A significant number of new readers are joining us this month, so welcome to you. Thanks too, to all of you who have been with TIPS and TOPICS for many months and even years. I appreciate the many comments and messages of appreciation you send me.

SAVVY
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Tips:

• Notice what contributes to good outcomes in mental health courts and drug courts

Before sharing what I found in the research literature, here are a few brief history facts:

--> 1989 – First drug court established in Miami, Florida.
--> 1980 to 1992 – the proportion of mentally ill persons in jail increased by 154%.
(Travis J (1997): “The mentally ill offender: viewing crime and justice through a different lens.”
Presented at a meeting of the National Association of State Forensic Mental Health Directors, Annapolis, MD – www.ojp.usdoj.gov/nij/speeches.htm)
--> 1997 – First mental health court established in Broward County, Florida.

You can see that drug courts have been around for just over 15 years, while mental health courts are less than 10 years old---still quite a young movement with lots to learn. But so far drug courts have demonstrated positive outcomes of lower re-arrest rates, reduced substance abuse and criminal behavior, and significant savings in taxpayers' money. Mental health courts have had similar results with decreased use of county jail slots.

Here are a few findings on what works to achieve good outcomes in mental health and drug courts:

1. Enhanced collaboration among all agencies – team approach to screening and evaluation, crisis intervention, short-term treatment that includes suicide prevention, case management, counseling, psychotropic medication and community integration.
2. Increased awareness of the needs of substance- using clients in the criminal justice system.
3. Build strong collaborations – improved coordination and continuity of care.
4. Maintain good communication.
5. Recognize competing interests in developing procedures for drug and mental health courts.
6. Increase drug court participation, treatment retention and completion rates.
7. Judicial supervision of community-based treatment.
8. Identification and referral shortly after arrest.
9. Regular hearings to monitor treatment progress and adherence.
10. Series of graduated sanctions – mental health courts use various creative methods of disposition of criminal charges to mandate adherence to community treatment. In contrast, drug courts commonly use jail and other sanctions for nonadherence. Mental health courts rarely or occasionally use jail for sanctions.
11. Mandatory drug testing.
12. Assurance of existing appropriate treatment slots.

Reference for points 1-5:
Wolfe EL, Guydish J, Woods W, Tajima B (2004): “Perspectives on the drug court model across systems: a process evaluation” J. Psychoactive Drugs 36(3): 379- 86



Reference for point 6:
Fielding JE, Tye G, Ogawa PL, Imam IJ, Long AM (2002): “Los Angeles County drug court programs: initial results” J Subst Abuse Treat. 23(3): 217-24.

Reference for points 7-10:
Griffin PA, Steadman HJ, Petrila J. (2002) The use of criminal charges and sanctions in mental health courts. Psychiatr Serv. 2002 Oct; 53(10):1285- 9.

Reference for points 11-12:
Steadman HJ, Davidson S, Brown C (2001): “Mental Health Courts: Their Promise and Unanswered Questions” Psychiatric Services 52(4): 457-458.

Even if you are not directly involved in a mental health or drug court, the principles of good collaboration, communication, participation and treatment retention, community-based treatment, regular monitoring of adherence and accountability; and finally assuring access to needed services are all, in and of themselves, methods for success for all disorders in behavioral health.

• Compare how drug and mental health courts work with offenders and contrast that with traditional courts.

Arizona held their first conference on Mental Health Courts in Phoenix in September: “Judicial Efficiency and Therapeutic Jurisprudence: Strategic Utilization of Mental Health Courts”. Not only was I able to teach some judges and others; but they were able to teach me too. Here is how Judge Carmen Dolny, a mental health court judge in Pima County Justice Court, Arizona outlined succinctly but comprehensively her top 10 comparisons on how mental health courts work with offenders:

The Style and Focus of Traditional Courts	The Style and Focus of Mental Health Courts
1. Conflict resolution – between two adversaries	Problem solving – create the best chance of success
2. Adversarial	Collaborative
3. Blame-oriented	People-oriented
4. Rights-based – fighting for ones rights	Needs-based – matching services to needs
5. Narrow, limited service – just adjudicate the case	Broad services – what services are needed
6. Judge as arbiter	Judge as coach
7. Formal – strict rules and procedures	Informal – talk together as a team
8. Legalistic and rule oriented	Common sense and what will work
9. Efficient e.g., if you no show, warrant issued	Effective – what will engage the offender
10. Authoritarian with rigid structure	Flexible to adapt to what will work

I was impressed, informed and more savvy about how a good mental health court and judge should work. More from Judge Carmen later.

SKILLS
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SOUL
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I was pondering what it would be like to suddenly lose every material thing you have. I was speaking at a conference in Baltimore at the time New Orleans flooded. In the audience were staff and some consumers from a treatment program in New Orleans. The consumers had won an essay competition to attend the conference. These attendees had no homes nor treatment program to which to return.

Twice, in Australia and Boston, our home was threatened by flood waters. Twice, the water came within a foot of the floor boards, and then receded. Heavy rain not hurricanes brought the water, so we didn't have to rush from our home deciding what was important to us to take.

When I was in Medical School, my parents didn't have time to decide what to take when our home burnt down. In the hot dry Aussie weather, a spark from the washing machine ignited some dry cleaning fluid. In minutes, my parents had their lives but just the clothes on their backs. Gone were all their wedding photos, baby pictures, clothes, furniture etc. I was a thousand miles away on summer break. I saw our house burning and my father interviewed on TV.

It is not a cliché to say that as long as you have your family and no one is hurt the rest are just things. But there are some things more important than others - things that are irreplaceable. So what would you take if you had to evacuate and flee? What do you value most? What would you take with you if you thought your house might not be there when the storm passed?

We faced that situation one time when living in Hawaii. There was a tsunami warning after an earthquake in Japan. Our house was one block from the ocean. We had time only to load up our minivan with the kids and a few priorities, and go to higher ground. Remembering the fire in my parents' home, we gathered up photos, audiotapes and videotapes of the kids through all their development thus far. Besides important documents like passports and legal papers, that was it.

As we've watched Hurricane Rita and déjà vu with New Orleans, those practical and philosophical questions surface again: What is most important to you? What would you take with you if you thought you might never see your home again?

STUMP THE SHRINK
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Question:

1. “We are considering utilizing the existing State Legislation (that currently is not being implemented), related to involuntary treatment for persons impaired by chronic alcoholism. This mirrors the involuntary commitment for mentally impaired individuals, the Lanterman-Petris-Short Act here in California. In looking into the utilization of this intervention, I am looking to find literature that describes "best practice" models for the treatment of chronic inebriants. Anything related to treatment models that may include the use of involuntary holds, and/or locked treatment facilities, would be helpful as well. Our work with the chronic street homeless, particularly the chronic public inebriant, is driving our consideration for more drastic treatment interventions for assisting this population gain better quality of life and health.”

David Nakanishi, MPH, LCSW
San Francisco Department of Public Health
Community Programs

2. “I was interested if you felt there is a place for involuntary treatment of addicted persons. I know presently enforced treatment occurs via criminal orders but actually wonder if that leaves things a little too late for some and focuses only on one aspect community risk. The persons I am most interested in are ones who have some form of disability i.e. alcohol related brain injury, mental illness and often both. The evidence I can gather at present appears mixed as to efficacy and I wondered if you had experience or personal beliefs.”

Mark Powell
Australia

Answer:

I have not carefully studied this issue for persons impaired with chronic alcoholism.

I have some familiarity with outpatient commitment for severe and persistent mental illness to mandate treatment. Of course there has always been involuntary commitment for inpatient treatment for those who are imminently in danger to self or others.

There does seem to be some success with outpatient commitment and expectation for treatment. For addicted persons, I think a version of that would be effective too. But my own clinical opinion is to work on any leverage and incentives that would be available to "raise the bottom" before focusing all efforts on this client who is still in very early stages of change.

I have more interest in the efficacy of motivational enhancement strategies, motivational interviewing, focus on the alliance and engagement. If the person is close to being incompetent because of brain injury or severe mental illness, then those would be other reasons to look at involuntary commitment. However if a person is in an early stage of readiness, I would rather have clinicians work with the system around them to create incentives to get what they want- e.g., I'll look at my substance use because I really want to get independent housing; or keep my benefits; or stay out of jail etc.

David

Until Next Time
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David