Do MHCs Work?What Current Research Indicates about

Mental Health Courts

Stephen G. VanGeem, PhDUtah State University

Do MHCs Work?

General Background Variability Among Courts Variability Among Evaluations

Utah’s First District: A Case Study

Effectiveness and Correlates Criminal Justice Outcomes Mental Health Outcomes Comorbidity

MHC Background

3 characteristics: (1) a problem-solving court, (2) interdisciplinary collaboration, and (3) a focus on accountability

Earliest specialty docket: Marion County (Indianapolis), IN, in 1980 First visible MHC was in Broward County, FL, in 1996 346 adult and 51 juvenile MHCs in 2013

Early ones grew out of judicial interest Specific judges attempting to reduce “recycling”

MHC Background cont.

Participants must meet eligibility criteria (i.e., diagnostic, criminal, etc.)

Participants must agree to treatment conditions May include: plea in abeyance, no drug/alcohol use,

frequent status hearings, participate in treatment

Court may use incentives and sanctions to gain compliance Potentially jail terms due to conditions violation or

treatment non-compliance

So, do they work?

So, do they* work?

*What do we mean by “they”?

The issue with “they”

“If you’ve seen one mental health court …”

– Hallie Fader-Towe

The issue with “they”

“If you’ve seen one mental health court, you’ve seen one mental health court”

– Hallie Fader-Towe

MHCs vary in:

Economic Capital – $ Funding matters

Human Capital – The individual skills, knowledge, and similar attributes that affect human capabilities for productive work Personnel matters

Social Capital – The networks that arise from relations between and among people Community resources matter

MHCs vary in:

Charges eligibility Felonies vs. misdemeanors Violent offenses?

Diagnostic eligibility Axis II diagnoses/personality disorders? Comorbidity issues?

Resource availability Number of treatment providers How often can you meet?

Two issues to tackle when talking about “they”

Ecological Fallacy Erroneously basing conclusions about individuals solely on

the observation of groups Ex: “Women make 72 cents on the dollar, but that doesn’t

mean every woman makes less than every man”

Individualist Fallacy Attempts to explain a particular phenomenon in terms of

limited and/or lower-order concepts Ex: “Just because you know a well-compensated woman, it

does not deny the trend that most women are underpaid”

The issue with “they”

Fact I: General patterns exist (but there are individual exceptions)

Fact II: Differing individualized experiences are valid (but they cannot diminish trends)

So the sweet spot lies in the overlap Everyone in this room knows ONE MHC really, really well The question is how we makes sense out of our collective

experiences

So, do they work?

So, do they work*?

*What do we mean by “work”?

The issue with “work”

“Success” depends upon your worldview How would a judge define “success”? How would a treatment provider define “success”? Or a probation officer? Or a public defender? Or a local politician? Or someone in the general population? Or the MHC client him or herself ? Or the client’s mom?

The issue with “work”

Traditional measures of “success” Program completion rates Reduced criminal activity (police contacts, charges, arrests,

convictions) Reduced jail/prison time Less severe offending Increased treatment contacts Reduced hospitalization Reduced chemical dependency Increased procedural justice

Evaluations vary

Most MHC evaluations are single-site Growing number of multi-site studies

Some measure within-group change Difference in participants from Time 1 to Time 2

Some measure between-group change Graduates vs. non-graduates Participants vs. non-participants (or opt-outs or “treatment as

usual”)

Some measure both

Research Issues to Consider

Strongest research design: The CLASSIC EXPERIMENT Pre-test/post-test measures

Random assignment into treatment and comparison groups

Issue #1: We can’t do the CLASSIC EXPERIMENT; why not?

Research Issues to Consider

Strongest research design: The CLASSIC EXPERIMENT Pre-test/post-test measures

Random assignment into treatment and comparison groups

Issue #1: We can’t do the CLASSIC EXPERIMENT; why not? All MHC evaluations are QUASI-EXPERIMENTAL

A Case Study: Utah’s First District MHC

Began in 2008 as a political decision No local needs-based assessment

Motivated by the success of the Third District Mental Health Court in Salt Lake County

In April 2008, Kevin K. Allen was sworn in and charged with establishing the MHC

Court officially began operation in December 2008

Utah’s First District and Cache County

Located in Northern Utah

Population of 112,656 in the 2010 US Census

Predominantly white (89.12%) 9.96% Hispanic

County seat is in Logan Population of 48,174 Median family income is

$33,784 Main industries are education,

manufacturing, and agriculture

Criminal Justice Outcomes

Graduation is significantly associated with: Fewer jail days post-discharge (NC, NV)

Fewer arrests post-discharge (MO, NC, UT)

Fewer violent crimes (CA)

Lower severity of new offenses (NC)

Smaller hazards rates of rearrest (MO, NY)

Longer period before new charges (CA, UT)

Research Issues to Consider

Issue 2: The ENDOGENEITY PROBLEM Endogenous variable develop from within

Exogenous variable develop from without

Typically, exogenous variables = the CAUSE (X) and endogenous variables = the EFFECT (Y)

So what’s the problem?

Research Issues to Consider

Issue 2: The ENDOGENEITY PROBLEM Endogenous variable develop from within

Exogenous variable develop from without

Typically, exogenous variables = the CAUSE (X) and endogenous variables = the EFFECT (Y)

So what’s the problem? What if the change we see in X is due to something

internal?

Research Issues to Consider

MHC participants may be suffering from a period of “bad functioning” where antisocial behavior is relatively atypical

Graduate-only treatment groups run a greater risk of being biased due to “endogenous change” May be a low-risk group

Criminal Justice Outcomes

Graduation is associated with: Fewer jail days post-enrollment (so during participation;

GA)

Fewer arrests post-enrollment (so during participation; GA, OR)

Criminal Justice Outcomes

Participation alone is significantly associated with: Fewer jail days post-discharge (CA, IN, MN, WA)

Fewer arrests post-discharge (CA, DC, IN, MN, WA)

Smaller hazards rates of rearrest (DC)

Longer period before new charges (FL)

All findings match up with our study of the Utah First District MHC

Correlates: Criminal Justice Outcomes

Age is a major risk factor

Youth is significantly associated with: Rearrest (MO, NY, UT) Jail sanctioning during enrollment (NY) Participant offending during enrollment (VT) Termination (MI)

FAILS to match up with our study BUT age does predict a higher hazard of rate of reincarceration

Correlates: Criminal Justice Outcomes

Axis II/Personality Disorders is a moderate risk factor

Personality diagnosis is significantly associated with: Rearrest (AK)

Rejected referral to MHC (Nova Scotia)

MATCHES our study Increases likelihood of rejected referral

Correlates: Criminal Justice Outcomes

Other significant factors increasing rearrest and termination Gender Number of prior arrest Any prior arrests Number of prior jail days Any jail stays Failure to adhere to MH counseling

Only prior jail stays match our study Increases hazard rate of reoffending

Correlates: Criminal Justice Outcomes

Co-occurring Substance Abuse is a major risk factor

Substance diagnosis is significantly associated with: Rearrest (AK, DC, MO, NY)

Rejected referral to MHC (Nova Scotia)

Termination (GA, MI, NY, Ontario)

Correlates: Criminal Justice Outcomes

MATCHES our study although indirectly Increases likelihood of rejected referral

Increases hazard rate of reoffending

Increases likelihood of judicial sanctioning which in turn increases likelihood of termination (affect on termination is indirect)

Mental Health Outcomes

Graduation is significantly associated with: Lower drug use at discharge (CA)

Higher scores on GAF (CA)

Higher scores on Lehman QOL scale (CA)

Lower scores on Addiction Severity Index (CA)

Effectiveness: Mental Health Outcomes

Participation alone is significantly associated with: Greater alcohol/drug abstinence (NY) Lower drug use at 6 months post-discharge (CA) More treatment episodes (WA) Higher treatment hours up to 2 years post-discharge (CA, UT)

FAILS to match up with our study Greatest predictor of enduring treatment post-discharge is

having a relationship with treatment PRIOR to MHC

So, do they work?

So, do they work?

Answer: Yes and Maybe

Conclusions

Yes, MHCs appear to lower recidivism

But, there are mixed results for treatment outcomes

The question now becomes “Why do MHCs work *when* they work?” or even “Why don’t they always work?” Age? Personality? Gender? Criminal history? Substance

abuse?

Conclusions

The “active ingredient” that lowers recidivism has not been identified in either mental health or drug court research, although it may involve some combination of intensive monitoring and supportive relationships with MHC staff. (Goodale, Callahan, Steadman, 2013)

Questions?

Contact me at stephen.vangeem@usu.edu