Virginia is NOT for Lovers of Mental Health Courts…

Virginia is for lovers

Virginia’s history of the implementation and maintenance of mental health courts (MHC), is as dismal as most other states. This isn’t to say that we should take comfort in our universal ineptness, but it should serve as a warning sign as to the abundance of hurdles, lack of oversight, and gap in funding for having truly effective mental health dockets.

Virginia currently has 32 general district courts which typically act as the primary entry point any person has with the judicial system due to it generally covering all traffic cases and other misdemeanor and civil cases involving amounts of under $25,000. Out of those 32 courts, only 2 have mental health dockets –  the cities of Richmond and Petersburg. As for circuit courts, Virginia currently has 120 courts that handle civil cases over $25,000, felony charges, and serve as an appellate jurisdiction for any cases originated in the General District Courts. Virginia has only one, Norfolk, which utilizes a mental health docket.

Court Flow Chart

Now let’s take a closer look at the history of Norfolk’s MHC. After over 2 years of trying to implement this specialized docket, it was officially established in 2008. Since that time, approximately 30 participants have been involved with the diversional program at any given time, and typically remain active for at least a year (obviously this number doesn’t even come close to addressing the disproportionate number of incarcerated individuals with serious mental illness, but its a start). With the Virginia Commission on Mental Health Law Reform  increasing focus on MHCs, Norfolk’s program became the prototype for all others in the sate to follow. This also put it under a high level of scrutiny from legislators and people within the judicial system. Old Dominion University was commissioned to completed a comprehensive study and issued a report on the MHC’s measurable outcomes. Due to this and other studies being conducted across the nation, the Commission was forced to acknowledge the substantially higher rate of access to services, less time spent incarcerated, better collaboration of services, improved mental health and engagement in treatment, and lower recidivism rates that came with the effective use of MHCs. Most important to legislators was the significant savings in jail costs, with $1.63 million being saved during the ODU study period of 18 months in Norfolk’s jurisdiction! One could assume that for this reason alone, more courts would quickly be following in step with Norfolk’s MHC.

money-grow

In 2005, both Richmond City and Petersburg City began to work towards the creation of a MHC through grants and subsidies from the federal government, yet it wasn’t until April/May 2011 that the dockets became active. Even after that long stretch of time to iron out the wrinkles, Richmond City’s docket was met with dissension from within its own judicial ranks. By November 2011, the Virginia Supreme Court issued a memo that stated the creation of any “problem-solving courts” was legislatively unauthorized. The memo sent by Chief Justice Cynthia D. Kinser to over 400 statewide judges, specifically warned that the creation of any specialized docket would need General Assembly approval before being implemented. This one memo created a level of fear in many judges across the state (even those who serve on other specialized dockets like “Drug-Courts”) to temporary suspend services until substantial research and collaboration with the General Assembly could be worked out (and we all know the speed at which the GA works!). Concurrently, Petersburg City was facing additional issues of their own. For example, they recognized that they were missing a critical factor: a position of a coordinator that could work with all of the necessary agencies since there was no precedent for inter-agency collaboration prior to the MHC creation. <Insert eyeroll> Luckily the Cameron Foundation provided funds for the position… for approximately 1 1/2 months! (Le sigh). It was after this rocky start that from a media standpoint, information on Richmond’s and Petersburg’s MHC dissolved into oblivion.

GA

With no general information available on the  interwebs, I was left cold-calling each General District Court for information. Both courts stated that their MH dockets are “active;” however, trying to get more specific information on its use, effectiveness, and evaluation proved almost impossible. After leaving numerous voice mail messages, I finally received a call back from Petersburg’s General District Court clerk’s office. Again, most of my specific questions were met with “Oh geez, I really don’t know,” but I was able to get some generic information. For instance, the process of a defendant’s inclusion on a mental health docket is a little different than in other jurisdictions. Petersburg police officers responding to a call can “fill out a form and report” to submit along with the other charge documents “if it appears that the defendant has a history of mental illness” (Leave it up to untrained and overworked police to fill out a form!?) From there, the paperwork is “routed” to the current Mental Health Docket Coordinator for review (The coordinator has evidently been in flux, because it took 4 attempts to find this person’s name and transfer me to their voice mail). A “through” case review is conducted and eligibility is determined based off of “prior police reports and additional information.” From there, District 19 conducts a mental health exam if one already hasn’t been completed to screen for Axis I diagnoses. (I’ll save my complete and utter disdain for District 19 and their unethical/ineffective services for a later post.)

I don’t think it takes a PhD in research to see the numerous shenanigans of Virginia’s Mental Health Courts. After a rocky start, contempt from naysayers, and general funding and logistical concerns, one can easily see where program access, effectiveness, and outcomes can be called into questions. Even with the totality of these chronic issues, it does not signify a need to scrape the whole idea of mental health courts – as research shows them to be overwhelmingly beneficial to consumers, the judicial system, communities, and tax payers. Instead I believe it shines a spotlight on the necessity to establish funding streams and subsidiaries to encourage the creation of specialized dockets, provide technical assistance  to negotiate inter-agency collaboration and fast-track MHC creation,  and have a regulatory body provide oversight and adherence to evidence-based practices that serve the consumer above all else.

The Band-Aid of a Failed System?

Mental Health Court

“Mental health courts exist because the system has failed.
If these people were being treated,
they wouldn’t end up with misdemeanor charges or
felony charges against them in the first place.
The very existence of mental health courts is really an
indication of the system’s failure.”
– E. Fuller Torrey (psychiatrist/activist)

Mental Illness and the Law: Thursday February 28, 1-2 pm
(Midday on the Law’s Podcast with Judge Gale E. Rasin discussing Baltimore’s “Mental Health Case Management Docket”)

The Bureau of Justice Assistance’s definition of a mental health court:

A mental health court is a specialized court docket for certain defendants with mental illnesses that substitutes a problem-solving model for traditional criminal court processing. Participants are identified through mental health screening and assessments and voluntarily participate in a judicially supervised treatment plan developed jointly by a team of court staff and mental health professionals. Incentives reward adherence to the treatment plan or other court conditions, nonadherence may be sanctioned, and success or graduation is defined according to predetermined criteria.

I believe it is within the very vagueness of this definition that the trouble lies. Each jurisdiction is allowed to establish their own criteria for establishing a mental health court system. For example, some dockets seem largely dedicated to ensuring that criminals are competent enough to stand trial or stay on probation, rather than actually finding necessary treatment for mental disease; whereas, others have expanded that mission, by focusing on assessment, treatment, and reintegration into society. Similarly some dockets across the US have a rather frightening  “forced treatment” feeling, with outlandish sanctions for noncompliance that create dangerous loopholes where defendants have ended up in worse shape then if they never entered the mental health court to begin with.

As you can see, the current status of mental health courts is far from perfect; however, I believe the problems lie more in the lack of appropriate policy, as well as general ignorance of mental illness within our judicial system. A central governing body (state, federal, organizational, anything!) needs to be able provide sound best-practices and oversight in creating, evaluating, and regulating mental health courts to ensure that each one adheres to true evidenced based practices which serve the benefit of the consumer only. Second, we have to also make sure that there is sufficient funding for these specialized dockets (you don’t want me to start ranting on some jurisdictions that only offer dockets if a judge is willing to “donate” their time). Lastly, I believe that our criminal justice system needs to ensure better methods to “funnel” necessary defendants to these specialized dockets to make sure they are being utilized correctly and with the most beneficial acceptance criteria (again, please don’t make me rant about some jurisdictions with eliminating factors like: no violent crimes – no exceptions,  required guilty pleas, no repeat offenders, etc.)

MHC Judge Hug

The organization Mental Health America has made substantial efforts to address these very topics by specifically identifying key aspects that SHOULD be present in all mental health courts (let me stress that ‘should’ word again!)

  1. Comprehensive mental health outreach – Access to community-based mental health treatment services for all people needs to be improved, and should not depend on the existence of mental health courts. Equally effective services should be assured for the treatment needs of persons not accused of crimes. This requires an investment in outreach services to promote voluntary treatment as an essential complement to any mental health court program.
  2. Maximum diversion – Pre-booking diversion should be assured for all persons accused of crimes for whom a voluntary mental health treatment plan is a reasonable alternative to the use of criminal sanctions. Timely and accurate mental health screening and evaluation is the single most critical element in a successful diversion program. Mental health courts may be helpful in assuring such diversion, but should never be the only way, or even the primary way, that it can occur.
  3. Meaningful diversion – Meaningful diversion would require that when appropriate, no charges would be filed, and the individual is diverted directly to treatment without entering the criminal justice system. In the alternative, when charges must be filed, criminal proceedings should be deferred for a set period, usually not exceeding a year. Dismissal of criminal charges would then be guaranteed after a set period of successful treatment participation.
  4. No requirement for a guilty plea – A guilty plea should not be required to enter a mental health court program. This requirement precludes diversion from the criminal justice system at the earliest possible point in time and further criminalizes a person because of his or her mental illnesses. As indicated above, the preferred method is to hold charges in abeyance until the successful completion of the treatment program.
  5. Voluntary/Non-coercive – While the threat of criminal charges influences any decision, participation in any mental health diversion program should involve the same level of voluntary choice required of a criminal plea. No one should have to decide whether or not to accept diversion until the terms and the nature of the proposed treatment plan have been fully discussed and documented.
  6. Least restrictive alternative – All persons participating in diversion programs should be treated in the least restrictive alternative manner available, and all unnecessary institutionalization should be avoided. Jails are generally an inappropriate place for persons waiting for diversion as jail experiences tend to exacerbate underlying symptoms of mental illnesses. Long jail stays should be avoided in all diversion cases.
  7. Right to refuse treatment – The qualified right of a person with mental illness accused of a crime to refuse a particular treatment, including a particular medication, should be protected in a manner at least as protective of the consumer as the civil commitment process. A process should be established to review treatment refusals of persons diverted from the criminal justice system so that any decision to reinstate charges is made in an informed manner after all reasonable alternatives have been exhausted.
  8. Advocate/Counselor – In addition to competent legal counsel in any criminal case, an experienced counselor, who may be a peer or other non-lawyer counselor, independent of any treatment facility, should be available to help the accused person to reach an informed decision. This person should also serve as an advocate to ensure that necessary services that have been mandated as part of a treatment plan are provided in a timely and appropriate manner. MHA affiliates and other consumer advocacy groups may take on this important role.
  9. Confidentiality – Networking to find an appropriate treatment setting, without safeguards, could compromise client confidentiality. Systems must be put in place to ensure confidentiality from the time that a person enters a mental health program.
  10. Cultural and linguistic competence – Cultural and linguistic competence is essential to treatment success. MHA believes that services must be tailored to the specific needs of communities and individuals in order to effectively address public health problems.
  11. Community coalitions – The development of community coalitions, including partnerships between criminal justice, mental health and substance abuse treatment agencies, is essential to successful diversion programs. Such coalitions also should be involved in the creation and oversight of mental health courts. Consumers of mental health services and family members affected by mental illness need to be included in all such coalitions to assure that they address the real barriers to effective mental health treatment in that community.
  12. Comprehensive outreach and training – Community coalitions need to reach out to all criminal justice system personnel and ensure that training is provided at all levels to deal with issues of mental illness, wherever and whenever they occur.
  13. Co-occurring disorders – In addition, persons with co-occurring disorders, and especially substance abuse, must be treated in an integrated way, so that substance abuse is not an impediment to diversion.
  14. Convening role – The focus of mental health courts should be on convening prosecution, probation, treatment and social services agencies to promote interagency collaboration in the interest of the individual. The focus should not be on the use of criminal sanctions to compel treatment.
  15. Consolidation and coordination of cases – Cases should be consolidated to assure that the individual is the focus rather than the case. Centralized, coordinated case management and a single treatment plan are needed to avoid fragmentation, with or without a mental health court.
  16. Handling relapses in the court setting – Relapses are inevitable during the recovery process. As such, an individual’s time under jurisdiction of the mental health court should not be extended as a result of these relapses.
  17. Evaluation – Timely monitoring of court processes, waiting lists, and consumer outcomes are essential to ensure that mental health courts are responding appropriately to persons with mental illness, that waiting lists are kept to a minimum, and that treatment providers are held accountable for consumer outcomes.

Welcome Back to The Dark Ages…

This past week, the nation was shocked to learn of the story of Stephen Slevin.

Slevin

After suffering from years of severe depression, Mr. Slevin (59) awoke one morning and decided to drive cross-country with no set route or destination in mind. On August 24, 2005, he was arrested on aggravated DWI charges and for driving a vehicle that he did not own, which landed him in the Dona Ana County (New Mexico) Detention Center. He was immediately placed naked, with only a suicide smock on, into a padded cell to await processing. Slevin was then moved for 2 weeks of observation before being placed in solitary confinement. For the first three months living in a segregation cell, Slevin was able to write letters; some to his sister and others were sent to his very own jailers politely requesting assistance for medical attention, trouble sleeping, and increasing panic attacks.  Within 3 months of solitary confinement, he became delirious and had profound symptoms of psychosis. Slevin lost the ability for most meaningful communication, was no longer able to write, and spent the entirety of his days rocking back and forth. Initially, he was able to get out of his small cell a few times a month, but he eventually would go for periods up to four months without ever walking out his cell doors. Slevin was given food and medication, but was not bathing, had fungus growing on his skin, developed bedsores, and even had to perform his own tooth extraction due to severe decay.

During May 2007, Slevin was sent to a psychiatric facility for two week where there was drastic improvement in his cognitive and mental functioning due to the proper care, socialization, and medication he was provided. Unfortunately, he was returned to his segregated cell at Dona Ana Detention Center, where he  once again rapidly decompensated. On June 22, 2007, Slevin’s case was finally brought before a judge and was eventually dismissed.

The news story that swept the nation was not the shocking fact that Stephen Slevin spent 22 months in solitary confinement under inhuman conditions; instead, it was headlines of him being awarded $15.5 million in a lawsuit that caught the media’s eye. Slevin, who was recently diagnosed with lung cancer and given 1 year to live, suffers severe post traumatic stress that this windfall of money can only offer minimal relief from.

One has to wonder how many other Stephen Slevins are currently lost in our criminal justice system, not receiving proper care, treatment, or case management? A quick search on the internet yields a startling number of local news stories, blogs, and videos on this very topic. Most of these tend to be “after the fact” stories… like those of Armando Cruz or Tony Lester… who’s suicides could have been prevented with the appropriate mental health care received prior to or during their incarceration.

I am left wondering who is to blame for the downfall of our system? The US is plagued with ineffective policy, legislation, and improper funding towards every aspect of mental health treatment and care; maintains a longstanding stigma on the incarcerated and mentally ill;  supports a broken punitive-based judicial system; and endorses the misguided privatization of our very jails and prisons.  The answer appears to be as vague as the path to fix it, as this has become everyone’s problem – from policy maker, to consumer, to tax payer.

For informational purposes, I’ve decided to include two of my favorite videos on this very matter…

FRONTLINE: The New Asylums (2005)
America’s severely mentally ill, who once would have been in state psychiatric hospitals, are now in state prisons. Why is this happening? And what is mental health care like behind bars? FRONTLINE goes deep inside Ohio’s prison system to examine a troubling and growing issue.
Direct link where additional information and continuous video play pack available HERE.

Fault Lines: Mental Illness in America’s Prisons (2009)
Al Jezeera’s correspondent Josh Rushing goes deep inside one of the largest prison systems in the United States to look at the criminalization of the mentally ill.

There is no single answer that can once again take us back out of the Dark Ages in how we mistreat and subsequently criminalize the mentally ill. But in the coming weeks I look forward to exploring one significant step that we can take as a nation to address our most vulnerable people – the movement towards the creation and regulation of Mental Health Courts throughout all of our federal, state, and local jurisdictions!