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International Journal of Law and Psychiatry The Broward Mental Health Court: process, outcomes, Roger A. Boothroyd*, Norman G. Poythress, Annette McGaha, John Petrila Department of Mental Health Law and Policy, Louis de la Parte Florida Mental Health Institute, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612, USA Mental health courts are one of a variety of special jurisdiction courts that have been created in a number of countries, including the United States While there is noprototypical mental health court Hanrahan, 2001), most of those in existence today share several common characteristics.
These include (a) the creation of a special docket (usually, but not always, nonviolentmisdemeanants with mental illness) that is (b) handled by a particular judge, with (c) aprimary goal of diverting defendants from the criminal justice system and into treatment In addition, the principle of therapeutic jurisprudence has been influential as a philosophic basis for the creation of some if not all mental health courts. ‘‘Therapeutic jurisprudence’’ hasbeen offered as a way for courts and attorneys to examine ‘‘the extent to which substantiverules, legal procedures, and the roles of lawyers and judges produce therapeutic orantitherapeutic consequences’’ Both mental health court 1998) and drug court judges have been explicit in theirreliance on therapeutic jurisprudence as the underpinning of their courts.
We are currently evaluating the Broward County Florida Mental Health Court (MHC), one of the first mental health courts in the United States.1 Full details of this evaluation are * Corresponding author. Tel.: +1-813-974-1915; fax: +1-813-974-9327.
E-mail address: (R.A. Boothroyd).
1 The Broward Court, created in 1997, appears to have been the first mental health court created in the 1990s, subsequent to the widespread development of drug courts. However, a court in Marion County, IN, created in1980, may have the distinction of being the first mental health court created in the United States 2001).
0160-2527/03/$ – see front matter D 2003 Elsevier Science Inc. All rights reserved.
PII: S 0 1 6 0 - 2 5 2 7 ( 0 2 ) 0 0 2 0 3 - 0 R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 described elsewhere McGaha, & Boothroyd, 2001). In one part of the evaluation, we have examined the MHCprocess itself, including the volume and nature of courtroom communications and formaloutcomes. We have also gathered data on the utilization of treatment services by individuals inthe MHC as well as by individuals in a traditional misdemeanor court chosen as a comparisonsite (Hillsborough County). In this article, we report findings from these two aspects of theevaluation, referring to them as Study 1 (the court process) and Study 2 (the utilization data).
2. Study 1: description of mental health court process and outcomes The Broward Court, like many drug and mental health courts, describes itself explicitly as a treatment court. In treatment courts, the roles of the judge and counsel are oftencharacterized as less adversarial than in traditional court, with an emphasis on enabling thedefendant to gain access to treatment and other supports.
Informal observations of the Broward Court indicated a substantial role for the defendant, presumably because of the court’s desire to create an alliance with the defendant. Ourdescriptive study of the court process focused on the extent to which various participants wereinvolved in the proceeding and the topics that were discussed. In contrast to traditionalmisdemeanor court, where informal observation revealed that the primary focus of theproceedings was to move the case to a legal disposition,2 we anticipated that discussion offormal legal issues would be minimal in light of the greater focus on mental health andtreatment related topics. At the same time, however, the defendant’s entry into the mentalhealth court must be voluntary3 and, as in any criminal proceeding, defendants must beconsidered competent to proceed.4 Thus, we examined the extent to which these issues wereaddressed in the transcripts.
Finally, our informal observations of the Broward Court suggested that, despite its emphasis on linking defendants to treatment, neither the treatment linkages nor the formallegal outcomes were identical across all cases. A mental health court such as the BrowardCourt has a variety of ways in which it might resolve a case. The court may close a case atfirst hearing, or it may keep the case open (in order to maintain jurisdiction) and monitor thedefendant’s progress in treatment through subsequent ‘‘status’’ hearings. It is important tounderstand how these paths were articulated and how many defendants were placed on eachpath. Similarly, there may be variations in the court’s stated expectations regarding treatment.
As our evaluation progressed, it became evident that some individuals did not enter mentalhealth treatment from the mental health court. That could have reflected a lack of follow-upby the court or treatment providers, or it could have reflected a decision by the court to simply 2 In Study 2 below, we describe a sample of cases from a traditional misdemeanor court.
3 Defendants have the right to decline participation in the mental health court and have their cases heard in a regular misdemeanor court. As the discussion below suggests, not all defendants report that they are aware of thisright.
4 There is a legal presumption of competence that can be challenged by either party or by the court; in the absence of such a challenge, cases are allowed to proceed.
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 close a case. In order to attempt to understand this issue more clearly, we thought it importantto ascertain how the court framed its expectations regarding the question of subsequenttreatment for the defendant.
Our prospective study of the MHC included 121 defendants whose cases were accepted into the court between December 1, 1999 and April 30, 2001 (see Study 2 below for adescription of the sample). To evaluate the court process and outcomes for these cases, weobtained and coded official court transcripts for these cases.5 A comprehensive form was created for coding the content of the transcripts. Content categories related to legal issues (e.g., mention of the voluntary nature of the court, mentionof the defendant’s competence, mention of current or prior offenses), mental health issues(mention of current or past illness, treatment, use of psychotropic medications, etc.), anddisposition (legal findings, directives into treatment). A dozen cases were initially coded bythe third author and a graduate student, resulting in high levels of agreement across allcategories. Subsequently, the graduate student coded the remaining cases.
From a simple count of the number of times a participant was listed as a speaker in each transcript, the mean numbers of utterances for each participant was calculated. On average,about 54 utterances were made at initial hearings in mental health court. The judge,defendant, mental health staff, public defender, and state attorney were usually the onlypeople who spoke. The process was substantially a dialogue between the judge—whotypically was responsible for nearly half (47%) of the communications at the hearing(M = 25.72, S.D. = 19.21) and the defendant—whose comments accounted for 33% of theutterances on the record (M = 17.39, S.D. = 15.75). The remaining comments came from themental health staff (7%) and attorneys (12%). The mental health staff did not testify as swornwitnesses, nor did they (or any other witnesses) take the witness stand. Rather, they merelyresponded from the floor, usually in response to queries from the judge. Very infrequently,and usually very briefly, a friend or family member of a defendant also spoke at the hearing.
2.2.2. What is discussed at mental health court? Both legal and clinical issues appeared in the MHC transcripts. Two important legal issues relevant to MHC participation include (a) the defendants’ understanding that the primaryfocus of the court is on treatment involvement rather than adjudication of the legal case and 5 We are grateful to the MacArthur Foundation Research Initiative on Mandated Community Treatment for funds used to purchase the mental health court transcripts. Copies of transcripts could not be obtained from thelegal transcription service for 17 of the mental health court cases; therefore these analyses are based on 104 cases.
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 (b) the defendants’ understanding that participation in the court is voluntary—defendantschoose to have their case adjudicated in a regular misdemeanor court rather than in MHC.
Our coding of the transcripts revealed that the primary purpose and focus of the MHC wasexplicitly announced in 28.4% of cases.6 In 15.7% of cases, the transcript included explicitstatements by the judge regarding voluntary participation and/or the defendant’s prerogativeto have his or her case transferred to regular misdemeanor court.7 The transcripts contained some mention of a defendant’s competence-to-proceed in 29.4% of cases. When this issue did arise, the court declared the defendant to be competent 73.3% ofthe time and incompetent in only 3.3% of cases. Mental health evaluations were ordered in13.3% of these cases; in 10% of the cases in which the issue was mentioned, the action taken(if any) was not clear from the record.
Consistent with the court’s identification as a ‘‘treatment court,’’ the presentation of material related to the pending criminal charges was cursory. Although the name or natureof the defendant’s charge was mentioned in 70.6% of cases, this most commonly occurredin a single utterance when the judge called the case from the docket, as in ‘‘The next caseis Mr. ___, who is here on a charge of trespassing.’’ In only 2.9% of cases did any otherinformation about the charge appear on the record and witnesses to the offense were nevercalled for questioning. Observation of the court by the authors suggests that the court avoidedextended discussion of the pending charges to avoid compromising the defendant’s right toavoid self-incrimination. A defendant’s prior record was alluded to in 58.8% of the cases,usually when the court was considering public safety issues in contemplation of disposition.
No detail on prior offenses was found in any transcript.
Mental health issues were discussed in most cases and these discussions were typically more extensive than were those of legal issues. Transcripts revealed that defendants’ currentor prior symptoms and diagnoses (42.2%), use of psychotropic medications (24.5%), andtreatment/placement issues (83.6%) were the most commonly explored mental health issues.
Other issues related to mental health and social adjustment that arose with some frequencyincluded housing (34.0%) and employment (10.2%).
At the conclusion of the initial hearings in MHC, the defendant’s legal case remained open in about one-third (36%) of cases. These cases were usually scheduled for a ‘‘status hearing’’ 6 It is highly likely, however, that more than 28.4% of the defendants in our sample were aware of the primary purpose and focus of the mental health court and more than 15.7% were aware of the voluntary nature of the court.
In our frequent observations of the court, the judge sometimes, prior to calling cases, offered a blanket statement toall present in the court, including the array of defendants waiting to have their individuals’ cases called. Thisblanket statement sometimes included statements about the treatment approach of the court, the voluntary natureof the court, or both.
7 A slight majority (53.7%) of the clients indicated being told about the voluntary nature of the court when asked in their enrollment interviews. However, over half (54.7%) of those who indicated such knowledge said theywere told about the voluntary nature of the court after their initial hearing. Clients self-reported that they were toldabout the voluntary nature of the court by the public defender (31.8%), judge (28.8%), and mental healthprofessionals (25.8%).
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 several weeks later at which the court would receive information about the defendant’sparticipation and progress in treatment and reconsider legal disposition of the case.
In most other instances,8 the court made a legal disposition of the case. In 26% of cases, the defendant was found ‘‘guilty’’ and credited with time served (21%) and/or assigned a briefperiod of probation (5%). Charges were formally dismissed in 2% of cases and, in theremainder (39%) of cases, the disposition was ‘‘adjudication withheld,’’ usually (33% of allcases) without probation.9 Our informal observations of court hearings revealed a variety of ways through which the MHC attempts to link defendants to mental health services. Often the defendant was someonealready known to the local treatment community and had been involved in treatment prior tohis or her arrest on the index offense; the court in such cases typically sought to identify theexisting treatment provider and to encourage the defendant to continue with a previouslyestablished treatment plan. Some defendants had been referred to a crisis stabilization uniteither from the jail, or after appearing before the MHC at a first appearance in such an acutestate that they appeared unable to consent competently to participation in the court. Suchdefendants often returned to the court within a week or two after stabilization and with atreatment plan that had been developed during this initial intervention; linkage in this casewas commonly to encourage the defendant to pursue this newly established plan.
A second type of linkage was derived from the recommendations of the mental health staff that evaluated defendants as they came into court. These brief assessments sometimesresulted in recommendations to the judge for referrals to specific community agencies knownto provide services appropriate to the assessed needs. In these cases, the client was referred tothe specific agency (sometimes with assistance from court personnel in making the initialappointment) and/or provided funding for initial transportation to the service agency.
Finally, it was observed in some cases that the court-based either on recommendations of court mental health staff or self-reported needs of the defendant—would merely providegeneral information (e.g., an agency name and address, an agency brochure describingservices) about where services might be sought. These defendants were encouraged andexhorted to follow-up on their own, and the court did not explicitly commit court resources(personnel or transportation funds) to assist in making the linkage.
Each of these linkage methods was reflected in the transcripts of our sample of MHC defendants. The primary linkage strategies utilized by the court involved either referral to anagency with which the defendant had a previous or recently established treatment plan(35.3%), or referral to a specific agency deemed to provide services appropriate with assessedneeds (35.3%). A small group of defendants (11.1%) was encouraged to initiate treatment 8 In about 3% of the transcripts, legal disposition of the case was not explicit.
9 Florida courts have the authority to withhold an adjudication of guilt and may also place the defendant on probation. Fla. R. Crim. P. 3.670 (2002). According to the Honorable Ginger Lerner Wren, who presides over theBroward County MHC, ‘‘adjudication withheld’’ is used as an outcome at the end of a case; she views this as averdict ‘‘softer’’ than a verdict of guilty (personal communication between Judge Lerner Wren and John Petrila,July 9, 2002).
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 contacts largely through their own efforts and, for about 18% of defendants, the courttranscript did not include explicit linkage information.10 2.2.5. Equity in the mental health court process In a final set of analyses, we examined whether various aspects of the MHC process and outcomes, as described above, were administered equitably across race and gender.
We found no evidence of differential treatment by race (Caucasian, n = 64 vs. African – American, n = 23) in terms of the extensiveness of the hearings.11 Transcripts revealed a meanof 63.00 utterances (S.D. = 48.1) in 21 cases involving African – American defendantscompared to 52.35 (S.D. = 36.8) utterances in 62 cases involving Caucasian defendants[t(81) = 1.26, P=.213]. Similarly, the mean number of utterances in hearings involving 28female defendants—59.96 (S.D. = 44.09) did not differ significantly from the mean in thehearings of 65 male defendants—52.71 (S.D. = 41.20) [t(91) = À 0.77, P=.44].
A pair of 2 Â 2 contingency tables was constructed to compare legal disposition (adjudicated guilty vs. adjudication withheld) separately by race (Caucasian vs. AfricanAmerican) and by gender. These analyses revealed no significant difference in the proportionadjudicated guilty either by race (c2 = 0.34, P=.56) or by gender (c2 = 3.08, P=.08).
Contingency tables were constructed to compare the distribution of three treatment linkage strategies (described above) separately across groups by race (African – American vs.
Caucasian) and gender. These analyses revealed no significant difference in the utilizationof treatment linkage strategies either by race (c2 = 0.14, P=.93) or by gender (c2 = 0.63,P=.73).
3. Study 2: pathways into treatment and mental health service utilization In Study 2, we explored the use of mental health services by defendants in the Broward MHC, including a comparison with mental health service utilization by a group of mentally illmisdemeanants tried in a traditional misdemeanor court. Three specific questions wereaddressed: Does involvement with the MHC affect the likelihood that a misdemeanant with mentalhealth problems will subsequently receive treatment? Among defendants who access behavioral health services, does the MHC impact thevolume of services a defendant received? Among defendants whose cases are heard in the MHC, what is the relationship between theuse of mental health services and type of service linkage strategy noted in the courttranscript? 10 Because of the (sometimes extensive) off-the-record conversations between the court mental health staff and defendants, it is possible that explicit treatment linkage strategies were communicated to some of these defendants.
11 Analyses by race were limited to African –American and Caucasian defendants, as these were the only categories with sizeable numbers for comparisons.
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 The Broward MHC sample (n = 121) consisted of English-speaking defendants of either gender, between the ages of 18 and 64, whose cases were accepted by the MHC betweenDecember 1, 1999 and April 30, 2001. MHC jurisdiction depends on judicial findings that theindividual (a) is charged with a nonviolent misdemeanor, ordinance violation, or criminaltraffic offense;12 (b) currently has, or previously has had, mental health problems;13 (c) is ableand willing to make a voluntary choice to have the case disposed in the MHC; and (d) wouldnot pose significant public safety concerns. Individuals not meeting all of these criteria arereturned to a regular misdemeanor court for disposition of their cases.
Our comparison group included 101 defendants from another county in Florida that does not have a MHC but who met the criteria (a) and (b) above for MHC jurisdiction in BrowardCounty. Each currently had, or reported a history of, mental health problems.14 To minimizethe chance that clinical and demographic variables would be confounded with site differencesin this study, our design called for the MHC and comparison samples to be matched oncertain demographic variables (age, gender, race) and on current mental status. Thus, therecruitment in the comparison county lagged recruitment in the Broward MHC by a couple ofmonths in order to permit selection of comparison clients whose demographic and clinicalfeatures matched those of the Broward sample.
The characteristics of the subjects from the Broward County Mental Health Court and the comparison court in Hillsborough County are summarized in 15 Data are onlyreported on 116 mental health court clients and 97 comparison court clients as severalparticipants in each group had requested to be disenrolled from the study and as such theirdata have been excluded from these analyses. As can be seen, the procedure for matchingsamples was successful; no significant differences were found between the two groups ofdefendants in terms of gender, race/ethnicity, age, or overall level of psychopathology 12 Individuals charged with misdemeanor battery offenses may be accepted into MHC if the victim in the case agrees to this route of disposition. The Broward MHC does not accept persons charged with domestic violence ordriving while intoxicated charges.
13 Mental health screening is conducted in court or just prior to court by mental health professionals who work with the court or graduate students in clinical psychology from Nova Southeastern University working undersupervision However, the court may accept jurisdiction in the absence of formal diagnosticfindings.
14 In the comparison county, defendants with mental health issues were not automatically identified by the fact of their referral to/acceptance by a MHC. Thus, at the control site, research assistants identified individuals at thedaily first appearance court with charges of a nature that would allow them into the mental health court. Those ofthis subset, who were housed on mental health units in the jail, were referred for psychiatric care/assessment in thejail, or who based on observation were possible candidates were considered for interviews. When the presence ofcurrent symptoms and/or a history of mental illness was questionable prior to the consent process the researchassistant conducted a brief screen to probe on issues such as current symptoms and history (see 2002 for more details).
15 Due to a small number of cases with missing data, the n’s reported here differ slightly from those reported in R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 Table 1Characteristics of study participants (measured using the Brief Psychiatric Rating Scale—Anchored Version: & Kane, 1988). Self-reported mental health service use.
research protocol and using procedures described elsewhere in greaterdetail self-report data on the use ofmental health, medical, and substance abuse services were obtained from subjects in theMHC and comparison samples. Briefly, participants were recruited using proceduresapproved by the University of South Florida Institutional Review Board. Informed consentwas obtained at enrollment, and trained research assistants contacted participants 1, 4, and 8months after enrollment for subsequent administrations of the protocol.16 Each participantwas paid US$20 upon completion of each protocol administration. Administrative data sources.
Additional data were obtained from administrative data sets available to our research team. We retrieved records of all mental health andsubstance abuse services paid for by either Medicaid or State general revenue dollars for all 16 The 8-month timeframe for follow-up with the comparison group was driven by another aspect of the research that involved analyses related to criminal recidivism. For the MHC group, additional waves of interviewsat 12 and 16 months provided further service use data (not reported here).
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 213 participants for the 8-month period preceding enrollment in the study and for the 8-monthperiod postenrollment (the same time period covered by the self-report data).
A two-group repeated measures analysis of variance (ANOVA) was conducted using the administrative data to assess for group differences in the service penetration rates and thevolume of services defendants received in the 8 months before and after their initial courtappearance. Penetration was defined as having received any treatment at all (regardless of thenumber or type of services received) during the time frame of analysis, while volume was agross measure of treatment involvement computed by totaling the number of discrete serviceunits received.
Independent t-tests were conducted on the self-report data to compare the service penetration rates and volume of service between the two groups during the 8 monthsfollowing their court appearance. Finally, for those defendants whose cases were heard inthe mental health court, the relationship between the use of services and type of servicelinkage strategy noted in the court transcript (see Study 1) was examined using chi-squareanalyses.
The findings are summarized by the major research questions.
3.2.1. Does involvement with the MHC affect the likelihood a misdemeanant with mentalhealth problems will subsequently receive treatment? Analyses of administrative and self-report service use data were conducted to compare the penetration rates for defendants served by the mental health and comparison court. Given that22 of the defendants returning to the MHC came directly from a hospital or crisis stabilizationunit and therefore were more likely to have an existing treatment plan and the fact that similardefendants in the comparison court could not be identified and enrolled in the study, these 22defendants were omitted from the analysis to permit a fairer and more conservativecomparison of the impact of the MHC in engaging individuals in treatment. The results ofthis analysis are summarized in As is shown in this figure, no significant difference was found in the behavioral health service penetration rates between sites prior to enrollment into the study [t(197) = À 1.06,P < .29], although misdemeanants in the Broward County MHC were slightly more likely tohave received behavioral-health services in the 8 months prior to enrollment in the study(36%) compared to individuals residing in Hillsborough County (29%). However, evenwhen controlling for these small initial differences in service utilization, a significantcounty-by-time interaction was found [ F(1,197) = 6.21, P=.05]. The use of behavioral healthservices by defendants whose cases were heard in the MHC increased significantly duringthe 8 months following enrollment in the study (from 36% to 53%), while the likelihood ofusing services among defendants in the comparison court remained virtually unchanged R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 Fig. 1. Pre- and post-service penetration rates (administrative and self-report data).
(from 29% to 28%). The effect size of this difference in administrative data penetration rateduring 8 months following the initial court appearance is 0.52, a moderate effect accordingto Administrative service utilization data were available on 21 different behavioral health services. Higher rates of service use were reported by defendants served by the mental healthcourt in 14 of the 21 service categories. A sign test performed on these findings suggest theprobability of this occurrence is P=.09, assuming a random effect (50–50). Interestingly, theservice categories in which defendants from the comparison court had higher levels ofutilization were emergency services and more intensive levels of residential treatment.
A related analysis investigated whether the defendants using services after their initial court appearance were the same individuals who were using services prior to their courtappearance. These findings are summarized in A chi-square analysis was performedto determine if the pre- to postservice utilization patterns differed between courts and asignificant difference was found [c2(3, n = 192) = 13.76, P=.003]. As is shown in this table,defendants in the comparison court were more likely to not be using services both before andafter their court appearance relative to those who appeared in the mental health court.
Additionally, comparison court defendants were less than half as likely to begin treatmentafter their court appearance and nearly 50% more likely to stop receiving treatment after theircourt appearance relative to mental health court defendants.
Table 2Service use patterns pre- and post-court appearance (administrative data) R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 Service penetration rates for the 8 months following court appearance were also examined using defendants’ self-report data. Due to the inability to conduct follow-up interviews afterthe initial court appearance, 10 MHC defendants (10.3%) and 9 comparison court defendants(8.9%) were lost to attrition. The number of interviews among those who were intervieweddiffered significantly between the two sites [t(177) = 2.26, P < .05]. Self-report serviceutilization was based on an average of 2.08 interviews (out of 3) among mental health courtdefendants and 2.35 interviews among those in the comparison court. The smaller number ofinterviews among MHC recipients decreases the opportunity for them to report service use,also making this a conservative analysis. Despite this fact, MHC participants were morelikely to have reported receiving behavioral-health services during the 8-month follow-upperiod (73%) than were participants from the comparison court (60%); however, thisdifference is not significant statistically [t(188.97) = À 1.89, P=.61]17 (also see Despite failing to reach a classical level of significance, the effect size associated with thisdifference in self-reported penetration rate during 8 months postcourt appearance is 0.27, asmall effect.
During each interview, respondents were asked about their use of 27 different types of mental health and substance abuse services. Higher rates of service use were reported byMHC defendants in 20 of the 27 service categories. A sign test performed on these resultsindicate the probability of this occurrence is P < .05, again assuming a random effect (50–50).
Similar to the findings based on the administrative data, many of the service categories inwhich defendants served by the comparison court reported higher levels of service utilizationinvolved emergency services and detoxification.
3.2.2. Among individuals who accessed behavioral health services, did the MHC impact thevolume of services a defendant received? Between defendants in the two courts who reported receiving any service at all, the mean number of service units received was compared to assess whether there was a difference inthe volume of behavioral health services received by MHC and comparison court defendants.
A two-group repeated measure ANOVA was performed on the administrative data to assessfor group differences in the volume of services received in the 8 months before and after courtappearance. These results are summarized in A significant group-by-time interaction [ F(1,196) = 6.27, P=.013] was obtained. The mean number of units of behavioral health services defendants in the mental health court receivedincreased by 61.6% (from 18.23 units in the 8 months before to 29.47 units in the 8 monthsafter), while the number of units of service for defendants served by the traditionalmisdemeanant court decreased by 18.3% (from 19.25 to 15.72 units). The effect size of thisdifference in service volume during 8 months postcourt appearance is 0.44, bordering on amoderate effect.
A similar analysis was conducted based on defendants’ self-report service use data.
Significant differences were found in the volume of behavioral health services favoring 17 Degrees of freedom have been adjusted for unequal group variances.
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 Fig. 2. Pre- and post-service volume (administrative and self-report data).
mental health court defendants [t(89.05) = À 5.43, P < .001]. MHC service users reported anaverage of 61.57 units of service in the 8 months following their court appearance, whilethose in the traditional court reported an average of 15.84 units of service during the sametime period. This difference represents a large effect (1.91).
3.2.3. What is the relationship between their use of mental health services and the type ofservice linkage strategy noted in the mental health court transcript? Chi-square analyses were conducted to examine the relationship between court expectation and anticipated treatment linkages noted in the court transcripts and the likelihood ofdefendants’ subsequent service use (see No significant relationship was foundbetween the type of treatment expectation noted in the court transcript and the likelihood thatdefendants would use behavioral health services in the 8 months following their hearing. Thiswas true for both the self-report [c2(3, n = 74) = 4.33, P = NS] and administrative service data[c2(3, n = 76) = 2.75, P = NS]. There was no explicit mention of treatment in the courttranscripts of 15.0% of the defendants reporting no service use in the 8 months following theirinitial court appearance; there was also no explicit mention of treatment in the courttranscripts of 16.7% of the defendants who reported service use during this period.
Examination of the administrative data, however, reveals a somewhat different finding. Only Table 3Receipt of behavioral health services by level of treatment expectation and service data source Treatment expectation noted in transcript Provided general referral information (n = 10) Continue with existing treatment plan (n = 35) Provide with a explicit referral (n = 34) R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 12.5% of the defendants who used services in the 8 months after their court appearance hadno mention of treatment in their court transcripts compared to 22.2% defendants who did notuse services. Although not statistically significant, this represents a large effect (effectsize = 0.89).
The findings from these studies provide some interesting insights into the Broward MHC process as well as preliminary data regarding service utilization of defendants in the MHCand in a traditional misdemeanor court. The court transcript analyses in Study 1 provide aquantitative and systematic accounting of the court process that distinguishes the MHC fromtraditional misdemeanor courts. First, the judge appears to have chosen a strategy ofdeliberately engaging the defendant in a conversation regarding the defendant’s perceivedtreatment needs; there is little that reflects traditional ‘‘lawyering’’ as the attorneys arerelegated to relatively minor roles in the hearings. The transcripts also show a focus ontreatment issues that is consistent with the court’s self-characterization as a ‘‘treatment court.’’The offense itself is rarely discussed. As noted above, our live observations of the courtsuggest that the court deliberately stays away from discussion of specific details regarding theoffense in large part because of a desire to avoid self-incrimination issues in the event the casehas to be handled in an ordinary misdemeanor court. Regardless, discussion between thejudge and defendant of treatment-related issues comprises the bulk of conversations in thecourt.
The transcripts also reveal that not all cases before the MHC take the same path. As noted above, the court closed 63% of the cases in our sample at the initial hearing, with a smallpercentage of these defendants placed on probation. In only about one-fourth of cases was thedefendant adjudicated guilty; more often the disposition is ‘‘adjudication withheld’’ and noconviction appears on the defendant’s criminal record. This is in stark contrast to the resultsreported from other studies of other, more traditional misdemeanor courts. For example,reported that upwards of 90% ofmisdemeanor cases in Hillsborough County (the comparison site in Study 2) resulted in pleasof either guilty or no contest. In about one-third of cases, the judge in the Broward MHCcontinues the case, apparently as a mechanism for maintaining jurisdiction so that cases canbe monitored, through ‘‘status hearings,’’ for oversight of the person’s mental status and useof mental health services. This is important in considering how judicial and other resourcesare allocated in special jurisdiction courts. The Broward Court, at least, does not use a ‘‘one-size fits all’’ approach to all cases.
Findings from both studies are interesting in light of the potential presumption among policy makers and others that all defendants who come before the MHC are linked totreatment. Although it is the court’s aspiration that defendants do engage in and comply withmental health services, the court transcripts revealed explicit treatment-linkage strategies inonly 82% of cases In Study 2, only 73% of mental health court clients self-reportedinvolvement in treatment during the 8-month period following their court appearance, and an R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 even smaller portion (57%) were documented as having received Medicaid or state-fundedmental health services.18 Given that many of its clients are individuals with chronic illnesses who may long have been difficult to engage in treatment, and given the court’s limited staff resources to monitorits treatment directives, the fact that not every defendant appearing before the court receivestreatment is not surprising. This outcome is also consistent with the court’s aspiration to be anoncoercive influence in the lives of its clients. As noted by (2000) and supported by our transcript data, the Broward Court rarely if ever uses punishment(e.g., probation or jail time served) and in many cases is not particularly specific or directivein articulating its expectations regarding treatment.
At the same time, the findings from Study 2 suggest that involvement with the Broward MHC increases the likelihood that defendants will become engaged in the mental healthtreatment system. There is also evidence based on the cumulative number of service unitsreceived that suggests that individuals who do receive treatment receive a higher or moreintense dosage of treatment than defendants in the study who appeared before the traditionalmisdemeanor court. Although the impact of these services on the longer-term outcomes of thedefendants is at this time unknown, it is well documented that the ‘‘. . .evidence for treatmentbeing more effective than placebo is overwhelming’’ Services, 1999, p. 65).
It also is worth noting that the categories in which comparison court defendants appeared (based on self-reports or administrative data) to have higher levels of service utilization weretypically crisis or emergency services or more intensive levels of residential treatment. Whileour cost analysis study of the Broward MHC and comparison court is on-going, the servicesused more frequently by defendants in the comparison court are generally associated withhigher cost service categories.
These results in the aggregate appear to provide clear evidence that the Broward MHC meets its goal of facilitating access to treatment, albeit imperfectly. The findings from Study 2do suggest that a greater proportion of defendants in the MHC do subsequently utilize mentalhealth services than defendants in the traditional misdemeanor court. It also appears that thisoccurs in a manner that enhances procedural fairness while minimizing perceived coercion One curious finding from Study 2 was that the MHC clients’ subsequent use of mental health services is independent of the court’s expressed expectations about treatment, asreflected in the treatment-linkage strategies coded in Study 1. As revealed, defendantswhose transcripts contained no explicit discussion of treatment-linkage were not statisticallyless likely than others to access some type of mental health service during follow-up. A 18 Such differences between self-report and administrative data are not uncommon (see Snyder, & Zong, 2002 for discussion). While there are many reasons why self-report penetration rates and servicevolume are consistently higher than those obtained from administrative data sources, prominent among these arethat administrative data are restricted by pay or source (in these analyses Medicaid and state general revenue)while self-report data are independent of this limitation and can include informal service sources such as self-helpgroups (e.g., AA).
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 precise explanation for this unexpected finding cannot be determined from our data, althougha number of factors may come into play here. First, transcripts simply may not tell the wholestory regarding the Broward MHC process. While the court stenographer’s version of thehearing is probably the best record available, it is clear from observing the court that noteverything gets captured in the transcript. The relaxed procedure in the mental health court(e.g., witnesses are neither called nor sworn; speaking order is not controlled) sometimesresult in several individuals talking at once or several conversations going on simultaneously,and the court reporter cannot monitor all of them simultaneously. Further, there are oftenprivate conversations between the defendant and other court participants, including the publicdefender or mental health consultants, in which treatment-related information (or exhortation)may be communicated.
Second, some of the participants in our study may have previously been to the court, with their mental health histories already known to the judge or other participants at the hearing forwhich we obtained a transcript. It is possible that in some instances implicit expectationsabout treatment rather than explicit ones were communicated to the defendant, or thatcommunication occurred in conversations (e.g., with defense counsel or treatment staff)outside of the court hearing as reflected in the transcript. Third, although the court has limitedstaff resources for the active monitoring of clients’ involvement in treatment, some defend-ants whose transcripts were bereft of treatment-linkage information may have been aided inaccessing treatment by the efforts of support staff. Fourth, these findings may reflect ajudgment by the court that certain clients had the ability and the means to autonomouslypursue treatment.
If there is one potentially troubling finding from the study of MHC transcripts, it is that there is probably considerably less explicit discussion and resolution of the ‘‘voluntaryparticipation’’ issue than legal purists would find desirable. In only 15.7% of transcripts wasthis issue explicitly discussed, though a little more than half (53.7%) of the clients self-reported during the enrollment interview that they knew that participation in the court wasvoluntary. This awareness may have come from attending to the judge’s general statementsabout the nature of the court8; in addition, some may have been apprised of their legal choicesin conversations with their public defender. Nevertheless, this is an issue of some importancethat can, and arguably should, be handled on the record in each case individually.
It is also reasonable to ask whether other strategies not used by the Broward Court would affect entry into and retention in treatment. For example, what would be the impact of the useof punishment for noncompliance with treatment? What if the court retained jurisdiction in ahigher percentage of cases, or required subsequent status hearings as a matter of course?Should a MHC retain staff that assure that treatment orders are followed up, or should thatresponsibility be vested elsewhere, for example, in the treatment provider or in probationstaff? Does the choice of strategy matter in terms of treatment? In addition, while the courthas available client specific information regarding mental health needs and treatment options,neither the transcripts nor our observations suggest that such material is made available to thecourt in systematic fashion. Would more formal presentation of such information have animpact on judicial decision making, or does the informal nature of the court facilitate itswork? These questions, while important, also assume of course that treatment is available.
R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 Our findings suggest that the Broward Mental Health Court operates in a manner consistent with its stated mission as a treatment court. They also suggest that at least in comparison to atraditional misdemeanor court, the Broward County MHC enhances treatment access andinvolvement for a substantial number of defendants appearing before it. While the jury is stillout regarding the impact of this treatment on defendants’ mental health status, or whether itreduces the likelihood of re-arrest and return to jail, most will likely agree that gaining access totreatment is a necessary if not sufficient condition for attaining these ultimate goals.
This research was supported by grants from the John D. and Catherine T. MacArthur Foundation and the Florida Legislature. We appreciate the comments and suggestionsprovided by John Monahan, Marvin Swartz, and Henry Steadman, who reviewed an earlierdraft of this paper.
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Stiles, P., Boothroyd, R. A., Snyder, K., & Zong, X. (2002). Service penetration by persons with severe mental illness: how should it be measured? Journal of Behavioral Health Services, 29, 198 – 207.
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R.A. Boothroyd et al. / International Journal of Law and Psychiatry 26 (2003) 55–71 Wexler, D. B., & Winick, B. J. (1991). Essays in therapeutic jurisprudence. Durham, NC: Carolina Academic Woerner, M. G., Mannuzza, S., & Kane, J. M. (1988). Anchoring the BPRS: an aid to improved reliability.
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