(Illustration: Nigel Buchanan)

Mental health courts sound like a great idea—just like the drug courts that inspired them. People with psychiatric disorders often have difficulty controlling their behavior; if you treat them effectively, you’ll reduce crime and the need for prison terms. With at least 1.1 million inmates in the United States suffering from mental illness, expanding access to mental health courts could potentially reduce mass incarceration.

Introduced in the U.S. in the 1990s, these courts are procedurally similar to drug courts. Defendants charged with crimes linked to psychiatric problems are evaluated and given a treatment plan, which is overseen by a judge.

In some mental health courts, defendants plead guilty and receive suspended sentences. If they complete the program, the sentence is not imposed; if not, they do the time. In others, charges are suspended until the defendant completes the program, then dropped when they satisfy treatment requirements. Those who don’t comply are simply returned to the regular court system to face the original charges.

But as with drug courts, the devil is in the details. Fewer than 400 mental health courts exist, and the variety of their approaches makes it difficult to draw general conclusions. Research is only beginning to examine whether they work, what the drawbacks are, and what practices are most effective.

Fairly or not, the judicial system sees people with mental illnesses as less culpable than those with addiction, which makes mental health courts less punitive than drug courts—even though an extremely high proportion of their participants also have addictions. These courts are more forgiving of lapses and less likely than drug courts to use jail terms as sanctions for non-compliance, recognizing that incarceration is likely to exacerbate symptoms and interrupt medical treatment.

Mental health courts are also more deferential to medical authorities. Unlike in drug courts, judges in mental health courts do not determine what treatments are allowed; they leave that to the doctors. On average, about 60 percent of defendants who start these programs complete them.

Here are five studies about mental health courts—and what they’re teaching us about rehabilitation.

MENTAL HEALTH COURTS CAN WORK

In a 2015 literature review of mental health court data, 15 articles examined recidivism rates; of these, 13 found significant reductions in new arrests and days spent incarcerated. For example, one study of over 1,000 participants showed that mental health court participants spent 44 percent fewer days in jail—82 days fewer in total—compared to regular court defendants, who spent 152 days in jail on average. Only one article included in the review suggests that mental health courts might not work—the reasons why are unclear—while the final paper found no difference between mental health courts and traditional courts. The author of the review concludes, “Thus far, a small but growing body of mental health court research indicates that it is plausible that these courts have the ability to accomplish their primary aim, that is, to reduce criminal recidivism rates of persons with mental illness.”

—“Does the Evidence Support the Case for Mental Health Courts? A Review of the Literature,” Honegger, L.N., Law and Human Behavior, 2015.

AND THE RESULTS HAVE STAYING POWER FOR GRADUATES

In a five-year follow-up study comprising all defendants in North Carolina’s first mental health court, researchers compared people who completed the court successfully with those who didn’t. Among 449 defendants, 75 percent of dropouts were re-arrested during the five years after they started mental health court, compared to 40 percent of those who completed the program. The average time to re-arrest was also longer for graduates: 17 months, versus 12. While these numbers may simply suggest that people who complete mental health court are more motivated to change their behavior, it also shows that, at a minimum, the courts do not hinder the process of recovery—and might well improve it.

—“Long-Term Recidivism of Mental Health Court Defendants,” Ray, B., International Journal of Law and Psychiatry, 2014.

DROPOUTS DON'T SEEM TO BE HARMED—UNLESS THEY ARE SEVERELY PUNISHED

Research has found that drug courts may sometimes harm dropouts: They display higher rates of recidivism than defendants who simply plead guilty in regular court. These findings have some worried that mental health court dropouts might face similar disadvantages. Yet, according to one study, mental health courts are less likely to foster recidivism than regular courts. Troublingly, for mental health court dropouts, recidivism tracked with the severity of punishment: 39 percent of defendants whose cases were dismissed were re-arrested within six years, while 58 percent of those given probation were re-arrested. The increased risk of re-arrest remained even when the researchers controlled for the type of crime and prior arrest history: It was five times greater for those who were incarcerated. The researchers note that this data raises the question of whether many of the defendants should have simply had their charges dismissed at the outset. If mental health courts are to reduce incarceration, they need to be targeted to the right defendants.

—“What Happens to Mental Health Court Non-Completers?” Ray, B., et al., Behavioral Science and the Law, 2015.

BUT ACTUAL MENTAL HEALTH TREATMENT ALSO DOESN'T SEEM TO MATTER

Mental health courts operate on the assumption that untreated psychiatric illness drives crime among those affected by it—thus, providing treatment should reduce crime. But oddly, treating mental illness by itself doesn’t seem to work. In a recent study, nearly 700 defendants in mental health courts were matched according to certain variables—type of illness, age, race—and compared to those with similar charges detained in jail. Nearly all members of both groups had co-occurring addictions. Mental health court participants did get into treatment more rapidly and received more intensive care than those who were incarcerated. However, the type and intensity of treatment received—or whether the participant received any at all—had no relationship with recidivism rates. The authors suggest that mental health treatments are ineffective because they don’t address factors linked with repeated crimes, like unemployment and having a peer group highly involved in antisocial behavior. “[T]o achieve public safety goals, treatment must focus on crimogenic risk factors,” they write.

—“The Impact of Treatment on the Public Safety Outcomes of Mental Health Court Participants,” Keator, K.J., et al., American Behavioral Scientist, 2013.

MENTAL ILLNESS DOESN'T CAUSE CRIME—BUT IT HAMPERS REHABILITATION

Carol Fisler, the director of mental health court programs at the Center for Court Innovation, notes that mental illness itself “is not considered a risk factor for criminal conduct.” Why, then, do so many mentally ill defendants wind up in the criminal justice system, where prisons and jails have become, essentially, the biggest psychiatric hospitals in the country? Fisler quotes Judge Stephanie Rhoades of the Anchorage Mental Health Court, one of the first ever established: “We believed mental illnesses were the direct cause of criminal justice involvement, and really it turns out that it’s very few people for whom that’s true. It appears now ... that mental illness is a reason why [some] people can’t necessarily change as easily as other people.” If this is true, mental health courts may work when they stop a cycle of repeated harsh punishment, and instead give people with mental illness the tools they need to change their behavior. It also suggests that we are creating special courts mainly to reduce harm done by other parts of the justice system—and that we might do better by ending harmful practices and implementing better policies in every court.

—“When Research Challenges Policy and Practice: Toward a New Understanding of Mental Health Courts,” Fisler, C., Judges’ Journal, 2015.

Five Studies is Pacific Standard’s biweekly column that identifies and analyzes the best academic research to deliver new insights on human behavior.

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