Helping or hurting: A review of the impact and effectiveness of mental health courts

Kelli Canada, University of Missouri
Stacey Barrenger, New York University
Bradley Ray, Indiana University Purdue University at Indianapolis

Existing reviews of mental health courts summarize the effectiveness of these programs without consideration of the component parts of the mental health court and who the court serves. This systematic review addresses this gap by using specific criteria for what constitutes a mental health court and presents results based on the charge type for the target population. Only experimental or quasi-experimental research designs are included in this review. Studies included involved mental health courts containing essential elements and included measures of recidivism or other mental health and quality of life-related outcomes. Twenty-nine articles were reviewed. Research on mental health courts primarily originated in the Unites States, covering 14 states. Findings are synthesized by whether the courts served people with felony, misdemeanor, or combination charges. These findings inform the need for national or international standards or clear guidelines for what components or elements define a mental health court. State-level policy is also needed to encourage the systematic collection of data on mental health courts to inform who mental health courts work for in specific communities. These data can also be used to inform local mental health court policy decisions.

systematic review, mental health courts, essential elements

“People with mental illnesses are overrepresented in the criminal justice system. Interaction with the criminal justice system puts people at risk for exacerbation of mental and physical health symptoms. Once arrested and incarcerated, persons with mental illnesses are more likely to be unable to post bail and wait longer for adjudication of cases; and, once convicted, they are more likely to serve their entire sentence rather than qualifying for early release. In an attempt to ameliorate these disparities associated with incarceration, municipalities have focused efforts on diverting individuals away from jail or prison through the use of alternative to incarceration programs. While these diversion programs can take many forms, one of the most utilized is the mental health court (MHC).” (p. 73)

“MHCs are collaborative efforts between criminal justice, mental health, and substance use treatment systems. They are one part of an overall strategy to reduce the incarceration of persons with mental illnesses. MHCs differ from traditional courts in that they include a specialized docket for people with mental illnesses, voluntary diversion into the court, engagement in treatment as a condition of participation with the use of rewards and sanctions to facilitate compliance, and regular status hearings. […] In 2007, the Bureau of Justice Assistance (BJA), in collaboration with various stakeholders, recommended 10 essential elements of MHCs that include up-front collaborative planning and administration of courts, defining the target population, timely identification of participants and linkage to services, clear terms of participation with informed choice, adequate treatment supports and services that are grounded in evidence, the composition and functioning of the court team, monitoring and confidentiality, and sustainability (Thompson et al., 2007).” (p. 73)

“While some research shows reduced recidivism and a better connection to mental health services for MHC participants, at least one study shows an increase in criminal justice involvement related to increased monitoring. Research using quasi-experimental designs show participants in MHC, on average, recidivate less than they did before MHC and in comparison with matched samples.” (pp. 73–74)

“To date, however, existing reviews conflate varying MHC models as one single model. […] This is problematic because burgeoning evidence suggests the impact of MHC participation may vary by factors like charge status (i.e., misdemeanor or felony) and psychiatric diagnosis. Further, MHCs are not required to include the 10 essential elements to be called an MHC. Surveys of MHCs show great variability in what jurisdictions identify as an MHC. This is especially problematic in reviews that aim to formulate conclusions about the effectiveness of MHCs.” (p. 74)

“To further develop the knowledge base about the effectiveness of MHCs, it is important to compare similar MHCs to one another to discern the population of people best served by MHCs, a current deficit in the literature. This project addresses the current limitations in the review literature by conducting a comparative systematic review of MHCs as defined by Thompson and colleagues (2007), where findings are synthesized by charge type.” (p. 74)

The research questions was: “Is diversion to MHC effective in reducing recidivism, improving mental health, and increasing access to mental health services for adults with mental illnesses?” (p. 74)

The systematic review included studies about adults with mental illnesses who came into contact with the criminal justice system who underwent an intervention defined as an MHC according to Thompson and colleagues’ (2007) criteria (target population of people with mental illness, informed voluntary participation, provision of treatment and services, integration of criminal justice and mental health staff, ongoing and consistent monitoring).

The included comparisons in the research included randomized control trial compared with normal court processing with pre- and postmeasurement, randomized control trial compared with normal court processing with postmeasurement only, comparing MHC participants to a matched sample (e.g., a group of people eligible for MHC in a county without an MHC), comparing MHC participants to a matched sample of people who were eligible for the MHC but did not participate, nonrandomized comparison of MHC to normal court processing, and within group comparison of pre- and post-MHC participation.

The outcomes included criminal recidivism, as shown by new arrests, number of days to recidivism, and violations to probation, and mental health, as defined by symptom severity and quality of life, psychosocial factors, substance use, and access to and use of treatment and services. The present review included research involving MHCs outside of the United States.

“Over half of the articles identified conducted research on MHCs involving people with misdemeanor and felony charges. Within this body of work, results are generally promising for graduates of MHCs but for people who do not complete MHC, recidivism remains high. Research on felony only MHCs account for only a small portion of existing MHC studies. It is important to increase the research on these programs to further disentangle emergent research that MHCs may have a disparate impact on people by charge type. Across all studies in this systematic review, recidivism was the primary outcome on interest with fewer studies assessing within or between group treatment use or mental health differences.” (p. 86)

“Complex interventions like MHCs are typically lumped together in research and treated as a single program or intervention. When the component parts of those programs and interventions are the same, data can be synthesized; however, when component parts vary across programs, it complicates the ability to compare across programs and to summarize findings. Further, when a program may actually work differentially for different subpopulations, it is important to attend to those subpopulations to ascertain who benefits from MHC and under what specific conditions.” (p. 87)

“When looking across subgroups, MHC graduates consistently fare better compared with noncompleters in misdemeanor only or mixed felony/misdemeanor MHCs. […] It is unclear from studies in this review why MHC noncompleters fail and if MHC is the most effective way to engage this subpopulation.” (pp. 87–88)

“Findings from this review also highlights the need for additional, rigorous research on MHCs, especially felony MHCs. According to the Council of State Governments (2019), there are over 300 MHCs in the United States. This review identified four studies of felony MHCs, and across all charge types, only 14 states were represented. Many other MHCs exist in the United States and across the world; research and evaluation is needed to better understand the impact of these programs.” (p. 88)

“MHCs continue to be one of the more prominent interventions for diverting people with mental illnesses from serving time in prison. Despite the wide-spread implementation, important research is needed to determine who is best served by MHCs. This review is just one step in this process. Synthesizing outcome data by charge type helped to illuminate the need for further outcome research on felony MHCs and to highlight the mixed findings in misdemeanor only MHCs. The difficulty in randomizing MHC participants and the lack of a cohesive MHC model has presented broad methodological challenges to the study of these programs. Currently, the essential elements outlined by the BJA offer the best guidance of what critical and necessary elements of the MHC model might be. As such, accurate and consistent reporting on these essential elements, as well as rigorous quasi-experimental research designs, are crucial to understand the overall impact and effectiveness of MHCs in accomplishing the primary goals of reduced recidivism and improved mental health outcomes. Above all, people with mental illness and treatment needs are best served in the community. Continuing to hone criminal justice practice and policy to divert this population successfully is critical to the welfare of people and communities and there should be an attempt to develop a range of programs across the criminal justice systems that vary in intensity.” (p. 89)

“MHCs are examples of complex interventions. Although BJA and stakeholders identified 10 essential elements that define MHCs, additional exploration is needed from practitioners, researchers, and participants to identify the benefits and limitations to creating more structure around what constitutes an MHC. To this end, research is needed to examine and explore the utility of the essential elements and whether they individually or collectively contribute to participant outcomes. […] To assist in this process, authors should note whether MHCs under study include the essential elements, and if not, identify what elements are missing in addition to providing rich details regarding MHC policies on selection and admissions, services offered, and if guilty pleas are required, to name a few.” (p. 88)

“Since their inception, MHCs have been taking on more serious offenses, as many courts now accept felony defendants. The findings from this study suggest that this may be a positive trend, as MHC defendants with a felony are at no greater risk of recidivism, but also that felony MHCs experience the greatest success in outcomes. These results also echo the suggestion that MHCs might avoid accepting low-level misdemeanor offenders. In terms of the Risk-Need-Responsivity (RNR) principles, which suggest offenders should be matched to an intervention based on their recidivism risk level, it is important to consider that MHCs are generally an intervention that entails a high level of supervision over a long period of time. Thus, defendants with minor offenses under MHC supervision might not only be a potential waste of resources, but might also lead to iatrogenic effects whereby outcomes are worsened.” (p. 88)

“Moreover, offense type is only one of many ways that researchers might consider contextualizing the extant literature on MHCs to examine differences and future research should explore other court factors within this literature. Once the core components and mechanisms that collectively define an MHC and best practices are identified and known to be effective at keeping individuals out of jails and prisons, national standards to guide MHC development and sustainability can be established. Likewise, through dissemination and implementation science, researchers can also aim to develop instruments or checklists that measure key components of the MHC to better assess fidelity to the model and develop effective practices. MHC administrations can use data to make policy and programmatic decisions, which is especially important when resources are scarce. While local conditions and context should be taken into account when developing MHCs, municipalities should also have some confidence around which elements are essential and which ones can be changed to take into account local resources.” (p. 88)

“Further exploration is needed regarding who benefits from MHC participation. […] State-level policies should include requirements for MHCs to collect data on the impact of the program, including data on index charge, demographics, completion status, and at minimum, 12 months of rearrest data. […] Using data to drive both policy and programming decisions will help counties make informed and evidence-based decisions on what they need to reduce the contact people with mental illnesses have with the criminal justice system.” (pp. 88–89)

“State-level data can also inform the costs and benefits to establishing or expanding MHCs. The resources available across communities varies, and because MHCs rely heavily on community mental health services, knowing who benefits most from MHCs and what cost MHC participation has on various systems is needed to determine if more people could be served by MHCs and if MHC policies require modification to ensure the program is working in the way it was intended. […] Requiring MHCs to collect and report on basic demographic and recidivism data would allow for routine cost-benefit analyses.” (p. 89)

“Finally, it is well established that randomization to MHC is a methodological challenge. Conducting applied research on programs in the criminal justice system can be especially difficult. However, caution is needed when interpreting findings from research with comparison groups. Some of the strategies used in the MHC research in this review are inherently flawed. When groups are systematically different from the start, comparing outcomes lacks significant meaning. Studies utilizing comparison groups involving people who were eligible for MHC but were not referred or selected or who opted out, jeopardize internal validity because of selection bias. Despite efforts to use post hoc strategies to match or control, it is possible that groups differ in a more meaningful way than demographics, clinical variable, or criminal histories. Despite these challenges and uncertainties, it is well known that people with mental illnesses fare far worse when sentenced to prison. Diversion from prison is not only healthier to the individual but also their family members and community.” (p. 89)

“Identifying whether an MHC included the essential elements was imperfect; as such, it is possible that MHCs including the essential elements were unfairly omitted from this review and likewise that authors stated a court adhered to these elements without fully knowing. However, authors did their due diligence in determining appropriate inclusion. […] In addition, using the essential elements to define the bounds of an MHC may have created too narrow a pool of MHC studies. Like any systematic review, this study was also limited in the types of outcomes examined in the extant literature. To this end, many of the studies focused on recidivism with fewer looking at mental health outcomes. There was inconsistency in how these outcomes were measured, making data synthesis for these mental health outcomes more challenging. Finally, emergent research on variation in outcomes by charge type was used to guide this review. It is possible that other key elements like requiring a guilty plea are just as important to consider when synthesizing findings.” (p. 89)

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