Mental Health Courts: Does Coercion Add Anything of Value to Treatment?

Mental health courts are America’s sad, broken way of dealing with people who have mental illness — who also happen to have committed a crime. Even something as small as a misdemeanor. I mean, what better way to treat a person’s mental illness than to send them to a court tailored for their mental health needs?

The truth is that if a person is receiving adequate care in the community through the public mental health system, there’d likely be far fewer people who get involved in criminal justice system to begin with. People with mental illness get involved in the court system for a wide variety of reasons (psychosis, drugs, mania, etc.). Such involvement is usually just a side effect of a person who isn’t getting any kind of decent treatment.

So do mental health courts work? Or could you offer the same services to people without the coercion and get similar results? The long-term data is in.

Two studies published in the April 2016 issue of Psychiatric Services help provide some insight into this question.

The first study (Hiday et al., 2016) examined the two-year recidivism rate between two groups of people — those who went through the mental health court (MHC) system, and those who went through the traditional criminal court (TCC) system. Both groups received a similar set of supervision, case management, and pre-trial services from the exact same community agencies setup to help people. These services included treatment for participants with a co-occurring mental and substance use disorder.

While we might consider the TCC group “treatment as usual” (compared to the “active treatment” MHC group), this TCC group actually received a lot of mental health services that aren’t typically given to criminals. The only real difference between the two groups is that the MHC group stood in front of a judge and agreed to the “voluntary” coerced treatment of the MHC, while the TCC group did not. If you do not follow the MHC mandates you agreed to, you face going back into the regular system.

The researchers started out with 238 people who completed the MHC program and 170 (actually, 210, but the researchers claim the lower number¹ who didn’t (out of 448 MHC participants). So already see the first problem with the MHC program — nearly half of people don’t make it through.

The MHC participants also look different than the TCC folks — they had statistically fewer arrests before going into the program. So it’s not surprising to find their re-arrest rate also ends lower than those folks in the TCC group.

Noncompleters Worse than TCC Group Members

But here’s the real kicker and a good reason to argue against mental health courts. Remember that nearly half of the MHC participants don’t complete the program? The researchers found this group of people actually had the highest re-arrest rate — significantly higher than even the TCC group (55 percent compared to 48 percent).

Sure, the completers in the MHC group had the lowest re-arrest rate — 25 percent — which is nearly half of the TCC group. But why would people who received a “partial dose” of the MHC treatment program do so much worse than the TCC group? This was a novel finding not predicted by the researchers.

Likely it has to do with the coercive and paternalistic nature of mental health courts. While folks’ hearts are in the right place to offer this sort of “treatment” to people, it’s clear that there’s a double-edged sword in using coercion in this manner. It works great for most people but backfires for the other half.

Both Groups Improved in Recidivism

Both MHC and TCC groups had fewer re-arrests at the two-year followup. But the difference in the TCC group was even greater than that of the MHC group when considered as a whole (both completers and noncompleters). When only the completers are considered, only then does the MHC group shine — just slightly better than the TCC “treatment as usual” group.

This is one of the few, well-designed long-term studies to look at mental health courts. And quite frankly, its results suggest that mental health courts are not the magic pill so many people believe them to be. Instead, it looks like simply offering people the kinds of resources and services they should be getting anyway is the real difference here.

Another Study Shows It’s the Services, Not the Coercion

Another study in the same issue (Han & Redlich, 2016) comes to similar conclusions between two groups of people — those who received treatment as usual, and those who went through a mental health court. What did they find?

We found that both groups improved in the postenrollment period, such that their treatment compliance and use increased and arrests decrease. After the analysis controlled for a priori time and group differences, only appointment compliance significantly increased over time, but a between-group difference was not found.

And if you look at their data, you also see that the treatment-as-usual group actually partook of significantly more mental health and substance abuse services at the six-month followup than when they began. This suggests that when you don’t coerce treatment, you may actually get more people interested in engaging with it.

Both groups enjoyed a significant reduction in their re-arrest rate at the six-month followup, with no meaningful difference between the two groups.

Mental Health Courts Probably Don’t Work As Well As People Think

These two studies, looking at large groups of people studied over a longer period of time than most previous studies show pretty conclusively that the benefits of mental health courts are a mixed bag.

What they really seem to show is that if you offer people more access to treatment services, medication, case management and all the wonderful things the public mental health system used to provide at one time to the less fortunate members of society, they get better. Their criminal activities used to try and (poorly) cope with their mental illness go away. They actually become engaged members of society again.

That’s not the result of the mental health court system. That’s the result of good, voluntary treatment services being offered. And treating people like the regular human beings deserving of respect that all of us want for ourselves and our loved ones.

References

Han, W. & Redlich, A.D. (2016). The impact of community treatment on recidivism among mental health court participants. Psychiatric Services, 67.

Hiday et al. (2016). Longer-term impacts of mental health courts: Recidivism two years after exit. Psychiatric Services, 67.

Footnotes:

1. The study doesn’t start off well when the researchers remove 40 subjects from the MHC sample for non-completion of the program because they either didn’t attend their first MHC hearing (umm, that’s still someone who was in the MHC program, and then dropped out of it) or who were sent back to TCC at their first MHC hearing (again — people who clearly couldn’t complete the program) but were still in the program to start off with.

from World of Psychology http://psychcentral.com/blog/archives/2016/04/17/mental-health-courts-does-coercion-add-anything-of-value-to-treatment/