June 1999 

King County's Mental Health Court:
An Innovative Approach for Coordinating Justice Services

by the Honorable James D. Cayce and Kari Burrell

It is rare that an idea to improve on our system of justice gets virtually unanimous support and commitment. Yet, the concept of creating a Mental Health Court in the King County District Court has done just that. From its first mention over one year ago through its implementation in mid-February, the idea that we can do a better job in handling misdemeanant cases involving mentally ill defendants has received tremendous support. This support has included not only the commitment of time and energy from literally hundreds of planning participants, but also the necessary financial backing. The general consensus going into this project was that it was "the right thing to do" for many reasons.

In August 1997, retired Seattle Fire Captain Stanley Stevenson was fatally stabbed by a man later found to be criminally insane. That tragic incident has been the catalyst for some sweeping and innovative changes in the criminal justice and public health systems in which mentally ill offenders are handled. Shortly after the Stevenson incident, King County Executive Ron Sims formed a statewide task force of individuals representing the key treatment and legal service systems involved with the mentally ill. The task force included judges, prosecutors, public defenders, police, mental health professionals, mental health board, family advocates and government officials. Retired Justice Robert Utter was selected to chair the Mentally Ill Offenders Task Force. After an intense two months of meetings, the Task Force Report was issued with numerous recommendations for change and the implementation phase began. The civil and criminal laws under which these cases come before the Superior Court and the Courts of Limited Jurisdiction have been revised to give the courts far more options in dealing with this complex population. One of the numerous system changes recommended was a pilot Mental Health Court project to test whether an alternative approach to handling cases for mentally ill misdemeanants could be more effective than the regular court system in reducing jail time and recidivism, and in providing better linkages to the mental health treatment community. Executive Ron Sims asked King County District Court Presiding Judge James Cayce to chair a Mental Health Court Task Force for the purpose of further exploring this specific recommendation.

The issues that the Mental Health Court Task Force convened to address in Washington state are similar to issues faced by numerous localities nationwide. There is some evidence that, with the movement to substantially reduce the use of state mental hospitals as a treatment option for the mentally ill, the numbers of mentally ill in the community who receive inadequate or even no treatment has increased. Furthermore, some have hypothesized that, in fact, an emerging trend is the "criminalization" of mental illness: that the mentally ill are landing in jails and prisons with increasing frequency due to issues related more to their illness and less to the crimes they may have committed. The National Alliance for the Mentally Ill estimates that 25 to 40 percent of the mentally ill today will come in contact with the criminal justice system for one reason or another.¹

National research studies have documented that the numbers of mentally ill incarcerated in jails and prisons is a significant percentage of the overall jail and prison population. One source indicates that more than seven percent of the incarcerated are diagnosed as having one of the three serious mental disorders (schizophrenia, bipolar disorder and major depression) and that more than 50 percent have other mental health diagnoses.² A study completed in 1997 indicated that the numbers were even higher — more than 10 percent of the incarcerated population had a diagnosis of a serious mental disorder. This study indicated that in jails (rather than prisons), nine percent of men and 18.5 percent of women in custody were seriously mentally ill. This rate of serious mental illness is four times higher than the rate in the general, non-incarcerated population.³

The growing number of mentally ill in the jail and prison population is problematic for a number of reasons. There is the concern that many individuals are arrested for behavior that probably could have been better addressed through the mental health treatment system. Another concern is that jail and prison environments may further aggravate, rather than improve, mental health conditions. Finally, there is evidence that the mentally ill are arrested and jailed more frequently and have longer average jail stays than the general population. A 1991 study of mentally ill offenders in the King County Jail showed that inmates with misdemeanor charges admitted to the Jail's Psychiatric Unit had an average length of stay three times longer than that of other misdemeanants.⁴ The longer jail stays for this population in King County may be partially attributed to concerns about releasing inmates without a treatment alternative.

In February 1998, Judge Cayce and 10 others from King County, the City of Seattle and Jail Alternative Services visited Broward County, Florida, to observe the then only operating Mental Health Court in the United States. All trip participants, including judges, attorneys and treatment providers, were enthusiastic about what they saw and how well they thought the model could be implemented, with some modifications, in King County. The Mental Health Court Task Force met initially in April 1998 to explore how the Court could work cooperatively with other criminal-justice agencies and the treatment community, and to develop specific recommendations for a King County Mental Health Court model. In August 1998, a final Mental Health Court Task Force report was released which outlined a proposed blueprint for the pilot court. After the report was released, King County Budget Office staff worked with the various partner agencies to secure funding.

Resources for King County's pilot Mental Health Court project came from three sources: leveraged existing funds and staff, additional new county funds, and an externally funded grant. The Prosecuting Attorney's Office, the Office of Public Defense, and the District Court have all absorbed portions of the staffing costs of this program. Additional new funds from the County General Fund, the County Criminal Justice Fund, and the County Mental Health Fund have been temporarily allocated to this project. The treatment funds allocated for the pilot project are coming from the County Mental Health Division's "fund balance," a non-renewable source of funding. If the pilot proves successful, a more permanent source of treatment dollars will have to be secured. A final funding source for the pilot came from the federal Bureau of Justice Assistance, which provided an 18-month grant of $150,000.

The pilot King County District Court Mental Health Court was launched on February 17, 1999. On April 29, 1999 the pilot court program was dedicated to the memory of Captain Stanley Steven-son. Many of the program policies and procedures are being established as the project unfolds. But the important elements of the model, as outlined by the Mental Health Court Task Force Report, are all in place. The Mental Health Court differs from a regular court in three fundamental respects. First, the cases are heard on a separate calendar and are all handled by the same core team of professionals. Second, there is an increased emphasis on linking the criminal justice system and the mental health treatment system. Third, the participants in this program receive increased court supervision.

As proposed by the task force, cases referred to the Mental Health Court program are transferred from the regular calendars and set on their own calendar. Mental Health Court cases receive extra courtroom time, ensuring that the intricacies of the case are addressed and that the defendant is fully engaged in the proceedings. In regular courtrooms, judges may rotate and different prosecutors and defense attorneys may appear for hearings. All cases handled in the King County Mental Health Court are seen by the same judge, prosecutor, public defense team (with the exception of those represented by private counsel), treatment community liaison, and probation officer. The core team approach ensures that defendants work with a limited number of individuals who become familiar with the specifics of their case and treatment needs. This approach also ensures that the court team gains growing expertise in mental health issues and the relatively complex legal issues that can arise.

The second manner in which the Mental Health Court differs from other court venues is the emphasis on creating and maintaining a strong linkage with the mental health treatment community. A Court Monitor functions as a liaison between the court and the treatment community. The Court Monitor links the defendants with appropriate community treatment resources and monitors both the defendants' and the service providers' compliance in fulfilling the elements contained in each individualized treatment plan. In addition, each defendant's mental health case manager is encouraged to join his or her client in court for hearings to report on progress, both successful and unsuccessful. Case managers are encouraged to strengthen their clients' personal support networks, and family members are also welcomed and encouraged to participate.

The third important component of the Mental Health Court model is that defendants who opt into the program receive greater supervision and support. As mentioned above, case managers and family members are encouraged to be actively involved in a defendant's case. Mental Health Court cases are scheduled for more frequent review hearings than are regular cases. Also, Mental Health Court defendants on probation are assigned to a mental health specialist probation officer who carries a reduced caseload. Regular probation officers may have caseloads of up to 300 cases; the Mental Health Court probation officer has a caseload capped at 20-40 cases, so that these cases may be given intensive supervision as is warranted.

Mentally ill misdemeanant offenders are not required to appear before the Mental Health Court; rather, the program is an alternative for those who are interested in and committed to seeking treatment to ameliorate the mental health conditions that contribute to their unlawful behavior. Defendants are given a choice of "opting in" to Mental Health Court if they are willing to waive a trial on the merits of their case and are willing to comply with a supervised treatment plan. Based on experience to date, defendants who do choose to opt into the program are likely to be offered either a deferred or a reduced sentence. An important exception to the voluntary nature of this program is for cases in which competency is at issue: defendants in these cases may be referred to Mental Health Court, regardless of their preference, until the competency issues can be resolved. The Mental Health Court will not accept a defendant into this alternative court program if the defendant's mental health condition does not appear to be of a serious nature and to be a contributing factor in the alleged crime. The Mental Health Court program is not simply a jail-diversion program — out-of-custody defendants are equally eligible to participate, and in-custody defendants are not automatically released, as many present a significant public-safety risk.

During the first two months of operation, the court received referrals for 49 misdemeanant defendants, approximately six referrals per week, who were identified as having either a serious mental disorder, dementia, a brain injury or a developmental disability. The early experience of the Court indicates that many of the Court's cases are very complex. Thirty of the defendants, roughly 60 percent of the total group, were not enrolled in mental health treatment services at the time of referral. Eighteen of the defendants, roughly 35 percent of the total group, presented with housing issues; nine defendants had unstable housing arrangements; and nine defendants were homeless. Fourteen of the defendants, roughly 30 percent of the total group, presented with a dual diagnosis of a serious mental illness and a drug or alcohol addiction, and needed referrals to MICA (mentally ill/chemically abusing) treatment services. Defendants with a housing and/or a dual diagnosis treatment need are very difficult to place if they are also either acutely psychotic or have a history of committing violent acts. Additionally, many of the defendants (at least 25 percent) have active cases in other court jurisdictions including municipal courts, superior court, and other counties, making case planning more complicated due to other outstanding warrants or probation requirements.

One early outcome of the Mental Health Court pilot project has been that service gaps in the currently available community services continuum have been highlighted. Appropriate in-patient MICA services are not available and crisis or transitional housing for this population is also not readily available. Additionally, in this era of managed care, contingency funds for wraparound service needs (such as temporary medication coverage or transportation costs) are also difficult or impossible to obtain. The Mental Health Court team will likely be undertaking a grant-writing campaign in hopes of securing additional, non-county funds for the unmet needs of this pilot program.

Cases heard in Mental Health Court so far vary widely in terms of the defendants' current charges and past criminal histories, the degree to which their mental illness impacts their life functioning, and their ancillary service needs. Some defendants referred to Mental Health Court are facing their first criminal charge. An example is 19-year-old Mr. Smith,⁵ facing a domestic violence assault charge for allegedly hitting his mother, with whom he lives. Mr. Smith's mother appeared with him at his first Mental Health Court appearance and explained that he had been an honor student, soccer player and a band member in high school, but that he had experienced his first mental break about a year ago and has not been the same since. Mr. Smith's mother believes that his assaultive behavior is attributable to his mental disorder and is not indicative of a battering problem. Mr. Smith had not been enrolled in formal mental health services at the time of his first appearance with the court, and his mother requested assistance in facilitating this process. His mother also requested assistance in locating appropriate alternative housing for him because she fears for the safety of her young, disabled granddaughter, who also lives in her home. As the treatment team works to find appropriate resources for Mr. Smith, the legal team will determine whether he appears competent to assist in his own defense and proceed to trial, and will work with him to explain the benefits and tradeoffs if he opts into the program.

Another case involves a defendant with a more chronic mental health disorder and criminal history. Although there are indications that Ms. Jones⁶ began experiencing symptoms of a mental disorder at least 10 to 15 years ago, she had been a high-functioning member of the community — a multilingual mother of two small children, a teacher, and a doctoral student close to completing work for her Ph.D. More recently, however, Ms. Jones' mental condition has seriously deteriorated. She is divorced, is no longer employed, has become well-known to the staff in the Prosecutor's office, and is considered to be quite dangerous. Over the last five years she has acquired a lengthy history of various stalking, assault and trespassing charges all related to her compulsion to contact a few men she dated or was married to previously. All of Ms. Jones' prior charges had to be dismissed because of her incompetency to assist in her own defense or proceed to trial. Ms. Jones appeared before the Mental Health Court in early March with a new set of charges. She was found to be incompetent, but the charges were not dismissed, as she was eligible for hospitalization for the short period of time allowed under the new law for competency restoration. Ms. Jones' competency was successfully restored after a few weeks' stay at Western State Hospital and she returned to Mental Health Court. Ms. Jones communicated to the Court for the first time that she accepts that she has a mental illness and that she will most likely need to commit to lifelong treatment. Ms. Jones accepted a plea agreement offered by the prosecutor, which suspended jail time in return for strict compliance with a supervised mental health treatment program and other probation conditions, including weekly visits with her probation officer.

As demonstrated by the case examples outlined above, our early experience with this project indicates that a number of misdemeanants who appear before King County District Court present challenging public safety concerns and have complex treatment needs. As we noted above, it is rare that an idea to improve on our system of justice gets virtually unanimous support. However, it has been with the cooperation, top to bottom, of all three branches of government in King County and the community mental health treatment system, that the initially vague concept of a Mental Health Court has resulted in a project that we are proud to say is receiving both local and national recognition. It is our opinion, after our first few months of operation, that the Mental Health Court is a vast improvement over the old way of handling the mentally ill misdemeanant population. We see a positive difference in the defendants' personal level of satisfaction with their role in the system, the use of our limited jail resources, and in protecting public safety.

James D. Cayce was appointed to the bench in the Aukeen Division of King County District Court in 1992. He is now in his third year as Presiding Judge of the District Court. Among his other responsibilities, Judge Cayce committed time to chair the task force which led to the creation of the Mental Health Court pilot and he now presides over the Mental Health Court calendars.

Kari Burrell is the Program Manager for King County District Court's Mental Health Court program. She holds a Masters of Public Policy degree and has a background in social service program management.

Questions regarding the Mental Health Court pilot project may be directed to the Office of the Presiding Judge, King County District Court, W-1034 King County Courthouse, 516 Third Avenue, Seattle, WA 98104, 206-296-3594.