Seattle Mental Health Courts
Councillor Jennifer Clarke
October 2001

Summary

Like many cities, Seattle, Washington, has a significant group of people who are either homeless, mentally ill, substance abusers or a combination who are repeat offenders of low level offenses that formerly consumed expensive court and hospital services with no improvement in their condition or public order. Seattle officials say that prior to 1999 too many people were inappropriately getting caught in the justice system who should have been triaged out and weren't due to lack of quick entry routes to proper care. In June 1999 a task force recommended the city integrate publicly funded services for mentally ill and drug/alcohol offenders into a single administrative and service delivery authority. The first point of entry into this system for many patients is either the Mental Health Court (MHC) or the Crisis Triage Unit (CTU) at Seattle's Harborview Medical Center which link up and enforce treatment, housing and case management solutions for the clients they see. Feedback from police, hospitals and court personnel is that these mechanisms have significantly cut down on the time mental patients spend in jails, courts, and hospitals. The results are diminished costs, decreased escalation of behaviour due to lack of early intervention, and strengthened linkages for ongoing care and stabilization for the patients seen.

Seattle has two mental health courts, one operated by the city and the other by King County, in which Seattle is located. They operate across the street from each other, and from a Canadian perspective they are redundant. They are both courts of limited jurisdiction that deal with patients charged with a lower level offense (a misdemeanor which is punishable by up to 1 year in jail). The Canadian equivalent is a summary offense which includes shoplifting, dine and dash, public disturbance, simple assault, etc. Felonies which are more serious offenses cannot be seen in mental health court.

Each MHC has a designated judge who sits daily to hear cases referred to it either by police during arrest, jail staff after arrest, regular court personnel during arraignment (first court appearance) or families of the accused. The court has patients come back in for progress reviews either at regularly scheduled intervals or when a client is having trouble and additional intervention is thought to be necessary. Information on these clients is linked through databases with police, courts, and service providers so that if a client relapses he can quickly be linked back to his case manager and service providers. Critically, the MHCs enforce both the offender's compliance with the treatment plan and the service provider's provision of the treatment. Failure to comply can result in sanctions such as jail for the patient and a stronger series of servicerequirements or the threat of contempt of court proceedings for the publicly funded service provider. Successful completion of the court imposed treatment plan (which can take up to 24 months) results in charges being dropped, a more stable life and less ongoing expense and disruptive behaviour to the citizenry.

The following sections explain how the Mental Health Courts (MHCs) and the Crisis Triage Unit (CTU) work in daily application followed by a section on what the agencies have learned in practice since inception.

Mental Health Court

The goals of the Mental Health Court are to

· Protect public safety

· Reduce the use of jail and repeated interaction with the criminal justice system
· Connect or re-connect mentally ill persons with needed mental health services
· Improve their likelihood of ongoing success with treatment, their access to housing or shelter, and linkages with other critical support

The MHC in many ways follows the normal court model. There is a judge who makes decisions and issues orders, a prosecutor who represents the public interest which is primarily safety, a public defender who represents his clients' interests, probation officers who monitor the clients' progress and report to the court, as well as the usual recording and security staff. What is different, is the addition of a "court monitor" and several mental health professionals and social workers who assist the monitor. The monitor is a clinician and the linchpin for mental health assessment, referral and service linkup as well as for recommendations to the court as the court's pre-adjudicator. The key issue for the MHC is whether the alleged criminal behaviour is related to or caused by mental illness. Last year, Seattle's county court monitor saw 464 individuals who chose voluntarily to have their cases diverted from the regular court process in order to be handled in the Mental Health Court.

Together the MHC teams assess the best therapeutic and case management approach for the client's situation and offense. Unlike regular court which is more adversarial the team tries to determine what is in the best interests of the client keeping in mind any public safety concerns which may exist. The county and municipal MHC's take a slightly different approach from each other to their cases. The county MHC team including prosecution and defense lawyers meet without the MHC judge to recommend a client plan to the court. The judge then hears their recommendations, with differing opinions if any, and makes a decision. The municipal MHCjudge, by contrast, meets with the team during its deliberations and participates in discussions before the court session at which the decision making process is completed with the client present.

The most frequent mental illnesses seen were bipolar disorder, schizophrenia and schizoaffective disorder although the court will see people with significant brain injury impairment or developmental disability ( less than 15% of the caseload.). More than two-thirds of the individuals also had drug or alcohol addictions and the majority of them were homeless.

The charge types reflected nearly all misdemeanors, with the most frequent being assault, theft, harassment, trespass and property damage.

Of the 10-30 referrals per month
70% were in jail
50% were not in any treatment
50% had known housing arrangements
50% were homeless/in shelters
70% had co-occurring disorders such as substance abuse.

Participation in the court is voluntary for the accused who must be 18 years or older. Offenders under 18 years are referred to juvenile court. To be eligible for MHC the client must be willing to agree to the treatment plan, take their prescribed medication, see their case manager, release information pertinent to their case, and agree to plead guilty, no contest or to a deferred prosecution of their charge. If the client fulfills the court ordered treatment plan, the plea is wiped out. If they don't fulfill the plan, the judge's "stick" is that the original charge and sentence can be imposed. The "carrot" is that if treatment is fulfilled the guilty plea is erased and the client is in a more stable situation that has long term positive prospects for all concerned. In the county MHC, approximately 40% elect to go to trial for the offense because the time to be served for the misdemeanor is much shorter than that would be spent in treatment with long-term court follow up. 60%, however, elect the helping hand that the mental health court offers. Many who elect jail time initially, on subsequent offenses are persuaded to opt-in to the MHC route.

Clients who are judged by the monitor to be incompetent to enter a plea are not eligible for MHC. These clients are referred to the state mental hospital to be "restored" to competency through medication and treatment at the end of which they can be referred back to the MHC to see if they wish to participate voluntarily now that they are competent. If they do not want to participate they go through the regular criminal justice system.

The way the MHC referral works is that each morning clients who are identified by their behaviour or history either by police at arrest, jail staff in detention, court staff during arraignment (first appearance before a judge on a charge) or by their families are referred to the mental health court " monitor". The monitor also studies the jail lists to see if a known client is on the list and whether any new detainees are on the psychiatric floor of the jail. The monitor then goes to see the offenders in custody and does a quick assessment to see if they are candidates for MHC. The assessed client is seen that same day at the 2 p.m. session of the MHC. If there is time, the court team's public defender will meet with the client prior to the first hearing. If not, the client goes back into custody until the following day when the court team and public defender have done an assessment of the best case management approach for the client. The object is to get the client out of criminal justice custody and into treatment/housing based care as soon as possible.

Many offenders referred to MHC have co-occurring mental illnesses and substance abuse problems as referred to above. Their treatment plan will involve treatment for both the mental illness and chemical dependency. There are 17 publicly funded agencies in King County that provide mental health or substance abuse care. The county has hired one behavioral health management firm, United Behavioral Health (UBH), to manage all 17 agencies to ensure linkages and break down fire walls between them and to make sure the county receives good value for the dollars it spends on care.

MHC cases appear on their court dates in very high percentages, reflecting the approaches of immediate monitoring, "wrap-around" services, personal knowledge about the defendants and next day hearings.

Most importantly, more than two thirds of all those offenders who agree to participate in the MHC continued to be successfully engaged in their treatment program at the end of one year.

Crisis Triage Unit

This locked unit was started at Harborview Medical Center next to the Emergency Room as an alternative to the previous shuttling of seriously ill patients between detox, emergency rooms, jail and the streets. It triages and refers individuals who are in crisis because of serious mental and/or chemical dependency problems. Previously these individuals had swamped the county's ERs with high resulting cost, but no commensurate improvement in their conditions. Forty percent are brought in to the CTU by Seattle Police, particularly the Crisis Intervention Team, a police unit trained to assess and refer individuals with these problems. The balance of clients come in either by themselves or with others voluntarily.

The unit has 10 beds and has a maximum hold time of 24 hours during which time a discharge and follow up plan must be created for the patient. The average length of stay is 8-9 hours. The same company that manages the county's 17 mental/chemical dependency treatment providers (UBH) has here a pivotal unit clinician who follows up on the care and linkages between agencies for patients after discharge. Clients are referred either to mental health court for disposition of criminal charges and follow up treatment, to one of a variety of community based treatment options if there are no charges, or to Harborview's psychiatric ward or the state mental hospital as appropriate. The unit has studied recidivist patients to see how to improve care and prevent readmission. The Linkage Coordination/Case Review Team was able to reduce visits by 72% for 28 recidivist patients studied in a six month period with a resulting decrease in unit costs of $200,000 for that same period. This unit has about 8000 admissions per year representing about 5200 individual patients.

What Seattle's MHC and CTU Have Learned

Systems of mental health and substance abuse care need to be integrated. The five ingredients to integration are
shared information
shared planning
shared clients
shared resources
shared responsibility.

The most difficult to share for the agencies concerned was planning, but if you have only 4 out of the 5 ingredients necessary to integration it won't work.

Agency linkage and case management is critical. Database access to re-link a client with his/her case manager and treatment provider when he/she falls off the plan is critical to keeping the client out of detention in hospital or jail and out of trouble in the community. Clients falling off the treatment plan is to be expected.

For a treatment plan to work it needs the three ingredients of housing, treatment and case management. If any 1 element is missing it won't work.

All housing is not equal. Housing for patients without case management and supervision will not work. Housing without appropriate support will end up being a haven for drugs, weapons and crime in short order. As a transition to stable and secure housing the county has contracted with several shelters to provide "respite beds" for the homeless. These are designated beds visited bya community health nurse who gives out medications and treats low level health complaints and injuries for patients that don't require hospitalization, but do require some level of extended follow up and care.

Mental Health Court results in a lower rate of bookings and fewer days in detention for clients.

For a MHC to work it needs a good clinician for diagnosis and a good case manager to integrate systems. The court team must be dedicated, trusting, stable and willing to meet on an ongoing basis to develop a knowledge of the clients as well as expertise in mental health, substance abuse and criminal law issues.

MHC Evaluation

A phase one evaluation has been conducted on the King County MHC program by the University of Washington on the results from the first 2 years of operation. The analyses compared clients who opted-in versus those that opted-out of the MHC route and indicated that:

· MHC was more successful in linking opt-in defendants to treatment services and increasing the amount of treatment received.

· MHC was more successful in establishing compliance to treatment regimens.
· MHC opt-in patients experienced significant improvements in adaptive functioning
· MHC resulted in fewer problems with the criminal justice system for defendants seen.
· MHC opt-in defendants on average spent fewer days in detention.
· MHC opt-in participants had a significantly lower rate of new bookings after contact as opposed to the rate for those who chose not to participate.

Financial Implications

King County believes it is spending less on dealing with mentally ill clients and getting better results than it was before it set up the Mental Health Court began if all costs including police, court, jail, hospital, community based treatment and housing costs are taken into consideration.

(c) 1998 City of Vancouver