State of the Field: Mental Health Courts

Christina Lanier:

Welcome back to the Justice to Healing Podcast. I'm Dr. Christina Lanier, one of the codirectors of the National Drug Court Resource Center, and alongside, I have Dr. Kristen DeVall, the other codirector.

Kristen DeVall:

Hello.

Christina Lanier:

We are excited to bring you another episode in our series that's looking at the state of the field. Today, we are going to focus on mental health courts and we're excited to have our guests, Dr. Lisa Callahan, a senior research associate at Policy Research Associates. Welcome, Dr. Callahan.

Dr. Lisa Callahan:

Thank you so much for asking me to come and talk about mental health courts. It's a topic of great interest of mine, both personally and professionally. So happy to have a conversation about it today.

Kristen DeVall:

Fantastic. We're very excited to have you here. Before we get started, we were wondering if you could tell us a little bit about yourself and how you got started in the field of mental health courts.

Dr. Lisa Callahan:

My background going way back when I started graduate school was always in the intersection of the criminal justice and mental health systems in different ways as that's evolved. And when I developed courses for teaching criminal justice students, one of the areas that was emerging at that time were drug courts in particular and something of interest to them. I think there's something about new and different programs that really stimulate our curiosity. And so I learned as much as I could about them for conveying that information to students. And I was given the opportunity to take a job at Policy Research to head up the MacArthur Foundation's Mental Health Courts Studies.

                They had been underway for a couple of years when I came on board, but I was able to finish up all that goes in to completing a research study and doing the analysis and the reporting and found there were so many interesting angles in so many different features of mental health courts that really, not only prompted my curiosity professionally, but also really feel quite passionate that they're an important part of the continuum in the criminal justice system for people with mental health problems and the drug courts don't really do the job for people with mental illness.

Christina Lanier:

So to start us off, can you talk a little bit about mental health courts? What are they and then also kind of how are they structured and how do they operate?

Dr. Lisa Callahan:

I think one of the most important things to know about mental health courts is they are not drug courts for people with mental illness. They're really different. Now they may at first glance looks similar and that they're obviously a court, there's a judge, there's a prosecutor most cases, the defense attorney and the participants, but that's about as far as the similarities go in the work that I've done in observing countless numbers of mental health courts across the country. They have evolved for many of the same reasons, the drug courts did.

                Judges realized they weren't doing a particularly good job at keeping people with drug histories for example or addictions out of the revolving door, so that gave birth to drug courts and pretty much the same really origin of mental health courts that judges became really concerned that they would see the same clients, the same defendants over and over again and it didn't seem like their underlying mental health concerns and issues that were probably contributing to their criminal behavior weren't being dealt with. So they also then extended that drug court model into applying to people with mental illness.

Christina Lanier:

So in terms of a target population, what do you see as sort of some parameters around who should mental health courts be targeting specifically?

Dr. Lisa Callahan:

Most mental health courts, at least in their printed material if you will, their guidelines, will state that they are targeting people with serious mental illness such as schizophrenia, bipolar disorder, severe trauma, severe depression. And that is predominantly who is in a mental health court, but that's really just the surface. Most of the individuals in the mental health courts that we studied in subsequent studies are people who have pretty significant trauma histories and those trauma histories bring with them just a complex series of problems, both physical illness.

                In many cases, they have a cooccurring substance use disorder. There's different explanations of why someone may have a co-occurring substance use disorder. It may be that they're self-medicating, that they didn't have access to treatments that either suited their illness or that they had access to purchase because they're very expensive. That's one way of looking at it, but the other way of looking at it is that they work. Street drugs as controversial and unhealthy as they are for people who don't have access to regular medications and regular treatment, they do have access to street drugs. And in the short term, especially for someone with a trauma history, they fit the bill, although it's not exactly ... We wouldn't want to encourage it. We do need to understand why it is. They may be taking street drugs in addition to trying to treat their mental illness.

Christina Lanier:

Right. In terms of his team members, I know you talked about some similarities with the adult drug court model in terms of having a judge and a prosecutor, a defense attorney, can you talk a little bit about the other team members in mental health courts or who should be on the team?

Dr. Lisa Callahan:

Yeah, the should be part is a really important thing and that really circles back to the target population. In those communities where they try to just make a mental health court look like a drug court but for people with mental illness, the team probably would look a little bit different than what it should look like because in this target population, as I mentioned, you have people with really significant trauma histories with serious mental illness, they tend to be a little bit older than people who are in drug court. They tend to have a much longer history of involvement in the justice system and mostly really low-level crimes. We're talking about trespass and other kinds of crimes that are associated in many cases with people who have nowhere to live and have no access to treatment.

                And so if you think about what their lives are like, that's really who you're likely to find in a mental health court, unlike many drug courts who really target younger offenders, people who don't have a long life that had been involved in the addiction and in the drug world. Whereas people in the mental health courts typically have a very long history of treatment and really fractured treatment and high experience with homelessness and all that goes with that, no access to general or primary care. So there's a lot of physical comorbidity too with physical illness. So all that said, if you think about who is the ideal target population for mental health courts, you want to have a team that can serve those needs and really identify them, assess them properly and in terms of the treatment providers.

                But I would argue you would want to have a judge who has some experience, not only in the criminal court but also just having an open mind to how mental health court is probably going to be a little bit different. It's not going to run the way certainly the regular docket would or either the way the drug court would or a veterans treatment court. So you want to make sure you have a judge who is open to that, being a little bit more flexible and certainly very individualized responses to the people who are in the mental health court. There's not a template for, what is it, a way someone is going to progress through a mental health court.

                So your team is probably going to be a lot broader than your team would be in other kinds of treatment courts because you're going to have to have substance use providers or at least or someone representing them, a community provider that provides evidence-based substance use to treat those cooccurring disorders, ideally treat them together. You need to have people who are specialists in treating serious mental illness. You need to have people who are experienced with identifying and responding to trauma. And from there, you might choose to have other kinds of team members.

                Some of the larger or communities that have mental health courts have a public defender who is just devoted to the mental health court. They don't switch off, so you're not having a different public defender show up each week, but instead you have someone who has an interest in this kind of work. So they're able to talk the language of treatment with their client and also with the other team members which is really important because treatment courts aren't necessarily widely embraced by the defense bar. Sometimes it's not a good deal for their client in terms of the length of time they're going to be under supervision.

                So you want to make sure you have a defender who understands that this perhaps longer time in treatment and supervise treatment is going to have a longer payoff ultimately in this person's life that 18 months down the road, they're not going to be arrested again for another low-level offense and start the whole process again. So having a public defender and clearly also a prosecutor is open-minded to understanding the dynamics of mental illness and substance use and all of the complexities of people's lives is really key on a mental health court team. I would say they require a lot of flexibility, a lot of willingness to trust the other team members, ability to collaborate, not having to win.

                There's no win here. It's not sides and it's really what's best for the participants within the confines and within the structure of a court. It's a court after all. It is a court. So ultimately the judge is in charge, but when you staff a team, everybody has a little bit more voice.

Christina Lanier:

In terms of the program structure, so the activities that participants would engage in and for a length of time, do you have any thoughts about what the ideal program looks like in terms of structure?

Dr. Lisa Callahan:

I do. I've seen some really excellent mental health courts. Some that just really, almost left me breathless hearing the ... You wouldn't know whether it was the prosecutor talking to the defense attorney talking in terms of their interest in really the participant's wellbeing at heart, truly that that's what they all are working toward. There are different models in terms of, for example, whether case management is done by a probation or by a clinical case manager. Whichever that is, I think they each have to be cross trained. So if you are doing case management through probation, which perfectly a legitimate way to do it, the probation officers need to have an understanding of mental illness and cooccurring disorder, that's trauma. They need to be able to sound like a case manager who's trained, say, as a social worker.

                And at the same time, if you have case management provided by someone who's more clinically oriented, they need to understand that this is a court and there are charges, criminal charges that this individual is either pleaded guilty to in order to engage in the court or has had set aside to see what how they do in the program, one or the other. It is still a court. It is still the criminal justice system. So I think that cross training, and that's becoming more common, many, many communities have case managers who are forensically trained. So they understand the law, they understand the criminal law.

                And at the same time, you have specialized probation departments, which has fantastic. They choose and they specialize in working with people who are under community supervision, but who have really complex mental health and substance use problems.

Christina Lanier:

That's great.

Dr. Lisa Callahan:

So I think that that kind of supervision, whether they're uniformed or not or whether they're carrying a gun or not, I've found is really more about local rules and procedures, not so much about, "This is how the judges decided this particular court is going to be," but really about, "What are the requirements of the profession itself?" In some states, probation officers carry guns and they just do. That's just part of their orders. Whereas in other states, they don't. So I think it's more left up to that local traditions, local procedures.

Christina Lanier:

Right. Good.

Dr. Lisa Callahan:

I think other program structures, I don't think it can be emphasized enough. And honestly, this is something that courts are coming to embrace them today, not so in the very beginnings of mental health courts, going back way into the early 2000s when mental health courts were really starting to take a hold. It's the really important role of peers or people with lived experience being part of the team.

Christina Lanier:

Right.

Dr. Lisa Callahan:

More and more states have certified peer specialist training certifications, some that are particularly, they'll have a track to train people to work in the justice system. They sometimes call them forensic tracks. Peers can do work that others can't. They've walked in this person's shoes and I think the closer you have someone in your mental health court, who in fact, has been in re in treatment and is in recovery from their mental illness, I think it's really important. They can really be honest with the participants about, "It's going to be a lot of work upfront. It seems like there's a lot of hurdles here that you're going to have to get over, but you need to just really trust everybody, that people really have your best interests at heart here. And it's a lot of work, but the work is all good." And I think that's something that only peers can honestly convey that message to participants.

Christina Lanier:

That's a great point. In terms of incentives and sanctions, this is oftentimes one of those topics in other treatment court types, so any thoughts around the use of incentives and sanctions and how that may be unique for mental health courts?

Dr. Lisa Callahan:

I do. Some of it's been based on observation and some of it's been based on the research that we've done. Both in terms of my observations, but also what the research showed that we did with the various mental health courts that were in the MacArthur Studies is incentives really matter. This is one of the areas that I would love to have people do more research on because I think it requires a much more qualitative study and some much more in-depth interviews with people who are in and have completed or maybe left the mental health court. That happens to not everybody leaves willingly.

                And perhaps, it's the nature of the histories of the majority of the people who come to mental health courts. A dear friend of mine, a judge who unfortunately passed away, he used to say that people in mental health court are sick and tired of being sick and tired. And in that respect, they may differ some from people who are in drug courts. The average age is around 40 which is pretty old for treatment court, for any court for that matter. And so you have people who have in many cases, especially if their mental illness is something that they've lived with for decades, they have not been treated particularly well by any system honestly, starting probably with their family system and the education system and so forth.

                So when you create a program like a mental health court and run it, meaning the hearings and all of the different activities, run it in a way that is really sensitive, and I don't mean hug-a-thug kind of sensitive, I mean being sensitive to the lives that these individuals have led up until that moment, I think you can really start to understand why incentives matter.

                There's been some research and this actually was an area that we looked at, but others looked at, "Are they coercive? Are they voluntary? Do people feel like they're pressured into going into a mental health court?" We found that they didn't really feel coerced. And in discussing that with others who've been involved in mental health courts and some of the peers that we've come across, so they've been told what to do their whole lives.

                So coming to court and for the first time, the judge knowing their name and the judge asking them how their day was and the judge asking them whether or not they thought their treatment provider was a good match, what they did on the weekend, that's a first for them. And so that relationship that is nurtured with really all the team, not just the clinicians, but I would say even to a greater extent with the justice professionals because it's unexpected, it's not consistent with their lives up until that time, that is a big incentive and it costs nothing. It costs nothing to treat people with respect.

                And if I could give you an example and this, I almost well up when I talk about this because it was so moving and I had been in a number of mental health courts before this point, but I was in the Pueblo, Colorado mental health court and Judge Alexander is the presiding judge in that court, and their court, in fact, all of the participants have really serious mental illness. The only public state hospital in the state of Colorado is in Pueblo, so a number of the people who eventually come into mental health court are people who do have state hospital experience.

                And of course, typically only people with serious mental illness ever quite had been in a state psychiatric hospital. So this community supports an awful lot of people who have serious mental illness and the court reflects that. And before, each person appears before the judge and this is with the whole audience, so all the participants are there. The providers are there. Family and friends can be there. We were there as visitors. Judge Alexander asked the person to stand up when it's their turn and he tells them something that they did really well that week. And then, the prosecutor turns and faces the person, doesn't say it like over their shoulder, but literally changed faces and makes eye contact with the participant and tells them something they did well that week. And the entire team goes through that process with every participant. It's really moving.

Christina Lanier:

I can imagine. Right.

Dr. Lisa Callahan:

And it costs nothing. It's not bells and whistles. It's showing humanity, it's showing respect. I had seen this court a number of times, it's just really powerful to see that kind of kindness and understanding shown to people, who in many cases, that's not something they've had extended to them, at least for most recent history. The trauma histories of the people who were in our study were just overwhelming.

Kristen DeVall:

So Lisa, what about the other side of that and sanctions? Given all of your observations that you've done, we know that sanctions can be applied perhaps inappropriately in some cases, oversanctioned, undersanctioned. What did you guys see as you did your observations for the study?

Dr. Lisa Callahan:

Most of the sanctions that the participants remembered when we interviewed them really would be what we call today sanctions that are tied to treatment which is one of the guiding principles of drug courts, right? The sanctions should somehow be connected, not just a punishment, but really have a substantive connection to their treatment. Well, that wasn't the way in which it was ... That wasn't the terminology because that's a new concept. That was what they expressed, for example, and I'm not sure the therapist would appreciate this being considered a sanction, but they perhaps needed to see their therapist more frequently. I'm not sure I would see that as a sanction, but I understand why the participants didn't because it's a lot of work being in one of these treatment courts.

                You have to report to court. You have to report to your case manager your probation. You've got lots of appointments to keep, and group treatment, you really have a lot to do. So having to add something else to that list probably would be considered a sanction by them. We didn't find ... Well, we found that the judges really resisted using jail as a sanction. And they understood that that, a, wasn't going to make them any better, and b, that there's so much collateral damage that happens when you send someone with a mental illness to jail, that unless it's for a new offense or something that we would typically sanction someone with jail for, the team's really bent over backwards to avoid that. And I think that's appropriate.

                There are circumstances under which jail is justified as a sanction, especially for people who are engaged in treatment and perhaps and probably almost all of their cases taking psychiatric medications. When someone goes to jail, they can't take their medications with them. And so now they are either going without their medications that let's just assume some percentage of them were willing to take because they were still in the court, right? They were still were following what their treatment plan was, and now, if they do get to take a medication in the jail is probably not going to be the one that they were taking. So it really disrupts the treatment in a really profound way-

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Dr. Lisa Callahan:

So it really disrupts the treatment in a really profound way. And this is something I've come to appreciate more the longer I've looked at this and engaged with psychiatrists who work with this population, is that, that continuity of care is so important.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And they of course, depending on how long they go to jail for, if someone were to go, if you live in a state that is a Medicaid termination state, what that means is if you were in jail or prison, but jail for longer than 28 days your benefits are suspended and you have to apply all over again. In suspension states, which is a majority of the states but not all, they're just suspended because you can't receive Medicaid when you're in jail.

                That's a really important question for people, as they're thinking about what they make their courts look like, and under what circumstances someone might be sent to jail, it is so disruptive. And not to mention what it does to the person it's very traumatic to be sent to jail and shackled and searched and all of those things that are necessary components of being booked into jail. But there are circumstances under which judges will send someone to jail, they'll remand them. The cases that I saw where someone was remanded from the court often really were situations where there had been some kind of violent encounter. And that was just something that pretty much, that's a line in the sand pretty much everybody draws.

Christina Lanier:

I think that's a great point about just access to medication. And even if participants do have access to medication, it might not be the exact, prescription that they were given. So I think that's a great point that really is applicable to all treatment court types. The issue around the Medicaid and then also the medication, when you think about sanctioning and using jail pretty sparingly.

Dr. Lisa Callahan:

And the medication piece is I, just out of necessity, have learned more about this over the years. And the formularies that jails have are pretty basic and it's a huge part of their budget. So they are not going to be having on their formulary, the really expensive psych...

Christina Lanier:

Exactly.

Dr. Lisa Callahan:

Psych meds that some patients who've been in psychiatric care for a long time... They've tried a lot of different medications. They've worked with their clinicians over the years and have settled on one that works for them. And they... It works for them and it works for them. I mean it doesn't have just terrible side effects that are really imponderable. So if someone is put in jail, even for a weekend.

Christina Lanier:

Right.

Dr. Lisa Callahan:

That can really disrupt their treatment. And again, I'm not saying that there aren't circumstances under which that is the only sanction that the judge really can issue, but it shouldn't be anywhere near the first.

Christina Lanier:

Right.

Dr. Lisa Callahan:

There's a lot of other things you can do it. And honestly, the people in our study who we interviewed, it was close to a thousand, they really want approval. They want acknowledgement from their case manager or their probation officer and the judge and the others that they're really trying. And they're doing what they're being told to do. And getting those just the compliment from the people in power just goes a long way and it costs nothing.

Christina Lanier:

I was just going to say it doesn't cost a penny to implement that.

Dr. Lisa Callahan:

And I would argue at the end of the day, another area that we have been involved in doing research in and training is around trauma, vicarious trauma. This is really hard work that these individuals do with this population. They hear the stories, get to know them, right? It isn't just a one-off that they just represent someone in the 18 seconds there before the judge. They're with them for a year or two years, they get to know their stories and they're really hard stories to hear. I mean, 70% of the women in our mental health care study had been sexually assaulted before they were 20 and 25% of the men said that they had been... Now we know how under-reported sexual assault is.

Christina Lanier:

Right?.

Dr. Lisa Callahan:

So you learn those studies. I mean, it doesn't matter. You're not just the case manager, but their attorneys learn this, the judges learn this probation, the bailiffs know. This is hard work. So when people do well, when the participants do well and have breakthroughs, it is a lot of vicarious satisfaction. That, "Gosh, we, we put together the right program for this person. This is great." And you have to celebrate those wins because it is hard work. And if you don't take care of yourself as a professional, working in this field, working in this area, it's going to wear you down because listening to the stories and knowing... I mean, the other thing is suicide and drug overdose is not that uncommon in this population. And that's very hurtful to teams when they lose someone to care about.

Christina Lanier:

Yeah. That's a great point that I think sometimes we don't talk about that piece of it, sort of the professional self care.

Dr. Lisa Callahan:

Absolutely.

Christina Lanier:

Yeah. So Lisa, we've talked about the program structure and sort of how I think we've detailed some great characteristics of the mental courts that might differ a little bit from other treatment courts. But one of the areas that we find fascinating at least to try to... Even with other treatment court types is to really define what is success. The bi-modal recidivism yes or no question tends to be the one that filters up to the top, but there's definitely other things that could indicate success. So for mental health courts, what do you see as, in general, what constitutes success or what kind of outcomes or goals should a mental health court be focusing on?

Dr. Lisa Callahan:

I mean, I think that's a really important question because, and I'll kind of refer back to that this isn't the same as a drug court. This isn't, I'm not arguing for a second that addictions are in any way easy to overcome, not arguing that at all. And a lot of people in drug court have underlying mental health problems. So there's that, but people who have a serious mental illness, let's just say schizophrenia or bipolar disorder, there are definitely very effective treatments for those disorders, but you're not found to be no longer having those disorders. If you say, are in treatment and you're successfully in treatment, you still, I mean, you can function at a very high level and go long periods of time, maybe the rest of your life without having a particularly difficult time with it.

                But because it's different from addiction, we don't really think about people having an absence of what brought them into the mental health court. It's not...

Christina Lanier:

Right.

Dr. Lisa Callahan:

It's not an abstinence model. It's a maximum benefit model. And what's included in maximum benefit? Have we created a program and provided treatment and supports for this person that they're living the best life that they can live under the circumstances. And I mean, also what their social resources are too, not just medically or psychiatrically, but is their quality of life such that we, as the team think that they're ready to now be kind of turned over to just being with community supports and the treatment supports that we've helped nurture during this time, meaning they don't need to check in anymore.

                And that's honestly, it's a little bit controversial in that for many people who get to that last, when they're getting ready to leave mental health court. And I would say most of them have a graduation in ways that we come to understand them for treatment courts, but they don't have the checklist about what has to have occurred or what they have to have accomplished in order to graduate in the same way that other treatment courts do. Because some of the requirements aren't attainable by everybody.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And in one of the mental health courts in Cleveland that I have spent quite a bit of time observing over the years, their goal was to provide evidence-based practices, get people connected to housing, get people connected to other supports in the community and take this the way it was intended, the way they said it said this and never see them again.

Christina Lanier:

Right.

Dr. Lisa Callahan:

I mean what they mean by that is that they're able to live with the supports that they've helped get in place, the connections they've been able to make, stay engaged in treatment, maybe get involved in a fairly treatment intensive program in the community, like an ACT team or something like that, but that they don't need court supervision anymore.

Christina Lanier:

Right.

Dr. Lisa Callahan:

So it's going to vary by every person. I mean, there are people who make their way into mental health court, whether it's appropriate or not is a different question, but who have significant neurological or cognitive impairments. Their maximum benefit is going to be different than someone who has schizophrenia, who when responding well to treatment is a very successful college student. I mean, it's just going to be different, what they can gain from that.

                So, and that's what both of those are true. Both of those are cases I've observed. Some that are barely able to read and others who are absolutely brilliant and just kind of got off course a bit and got in trouble and were able to get back on course. And they're back living a very fulfilling life. So it's very much individualized what that maximum benefit is. And that's really where that trust that has to happen in, I think all treatment courts, but I'll just... We're talking about mental health courts, between the justice and the treatment professionals. They really have to trust when the treatment provider says, "This is the best treatment that we have. They're being responsive. They still have some other issues that are going on that maybe are not optimal, but we think this is as good as it's going to be for now."

                And the judge and the prosecutor and the defense attorney have to accept that, that they know. I've observed mental health courts where some of the participants really don't have any capacity to read. And it's not because English isn't their first language, and everybody's speaking English. They had to draw pictures for him to tell him what the requirements were for him to be in the program. That even the verbal explaining was just not resonating with him. He wasn't understanding it. So now some might argue he has no business being in the criminal justice system with that level of understanding. But again, that's someone else's decision.

Christina Lanier:

Right.

Dr. Lisa Callahan:

But they they worked so hard, the treatment providers, to figure out how they could communicate with him successfully. And the defense attorney and the prosecutor were like, "Okay, that's what we're going to do. We're going to have to have pictures."

Christina Lanier:

I think what you've just described, lays the foundation for the fact that mental health courts have a very diverse population that they serve. And so getting people to think about how do we provide services to folks that have such varying needs. That has really come to the forefront based on what you've said thus far. So thank you.

Dr. Lisa Callahan:

I'm glad that you mentioned that because I think that when communities start thinking about who it is they would serve in a mental health court... Now compared to drug courts, there aren't very many adult mental health courts. There are somewhere around 550 total across the United States. Whereas there are, I don't know, 4,000 drug and veterans treatment courts and DWI courts, all those combined that are built on the drug court model.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And there's a lot to learn from all the great work that's been done on adult drug courts, with all of the standards and... There's great work. And I think there's a lot to be learned, should the people who control the funding on a national level ever find it an important enough area to fund, which has never happened. There are no mental health court standards nationally. None. There's no best practices. There's no guiding principles. There are in states, but no national ones. So we just don't have the, I mean, every state but five, I think it's still five, every state, but five have at least one adult mental health court. Most counties though, only 15% of counties across the country have a mental health court.

Christina Lanier:

Wow.

Dr. Lisa Callahan:

Yeah. And I don't think I'm going out too far out on a limb here to say that almost every county in the United States, residents have access to a drug court. It may be a regional one, but they do. So only people who are living in 15% of the counties in the country have access to a mental health court. So it makes you wonder where are they being served?

Christina Lanier:

Exactly. Yeah. So keeping the idea of maximum benefit in mind in terms of kind of what programs are working toward, what suggestions do you have Lisa for how programs should be structured in terms of the length of the program, as well as how do individuals progress through from beginning to end?

Dr. Lisa Callahan:

I think this is a topic of great discussion when people are planning their mental health courts or revisiting them after a period of time they've been in operation, how are we doing? And that internal evaluation. I would say most mental health courts have on-paper phases, similar to other drug courts, DWI courts, et cetera. Usually there's four. And usually they are, I mean, probably the first phase and the last phase are the easiest to picture, you have the orientation and getting people sort of used to the process, they report more frequently, typically come before the judge every week or every other week, and have a lot of appointments, a lot of time taken up by getting enrolled and getting up to speed in the court.

                The last phase, whether it's a fourth or a third phase, but the last phase is getting people ready to sort of cut them loose, like, "Okay, you're not going to need to come to court so frequently. In fact, we don't want you to come to court maybe once a month but we'll check in with you and make sure that you're doing the things that you've come accustomed to doing, to stay in recovery and staying engaged with treatment. See how your housing's going, et cetera."

                What happens in the middle is a little gray, because many of the hallmarks that drug courts, for example, and I keep using that as sort of a comparison because we know so much about them. And I think it's a common language that people are aware of. People often say, "Well, how many phases in your mental health court? We have four in drug court and isn't that what we should have?" What happens in that middle space is a much grayer and much less structured than what you would find in another type of treatment court, because that's where you really get into working with the individual.

Christina Lanier:

Okay.

Dr. Lisa Callahan:

So if you think about what happens clinically with someone who has an addiction and they detox, and sometimes that's required before they plead in, the same is true for people with mental health issues. I mean, once they stop using illicit drugs and are on a medication regime or a regime that's appropriate for them, sometimes the middle can be really rocky.

Christina Lanier:

Right.

Dr. Lisa Callahan:

Because all of what's kept... And I find people that plead into mental health court, amazing survivors. And the fact that they have retained their hope that they can turn their life around, despite all the things that have happened to them and things they've done, and in many cases have cut off all... They have no contact with family, friends. They still want to try.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And when the therapeutic process starts, that middle part, which we might in another court called phase two and phase three can get really rocky. And there can be a lot of backsliding because when you take away someone's coping mechanisms. And let's just say, for example, illicit drugs. They got to put something in their place.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And that's where that really important therapeutic connection and engagement comes. That it can't just be anybody who does this work. They really have to understand the significant trauma that is going to come to the surface as soon as people stop using illicit drugs and are on a treatment regime that's healthy and appropriate. There's going to be a lot of stuff happen. So again, that trust in the team for the treatment provider to be at... Let's say, someone did great phase one, they're going to all their appointments, they come into court every week, they report to their probation officer or case manager whoever's charged with supervision.

                And then all of a sudden something... There's a backsliding or there's a problem. And for the treatment provider to be able to be honest with the justice professionals and for them also to know to expect that, that this is something that is going to be more typical when you have someone whose life is so complex. And there are so many risk factors there that it takes a while to dig in and find where's the points of resilience. It takes a lot of work to find that sometimes when someone's been living, essentially been living on the streets for the last 15 years.

                So the phase part in the mental health court, I would say is a little more loosely defined. Some states require phases in their treatment courts. But if you were to observe them and sort of measure, how many people are... How long are they in phase two? And how long are they... That kind of progression, I think you'd probably find that it's a little gray and not really, "Oh, the average length of time is this." I think they would probably qualify it with, for people with these issues who come into our court, the average length of time in the program is 12 months. We know from our research that people who have co-occurring substance use and mental health disorders in mental health court spend considerably longer periods of time under supervision than people without a co-occurring disorder.

Christina Lanier:

Okay. Great.

Dr. Lisa Callahan:

So kind of have to know that, know your population, right? And make sure your program can support that. I mean, if you're going to take people into your program, which I would say everybody is because that's just the nature of the population, who has a co-occurring substance use and mental health disorder. You're going to take them into your mental health court. You need to make sure you have the right, you can match the treatment to help them.

Christina Lanier:

Right. I think to what you said about having qualified people, providing the services to address need is really important.

Dr. Lisa Callahan:

And I think as much as COVID has been just a tragedy across the board, in trying to look at silver linings we've found in the work that we do at PRA is that the demand for telemedicine has just gone through the roof.

Christina Lanier:

Right.

Dr. Lisa Callahan:

Even on our own personal lives. I know my primary care doctor asked me recently, I was just there for a regular routine exam. Would I be open to telemedicine? Sure. But I had never been asked that question before. So I think with mental health courts, telemedicine provides a couple of unique opportunities that I really hope communities embrace. For those 85% of counties that don't have mental health courts, here's an opportunity where you can use telemedicine to really have the consultation, the expert consultation, I would say primarily the clinical staff obviously, to be able to provide you with evidence-based treatment and assessments and evaluations and interventions for your population. You may not have those individuals living in your county, you do in your state.

                No matter how small or how sparsely populated a state is they have qualified professionals somewhere in the state. And to be able to have a psychiatrist, for example, consult via telemedicine, to be able to provide really top-notch medication management and prescribing for this population would be remarkable.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And the pharmacies in your town can support that. It's not like these are compounded pharmaceuticals, they're regular medications, but they don't have the prescribers that really have the expertise and the training and the experience to be able to really understand the complexities of the issues that people have. They have to be more general. When you work in a small community, you have to be a generalist.

Christina Lanier:

Right.

Dr. Lisa Callahan:

So telemedicine, I think really from a prescribing and clinical perspective, I think really provides a great opportunity for communities to expand the mental health boards, now. At the same time, again, this might be kind of counterintuitive, there's a mental health court in Northeastern Oklahoma that I have observed. And the judge there got a grant and they were able to obtain tablets, like iPads, for all of their mental health court participants. Now, for people who are like, "You can't have them surfing the internet and doing this," they were all regulated. So they just had limited use that they could use. And they provided them with the service, with the wifi service so that they could report via iPad. This is...

PART 2 OF 4 ENDS [00:50:04]

Dr. Lisa Callahan:

... with the wifi service, so that they could report via iPad. This is way before COVID. This is like five years ago. And what they found was they would offer lot of their participants that were reluctant to come to court for any number of reasons, sometimes it was their mental illness. Sometimes they were having an acute paranoid episode.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And they didn't want to come into a room with at least people they didn't know very well. And so they were able to report to the judge, everybody could [inaudible 00:50:30] all the justice people they could check in with them and check in with the provider and say, "Yes, I've been meeting with him or her or them and they're taking the medication, we're doing group, we're doing individual therapy, doing really well. They just are having a hard time coming out of, in public right now.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

That's... Wouldn't you much rather keep that person engaged? Then say if you can't show up the court, you're out of here? And the other thing is a lot of people with in mental health care don't have transportation, right? Driver's licenses are not really a common phenomenon with this population. Now that doesn't mean they can't get a driver's license or that they didn't have one at one point.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Often don't have cars, public transportation, again, unless you live in a city center, public transportation's terrible.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And unless you have a church, there was a mental health court in rural Georgia that they were able to enlist the church to use their bus.

Christina Lanier:

Okay.

Dr. Lisa Callahan:

And volunteers to drive them to court, to go pick people up and drive them to court on court day.

Christina Lanier:

Uh-huh (affirmative).

Dr. Lisa Callahan:

But telemedicine, I think really has the opportunity of making mental health courts much more in reach for communities than, and just, we are forced to face this with COVID, but I think there's a silver lining to that.

Christina Lanier:

Right. Yeah. I think what you've just described is really thinking creatively about how do we, how does the program meet the needs of participants, where they are. [crosstalk 00:52:07]. While, and they can do that creatively. I think that the iPad example is a is a great one. They can still, show up. It's just in a different way, but they're in, and it's also being responsive to sort of where the participants are. So that, yeah.

Dr. Lisa Callahan:

Yeah. One of my really close colleagues, who's a probation office, who's chief of probation in a county in Texas. They do supervision of the drug courts. And she was talking about using telemedicine for some of the really outlined communities. And what she said, probation and I think the same could be said for the case manager, some from a clinical perspective. There's also a benefit of people reporting from their home as you can actually see the condition of their home.

Christina Lanier:

Right.

Dr. Lisa Callahan:

You can see if ask them 'Hey, what'd you have for dinner last night? What are you fix... Why don't you show me what you're fixing tonight?' And have them show the refrigerator. If there's no food in the refrigerator, then they know they need to send adult services, protective services to at least provide groceries for them.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

And they can tell whether there's people there who shouldn't be there, which also sometimes happens. People get taken advantage of.

Christina Lanier:

Right.

Dr. Lisa Callahan:

So, seeing people literally where they are can also have the added benefit of checking, of a check in a wellness check, almost for people right beyond their psychiatric wellness, but their quality of life wellness is also.

Christina Lanier:

That's a great example.

Dr. Lisa Callahan:

[crosstalk 00:53:38] Some of the things, I'm sorry. [inaudible 00:53:39]. Some of the things that people need in mental health court, I think, those of us, who've worked in the field for a long time and, we're all do gooders, right? And we imagine, and this is something that when I came to understand mental health courts better, I realized that for the most part, we're not talking about really heavy lips here. There was a case I was watching a woman being her. She was being considered for enrollment in a mental health court. And they had a position available for her. They had a, they had housing available for her. She was coming from the jail. They had housing available for her, which of course, everyone one knows is so hard.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

And they didn't want to lose the spot for her. And, and housing for women is less than housing for men too.

                So that's even more difficult. And the provider was there and she was willing, she was ready to take this woman who wanted to go into the mental health court. Everybody wanted her to plead in, wanted to take to the housing. And there was this whispering going on and that she might not be eligible to go. And of course I was curious, why not? They just all said she was legally eligible, clinically eligible. There was a bed. What the heck is the problem?

Christina Lanier:

Yeah, yeah.

Dr. Lisa Callahan:

Come to find out the reason why she wasn't eligible. This just breaks my heart, is that she didn't have any underwear.

Christina Lanier:

Oh my gosh.

Dr. Lisa Callahan:

And you had to have your own underwear. They could get them other clothes at the shelter where she was going or the residents where she was going. But people had to come with their own underwear. I mean, I wanted to go run to the convenience store the corner and buy her, couple packages of underwear.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

But I mean, that isn't the truth, everybody, but it isn't always something that's that hard to provide for people.

Christina Lanier:

Mm-hmm (affirmative), right. Don't let the little things be a barrier to participation.

Dr. Lisa Callahan:

Yeah. And I'm sure. So somebody from the court probably did run out and buy her underwear so she could go to the residents, but...

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Sometimes it's basic again, the human humanity, we're just, what are things that people need to feel respected?

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

They need to feel like a human being that people are listening to them. They care about them. And some courts just do an exceptional job at bringing that into this, otherwise really scary environment.

Christina Lanier:

Mm-hmm (affirmative). Lisa you've already provided some really great ideas for communities that might want to implement a mental health court. What other tips might you have for those communities?

Dr. Lisa Callahan:

My first recommendation is that you have a judge who is willing to, to start the court.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

As I said before, it still is a court. And the judge really has to be on board. And to the extent they can provide the leadership, not just within the justice community, but beyond that.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

When judges with the exception of perhaps defendants, when judges ask you to come to a meeting, you show up [inaudible 00:57:03].

Christina Lanier:

Right.

Dr. Lisa Callahan:

Defendants don't always show up, but everybody else does. So, if a judge decides that they want to start a mental health court, and this could be a it's not unusual for a drug court judge to say, you know what, we're really missing a population here. I think we really need to start a mental health court or a docket. Let's try a docket within.

Christina Lanier:

Mm-hmm (affirmative), right.

Dr. Lisa Callahan:

And move people over to that. But I really do think it takes the leadership of the judge. Some states have really sophisticated funding structures for all treatment courts. They don't prioritize, or at least don't appear to prioritize one kind of treatment court over another.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

And so if you wanted to start a mental health court, you probably, there would be certain protocols you'd have to go through and they would have rules for you to follow right to start this court.

                That isn't true in most states though. And also it's important to keep in mind, there's not any federal funding at this point in time for mental health courts. So, that money either comes from your state, your county, your maybe co-sharing with your mental health will and your justice partners. But unlike drug courts, which are funded very extensively by the federal government, mental health courts have never had that kind of, that kind of support, which probably helps account why they're only 550 of them. So, having a judge be the champion comes into play in not only because he or she, or they have to be over the court, but they know who to go and tap on their shoulders and say, we need some help with this.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Would you be willing to, of course you say yes to a judgment when you're asked that question [inaudible 00:58:57] .

                One of the mental health court judges that was in our study. And also then we did, I did a number of site visits with him to other mental health courts. After that he was quite the fundraiser.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

And he did say there was never a door that he wasn't willing to knock on. And he was able to get the medical school. And he happened to be in a big city. So, he had access to this, the medical school to have the court, the mental health court be a rotation for the psychiatric residents.

Christina Lanier:

Hmm. Oh, that's great.

Dr. Lisa Callahan:

So of course that was free.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Free to them. Of course the residents, it wasn't free to them, but it was to the court. So, and then they would, he was able to get a nurse practitioner assigned to the court the days that court was convening. So it was only one day a week and she would do medication management then with them. And she would, talk to them about side effects and, and do all of that work with them, not another appointment, but when they're at court. And again, this was a donated service from the local mental health authority there in the city where he was.

                So having someone who has the vision and has the willingness and has the power to make this a community effort is, [inaudible 01:00:16], is a shortcut to get to starting of court.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

He's also someone who taught me that it was a phrase he used quite often. He said, you build the bus and eventually you just have to start driving it and see if the wheels fall off [inaudible 01:00:32].

Christina Lanier:

Right.

Dr. Lisa Callahan:

You may have the absolutely worst ideas in the world, but until you try, you never know.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

So that would be my fur that is really critical. And if you don't have a judge, who's willing to be that person. It's not going to work.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

I mean, you can have the best treatment providers anywhere. You can have staff, you can have a court coordinator, but if you have a judge who isn't all in.

Christina Lanier:

Right.

Dr. Lisa Callahan:

It's going to be a, it's going to be a heavy lift. A judge who I've observed his court, both drug court and mental health court. And he is, he used an example we were co-presenting on mental health courts at the NADCP meetings a couple years ago. Last time we met in person, actually the conference met in person. And he put up a, he said he was talking about mental health courts and mental health [inaudible 01:01:22] coexisting with drug courts in the same community because there can sometimes be some tension about...

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

His clients or whose. And he put up a painting. The painting, a representation of the Mona Lisa.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

[inaudible 01:01:34], this is what a drug court is. The outlines are clear. There's a little bit of nuance in the back. You're not quite sure what the background is, but it's, pretty clear what this is. This is what a drug court is. And then he put up a Jackson Pollock painting, [inaudible 01:01:49] [crosstalk 01:01:49] who aren't familiar with Jackson Pollock. He's the one who people think he just threw paint at the canvas, but it's an abstract painting. And he said, this is a mental health court.

Christina Lanier:

Right.

Dr. Lisa Callahan:

So, that's what you have to be prepared for that it's not going to be neat and tidy lines.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

So making sure that you have people on your team who are experienced and don't need neat and tidy lines all the time.

                So you want to have a public defender who's experienced. You want to have a, unfortunately I've been in courts, mental health court where drawing the mental health court straw means you got the short straw.

Christina Lanier:

Right.

Dr. Lisa Callahan:

For the prosecutor's office. That's not who you want in the room.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

You want someone who who's been around long enough to know that there's some cases we just don't do a very good job with, maybe this is a good alternative. So you want to make sure that you recruit the right people. And I think the judge again, has a lot of influence in that, in that regard, speaking with the public defender, speaking with the prosecutor and say, this is what we want to do. I need you on board, et cetera. And work with them to develop, like, what are the legal, legally eligible crimes?

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Many of them start small, meaning not serious, but that's a kind of a tough sell to the defense bar. If, most defense attorneys view their work as getting the best deal for their client, if someone's charged with trespassing, going into a special specialty court with one year of supervision is not a good deal.

Christina Lanier:

Right.

Dr. Lisa Callahan:

It may be what's best for the person.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

But you've got to have a public defender who sees that and has support in their office to do that again, experience matters. And I would say that trickles all the way down to all of your, whoever is going to be your community supervisor, case manager, probation, whoever that's going to be, making sure that you have, if you're going to do drug testing, which the majority of mental health it's due drug testing.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Probably not to the same extent that drug courts do.

                And not with everybody, even if it's known that they use illicit substances, not everybody gets drug tested, but making sure that that provider is [inaudible 01:04:16] is provider, that you can have a conversation with about this, about your population, that sometimes they're just not going to be able to report and maybe trying to figure out why maybe having someone else, someone different, be the observing, the testing. So it's, there's a lot of that kind of collegiality and coalition building around this, like getting people on board.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

That are thinking about this in the same way that this is a population who, whose needs and problems are not being well addressed in other courts, general or treatment courts. And you're going to try something a little bit different.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

I would encourage communities to do a broad RFP to their provider community to see who would be the best fit for the or for multiple...

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Which providers would be the best fit. It isn't necessarily going to be the ones that they know.

Christina Lanier:

Right.

Dr. Lisa Callahan:

So that would be something that I would really encourage a community to find out like, who the heck could we could we drawn in our community and it might be, again, going back to telemedicine.

Christina Lanier:

Mm-hmm (affirmative) [inaudible 01:05:37].

Dr. Lisa Callahan:

It might not be the same old provider that you've used for everything else. Okay. I think when people issue RFPs, they might be surprised at some of the resources that are available right in their own backyard.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

The, I think it's important to, and this is a clinical requirement because of the complexity of the population that you really need to make sure you have very qualified people who can do the screening and assessments.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

That are required not just for a mental illness and substance use, but also for trauma. And speaking with people who are experienced in this deciding when it's best for example, I mean, typically for someone to be eligible for mental health court, they have legal requirements that it, has to be these offenses and not these offenses. But I will say that mental health courts tend to be a lot more, have broader eligibility than drug courts do.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

That's part of the beauty of not having any federal support, because then you're not told what [crosstalk 01:06:47] you can accept in your court. But so that's those screening and assessment for mental illness and substance use pretty much has to be done up front because you have to find out if someone's eligible.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Meets the eligibility criteria. And if they may in fact meet regardless of what state you're in, whether you're in a Medicaid expansion state or not, it could be that their underlying mental illness does qualify them for Medicaid, even in a non-expansion state, because it may be a disability.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

It may a disability criteria. So that's really important to do upfront, but the trauma piece is a little trickier. I would advise people considering these kinds of courts to assume everyone who you're going to accept into your court has a significant trauma history.

Christina Lanier:

Okay.

Dr. Lisa Callahan:

It's it's not something you need to know what that is day one.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

It doesn't have to be done at the same time as the alcohol and other substances and mental illness screening and assessment. It has to be done eventually because you want to make sure you're matching them with a good provider.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

But, that kind of information is slow to be revealed for good reasons, right?

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

You don't want to tell a total stranger, your worst nightmare and the worst days of your life. So it's important to include. We've done, we did some work a couple of years ago with Queens, New York, with the treatment core judge there. And we worked with them on timing, the screening assessment, because it was too much to do upfront and probably were not getting reliable information.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

One thing that the trauma research shows is that people who are experiencing and have experienced significant trauma will, I'm not going to call it lying because I don't think that's what it is.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

They will say what they need to, to make themselves safe in the moment.

Christina Lanier:

Right.

Dr. Lisa Callahan:

So they're not going to divulge everything that comes out in time in a it's important to do that, but tying it to a little bit later when they've developed a therapeutic relationship with someone is probably better timing.

Christina Lanier:

Right.

Dr. Lisa Callahan:

Then they only have to tell it once.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

That's another thing, people having to tell their story multiple times.

Christina Lanier:

Yeah.

Dr. Lisa Callahan:

Being careful that that's not the case. We talked about, the provider a bit about who the providers are knowing who's in your community.

                And again, it may not be your public provider. It may be an individual practitioner in your town who is really quite skillful with women, for example, who have co-occurring disorder and trauma histories that you might have better outcomes, engaging that provider than your who you would normally go to. So again, go, I know I'm repeating myself, but making sure you understand the complexity of the population you're targeting and making sure that you have the right providers on board.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

And for many people in mental health court, having someone screen them and work with them, making sure that all of their eligible entitlements come to them is really important because of that, the interruption of services that we were discussed earlier, sometimes they've gotten detached from all of their entitlements.

Christina Lanier:

Right.

Dr. Lisa Callahan:

Treatment housing, any number transportation. So having someone who is trained such that's, someone who's gone through the soar training.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

So that they can have people in your, the other thing too, is mental health court tends to be longer than drug court.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

So you're going to have people around for a while. So you have time to do these things, to make sure that you have them connected back to Medicaid, that back connected with SSDI.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

In most states, even in non-expansion states, if someone has what we would've in the old days called an Access One Diagnosis, Schizophrenia, or Bipolar Disorder, they probably qualify as having a disability.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

So get those services for them, right? I mean, this often housing come attached to some of those services.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Really with this population, as opposed to some, in other, other treatment courts, you probably have need a wider, you definitely need a wider treatment provider network.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

But you also have more resources available, but you need to have someone on who can access those because it's hard work, putting all that, all those materials together is hard work.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Some communities are, have great relationships with pharmacists who really taken upon themselves to be really creative in helping meet the needs of the court and of the population. For example, there are, I'm not a pharmacist, so I don't know the properties of this, but I know there are non amphetamine based medications that can be used for people who perhaps have been, had a, an addiction to methamphetamine. And you clearly don't want to give them amphetamines if they have ADHD, but they're non amphetamine substitutes, but the pharmacist needs to be involved in that because they know how to access those. They can often get donations from pharmaceutical...

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

...companies for some of these medications. So having a partner or partners in your community that are, will to work with you around medication, because many people in mental health court, they they're going to be on some kind of psychiatric medication. They're probably going to need medications to alleviate some of the side effects that those medications have.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

They also likely have medical problems that require medications, high blood pressure, diabetes, et cetera. So you want to make sure that whatever medications they're getting, the pharmacist can advise you that. Well, that's probably not the best combination. So...

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

It's having that relationship and engaging them as a partner, right? I mean, frankly, I think they would think it was kind of cool.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

To be tab their expertise tapped into, in this way, the extent to which you have a an active NAMI.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Organization in your community, great partners to have, they can bring resources to bear that you didn't know existed.

                NAMI has both family and peer components. They may be a great organization to tap in for support for starting say, if you don't have a already have an established peer support network in your community.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

You can do that. If you don't have a local NAMI chapter, you have a state NAMI chapter, and they can just get the ball rolling for you. And that's at least a place to start. There are a number of states who have great peer support programs. And if you happen to when those states, there's, there'll be a state leader who will be able to hook you up with someone in your community and make sure that they're involved in your, in setting up the court and, and being part of it. Housing is one of the biggest barriers to this, to this court and treatment courts generally.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

Many people who eventually make their way to mental health court have a reputation in the community in around housing, and maybe have been barred from some housing.

Christina Lanier:

Mm-hmm (affirmative).

Dr. Lisa Callahan:

That's something you can work with your justice partners. That's a really good role for like the judge and the prosecutor to maybe circle back with some of them and say, we're doing things differently now, or providing supervision. And we wouldn't send anyone there who we thought was at risk for being disruptive or being dangerous. So using those partners who have sort of the justice clout versus the treatment.

PART 3 OF 4 ENDS [01:15:04]

Dr. Lisa Callahan:

Partners who have sort of the justice clout versus the treatment clout, using them in a way to alleviate some of the concerns that your community partners have. Businesses might be a little hesitant at first, if they think that there are frequent faces around their business are now not going to be ... The police aren't going to respond, etcetera.

                So making sure that all of those partners, all of your community really. The community is aware of it and what you're doing. So, I think that most communities, no, there's a need for something different. They may not know how to begin. And I totally understand that. As I said, unfortunately, there aren't any national guidelines for mental health courts. There are some state guidelines and there are some states that have really good guidelines that it can be shared. If they want to know, like how should we set up a mental health court, what should it look like? There are states that have really good guidelines, that have gone through a really excruciating process of developing those guidelines with input from every corner of the community. Those are, like Michigan has really extensive guidelines. Arizona does, Ohio does, Georgia does. So these are states that have gone through the process of developing statewide guidelines. And in order to call yourself a mental health court in those states, you have to meet those requirements, which is important, I think.

Christina Lanier:

Yeah, that's a great resource. We'll be sure to find those guidelines and ensure that they're on our website, ndcrc.org, so others can access those guidelines. And I think, Lisa, when you were talking about the relationship between programs and pharmacists, I think just in treatment courts in general, we talk about programs having relationships with doctors, specifically ones that are prescribing maybe medication for opioid and alcohol use disorder. But I hadn't really thought about the relationship with a pharmacist. And so, again, kind of the utility of that and what they can provide that may be unique. But that's really interesting and helpful.

Dr. Lisa Callahan:

Well, the program I referenced earlier in Northeastern, Oklahoma, it was actually the pharmacist locally who developed a reporting software for the court and he was just totally into it, and it was a hobby for him, I guess, or an extension of his professional interests. But the court could, excuse me, not the court. The providers could see whether people had picked up their medications. Of course, you don't know whether they're taking them or not. If they're dispensed, then there's an assumption that, to some extent, they're being taken.

                So, they're a great resource. And I think for mental health courts, clearly there are going to be people in mental health court that are also going to be on MAT.

Christina Lanier:

Right.

Dr. Lisa Callahan:

And so that's a very complex relationship I would expect between taking MAT and taking a psychiatric medication and being able to manage those side effects and being able to talk to individuals who maybe have never tried to stop taking whatever opioids they've been taking for the last some number of years, but to really have someone so knowledgeable and has the time and the willingness to explain what's going on, I think, is a real resource. And again, this population is more complex than a typical drug court population. So I think they're really valuable partners.

Christina Lanier:

Yeah. That's excellent. For our listeners that may be researchers or aspiring researchers, what would you suggest in terms of some future avenues that folks could explore as it relates to mental health courts?

Dr. Lisa Callahan:

We were able to just touch on and not to the extent that would have been very valuable, the how co-occurring disorders are best handled in mental health courts. If you think about, again, going back to the there's only 550 mental health courts and 4,000 drug courts, most people with a co-occurring disorder are in a drug court. Just they have to be. And because it's a drug court, there are substance use. And this is, I mean, I'm sure as everyone listening who's familiar with drug courts, what often happens is they, through their drug court involvement, they become abstinent. And then their underlying mental illness comes forward. Right? And then they realize that, oh, we're dealing with the psychosis here, or we're dealing with PTSD here, or we're dealing with depression here.

                And fortunately, there's much more emphasis on dealing with and effectively treating co-occurring disorders in drug courts. I'm thrilled with that direction. But there's really not very much research on that population and whether they're better served in a mental health court or in a drug court. And I really think it's important. And I haven't designed a study in my head. I designed lots of studies in my head but that isn't one of them. But I think for the number of people we're talking about and being able to have the most impact, that would be something very valuable to do, because I think what happens is people will be in drug court for a period of time. And this was shown in the evaluation that was done at the Bronx and the Brooklyn mental health courts. And we also found it in one of the courts that was in our study, is that people spend a lot of time in drug court because first, because they're arrested for a drug offense and they're using, and that's obvious that that's part of what's going on. So they go into a drug court, plus the drug courts are available.

                And as I mentioned, then they get into treatment and they become abstinent. And they realize they can't really treat the underlying mental illness effectively with their provider network. And so if there's a mental health court, they sometimes transfer them over to mental health court to deal with the mental illness. But wouldn't it be nice if they didn't have to do that consecutively, but they could do it at the same time? And that's, from my colleagues who are clinicians, that's the gold standard.

                So finding, and rather than saying, we can't take anybody with co-occurring disorder, which I think would be a tragedy. I don't think we've landed on the best way to respond to their clinical needs. As I said, we found that they stayed the longest and were most likely to have a jail sanction, actually going back to that question, most likely to be remanded to jail, most likely to be terminated, typically terminated after a long period of time.

                So it wasn't like they're in three months and things aren't working and they're terminated. They're in 18 months and things aren't working. So I'd like to see some work done in that. And I think that's a combination of really getting the best minds together about the clinical issues underlying this. I think the opioid addiction is probably complicated even more than maybe sort of the co-occurring disorders in past like 15 years ago.

                I also think that we don't have ... Some of the questions that you asked, I think, really led me to suggest this. We don't know very well why mental health courts work. It's kind of embarrassing to say that. We know they work. We know they work. We know that they reduce contact with the justice system. We know that people are more likely to get engaged in treatment faster and stay in treatment longer. We know that their quality of life has improved, not just subjectively because they're in housing, but we interview them. They restored with some relationships, restorative, etcetera, quality of life. But we don't know what's the operating mechanism here. Is it being connected to good treatment that really is ... Very patient centered treatment.

                If that's the case, maybe we need to do that a little sooner in the system. If it's keeping people out of trouble that have gone all the way to the point of getting into a mental health court, which is pretty far down the criminal justice pathway, gosh, if we could get them engaged in treatment earlier and interrupt that ... I had one fellow who had 200 and some arrests in one of our sites. Maybe at arrest 10, if something could have been done differently, it would have saved him a lot of heartache, a lot of trauma, and it would've saved the community a lot of resources.

                So I think understanding what the operation, what it is that is the operational, the black box, if you will, I think would be, I think we're at that point with mental health courts. I don't think we need to justify anymore why there are mental health courts or if they work and kind of what they look like, who needs to be there.

                I mean, I think we have a pretty good idea of that. I think I could design a pretty good mental health court for a community, but I'm not sure why it would work. I'm confident I would. I would bet that it would. But I think that's an unknown. That may be true of the whole behavioral health field.

                So we know treatment works. We don't know why.

Christina Lanier:

Right. The million dollar question. That's excellent.

Dr. Lisa Callahan:

I think that the role of peers is really just ripe for research. And I think that, and this is maybe a topic for another day, but peers who specialize in working with people with serious mental illness, I think are really key. And they're there. Justice involved, people with lived experience who have mental illness and maybe had a co-occurring disorder, clearly certain types of trauma history. Gosh, they're such good team members and very valuable professionals in the courts.

                But again, I think knowing that, because what happens sometimes is that peers are expected to be volunteers rather than paid staff, paid professionals. And I think being able to study the impact of peer support would further cement what many of us know, is that they bring value to a program and I think should be compensated accordingly.

Christina Lanier:

Absolutely. Yeah.

Dr. Lisa Callahan:

There's one other area I think there's been some research in, but I can't go to any community where everybody does this, first thing out of their mouth is housing, housing, and housing. The kind of supportive housing that would be most appropriate for mental health clients, mental health court clients, I think is also worth researching. Whether it's a housing first model or a sober living model, those are different from one another.

                The sober housing tends to be the dominant model in drug courts. Housing first may be more appropriate for mental health court. And housing first is an evidence-based practice. So it's not something that I'm suggesting out of the blue, but when we were doing a site visit in a community in California a couple of years ago, and they were combining, they weren't, the program combined drug courts, mental health courts. They called them collaborative courts.

                And we were in a site visit with people from both the substance use field and the mental health field. And they were talking about the resources that existed and didn't exist and the people in the substance use field said, well, we don't have any housing for anyone in our community. I'm not going to name the community. In our community, where people don't have to be detoxed and sober before they are admitted into residence. And the mental health people said, yes, we do. We have. And they listed off all of these housing first programs in their community that the substance use people didn't even know about.

Christina Lanier:

Oh, wow.

Dr. Lisa Callahan:

So I think it would be an interesting study to compare which is more effective and put resources in that direction.

Christina Lanier:

Right. Absolutely. Not just assuming there's one model of housing, just as there's not one model of treatment. There's not one model for program structure, but being flexible based on the needs of the target population. Yeah.

                Lisa, we would like to provide listeners with a call to action of sorts. So do you have any strategies in mind for how listeners can integrate the information that you've talked about today into practice?

Dr. Lisa Callahan:

I do. I think that most communities have room for addressing the population that you would typically have in the mental health court. And the reason I phrased it that way is not all communities probably have the resources to have a fully separate court. But I do think that if teams, whether it's initiated by the treatment provider or by the justice folks, the judge and others, to really have an honest conversation with themselves about, okay, look back, last year, five years, 15 years, however long you've had your court, whose needs are we consistently not meeting? Who are we having a hard time with? And I don't mean because they're a pain in the neck. I mean, because we're clearly not meeting their needs because they are continuing to have difficulty in our program.

                So I think that's a place to start, is having that hard conversation. Now, there may already be a lot of incentive for having a mental health court in your community. I think that's great. And as I said earlier, get the judge on board, have the judge and others who, maybe the head of your local behavioral health center, start making the rounds. I mean, it's a a PR effort. Right? I mean, you've got to drum a business. I mean, and support for this. Communities don't like change. Maybe some communities are more right for change right now, given the very public failings of addressing people in the community with mental illness, people who become justice involved, sometimes because of their mental illness and the outcomes are not good.

                I think communities can have this conversation in the context of that as well, because the kinds of wraparound services that mental health courts provide are what people with serious mental illness need. And to add the additional, I mean, I said earlier that maybe all they need is treatment and we can move it up close to. The fact is that you're always going to have people coming into contact with the justice system who have serious mental illness. And some portion of them are not going to be engaged in treatment. And it may be because it wasn't available or it wasn't the right treatment or they've moved around and not been able to stay engaged in treatment.

                But so, there's a lot of reasons why people are not engaged in treatment and come into contact with the justice system. But I would argue that to see this as part of a larger response, community response to effectively addressing the needs of people with mental illness in the justice system, the same kind of conversations that are taking place, like making sure we know that people are screened at the jail, using the brief jail mental health screen or whatever tool you use. Making sure that there's training, not CIT training, but specific like mental health first aid for all police officers and first responders.

                I think this can be part of that conversation because you are going to have people who, by virtue of what they've done, they're going to penetrate the criminal justice system. And it may be that their mental illness simply is exacerbated by their experiences, the trauma and the not having medications and not having the support and being afraid.

                So, I think it could also take, that you don't have to start a mental health court, like just out of fresh, all new cloth. You can think about other programs that you have, that this would be different from, but maybe you could share some resources because I don't think any communities have an abundance of resources. So sharing resources, but having a different philosophy and really starting with, again, the people who you trust in the community, the judge is going to lead this, whoever the coordinator is going to be, perhaps the chief probation officer, your sheriff. I mean, all of these main partners who, you're all dealing with the same people on a regular basis, and thinking about what this would look like to effectively address the mental health court population.

                It's not a threat to drug courts because chances are that these are the individuals who they'll admit they don't do very well with and asking them, not who can we take off your hands, but how could you do your job more effectively? What program participants should we have, that you could do your job more effectively and we could do our job effectively by treating a different population in a different way?

                It still holds them accountable. And I don't think people who are listening to this podcast, this conversation, would think this, but there are an awful lot of people in the public who think that people with serious mental illness are intellectually impaired. That is just simply not the case. These are not individuals who are not capable of being accountable and contributing to our communities, but the right programs and supports have to be in place for them to be able to have that maximum benefit.

                And they're going to be different than they are in drug court. There are going to be some shared partners, but there's going to be some additional partners or partners doing their work in a different way. Understanding that a population that should be the target of a mental health court are not to be necessarily the same people who they're going to be in a drug court. They're just going to be a different population. And it should be created a new, from the ground up. Who are we and how can we set up a program that would best meet their needs?

Christina Lanier:

Great. Well, Lisa, we would like to thank you for joining us today. We really appreciate your time and your willingness to share your knowledge about mental health courts.

Dr. Lisa Callahan:

Thank you. I enjoyed the conversation.

Christina Lanier:

To our listeners, thank you for being here. We hope you find this information useful and relevant to your work as treatment court practitioners. Please join us on the NDCRC Justice to Healing discussion board to continue the dialogue. And join us next month for another episode of Justice to Healing and always remember to do better.

Voice Over [Outro]:

To our listeners. We thank you for listening and we hope you enjoyed the show. Be sure to hit subscribe to stay updated on the podcast. Follow us on Facebook, Twitter, and LinkedIn to stay engaged with us and check out our website, NDCRC.org. Thanks again. Catch you next time on Justice To Healing.

The Justice to Healing podcast is presented by the National Drug Court Resource Center and was supported by the grant number 2019-DC-BX-K002, awarded by the Bureau of Justice Assistance, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime and the SMART Office. Points of view or opinions in this podcast are those of the author and do not necessarily represent the official position or policies in the United States Department of Justice.

PART 4 OF 4 ENDS [01:37:22]