Courting Improved Relationships for People With Mental Illness in the Criminal Justice System

By Sue Coyle, MSW

Individuals struggling with mental illness often feel and are isolated. The symptoms and challenges related to many mental illnesses, in addition to a limited understanding of the diagnoses, can lead to an individual and his or her support system pulling apart.

“In my opinion, mental illness can destroy relationships between individuals and their supports for various reasons,” says Jordan Levy, LCSW, a mental health therapist in Philadelphia. “It divides people; just like anything else in life—when people don’t understand it, they assume it is ‘wrong.’ If [the support system] doesn’t have experience with mental illness and has no lens to see the world through the sufferer’s eyes, there is often automatic judgment, unconscious or not.

“People with mental illness often know this,” she continues, “so they may push their supports away before their supports even have a chance to try to help, understand, or form an opinion. The stigma [of mental illness] is very real, even within one’s closest relationships.”

That separation can occur subtly, particularly if the individual does not feel comfortable sharing with his or her family and friends. “In my experience, society has taught people not to disclose their mental health struggles, and therefore, relationships, that may have been deep at one time, become more superficial,” Levy says.

“If a person cannot talk about how they really feel, they will feel lonelier, which may also make their illness worse.”

Alternately, the support system may pull away, unsure of how to assist their loved one. Levy notes that a lack of education and resources can create a feeling of helplessness and drain support systems emotionally.

There are also instances when safety becomes an issue. This is particularly true—though not always—when individuals are involved in the criminal justice system and/or substance use comes into play.

These fractured relationships are cause for real concern, as support is a vital aspect of stability. Thus, researchers and professionals throughout the field look for resources and interventions that may improve or strengthen an individual’s relationships.

One such researcher, Kelli Canada, LSCW, PhD, an assistant professor and director of the Integrative Behavioral Health Clinic at the University of Missouri School of Social Work, recently looked into the impact mental health courts have on relationships.

The Program
“A mental health court is an intensive, community-based, treatment-focused program housed within the criminal justice system,” Canada says.

The program model developed out of the drug court model, which specifically works with individuals involved in the criminal justice system and struggling with substance use/abuse. “The models are very similar,” Canada says. “The main difference is that the mental health court is specific for people with mental illness. The treatment team for the mental health court includes substance use and mental health providers. In many drug courts, the substance use provider is the only provider.”

The presence of the mental health court allows for individuals with mental illnesses or dual diagnoses to enter a program focused on mental health and, as the drug court does, helps prevent individuals from being funneled into jail or prison without first looking at a rehabilitative alternative.

Eligibility for mental health court varies not only from state to state but from county to county as well. Not all individuals with mental illness are able to take part. “They typically take [individuals who committed] nonvictim and nonviolent crimes. Although in some places, such as Chicago, they take people who committed such crimes, but you have to have the permission of the victim,” Canada says.

She notes that the charges are usually either low-level felonies or misdemeanors and that community safety is an important aspect of determining eligibility. “It is a balance of community safety with complex needs,” she says.

Depending on the specific program (and varying by court and charge), the eligible person is a part of the mental health court for 12 to 24 months after voluntarily entering. “While in the program, they receive intensive treatment—community based or inpatient if they are dual diagnosed. They get regular monitoring from the court,” Canada explains. At the start of a program, the individual may go to court every week and participants are often asked to comply with random urine screens. They must also be in compliance with treatment and meet as scheduled with their probation officer. However, dismissal from the program is not the first reaction to lack of compliance.

“If someone is not adherent to their treatment, the court tries to understand what the barriers are. [The participant] wouldn’t necessarily be sanctioned for not taking their medications,” Canada says by way of example. “It takes a while to get people off drugs and engaged in treatment.”

This understanding of the complexities of treatment and mental illness comes from including a wide variety of professionals in the mental health court program. “It’s really a perfect blend of interdisciplinary work,” Canada says. “You’ve got mental health providers with the judge, with probation. They’re talking about the welfare, treatment, and stability of people who are in the criminal justice system. Typically, in the criminal justice systems, all those entities work separately, [but in mental health courts] they utilize each other’s strengths as professionals.”

Studies and Findings
Mental health courts are no stranger to studies, perhaps because of their unique makeup, goals, and expertise. However, the majority of the studies completed look at community safety and other factors external to the individual.

“Researchers were looking at effectiveness with administrative data,” Canada says. “Which is great! We need to know if community safety is at risk.” To determine that, studies examined recidivism, improved access to treatment, and substance use.

However, Canada noted a gap in the research. “As social workers, we want to talk to people who are in the programs,” she says, “and I didn’t see any studies where people were asking what it is like to be in the program. No one asked, ‘How is it affecting you? Are they coercive? Is it empowering?’”

To delve into those questions, Canada completed a mixed method study over the course of three years in which she looked at several variables, such as treatment adherence, violations, and days spent in jail. She looked at two specific programs in the Midwestern United States.

The two programs were similar but had some notable differences. “The difference between the two locations was the way that they worked with community providers,” Canada says. “The people providing direct service at one were sitting with the judge. They were a part of the team. The other location had caseworkers who worked with contracted providers in the community for mental health and substance use treatment. The caseworkers were a part of the team but not providing therapy or treatment.

“Some of the participants felt like they didn’t have an advocate really working with them [in the second program]. Some of the treatment was a little scripted. They had a one-size-fits-all model, and that didn’t work for all of the clients. In the other program, the treatment providers really acted like advocates. They were still working with the judge, but they were transparent.”

As a part of the study, Canada had conversations with participants about their time in the program. “I completed interviews and read across the transcripts looking for themes that came up about changes they [the participants] had seen in their lives. One thing that came up consistently and was very apparent was this change that people saw in their relationship with their families.”

Many of the participants had fractured relationships with their families and had not had the opportunity to repair them.

Canada remembers one participant in particular who, as he was leaving the program, was asked whether he was nervous. His response: “I’ve never been so invested in my recovery. My brother wouldn’t talk to me for years, and last month, he asked me to watch my niece. I can’t lose that.”

The court had provided him (and others like him in the program) with the chance to become stable, engage in treatment, and reach out to family members in a manner that hadn’t been possible previously.

Moving Forward
Notably improved familial relationships like the one described above may not always be the norm in mental health courts but they can become more so. Canada notes that collaboration not only between professionals but with support systems as well is a key aspect of this.

“The courts always encourage families to come to court,” she says. “When there were opportunities to use families, they did.”

She describes newly completed research in which she interviewed probation officers and treatment providers. “That was one thing that people noted,” she says. “Developing a relationship with the client and the family, and helping them understand the weight of what they were going to do [was vital].”

Canada also reflects on previously published research in which participants were able to discuss their relationship to the criminal justice system. “Most of the time, people in my study said a judge had never talked to them before in their life.” But when the judge made an effort to foster a relationship with the participant and promote transparency and understanding, the participant felt the process was fair. “They feel that the team and the judge care about them,” she says.

As mental health courts continue to offer a rehabilitative alternative for those involved in the criminal justice system and struggling with a mental illness, it is hoped that more positive relationships are created—between the individual and all stakeholders but particularly with his or her support system. And perhaps, these relationships will help alleviate the all-too-common feeling of isolation while leading to greater success for the individual and the community.

— Sue Coyle, MSW, is a freelance writer, a social worker in the Philadelphia suburbs, and a 2017 NASW Media Award winner for Best Article in a Trade Publication. Read the article at http://www.socialworktoday.com/archive/011716p20.shtml.