Target Problem and Rationale
In California, as in other places, deinstitutionalization of the mentally ill from state institutions and the inability of the community-based mental health system to provide sufficient resources to meet treatment needs has contributed to more mentally ill persons being found among the homeless, drug-addicted and criminal justice populations (Whitmer, 1979). San Bernardino?s Mental Health Court was established to respond to the large numbers of mentally ill persons found in the local jail population, recently estimated by corrections officials to account for 12 percent of the inmate population. At the same time, the Honorable Patrick Morris recognized the challenges posed for treatment by substance-abusing offenders with mental illness as a co-occurring disorder through his experience presiding over San Bernardino?s drug court. In 1998, a health and justice system task force was formed of representatives from the justice system, the mental health system, and city council to examine the problems of the mentally ill offender. As a result of its recommendations and with initial funding from the Department of Behavioral Health, the Mental Health Comprehensive Offender Umbrella for Release and Treatment (MH COURT) began as a pilot program in the San Bernardino Superior Court in January 1999, with the Supervised Treatment After Release (STAR) Program as its principal component.
The San Bernardino Mental Health Court differs from the other mental health courts in its admission of defendants charged with nonviolent lower level felonies, punishable by up to 6 years in prison, as well as defendants facing misdemeanor charges, punishable by up to 1 year in jail. Some defendants charged with violent offenses may be considered for the program, on a selective, case-by-case basis, if it is clear from an examination of the facts that it was not a truly violent incident, despite the seriousness of the charge, and that the offense was linked to mental illness. Because one of its aims is to address the jail-based or jail-bound population of mentally ill offenders, all candidates are in custody at the time of their referral to the Mental Health Court. In addition, the San Bernardino court limits eligibility for the STAR Program to defendants with previously diagnosed and persistent mental illness and a history of recidivism that would make jail terms likely. Candidates for Mental Health Court must live in the San Bernardino area and be eligible for SSI benefits or be employed, so some contribution to the costs of treatment is possible. To date, few participants have been employed and most have been eligible for SSI benefits because of their previous diagnoses. Participants who are not receiving benefits at the time of admission to Mental Health Court are supported in treatment until their benefits are applied for and received.
San Bernardino Mental Health Court Procedure
Most potential candidates are identified for the San Bernardino Mental Health Court while in detention in the West Valley Detention Center by jail mental health staff, subsequent to arraignment, which must occur within 48 hours of arrest. (For an overview of the San Bernardino Court procedure, see Figure 4.) The staff consists of two clinicians with PhDs in psychology, and one licensed clinical social worker. These clinicians also function as case managers, who provide supervision for the participants who are admitted into the program. At that time, they are interviewed and screened by a mental health clinician who explains the Mental Health Court program and confirms that the defendant has been diagnosed as having a history of an Axis I category of mental illness.22 Candidates who appear eligible for the Mental Health Court sign a waiver permitting information to be conveyed to the court relating to the mental illness and indicate they wish to participate in the treatment process. Once candidates request admission to the program, screening information is passed on to the probation officer, the prosecutor and the public defender assigned Mental Health Court duties. The practice of considering only candidates who have requested admission to the treatment program helps ensure that resources are focused on persons who will enter the program and engage in treatment once admitted.
The defendant-candidate will make a first appearance in Mental Health Court about 2 or 3 weeks after arraignment. The period between referral (after arraignment) and first hearing in Mental Health Court is used to develop background information about the candidate?s mental health and criminal history and to stabilize the individual on medication, if necessary. This is done so that participation is meaningful in the first hearing, and the candidate can comprehend the proceedings and make an informed acceptance of the program conditions. Because the Mental Health Court purposely targets persons who would be spending time in jail upon conviction, the criminal histories of participants are often significant, although violent prior offenses might preclude participation in the program.
Admission to the Mental Health Court requires consensus of all members of the court team. If any member of the team, including the defender, the prosecutor, the mental health caseworker, or the judge objects, the defendant will not be accepted into the program. The probation officer performs an intensive interview of the defendant and reviews his prior criminal record. If the defendant is believed to be appropriate for the program, the probation officer will complete a pre-sentence investigation and prepare written terms and conditions that outline specific requirements that the defendant must adhere to for his treatment to be effective. The prosecutor also checks into the defendant?s criminal history. Crimes of violence are checked to ascertain their actual circumstances and seriousness. True violent offenders are not eligible for the program. If a consensus is reached and the defendant is approved, the case is listed for Mental Health Court. Prior to the hearing, the prosecutor and the defense attorney engage in plea negotiations, so that they are prepared to present an agreement to the court at the defendant?s first appearance, assuming the defendant is competent.
San Bernardino Mental Health Court hearings are held once a week on Wednesdays. The court team meets to discuss the case prior to the hearing, as well as any issues that should be addressed in court. As in the other courts, the first issue addressed in the San Bernardino court is competency. Felony defendants who are thought to be incompetent are returned to the jail and the court will order that they be assessed by a licensed psychologist or a psychiatrist for competency. A hearing on the issue will then be held. Defendants found to be incompetent are examined by a therapist from the county Department of Mental Health to determine appropriate placement. If hospitalization is deemed appropriate, the defendant may remain in the hospital while steps are taken to restore competency. In fact, that process may take up to 3 years, or the statutory maximum associated with the crime charged, whichever is less. In misdemeanor cases, the court will attempt to avoid hospitalization, which can cost approximately $350 per day. It is more likely that the misdemeanor defendant will be placed in a public or private treatment facility approved by the Department of Mental Health or in a community-based program, in an attempt to restore competency. The criminal proceedings are suspended pending the restoration of competency, up to a period not to exceed the statutory maximum.23 Defendants who are unstable when they enter the jail are generally stabilized during the 2- to 3-week detention period while being considered for treatment court. Unstable defendants must consent to treatment while in jail in order to qualify for Mental Health Court, so that while they are housed in the psychiatric wing, they can be stabilized with therapy and medication. Most unstable defendants are ultimately denied program admission due to their inability to cope with the highly structured nature of the treatment program.
Assuming that a defendant is competent, he or she enters a guilty plea as a condition of entry into the program. The defendant is placed on probation for a period of 2 years in misdemeanor cases or 3 years in felony cases, with participation in Mental Health Court treatment ordered as a condition of probation. Each participant must also sign an individualized treatment contract that specifies the mental health services to be provided, the frequency of those services (and the required attendance), and any other activities required of the participant. Upon successful completion of the program, the plea may be withdrawn, the charges against the defendant may be dismissed, and the participant may also petition the court to have the record expunged.
Once the treatment plan has been agreed to, most participants are released into an augmented board-and-care residential treatment facility. (There are presently 24 beds allotted to the Mental Health Court program.) The case managers transport the participant to the facility and then visits the client several times a week to ensure compliance, providing intensive supervision to assure that he is attending psychiatric counseling, stabilizing on medication and abiding by the terms of his probation. Upon request, the probation officer will intervene if the client becomes disruptive or uncontrollable at the facility, and will arrange for transport back to court for a hearing before the judge. Clients who fail to cooperate or comply with program standards, or who otherwise are in violation of probation, will have sanction recommendations made for them by the mental health clinicians.
A small number of participants may have the family support and stability to allow them to be supervised from their homes. The case manager will conduct home visits two times per week, to determine that the living conditions are appropriate, and that clients are not in possession of any illegal or inappropriate items that would impede their progress in treatment, and to perform urine analysis testing for illegal substances. When the conditions in the residence are found to be unsuitable, the officer will find new arrangements for the participant. When a participant is found to be in violation, the officer will recommend sanctions.
Status hearings are held every 3 to 4 weeks to track the level of compliance by the participant and to address any problems that may arise. Noncompliance sanctions range from an in-court reprimand from the judge and loss of privileges, to increased restrictiveness of placement that includes more meetings with the case manager and more meetings in the 12-step program, or community service, and even jail time (usually a weekend, or more for continued violations). The noncompliant participant will also be reevaluated to ascertain if changes in treatment and/or living arrangements are necessary to aid them in attending to program rules. Serious and willful recurring violations may result in program termination and a return to traditional court. San Bernardino differs from the other early mental health courts in its close adaptation of the drug court model to the mental health court treatment process, including the use of jail as a sanction. If the defendant commits a new minor crime, he or she will probably be sanctioned with jail time, but may not be terminated from the program. An arrest for a new, more serious crime will result in termination. The benefits of compliance are privileges granted at the treatment facility.
The Treatment Approach in the San Bernardino Mental Health Court
The treatment process centers on the Mental Health Court judge and the court team. After the initial court session during which a participant formally enters the treatment program (STAR), participants attend court for status reviews as frequently as needed but average every 3 to 4 weeks. Prior to a court session, the treatment team reviews each case, including its problems and progress, with the judge who makes notes about the issues that need to be addressed. The team includes the judge, the prosecutor, the public defender, the probation officer, the case manager, the day treatment provider and sometimes the housing service manager. In the courtroom, the Mental Health Court resembles a drug court. The San Bernardino court sessions are very carefully organized and prepared. The judge discusses each participant?s situation, problems and progress, and encourages, reprimands, sanctions or modifies the treatment plan. Participants are treated differently depending on their symptoms, illness or stage of treatment. For some, the judge?s message is stern and a jail sanction may be applied. For others, the judge may be very supportive of small steps taken in a constructive direction. One of the reasons the Mental Health Court seems similar in style to the drug court is that most participants also suffer from serious substance abuse problems.
Nearly all of the participants in the San Bernardino Mental Health Court are initially placed in one of four augmented board-and-care facilities, the Redwood Guest Home, Fontana Board and Care, North End Board and Care and Linda Villa. These facilities receive funding that enables them to provide additional services tailored to the needs of the mentally ill offender. The facility supervisor must be at least a licensed clinician, who is qualified to dispense medications and provide individual and group treatment on site if necessary. These gateway facilities not only provide a temporary place to live, but also an array of supportive services to help the participant begin the treatment process. These include 24-hour supervision, group therapy, dispensation of client medications, assistance in helping with finances through the teaching of budgeting skills, assistance in spending money in appropriate ways, and transportation to the day treatment program that provides treatment services.
Because this type of care is expensive, the number of beds allotted to the treatment program is limited to 24 beds. As clients progress and become more stable, they are moved to one of the six regular licensed board-and-care facilities with which the court has contracted, and finally to basic room and board or other independent living situations. Only very stable clients are initially released into a regular, licensed board-and-care facility, where, in contrast to the augmented-care facilities supportive services, day treatment and dispensation of medications are not included in facility services (and the educational level required for staff is not as high). A small number of participants may be released directly to their family when family support is sufficient to facilitate the treatment process.
San Bernardino Mental Health Court participants generally receive day treatment from the Pegasus program which was run by Mental Health Systems, Inc., and tailored to fit the needs of the Mental Health Court. Pegasus began servicing the Mental Health Court in February 1999. Although Pegasus also takes referrals (of mainly individuals with some form of criminal justice involvement) from the other courts and agencies, the majority of its clients are participants in the Mental Health Court.
Defendants attend the day treatment program 5 days per week, from 8:30 a.m. until 1:00 p.m. The services provided include anger management, socialization skills, psychotherapy, medication therapy, and chemical dependency treatment, which includes a ?12 + 5? step program specifically geared toward the dually diagnosed client, as well as drug testing. (Most San Bernardino Mental Health Court participants also have serious substance abuse and self-medication problems.) Pegasus also provides prevocational training, which is meant to prepare participants for educational or work programs. Participants also receive individual case management; regular conferences are held to discuss client needs and progress. The program will transport participants to scheduled doctor?s appointments.
The day treatment component is intended to last for 1 year, at which point participants who have made satisfactory progress will be considered for vocational or educational training, or full- or part-time employment. Participants are referred to the state vocational rehabilitation department to receive training. Court (STAR) participants move from one level of care to another as a result of recommendations made by clinicians to the judge and the attorneys at periodic treatment meetings.
The mentally ill offenders grant is being used to fund two new programs: STAR LITE and SPAN. STAR LITE is an intermediate level treatment program designed to cover a similar mentally ill population to the one covered by STAR, but with Less Intensive Treatment Episodes. It offers services and case management for defendants who have less need for supervision; however, these participants will still be on supervised probation and be subject to specific medication and treatment requirements. They are also required to meet regularly with their case managers. Review hearings will be held approximately every 3 months. SPAN, which stands for San Bernardino Partners for Aftercare Networking, was designed to provide case management and augmented services to in-custody defendants who had not been previously diagnosed, but rather were diagnosed with an Axis I illness in jail,24 and who are not chronic offenders. Lower level services are offered to these defendants, and only regular board-and-care referrals are available for homeless participants. SPAN participants may not have probation terms and conditions relating to taking medications and treatment. There are no regularly scheduled review hearings required for them. Rather, they are tracked through brief meetings with a case manager and a counselor who will check in on them to assure that they are stable.
From the San Bernardino Mental Health Court?s inception in January 1999 through November 16, 1999, 181 referrals were made to the Court. Of these, 106 were actually evaluated, resulting in the acceptance of 25 participants and the rejection of 81 candidates. The majority of the rejections came from the office of the District Attorney. Most of those accepted were placed in the Pegasus program, with the majority of these housed in augmented board-and-care facilities. Sixty percent of entering participants were remanded to jail at least once during their treatment period, with 40 percent remanded more than once. Six participants were terminated from the Mental Health Court program, half due to AWOL status, and half due to serious or persistent violation of terms and conditions. Nineteen participants were active in the program as of November 19, 1999.
Success and Failure in the San Bernardino Mental Health Court
The San Bernardino Mental Health Court accepts participants facing misdemeanor or felony charges who have serious mental health problems based on past history and current diagnosis of Axis I conditions. All participants plead guilty and are sentenced to probation for 2 or 3 years, depending on the offense. The STAR Program aims to place mentally ill offenders in appropriate services and to move them to different and less intensive levels of care when success is demonstrated in various stages. An overriding goal is to place participants in treatment programs and to link them with the appropriate services so that, when their participation is concluded, they continue to make use of these resources, which will assist them to function normally and not to return to the criminal justice system. A related goal is to maintain the mentally ill offenders in the community and to avoid their confinement in the local correctional facility. Participants who are successful move from intensive services to more independent and self-sufficient living situations, complete probation successfully and have their pleas withdrawn, their charges dismissed, and their arrests expunged. The program?s first graduation is expected to occur in June 2000, when it is anticipated that up to six participants will have successfully completed the program.
After entering the Mental Health Court, participants who cannot comply with the requirements of the treatment process are sanctioned, much as in Judge Morris? drug court. They often receive stern lectures and reprimands, sometimes resulting in sitting in the jury box during the court proceedings, possibly being placed in a more restrictive and structured treatment setting, and, occasionally, being returned to jail until further plans can be made. Court staff considers the use of the jail appropriate in a therapeutic not a punitive sense, helping some participants see the consequences of their actions and encouraging them to refocus their efforts. Unsuccessful participants may be terminated from the Mental Health Court, have probation revoked and face serving terms of confinement in jail or a state prison facility.
22 See footnote 10.
23 See the California Codes, Penal Code Sections 1367-1375.5.