Ramsey County Mental Health Court: Working with the Mentally Ill Defendant

1. Ramsey County Mental Health Court:Working with the Mentally Ill Defendant Judge John H. Guthmann, Second Judicial District, State of Minnesota Judge William H. Leary, Second Judicial District, State of Minnesota Judge Teresa R. Warner, Second Judicial District, State of Minnesota Brandi Stavlo, Program Coordinator, Ramsey County Mental Health Court

2. Topics Covered • Description of the Need • Ramsey County Mental Health Court • How You Can Help?

3. Description of the Need

4. Scope of the Need • People with mental illness are heavily overrepresented in the criminal justice system. • Criminal justice contact because of untreated mental illness is preventable. • Mental illness creates barriers to treatment, employment, and safe housing - all resources that help people remain healthy and safe in the community. • People with mental illness lack access to appropriate mental health treatment, services, and supports in the community and in corrections. Without access there is a greater likelihood of recidivism.

5. It Is A National Problem • Criminal Justice System: Nationwide,64% of those in jails and prisons have a mental illness.¹ • General Population: By contrast, • about 26% of people in the general • population have a mental illness.² ¹ Bureau of Justice Statistics (2006) ² National Institute of Mental Health (2012)

6. What is a Mental Illness? A mental illness is: • A medical condition, disrupting a person’s thinking, feeling, mood, ability to relate to others and daily functioning. The condition is characterized by alterations in thinking, mood, and/or behavior associated with distress and/or impaired functioning in social, occupations, or other areas. • A mental illness should be treated with the same urgency as diabetes or heart disease. • Most mental illnesses can be treated effectively with medication, therapy, diet, exercise and support. Recovery is possible.

7. Mental Health Data • Many individuals with mental illness have multiple diagnoses. • Data from RCMHC 2010-2012 Triennial Report

8. Ramsey County Mental Health Court

9. Development of Mental Health Courts • There are more than 349 mental health courts across the country with many additional courts in the planning phase. • At present, Minnesota has three operational mental health courts. • Ramsey County (St. Paul) • Hennepin County (Minneapolis) • St. Louis County (Duluth)

10. RCMHC Background • Ramsey County Mental Health Court (RCMHC) began in May 2005. • RCMHC provides people whose criminal acts are driven by mental illness an opportunity to go into court-supervised treatment. • Instead of focusing solely on the criminal activity of the defendant, RCMHC focuses on addressing and treating the defendant’s underlying mental health and chemical health needs. • RCMHC hasdeveloped around our desired outcomes andisan adaptation of the national drug court model. • Desired outcomes: Connect people with existing mental-health and social-service resources that participants can access during and after court involvement. For that outcome, RCMHC formed a partnership with Ramsey County case-management services.

11. Goals • The goals of the RCMHC are: • PRIMARY • Reduce recidivism. • Improve public safety. • Reduce the costs of arrest, prosecution, incarceration and treatment. • SECONDARY • Improve access to mental health and other treatment and social services within the community. • Enhance collaboration between criminal-justice agencies and the mental health system to better serve those with mental illness. • Improve the quality of life of mentally ill defendants.

12. How does RCMHC differ from Traditional Criminal Courts?

13. Eligibility Criteria • 18 years of age or older. • County resident. • A significant relationship between mental illness and criminal behavior. • Legally competent. • No history of violent offenses, as defined by the federal Bureau of Justice Assistance. • Willing to voluntarily participate and commit to a rigorous treatment plan.

14. Program Denial Reasons • Failure to meet eligibility criteria. • Present or past history of a violent felony offense, sex offense, and/or weapon offense. • Significant history of being non-compliant and/or unresponsive to authority, treatment and/or services. • Bench warrant status.

15. Criminal Data • Offense Category of Most Serious Charge at Entry • Data from RCMHC 2010-2012 Triennial Report

16. Important Considerations for Eligibility • Will the defendant benefit from the program? • Can the program provide or connect the defendant to appropriate community resources for recovery? • Is the defendant capable of following through with the program and all its conditions and treatment recommendations?

17. What is the Incentive for the Participant? • Participants Must Agree • Practical Reasons • Recovery/Services

18. RCMHC Team • The RCMHC uses a collaborative model in making intake, eligibility, evaluation, treatment alternative and case management decisions. • The team includes: • program coordinator • two community human services case managers • three judges who rotate • two prosecuting attorneys • three pro bono defense attorneys who rotate • one certified student attorney • one graduate clinical case management intern

19. Collaboration • RCMHC collaborates closely with: • Ramsey County Community Mental Health Center • Project Remand, Pretrial Conditional Release Agency • Ramsey County Community Corrections, Adult Probation • Ramsey County Correctional Facility • Second Judicial District Research Department

20. Referral Sources • Data from RCMHC 2010-2012 Triennial Report

21. Demographics • Gender: Women comprised 60.7% RCMHC participants; men 39.3%. • Age: Participant ages ranged from 18 and 63, with the average age being 36 years. • Race: Participants were more likely to identify as Caucasian (54.1%), followed by African American (27.9%), Native American or Hawaiian (6.6%), Hispanic (4.9%), Asian (3.3%), and Multi-Racial (3.3%). • Education Level: A large number of accepted participants reported having a Diploma/GED (44.3%), followed by some post-high school education but no additional degree (31.2%). Other participants reported an education of 11th grade or below (14.8%), a technical degree or certificate (3.3%), a four-year degree (3.3%), or a post-graduate degree (3.3%). • Employment: Most participants reported being unemployed (86.9%) at program entry, followed by part-time employment (6.6%), full-time employment (3.3%), or stay at home parent (3.3%). • Housing: A large number of participants reported living independently (44.3%), followed by living with parents or adult relatives (23%), or homeless (11.5%). The remaining were in Corporate Foster Care (8.2%), Board and Lodge Care (4.9%), IRTS Facility (3.3%), Living with Friends (3.3%), or Jail (1.6%). • Data from RCMHC 2010-2012 Triennial Report

22. Funding • RCMHC is currently funded by the Minnesota Department of Human Services, Adult Mental Health, and a federal Bureau of Justice (BJA) and Mental Health Expansion grant. • Historical Funding: • 2005: Second Judicial District Court and Ramsey County Community Human Services, Adult Mental Health. • 2006: Awarded the Problem-Solving Partnership Grant from the MN-Office of Justice Program. • 2008 – 2015: Minnesota Department of Human Services, Adult Mental Health from 2008-2015. • 2010 – 2012: Awarded the Bureau of Justice Assistance (BJA) Adult Drug Court Discretionary Grant Program Expansion grant that allowed the program to expand to felony level offenders. *RCMHC was 1 of 3 awarded in MN* • 2013 – 2015: Awarded the Bureau of Justice Assistance (BJA) Justice and Mental Health Collaboration Program Expansion grant that allowed the program to double its capacity. *RCMHC was 1 of 11 awarded this grant in the nation*

23. How it Works • Better Information Leads to Better Decisions: • The case manager provides the team with detailed psycho-social assessments of each defendant referred to RCMHC. This information is used in two ways. • First, it allows the team to make an informed decision regarding the nature of a defendant’s illnesses—and the risks they pose to public safety. • Second, the information is used to craft individualized treatment plans for each defendant, matching the defendant to appropriate service programs.

24. How it Works continued… • Judicial Monitoring: • Every defendant in the RCMHC is required to regularly return to court to meet with the case manager and appear before the judge to report on treatment progress.

25. How it Works continued… • Holds Defendants Accountable: • The court, in coordination with treatment providers, uses an array of graduated rewards and sanctions to respond to progress and setbacks in treatment. • Treatment plans are also modified as necessary. • Regular monitoring of treatment progress also holds treatment providers accountable to the judge. • Defendants who comply with all treatment mandates have their criminal charges dismissed or reduced.

26. How it Works continued… • Coordinated Services: • Many mentally-ill defendants are homeless, unemployed, abusing drugs and alcohol, and have serious health problems. Accordingly, RCMHC works with a broad network of government and not-for-profit service providers to address these interrelated issues.

27. Mental Health Supports • Among the mental-health supports and programs to which participants are connected are: • County Case Management • Adult Rehabilitative Mental Health Services (ARMHS) • Personal Care Attendant • Representative Payee • Dialectic Behavioral Therapy (DBT) • Mental Health Day Treatment • Mental Health Pro-Social Centers • Mental Health Support Groups • Mental Health Inpatient and/or Outpatient Treatment • Data from RCMHC 2010-2012 Triennial Report

28. Recent Program Statistics [December 2013] • Program highlights include the following: • RCMHC has served 409 participants with serious mental illness. • 99.3% have mental health community supports and programs in place at program completion. • 82.6% have chemical health community supports and programs in place at program completion.

29. Recent Program Statistics Continued… • There have only been 28 psychiatric inpatient hospitalizations and 17 psychiatric crisis outpatient, emergency room, or acute psychiatric crisis visitssince inception. • RCMHC graduates spent significantly less time in jail and were less likely to be charged or convicted with a new offense than those in the comparison group. • A total of 2,070 hours of community work service have been completed by RCMHC participants.

30. Ramsey County: Research Outcomes • RCMHC has a proven record of success in reducing recidivism and jail time. There has also been significant cost savings by reducing participants’ engagement with police, prosecutors, public defenders, and administrative and judicial staff. • A comparison group was selected from the Ramsey County jail database to evaluate the effectiveness of RCMHC. The comparison group was selected using the same eligibility criteria and charge history of those participating in RCMHC. • In one- and three-year comparisons, RCMHC graduates spent significantly less time in jail and were less likely to be charged with a new offense than those in the comparison group.

31. National: Research Outcomes • National: • A long-term research study conducted by Policy Research Associates, Inc. (PRA), with funding provided by the MacArthur Foundation, showed that mental health courts can lead to cost savings through lower recidivism and the associated jail and court costs, and through a reduction in use of the most expensive types of mental health treatment. • The second phase of the research study is expected to be released in 2014 and will examine the costs and benefits of mental health courts.

32. RCMHC COMPARISON GROUP Recidivism and Jail Impact • In both a one year and three year follow-up, RCMHC graduates have been less likely to be charged with a new offense and spend time in jail than those in a comparison group.

33. Chemical Health Data • Co-occurring Disorders: Co-occurring disorders are mental-health and substance-related disorders that are present in an individual at the same time. • Substance Abuse: The vast majority of RCMHC participants had a history of substance abuse at program entry (74.2%). • Data from RCMHC 2010-2012 Triennial Report

34. Chemical Health Supports • Chemical Health Supports:Among the chemical health community supports to which participants are connected to are Chemical Health Assessments, Drug Testing, Structured Outpatient Program, Inpatient Treatment Program, and AA/NA/DRA Support Groups. • Data from RCMHC 2010-2012 Triennial Report

35. Accomplishments

36. Awards and Recognition • 2009 Second Judicial District Pro Bono Award: Warren Maas, RCMHC pro bono defense attorney, was the 2009 Recipient of the Second Judicial District Pro Bono Award which recognized his outstanding commitment to pro bono work and extraordinary contributions to the criminal justice system. • 2013 Minnesota Justice Foundation Award:Briggs and Morgan attorneys were recognized for their outstanding commitment to pro bono work with RCMHC. Suzula Bidon, a RCMHC legal intern, received the WMCL Student Award. The integrity and devotion they have brought to their RCMHC work has been a tremendous contribution to the district. • 2014 Unsung Legal Hero Award: Brandi Stavlo received award from Minnesota Law and Politics for her local, statewide and national efforts on behalf of mental health courts. • Federal Recognition: Brandi Stavlo, RCMHC Program Coordinator, • was selected to be trained nationally by the Council of State • Governments Justice Center to provide training to Minnesota • courts that are interested in starting a mental health court or • improving their existing program.

37. How You Can Help?

38. Current Challenges • Lack of Adequate Treatment Facilities in • Community • Riverwood Centers, a provider of mental health • services for about 3,000 people in east central • Minnesota, abruptly closed on March 17, 2014. • Funding • Treatment and resources need to be funded locally, statewide, and nationally. • Invest in community mental health services which will support individuals when they are discharged from treatment and hospitals.

39. How You Can Help? • The goals are to have individuals with mental illness: • Functioning in the community • Not committing crimes • Obtain and maintain housing and treatment support groups • Learn how to reach out to providers when experiencing a crisis • People with mental illness are more likely to succeed if they have the necessary tools, such as treatment, housing, employment or income supports, identification, a reasonable supply of medication and health care benefits.

40. Invest in Better Mental Health Services • Addressing the mentally ill who engage in criminal behavior and endanger public safety is low-hanging fruit. Make use of existing resources and divert people with mental illnesses from the criminal justice system into treatment and stable life-styles. Advocate for: • Community mental health centers • Mental health mobile crisis teams • Supportive housing and employment • Mental health training for law enforcement • Mental health courts • “There is no quick fix to the problems in our mental health system. Building more beds or a huge assessment facility will not address the core problem. We need community services available to support them when they are discharged. If not, we start the entire cycle over again.” • Sue Abderholden, MPH, Executive Director of NAMI Minnesota

41. Final Thoughts…. These folks are people who have lost all their natural supports. They don’t have advocates any longer, they don’t have family members to take them in, and they’ve burnt all their bridges with treatment and everyone else. They’re the tough customers, and their lifestyles are really dissonant with the medical model of mental health and substance abuse treatment delivery. They tend to be more likely than not homeless, co-occurring disordered, without money. They don’t show up for appointments, and they often have complicating medical issues. On top of all that they often have a criminal history that makes them look in many ways worse than they are to the treatment system. So I think that the resource of a boundary-spanner and a linker, the case coordinator [manager] who can actually take the individual and hook them up with services appropriate to their condition is a tremendous resource. And what I’ve found is that the treatment system is far more likely to serve an individual who’s being monitored in the mental health court. And I think that what this tells me is to never give up. Don’t give up on anybody because there may be a time in anyone’s life where they are ready, and readiness for change is so critical because you could meet a person four times during their life or even during the course of a couple of years, and if they’re not ready it’s not going to happen. Stephanie Rhoades, Judge, Anchorage Mental Health Court

42. Additional Resources on Mental Illness National resources • NAMI — National Alliance on Mental Illnesshttp://www.nami.org/A community of mental health advocates, helping those in need receive services, treatment and support. • NIMH— National Institute of Mental Healthhttp://www.nimh.nih.gov/index.shtmlWorking through research to better understand how to understand and treat mental illnesses. Minnesota resources • NAMI Minnesotahttp://www.namihelps.org/Improving the lives of children and adults with mental illnesses in Minnesota through education and support. • Mental Health Association of Minnesotahttp://www.mentalhealthmn.org/Working to enhance mental health, promote individual empowerment and increase access for those with mental illnesses. • Minnesota Association for Children’s Mental Healthhttp://www.macmh.org/Promoting positive mental health for infants, children, adolescents and their families. • Mental Health Consumer/Survivor Network of Minnesotahttp://www.mhcsn.org/An organization in Minnesota that fosters mental illness recovery and wellness.