Monthly Archives: February 2014

Innovation on the Last Frontier: A Conversation about the Anchorage Mental Health Court

Stephanie L. Rhoades
, who helped found and has presided over the Anchorage Mental Health Court since 1998,
and Kathi
R. Trawver
, associate professor of the School of Social Work at the University of Alaska, Anchorage, discuss
the court’s origins, accomplishments and lessons. They co-authored “Homesteading a Pioneering Mental Health Court: A Judicial Perspective from the Last
” for American Behavioral Scientist.

V. WOLF:  Hi, I’m Rob Wolf, Director of Communications at the Center for Court Innovation, and welcome
to New Thinking, the podcast where we interview justice reformers and innovators. Today I have on the phone two experts
who are well versed in the intersection of mental health and justice. They are Judge Stephanie L. Rhoades, who has
presided over the Anchorage Mental Health Court since the court was created in 1998, and Kathi R. Trawver, associate
professor of the School of Social Work at the University of Alaska, Anchorage. I know you’re both very busy,
so I really want to thank you for taking the time to talk today.

JUDGE RHOADES: Thank you, Robert.

ROB WOLF:  I thought we could focus on the article you both recently co-authored in American Behavioral
Scientist, where you draw some lessons from the experience of the Anchorage Mental Health Court.  The article
is Homesteading A Pioneering Mental Health Court: a Judicial Perspective from the Last Frontier.
And I’ll put a link to it on the podcast page, although I think people need to be a journal subscriber to actually
download it. You note in the article that there are about 300 mental health courts in the U.S. today, but back in
1998 there were only a handful and Judge Rhoades actually created the Anchorage court without ever seeing a model
in action. So Judge Rhoades, can you describe some of the motivations—and I know there were some personal ones and
professional ones—that led you and a special commission to explore creating one of the first mental health courts
in the country.

JUDGE RHOADES:  I will.  Some of the motivation was exactly
what are the motivations for all the courts that are developed, which are the over representation of people with
mental disorders in corrections, basically. And the frustration of judges who would sentence folks on low-level misdemeanor
offenses, and they were committed largely because people are disordered, homeless, they’ve got other challenges,
and the sentences really don’t have an impact because these folks go out the back door of the jail the same
way they come in the front doors. And so nothing’s really changed and there was a kind of a harmonious convergence
of the Department of Corrections in Alaska getting some technical assistance nationally to form a Criminal Justice
Assessment Commission, which was a policy-level group to think about how to reduce the number of people in jail. 

So one of the issues that they explored was the over representation of people with mental disorders. Meanwhile,
in my personal life, I have a brother who has both intellectual disability and some mental health issues. And I recognize
that, you know, if anything like this had happened to him and he’d gotten arrested, that he would have certain
needs that nobody in the system was ever going to be able to fulfill. And that is basically what got me thinking
about a mental health court, which is a way to have people be helpful to individuals who were going through the criminal
justice system, to hook them up with treatment and other resources that would, hopefully, address the underlying
issues that brought them before the court, and to prevent them from returning.

The Anchorage Mental Health Court, one of the many things that’s interesting about it is that it was the first
problem-solving court in Alaska.  And to my knowledge, most of the time that states have created a mental
health court, they’re usually already familiar with linking defendants to services through their work with drug
courts. I’m wondering how you presented the concept to other court players, and prosecutors, and defenders,
without having, you know, a drug court to point to or some other kind of problem-solving court to point to as an

JUDGE RHOADES:  Well, I’ll take that one on, Robert.  It’s Judge
Rhoades here. You know, there’s a great saying up here in Alaska: “We don’t do it like they do it outside.”
And we were, in fact, I think the last state to get a drug court, which is sort of funny.  

know drug courts were top down planned courts.  They were federally funded, the start-ups were federally
funded, and the way the mental health court started here, basically, was more of a ground floor response by people
who were experiencing this frustration. I think the deal here is that, generally speaking, our prosecutors have more
understanding that—and more sympathy, perhaps—for people who have mental health disorders, who get caught up in the
system, than they do for people who have addiction disorders. 

I think there’s still
quite a bit of thinking about drug and alcohol addictions that basically these are voluntary and that all you have
to do is just say no, but I think the prosecutors definitely got the fact that there are some people who have mental
disorders who just are, you know, really—you can’t punish the disorder out of them.

I imagine that you, with your personal connections with your brother, had a greater credibility to present the need
for this kind of court.

RHOADES:  Frankly, Robert, I never divulged to anybody that I
had a brother.  It’s a small town here and he lives here, so that really wasn’t something that
anybody knew about me. I think what was really helpful was judicial leadership. You know, when a judge calls somebody
and says ‘let’s have a meeting,’ they show up. That didn’t happen when I was a lawyer. It didn’t happen
when I was, you know, in any other profession and so judges tend to have this really wonderful opportunity to convene
people, to get stakeholders together.

WOLF:  Professor Trawver, maybe you can put mental
health courts in context. With the rate of mental illness so high among the justice-involved population, why are
mental health courts significant?

PROFESSOR TRAWVER:  Good question.  I guess
I can preface my answer by saying that I think, along with other folks, that we don’t really believe, necessarily,
that mental health courts are the only answer or the best answer, but still a really significant contribution to
the continuum of potential diversion opportunities, and I think that they are important in several ways. 

First, I think they offer an improved court-based process for individuals. Second, there’s strong evidence
that mental health courts improve access to treatment, even—funny—even when treatment is already available. So they’re
already actually entitled to it, but they seem to still improve access. And I guess the third—another thing that’s
significant about mental health courts is that there’s a strong developing evidence base that mental health
courts result in reduced rates of recidivism. And finally with the development and expansion of mental health courts,
I think they’ve raised awareness about the intersection of mental health and criminal justice involvement. So for
example, in the Anchorage Mental Health Court, all the nursing students who go through UAA are required to come to
watch the mental health court during their psychiatric rotation.

WOLF:  One of the key
goals at the outset for the Anchorage Mental Health Court, as you describe in your article, was to try, to some extent,
to decriminalize mental illness and get the mentally ill out of the justice system. Judge Rhoades, why is decriminalization
so hard to achieve, and have you been disappointed or frustrated that you haven’t been able to move further
in that direction?

RHOADES:  The premise was that we believed mental illnesses basically
were the direct cause of criminal justice involvement, and really it turns out that it’s very few people for
whom that’s true.  It appears now, from more recent research, that mental illness is a reason why people
can’t necessarily change as easily as other people. Really they are just as susceptible, and perhaps more susceptible,
to what we call criminogenic risks and needs.  Anti-social behaviors, anti-social personality patterns,
anti-social thinking, anti-social associates, you know, being close associates with people who aren’t law abiding. 
Having poor family or marital relationships, not having education or work opportunities, not having pro-social leisure
and recreation, and substance abuse.  I think that, unfortunately, people with mental illness tend to experience
these factors perhaps more than other people.  

You know, for example, substance abuse
is very highly associated with people who have mental illness. These factors are things that we really did not dig
down into and look at when we first started the court, and now that we are informed by some of this information,
we have begun to actually measure these things on validated instruments to see where people are experiencing high,
medium, or low risks and needs in these areas that predict recidivism. By doing that, we can be more effective in
terms of how and what we are linking people up with, so that they can actually, you know, reduce their recidivism. 

WOLF:  I think there are probably many unique things about Alaska, and I wonder if, in particular,
relating to the population you’re working with, are there unique challenges regarding the mentally ill?

TRAWVER:  There’s a long list.  First is just geographic challenges.  If
you sort of think about how huge Alaska is, and many people live off the road system in rural areas and in conditions
that I am pretty sure that most New Yorkers would consider Third World conditions. Social problems—Alaska has the
distinction of ranking very high among states in a lot of contributing social problems.  For instance, we’re
number one in our rate of adult drug use, number two in alcohol consumption, number two in rates of suicide across
the board, very high rates of trauma and family violence, and that’s disproportionately true among Alaska natives.

Third, I would say access to behavioral health services is a major problem in Alaska.  So we do
have some innovations in terms of tele-behavioral health which is interesting and used by a lot of paraprofessionals,
behavioral health aids in remote and rural areas, and housing is just a major barrier in many communities, and there’s
still a great deal of stigma and nimbyism, particularly in some of the larger communities.

I only want to add one other thing about what makes Alaska’s court different. We take a very broad diagnostic
group, much broader than, I think, most other courts.  because we are serving people who have any mental
health disorder, and co-occurring substance abuse disorders, so long as they can be linked and matched with services
in the community, that means for us that we have to become competent at linking and monitoring people in the intellectual
disabilities community as well as the mentally ill community, as well as the substance abuse community. And Alaska
experiences very high rate of traumatic brain injury and fetal alcohol spectrum disorder, which are very difficult
disorders to link with treatments.

WOLF:  What are the takeaways?  What lessons,
Judge Rhoades, do you have for other judges?  And Professor Trawver, what do you think, from your perspective,
are the take-aways from the Anchorage Mental Health Court?

TRAWVER:  I have some things
I would say about Judge Rhoades.  I view her as a true pioneer. Even though she made it sound really simple
when she was talking about how she started the court, I know that she struggled and actually sacrificed a great deal
professionally to create the Anchorage Court.

JUDGE RHOADES:  It is true that it was
a long road getting started, but my advice to other courts would be a couple things. One is you really have to get
an education about different diagnoses and what the behaviors are that go along with those, so that you can understand
the perspective of each of the people that come before the court. Judges really need to learn how to talk candidly
to people about mental illness and about other kinds of disabilities because you know it’s really important
to note that they have strengths and challenges, and that they can do really well. And I think the other part of
it is that in terms of the structure of any court, what I would give as advice is that like any project, you’ve
got to have a mission, you’ve got to have policies and procedures that are clearly stated and enforced, and
understood by everybody, most especially the participants, and you really have to go back and every time that there
is a decision to make, because there are many decisions to make that pose ethical dilemmas, every one of those decisions
should really hearken back to whatever your stated mission is. 

These courts really have
been put together without much research to guide them. So it’s very easy, under circumstances like that, to
get off the reservation, especially from a very paternalistic point of, you know, let me do good for you, I’ll
put you in jail these five days because you didn’t take your medications. Well, that’s not meeting your
mission if your mission is decriminalization, or reducing the number of days they spend in jail.

Well thank you very much for both of you sharing your experience and knowledge. I’ve been speaking with Judge
Stephanie L. Rhoades, who have presided over the Anchorage Mental Health Court since the court’s very beginning
in 1998, and I’ve also been speaking with Kathi R. Trawver, who’s an associate professor of the School
of Social Work at the University of Alaska, Anchorage.  So thank you both very much.

Thank you, Robert.

TRAWVER:  Thank you, Robert.

WOLF:  And
for folks who are interested in learning more about the Anchorage Mental Health Court, you can read the article that
they co-authored, that is in the American Behavioral Scientist.  It’s called Homesteading
A Pioneering Mental Health Court: A Judicial Perspective from the Last Frontier
.  And there will
be a link to it on our podcast page at our website,  I’m Rob Wolf, Director
of Communications at the Center for Court Innovation.  Thanks very much for listening.


Mental Health and Juvenile Justice: A Discussion about QUEST Futures

QUEST Futures is a juvenile mental health initiative that seeks to establish a comprehensive, coordinated response
to youth with mental illness involved in the juvenile justice system in Queens, New York. Here, researcher Josephine
Hahn discusses the findings of an impact
of the program. (February 2014)

Sarah Schweig, of the Center for Court Innovation, and today I’m talking with Josy Hahn, the author of new research
about a special program that works with kids with mental illness, who are involved in the juvenile justice system.
The publication, 
Mental Health and Juvenile Justice, records
the findings of the impact evaluation of QUEST Futures. Thanks for speaking with me today and welcome.

JOSY HAHN: Thanks, Sarah.

SARAH SCHWEIG: So, QUEST Futures operates out of a community-based
alternative to detention program. QUEST stands for Queens Engagement Strategies for Teens, so this is in Queens,
New York. And QUEST Futures, specifically, works to engage kids with mental illness and their families in specialized
services. So, now that this program, which was launched in 2008, has been in operation for about five years, maybe
you can start off talking a little bit about the model, what the goal of the program was and the structure, and then
we can get to talking about the evaluation.

JOSY HAHN: Absolutely. So the QUEST Futures program
is so important. We know that youth in the juvenile justice system experience mental health illness at really high
rates, up to 70 percent, and that’s compared to 20 to 25 percent of youth in the general population. There is a huge
need, and yet there are very few resources in the juvenile justice system. So, juvenile detention and jail actually
become the default, which is alarming. Here in New York, QUEST was launched by the Center for Court Innovation—and
it was in collaboration with a number of juvenile justice and mental health agencies—and the overarching goal is
to reduce recidivism among youth in the juvenile justice system by addressing mental health needs. And there are
a couple other key features. One is that they engage with families early on in the case: so pre-adjudication phase.
Another is that really comprehensive individualized treatment plan that provides direct services on-site and also
a vast network of referrals. And then finally, the purpose of QUEST Futures is to increase the capacity of the juvenile
justice system to provide alternatives to detention, which is incredibly important.

Maybe give us an idea of what QUEST Futures looks like.

JOSY HAHN: So, it’s either through a judicial
mandate, so the judge mandates the program, or a voluntary referral. So in our study, all of the QUEST Futures youth
comes from QUEST ATD referrals. QUEST ATD serves youth with juvenile delinquency cases in the Queens family court,
and they are classified as moderate risk of re-offending, or failure to appear in court. And they are deemed eligible
for community supervision, and that can mean anything from curfew checks and school attendance monitoring, to after
school programming and required services in the community. But in terms of QUEST Futures, every single youth is given
a diagnostic predictive scale, and that’s a mental health instrument that screens for 18 different mental health
disorders—mania, bipolar, depression, post-traumatic stress disorder, and anxiety. If they flag on the DPS and meet
criteria for impairment, they are eligible to go to QUEST Futures. So there’s an intake set up with QUEST Futures
staff and youth and families. There’s a full bio-psycho-social assessment, and this includes a psychiatric evaluation
and supplemental information from home visits, and interviews with the youth support system: so, a parent, caregivers,
other family members, teachers, etc. And then, based on all of that information, program staff are working with youth
and families to build trust and collaborate on what works best to meet the needs of the youth. A feature of QUEST
Futures that’s really impressive is how multi-disciplinary its staff is, from the social workers, case managers,
youth developers, court liaison, a consulting psychiatrist and the senior staff, of course. But then also how often
they’re communicating and working closely with the judge, the prosecuting and defense attorneys, and the community
service providers.

SARAH SCHWEIG: There are many moving parts to that. So, maybe you can talk
a little bit about this evaluation. Maybe you can talk a little bit about the kind of data you collected and the
process for that.

JOSY HAHN: Sure. So, there’s very little research on juvenile diversions in
general, and there’s very little research on juvenile diversions in general, and the results are mixed on recidivism,
you know, whether youth in these programs are doing better or not, and there’s even ones on diversions for specialized
programs like mental health. So in this study we wanted to know how effective QUEST Futures was meeting the needs
of youth with mental health diagnoses in the juvenile justice system and we did this by looking at the impact of
QUEST Futures on a number of outcomes. And I’ll mention that we looked at recidivism—that’s re-arrest—at about one
year after program start, and one year after program end, we looked at final case dispositions—so, whether youth
were released into the community or put in a detention facility and placement, and then also the total detention
days served after program enrollment—if they were, and if so, how long? And we looked at data for background information
and outcomes for QUEST Futures youth and also a comparison sample. It was 392 youth altogether. They were all flagged
for some kind of mental health screen, and they were classified as mostly low to moderate risk, according to a risk
assessment instrument that we use in New York City. So, for the 131 youth in QUEST Futures that were compared to
a similar group of 261 youth in three alternative-to-detention programs that are throughout New York City.

SARAH SCHWEIG: What were some of your findings in looking at the group that did go through QUEST Futures
versus the sample that did not?

JOSY HAHN: So overall, the sample was mostly male and black or
Latino, and the average age for both groups was between 14 or 15. They were eighth grade on average. Both actually
had similar mental health screens, they were mania, post-traumatic stress disorder, and any substance abuse—so that’s
alcohol or any drug. And this related to about a third or more kids in the sample flagging for these issues. We use
propensity score adjustment and that is a great technique to balance any differences between our QUEST Futures and
our comparison group so that they would be similar. We also ran a number of tests to make sure what we were seeing
was the true effect of the QUEST Futures program. What we found was that QUEST Futures youth are significantly less
likely to commit felony offenses. It’s actually about a 12 percent difference compared to their counterparts. And
this is at about one year after program start. And this difference held mostly for one year at program end. The significance
was marginal, but the difference was still 10 percent, and so this was a really promising finding. It means that
the goal of QUEST Futures to reduce recidivism did occur. And then we also found that QUEST Futures youth were actually
less likely to receive a probation disposition when their case had closed, but they were more likely to receive other
kinds of dispositions, where they would still be released into the community. So that’s—it was mostly adjournment
in contemplation of dismissal, or conditional discharge. And then we also found that QUEST Futures youth and their
comparison group were equally likely to be detained after they were in program ATD enrollment but when they were
detained, QUEST Futures youth were actually more likely to spend more days in detention, so about five more days,
and that was a significant difference. So that’s definitely not ideal and something we have to look at in terms of
practicing and policy implications. A couple of the reasons might be that this might indicate a greater awareness
of the judge and other court stakeholders in knowing about the complex mental health needs of youth, and so that
contributes to longer detention stays because they might not have the appropriate care in the community. It might
show a potential supervision effect and this means that closer monitoring by the program and also by the court might
lead to longer detention stays. But in general we actually don’t know why the youth were detained in both groups,
we don’t know the reasons for them—whether they were a program violation like breaking curfew or not going to school,
or if they are new arrests after the program end. We also did an exploratory analysis to see if anything else predicted
outcomes of recidivism and detention days, and we did find some results that weren’t that surprising. Females are
less likely to be rearrested about one year after the program. Youth who flag for any substance abuse are more likely
to be rearrested. That’s not too surprising. But an interesting thing was that youth who flagged for suicide risks,
they were more likely to spend more days in detention, but they were less likely to be rearrested. So that actually
gives some support to the fact that more complex mental health needs, like suicidal ideation might mean that youth
will be in detention for longer. It’s still an issue.

SARAH SCHWEIG: Right, just because there
aren’t resources to deal with that?

JOSY HAHN: Right, not immediately given—even in New York with
such a vast network of quality providers, they might not always have the ability to meet the needs of a youth with
an emergency issue. So I just provided a very brief overview of the complex model that QUEST Futures is, but Kelli
Henry wrote up a process evaluation and some initial results for the outcome evaluation where she describes thoroughly
the planning process for the QUEST Futures model—so how the collaborations occurred, what happened in terms of implementation
and program launch—and she also wrote six very thoughtful case studies around different youth and their paths through
the QUEST Futures program and the juvenile justice system. So, a big plug to Kelli’s process evaluation, Kelli Henry,
on the Center for Court Innovation website as well.

SARAH SCHWEIG: Okay, so maybe just as a last
takeaway, what are some of the lessons that you can see from some of the findings?

Well the main goal of QUEST Futures to reduce recidivism, especially for more serious offending was met, and so these
are findings that give support to collaborative models for specialized diversions and ways to meet youth with mental
health needs in the justice system, which is fantastic. This does add to a small but growing base of evidence around
specialized youth diversions, and it’s critical because the juvenile justice system is definitely looking at alternatives.

SARAH SCHWEIG: Well it was great speaking with you today. I’m Sarah Schweig and I’ve been speaking with
researcher Josy Hahn about mental illness and the juvenile justice system. To find out more about the Center for
Court Innovation, or to download Josy’s report, visit our website at Thanks for listening.