The Classification of Violence Risk.

(Reprinted with permission from Behav. Sci. Law 24: 721-730, 2006).

Revising the paradigm for jail diversion for people with mental and substance use disorders: Intercept 0.

A conceptual model for community-based strategic planning to address the criminalization of adults with mental and substance use disorders, the Sequential Intercept Model has provided jurisdictions with a framework that overcomes traditional boundaries between the agencies within the criminal justice and behavioral health systems. This article presents a new paradigm, Intercept 0, for expanding the utility of the Sequential Intercept Model at the front end of the criminal justice system. Intercept 0 encompasses the early intervention points for people with mental and substance use disorders before they are placed under arrest by law enforcement. The addition of Intercept 0 creates a conceptual space that enables stakeholders from the mental health, substance use, and criminal justice systems to consider the full spectrum of real-world interactions experienced by people with mental and substance use disorders with regard to their trajectories, or lack thereof, through the criminal justice system.

Police Responses to Persons With Mental Illness: Going Beyond CIT Training.

Since 1988, a major development to reduce lethal encounters between police and persons displaying signs of mental illness has been the adoption by many police departments of crisis intervention teams (CITs). Created in Memphis, Tennessee, CIT programs incorporate deescalation training, police-friendly drop-off centers, and linkage to community treatment programs. The authors summarize issues discussed at a recent Substance Abuse and Mental Health Services Administration workshop at which participants highlighted the importance of going beyond CIT training to most effectively include police in a crisis care continuum model. Such an approach focuses on how police can be engaged as partners with behavioral health providers who are designing and implementing services in the crisis care continuum. Reframing the approach to police responses to persons in mental health crises offers the prospect of improving both public health and public safety goals.

Gun Violence and Victimization of Strangers by Persons With a Mental Illness: Data From the MacArthur Violence Risk Assessment Study.

OBJECTIVE: Highly publicized incidents in which people with apparent mental illnesses use guns to victimize strangers have important implications for public views of people with mental illnesses and the formation of mental health and gun policy. The study aimed to provide more data about this topic. METHODS: MacArthur Violence Risk Assessment Study data were analyzed to determine the prevalence of violence by 951 patients after discharge from a psychiatric hospital, including gun violence, violence toward strangers, and gun violence toward strangers. RESULTS: Two percent of patients committed a violent act involving a gun, 6% committed a violent act involving a stranger, and 1% committed a violent act involving both a gun and a stranger. CONCLUSIONS: When public perceptions and policies regarding mental illness are shaped by highly publicized but infrequent instances of gun violence toward strangers, they are unlikely to help people with mental illnesses or to improve public safety.

Applicability of the Risk-Need-Responsivity Model to Persons With Mental Illness Involved in the Criminal Justice System.

OBJECTIVE: National efforts to improve responses to persons with mental illness involved with the criminal justice system have traditionally focused on providing mental health services under court supervision. However, a new policy emphasis has emerged that focuses on providing correctional treatment services consistent with the risk-need-responsivity (RNR) model to reduce recidivism. The objective of this review was to evaluate empirical support for following the RNR model (developed with general offenders) with this group and to pose major questions that the field needs to address. METHODS: A comprehensive search using PubMed and PsycINFO yielded 18 studies that addressed the applicability of the RNR model to the target population. The results of these studies were synthesized. RESULTS: There is strong support for using general risk assessment tools to assess this group's risk of recidivism. Preliminary evidence indicates that cognitive-behavioral programs targeting general risk factors are more effective than psychiatric treatment alone. However, there is as yet no direct support for the applicability of the three core RNR principles to treat this population. CONCLUSIONS: Although the new policy emphasis shows substantial promise, the field must avoid rushing to the next "evidence base" too rapidly and with too little data. There must be explicit recognition that RNR principles are being applied to a new population with unique characteristics (mental illness combined with justice system involvement), such that generalizability from general offender samples is uncertain. Moreover, public safety goals for the target population should not eclipse those related to public health. This group's unique features may affect both the process and outcomes of treatment.

Best practices for increasing access to SSI and SSDI on exit from criminal justice settings.

Transitioning from jail or prison to community living frequently results in homelessness and recidivism. Access to benefits such as Supplemental Security Income (SSI) and Medicaid can increase access to housing and treatment and reduce recidivism. The authors review best practices for prerelease access to these benefits by using examples from five jails and four state prison systems. In these settings, approval rates for SSI applications averaged 70% or higher, with evidence of improved access to housing and reductions in recidivism. Success depends on the commitment of resources and leadership, ongoing communication, and monitoring of results.

Criminal justice and behavioral health care costs of mental health court participants: a six-year study.

OBJECTIVE: This study examined whether there were differences in costs for mental health court (MHC) participants and a matched comparison group for three years after a target arrest. METHODS: Data from the MacArthur Mental Health Court Study, the first multisite study of MHCs, were used to compare behavioral health treatment and criminal justice costs for MHC participants and a matched group (using coarsened exact matching) of jail detainees who were not enrolled in an MHC but who received jail-based psychiatric services in the same cities. Cost data for three years before and after a target arrest were calculated separately for each year and for each participant at three sites of the multisite study-296 MHC participants and 386 matched jail detainees. High-cost MHC participants were identified. RESULTS: Total annual costs for MHC participants averaged $4,000 more for all three follow-up years. The additional costs resulted from treatment costs, which were not offset by criminal justice cost savings. The highest-cost MHC participants were those with diagnoses of co-occurring substance use disorders and those who had more arrest incarceration days before their target arrest. Separate analyses determined that the higher average costs were not the result of outlier cases. CONCLUSIONS: Participation in an MHC may not result in total cost savings in the three years after enrollment. To become more efficient and to serve participants with the greatest needs, MHCs need to more effectively define the target group for intervention.

Transitional case management for reducing recidivism of individuals with mental disorders and multiple misdemeanors.

OBJECTIVE: The purpose of this study was to measure the impact of a transitional case management (TCM) program targeted to individuals with mental disorders and multiple arrests for misdemeanor offenses. METHODS: The sample included 178 individuals who were diverted from jail at arraignment (N=125) or who voluntarily enrolled in TCM (N=53). Number of arrests and case management sessions attended were compared. RESULTS: The mean ± SD number of arrests of the 178 participants declined by 31% from the 12 months preenrollment to the 12 months postenrollment. Lifetime arrests and age were significant factors in the count of arrests postenrollment. Diverted and voluntary participants had similar numbers of postenrollment arrests (2.5 ± 3.0 and 2.5 ± 3.5, respectively). Differences in mean postenrollment arrests for diverted participants who completed or did not complete TCM were not significant. Diverted and voluntary participants received an equivalent mean number of case management sessions. CONCLUSIONS: Individuals in TCM experienced a reduction in arrests in the 12 months postenrollment.

The cost of assisted outpatient treatment: can it save states money?

OBJECTIVE: The authors assessed a state's net costs for assisted outpatient treatment, a controversial court-ordered program of community-based mental health services designed to improve outcomes for persons with serious mental illness and a history of repeated hospitalizations attributable to nonadherence with outpatient treatment. METHOD: A comprehensive cost analysis was conducted using 36 months of observational data for 634 assisted outpatient treatment participants and 255 voluntary recipients of intensive community-based treatment in New York City and in five counties elsewhere in New York State. Administrative, budgetary, and service claims data were used to calculate and summarize costs for program administration, legal and court services, mental health and other medical treatment, and criminal justice involvement. Adjusted effects of assisted outpatient treatment and voluntary intensive services on total service costs were examined using multivariate time-series regression analysis. RESULTS: In the New York City sample, net costs declined 43% in the first year after assisted outpatient treatment began and an additional 13% in the second year. In the five-county sample, costs declined 49% in the first year and an additional 27% in the second year. Psychotropic drug costs increased during the first year after initiation of assisted outpatient treatment, by 40% and 44% in the city and five-county samples, respectively. Regression analyses revealed significant declines in costs associated with both assisted outpatient treatment and voluntary participation in intensive services, although the cost declines associated with assisted outpatient treatment were about twice as large as those seen for voluntary services. CONCLUSIONS: Assisted outpatient treatment requires a substantial investment of state resources but can reduce overall service costs for persons with serious mental illness. For those who do not qualify for assisted outpatient treatment, voluntary participation in intensive community-based services may also reduce overall service costs over time, depending on characteristics of the target population and local service system.

PTSD as a mediator between lifetime sexual abuse and substance use among jail diversion participants.

OBJECTIVE: Many of the individuals with serious mental illness involved in the criminal justice system have experienced interpersonal victimization, such as sexual abuse, and have high rates of alcohol and drug use disorders. Little attention has been paid to the prevalence of posttraumatic stress disorder (PTSD) and its potential role in the substance misuse of offenders with mental illness. METHODS: The study used a path analytic framework to test the hypothesis that PTSD mediates the relationship between sexual abuse and level of alcohol and drug use among individuals (N=386) with mental illness enrolled in a multisite (N=7) jail diversion project. RESULTS: Sexual abuse was strongly associated with PTSD, which was in turn associated with both heavy drug use and heavy drinking. CONCLUSIONS: These findings suggest that PTSD may be an important target for jail diversion programs.

Law & psychiatry: what can we say about mental health courts today?

Mental health courts (MHCs) are a popular type of problem-solving court, and there is ample evidence that they reduce recidivism and increase participation in community-based treatment. The authors summarize evidence for the effectiveness of MHCs and present findings from a study in which they identified and characterized 346 adult and 51 juvenile MHCs currently operating in the United States. The continued growth of MHCs will be based in large part on funding for services. The Affordable Care Act will have major consequences for services provided to this population, and its implementation may therefore affect the future of MHCs. The authors note that it is preferable that people with mental illness not become involved in the criminal justice system in the first place. Despite the success of MHCs, they are not a substitute for an adequate mental health system.

A multi-site study of the use of sanctions and incentives in mental health courts.

Mental health courts (MHCs) have become widespread in the United States as a form of diversion for justice-involved individuals with mental illness. Sanctions and incentives are considered crucial to the functioning of MHCs and drug courts, yet with little empirical guidance to support or refute their use, and there are no definitions of what they are. The use of sanctions and to a lesser degree incentives is the focus of this article, with particular emphasis on jail sanctions. Subjects are participants (n = 447) in four MHCs across the United States. Results show that jail sanctions are used in three of four MHCs, and other sanctions are similarly used across the four MHCs. Participants charged with "person crimes" are the least likely to receive any sanctions, including jail, whereas those charged with drug offenses are most often sanctioned. The factors associated with receiving a jail sanction are recent drug use, substance use diagnosis, and drug arrests; being viewed as less compliant with court conditions, receiving more bench warrants, and having more in-custody hearings; and MHC program termination. No personal characteristics are related to receiving sanctions. Knowing which MHC participants are more likely to follow court orders and avoid sanctions, and identifying those who have difficulty adhering to court conditions, can help guide court officials on adjusting supervision, perhaps avoiding reoffending and program failure.

A national survey of U.S. juvenile mental health courts.

OBJECTIVE: The authors surveyed U.S. juvenile mental health courts (JMHCs). METHODS: Forty-one were identified in 15 states, and 34 returned surveys; one was completed on the basis of published information. Topics included the court's history, youths served, inclusion and exclusion criteria, the court process, and services provided. RESULTS: Half (51%) reported that the juvenile court was responsible for the program; for 11% the probation agency had the responsibility, and 17% reported shared responsibility by these entities. Fifty-one percent reported that all youths with any mental disorder diagnosis are eligible. The most commonly reported participant diagnoses are bipolar disorder (27%), depression (23%), and attention-deficit hyperactivity disorder (16%). Seventy percent currently include participants with felony offenses, and 91% with misdemeanors; 67% exclude status offenses, and 21% exclude violent offenses. A guilty plea was required by 63%. Incentives to participate included dismissal of charges (40%), reduction in court hearings (43%), praise by the judge and probation officer (60%), reduction in curfew restrictions (23%), and gift cards or gifts (71%). Sanctions for not participating included increased supervision or hearings (60%), performing community service (54%), and placement in residential detention (60%). Most JMHCs reported use of a multidisciplinary team to coordinate community-based services to prevent protracted justice system involvement. CONCLUSIONS: JMHCs are being developed in the absence of systematically collected outcome data. Although they resemble adult mental health courts, they have unique features that are specific to addressing the complex needs of youths with mental disorders involved in the justice system. These include diagnostic and treatment challenges and issues related to involving families and schools.

Exploring Racial Disparities in The Brief Jail Mental Health Screen.

The authors analyzed validation data from the Brief Jail Mental Health Screen (BJMHS) to determine whether race predicted screening results and if such a prediction was driven by particular screen items. A total of 22,000 individuals entering five jails over two 8-month periods were screened. The authors constructed binary logistic regression models to assess the impact of race on screening positive and endorsing particular items. Blacks and Latinos had lower odds than Whites of screening positive. Blacks and Latinos had somewhat lower odds than Whites of endorsing two or more symptom items but had appreciably lower odds of endorsing items regarding prior mental health service utilization. Racial differences in BJMHS screening results likely reflect the reproduction of racial disparities rather than valid differences because results were driven by items reflecting known barriers in access to mental health services. Nonetheless, the instrument is likely to remain an improvement over typical jail screening procedures.

Effect of mental health courts on arrests and jail days: a multisite study.

CONTEXT: Mental health courts are growing in popularity as a form of jail diversion for justice system-involved people with serious mental illness. This is the first prospective multisite study on mental health courts with treatment and control groups. OBJECTIVES: To determine if participation in a mental health court is associated with more favorable criminal justice outcomes than processing through the regular criminal court system and to identify defendants for whom mental health courts produce the most favorable criminal justice outcomes. DESIGN: Longitudinal study. SETTING: Four mental health courts in San Francisco County, CA, Santa Clara County, CA, Hennepin County (Minneapolis), MN, and Marion County (Indianapolis), IN. PARTICIPANTS: A total 447 persons in the mental health court (MHC) and 600 treatment-as-usual (TAU) controls. INTERVENTION: Eighteen months of pre-entry and postentry data for 4 jurisdictions. All subjects were interviewed at baseline, and 70% were interviewed at 6 months. Objective outcome data were obtained on all subjects from Federal Bureau of Investigation arrest records, jails, prisons, and community treatment providers. MAIN OUTCOME MEASURES: Annualized rearrest rates, number of rearrests, and postentry incarceration days. RESULTS: The MHC and TAU samples are similar on the major outcome measures in the pre-entry 18-month period. In the 18 months following treatment, defined as entry into mental health court, the MHC group has a lower annualized rearrest rate, fewer post-18-month arrests, and fewer post-18-month incarceration days than the TAU group. The MHC graduates had lower rearrest rates than participants whose participation was terminated both during MHC supervision and after supervision ended. Factors associated with better outcomes among the MHC participants include lower pre-18-month arrests and incarceration days, treatment at baseline, not using illegal substances, and a diagnosis of bipolar disorder rather than schizophrenia or depression. CONCLUSIONS: Mental health courts meet the public safety objectives of lowering posttreatment arrest rates and days of incarceration. Both clinical and criminal justice factors are associated with better public safety outcomes for MHC participants.

Assisted outpatient treatment in New York: regional differences in New York's assisted outpatient treatment program.

OBJECTIVE: This study sought to describe the implementation of "Kendra's Law" in New York State and examine regional differences in the application of the program. METHODS: Between February 2007 and April 2008, interviews were conducted with 50 key informants across New York State. Key informants included assisted outpatient treatment (AOT) county coordinators, county directors of community services, judges, attorneys from the Mental Hygiene Legal Service (MHLS), psychiatrists, treatment providers, peer advocates, family members, and other referred individuals. Additional analyses were conducted using AOT program administrative and evaluation databases and client history data. RESULTS: From program inception in 1999 through 2007, a total of 8,752 initial AOT orders and 5,684 renewals were granted. Notable regional differences were found in the use of two distinct models of AOT: AOT First and Enhanced Voluntary Services First. Regional differences were also found in how the AOT program was implemented and administered. Other variations stemmed from the court proceedings themselves, the continuity and interest of the presiding judge, and the attitudes of the MHLS attorneys. CONCLUSIONS: Many regional adaptations of the AOT program were found. Many were the result of lack of guidance in implementing Kendra's Law. Policy makers may want to consider whether the law should change to allow for these differences or whether additional support from a central source is warranted to ensure more uniformity in the implementation of AOT and thus the fairness of its application across the state.

Assessing outcomes for consumers in New York's assisted outpatient treatment program.

OBJECTIVE: This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. METHODS: Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. RESULTS: On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. CONCLUSIONS: Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.