The Washington Institute for Mental Illness Research and Training

University of Washington

ACKNOWLEDGEMENTS

The authors of this report gratefully acknowledge the contributions of many individuals and agencies to this project. Dr. Henry J. Steadman provided seminal consultation during the project's incipience. Dr. Richard Almbaugh, Dr. Gregg J. Gagliardi , and Dr. Paul Peterson of the Washington Institute of Mental Illness Research and Training lent critical support to the project by contributing to the evaluation design, drafting text for the initial proposal, and reviewing drafts as the project progressed. UW clinical psychology residents and externs assisted throughout the project. Members of the MHC team spent many hours explaining their work, clarifying issues, and simply helping us get things right in regard to the many technical issues involved in the-day-to-day functioning of the MHC. Our research required a significant amount of time on an almost daily basis from the MHC Program Manager, Kari Burrell. Kari consistently handled our requests in a gracious and timely manner. Jim Harms, now with the office of the County Executive and Linda Ip of DAJDS were invaluable in assisting us with all aspects of collecting and understanding detention data. Key informants and stakeholder who granted interviews were very generous with their time, observations, insights, and wisdom.

Members of the MHC Evaluation Advisory Group were helpful in every phase of the project. Some members of this committee were instrumental in guiding us efficiently through the process of gaining permission to access data systems. They set a very high standard for a first phase process evaluation while providing encouragement and perspective to the evaluation team.

1. Judge Jim Cayce
   Judge, King County Superior Court
   
2. Judge Mark Chow
   Mental Health Court Judge, King County District Court
   
3. Judge David Steiner
   Presiding Judge, King County District Court
   
4. Kari Burrell
   Program Manager, Mental Health Court, King County District Court
   
5. Shelle Crosby
   Acting System Evaluation, Quality Management & Training Section Coordinator, Mental Health, Chemical Abuse and Dependency Services Division, King County Department of Community and Human Services
   
6. Clif Curry
   Senior Legislative Analyst, King County Council
   
7. Beth Goldberg
   Budget Section Supervisor (Law Safety and Justice, Health and Human Services), King County Office of Budget and Strategic Planning
   
8. Shannon Greene
   Member, Quality Review Team, Mental Health, Chemical Abuse and Dependency Services Division, King County Department of Community and Human Services
   
9. Jim Harms
   Program Analyst, Adult Justice Operational Master Plan Project, King County Office of Budget and Strategic Planning
   
10. Steve Nolen
    Criminal Justice Senior Policy Advisor, King County Executive's Office
    
11. Larry Smith
    Psychiatric Services Administrator, King County Department of Adult and Juvenile Detention
    
12. Margaret Smith
    Program Analyst, Mental Health, Chemical Abuse and Dependency Services Division, King County Department of Community and Human Services
    
13. Doug Stevenson
    Legislative Lead Analyst, King County Council
    

EXECUTIVE SUMMARY

A team of researchers from the University of Washington and the Washington Institute for Mental Illness Research and Training (WIMIRT), led by Dr. Eric Trupin, conducted the first phase of program evaluation of the King County District Court Mental Health Court (MHC), a court designed to address the unique needs of mentally ill misdemeanants. This phase of the evaluation focused on program fidelity to goals, efficiency of functioning during the first year of operations, and the analysis of preliminary outcome data on defendants referred to the court. Sections on qualitative findings, quantitative findings, and integration/recommendations organize the report.

The evaluation relied on four methods of data collection:

1. Intensive structured interviews were conducted with key informants within the MHC, the County council, the State legislature, the judiciary, the office of the county executive, county agencies, and treatment providers.
   
2. An anonymous survey was administered to key informants from involved agencies.
   
3. Evaluators informally observed MHC process and role performance of key MHC staff.
   
4. Archival data was collected and analyzed from the District Court, the County Department of Adult and Juvenile Detention (DAJD), and the County Mental Health, Chemical Abuse and Dependency Services Division (MHCADSD) information systems.

Qualitative process-related findings from an anonymous survey, confidential structured interviews, and researcher observations indicate that:

1. The MHC is currently providing adjudication services to the target population of individuals charged with misdemeanor offenses and identified as suffering from a significant mental illness. Mental illness is defined broadly to include developmental disabilities and brain injuries, or general psychiatric symptoms of at least moderate severity.

2. The MHC team is coherently organized, well managed, and routinely applies specialized knowledge and expertise to the adjudication of mentally ill defendants. Consistency and teamwork of core staff and increased intensity of supervision and monitoring of clients are essential components of the MHC model.
   Although the MHC functions as a Judge-centered team, the unique roles of the Court Monitor and Program Manager were viewed by almost all informants as critical to the success of the court.
   
   
   Because of the recognized importance of teamwork among MHC core staff, turnover has become an issue of concern.
   
   

3. Stakeholders and agencies in operational contact with the MHC indicated high regard for the MHC leadership and staff. Expressed stakeholder and agency support for the program was high.

4. Key stakeholders and members of the MHC share a common understanding of the MHC as a problem solving court that administers justice for mentally ill defendants by pursuing value-laden objectives. Among these objectives are:
   a. Preventing the criminalization of the mentally ill through informed legal case management;
   b. Improving the defendant's well-being and ability to conform to the requirements of the law by engaging the defendant in needed treatment and providing linkage to other needed resources;
   c. Managing cases to insure public safety; and
   d. Supporting the defendant's personal autonomy through the exercise of personal responsibility and legitimate prerogatives.
   
   

5. MHC team members, like the larger stakeholder group, differed in their views about how the balance should be struck, both in principle and in specific cases, among shared objectives.
   In a significant minority of cases, differing views of priorities contributed to an intensification of the adversarial model, as opposed to the MHC's usual teamwork approach.
   
   
   An adversarial approach combined with the broadly defined roles of mental health core staff have contributed to inefficiencies in gathering and sharing information.
   
   

6. The MHC has enhanced communication between systems and agencies that previously worked in relative isolation and has increased awareness among key stakeholders of the needs of mentally ill misdemeanants.

7. Linkage of defendants to mental health and other resources has been significantly increased by MHC activities.
   Limited availability of appropriate housing and the absence of a full continuum of integrated substance abuse services for the mentally ill remain significant obstacles to improving community management of participants.
   
   

8. The MHC routinely provides specialized, intensive community supervision and responds rapidly to changes in the mental health or compliance status of participants.

9. The decision to opt for participation in MHC is strongly impacted by the advice of the defense attorney and prosecutorial recommendations, which in turn is influenced by the severity of the alleged offense, the defendant's criminal history, and the type and severity of psychiatric symptoms.
   Defendants with insight into their psychological symptoms or who are already engaged in mental health services are more likely to opt into MHC than individuals with less insight or paranoid symptoms.
   
   

10. MHC is more likely to grant deferred sentences and deferred prosecutions than other courtrooms.
    Deferred or suspended sentences are more likely if clients are making proactive efforts in treatment and/or if criminal history appears related to mental illness.

Quantitative analysis was conducted on available archival data for the first 246 defendants seen in the MHC. These data were provided by the MHC and from the information systems of the District Court, DAJD, and MHCADSD. When possible, defendant mental health and detention histories were compared before and after contact with the MHC. These analyses indicate that:

The MHC population is fairly representative of the detention population in terms of gender and ethnicity. The average age of participants was 37 years, with a range of 18 to 81 years of age.

41% of referred defendants opted to participate in the MHC (Opt-Ins) versus 31% who declined participation (Opt-Outs).

85% of those referred were diagnosed with severe mental disorders such as psychotic disorders, bi-polar disorder, major depression, and organic brain dysfunction, suggesting that the program was successful in targeting mentally ill defendants.

When compared to Opt-Out defendants, Opt-In defendants were almost three times more likely to have a new treatment authorization request made on their behalf during the study period, indicating that the MHC was successful in linking offenders to treatment services.

Opt-In defendants received significantly more hours of treatment after contact with the MHC, when compared to both their previous treatment histories and to Opt-Out defendants, indicating that the MHC was successful in engaging patients in treatment and establishing a greater measure of compliance to treatment regimens.

Clinician ratings indicated that only defendants opting into MHC experienced significant improvements in adaptive functioning following MHC contact.

Quantitative analysis of detention data for 77 participants over the one-year period prior to the formation of the MHC through its first year of operation led to the following key findings:

Several quantitative analyses indicated that defendant involvement with the MHC resulted in increasing the amount of treatment received and decreasing problems with the criminal justice system. This impact was greatest for Opt-In defendants.

For both Opt-Out and Opt-In defendants, lower motivation to deal with alcohol and substance use problems was associated with an increase in new bookings.

For both Opt-Out and Opt-In defendants, as the number of treatment episodes increased, time in detention decreased. This relationship was strengthened after defendants had contact with the MHC.

After contact with the MHC, Opt-In defendants on average spent fewer days in detention than Opt-Out defendants.

The rate of new bookings after contact with the MHC decreased significantly for Opt-In participants, but did not for those who chose not to participate.

The following recommendations are offered in the context of findings that are highly supportive of the MHC and which indicate a successful first year of operation. Several of these recommendations involve program enhancements or program expansion. Their implementation may require additional resources. Other recommendations are aimed at preserving program integrity and are achievable within currently available resources.

1. In response to this report, the MHC should review its mission with the goal of establishing a working consensus concerning priorities among its objectives.

2. Role clarification and refinement should be supported through the submission of written work content and process descriptions to the Judge and Program Manager for review, revision, and discussion in team meetings.

3. Team meetings should remain a high priority, and some portion of each meeting should be documented in minutes that can serve as the basis for ongoing review of the team's process.

4. Standardized assessment instruments should be adopted for use in clinical monitoring.

5. A formal process for assessing risk for future dangerousness should be adopted. This process should rely on validated risk assessment instruments administered by appropriately trained staff.

6. Stronger judicial oversight of the provision of treatment should be established by setting the expectation that detailed treatment plans will be reviewed by MHC. The type and methods of treatment referred to in the plans should be available to the MHC in sufficient detail to determine the appropriateness of the treatment to mentally ill defendants.

7. Protective payee arrangements and the establishment of a flexible fund for minor expenses should be considered as ways to increase contingent incentives for participant success.

8. If resources are made available to manage the additional caseload, the MHC should be empowered to accept cases from additional municipal courts and to adjudicate some less serious felonies.

9. The need for additional staff time for each role in the MHC, and for administrative support, should be reviewed.

10. Guidelines should be established to specify the conditions under which diversion of cases from the criminal justice system should be considered.

11. For some refractory cases, outpatient commitment proceedings may be an appropriate outcome of repeated decompensation and reoffending. A review of the use and appropriateness of the current statute for this purpose and the treatment system's ability to support this process should be conducted by a body that is independent of the MHC, such as a Task Force.

12. A Community Advisory Committee should be established that would include a wide range of knowledgeable and concerned citizens.

13. A review of possible early course "model drift" is in order, given the completion of this preliminary study, turnover in the MHC, the loss of the program's novelty, and potential challenges to its resources.

Full Report of Phase I Process Evaluation Report of KCDC Mental Health Court has been removed. For a copy, please send an e-mail to Lois Smith.