Phase II Study Description

Individuals with mental health disorders are highly overrepresented within the United States correctional facilities (Prins, 2014). Since the Community Mental Health Act was passed in the 1960s, long-term, residential state hospitals for mental health treatment were shut down across the nation. These state hospitals were viewed as warehouses for individuals with mental illness, and frequently had improper funding and care for those who were “institutionalized” in them. While the aim of this deinstitutionalization was to shift mental health care from these large, state hospitals to communities, instead, the United States prison system has become the number one provider of mental health services: the National Alliance on Mental Illness has estimated that at least 400,000 inmates across the United States have a mental illness (Ford, 2015).

The goal of the second phase of the study was to assess the efficacy of Utah’s MHCs using a matched sample of individuals with similar treatment and criminal histories. Four jurisdictions were considered for the evaluation, as these were the only jurisdictions with a sufficiently large sample of cases: Utah, Salt Lake, Cache, and Weber counties. Propensity Score Matching (PSM) was used in an attempt to identify comparison groups based on variables that predict the likelihood of being placed in the treatment group (in this case, the likelihood of participation in the MHC). A large number of PSM algorithms were employed in an attempt to obtain a matched comparison sample.

Unfortunately, due to a high degree of missing mental health history data, PSM could not identify an appropriate comparison group. Because the study was unable to implement the intended methods to examine MHC outcomes, the MHCs were evaluated using an alternative, and less rigorous, method. Using pre-post data for MHC clients only, participant data were assessed regarding defendants’ offending behavior in all four MHCs, and mental wellness for the Salt Lake and Utah MHCs. Each court was evaluated separately for both recidivism and mental health outcomes. Given the inability to implement the intended PSM design, some of the challenges that future studies would face and recommendations for how to address these issues are discussed.

Mental Health Courts (MHCs) are problem-solving courts that have been implemented across the nation in order to ameliorate this issue. These courts have been developed to divert non-violent defendants with mental health disorders away from the criminal justice system and into community-based treatment, monitored by the court. When offending behaviors are attributable to mental illness, the MHC aims to prevent reoffending by treating the issue underlying this behavior, while simultaneously avoiding conventional punishment. In providing court-monitored treatment, MHCs also hold mentally ill defendants accountable for engaging in necessary treatment services (Berman & Feinblatt, 2001; Berman & Fox, 2010; Goldkamp & Irons-Guyunn, 2000).

MHCs vary widely in both populations and procedures, but they do have some similarities, including: a docket for defendants with mental illness that has been separated from the traditional court docket; ability of defendants to opt into the MHC (with the alternative of being processed through the traditional court system); dedicated judges, prosecution, and defense attorneys; collaboration between court staff and mental health providers in determining treatment plans and justice system-related repercussions; court monitoring of treatment processes and outcomes; and justice system-related rewards for completion of program requirements, including potential dismissal of charges or averting incarceration (Campbell et al., 2015; Goldkamp & Irons-Guyunn, 2000).

Although MHCs have been developed to work with a common type of population (justice system-involved individuals who have mental health disorders), the exact populations involved with MHCs, and the procedures with which MHCs handle them, vary widely by individual court. In a systematic review of 38 MHCs targeted for adults (Worwood, Sarver, Borgia, & Butters, 2015), the majority of MHCs accepted defendants who had committed either misdemeanors or felonies. Defendants who had committed violent felonies were excluded from about over half of these courts. Other courts included those with violent charges only on a case-by-case basis. Several courts only allowed defendants who had committed misdemeanor offenses or infractions, excluding defendants who had committed a felony offense entirely. Additionally, one court only accepted defendants who had committed felonies.

This review also showed a variety of mental diagnoses that were considered acceptable among defendants. The majority of courts accepted defendants with psychosis, schizophrenia, and/or depression. Half of the courts accepted defendants with anxiety disorders. Lower numbers of MHCs accepted defendants with other mental health issues, such as traumatic brain injury, personality disorders, developmental disabilities, attention deficit/hyperactivity disorder, or substance-related disorders, unless they were paired with other accepted disorders (Worwood, Sarver, Borgia, & Butters, 2015). Procedures engaged in by MHCs show no less variety than defendant eligibility criteria. Programs differ widely in terms of when in the court process defendants can enter an MHC (i.e., before or after a plea); types of supervision or case management defendants are placed under (e.g., probation, electronic monitoring, intensive case management); and types of services that MHCs can offer to defendants (e.g., housing, employment, education, financial).

Image of a graph displaying Figure 8 Trajectory for Offending Probability over Time for the Salt Lake MHC

Results

As with Cache, a curvilinear trend was necessary to model the data in Salt Lake. The trend was significant (EDF = 3.00, (3.00) = 164.5, p = .000). Figure 8 shows the results of the GAM model fit to the Salt Lake data. One can see that the probability of offending rose sharply until the year marking the start of MHC participation. The trend reverses in the year following starting MHC, and the trend continues downward over the course of the next two years. At three years post MHC start, the trend levels out relative to two years post start, displaying a slight, but non-significant, upward trend. Notably, the probability of offending for all three years post-MHC start is below the average probability of offending within the Salt Lake MHC sample.

The model for Salt Lake accounts for time in prison and jail, but not hospitalization. While the trend appears to suggest that MHC participation may have helped stabilize clients after a period in which they were particularly likely to offend, other explanations are also possible, including: clients were not in the community to reoffend and systemic changes may have taken place in the enforcement of certain offenses. While the latter explanation cannot be ruled out, it is not a likely explanation for the pattern for the same reasons as outlined for Cache above.

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Evaluation of Utah’s Mental Health Courts

Report: Evaluation of Utah’s Mental Health Courts—Limited Findings and a Review of Research Challenges 2018

Phase II Study Description

Results

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