Target Problem and Rationale
A 1997 (Care Systems North) study of the incarcerated population in Alaska found that about one-third of inmates suffered from serious mental illness, a rate about twice as high as the estimated national average of 16 percent (Bureau of Justice Statistics, 1999). That group included a large number of persons with developmental disabilities and organic brain injuries. The study noted that the Alaska Department of Corrections had become the largest provider of institutional mental health services in the state. Against the background of efforts to address institutional overcrowding, the challenge facing Corrections to provide services for its mentally ill inmates was extraordinary, particularly in Anchorage, one of the state?s largest population centers.
In 1998 the Criminal Justice Assessment Commission, formed to examine jail crowding problems in Anchorage, identified the mentally ill and disabled as a special population presenting difficult problems for the jail and local justice system. One of the recommendations of the Decriminalizing the Mentally Ill Subcommittee was to explore means of identifying mentally disabled offenders for diversion away from the justice system into coordinated community treatment services. A special jail-based program to provide placement in community mental health treatment programs for inmates, the Jail Alternative Services Pilot Program, was instituted during July 1998. The subcommittee also recommended development of a mental health court, referred to as the Court Coordinated Research Project (CCRP), to address misdemeanor defendants and offenders with mental disabilities. During the planning stages, the experiences of the Broward County and King County Mental Health Courts were considered and adapted to the special problems of the local justice system in Anchorage. Circuit Court Presiding Judge, the Honorable Elaine Andrews, signed an administrative order that officially established the Court Coordinated Resources Project in April 1999 and appointed Judges Stephanie Rhoades and John Lohff to preside over the ?specialty mental health court.?
The two-pronged mental health court initiative went into operation in July 1998. One component, the Jail Alternative Services (JAS) Program, established alternative mental health programming in the community for specially targeted mentally ill inmates. The other, the CCRP, established a court-centered approach to identifying and treating mentally ill persons in the criminal caseload in the Anchorage District Court. The mental health court process is presided over by two District Court judges, the Honorable John Lohff, Deputy Presiding District Court Judge, and the Honorable Stephanie Rhoades.
CCRP was designed to provide an alternative to jail and routine adjudication of misdemeanor cases for persons with mental disabilities by instituting special procedures that allow trained judges to address and treat mental illness and create more effective linkages and coordination between the courts, other justice agencies and mental health resources. Although the court-based initiative was motivated by the pressing need to address problems associated with jail overcrowding in Anchorage?hence the special Jail Alternative Services Program initiative for persons in custody?CCRP aims at a broader population. It accepts mentally ill persons in the misdemeanor population whether or not they are confined. Although CCRP places some defendants in the JAS Program, it draws upon a large array of community mental health and other supportive services. While the aims of the Anchorage District Court?s CCRP initiative to link mentally ill defendants with community-based mental health services are similar to those of other mental health courts, the court chose not to call itself a ?mental health court? to avoid the stigma that might be associated with participation in a court designed to respond to the mentally ill.
The jail-based component of the mental health court initiative, the JAS Program, began on July 6, 1998 as a pilot project operated by the Alaska Department of Corrections and funded through the Alaska Mental Health Trust Authority. To be eligible for the JAS Program, defendants must be confined in the Anchorage jail on misdemeanor charges (punishable by a statutory maximum of 1 year in jail) and be found to suffer from a major mental illness with a history of psychosis or an organic brain injury. Prior records of convictions are anticipated by the mental health court. These restrictive criteria ensure that the JAS Program is very selective. It is limited to 40 participants, 5 of which are to be defendants suffering from organic brain impairments.
Eligibility criteria for participation in the District Court?s mental health court program (CCRP) also begin with the limitation that defendants?in or out of custody?must be charged with misdemeanor offenses and defendants with prior records are not excluded. Beyond these threshold criteria, CCRP criteria are less restrictive than those that apply to JAS participants. Defendants diagnosed with or showing obvious signs of mental illness, developmental disability, or organic brain syndrome are considered appropriate candidates for the mental health court program. However, there is no requirement of a history of psychosis, as in the JAS Program, and the defendant need not have been in custody, a JAS eligibility requirement as well. CCRP has not attempted to limit enrollment to a certain number of participants. Candidates are referred to Anchorage?s CCRP by the correction department?s jail staff, the attorneys handling the case, other judges, family members, concerned friends or other relevant sources.
Anchorage Court Coordinated Resource Project (mental health court) Procedure
The Court Coordinated Resources Project operates in Anchorage?s District Court, which has jurisdiction over both state and municipal misdemeanor offenses. (For an overview of the Anchorage Court referral procedure, see Figure 3.) An arrestee who is charged with a misdemeanor will have an arraignment before a judge within 24 hours. Persons detained after arraignment are screened by jail staff. If they appear to be candidates for the JAS Program, the JAS coordinator is notified. The JAS coordinator in turn notifies the court and the court notifies the prosecutor and defense attorney. If the defendant is interested in being a JAS participant, the JAS coordinator meets with the defendant (and/or attorney) to conduct an assessment to determine JAS Program eligibility. The coordinator explains the treatment program available under JAS. If the coordinator determines that the defendant meets the eligibility criteria and is willing to participate in the program, the coordinator submits a brief report to the CCRP judge, indicating the defendant?s treatment needs. The report also proposes a treatment plan, with specific recommendations for mental health and/or substance abuse treatment in the community, and, if needed, provisions for medication and for monitoring the defendant?s medications, and provisions for addressing housing needs. This report is made available to the judge and the attorneys at the mental health court hearing. If the defendant is not eligible for JAS, but still appears to meet the criteria for participation in CCRP, the jail staff refers the defendant to the court for CCRP evaluation.
At their first appearance in mental health court, defendants must be stable and competent to decide whether they wish to participate in the JAS or CCRP court-supervised treatment programs. Because the arraignment hearings are generally done so quickly, issues of competency often fail to arise at that point unless defendants have obvious mental health problems that have an impact on their ability to attend to even this cursory proceeding. Even if competency problems are suspected, the arraignment judge often defers the examination of the issue to the CCRP judge who has received special training in the recognition and handling of mental health problems. Defendants who do not appear sufficiently stable will have their first mental health court hearings continued to give the corrections mental health staff time to improve stability. If the mental health court judge believes that a defendant is incompetent, the judge will order the defendant to the state hospital (the Alaska Psychiatric Institute) for a competency evaluation.19 If the defendant is found to be incompetent by the state medical staff, the court must hold a hearing at which evidence is presented on the issue of incompetence.
If the defendant is found, by a preponderance of the evidence, to be incompetent, the criminal proceeding will be stayed, and the defendant may be committed to the hospital for treatment for a period of 90 days. In those cases, at the end of the 90-day period, a hearing must be held before the mental health court judge to determine whether competency has been restored. If the defendant is still incompetent, he or she may be returned to the hospital for treatment for an additional 90-day period. A defendant who remains incompetent at the expiration of the second treatment period has the charges dismissed without prejudice; unless they involved force against a person, the defendant is a danger to others, or there is a substantial possibility that he will regain competence within a reasonable period of time. If these conditions are met, the defendant?s commitment may be extended for an additional 6 months. At the end of this period, defendants whose competency has not been restored will have all charges dismissed without prejudice.20
At the first mental health court hearing, in cases when defendants are competent and stable, the judge determines whether the candidate understands what the mental health court (CCRP or JAS) treatment options involve and asks whether the defendant wishes to participate. The defendant makes this decision with the assistance of counsel and the court ensures that the decision to participate is voluntary. To enter the program, in most cases, the defendant is required to enter a plea of guilty or no contest to his misdemeanor charge in exchange for a plea agreement that the sentence will not involve jail. In rare cases involving very minor offenses and no prior criminal records, participants enter the mental health court via deferred disposition, which involves court-ordered conditional release of the defendant to community treatment prior to adjudication with court monitoring for compliance. Defendants who successfully complete the court program under these terms may be eligible to have their charges dismissed.
Once the plea has been entered and accepted, a sentencing hearing is scheduled. Ideally, if an acceptable treatment plan has already been prepared and approved and the participant is already in treatment and in an acceptable supportive living situation, the sentencing may be held immediately after the plea of guilty is accepted. If the defendant is assigned to the JAS Program, he will be sentenced and released as soon as the appropriate interviews are completed and the treatment plan set up. Due to a lack of separate funding available to support treatment services in the mental health court, CCRP participants may wait longer than JAS candidates before their treatment plan is prepared and approved because they have to make arrangements for services themselves through their attorneys and community mental health services.
Defendants who are in custody remain there until a satisfactory treatment plan has been approved by the judge, unless a reliable third party who is acceptable to the judge steps forward to take on the responsibility of providing supervision in the community during this interim period. When prospective participants are in jail awaiting approval of their treatment plans, the court tries to expedite the sentencing hearing so that the defendant can be released as soon as possible. Typically, the adjudicated defendant receives a probationary term with a suspended sentence, with treatment through CCRP as a condition of probation. Although the probationary term for a misdemeanor conviction in Alaska can extend up to 10 years, the probation sentence in mental health court is usually between 3 and 5 years. Unlike the few deferred disposition defendants, these defendants are not eligible to have their charges dismissed upon successful program completion. Because many would have been subject to jail time in normal court, the suspended sentence is thought to provide an incentive to encourage participation in the mental health treatment process.
In the event that a defendant wishes to pursue pretrial issues or motions before making a decision about entering CCRP, the motions may be heard before one of the mental health court judges, Rhoades or Lohff, or may be heard by another judge in the normal district court process. If a defendant is successful, the charges may be dismissed. A defendant who wishes to litigate a pretrial issue and loses may still decide to enter the mental health court treatment process. Defendants who wish to proceed to adjudication, in the belief that they will be found not guilty, may or may not have their cases heard before either of the mental health court judges (both judges also preside over a normal criminal caseload). Mentally ill defendants assigned to other criminal judges and found guilty, may or may not be sent by the trial judge to the mental health court judges for sentencing.
In the event that a defendant qualifies for the selective Jail Alternative Services Program, the JAS coordinator, who also is the caseworker, is assigned to link the defendant to community treatment, to oversee and facilitate the treatment process and to report progress and potential violations to the court. The coordinator/caseworker monitors the defendant to be certain that their living situation is stable and that the participant is complying with court-ordered conditions of probation. This involves meeting with the participant on a regular basis; the frequency of the meetings varies from case to case, from twice a week to once every 4 to 6 weeks. A status hearing before the judge is scheduled after the defendant?s release, with additional dates scheduled on an as-needed basis.
Minor violations of conditions of program participation generally result in adjustments being made in the participant?s treatment plan to better meet his needs and to prevent future violations. Participants in the JAS Program who have difficulty complying with program conditions or who pose higher risks of violation may be scheduled for regular monthly status hearings at which they are required to explain problems to the judge. If the defendant appears not to be interested in cooperating after numerous chances, the caseworker may file an affidavit of noncompliance and petition to revoke probation. The defendant must then return to the CCRP court to answer for the noncompliance. As a last resort, the order may be vacated and the defendant may be sentenced on his original charges, with credit given for time served should the court determine that jail time is appropriate. Participants who decide that the program is not working for them have the option to drop out of the program. In such an instance, the JAS coordinator will recommend to the judge that the JAS order be vacated and the offender sentenced by the CCRP court.
Mental health court candidates not qualifying for JAS, but qualifying for treatment through the CCRP program, will be released on probation to follow the court-approved treatment plan as a condition of release. Due to lack of sufficient resources, CCRP participants are not supervised by a caseworker. The participant is required to sign a release of information document that permits the judge and the prosecutor to receive reports about compliance with program conditions from the mental health facility or program to which the defendant has been assigned. If violations occur, the prosecutor will file a petition, and a status hearing will be scheduled. In addition, compliance is monitored through regularly scheduled review hearings.
Unfortunately, as of this writing, there is no separate funding available to hire a court monitor or a caseworker to support the CCRP program. As a result, the burden of coordinating services falls mainly upon the judge, who recommends programs for the defendant and his attorney to explore, but who relies heavily upon the defense attorney for developing suitable treatment options. In addition, there is no staff person assigned to supervise or case manage the participant once he is released on an acceptable treatment plan. Supervision is accomplished by the monitoring of the prosecuting attorney and the court through regular review hearings.
CCRP participants who violate conditions of their participation in the treatment process while on probation may be assigned sanctions that range from counseling by the judge at the hearing and threats of jail time, to revocation of probation and imposition of portions of the suspended sentence, to termination from the program and imposition of the full suspended sentence. Judge Rhoades notes that, for lack of compliance with program conditions, the court will not penalize defendants for participating in CCRP and not employ sanctions for noncompliance more severe than the standard sentence would be if the case had been adjudicated through the normal misdemeanor court process. When a mentally ill participant fails in the CCRP program, and ends up receiving a ?normal? sentence and then is rearrested, the new case will be flagged to return to mental health court. At that time, depending on the seriousness of the new charge (it must be a misdemeanor) the defendant may be given another opportunity to enter the treatment services provided by the CCRP program. Readmission can occur after careful evaluation by the court team to determine whether circumstances or attitudes have changed and the candidate would be more amenable to treatment this time.
The Treatment Approach in the Anchorage Mental Health Court
Like the other mental health courts, the Anchorage Court Coordinated Resources Project places the court at the center of a therapeutic process and relies on a dedicated team model of staffing. Two judges are assigned to hear the mental health court cases in addition to performing their normal criminal court duties. Both judges have received specialized training in mental health issues. Judge Rhoades carries the additional responsibility of coordinating existing resources among corrections, the court, prosecuting and defense agencies and community mental health providers to ensure appropriate community-based treatment for the mentally disabled offender.
Compared to proceedings in the normal misdemeanor criminal courtroom, mental health court hearings take much longer to conclude. Rather than moving the case expeditiously to its disposition, the aim of the mental health court proceedings is to take the time to carefully explain options to defendants, who may have difficulty understanding. The hearings aim to encourage participant entry into treatment. This may include finding a suitable community treatment alternative to jail. The Anchorage mental health court proceedings are much more informal than normal adversarial proceedings in criminal cases, and follow after the fashion of drug courts. Once the person has reached the court (has pled guilty, etc.) the mental health court supports the mentally ill offender in treatment. The adversarial process resumes when it appears that a participant risks termination from the program and faces violation of the conditions of sentence with the possibility of serving time in confinement.
With the therapeutic aims in mind (and the related emphases to support the participant in treatment in the community), the Anchorage mental health court maintains a special concern for public safety and avoids any arrangement that will place the community at risk from participant behavior. The prosecutor wields considerable influence in setting the terms of the plea for candidates who are accepted in the program and in reacting to reports of noncompliance. The judge has the final say in accepting or rejecting candidates for participation in the two-pronged mental health court program. In the courtroom, the prosecutor supports the treatment process, while considering the implications for public safety. The defense attorney is also more flexible in mental health court than in traditional misdemeanor court, allowing direct dialogue between the defendant and the judge after the fashion of the drug court model. In addition, much more input is encouraged and allowed from participants? family members and others supportive of the treatment process. Counsel will consult with a participant?s legal guardian, when appropriate. Once the participant has been sentenced and is in the program, the court and the dedicated staff become closely involved in monitoring his or her progress.
Initially, review hearings are scheduled 1 month from sentencing; then they are held as needed to ensure that the conditions of CCRP or JAS participation are being adhered to. At the hearings, the judge discusses the participant?s progress in treatment with him or her directly, identifies any problems, and encourages continued participation. Defendants are encouraged to maintain contact with the court and to return at any time, particularly if something is not working and they need assistance in solving treatment-related problems. Again, following the drug court model, defendants who have passed important milestones or have good reviews may receive praise from the judge and even applause from other participants seated in the courtroom. Thus, as a therapeutic tool, the courtroom is intended to provide positive incentives and support for the treatment process and to help establish the boundaries for acceptable behavior.
The courtroom staff includes a designated member of the municipal prosecutor?s office, as well as attorneys from the two defense firms who contract with the city and the state to provide legal services to the indigent. The JAS coordinator/caseworker handles eligibility assessments, treatment plans and supervision of all JAS participants. All inmates booked into custody receive medical and mental status screening by the nursing staff within 24 hours of arrest. When mental illness or psychiatric symptoms are detected, inmates are referred to the correction department?s mental health clinician who will research their records, conduct a diagnostic evaluation and make recommendations for treatment or behavior management. The JAS case coordinator works with the clinician to identify all mentally ill misdemeanants in custody, assess their current mental status and determine whether they may benefit from participation in mental health court. The purpose of the dedicated team model is to develop expertise in working with the mentally ill, create familiarity with the specific cases and defendants being processed through the court and contribute to a smoother and more efficient court operation conducive to dealing with the mentally ill and disabled.
JAS Program participants are placed on probation on the condition that they follow the treatment plan submitted by the JAS coordinator. Most JAS clients are placed in supportive living situations and are required to attend a day treatment program on a daily basis. Only the state hospital, with limited capacity, is available to meet the needs of participants requiring in-patient treatment services. For JAS mental health court participants, an important aim is to reduce the level of supervision and structure provided to the clients over time as their level of independence increases, and to develop strong links to treatment so that treatment will continue after the probationary period and mental health court involvement.
Very few of the defendants have a place to live when they are placed in the Anchorage CCRP or JAS Program. Most need assisted living with varied levels of structure and support to enable them to function appropriately in the community, ranging from 24-hour staff availability to apartment settings with staff available to look in on them once a day. Chronically ill and/or personality-disordered defendants or those with ongoing substance abuse problems are more difficult to place in available programs. Some programs are reluctant to accept JAS participants because of the risk they pose to other clients or the potential to be disruptive to the overall treatment programs. Unfortunately, for such individuals there are few resources available to provide the living situation and services needed. Instead, JAS participants are forced to make use of two unsupervised shelters in the Anchorage area; or they are placed on the ?hotel plan? under which they are placed in an inexpensive hotel, and closely monitored by the caseworker and the staff at the day treatment center they attend. They are essentially ?wrapped? in services that take them through the weekdays from morning until night, and provided with assisted living as needed for their day-to-day functioning (preparing meals, buying groceries, managing money).
Staff views these housing arrangements as less than ideal. Staff have no control over other potential residents who tend to frequent these living quarters. Neither the unsupervised shelters nor the inexpensive hotels are viewed as desirable settings for JAS participants, who require supportive services. Attempts are made to compensate for the poor housing situations by providing JAS participants with day treatment services, an aggressive outreach component, and case managers who check in on them and respond to their needs on a daily basis. A small percentage of JAS clients have supportive home situations and do not require structured housing.
Day treatment is supplied to the JAS program mainly by the South Central Counseling Center, which provides substance abuse treatment, training in social and independent living skills, daily medication dispensing, and vocational training. Each defendant is assigned to a team based upon individual treatment needs. Most of the JAS defendants require an intensive level of treatment accompanied by an aggressive outreach component. (Staff will go out in the community to look for them if they fail to appear for group sessions or medication.) The JAS program also contracts with the South Central Foundation in Anchorage, which works primarily with the native Alaskan population. That program provides day treatment programs as well as cultural links and activities, some outreach, and limited housing. While most JAS clients require day treatment, at least at first, some are stable enough, or become stable enough, to be placed in vocational programs or to take on part-time jobs. Unfortunately, only a small percentage of JAS clients have the ability to ever hold a job.
At least in its initial stages, the JAS program has not been able to draw on good options for placing dually diagnosed participants in treatment. Substance abuse is common among the mentally disabled JAS participants, with an estimated 82 percent having significant substance abuse issues.21 With only 2 facilities and a combined capacity of 25 beds, this lack of treatment resources is most acutely felt when dealing with clients with personality disorders or who display severe symptoms of mental illness, and who need, but are unable to function in, the available in-patient programs. When their criminal histories are also taken into consideration, this type of participant is not usually eligible for most treatment programs. As a result they are placed in out-patient MICA groups with regular monitoring and drug screening, supplemented by day treatment with ?aggressive? outreach activities. JAS staff believe that this approach is unlikely to address the treatment needs of the dually diagnosed participants.
JAS clients who have organic brain impairment are placed with agencies specifically dedicated to addressing their problems, some of which are permanent in nature and do not respond to treatment. These agencies provide services including daily living assistance and maintenance. The clients are assisted, for example, in getting their food and cooking meals. Daily activities are structured to meet their levels of functioning. These placements are intended to be permanent in that the clients can stay there even after the jurisdiction of the court has ended.
In contrast to the more structured approach of the selective JAS Program available to some mental health court participants, CCRP participants do not enter a structured program, staffed and supervised by the court. Rather, candidates must set up their own treatment plans through their attorneys. This task is difficult and time-consuming, and results in different arrangements for different participants based on the attorney?s ability to pull together an effective treatment plan, and the defendant?s financial situation. However, there is no accessible, integrated mental health treatment network for defense attorneys to draw on in designing an appropriate treatment plan for their clients and some attorneys do not have experience in developing such a plan. As a result, treatment plans for their mentally disabled clients vary in scope and potential effectiveness, ranging from simply attending AA meetings for substance-abusing mentally ill, to more comprehensive coverage that can be accessed only by defendants who have the means to pay for them.
At this stage, the Anchorage CCRP is supported by fewer resources than the other mental health courts (and far fewer resources than required for adequate operation). However, it is one of the emerging mental health court sites that, despite its limitations in case management and supervision, provides treatment and an alternative to jail for mentally ill or disabled defendants who otherwise would face confinement (many have significant prior criminal histories). The judicial supervision of the misdemeanor participants far exceeds the attention that would be paid to these defendants in a state in which misdemeanor probationers are not supervised. Thus, the judicial supervision that the defendant receives from CCRP is quite valuable. Participants, who may receive little assistance in accessing services and following up on services and treatment, are nonetheless provided with a treatment plan. The plan must meet court approval and is supervised by the treatment program?s case manager, with follow-up provided by the district attorney in the case of noncompliance, and by the court at scheduled review hearings. At this stage of the its development and on limited resources, the Anchorage mental health court provides therapeutic intervention in cases that otherwise would receive few services and result in jail terms.
Success and Failure in the Anchorage Mental Health Court
In its first year and a half, the mental health court in Anchorage?s District Court has attempted to identify mentally disabled misdemeanor defendants who would more appropriately be dealt with through supportive care and treatment than by the normal adjudication process. The Court Coordinated Resources Program has relied on the central participation and supervision of Judges Rhoades and Lohff to link candidates with treatment services when possible and to monitor and assist the treatment process, usually as part of a probation sentence. Since its inception in July 1998, CCRP accepted approximately 129 participants during fiscal year 1999 on the basis of a guilty plea and a sentence to probation with a suspended jail term. Data are not available at this stage describing CCRP participants, their progress, services employed, or case outcomes. Early failures from the program would be indicated by revocation of probation and imposition of suspended sentences. Most would not have completed probation yet in any case.
Some data are available for the specially funded JAS Program option from its early period of operation. From July 6, 1998, to June 30, 1999, 138 defendants were identified as eligible to enter the JAS Program. Only about 26 percent decided to enter the treatment program, however. This low rate of enrollment initially was apparently due to the large number of eligible defendants who were sentenced or released before they could be assessed for the program and processed by the JAS coordinator. As of February 2000, there were 49 participants, of whom 71 percent are male and the average age is 31. The population is composed mainly of native Alaskans (39 percent), Caucasians (39 percent), and African-Americans (20 percent). Most have co-occurring substance abuse problems. JAS participants have fairly extensive prior criminal histories, averaging 7 prior convictions, and almost all have a history of psychiatric hospitalization, averaging nearly 10 prior admissions. Early program information suggests that about half of the JAS participants, like those sentenced in the normal fashion, were rearrested for new offenses during the recent 12 months. Of the 49 individuals who have entered the JAS Program since its inception, 17 individuals have been rearrested on new misdemeanor charges, and only one has been rearrested on a felony charge.
19 See Alaska Statutes, Code of Criminal Procedure, Section 12.47.100.
20 See Alaska Statutes, Code of Criminal Procedure, Section 12.47.110.
21 Status Reports To The Trust Authority, Alaska Department of Corrections, February 2000.