mhc essential elements

Improving Responses toPeople with Mental Illnesses

The Essential Elements of aMental Health Court

Improving Responses toPeople with Mental IllnessesThe Essential Elements of aMental Health Court

A report prepared by theCouncil of State Governments Justice CenterCriminal Justice/Mental Health Consensus Project

for the

Bureau of JusticeAssistanceOffice of Justice ProgramsU.S. Department of Justice

Michael ThompsonDr. Fred OsherDeniseTomasini-Joshi

This report was prepared by the Council of State Governments Justice Center, which coordinates the Criminal Justice/Mental

Health Consensus Project. It was completed under cooperative agreement 2005-MU-BX-K007 awarded by the Bureau of Justice

Assistance (BJA), Office of Justice Programs, U.S. Department of Justice. The opinions and findings in this document do not

necessarily represent the official position or policies of the U.S. Department of Justice or the members of the Council of State

Governments. While every effort was made to reach consensus and represent advisory groupmembers’ and other reviewers’

recommendations, individual opinions may differ from the statements made in the document.

The Bureau of JusticeAssistance reserves the right to reproduce, publish, translate, or otherwise use and to authorize others to

publish and use all or any part of the copyrighted material contained in this publication.

Council of State Governments Justice Center, New York 10005

© 2007 by the Council of State Governments Justice Center

All rights reserved. Published 2007.

Cover design by Nancy Kapp & Company. Interior design by David Williams.

iv Improving Responses to People with Mental Illnesses

vThe Essential Elements of a Mental Health Court

Many thanks are due to all those at the Bureau ofJustice Assistance (BJA), a component of the Officeof Justice Programs, U.S. Department of Justice,who supported the development of this publication,particularly Domingo S. Herraiz, Director; A. Eliza-beth Griffith, Deputy Director for Planning; RobertHendricks, former Acting Senior Policy Advisor forMental Health; Michael Guerriere, former SeniorPolicy Advisor for Substance Abuse and MentalHealth; Ruby Qazilbash, Senior Policy Advisor forSubstance Abuse and Mental Health; and RebeccaRose, Policy Advisor for Substance Abuse and Men-tal Health.

Special thanks must also be given to theNational Drug Court Institute (NDCI), particularlyKaren Freeman-Wilson, West Huddleston, and Car-son Fox, for their guidance on how this publicationcould benefit from, and integrate, their experiencesdeveloping the seminal publication Defining DrugCourts: The Key Components.

Representatives of the sites awarded grantsunder BJA’s Mental Health Court Grant Programspent considerable time at a national conferencein Cincinnati in 2004 providing valuable feedback toa draft of Essential Elements. The Council of State

Governments Justice Center thanks them, as well asa group of leading mental health court experts whospent a full day at BJA’s conference Mental HealthCourts and Beyond in 2005 in Los Angeles to provideextensive comments on a subsequent draft of thedocument. In addition, representatives of BJA’s Men-tal Health Court Learning Sites added importantinformation throughout the review process.

A number of current and former JusticeCenter staff members were key contributors tothe document, including director of communica-tions Martha Plotkin, research associate LaurenAlmquist, and project coordinator DanielSouweine. The project also benefited greatly fromthe advice of Justice Center consultants Barry Ma-honey, President Emeritus of the Justice Manage-ment Institute, D. Alan Henry, Director Emeritus ofthe Pretrial Justice Institute, and Timothy Murray,Executive Director of the Pretrial Justice Institute.

Finally, Justice Center staff express their grati-tude to the hundreds of contributors who reviewedonline drafts. Through a web forum, these respon-dents provided valuable comments and offeredinsights and suggestions that made Essential Ele-ments a stronger, more practical resource.

Acknowledgments

vi Improving Responses to People with Mental Illnesses

viiThe Essential Elements of a Mental Health Court

Mental health courts are a recent and rapidlyexpanding phenomenon. In the late 1990s only afew such courts were accepting cases. Since then,more than 150 others have been established, anddozens more are being planned. Although earlycommentary on these courts emphasized their dif-ferences—and their diversity is undeniable—the similarities across mental health courts arebecoming increasingly apparent. In fact, the vastmajority of mental health courts share the followingcharacteristics:

• A specialized court docket, which employs aproblem-solving approach to court processing inlieu of more traditional court procedures for cer-tain defendants with mental illnesses

• Judicially supervised, community-based treat-ment plans for each defendant participating inthe court, which a team of court staff and mentalhealth professionals design and implement

• Regular status hearings at which treatmentplans and other conditions are periodicallyreviewed for appropriateness, incentives areoffered to reward adherence to court conditions,and sanctions are imposed on participants whodo not adhere to the conditions of participation

• Criteria defining a participant’s completion of(sometimes called graduation from) the program

The reasons communities give for establishingmental health courts are also remarkably consis-tent: to increase public safety, facilitate participationin effective mental health and substance abusetreatment, improve the quality of life for people

with mental illnesses charged with crimes, andmake more effective use of limited criminal justiceand mental health resources.

As the commonalities among mental healthcourts begin to emerge, practitioners, policymakers,researchers, and others have become interested indeveloping consensus not only on what a mentalhealth court is, but on what a mental health courtshould be. The purpose of this document is to articulatesuch consensus in the form of 10 essential elements.

About the Elements

This publication identifies 10 essential elements ofmental health court design and implementation.1

Each element contains a short statement describingcriteria mental health courts should meet, followedby several paragraphs explaining why the element isimportant and how courts can adhere to it. Ulti-mately, benchmarks will be added, enabling courtsto better assess their fidelity to each element.

Although both adult and juvenile mentalhealth courts have emerged in recent years, thispublication pertains only to adult mental healthcourts. There are two primary reasons for thisfocus. First, as of this writing, there are only a hand-ful of mental health courts targeting juveniles. Sec-ond, the significant differences between theprovision of mental health and criminal justiceservices for juveniles and that for adults makes itdifficult to develop a document that encompassesboth populations.

Just as the success of local drug courtsprompted the development of many mental health

Introduction

1. Essential Elements was developed as part of a technical assistanceprogram provided by the Council of State Governments (CSG) Jus-tice Center through the Bureau of Justice Assistance (BJA) MentalHealth Courts Program. The BJA Mental Health Courts Program,which was authorized by America’s Law Enforcement and MentalHealth Project (Public Law 106-515), provided grants to support the

development of mental health courts in 23 jurisdictions in FY 2002and 14 jurisdictions in FY 2003. The Justice Center currently pro-vides technical assistance to the grantees of BJA’s Justice and Men-tal Health Collaboration Program, the successor to the MentalHealth Courts Program.

viii Improving Responses to People with Mental Illnesses

courts, Defining Drug Courts: The Key Components, a1997 publication of the U.S. Department of Justice,inspired this document. Although there are signifi-cant differences between drug courts and mentalhealth courts, the Key Components document pro-vided the foundation in format and content forEssential Elements.

Two key principles underlie the 10 essentialelements. First, at the heart of each element is col-laboration among the criminal justice, mentalhealth, substance abuse treatment, and related sys-tems. True cross-system collaboration is necessaryto realize any of these elements and, for that matter,to successfully operate a mental health court. It isgenerally accepted that achieving this type of collab-oration is difficult, particularly in regard to breakingdown institutional barriers and eschewing theadversarial process. Second, the elements makeclear, both explicitly and implicitly, that mentalhealth courts are not a panacea. Reversing the over-representation of people with mental illnesses inthe criminal justice system requires a comprehen-sive strategy of which mental health courts shouldbe just one piece.

Though these elements are drawn in large partfrom the experience of existing courts, they are notresearch-based. Only a few studies have been com-pleted, though more are underway, to better under-stand the operation and impact of mental healthcourts. Proponents of mental health courts hopethat these investigations will substantiate the rela-tive importance of different elements for courtfunctioning and client outcomes. In the meantime,these elements should prove useful for communi-ties interested in developing a mental health courtor reviewing the organization and functions of anexisting court program.

The elements described in this document willnot be present in every mental health court. When

the elements are present, they will manifest differ-ently across jurisdictions. In addition, some mentalhealth court practitioners may disagree with someof the statements below, identify elements that maybe missing, or argue that some of these elementsare unrealistic. This debate will drive strongerefforts in the field and maximize the effectivenessof America’s mental health courts.

Because mental health courts will continue tomature and new research will become available,changes to this publication are inevitable. EssentialElements will periodically be updated to reflect inno-vative thinking from the field and to include thebenchmarks that mental health court administra-tors can use to assess their progress in implement-ing the essential elements in their courts.

Methodology

The essential elements are culled from a variety ofsources, including interviews with former BJA Men-tal Health Courts Program (MHCP) grantees, on-sitevisits to grantee and non-grantee mental healthcourts, and a review of the scholarly literature.2 Anoriginal draft of the elements document was preparedfor the 2004 BJA MHCP conference. Commentsfrom the conference attendees were incorporated intoa second draft, which served as sourcematerial for theGuide to Mental Health Court Design and Implementa-tion, a BJA-sponsored publication.

This latest version was informed by commentsfrom the field transmitted through a well-publicizedweb-based discussion forum. A group of practition-ers and experts reviewed and discussed these com-ments and suggested revisions to the draft. Thisversion incorporates those suggestions.

2. The first major investigation of mental health courts was “Emerg-ing Judicial Strategies for the Mentally Ill in the Criminal Caseload:Mental Health Courts in Fort Lauderdale, Seattle, San Bernardino,and Anchorage,” by John Goldkamp and Cheryl Irons-Guynn, April2000. Since then, several studies about mental health courts havebeen published, including the BJA-sponsored report entitled Guide

to Mental Health Court Design and Implementation, July 2005, andthe Rand study Justice, Treatment, and Cost: An Evaluation of theFiscal Impact of Allegheny County Mental Health Court, March 2007.Readers interested in these and other resources related to mentalhealth courts should visit www.consensusproject.org/mhcourts.

1The Essential Elements of a Mental Health Court

Mental health courts are situated at the intersectionof the criminal justice, mental health, substanceabuse treatment, and other social service systems.Their planning and administration should reflectextensive collaboration among practitioners andpolicymakers from those systems, as well as com-munity members. To that end, a multidisciplinary“planning committee” should be charged withdesigning the mental health court. Along withdetermining eligibility criteria, monitoring mecha-nisms, and other court processes, this committeeshould articulate clear, specific, and realizable goalsthat reflect agreement on the court’s purposes andprovide a foundation for measuring the court’simpact (see Element 10: Sustainability).

Ideally, the development of a mental healthcourt should take place in the context of broaderefforts to improve the response to people with men-tal illnesses involved with, or at risk of involvementwith, law enforcement, the courts, and corrections.Such discussions should include police and sher-iffs’ officials, judges, prosecutors, defense counsel,court administrators, pretrial services staff, and cor-rections officials; mental health, substance abusetreatment, housing, and other service providers;and mental health advocates, crime victims, con-sumers, and family and community members.

The planning committee should identify agencyleaders and policymakers to serve on an “advisorygroup” (in some jurisdictions members of the advi-sory group will also make up the planning commit-tee), responsible for monitoring the court’sadherence to its mission and its coordination withrelevant activities across the criminal justice andmental health systems. The advisory group shouldsuggest revisions to court policies and procedureswhen appropriate, and should be the public face ofthe mental health court in advocating for its support.The planning committee should address ongoingissues of policy implementation and practice thatthe court’s operation raises. Committee membersshould also keep high-level policymakers, includingthose on the advisory group, informed of the court’ssuccesses and failures in promoting positive changeand long-term sustainability (see Element 10). Addi-tionally, by facilitating ongoing training and educa-tion opportunities, the planning committee shouldcomplement and support the small team of profes-sionals who administer the court on a daily basis,the “court team” (see Element 8).

In many jurisdictions, the judiciary will ulti-mately drive the design and administration of themental health court. Accordingly, it should be wellrepresented on and take a visible role in leadingboth the planning committee and advisory group.

planning and administrationA broad-based group of stakeholders representing the criminal justice, mental health,substance abuse treatment, and related systems and the community guides the planningand administration of the court.

1Ten Essential Elements

2 Improving Responses to People with Mental Illnesses

Because mental health courts are, by definition,specialized interventions that can serve only a por-tion of defendants with mental illness, carefulattention should be paid to determining their targetpopulations.

Mental health courts should be conceptualizedas part of a comprehensive strategy to provide lawenforcement, court, and corrections systems withoptions, other than arrest and detention, forresponding to people with mental illnesses. Suchoptions include specialized police-based responsesand pretrial services programs. For those individualswho are not diverted from arrest or pretrial deten-tion, mental health courts can provide appropriatelyidentified defendants with court-ordered, commu-nity-based supervision and services. Mental healthcourts should be closely coordinated with other spe-cialty or problem-solving court-based interventions,

including drug courts and community courts, as tar-get populations are likely to overlap.

Clinical eligibility criteria should be welldefined and should be developed with an under-standing of treatment capacity in the community.Mental health court personnel should explore waysto improve the accessibility of community-basedcare when treatment capacity is limited and shouldexplore ways to improve quality of care when serv-ices appear ineffective (see Element 6: TreatmentSupports and Services).

Mental health courts should also focus ondefendants whose mental illness is related to theircurrent offenses. To that end, the planning commit-tee should develop a process or a mechanism,informed by mental health professionals, to enablestaff charged with identifying mental health courtparticipants to make this determination.

target populationEligibility criteria address public safety and consider a community’s treatment capacity, inaddition to the availability of alternatives to pretrial detention for defendants with mentalillnesses. Eligibility criteria also take into account the relationship between mental illness and adefendant’s offenses, while allowing the individual circumstances of each case to be considered.

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Providing safe and effective treatment and supervi-sion to eligible defendants in the community, asopposed to in jail or prison, is one of the principalpurposes of mental health courts. Prompt identifi-cation of participants accelerates their return to thecommunity and decreases the burden on the crimi-nal justice system for incarceration and treatment.

Mental health courts should identify potentialparticipants early in the criminal justice process bywelcoming referrals from an array of sources suchas law enforcement officers, jail and pretrial serv-ices staff, defense counsel, judges, and family mem-bers. To ensure accurate referrals, mental healthcourts must advertise eligibility criteria and activelyeducate these potential sources. In addition to creat-ing a broad network for identifying possible partici-pants, mental health courts should select one or twoagencies to be primary referral sources that areespecially well versed in the procedures and criteria.

The prosecutor, defense counsel, and alicensed clinician should quickly review referralsfor eligibility. When competency determination is

necessary, it should be expedited, especially fordefendants charged with misdemeanors. The timerequired to accept someone into the programshould not exceed the length of the sentence thatthe defendant would have received had he or shepursued the traditional court process. Final deter-mination of eligibility should be a team decision(see Element 8: Court Team).

The time needed to identify appropriate serv-ices, the availability of which may be beyond thecourt’s control, may constrain efforts to identify par-ticipants rapidly (see Element 6: Treatment Sup-ports and Services). This is likely to be an issueespecially in felony cases, when the court may seekservices of a particular intensity to maximize publicsafety. Accordingly, along with connecting mentalhealth court participants to existing treatment, offi-cials in criminal justice, mental health, and sub-stance abuse treatment should work together toimprove the quality and expand the quantity ofavailable services.

timely participant identificationand linkage to servicesParticipants are identified, referred, and accepted into mental health courts, and then linked tocommunity-based service providers as quickly as possible.

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Mental health courts need general program param-eters for plea agreements, program duration, super-vision conditions, and the impact of programcompletion. Within these parameters, the terms ofparticipation should be individualized to eachdefendant and should be put in writing prior to hisor her decision to enter the program. The terms ofparticipation will likely require adherence to a treat-ment plan that will be developed after engagementwith the mental health court program, and defen-dants should be made aware of the consequences ofnoncompliance with this plan.

Whenever plea agreements are offered to peo-ple invited to participate in a mental health court,the potential effects of a criminal conviction shouldbe explained. Collateral consequences of a criminalconviction may include limited housing options,opportunities for employment, and accessibility tosome treatment programs. It is especially importantthat the defendant be made aware of these conse-quences when the only charge he or she is facing isa misdemeanor, ordinance offense, or other non-violent crime.

The length of mental health court participationshould not extend beyond the maximum period ofincarceration or probation a defendant could havereceived if found guilty in a more traditional court

process. In addition, program duration should varydepending on a defendant’s program progress. Pro-gram completion should be tied to adherence to theparticipant’s court-ordered conditions and thestrength of his or her connection to communitytreatment.

Least restrictive supervision conditions shouldbe considered for all participants, especially thosecharged with misdemeanors. Highly restrictive con-ditions increase the likelihood that minor violationswill occur, which can intensify the involvement ofparticipants in the criminal justice system.

When a mental health court participant com-pletes the terms of his or her participation in theprogram, there should be some positive legal out-come. When the court operates on a pre-plea model,a significant reduction or dismissal of charges canbe considered. When the court operates in a post-plea model, a number of outcomes are possiblesuch as early terminations of supervision, vacatedpleas, and lifted fines and fees. Mental health courtparticipants, when in compliance with the terms oftheir participation, should have the option to with-draw from the program at any point without havingtheir prior participation and subsequent withdrawalfrom the mental health court reflect negatively ontheir criminal case.

terms of participationTerms of participation are clear, promote public safety, facilitate the defendant’s engagement intreatment, are individualized to correspond to the level of risk that the defendant presents to thecommunity, and provide for positive legal outcomes for those individuals who successfullycomplete the program.

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Defendants’ participation in mental health courts isvoluntary. But ensuring that participants’ choicesare informed, both before and during the program,requires more than simply offering the mentalhealth court as an option to certain defendants.

Mental health court administrators should beconfident that prospective participants are compe-tent to participate. Typically, competency determina-tion procedures can be lengthy, which raiseschallenges for timely participant identification. Thisis especially important for courts that focus ondefendants charged with misdemeanors (see Ele-ment 3: Timely Participant Identification and Link-age to Services). For these reasons, as part of theplanning process, courts should develop guidelinesfor the identification and expeditious resolution ofcompetency concerns.

Even when competency is not an issue, mentalhealth court staff must ensure that defendants fullyunderstand the terms of participation, includingthe legal repercussions of not adhering to programconditions. The specific terms that apply to each

defendant should be spelled out in writing. Defen-dants should have the opportunity to review theseterms, with the advice of counsel, before opting intothe court.

Defense attorneys play an integral role in help-ing to ensure that defendants’ choices are informedthroughout their involvement in the mental healthcourt. Admittedly, the availability of defense counselvaries from one jurisdiction to another. In some com-munities, defendants’ access to counsel depends onthe crime with which they were charged or the pur-pose of the hearing. Recognizing these constraints,courts should strive to make defense counsel avail-able to advise defendants about their decision toenter the court and have counsel be present at statushearings. It is particularly important to ensure thepresence of counsel when there is a risk of sanctionsor dismissal from the mental health court. Defensecounsel participating in mental health courts—likeall other criminal justice staff assigned to the court—should receive special training in mental healthissues (see Element 8: Court Team).

informed choiceDefendants fully understand the program requirements before agreeing to participate in a mentalhealth court. They are provided legal counsel to inform this decision and subsequent decisionsabout program involvement. Procedures exist in the mental health court to address, in a timelyfashion, concerns about a defendant’s competency whenever they arise.

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3. Evidence-based practices (EBPs) are mental health service interven-tions for which consistent scientific evidence demonstrates their abil-ity to improve consumer outcomes. R.E. Drake, et al., “ImplementingEvidence-Based Practices in Routine Mental Health Service Settings,”Psychiatric Services 52 (2001): 179–182. Other EBPs include assertivecommunity treatment, psychotropic medications, supported employ-ment, family psychoeducation, and illness self-management.

4. The term “case management” has multiple definitions. Moreover,specific interventions such as assertive community treatment(ACT) and intensive case management (ICM) are themselves casemanagement models. According to the Substance Abuse and Men-tal Health Services Administration (SAMHSA) “any definition ofcase management today is inevitably contextual, based on the needsof a particular organizational structure, environmental reality, and

prior training of the individuals who are implementing it, whetherthey are social workers, nurses, or case management specialists”(see SAMHSA’s Treatment Improvement Protocol [TIP] #27, “CaseManagement for Substance Abuse Treatment”). The definition of aparticular case management approach can be derived from its func-tions and objectives. Case management functions include assess-ing, planning, linking, coordinating, monitoring, and advocating.For example, the Office of Juvenile Justice and Delinquency Preven-tion (OJJDP) of the U.S. Department of Justice in its publicationDrug Identification and Testing in the Juvenile Justice System, definescase management as “an individualized plan for securing, coordi-nating, and monitoring the appropriate treatment interventions andancillary services necessary to treat each offender successfully foroptimal justice system outcomes.”

Mental health court participants require an array ofservices and supports, which can includemedications,counseling, substance abuse treatment, benefits,housing, crisis interventions services, peer supports,and case management. Mental health courts shouldanticipate the treatment needs of their target popula-tion and work with providers to ensure that serviceswill be made available to court participants.

When a participant is identified and linked to aservice provider, the mental health court teamshould design a treatment plan that takes intoaccount the results of a complete mental health andsubstance abuse assessment, individual consumerneeds, and public safety concerns. Participantsshould also have input into their treatment plans.

A large proportion of mental health court par-ticipants have co-occurring substance abuse disor-ders. The most effective programs providecoordinated treatment for both mental illnesses andsubstance abuse problems. Thus, mental healthcourts should connect participants with co-occur-ring disorders to integrated treatment wheneverpossible and advocate for the expanded availability ofintegrated treatment and other evidence-based prac-tices.3 Mental health court teams should also payspecial attention to the needs of women and ethnicminorities and make gender-sensitive and culturallycompetent services available.

Treatment providers should remain in regularcommunication with court staff concerning theappropriateness of the treatment plan and shouldsuggest adjustments to the plan when appropriate.At the same time, court staff should check withcommunity-based treatment providers periodicallyto determine the extent to which they are encoun-tering challenges stemming from the court’s super-vision of the participant.

Case management is essential to connect par-ticipants to services and monitor their compliancewith court conditions.4 Case managers—whetherthey are employees of the court, treatmentproviders, or community corrections officers—should have caseloads that are sufficiently manage-able to perform core functions and monitor theoverall conditions of participation. They shouldserve as the conduits of information for the courtabout the status of treatment and support services.

Case managers also help participants preparefor their transition out of the court program byensuring that needed treatment and services willremain available and accessible after their courtsupervision concludes. The mental health courtmay also provide post-program assistance, such asgraduate support groups, to prevent participants’relapses.

treatment supports and servicesMental health courts connect participants to comprehensive and individualized treatmentsupports and services in the community.They strive to use—and increase the availability of—treatment and services that are evidence-based.

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5. For information on complying with the Health Insurance Portabil-ity and Accountability Act (HIPAA), please visit SAMHSA’s Website at www.hipaa.samhsa.gov/hipaa.html.

To identify and supervise participants, mentalhealth courts require information about their men-tal illnesses and treatment plans. When sharing thisinformation, treatment providers and representa-tives of the mental health court should consider thewishes of defendants. They must also adhere to fed-eral and state laws that protect the confidentiality ofmedical, mental health, and substance abuse treat-ment records.

A well-designed procedure governing therelease and exchange of information is essential tofacilitating appropriate communication amongmembers of the mental health court team and toprotect confidentiality. Release forms should be partof this procedure. They should be developed in con-sultation with legal counsel, adhere to federal andstate laws, and specify what information will bereleased and to whom.5 Potential participantsshould be allowed to review the form with theadvice of defense counsel and treatment providers.Defendants should not be asked to sign release ofinformation forms until competency issues havebeen resolved (see Element 5: Informed Choice).

When a defendant is being considered for themental health court, there should not be any public

discussions about that person’s mental illness,which can stigmatize the defendant. Even informa-tion concerning a defendant’s referral to a mentalhealth court should be closely guarded—particu-larly because many of these individuals may laterchoose not to participate in the mental health court.To minimize the likelihood that information aboutdefendants’ mental illnesses or their referral to themental health court will negatively affect their crim-inal cases, courts whenever possible should main-tain clinical documents separately from thecriminal files and take other precautions to preventmedical information from becoming part of thepublic record.

Once a defendant is under the mental healthcourt’s supervision, steps should be taken to main-tain the privacy of treatment information through-out his or her tenure in the program. Clinicalinformation provided to mental health court staffmembers should be limited to whatever they needto make decisions. Furthermore, such exchangesshould be conducted in closed staff meetings; dis-cussion of clinical information in open court shouldbe avoided.

confidentialityHealth and legal information should be shared in a way that protects potential participants’confidentiality rights as mental health consumers and their constitutional rights as defendants.Information gathered as part of the participants’ court-ordered treatment program or servicesshould be safeguarded in the event that participants are returned to traditional court processing.

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The mental health court team works collaborativelyto help participants achieve treatment goals by bring-ing together staff from the agencies with a direct rolein the participants’ entrance into, and progressthrough, the court program. The court team func-tions include conducting screenings, assessments,and enrollments of referred defendants; definingterms of participation; partnering with communityproviders; monitoring participant adherence toterms; preparing for all court appearances; and devel-oping transition plans following court supervision.Teammembers should work together on each partic-ipant’s case and contribute to the court’s administra-tion to ensure its smooth functioning.

The composition of this court team differsacross jurisdictions. These variations notwithstand-ing, it typically should comprise the following: ajudicial officer; a treatment provider or case man-ager; a prosecutor; a defense attorney; and, in somecases, a court supervision agent such as a probationofficer. Many courts also employ a court coordinatorresponsible for overall administration of the court,which can help promote communication, efficiency,and sustainability. Regardless of the composition ofthe team, the judge’s role is central to the success ofthe mental health court team and the mental healthcourt generally. He or she oversees the work of themental health court team and encourages collabora-tion among its members, who must work togetherto inform the judge about whether participants areadhering to their terms of participation.

Mental health court planners should carefullyselect team members who are willing to adapt to anontraditional setting and rethink core aspects oftheir professional training. Planners should seekcriminal justice personnel with expertise or interestin mental health issues and mental health staff withcriminal justice experience. Planners should alsowork to ensure that the judge who will preside overthe mental health court is comfortable with its goalsand procedures.

Team members should take part in cross-train-ing before the court is launched and during its oper-ation. Mental health professionals must familiarizethemselves with legal terminology and the work-ings of the criminal justice system, just as criminaljustice personnel must learn about treatment prac-tices and protocols. Team members should also beoffered the opportunity to attend regional ornational training sessions and view the operationsof other mental health courts. New team membersshould go through a period of training and orienta-tion before engaging fully with the court.

Periodic review and revision of court processesmust be a core responsibility of the court team.Using data, participant feedback, observations ofteam members, and direction from the advisorygroup and planning committee (see Element 1), thecourt team should routinely make improvements tothe court’s operation.

court teamA team of criminal justice and mental health staff and service and treatment providers receivesspecial, ongoing training and helps mental health court participants achieve treatment andcriminal justice goals by regularly reviewing and revising the court process.

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Whether a mental health court assigns responsibil-ity for monitoring compliance with court conditionsto a criminal justice agency, a mental health agency,or a combination of these organizations, collabora-tion and communication are essential. The courtmust have up-to-date information on whether partic-ipants are taking medications, attending treatmentsessions, abstaining from drugs and alcohol, andadhering to other supervision conditions. This infor-mation will come from a variety of sources and mustbe integrated routinely into one coherent presenta-tion or report to keep all court staff informed of par-ticipants’ progress. Case staffing meetings providesuch an opportunity to share information and deter-mine responses to individuals’ positive and negativebehaviors. These meetings should happen regularlyand involve key members of a team, including,when appropriate, representatives from the prosecu-tion, defense, treatment providers, court supervisionagency, and the judiciary.

Status hearings allow mental health courtspublicly to reward adherence to conditions of partic-ipation, to sanction nonadherence, and to ensureongoing interaction between the participant and thecourt team members. These hearings should be fre-quent at the outset of the program and shoulddecrease as participants progress positively.

All responses to participants’ behavior, whetherpositive or negative, should be individualized.Incentives, sanctions, and treatment modificationshave clinical implications. They should be imposedwith great care and with input from mental healthprofessionals.

Relapse is a common aspect of recovery; non-adherence to conditions of participation in the court

is common. But nonadherence should never beignored. The first response should be to reviewtreatment plans, including medications, living situ-ations, and other service needs. For minor viola-tions the most appropriate response may be amodification of the treatment plan.

In some cases, sanctions are necessary. Themanner in which a mental health court appliessanctions should be explained to participants priorto their admittance to the program. As a partici-pant's commission of violations increases in fre-quency or severity, the court should use graduatedsanctions that are individualized to maximizeadherence to his or her conditions of release. Spe-cific protocols should govern the use of jail as a con-sequence for serious noncompliance.

Mental health courts should use incentives torecognize good behavior and to encourage recoverythrough further behavior modification. Individualpraise and rewards, such as coupons, certificates forcompleting phases of the program, and decreasedfrequency of court appearances, are helpful andimportant incentives. Systematic incentives thattrack the participants’ progress through distinctphases of the court program are also critical. As par-ticipants complete these phases, they receive publicrecognition.

Courts should have at their disposal a menu ofincentives that is at least as broad as the range ofavailable sanctions; incentives for sustained adher-ence to court conditions, or for situations in whichthe participant exceeds the expectation of the courtteam, are particularly important.

monitoring adherence tocourt requirementsCriminal justice and mental health staff collaboratively monitor participants’ adherence to courtconditions, offer individualized graduated incentives and sanctions, and modify treatment asnecessary to promote public safety and participants’ recovery.

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10Mental health courts must take steps early in theplanning process and throughout their existence toensure long-term sustainability. To this end, per-formance measures and outcome data will beessential. Data describing the court’s impact onindividuals and systems should be collected andanalyzed. Such data should include the court’s out-puts, such as number of defendants screened andaccepted into the mental health court, as well as itsoutcomes, such as the number of participants whoare rearrested and reincarcerated. Setting outputand outcome measures are a key function of thecourt’s planning and ongoing administration (seeElement 1).6 Quantitative data should be comple-mented with qualitative evaluations of the programfrom staff and participants.

Formalizing court policies and procedures isalso an important component of maintaining men-tal health court operations. Compiling informationabout a court’s history, goals, eligibility criteria,information-sharing protocols, referral and screen-ing procedures, treatment resources, sanctions andincentives, and other program components helpsensure consistency and lessens the impact whenkey team members depart. Developing additional

plans for staff turnover helps safeguard the integrityof the court’s operation.

Because sustaining a mental health court with-out funding is difficult, court planners should iden-tify and cultivate long-term funding sources earlyon. Court staff should base requests for long-termfunding on clear articulations of what the courtplans to accomplish. Along with compiling empiri-cal evidence of program successes, mental healthcourt teams should invite key county officials, statelegislators, foundation program officers, and otherpolicymakers to witness the court in action.

Outreach to the community, the media, andkey criminal justice and mental health officials alsopromotes sustainability. To that end, mental healthcourt teams should make community membersaware of the existence and impact of the mentalhealth court and the progress it has made. Moreimportant, administrators should be prepared torespond to notable program failures, such as whena participant commits a serious crime. Ongoingguidance from, and reporting to, key criminal jus-tice and mental health leaders also helps to main-tain interest in, and support for, the mental healthcourt.

sustainabilityData are collected and analyzed to demonstrate the impact of the mental healthcourt, its performance is assessed periodically (and procedures are modifiedaccordingly), court processes are institutionalized, and support for the court inthe community is cultivated and expanded.

6. The next edition of this document will include benchmarks thatwill help courts determine whether this is taking place in theirjurisdictions. For guidance on collecting outcome data, please seeHenry J. Steadman, A Guide to Collecting Mental Health Court

Outcome Data, May 2005, published by the CSG Justice Centerand available at www.consensusproject.org/mhcourts/MHC-Outcome-Data.pdf.


In courtrooms across the country, judges, prosecu-tors, and defense attorneys are seeing increasingnumbers of defendants who have serious untreatedmental illnesses charged with committing low-levelcrimes. Traditional court processes do little toimprove outcomes for many of these people. Theycycle again and again through jail, courtrooms, andour city streets.

As an alternative to the status quo, court offi-cials, working in partnership with leaders in themental health system and local and state policy-makers, have designed problem-solving mentalhealth courts. These courts depart from the tradi-tional model used in most criminal proceedings.Instead, as a team and under the judge’s guidance,prosecutors, defense attorneys, and mental healthservice providers connect eligible defendants withcommunity-based mental health treatment and, inlieu of incarceration, assign them to community-based supervision.

The number of mental health courts in theUnited States has grown significantly. These pro-grams share much in common from one county toanother. There are also aspects of each mentalhealth court’s design and operation that are unique,

as variation is the hallmark of this country’s crimi-nal justice system, and one of its strengths. At thesame time, experts in criminal justice and mentalhealth practice agree that there are essential ele-ments to mental health courts, which enable themto span both the criminal justice and mental healthsystems effectively and to ensure that the rights ofparticipants and community members arerespected. This publication describes and explainsthese essential elements of a mental health court.

To design and implement a mental health courtwith attention to each of these elements is a chal-lenge for those just starting a conversation about apossible mental health court, as well as for thosewho have operated a mental health court for years.Yet seasoned and new mental health court teamsalike have demonstrated a willingness to addresssuch complicated challenges. The essential ele-ments described in this document are written forthem and others following in their footsteps, all ofwhom work tirelessly to make communities health-ier and safer, promote the efficient use of publicresources and tax dollars, and improve outcomesfor people with mental illnesses who are involved inthe criminal justice system.

Conclusion

The Bureau of Justice Assistance, Office of Justice Programs,U.S. Department of Justice, provides leadership training, techni-cal assistance, and information to local criminal justice agenciesto makeAmerica’s communities safer. Readmore atwww.ojp.usdoj.gov/BJA/.

The Council of State Governments (CSG) Justice Center is anational nonprofit organization serving policymakers at thelocal, state, and federal levels from all branches of government.The CSG Justice Center provides practical, nonpartisan adviceand consensus-driven strategies, informed by available evidence,to increase public safety and strengthen communities. Readmore at www.justicecenter.csg.org.

The Criminal Justice/Mental Health Consensus Project is anunprecedented national effort coordinated by the CSG JusticeCenter to improve responses to people with mental illnesses whobecome involved in, or are at risk of involvement in, the criminaljustice system. Readmore at www.consensusproject.org.

Council of State GovernmentsJustice Center

www.justicecenter.csg.org

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mhc essential elements

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