How Do Mental Health Courts Work?

Mental health courts (MHCs), relative newcomers in the growing field of problem-solving courts, certainly seem like a good idea. Judges with special interest in justice-involved persons with mental illness clear court dockets for sessions focused on this selected group of arrestees, on the theory that treatment will reduce their criminal justice contacts. Using a variety of tools, the judges coach, cajole, and sometimes sanction the arrestees until they consistently engage in treatment, are less symptomatic, and avoid criminal justice contact.

This appealing but untested mechanism of action has led to spectacular growth of these courts. Unfortunately, this growth has come with little support or guidance from federal agencies or outcomes research. Key unanswered questions are whether MHCs can “work,” how they work, for whom, and under what conditions. Answers are surprisingly elusive, in part, because MHCs are inherently complex interventions, not easily amenable to simple randomized trials, in no small part because of the vexing diversity in how the courts operate—who they take in and how successfully they leverage the resources of treatment and service agencies well beyond their direct control. Most unclear is the courts’ capacity to leverage evidence-based treatments for justice-involved persons with complex comorbid conditions from woefully underresourced local behavioral health agencies.

In this month’s issue, Anestis and Carbonell’s study of a single court joins previous studies reporting that MHCs can reduce criminal justice recidivism, but generally without presenting evidence that the mechanism of action is via improved mental health status, which has led some to conclude that these courts exert their effects mainly by coaching their clients about avoiding criminogenic behaviors. In another report in this month’s issue, Steadman and coauthors conclude that reductions in criminal justice involvement do not offset the increased costs of mental health treatment incurred when these previously undertreated individuals are engaged in treatment.

One might conclude from both studies that spending more on mental health treatment for these individuals is a nonessential luxury when the court intervention itself seems to reduce recidivism with no measurable mental health benefit. Such conclusions would be vastly premature. Few studies of MHCs have been adequately resourced to directly and longitudinally assess the mental health functioning of court attendees, the appropriateness of the treatment they receive, and the extent to which the treatment comports with evidence-based models. Further, many court attendees have been disengaged from treatment altogether and therefore might only “save money” if their criminal justice incarceration costs were very high to start with. It is time to dig even deeper and carry out additional well-conducted studies of the effectiveness of MHCs.