illness are overrepresented in the criminal justice system and face difficulties accessing mental health services both during incarceration and upon re‐entry into the community. This study examines how such individuals describe their experiences receiving care both during and after their time in custody and explores the perspectives of mental health service providers who treat this population upon re‐entry. Semi‐structured interviews were conducted with 43 individuals identified as having a history of serious mental illness and criminal justice involvement, as well as with 25 providers who have worked with this population. Clients noted the stress of transitioning to criminal justice settings, the uneven availability of services within jail and prison, and the significant challenges faced upon re‐entry. Providers reported barriers to working with this population, including minimal coordination with the criminal justice system and challenging behaviors and attitudes on the part of both clients and providers. Findings identify potential target areas for improved care coordination as well as for additional provider education regarding the unique needs of this population. Copyright © 2013 John Wiley & Sons, Ltd.     

Contrasting jail diversion and in-jail services for mental illness and substance abuse: do they serve the same clients?

Baseline data from a study of jail diversion services and in-jail behavioral health services were used to examine the differences in clients served by these two models of responding to people with co-occurring mental health and substance abuse problems in the criminal justice system. Clients of the diversion service had more acute psychiatric symptoms and were more likely to have a diagnosis of psychosis NOS. Clients of the in-jail service were more likely to have been on probation or parole in the past and to have received substance abuse treatment. Different service models may attract and serve different populations of clients. Diversion services may cast a wider net that includes clients who may not have otherwise been involved in forensic services.     

Evaluating the efficiency and community safety goals of the Broward County Mental Health Court

Mental health courts have developed as one response to persons with mental illness who are involved with the criminal justice system. This study investigated the efficiency and safety goals of one such court in Broward County, FL. Mental health court (MHC) clients spent significantly fewer days in jail for the index arrest associated with study enrollment than a comparison group. MHC clients had similar survival time to re-arrest up to one year after study enrollment. MHC clients did not significantly differ from the comparison group in self-reported aggressive acts over an 8 month follow-up period, while they did self-report significantly fewer acts of violence than the comparison group at the 8 month follow-up. These findings suggest that some of the benefits associated with the MHC reported in prior studies were not achieved at the expense of efficiency and safety.     

Pre-arrest diversion of people with mental illness: Literature review and international survey

Mental health diversion is a process where alternatives to criminal sanctions are made available to persons with mental illness (PMI) who have come into contact with the law. One form of mental health diversion is pre-arrest, in which the police use their discretion in laying charges. Concomitant with the growth of pre-arrest diversion programs is a growing body of research devoted to the phenomenon. The purpose of this paper is to review the existing literature of pre-arrest diversion, and to report the results of an international survey of pre-arrest diversion programs we conducted to identify evidence-based practices. On the basis of our review and survey, we note that successful pre-trial programs appear to integrate relevant mental health, substance abuse and criminal justice agencies by having regular meetings between key personnel from the various agencies. Often, a liaison person with a mandate to effect strong leadership plays a key role in the coordination of various agencies. Streamlining services through the creation of an emergency drop-off center with a no-refusal policy for police cases is seen as crucial. While there is some indication that mentally ill offenders benefit from their participation in this form of diversion, the evaluative literature has not yet achieved the "critical mass" necessary to create generalizable, evidence-based knowledge. The absence of generally agreed-upon outcomes could lead to the inequitable application of basic principles of diversion. We suggest that indicators, benchmarks, and outcomes must be agreed upon if a comprehensive understanding of pre-arrest programs is to emerge.     

Challenges in implementing evidence-based treatment practices for co-occurring disorders in the criminal justice system

The presence of adults with mental health and substance abuse disorders within the criminal justice system has become increasingly evident over the past decade. Interventions and treatment services have been designed and research conducted in an effort to establish evidence-based practices that effectively address the complex needs of this population. However, adopting and implementing these evidence-based interventions and practices within the real-world setting of criminal justice environments is challenging. This article reviews the research literature related to evidence-based treatment practices for offenders with co-occurring mental health and substance abuse disorders and explores the inherent challenges of fitting these interventions and services within criminal justice settings.     

Gender and mental health: An examination of procedural justice in a specialized court context

The procedural justice framework has been applied in the criminal justice contexts of policing, corrections, and courts. According to this perspective, fair treatment, respectful dialogue and being given a proper voice will contribute to citizens' positive views of authority figures. While this literature has grown immensely, several questions remain unanswered. Do males and females perceive similar levels of procedural justice? Does mental health status influence perceptions of fair treatment? Whether procedural justice is a general perspective that can be applied across social groupings has important implications for correctional treatment in that programs that truly “work” for all are more cost‐effective. Toward that end, the current study investigates the relationships among procedural justice perceptions, gender, and mental health status in specialized drug courts, a context that has received little empirical attention. We do so using secondary data originally collected between 2003 and 2009 for Rossman, Roman, Zweig, Rempel and Lindquist's Multisite Adult Drug Court Evaluation (MADCE). Results from a full‐sample analysis reveal that women report higher levels of procedural justice; that drug court participation significantly influences procedural justice perceptions; and that depressive symptomology is a significant predictor of procedural justice perceptions. In male‐ and female‐specific subsamples, drug court participation exerts similar effects for males and females, as does depressive symptomology. Implications for theory, research, and practice are discussed.     

Correlates of Victimization in a Juvenile Justice Population

The Practical Adolescent Dual Diagnostic Interview is a structured diagnostic interview designed to gather basic information about mental health conditions; past emotional, physical, and sexual abuse; suicide attempts; and substance use disorders. This instrument was administered to 435 males and 61 females in juvenile justice facilities and adolescent diversion courts to assess prevalence of mental health and substance use disorders relative to maltreatment (defined as physical, sexual, and/or emotional abuse). Results showed that the majority of juveniles who experienced maltreatment were more likely to have diagnostic indications of behavioral health conditions. Additionally, for both males and females the odds of the individual having attempted suicide were more than twice as high for those acknowledging some form of maltreatment.     

The impact of mental health court: A Sacramento case study

Mental health courts (MHCs) use a collaborative justice approach to provide a therapeutic alternative to the traditional justice process for defendants with mental illnesses directly relevant to their alleged criminal offenses. MHCs have proliferated in recent years, in light of early research reports documenting their successes. The aim of this paper is to provide further evaluation of the effects of MHCs by evaluating the impact of the Sacramento County MHC in California. We analyzed quantitative data and conducted interviews with stakeholders and MHC participants to understand how the MHC influenced individual participants' recidivism rates, mental health, and quality of life. Results from the quantitative data analysis indicate that defendants had a lower rate of recidivism after the MHC program than before it. Moreover, graduates were less likely to be rearrested and rehospitalized than non‐graduates. Qualitative analyses revealed several core themes regarding participants' views on facilitators and barriers related to the MHC's success. These findings provide further insights into the effectiveness of MHCs.     

Criminal justice and the drug-abusing offender: policy issues of coerced treatment

Criminal justice populations, including arrestees, probationers, inmates and parolees, have become increasingly involved with drugs of abuse. These numbers have seriously impacted the criminal justice system from enforcement to the courts, corrections, and subsequent legal supervision agencies. Prevalence of substance abuse in these populations is reported, as well as the effectiveness of community-based and corrections-based treatment in effecting behavioral changes to reduce drug demand. The characteristics of successful intervention programs are described and an ideal model proposed for better integrating community treatment and criminal justice intervention efforts.     

Unequal Before the Law: Immigrant and Racial Minority Perceptions of the Canadian Criminal Justice System

This paper examines attitudes towards the criminal justice system among a large, diverse sample of residents from Toronto, Canada. The results indicate that while most residents positively evaluate the performance of the police and criminal courts, black and Chinese Canadians have less favorable views than whites. Compared to whites, racial minority respondents are also much more likely to perceive various forms of discrimination within the justice system. Perceptions of racial bias are particularly widespread among black respondents. Interestingly, these racial differences cannot be explained by immigration patterns. Indeed, regardless of race, attitudes towards the justice system are most positive among recent immigrants. However, attitudes become less favorable with time spent in Canada and are most negative among Canadian-born racial minorities. The paper concludes with a discussion of the theoretical and policy implications of these findings.     

Who Is Referred to Mental Health Services in the Juvenile Justice System?

We describe the mental health referral rate among youth in a correction facility, examine how sociodemographic and criminal history characteristics relate to referral, and explore how these variables and diagnostic class differ by referral source. Data were abstracted from case records. The referral rate was low (6%). Non-Latino youth, repeat offenders, and violent offenders were more likely to be referred compared to all detained youth. Referral source also varied by violent offense history and diagnosis type. Future studies examining access to mental health services should take into account a detained youth's sociodemographic, criminal history, and clinical characteristics.     

Predictors of Criminal Charges for Youth in Public Mental Health During the Transition to Adulthood

Dual involvement with the mental health system and justice system is relatively frequent for young adults with mental health problems, yet the research on factors predictive of dual involvement is incomplete. This study extends past research on predictors of criminal charges for people in the public mental health system in four ways. First, this study expands the longitudinal study period to include the time of transition to adulthood, from 16 to 25 years of age. Second, this study separately predicts specific types of criminal charges, including violent, property, drug, and nuisance charges. Third, this study examines whether residential treatment or inpatient hospitalization are predictive of criminal charges. Fourth, this study stratifies prediction by gender. Findings indicated high levels of dual involvement during this time period. In general, males and people diagnosed with substance use disorder or conduct disorder were more likely to have a criminal charge. Other predictors of specific criminal charges varied by gender. Residential treatment, inpatient hospitalization, and anxiety disorder were generally not related to criminal charges. Implications for cross-system collaboration and early intervention are discussed.     

Understanding community re-entry of former prisoners with mental illness: a conceptual model to guide new research

Criminal justice, mental health, and social service professionals face a myriad of role expectations in working with prisoners with mental illness to facilitate community re-entry. These expectations include those related to law enforcement, social welfare, and administrative efficiency. The challenge for front line workers and the multiple systems that employ them is to integrate all these expectations effectively on behalf of the individual as well as the community. Current models of re-entry for individuals leaving prison with mental illness focus on the management and interaction of service systems. This paper presents a model of prisoner re-entry that incorporates a larger social context, illustrating dynamics related to both individuals with mental illness leaving prison and their interaction with the community setting. This model was generated through an interdisciplinary team effort. It was refined through a focus group process that included advocates, community members and other informants from mental health and criminal justice systems in five states. The model is designed to generate new questions for research that address both individual and community level issues.     

Without Thinking: Impulsive Aggression and Criminal Responsibility

In the U.S. the decision to impose criminal responsibility rests on an assumption about the defendant's decision to engage in proscribed conduct. We punish only those who we believe had the capacity to make a choice. In an increasingly violent world, the criminal law and the assumptions upon which it rests are relentlessly tested. A new generation of neuro-imaging technologies offers to provide insights into structural and functional abnormalities in the brain that may limit the autonomy of many dangerous offenders and unravel the fabric of the criminal justice system. How will the results of these technologies be received by the courts—are they relevant to existing formulations of the prima facie case, the insanity defense, or mitigation of sentence; will changes in the science or the law be required to accommodate this knowledge? The new generation of technologies may appropriately play a role in assessing culpable mental states only if they are also reliable. This short article takes on these and a host of other related questions at the intersection between science, law, and science fiction. Copyright © 2008 John Wiley & Sons, Ltd.