C o m m u n i t y M e n t a l H e a l t h J o u r n a l , Vol. 22, No. 3, Fall 1986

A Hospital-Based Mental Health Court Gregory P. Sipes, Yh.D., Alan D. Schmetzer, M.D., Mary Stewart, A.C.S.W., Steven L. Bojrab, M.D

ABSTRACT: Deinstitutionalized chronically mentally ill patients face the prospect of

homelessness, insufficient community services, and the possibility of criminalization. Further, many communities do not have a mechanism for recognizing the special problems many of the chronically mentally ill have when they enter the legal system. The following is a description of a hospital-based mental health court, a nontraditional, highly effective program intended to identify chronically mentally ill persons in the community, as well as recognize and correct inadequacy in services available to the deinstitutionatized. Although the ideal of deinstitutionalization has been enthusiastically received, the process of achieving it has resulted in a number of serious problems (Lamb, 1984). Homelessness of the deinstitutionalized population has become an urgent national concern (Lamb, 1984; APA, 1984; Ball et al, 1984; Cohen et al., 1984; Bassuk, 1984). Even in the "golden age" of mental health funding, few states had sufficient financial resources to adequately fund long-term hospitals, community mental health centers, and the residential/rehabilitative services required to meet a full spectrum of needs. In fact, early in this process, few understood the entire spectrum of services necessary to maintain the chronically mentally ill in the community (Talbott, 1981). Fundamental problems not addressed early on involve the tendencies of the chronically mentally ill to be transient, to lack awareness of their need for treatment, and/or to lack motivation to commit to treatment programs (Lamb, 1984). This lack of understanding, along with poorly defined, designed, and implemented community-based services, has led to failure, frustration, and in many cases, either reinstitutionalization or homelessness (Sipes & Bojrab, 1985). M a n y have suggested that "criminalization" has been substituted for institutionalization of the chronically mentally ill. That is, housing for many chronic patients has moved from hospitals to jails (Lamb, 1984; Whitmer, 1984; Abramson, 1972; Bonovitz & Bonovitz, 1981). O f course, the problems are actually interrelated. It has been posited that homelessness, with its accompanying lack Gregory P. Sipes, Alan D. Schmetzer, Mary Stewart, and Steven gojrab are with the Indiana University School of Medicine.

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of community support and structure, leads to antisocial or illegal behavior on the part of the chronically mentally ill. It is becoming increasingly apparent that cooperation and coordination of a variety of community agencies are needed for deinstitutionalization not to result in criminalization (Talbott, 1981). This joint venture must identify the chronically mentally ill individual, and divert him or her away from the criminal justice system and into the mental health systems, with the assurance of appropriate treatment. This paper describes a decidedly nontraditional, highly effective program which combines the efforts of the mental health system, law enforcement agencies, the county jail, and the county municipal court system.

B R I E F H I S T O R Y OF T H E C O U R T Our city is a midwestern metropolitan community of approximately one million people. Four comprehensive mental health centers and two state hospitals serve the public mental health needs of the city. Both state hospitals are located in the city. One serves the longer term needs of the chronically mentally ill, while the other is an intermediate care facility functioning as a teaching and research hospital. The community mental health centers serve as "gate-keepers" for admissions to the state hospitals, as well as providing psychiatric care for those released from state hospitals into their respective catchment areas. Only one of these community mental health centers serves the inner city. Within the inner city lie all of the city's missions, the main bus terminal, the city lock-up, the county jail, and the county hospital, to which any arrested person who needs medical treatment and most indigent patients are brought. From its early days, our mental health center recognized the need to interface with the criminal justice system and offered its clinical and educational services to the county sheriff, the city police, and the municipal courts. These early educational meetings, as well as their own "street knowledge," led police to recognize that many whom they were dispatched to see were disordered rather than (or in addition to) disorderly. Their request for help with such people resulted in an agreement that when mental illness was perceived to be an issue, the individual would have a special notation placed after his/her disorderly conduct charge. Each day a list of the disorderly conducts with the special notation would be sent to a crisis clinician from our center. The clinician would then see that person in the holding area at the city-county building before his/her court appearance. The clinician would do a brief assessment and make a recommendation in writing to the appropriate court. This procedure was soon refined to allow the offender to be brought directly to the county hospital emergency room after arrest, rather than be taken to jail. The emergency room had a holding area staffed with police officers who could insure the person's custody during evaluation. This procedure provided greater convenience for the crisis clinician's assessment and routinely allowed an emer-

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gency room physician to screen for potential medical causes of disturbed behavior. It also allowed for more direct input from the psychiatrist who was available to the emergency room. Those individuals requiring hospitalization could be admitted directly, without the delay previously involved. Admission could occur simply by requesting an order for admission from the appropriate court. While the new procedure was a decided improvement, there were still 16 different municipal courts with 16 different judges, each of whom seemed to have a different knowledge base regarding mental illness. Even though the judges had access to a written "court memo" listing specific psychiatric recommendations, they often perceived the patient as a nuisance in an already over-loaded court docket, and consequently, ignored the psychiatric input. On occasion, memos were actually lost, and the patient would appear without the benefit of expert advocacy. Additionally, those patients who were admitted directly to the hospital usually had their charges dropped without a court appearance and were often unaware that their behavior was viewed as a community concern. O u r inner city mental health center, with the support of the three suburban centers, decided to open negotiations with the presiding judge of the county municipal courts to establish a single court to hear all specially noted disorderly conduct cases. The ensuing negotiations brought about a plan for a unified mental health court in which cases involving anyone charged with a minor crime who was suspected of being mentally ill, as well as all petitions for commitment, would be heard. This pilot project began in J a n u a r y 1980. The county hospital allocated space within its building for the newly established mental health court. This gave the judge easy access to the emergency room and inpatient unit to see individuals too ill to appear in court. Our inner city mental health center funded a full-time Masters level position to serve as a liaison to the court. The role of the liaison is to interpret medical records to the court, amplify disposition recommendations, and be available for reassessment, should the patient's mental status change significantly from the initial assessment. There is also a psychiatrist assigned each day to make reevaluations when the need arises. The other mental health centers agreed to admit people from their catchment areas arrested on the specially noted 'disorderly conduct charges to their inpatient units within 72 hours, if this were the recommendation of the crisis clinician and the court. Our mental health center also has clinicians who go to the jail each week day to interview persons whom the other municipal courts or the jail personnel believe may be mentally ill. If it is determined that a person is in fact mentally ill, every effort is made to transfer the charges to the mental health court. C o m m u n i t y response to this system has been remarkable. The court has received letters from patients and families describing life-changing decisions made as a result of having the court pay serious and timely attention to their concerns. In J a n u a r y 1982, the court was established as permanent through legislative action. However, since M a y 1985 the specially noted disorderly conduct charge has been challenged as not being defined dearly enough for legal purposes.

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T H E P H I L O S O P H Y A N D PURPOSE OF T H E C O U R T

It was planned from the start that this joint effort with both clinical and legal checks and balances would identify the psychiatric patient who commits a minor crime, especially the poorly motivated, chronically mentally ill patient. Demographic information available indicates that 58% of those cases heard by this court involve persons who fit the N I M H ( D H H S , 1981) criteria for chronic mental illness. This system was also designed to protect the rights of those who would be limited in their ability to advocate for themselves. Lastly, the court was to assure appropriate treatment rather than incarceration for those truly mentally ill individuals. The mental health court allows for heightened awareness of the extent and severity of mental illness within the community. The one mental health court with its one presiding judge is in the unique position of helping to identify weaknesses within both the mental health and the criminal justice systems. The court helps to avert criminalization of the chronically mentally ill by speedily placing these people into treatment, usually outpatient or partial hospitalization. The court also puts some "teeth" into the treatment recommendations of the mental health system with court-ordered treatment, and rehearings at regular intervals. Court-ordered treatment is controversial, and it has been argued that it is not effective in changing behavior (Fagan & Fagan, 1982; Ward, 1979; 1982). However, most of the research on forced treatment has focused on its use with drug and alcohol abuse (Fagan & Fagan, 1982; Ward, 1979(a); 1979(b); 1982; Salman, 1982; McGrath et al., 1977; Collins & Allison, 1982). More recent studies focusing on the use and effectiveness of outpatient commitment of psychiatric patients suggest that such commitments are effective (Peele et al., 1984; Miller, 1985). Further, the research suggests that the crucial ingredient appears to be cooperation and coordination between agencies (Miller, 1984). It is likely that a significant portion of the success of the mental health court in working with the chronically mentally ill is the result of the high level of cooperation and coordination between the police, the court, and the area mental health centers. It should be noted that although the court also does inpatient and outpatient commitments, the vast majority (75 %) of its cases deal with people who at the time of arrest were thought to be mentally ill. Those found in need of treatment are seldom committed to treatment in the traditional sense. Rather, they are ordered into treatment at the preliminary hearing. The preliminary hearing holds the possibility of a diversion to treatment. If the arrested patient complies with the diversion agreement, all charges are dropped at the continuance hearing. This obviously proceeds more quickly than the usual wait of several weeks for a commitment hearing. The coercive side of treatment is the threat that noncompliance will result in a possible jail sentence through contempt of court charges or reopening of the original arrest charge.

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THE PROCESS F R O M A R R E S T TO C O U R T TO T R E A T M E N T

The Arrest If a person is arrested on m i s d e m e a n o r charges, the officer m a y slate the person's case into the mental health court if it is believed that the persons' b e h a v i o r is the result of a mental illness. Most people so arrested are brought to the county hospital e m e r g e n c y r o o m and their custody t u r n e d over to the deputies in the e m e r g e n c y r o o m holding room.

The Evaluation Process T h e person is then seen by a triage nurse who assigns the patient to a medicine, surgery, or pediatrics physician d e p e n d i n g on what, if any, general health concerns are present. A physical e x a m i n a t i o n is p e r f o r m e d and necessary laboratory data obtained. C o n c u r r e n t l y with the e x a m i n a t i o n , the crisis clinician in the e m e r g e n c y r o o m is alerted to the presence of the arrested person, and the medical records staff begins to search for evidence of a psychiatric history. T h e crisis clinician interviews the patient, contacts c o n c e r n e d family or friends, and if the person is in active t r e a t m e n t elsewhere, attempts to make appropriate contacts. If there are any problems with diagnosis, indications for medications, or if admission to the hospital seems indicated, the clinician calls the psychiatrist on duty. If hospital admission is indicated, a hospitalization o r d e r is r e q u i r e d from the m e n t a l health court. If court is not in session, the patient m a y be admitted by t e m p o r a r y authority of the examining physician. T h e order is reviewed by the j u d g e w h e n court reconvenes. T h e person m a y be a d m i t t e d to a psychiatric unit or a medical/surgical unit d e p e n d i n g on the p r i m a r y p r o b l e m . If admission is not w a r r a n t e d , the crisis clinician writes a m e m o to the court with r e c o m m e n d a t i o n s for appropriate treatment and indicates the patient's willingness (or lack of) to follow the r e c o m m e n d a t i o n s . A m o r e detailed note is also written for the mental health chart, and both are r o u t e d to the court liaison. If the person is considered safe for release, a note is sent to the bail commissioner r e c o m m e n d i n g release on the person's own recognizance. I f the person is not in need of admission to the hospital, but is not felt to be a good risk for release, he or she is held in the city lock-up until the next court session. C o u r t is held M o n d a y t h r o u g h F r i d a y except on holidays. T h e process from arrest to the m e n t a l health court is outlined in Figure 1.

The Hearing Process Each person presenting beibre the b e n c h at the m e n t a l health court is given time to state his/her case. Unlike traditional municipal courts, where the sheer n u m b e r of cases precludes individual attention, the docket at the m e n t a l health

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court is limited to mental-health related cases only. The judge of the mental health court has developed a style of interaction with the patients which may, in part, contribute to the effectiveness of this system. The judge asks all involved to formally state their names for the record. The charges and police report are read. Each person present responds to the information presented and offers his or her interpretation. The judge seeks additional information and clarification through questions. Finally, he offers his summary and confronts the patient in a personal but judicial manner. Although individualized, the summation always carries with it certain themes:

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Even though the patient m a y have a mental illness, he or she is still a m e m ber of the c o m m u n i t y and responsible for his or her actions. 2. T h e person will be expected by the court to follow the t r e a t m e n t plan developed. T h e j u d g e and patient are entering into an a g r e e m e n t with the j u d g e serving as decision maker. If the patient chooses not to enter into this contract, a regular trial m a y be slated. In essence, this is a diversion p r o g r a m allowing for an alternative to criminal proceedings. . W i t h i n a specific period of time (30, 60, or 90 days), the t r e a t m e n t team will report the patient's progress to the court at a c o n t i n u a n c e hearing. At the c o n t i n u a n c e hearing, the patient will a p p e a r in court and the therapist's report will be read. If the report is unclear as to w h e t h e r the patient has m a d e a significant effort, a n o t h e r c o n t i n u a n c e date m a y be set. If the report indicates that the patient has not followed the court's orders, he or she m a y then be transferred to another court to stand trial, be charged with c o n t e m p t of court, or be reevaluated for c o m m i t m e n t . At this point, a public d e f e n d e r will be assigned to the case in the event that the patient does not have a private attorney. If, on the other hand, the report is favorable, the charges m a y be d r o p p e d . .

Following the hearing, the liaison m a y meet with the family a n d / o r patient to help get t h e m started on the t r e a t m e n t plan. An educational group is also available to help those involved u n d e r s t a n d the m e a n i n g of the charges or commitment. The Treatmenl If the person is in need of a place to stay, this can be a r r a n g e d t h r o u g h a contract the m e n t a l health center has with the Salvation A r m y . T h e partial hospital p r o g r a m or the c o m m u n i t y support center rehabilitation and vocational prog r a m are frequently utilized t r e a t m e n t modalities. Individual t h e r a p y is also used extensively. Reports on patients' progress must be sent to the court at regular intervals as ordered, as well as i m m e d i a t e l y u p o n any lack of compliance. F o r the latter situation, the j u d g e will frequently issue a b e n c h w a r r a n t to have the person brought to court as quickly as possible. T h e patient is then given a chance to explain his lack of compliance.

SUMMAR Y T h e m e n t a l health court has p r o v e d to be a cost-effective tool for o u r c o m m u nity in dealing with psychiatrically ill p e r p e t r a t o r s of m i n o r crimes, especially the chronically m e n t a l l y ill. It must be u n d e r s t o o d that while the coercive elem e n t in this system is the threat of jail, the aim is to avoid incarceration. T h e authors, therefore, stress the i m p o r t a n c e of h a v i n g a j u d g e who can a d e q u a t e l y function within this p a r a d o x . T h e individual j u d g e in the court described does so with a great deal of flexibility, knowledge, wisdom, and sincerity.

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In the described system, the court is in a position to identify mental health service flaws and has done so more than once. For example, recently the local state hospitals experienced a chronic bed shortage, resulting in a backlog of patients awaiting inpatient commitment. These patients quickly saturated the shortterm inpatient units, for which they were ill-suited and, therefore, had to be held in jail pending admission to the state hospital. Since all of these patients "passed through" the mental health court, the judge was acutely aware of the backlog. His concern about the inappropriate placement of these chronically mentally ill patients in jail resulted in a court order for the state hospitals to open more beds. Further, attention given to these issues brought public pressure to bear on the Department of Mental Health and the legislature for increased state hospital admission capacity. The mental health care providers have had to willingly acknowledge the shortcomings and try to create solutions. Some might look upon this exposure as a liability, especially since solutions, no matter how creative, usually require time and effort and increased funding. We have found, however, that the liabilities are small compared to the gains. Research needs to focus on whether or not the chronic mentally ill patients seen before the mental health court are representative of the chronically mentally ill populations in general. Research also needs to focus on long-term followup for rearrest patterns.

REFERENCES Abramson, M.F. The criminalization of mentally disordered behavior: Possible side-effect of a new mental health law. Hospital and Community Psychiatry, 1972, 23, 101-105. American Psychiatric Association. Recommendations of APA's task force on the homeless mentally ill. Hospital and Community Psychiatry, 1984, 35, 908-909. Ball, F.L.J., & Harassy, B. A survey of the problems and needs of homeless consumers of acute psychiatric services. Hospital and Community Psychiatry, 1984, 35, 917-921. Bassuk, E.L. Homelessness: The need for mental health advocates. Hospital and Community Psychiatry, 1984, 35, 867-870. Bonovitz, J.C., & Bonovitz, J.S. Diversion of the mentally ill into the criminal justice system: The police intervention in perspective. AmericanJournal of Psychiatry, 1981, 138, 973-976. Cohen, N.L., Pumam, J.F., & Sullivan, A.M. The mentally ill homeless: Isolation and adaptation. Hospital and Community Psychiatry, 1984, 35, 922-924. Collins, J.J., & Allison, M. Legal coercion and retention in drug abuse treatment. Hospital and Community Psychiatry, 1983, 34, 1145-1149. Department of Health and Human Services. Towarda National Planfor the ChronicallyMentally Ill. DHHS Pub. No. (ADM) 81-1077. Rockville, MD, 1981. Fagan, R.W., & Fagan, W.M. Impact of legal coercion on the treatment of alcoholism. Journal of Drug Issues, 1982, 12, 103-114. Geller, M.A. Sociopathic adaptation in psychotic patients. Hospitaland CommunityPsychiatry, t 980, 31, 108-112. Lamb, H.R. Deinstitutionalization and the homeless mentally ill. Hospital and Community Psychiatry, 1984, 35, 899-907. McGrath, J., O'Brien, J., & Liftile, J. Coercive treatment for alcoholic "driving under the influence of liquor" offenders. British Journal of Addiction, 1977, 72, 223-229. Miller, R.D. Commitment to outpatient treatment: A national survey. Hospital and Community Psychiatry, 1985, 36, 265-267. Miller, R.D:, & Fiddleman, P.B. Outpatient commitment: Treatment in the least restrictive environment? Hospital and Community Psychiatry, 1984, 35, 147-151. Peele, R., Band, D., & Heine, A. Outpatient commitment: A 13-year experience. Presented at the Annual Meeting of the American Academy of Psychiatry and the Law, Nassau, Bahamas, October, 1984.

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Salman, R . W . Role of coercion in rehabilitation of drug abusers. Journa! of Offender Counseling Services and Rehabilitation, 1982, 6, 59-70. Sipes, G.P., & Bojrab, S. Case managers: Are we committed to their success? Unpublished manuscript, 1985. Talbott, J.A. The Chronic Mentally Ill. New York: H u m a n Sciences Press, 1981. Ward, D.A. (Ed.). Use of legal coercion in the treatment of alcoholism, a methodological review. Journal of Drug Issues, 1979, 9, 387-398. Ward, D.A. (Ed.). Use of legal and nonlegal coercion in the prevention and treatment of drug abuse.ffournal of Drug Issues, 1982, I2. Ward, D.A., & Allwine, K.J. Effects of legal coercion in the treatment of alcohol-related criminal offenders. Justice @stemffournal, 1979, 5, 107-111. Whitmer, G.E. From hospitals to jails: The fate of California's deinstitutionalized mentally ill. AmericanJour hal of Orthopsychiatry, 1980, 50, 65-75.