Evidence-Based Practices in Diversion Programs for Persons with

Evidence-Based Practices in Diversion Programs for Persons
with Serious Mental Illness Who are in Conflict with the Law:
Literature Review and Synthesis
Prepared for Ontario Mental Health Foundation and
Ontario Ministry of Health and Long-Term Care*
Funded by Ontario Mental Health Foundation
November, 2004 B
Investigators:
Dr. Kathleen Hartford
Simon Davies
Chris Dobson
Carolyn Dykeman
Brenda Furhman
John Hanbidge
Donna Irving
Elizabeth McIntosh
Dr. Jim Mendonca
Ian Peer
Mike Petrenko
Veronica Voigt
Dr. Stephen State
Janice Vandevooren
Project Staff:
Dr. Robert Carey
Alex Craniescu
*All views, positions and conclusions expressed in this report are solely the authors and are not endorsed by the Ontario Ministry of
Health and Long-term Care.
Evidence-Based Practices in Diversion Programs for Persons with Serious Mental
Illness Who are in Conflict with the Law: Literature Review and Synthesis
CONTENTS
Main Messages
Executive Summary
1.
Introduction
2.
Methods
3.
Evidence-Based Typology
4.
Mental Health Diversion: Definitions and Context
Types of diversion
The Consensus Project
Diversion in Ontario
5.
Legal Issues Surrounding Mental Health Diversion
The criminalization of mental illness
Therapeutic jurisprudence
Overview of Diversion and Mental Health Law in Canada
6.
7.
8.
9.
10.
11.
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1
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2
2
2
2
3
3
4
5
6
9
11
13
14
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27
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33
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Pre-Arrest diversion
Court Diversion
Mental Health Courts
Site Visits
Survey Results
Recommendations
References
Appendices
Appendix I: Literature Review Methodology
Appendix II: Survey Methodology
Appendix lll: Experimental Designs
Appendix lV: Formative and Summative Evaluation
Appendix V: Differences Between Traditional
and Problem-Solving Courts
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Appendix VI: Court Diversion Programs in Ontario 39
Appendix VII: Legislation from Other Countries
40
Appendix VIII: Acknowledgements
43
Appendix IX: London Police and Mental Health Crisis
Service Memorandum of Understanding
45
Appendix X: Chesterfield/Colonial Heights
Memoranda of Understanding
for Court Diversion
48
Appendix XI: Mendocino County Memorandum
of Understanding for Mental Health Court
52
Appendix XII: Research Team Members
59
Appendix XIII: Standardized Literature Review Grid 60
Appendix XIV: Diversion Survey
62
Appendix XV: Survey cover letter
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Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are
in Conflict with the Law: Literature Review and Synthesis
KEY MESSAGES
Rationale
The criminalization of persons with mental illness (PMI) for minor offenses has been reported to be an
unintended consequence of deinstitutionalization and inadequate community-based treatment. Diversion
of PMI who are in contact with the law into appropriate treatment is an integral element of a humane
mental health system.
Research Question
The key question posed by the Ministry of Health and Long-Term Care is: what standards, benchmarks,
indicators, and evidence-based practices regarding mental health diversion exist?
Methods
A multi-method approach was used that included: a literature review, including both published and grey
literature; site visits and key informant interviews; and an international Web-based survey of existing
diversion programs.
Key Findings
Literature on mental health diversion has been primarily limited to descriptive accounts, and with the
exception of basic program statistics such as the numbers of people diverted, there remain few outcome
data in published studies. There is no information on optimal staffing or funding levels; nor does the
literature offer rigorous evidence on which to base decisions surrounding policy, planning, or training.
Nevertheless, the literature is extensive enough to suggest that the following are key themes in the
development and maintenance of successful diversion programs:
•Inter-agency/governmental collaboration
•Regular meetings among key personnel
•Steamlined services
•Formal case-finding procedures
•Enhanced community resources
• Increased awareness among key players
Recommendations
Our overarching recommendations are: 1) That enhanced capacity of community mental health
agencies and housing be funded through the Ministry of Health and Long-term Care; 2) That the interministerial Human Services and Criminal Justice System Coordinating Committee be re-constituted at a
provincial level; 3) That, with the advent of the new provincial local health integration networks (LHINs), a
close examination of the interface between proposed new health regions and existing regional forensic
programs, as well as local and other government department boundaries be proposed.
a) standardized training for police, court support workers (CSW), lawyers, justices of the peace
and judges; b) enhanced community mental health services, including housing and treatment
facilties; c) streamlined services, including telepsychiatry for fitness assessments, court docket for
PMI, and Memoranda of Understanding between mental health and criminal justice agencies;
d) increased research, focusing particularly on randomized controlled trials, program evaluation
and the development of uniform outcome measures.
i
Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are
in Conflict with the Law: Literature Review and Synthesis
EXECUTIVE SUMMARY
Rationale
The criminalization of persons with mental illness (PMI) for minor offenses has been reported to be an
unintended consequence of deinstitutionalization and inadequate community-based treatment. Diversion
of PMI who are in contact with the law into appropriate treatment is an integral element of a humane
mental health system.
With publication of the Making it Happen reports, Ontario embarked on major restructuring of mental
health services. This review of evidence-based practices in mental health diversion was funded by the
Ministry of Health and Long-Term Care (MOHLTC) as a contribution to that effort.
Research Questions:
This report addresses the following research questions posed by the MOHLTC:
1. What standards exist for diversion programs for persons with serious mental illness?
2. What evidence-based practices - including areas such as policy, planning, evaluation, funding,
training, and clinical interventions - are characteristic of successful diversion programs?
3. What benchmarks - including staffing and funding levels - exist for diversion programs?
4. What performance standards and performance indicators exist for the provision of specific
diversion programs?
5. What criteria and factors should be considered in the development of standards?
Methods
A multi-method approach was used that included: a literature review, including both published and grey
literature; site visits and key informant interviews; and an international Web-based survey of existing
diversion programs.
Defining mental health diversion
Diversion is a process where alternatives to criminal sanctions are made available to PMI who have come
into contact with the law. The objective is to secure appropriate mental health services without invoking
the usual criminal justice control of trial and/or incarceration. Mental health diversion programs take one
of three forms: (a) Police pre-arrest, or pre-booking diversion; (b) Court diversion and; (c) Mental Health
Courts (MHCs).
Key Findings
Literature on mental health diversion has been primarily limited to descriptive accounts, and with the
exception of basic program statistics such as the numbers of people diverted, there remain few outcome
data in published studies. There is no information on optimal staffing or funding levels; nor does the
literature offer rigorous evidence on which to base decisions surrounding policy, planning, or training.
Nevertheless, the literature review, our site visits, and the responses to our survey, suggest the following
are key themes in the development and maintenance of successful diversion programs:
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• All relevant mental health, substance abuse and criminal justice agencies were involved in program
development from the start.
• Regular meetings between key personnel from the various agencies were held.
• Streamlining services through a treatment centre with a no-refusal policy for police cases is frequently
seen as crucial.
• A key theme in the integration of services is that of a liaison person or "boundary spanner" with a
mandate to effect strong leadership in the coordination among agencies.
• Awareness of the pre-trial diversion option among lawyers and court staff is crucial.
• Formal case finding procedures are important for the early identification of mentally ill offenders in need
of services.
• Diversion is a realistic enterprise only to the extent that adequate resources exist in the community.
• Extended mental health treatment combined with active case management improves compliance and
reduces the likelihood of recidivism. Housing is frequently cited as a key issue.
Recommendations
In the absence of evidenced-based practices in the literature, the responses to our international webbased survey and reports in the literature indicate that communities have proceeded to develop organized
responses to the issue of criminalization of mental illness. It is recognized that the province of Ontario
cannot wait for the requisite research in order to take steps to further develop programs to decriminalized
mental illness. Our three overarching recommendations, therefore, are:
1) That enhanced capacity of community mental health agencies and housing be funded through the
Ministry of Health and Long-term Care, as the primary method of diverting persons with mental illness
from the criminal justice system;
2) That the Human Services and Criminal Justice System Coordinating Committee, comprised of senior
staff of the Ministries of Health & Long-term Care, Attorney General, Community Safety and Correctional
Services, and Community and Social Services be re-constituted at a provincial level to provide leadership
and direction to policy and program development for diversion of mentally ill persons from the criminal
justice system. For example, substantial interdepartmental investigation is required to ascertain the direct
and indirect costs of court diversion and mental health courts in Ontario;
3) That, with the advent of the new provincial local health integration networks (LHINs), a close
examination of the interface between proposed new health regions and existing regional forensic
programs, local Human Services and Justice Coordinating Committees and other government department
boundaries be proposed, and that boundary spanners at the local level be appointed, to ensure that
boundaries are contiguous.
We also propose that Ontario take a leadership role in the development of the following areas:
a) standardized training for police, court support workers (CSW), lawyers, justices of the peace
and judges. Highlights include:
• Stand-alone, accredited, in-service education such as the police training educational module Not Just
Another Call… Police Response to People with Mental Illness in Ontario (Hoffman & Putnam, 2004) be
offered by the Ontario Police College to all uniformed officers within three years of basic training.
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• Training of court support workers in forensics and mental health law should be standardized.
Consistent with recommendations offered by previous studies (e.g., MacFarlane et al, 2002), such
training would likely be best undertaken annually by a single, pan-provincial body such as the Centre for
Addiction & Mental Health. Training could be offered at different sites in the province.
• Judges, Crown Attorneys and Justices of the Peace involved in diversion and mental health courts be
encouraged to attend continuing education sessions in mental health law and mental illness.
b) enhanced community mental health services, including housing and treatment facilties.
• Police pre-arrest/prebooking diversion programs be supported by a free-standing, community mental
health crisis agency with a formal "no refusal" policy for police referrals of voluntary clients.
• Local police and mental health services agencies be encouraged to develop an organized mental health
response for police when dealing with mentally ill persons which results in increased pre-arrest diversion.
• Local human services and justice services coordinating committees be formed to examine and resolve
barriers to service at the interface of the mental health and criminal justice system.
•Active case finding should be supported by ensuring that court support workers have access to potential
clients, and to the mental health condition and history of potential clients, as early as possible.
c) streamlined services, including telepsychiatry for fitness assessments, court docket for PMI, and
Memoranda of Understanding between mental health and criminal justice agencies.
•Agencies employing court support workers are encouraged to develop Memoranda of Agreements with
community mental health, hospital and housing agencies.
•Regional forensic facilities be encouraged to enhance their ability to meet their regional mandates by
developing telepsychiatry capacity/linkages, and, in the interim, in jurisdictions where forensic
psychiatrists or telepsychiatry are unavailable CAMH, may be asked to assist with the conduct of timely
fitness assessments .
•Where volume does not warrant a dedicated mental health court, application of the principles of
therapeutic jurisprudence support the establishment of a mental health docket.
d) increased research, focusing particularly on randomized controlled trials, program evaluation
and the development of uniform outcome measures.
•Inter-provincial funding of evaluation of models of pre-arrest diversion programs be sought.
•Workload measurement of court support workers be performed in each court diversion program to
determine their primary function and assessing the proportion of time spent in activities related to direct
diversion of mentally ill clients as opposed to court support activities.
•Since court diversion programs are not established throughout the province yet, randomized controlled
trials be funded to assess the efficacy of court diversion.
•Consensus on the identification and definition outcomes of pre-arrest, court diversion and mental health
courts is required for research studies and for monitoring programs.
•The Ontario Ministry of Health and Long-Term Care investigate clinical diversion of persons with mental
illness who are arrested and found fit, or who are obviously fit.
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Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are
in Conflict with the Law: Literature Review and Synthesis
1. Introduction
A fundamental principle arising from Making It Happen, Ontario's Ministry of Health and Long-Term Care's
(MOHLTC) plan for mental health reform, is that effective diversion for persons with serious mental illness (PMI)
who are in contact with the law is an integral elemental of the mental health system (Ontario Ministry of Health and
Long-Term Care, 1999). Accordingly, the MOHLTC has embarked on a program of research to identify evidencebased practices in mental health diversion. In addition to its own activities, the Ministry has funded a review and
synthesis of all relevant published and unpublished literature. We addressed the Ministry's following research
questions:
1. What standards exist for diversion programs for persons with serious mental illness?
2. What evidence-based practices - including areas such as policy, planning, evaluation, funding,
training, and clinical interventions - are characteristic of successful diversion programs?
3. What benchmarks - including staffing and funding levels - exist for diversion programs?
4. What performance standards and performance indicators exist for the provision of specific diversion
programs?
5. What criteria and factors should be considered in the development of standards?
2. Methods
This report adopted a multi-faceted approach to the identification and analysis of the evidence-based practices
associated with diversion programs. Our literature review encompassed several strategies and focused primarily on
material about pre-arrest, court diversion programs and mental health courts in Canada, the United States,
Australia, New Zealand and the United Kingdom (see Appendix l). Based on the Ministry's directives, subjects
such as co-occurring disorders, youth diversion, and forensic treatment were excluded from the literature search.
After retrieving and evaluating a substantial number of texts, we examined their bibliographies to locate relevant
items that had not been identified in previous database searches. To recover grey literature, we conducted
extensive searches of the Internet for electronically published documents and for references to unpublished items.
Finally, the project’s investigators drew on their professional backgrounds and knowledge of relevant literature to
note additional items of importance, which were incorporated into the review. Ultimately, we recovered 519 items
(available in Reference Manager format).
In addition to the literature review, we employed two other methods to identify best practices in diversion. First, we
conducted site visits to mental health courts or court diversion programs in Toronto, Brampton, Etobicoke and
Scarborough. During these visits, we interviewed key informants, including crown attorneys, duty counsels,
diversion workers and judges. Second, we developed and distributed a Web-based survey to more than 734
representatives of diversion programs in North America, Great Britain, Australia and New Zealand (See Appendix
II). The survey was designed to elicit descriptive data about aspects of diversion that do not appear in the
literature, such as policy, planning, evaluation, funding, training, and treatment options. Responses were coded and
analyzed using a qualitative data analysis software called Nud*ist.
3. Evidence-Based Typology
The ability to identify evidence-based practices in diversion depends on the strength of the research design in the
literature. Generalizing from anecdotal accounts may be misleading because certain contextual factors, such as
the characteristics of legal and mental health systems, may vary from site to site. Accordingly, insights arising from
quantitative research are usually considered the "gold standard" in identifying evidence-based practice. We have
categorized the mental health diversion literature according to the research hierarchy represented in Appendix III.
Since much of this literature is evaluative, it is important to note the difference between formative and summative
evaluation. Formative evaluations are undertaken during the initial phase of a program to gain insight into further
development. Summative evaluations, on the other hand, are often carried out when a program has been in place
for some time; the purpose here is to study the program's effectiveness and to judge its overall value. Summative
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evaluations are typically used to determine how resources should be allocated, or to enhance public accountability
(Palys, 1997). Summative evaluation is more likely to lead to the kind of insights necessary to support evidencebased practice (see Appendix IV).
4. Mental Health Diversion: Definitions and Context
a. Types of diversion
Diversion is a process where alternatives to criminal sanctions are made available to PMI who have come into
contact with the law for minor offenses. The objective is to secure appropriate mental health services without
invoking the usual criminal justice control of trial and/or incarceration. Treating the mental disorder, it is hoped,
reduces the likelihood of further offending and the focus is on helping individuals to access community support and
treatment.
In general, mental health diversion programs take one of three forms: (a) police pre-arrest, or pre-booking
diversion; (b) court diversion and; (c) mental health courts (MHCs). Arrest diversion allows the police to use their
discretion in laying charges. Court diversion programs, on the other hand, are post-booking, pre-arraignment
programs that involve staying charges for eligible offenses if the person agrees to treatment. In addition to the
mentally ill defendant and her or his family, MHCs involve a dedicated judge, crown, defence, and court support
worker (CSW). Characteristics of MHCs include: (a) all identified mentally ill defendants are handled in a single
court/docket, (b) the use of a collaborative team which includes a clinical specialist who recommends and makes
linkages to treatment, (c) assurance of availability of appropriate clinical placement prior to the judge making a
ruling, and (d) specialised court monitoring with possible sanctions for noncompliance (Steadman, Davidson &
Brown, 2001).
b. The Consensus Project
The public profile of mental health diversion in the criminal justice system was advanced markedly by the Criminal
Justice/Mental Health Consensus Project (Council of State Governments, 2001) undertaken in 1999 by the U.S.
Council of State Governments (CSG) in response to requests from state government officials for recommendations
to improve the criminal justice system's response to PMI. To address the numerous issues related to PMI in all
phases of the criminal justice system, the CSG collaborated with six organizations: the Police Executive Research
Forum (PERF), the Pretrial Services Resource Center (PSRC), the Association of State Correctional Administrators
(ASCA), the National Association of State Mental Health Program Directors (NASMHPD), the Bazelon Center for
Mental Health Law, and the Center for Behavioral Health, Justice Public Policy. The resulting Consensus Project
Report <URL:http://consensusproject. org/> provides 47 policy statements intended to improve the criminal justice
system's response to PMI. Following each policy statement is a series of specific recommendations that highlight
the practical steps that should be taken to implement the policy. The report contains examples of programs,
policies, or elements of state statutes that illustrate one or more jurisdiction's attempt to implement a particular
policy statement. Although the Consensus Project is a milestone in mental health diversion, many of the initiatives
it advocates are so new that they have yet to be evaluated to assess their impact on individuals and systems.
c. Diversion in Ontario
In Ontario, two initiatives created by the MOHLTC sparked further interest in diversion. First, the Ministry
established a Forensic Mental Health Services Expert Advisory Panel in 2001 to advise the government on a
provincial strategy for the implementation of a comprehensive forensic mental health service system. The panel’s
final report, entitled Assessment, Treatment, and Community Reintegration of the Mentally Disordered Offender
(Ontario Ministry of Health and Long-Term Care, 2002) advocated a comprehensive and coordinated system of
services and supports to meet the needs of PMI who come in contact with the law. Among the panel’s specific
recommendation are: (a) increased community services – such as housing and forensic beds – to support PMI who
are undergoing diversion; (b) enhanced training and support for police officers to support pre-arrest diversion
programs; (c) revision to the Crown policy on mental health diversion, and (d) special training and support for
Crown prosecutors to allow them to offer formal diversion programs. One of the panel's key observations is that
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earlier intervention is necessary if the mentally ill person's engagement with the criminal justice system is to be
minimized in favor of treatment and community support. Consequently, the panel placed a great deal of emphasis
on the need to enhance pre-arrest diversion and other preventative measures. Additionally, the task force
recommended the use of telecommunications for forensic assessments (i.e., telepsychiatry) in order to expedite
assessments, make better use of clinical personnel and to decrease potentially unnecessary admissions to regional
forensic programs. This recommendation is supported by studies such as Monnier,Knapp and Frueh (2003) and
Brodey et al. (2000). Zaylor et al. (2001) conclude that telepsychiatry is an effective means of delivering mental
health services to the prison population.
Second, the Ministry established nine regional task forces in 2000 and 2001 whose mandate was to develop
recommendations for regional and local improvements to provincial mental health services. Accordingly, the final
report of the Provincial Forum of Mental Health Implementation Task Force Chairs, entitled Making It Happen:
Implementation Plan for the Reformed Mental Health System (Ontario Ministry of Health and Long-Term Care
2002) advocated a broad range of strategies intended to support a community-based system of care. Key among
these was new training for justice sector workers such as police, lawyers, judges, diversion workers and social
service workers in the justice system. Although not all task forces dealt substantially with forensic issues, most of
the reports reflect a belief that mental health diversion is advisable. Among the specific themes that recurred
among the task forces' reports are: (a) increasing the number of court diversion workers; (b) improving
collaboration among regional diversion workers; (c) enhancing inter-agency and inter-governmental collaboration;
(d) the need for more accessible pre-trial assessment services; (e) increasing the number of available forensic
psychiatrists or forensic community consultants, and (f) enhancing pre-arrest diversion initiatives.
Ultimately, the task forces' recommendations regarding diversion converged on three elements: (a) more effective
integration of services among various organizations within the criminal justice and mental health systems;(b)
standardized policies and procedures, and (c) interagency agreements. Most of the regional reports echo the
Forensic Mental Health Services Expert Advisory Panel's conclusion that the diversion of low risk offenders to the
human service system as soon as possible is critical. The report issued by the Champlain District Mental Health
Implementation Task Force (2002) for example, states that "police diversion is the most effective form of diversion,
since it ensures minimal contact with the criminal justice system." From an evidence-based perspective, however,
the confidence with which one can assert that a particular initiative is "effective" depends at least in part on the
extent and nature of the available evaluative research. Importantly, it was not within the provincial advisory panel's
or the regional task forces' scope to establish benchmarks regarding funding and staffing levels for various
elements of mental health diversion.
5. Legal Issues Surrounding Mental Health Diversion
a. The Criminalization of Mental Illness
The term 'criminalization' was first used in relation to mental illness by Abramson (1972). In this classic formulation,
the term refers to a social dilemma posed by the deinstutionalization of the mentally ill: "If the entry of persons
exhibiting mentally disordered behavior into the mental health system of social control is impeded, community
pressure will force them into the criminal justice system of social control" (Abramson, 1972, p. 103). In effect,
Abramson argues that the criminal justice system reinstitutionalizes PMI by subjecting them to criminal prosecution
for relatively minor offences. The criminalization of PMI, therefore, is at least partly understood as an unintended
consequence of deinstitutionalization and inadequate community-based treatment. More formally, three factors are
thought to contribute to the criminalization of mental illness: (a) increased numbers of persons with PMI residing in
the community, (b) police handling of PMI, and (c) PMI being unable to gain access to treatment.
As a result of complex structural changes to the delivery of mental health care - predicated both on fiscal necessity
and a philosophical inclination toward deinstitutionalization - community-based care is now a preferred treatment
modality for most PMI (Bachrach, 1978; DiCataldo, Greer & Profit, 1995). In Canada, the current round of
deinstitutionalization began in earnest in the mid-90s when, as Sealy and Whitehead (2004) point out, average
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days of care in psychiatric hospitals and psychiatric units in general hospitals began to decrease, primarily due to
bed closures. The movement of PMI out of hospitals and into the community led to a proliferation of PMI residing in
the community without adequate supports (Sealy & Whitehead, 2004). Among the recommendations for
improvement to the mental health system in Ontario are: (a) intensive case management; (b) 24-hour crisis
intervention; (c) housing, and (d) supports planned and run by consumers/survivors and families (Ontario Ministry
of Health, 1993; Ontario Ministry of Health and Long-Term Care, 2002). And yet, despite a general preference
among mental health professionals for community-based treatment, PMI may still face a dearth of community
resources because community mental health agency budgets have essentially remained static in Ontario since the
early 90s. Between 1994-1995 and 1998-1999, for example, the percentage of expenditures for community-based
psychiatric services (as a proportion of all expenditures) only increased from 25.8% to 27.4% (Ontario Ministry of
Finance, 1995, 1999). Appelbaum (2002) notes a similar trend in the U.S. Moreover, by 2003, Ontario was to
spend 40% of its mental health budget on institutional care and 60% on community services, as compared with an
approximate 80/20 split in 1992/1993 (Ontario Ministry of Health, 1993, p. 28). This tangible goal has not been
achieved.
b. Therapeutic Jurisprudence
Therapeutic jurisprudence (TJ) describes a non-traditional approach to criminal justice. Developed by Pound (1942)
and revisited by Wexler (1992) and Winick (1994) who suggested that the justice system should balance two key
objectives when sentencing offenders. That is, it must consider the nature of the sentence imposed and the degree
to which it serves punishment and deterrence mandates, while also attending to the potential therapeutic
consequences for the offender’s physical and mental well-being, and the eventual impact on society at large (Slate,
2003). Therapeutic jurisprudence represents a significant innovation for the justice system. In a traditional court,
the central position is occupied by a judge (Petrila, 2003). By contrast, problem-solving courts have judges,
prosecutors, defense counsel and mental health professionals, playing a more collaborative role in a more informal
atmosphere. Greater emphasis is placed on offender treatment issues and problem-solving. Tables 1 and 2 in
Appendix V outline some of the key differences between traditional courts and problem-solving courts informed by
the principles of TJ.
The advent of TJ in the American adversarial system, while welcomed by many, was equally criticized, for allegedly
compromising the integrity of the criminal justice system. For example, in two situations - opponents argue involuntary civil commitment and juvenile justice, the jurisprudence is based on the state’s parens patriae authority
(Haycock et al., 1994, p. 304). Thus, “…the criminal justice system does not function on behalf of the individuals,
but rather on behalf of the social order” (Haycock, 1994, p. 304). Haycock (1994) refers to TJ being perceived as a
method “to stray from rights-based perspectives” which comes with “grave risks” (p. 315). Critics argue that MHCs
use preferred selection in that candidates are among those with limited risks, because the new established courts’
survivability requires positive outcomes (Wolff, 2002, p. 431). Also, among other unintended consequences, the
same author argues that MHCs add to demand for treatment. The consequences will be either to “cut back on the
services already provided…or discharge some current clients”(Wolff, 2002, p. 433). Another negative aspect is that
using the court’s powerful position, some clients will “effectively jump queues or circumvent access barriers”(Wolff,
2002, p. 433). Others are afraid that by moving services into the criminal justice system the stigma of mental illness
will increase (Watson et al., 2000). Alternatively, some advocates favor of allocating resources to provide services
to people before they become involved in the criminal justice system.
Also controversy exists between rights discourse and TJ application. Some jurisdictions recognize a person with
mental illness’s right to refuse treatment (Winick, 1994; Greer & Appelbaum, 1993). In diversion programs, clients
forfeit the right to a trial by voluntarily entering the program. An innovative solution to potential conflicts between
individual liberty and therapeutic interest is postulated through a constraint or balancing approach:
When therapeutic interests conflict with individual liberty, one can advocate either of two plausible
relationships between the competing values. First, one can grant a priority to one value over the other
such that the first serves as a constraint on the second. According to this approach, for example,
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liberty might constraint therapeutic efforts such that any therapeutic program must give way when it
conflicts with protective liberty, regardless of the magnitude of the potential gains or losses to each
value. Alternately, one can balance the two competing values, […] deciding a case by weighing the
relative gains and losses to each value in the circumstances (Schopp, 1993, p. 517).
Informed consent and voluntariness of participation are pillars of diversion. The issue of offenders’ rights needs to
be analyzed carefully in the context of diversion, especially in jurisdictions where a guilty plea is a prerequisite for
acceptance into the program.
c. Overview of Diversion and Mental Health Law in Canada
Canada
Federal legislation: The Canadian Criminal Code (R.S. 1985, c. C-46) regulates matters involving mentally ill
persons in contact with the criminal justice system. Section 672.11, in particular, gives the court power to “order an
assessment of the mental condition of the accused, if it has reasonable grounds to believe that such evidence is
necessary to determine” whether the accused is unfit to stand trial, or whether the accused was, at the time of the
commission of the alleged offence, suffering from a mental disorder so as to be exempt from criminal responsibility.
The court may make an assessment order at any time during the proceedings on its own motion, at the request of
the accused, or at the request of the prosecutor. Such an assessment order will contain information about who is to
be assessed and where the assessment will be made, whether or not the accused will be in custody during this
period of time, and the period of time for which the order is in place. Section 672.38 of the same Act also provides
for establishment of Review Boards in each province that are able to “make or review dispositions concerning any
accused in respect of whom a verdict of not criminally responsible by reason of mental disorder or unfit to stand
trial is rendered.”
Provincial legislation: Provincial mental health legislation puts into effect the way in which the Criminal Code
(R.S. 1985, c. C-46) is applied. Inter-provincial variations in legislation exist in the: (a) time that a person can be
held for a fitness assessment, and (b) criteria under which an individual can be detained. “[The Provinces of]
Ontario and Saskatchewan have included provisions within their mental health acts that require the services
necessary to support [community treatment orders] CTOs [that are] to be available in the community and require
the patient to be capable of complying with the mandated treatment.” (O’Reilly, 2003). In Ontario, CTOs are
implemented by the Mental Health Act (R.S.O. 1990, c. M. 7, s.33) and in Saskatchewan by the Mental Health
Services Act (S.S. 1984-85-86, c. M 13.1, s. 24.3, S.S., 1989-90, c.54; 1992, c.A-24.1; 1993, c.59; 1996, c.9 and
17; 1997, c.12; and 2002, c.R-8.2). It should also be noted that most provinces have acts regulating consent to
treatment such as the Ontario Health Care Consent Act, 1996.
Fitness Assessment and Involuntary Commitment in Ontario: In Ontario, a justice of the peace can issue an
order for psychiatric examination under specified conditions involving threatening or imminent harm to self or
others. Mental Health Act (R.S.O. 1990, c. M. 7) allows a judge to send a person suffering from a mental illness to
psychiatric facility for not more than 2 months, with the consultation of a psychiatrist. Under certain conditions
(Section 20. (1.1) of the Act, based on a psychiatric examination, “The attending physician shall complete a
certificate of involuntary admission or a certificate of renewal.” Sections 21 and 22 of the Act provide for conditions
under which a judge can make orders for the examination and admission to a psychiatric hospital (for a period not
to exceed two months) of a person who appears before him or her charged with or convicted of an offence and who
suffers from mental disorder.
Court Diversion Policy: The Criminal Code of Canada (R.S. 1985, c. C-46, s. 717) allows for the use of
"alternative" measures. In the case of a PMI, alternative measures could include treatment. Inter-ministerial
agreements have guided the development of court diversion programs in Canada (Quebec and Alberta are the only
5
other provinces that have a formal court diversion program.). Based on protocols between the Ontario Ministries of
HLTC and Attorney General, court diversion can be conducted at the provincial level. In 1995, the Crown Policy
Manual for Diversion of Mentally Disordered Offenders (Ontario Ministry of the Attorney General, 1995) was
released. When the accused suffers from a mental illness that the Crown Prosecutor believes is the underlying
cause of the criminal conduct, the accused is seen as a suitable candidate for diversion. Usually violent crime
renders the offender ineligible for diversion. In Ontario diversion is offered mainly for Class I offences; these may
include joy riding, theft, or fraud under $5000 in damages. Diversion may also be offered for Class II offences –
such as uttering threats, public mischief, break and enter – in which there are extenuating circumstances not
involving violence. An accused with criminal record or who was previously diverted is not automatically precluded
from diversion. As of February 4, 1998, offenders with developmental disabilities were included in the diversion
protocol. We are aware that the Crown Policy manual has been under review and is slated for imminent release;
unfortunately the Ministry of the Attorney General, citing protocol, declined to make a copy available for use in this
study. Outside of Toronto, court diversion programs often operate in isolation. We provide, for the first time, a
listing of Ontario Court Diversion Programs in Appendix Vl obtained from our survey.
Mental Health Courts: In a comprehensive review, Hanbidge (2003) notes that no new legislation has been
required for the development of MHCs in Canada. Two MHCs exist currently: 102 Court established in Toronto in
1998 where psychiatrists conduct in-court fitness/not criminally responsible assessments, as well as facilitating
fitness/treatment orders, and certifiability issues off site. Similarly, the MHC in Saint John, New Brunswick,
established in November 2000, conducts fitness assessments and considers eligibility for diversion.
Police: In Ontario, police powers under the Mental Health Act, Section 17, allow a police officer, under certain
conditions, to take a person in custody to an appropriate place for examination by a psychiatrist. The conditions
under which police may apprehend the person are indicated. As well adequacy standards exist under the Police
Services Act that indicates required provincial services. For example, O. Reg. 3/99, s. 13. 1, under the Police
Services Act, stipulates: “Every chief of police shall establish procedures and processes in respect of, (g) police
response to persons who are emotionally disturbed or have a mental illness or a developmental disability.”
Other Countries: For an elaboration on legislation and policies related to all aspects of diversion in other countries
involved in the survey, see Appendix VII. In these countries, the following legislation regarding diversion was found.
(a) New Zealand’s federal Criminal Justice Act (Criminal Justice Act of 1985, No. 120, 1986 No. 83, 1987 No. 25,
85, and 168, 1989 No. 20, and 91, 1993 No. 43, and 93, 1994 No. 28, 1995 No. 69, 1997 No. 40, and 94, 1998 No.
37, and 78, 1999 No. 9, and 78, 2001 No. 60) and the Mental Health Act (Mental Health Act 1992, No. 46, 1999 No.
140, and 2003 No. 85), provide the legal framework for defining mental illness, compulsory assessment and
treatment, police involvement and court liaison services. (b) In Australia, individual state mental health legislation
governs definitions of mental illness, informed consent, assessment, voluntary admissions, and compulsory
treatment and community orders. The Queensland Mental Health Act (Q.C.A Mental Health Act 2000) also provides
the framework for Australia’s only MHC. Court diversion in New South Wales and the other Australian states is
described in Appendix VII. (c) Similarly, in the UK, Mental Health Act (Mental Health Act 1983) defines mental
illness, fitness assessment, compulsory treatment, police powers, etc. Criminal justice mental health liaison is
discussed by Cooke (1991) and an evaluation of the court psychiatry program in the five London boroughs,
supported by a Home Office circular, 66, 1990, is reported by James and Hamilton (1992). (d) Mental Health
legislation in the US is governed by the individual state, and a review exceeds our mandate. However, federal
funds have supported the establishment of 37 MHCs in 2002-2003.
6. Pre-Arrest Diversion
a. Introduction
In a definition proposed by Steadman, Morris & Dennis (1995), pre-arrest diversion involves the police using their
discretion in laying a charge for minor offenses against an offender thought to have mental illness. As Teplin and
Pruett (1992) note, involvement of the police with the mentally ill is based on two principles: (a) the protection of the
6
public; (b) parens patriae, which involves the protection of the disabled citizen. Increasingly, the police are seen as
the first entry point into the mental health system for PMI (Lurigio and Swartz, 2000). Pre-booking diversion,
however, is a complex process that frequently involves informal assessments by the officer on the scene; in a study
of 1,396 police-citizen encounters, for example, Teplin and Pruett found that police tend not to rely on conventional
mental health resources or arrest, but prefer informal dispositions because it requires "neither paperwork not
unwanted downtime (time off the streets)" (Teplin & Pruett, 1992, p. 152).
Increasingly, police responses to PMI are becoming more formalized. Many police services are organizing so that
community mental health agencies can be contacted to help with calls involving mentally ill persons and, rather
than charge the individuals, assist them to obtain treatment. For example, in a study intended to identify best
practices between the criminal justice system and the mental health system in four cities in Southwestern Ontario
(Hartford, 2003), systemic police responses to interactions with PMI ranged from: (a) modest in-service education
on mental health issues, (b) 40 hours of additional training in mental health issues for officers who would then be
first responders to calls involving PMI; (c) a service agreement with a mobile mental health crisis service to attend
calls from the police, and (d) a mobile crisis team consisting of mental health professionals and police officers
specially trained in mental health issues. Only one study has documented a method for identifying the numbers of
PMI in contact with police: an important outcome measure for assessing the effectiveness of pre-arrest diversion
over time (Hartford, Heslop, Stitt & Hoch, in press).
b. Synthesis and Evaluation of the Pre-Arrest Literature
Of the 519 items identified in the literature review, 92 are concerned specifically with some form of pre-arrest
diversion. The preponderance of these - 53 - arise from the United States. The sample of 92 articles includes no
experimental studies. Most are accounts of various programs containing descriptive statistics. Thus, while
quantitative evaluation of specific programs has been undertaken, the literature does not yet convey a clear and
consistent picture of best practices in pre-booking diversion. Since diversion programs have only developed
recently, it is unsurprising that the literature is mainly descriptive and not evaluative. Since few randomized,
controlled trials have been undertaken, little is known of short- or long-term outcomes of pre-arrest diversion
programs. Research tended to focus on various aspects of police training as a means of lowering arrest rates of
mentally ill offenders. Such research suggested that law enforcement personnel maintained negative attitudes
toward PMI and that this bias was due to lack of information (Cotton, 2004). Thus, it was proposed that police
should be trained in issues related to mental illness and crisis intervention so they could better serve this
population. In a survey of major U.S. police departments, 88% of the responding agencies reported that they
offered some form of training for their officers in how to deal with PMI (Deane et al., 1999). Early evaluations of
such training employed three primary outcome measures: knowledge of mental illness, attitudes toward PMI and
changes in job-related behaviour and performance (Godschalx, 1984). These early studies provide some limited
support for the ability of educational intervention to improve officers' knowledge of mental health issues. Similarly,
Mulvey & Repucci (1981) examined the effectiveness of crisis intervention training for police, but found no
significant differences between trained officers and a control group in terms of officers' attitudes, knowledge or
performance. Despite the inconclusiveness of this early research, several distinct models of pre-booking diversion
programs have since emerged. These include:
1. The Crisis Intervention Team (CIT) model, first implemented in Memphis, Tennessee in 1988. This program is
staffed by officers with 40 hours of special training in mental health issues (Borum, 2000). In situations with PMI,
CIT officers have a chance to defuse the situation before it escalates. Memphis CIT officers respond to
approximately 7,000 calls a year. According to Borum (2000), the Memphis CIT model shows a low arrest rate for
police calls involving PMI, a rapid response time, and frequent referrals for treatment. This type of program has
since been adopted in Portland, Oregon; San Jose, California; and Seattle, Washington, among others. In Canada,
the CIT model has been adapted by police departments in Vancouver, Camrose, Chatham and Calgary.
2. The Psychiatric Emergency Response Team (PERT) model, which has been operating in San Diego, California
since 1996. The program pairs licensed mental health professionals with police officers, both of whom response to
situations involving PMI. The mental health professionals and the police officers receive 80 hours of training over a
four week period. According to the Council of State Governments (2001), the San Diego PERT program has
7
responded to 3,000 calls since 1996, with only 1% resulting in incarceration. A similar model has been adopted in
Hamilton.
3. The Crisis Mobile Team (CMT) model operates in Santa Fe, New Mexico. It is comprised of behavioural health
experts who help police officers at the scene decide a course of action in incidents involving mentally ill offenders.
Case managers may refer the person to an appropriate outpatient facility. Unfortunately, evaluative literature about
this model remains sparse, although the program has been adapted in Canada by departments in London, New
Westminister, Gatineau and Halifax, among other sites.
One study has compared the three models. Steadman et al. (2000) found that the Memphis CIT model resulted in
lower arrest rates (2%, compared to 5% and 13% for the other study sites), and more incidences of a PMI being
taken to a treatment location (75% in Memphis, compared to 20 and 40% for the other sites). The authors attribute
the difference in part to the existence in Memphis of a mental health facility with a "no refusal" policy for police
cases.
c. Strengths and Weaknesses of the Pre-Arrest Literature
Literature on pre-arrest diversion programs has been primarily limited to descriptive accounts, and with the
exception of basic program statistics, such as the numbers of people diverted by the police, there remains few
outcome data in published studies. Most evaluations of pre-arrest diversion programs have taken on a formative
aspect whose purpose is to identify and describe process elements, rather than analyze program strengths and
weaknesses with an eye to improvement or replicability or to gauge outcomes. Consequently, the paucity of
generalizable evidence about pre-arrest diversion schemes precludes definitive statements about their overall
effectiveness. This implies a substantial need for further evaluative research.
Moreover, the literature surrounding pre-arrest diversion provides little insight into some of the key questions
behind this literature review. Other than the program descriptions noted above, there is virtually no information on
optimal staffing or funding levels; nor does the literature offer rigorous evidence on which to base decisions
surrounding policy, planning, or training. Nevertheless, a key strength of the extant literature is its rich descriptive
nature; among the themes to arise from the literature review, there appears to be strong consensus that the
following four key elements are associated with programs that were perceived to be successful.
First, all relevant mental health, substance abuse and criminal justice agencies were involved in program
development from the start. Numerous authors have noted that most forms of the diversion represent a profound
administrative challenge, insofar as such programs necessarily require collaboration among agencies with diverse
goals and objectives. For example, Steadman et al. (2001) studied a pre-arrest programs in three communities
using a primarily descriptive design and concluded that collaboration among stakeholders was a fundamental
element of the program's survival. In an earlier study, Steadman et al. (1995) noted that interagency agreements
or memoranda of understanding (MOU), in which agencies specify the availability of services to one another, were
essential for success.
Second, regular meetings between key personnel from the various agencies were held. Deane et al. (1999)
conducted case-study analyses of two pre-booking diversion programs and concluded that the teams benefited
from frequent inter-agency contact in making disposition decisions. The trained officers provided security,
transportation, law enforcement field resources and knowledge about handling violence. The mental health
specialists provided knowledge about mental illness and experience in diagnosis, crisis evaluation, and interacting
with psychiatric patients. Overall, the teams increased the percentage of PMI who had access to the mental health
systems.
Third, streamlining services through the creation of a dropoff center with a no-refusal policy for police
cases is seen as crucial. For example, in their 2000 study comparing various models of police response,
8
Steadman at al (2000) attribute differences in arrest rates and referral to treatment to the availability in Memphis of
a crisis triage center with a no-refusal policy for police cases. This specialized crisis response site allows police to
drop off individuals in psychiatric crisis and return to their regular patrol duties. The authors note several principles
that are important to the operation of these crisis response sites: having a single point of entry; having a
streamlined intake and a "no refusal" policy for police cases; and linking clients to community services.
A fourth related theme in the integration of services is that of a liaison person or "boundary spanner" with
a mandate to effect strong leadership in the coordination of various agencies (Steadman et al., 1999, p.
1620). Whether or not a specific position is created, an experienced individual who has the trust and recognition of
people from each of the systems involved can bridge administrative difficulties inherent in interagency
collaboration. In a descriptive account, James (2000) argues that diversion schemes in the U.K. suffered because
of the "disparity between the role that each agency is supposed to perform and the reality of its training and
availability" (p. 535), a problem compounded by the lack of any effective coordination between the agencies
involved, or the lack of any professional with a specific mandate to pursue such coordination.
7. Court Diversion
a. Introduction
Pre-trial court diversion generally refers to the crown's decision not to prosecute eligible offenses if a charged
offender with mental illness agrees to treatment. Often, such programs are known as post-booking, prearraignment schemes (Steadman et al., 1995). In Ontario, crown attorneys who wish to implement some form of
diversion are guided by the Crown Policy Manual (Ontario Ministry of Attorney General, 1995).
Requests for diversion may come from the defense counsel, the police, various mental health services, diversion
workers, court staff, or from citizens. The Criminal Justice / Mental Health Consensus Project Report (Council of
State Governments, 2001) identifies four elements of the pre-trial court diversion process. These include: (a)
appointment of counsel; (b) assessment of the offender; (c) consultation with the victim, and (d) prosecutorial
review of charges (including the decision to divert).
While most pre-trial diversion programs tend to consist of the same general procedures, they may vary enormously
in terms of staff and resources. For example, the diversion team for a pilot program associated with the Adelaide
Magistrates Court in Australia consisted of a coordinator with a background in mental health and disability issues, a
clinical psychologist who oversaw assessments, and a mental health liaison officer responsible for advising mental
health service providers (Burvill et al., 2003). In Ontario, however, diversion teams in smaller or rural communities
may consist of a single psychiatric nurse (Swaminath et al., 2002).
b. Synthesis and Evaluation of the Court Diversion Literature
Unfortunately, little is known of the long-term outcomes of pre-trial diversion programs. Few studies follow up and
evaluate the outcomes of pre-trial diversion of adult offenders with mental illness. Moreover, it is difficult to gauge
the overall effectiveness of court diversion programs due to jurisdictional/regional variations in treatment and
resources, and to varying conceptualizations of "effectiveness," which preclude the meaningful comparison of study
findings. Terminological confusion notwithstanding, such evaluative literature as exists tends to focus on the
following process and outcome variables: recidivism, compliance, monitoring/case management and
treatment/community services.
In a study of court diversion programs in two Ontario communities, Swaminath et al. (2002) found low recidivism
rates (2% and 3%) one year after diversion. The authors caution, however, that selection bias may account for this
insofar as the Crown Attorneys may have screened out offenders with criminal histories. Furthermore, diversion
was not recommended if a program of treatment was unavailable or could not be monitored. In their study of a Los
Angeles court diversion program, for example, Lamb et al. (1995) defined an unsuccessful outcome if, during a
9
year after arrest, a study subject had been psychiatrically hospitalized or arrested, had committed physical violence
against others, or was homeless. The authors found that 46% of those who had participated in the program had a
successful outcome, whereas 54% did not.
In a U.K. study of 65 mentally disordered offenders, Chung et al. (1998) found little difference in the quality of
offenders' lives six months and one year after diversion. The authors caution, however, that the results may not be
generalizable due to the due to the highly transient nature of study subjects, and due to the nature of treatment
options available. The authors found that few of the subjects had stable accommodation within the year-long
measurement period. Additionally, none of the subjects' treatment was monitored, nor were they assigned case
managers. Only 14% had regular contact with social workers and only 13% had regular contact with a physician;
the authors surmise that compliance would have improved with secure accommodation and monitored treatment.
According to Hiday (2003), homelessness is a strong predictor of recidivism, a finding echoed by Australian
researchers Hunter & McRostie (2001).
Few studies actually investigate the effect of specific aspects of court diversion programs on treatment or other
outcomes. For example, in terms of pre-trial diversion, only Steadman et al. (1999) studied measures to improve
diversion rates. These authors suggest that active case finding - noted in 8 of the 13 diversion programs studied tends to result in offenders being linked more quickly to diversion programs and to mental health services. As is
the case with many field studies, however, this article is insufficiently controlled to rule out confounding variables.
c. Strengths and Weakness of the Court Diversion Literature
In conclusion, the long-term outcomes of pre-trial diversion are vastly understudied phenomena. The
preponderance of literature consists of program descriptions or evaluations whose focus on outcomes is limited
primarily to the collection of descriptive statistics regarding program enrolment and completion. With the exception
of the studies noted above, there has been little effort to gauge the effect of diversion on recidivism, or on quality of
life. Nor has there been much systematic effort to delineate factors that contribute to successful diversion. Despite
this, the literature on pre-trial court diversion tends to support the following themes:
Some studies of diversion programs note difficulties in creating awareness of the pre-trial diversion option
among lawyers and court staff, who may not be aware of mental health issues (James, 1999). Swaminath et
al. (2002) found that some lawyers were not aware of the diversion procedure or found it cumbersome. In other
studies, the application to divert was made by professional staff who were knowledgeable about mental health
issues (Chung et al., 1998). Lamb et al. (1996) suggest it is crucial for nonclinicians in the criminal justice system
to have assistance in recognizing mental illness.
Formal case finding procedures are important for the early identification of mentally ill offenders in need of
services. In the U.S., court diversion workers are able to make rapid and regular use of both mental health and
criminal justice information systems to learn more about an individual's history (Steadman et al., 1995). While
similar links between criminal justice and mental health information systems may not be practicable in all
jurisdictions, some accounts of diversion programs suggest that, at minimum, program staff check daily rosters of
jail and remand inmates to find clients, interview them, recommend diversion if appropriate, and link them to mental
health treatment (Macfarlane et al., 2002).
Diversion is a realistic enterprise only to the extent that adequate resources exist in the community. The
few long-term studies support the proposition that stable accommodation enhances the possibility that the divertee
will remain in regular contact with her or his treatment provider (Chung et al.,1998; Lamb et al., 1996; Hiday, 2003).
Moreover, lawyers or court workers may be reluctant to apply for the diversion option if a program of treatment is
unavailable.
There is a general consensus in the literature that extended mental health treatment combined with active
case management improves compliance and reduces the likelihood of recidivism (Cervantes et al., 1987;
10
Steadman et al., 1999). Case managers perform critical functions, including client identification and outreach,
evaluation, direct consultation to the courts, and the development of an appropriate treatment plan, among others.
An equally important function, however, is that of monitoring the client's treatment to determine whether services
are in place and whether the client is compliant.
8. Mental health courts
a. Introduction
In MHCs, judges and attorneys work with clinicians and defendants to fashion treatment alternatives to trial
(Haimowitz, 2002). The oldest extant MHC in the United States was established in Broward County, Florida, in
May, 1997. The Broward County program involves a specialized court dedicated to handling PMI accused of
nonviolent, low-level misdemeanor offenses, excluding driving under the influence and domestic violence. The
court was created specifically to balance issues of treatment and punishment for defendants with mental illness and
was modeled after the drug court introduced in 1989 in Dade County, Florida (Steadman et al., 2001). Funding for
the $2 million program was provided through the budgets of state and county governments and miscellaneous
sources (Lurigio & Schwartz, 2000). King County's mental health court was modeled after the Broward County
program. Beginning operation in February, 1999, this program is funded by the Bureau of Justice Assistance, and
local criminal justice and mental health systems. The annual cost of the program is $900,000, most of which is
spent on treatment.
b. Mental Health Courts in Canada
Currently, there are two MHCs operating in Canada. Court 102 in Toronto began operation in 1998, sponsored by
the Attorney General, the Ministry of Health and Long-Term Care, and the Solicitor General (MacFarlane et al.,
2002). The creation of this dedicated court was motivated by factors such as the perception of an increased
number of mentally disordered accused in the criminal justice system, and the inability of regular courts to provide
an appropriate response to this population, as well as the slow rate of processing these cases. The features of
Court 102 include: shared spaced with the Ontario Review Board to facilitate fitness assessments; a psychiatrist
on site five afternoons a week to conduct assessments; mental health workers and a case manager; adjoining
cells, dedicated duty counsels, crown attorney and judges. As Court 102 has evolved, it has come to function
primarily as a fitness assessment court, although other support services are available (MacFarlane et al., 2002).
The mental health court in Saint John, New Brunswick, began in November, 2002. The court was initiated by a
judge and crown prosecutor as a response to an apparent increase in the number of mentally ill offenders
appearing in provincial court. The current court team consists of representatives from three sectors: (a) officers of
the court - judge, crown prosecutors, Legal Aid defense counsel, and probation officers; (b) clinical professionals psychiatrists, psychologist and mental health nurses; (c) community-based residential services - the Salvation Army
and special care homes (Goggin et al., 2003). The initiative was funded under the Legal Aid Initiative. There are
two main phases in the St. John Mental Health Court process: (a) the Admission phase consists of four
components: Presentation, Eligibility, Compliance and Acceptance, and; (b) the Program phase during which an
accused participates in a judicially monitored program. This phase continues until the accused graduates,
voluntarily withdraws or is removed from the program.
c. Synthesis and Evaluation of the Mental Health Court Literature
Although the Broward County program has been a highly influential model for subsequent mental health courts, no
single conceptual model common to all MHCs has yet been established (Slate, 2003; Petrila, 2003). Consequently,
much literature surrounding MHCs is less evaluative than normative. As Steadman et al. (2001) point out, "almost
any effort by the courts to better address the needs of PMI who engage with the criminal justice system can qualify
as a mental health court […]. In its confusion, the concept has come to have little meaning" (p. 458). Several
scholars have attempted to redress this conceptual confusion by delineating the necessary constituents of an MHC.
Among the most thoughtful of these efforts are Steadman et al. (2001), Slate (2003) and Goldkamp & Irons-Guyn
(2000). Following are common elements of MHCs, culled from the work of these authors:
11
• All PMI identified for referral to community-based services are handled on a single court docket;
• A courtroom team approach is used to arrive at recommended treatment and supervision plans;
• Assurance of the availability of appropriate treatment is necessary before the judge rules;
• Appropriate monitoring occurs under the aegis of the court, with possible sanctions for noncompliance such as
reinstituting charges for sentences;
• Court staff, including judges, function in accordance with principles of therapeutic jurisprudence;
• Participation of all key players from the initial planning process of the mental health court to periodic meetings
and evaluation after the court is operating;
• Much of the courtroom process is aimed at making an initial assessment of an individual for mental illness, and
then moving the person with mental illness out of jail and voluntarily into treatment as expeditiously as possible;
• A linkage to a varying range of treatment and support services, underpinned by inter-agency cooperation and
collaboration.
Despite these common elements, MHCs may vary in the way they deal with mentally ill offenders. Griffin et al.
(2002) found that some courts tended not to accept a plea and to withhold adjudication, whereby charges would be
dismissed upon successful completion of requirements (i.e., treatment) set by the court. In other courts, an
individual would be convicted and then placed on probation, sometimes via a deferred or suspended sentence.
Many of the courts stayed charges once the treatment program had been successfully completed. In one
jurisdiction, after successful complete of a treatment program, the guilty plea can be withdrawn. In another court,
once charges are dismissed, a request for expungement of the arrest from the record can be made (Griffin et al.,
2002). Varying methods of supervision also exist. Supervision may be maintained by representatives from area
community treatment providers, probation officers or MHC staff, or teams composed of both mental health and
probation personnel. These personnel can also be utilized in hearings to assist the court in monitoring the
progress of those under supervision by the court (Lurigio & Swartz, 2000; Petrila, 2003). Relatively few courts
resorted to jail confinement as a sanction for noncompliance. Employees under the MHC's control can also
function as boundary spanners or resource brokers to ensure that PMI who appear before the court can be linked
to services such as treatment, benefits, housing, or employment opportunities (Steadman et al., 2001). Boothroyd
et al. (2003) studied the case outcomes of Broward County's Mental Health Court over a two-year period. They
found that at the conclusion of the initial hearings, the defendant's legal case remained open in about one-third
(36%) of the cases. These cases were usually scheduled for a "status hearing" several weeks later at which the
court would receive information about the defendant's participation in treatment, and would reconsider the legal
status of the case.
d. Strengths and Weaknesses of the Mental Health Court Literature
As is the case with pre-arrest and court diversion schemes, the effectiveness of MHCs in reducing future contacts
with the legal and medical systems (i.e., arrests, convictions, hospitalizations, etc.) has not yet been evaluated
rigorously (Steadman et al., 2001). Although MHCs have been studied, this work tends to be primarily descriptive,
and is hampered by an absence of data regarding participants, the services employed, or outcomes (Goldkamp &
Irons-Guynn, 2000). Nevertheless, several evaluations have been undertaken, and we discuss these below.
In evaluating the effectiveness of the Seattle MHC, Trupin & Richards (2003) used a pre-test, post-test design in
which they studied charge, detention and mental health data for participants before and after their contact with the
MHC. In most cases (n=65), the measured effects were in the direction expected for programs intended to reduce
crime and criminal justice sanctions. Evidence for increased treatment referral and treatment compliance was
unequivocal. The authors acknowledge, however, that in the absence of a comparison group, some of the
indications of effectiveness used in the study - charge severity, global assessment of functioning ratings, and
booking rates - may arise from elements in the criminal justice system other than the MHC (such as police handling
and the nature of treatment).
12
Boothroyd et al. (2003) found that participants (n=95) in the Broward County MHC were more likely to become
engaged in the mental health treatment system that participants in a regular court (Hillsborough County, n=97) over
the eight months after their initial court appearance. Additionally, regular court defendants were 50% more likely to
stop receiving treatment after their court appearances relative to MHC defendants. In a related study, Poythress et
al. (2002) found that offenders participating in the Broward County MHC did not experience their involvement in the
court to be coercive.
Cosden et al. (2003) compared the results of an MHC in Santa Barbara that employed an assertive community
treatment (ACT) model of case management (n=137) with treatment as usual (TAU, n=98). The ACT model
consisted of frequent contact with case managers, transportation to meetings, housing assistance, vocational
training, and group skills training. TAU consisted of adversarial criminal processing and referral to the long-term
care team associated with local mental health services, where PMI received housing assistance and some
vocational training. Considerable variation was found in services received by clients in the latter model, although
both groups experienced similar gains in quality of life self-assessments. Moreover, both groups experienced less
self-reported distress at the end of 12 months of treatment. In terms of criminal activity, clients in TAU were
significantly more likely to commit and be convicted of a new crime during the 12 months subsequent to their
beginning the TAU program. Finally, participant in the MHC treatment program demonstrated greater self-reported
gains in developing independent living skills and reducing problems with drugs and/or alcohol. Again, factors
confounding these results are the validity of the self-report measures. Thus, while there is some indication that
mentally ill offenders benefit from their participation in mental health courts, the evaluative literature has not year
achieved the "critical mass" necessary to create generalizable, evidence-based knowledge.
In an evaluation of the King County MHC, Neiswender (2003) found that during the year after their initial court
appearance: 75% of the program's graduates did not commit a crime during the following year; jail time was
reduced by 90%; and fewer than 10% committed a violent crime. Neiswender concludes that the "King County
Mental Health Court significantly reduces criminal activity" (p. 10). Since this report does not include a control
group, it is likely that the term "significant" is best interpreted in a colloquial rather than statistical sense. In his
assessment of the Maricopa County MHC, Stodola (2004) uncovers similar indications of effectiveness as
Neiswender, but since Stodola's observation period encompasses only three months and since his sample includes
only 14 offenders, comparisons are difficult. Stodola is the only researcher to consider whether MHCs are more
cost effective than traditional courts, but concludes that insufficient data exists to answer the question.
9. Site Visits
a. Context of the Site Visits
Rather than conducting site visits after the survey was developed as originally proposed, the site visits were used
to develop the survey. Since the principal investigator was familiar with courts in Southwestern Ontario (Hartford,
2003), four site visits in Toronto were conducted in April, 2004 and key informants in these settings were
interviewed in person or by phone (Appendix VlIl). It should be noted that Mount Sinai Hospital, which was not
included in our site visits, provides court support services for the Black and Asian communities in Toronto.
In 2002, a review of five court support services was conducted (MacFarlane, 2002). The report identified Toronto
has having a mixed model of mental health services in the courts with one dedicated MHC (which conducted
mostly fitness assessments although support services were available at theToronto mental health court) and
mental health services that operate in courthouses with no dedicated mental health court (we noted that one court
that we visited had since dedicated a docket to mental health). Among many recommendations was the need for
the development of a program, protocols, outcome measures, etc. Also an internal review of the two CMHA court
support teams was conducted in 2004 which provides a detailed description of the two programs’ similarities and
unique differences. Direct program costs were calculated from approved budgets and data such as number of
clients served, proportion of time spent in consultation/case management, client demographics, previous history,
pending charges, etc. were abstracted from an established database. While more linkages with community
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agencies were identified as a service need, the need for a common management information system (MIS) data
system was also identified.
In Janurary, 2003, the Consortium on Mental Health Services in Toronto Courts was formed. It was composed of
the Executive Directors of CMHA-Toronto, COTA Comprehensive Rehabilitation and Mental Health Services,
Community Resource Consultants of Toronto, and representatives of CAMH and the Ministry of the Attorney
General. To date, the Consortium has produced: (a) Vision and Mission Statement; (b) Court Support Worker
Activities Statement; and (c) Policies and Procedures. Dialogue with key informants at the Centre for Addiction and
Mental Health (CAMH) and the Canadian Mental Health Association (CMHA) -Toronto identified further resources
such as an Agreement between the Ministry of the Attorney General and CAMH for forensic services.
b. Findings from Site Visits
Observations resulting from our site visits included: (a) mental health personnel connected to the court have a wide
variety of background preparation in mental health and criminal justice issues. Most were operating with no formal
education/training in criminal justice issues; rather they had learned on the job. (b) Mental health personnel were all
paid by community mental health agencies. Their ability to quickly access community resources varied widely, e.g.
access to Schedule 1 beds, supportive housing, etc. (c) Psychiatrists’ time was reimbursed by the Attorney
General’s Department through an agreement with CAMH; one psychiatrist was reimbursed by CMHA. One court
had a community psychiatrist who would accept referrals. (d) Mental health personnel connected to the court
identified eligible clients in a variety of ways that seemed dependent upon their relationship with the Crown. Close,
established relationships saw CSW case-finding in the cells, at bail court, with police, etc. When this relationship
was not as established, the crown referred cases to the CSW. As the relationship evolved, more “difficult” clients
were referred, i.e., multiple offenses, more severe offenses. (e) Not one court or agency could identify all the costs
associated with the CSW and the court diversion process; two courts had identified direct costs for their internal
report. (f) All courts had dedicated psychiatrist/s available for fitness assessment from 1 half day/week to 5 half
day/s week. It should be noted that this does not occur in most of the province. Only one court had dedicated
judges, legal aid defence counsels, mental health court workers, and case managers. (g) Office conditions ranged
from cramped and dingy to small and new: office conditions seemed to be irrelevant to functioning. Access to the
crown, defence counsel and private interviewing rooms were viewed as important. (h) In the Toronto area, there
were movements underway to standardize forms, job descriptions, etc. (i) CSW’s duties ranged from direct contact
with clients, crowns, psychiatrists and defence counsel, to indirect consultation to clients at the request of the judge
(up to 60-70% of CSW time in one site). At one site, a fulltime dedicated court existed while in one other site a
weekly docket was dedicated to mental health clients, but this wasn’t entirely satisfactory because the docket
before it often spilled over into it.
Frustrations mentioned included: (a) lack of access to Schedule 1 beds for acute clients, (b) clients’ deterioration in
the cells or jail because of lack of timely assessment and treatment, (c) lack of dedicated defence counsel,
dedicated crowns, dedicated court rooms and court dockets, lack of community psychiatrists for referral, lack of
housing and case management. It was acknowledged that volume of cases did not always justify a dedicated court,
and in these cases a dedicated docket, crown and defence counsel would be appropriate.
Outcomes: Charges stayed represented a successful outcome in one court, letters of satisfaction in another, and
reduced recidivism. In other instances, no outcomes were assessed. Monitoring of compliance with the diversion
plan is done by phone at several courts. Some courts declined to stay the charges if the client didn’t comply with
the diversion plan; some courts will not allow a person who re-offends to be diverted, while others do. All CSWs
could provide the number of clients served annually, most knew whether re-offense had occurred in their
jurisdiction but other outcomes were not known.
10. Survey Results
Because of the difficulties involved in compiling a comprehensive sampling frame of all diversion programs in
Canada, the United States, the United Kingdom, Australia and New Zealand, this survey was intended from the
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outset to yield a “snapshot” of mental health diversion as it is commonly practiced, rather than a statistically
generalizable dataset (see Appendix II). Since the agencies to which we distributed the survey were compiled from
numerous secondary sources – some of which proved to be obsolete or inaccurate – we are unable to assert that
the 266 potential respondents represent the actual statistical population of all mental health diversion programs.
Nevertheless, the survey provides a glimpse of common practices and concerns among the 125 respondents (47%
response rate). In the field of mental health diversion that is not reflected in the literature. Specifically, we found
that the following themes represent pervasive concerns in the field:
•The need to link mental health diversion practices to housing and accommodation for PMI;
•The importance of enhanced community mental health services, and their integral connection to successful
diversion programs;
•The advisability of intensive cross-training at all levels of mental health diversion practice;
•The seemingly pervasive shortage of forensic beds and treatment facilities.
Consistent with accepted practices of qualitative research, we present the key themes and illustrative raw data
below. Key observations are noted in bold.
a. Pre-arrest Diversion
Of the 54 police departments and pre-arrest diversion programs to respond, 30 were from Canada, 16 from the
United States, six from the United Kingdom and two from Australia.
Theme 1: Type of Program
Twenty-six respondents (48%) noted that they did not have a formal diversion program in place, while 15 (27%)
responded affirmatively. Forty-three of the respondents (79.6%) were unable to indicate how many PMI they
diverted in the previous year. Those departments and programs (n=9, 16%) who did respond to this question
indicated a wide range of diverted PMI, from a high of 1,700 to 6. Twenty-one (38.8%) of the respondents noted
that their department's program involves a Crisis Intervention Team, while an equal number note that their
department's program is associated with a mobile response agency. Only 19 (35%) of respondents offered a brief
description of their program; the following comments indicate the range of program types:
"Advice given to custody staff on mental health issues and if it is the public interest to prosecute. This is dependant
on the nature of the offence"; "[Our department] has a team of trained masters-level mental health specialists who
provide 24/7 mobile, on-site crisis intervention to stabilize consumers and link them with community mental health
resources - Mental Health Association, NAMI, Mental Health Center and Mental Health Court. In addition, the Crisis
Unit trains all officers on defusing volatile situations"; "Community Service Officer Unit consists of civilian social
workers, who work to assist officers in many situation involving a person with mental illness. This can include an
emergency psychiatric evaluation"; "Crisis Intervention Team program. We provide 40 hours of experiential training
to volunteer officers (25% of patrol) on mental illness and communication/active listening techniques. The
objectives of the program are to help keep officers and mental health consumers safe by educating officers about
mental illness and less physical tactics and techniques that have proven to be effective in helping officers deescalate these difficult, potentially volatile situations involving individuals in serious mental health crises."
Only 13 (24%) of respondents noted that their departments have written criteria that officers use to assess
whether an individual is an appropriate candidate for diversion. The majority of respondents indicate that they
rely on the officer's discretion on the scene, as the following comments suggest:
"Officers have to use their own experience in making the initial assessment"; "People arrested for offences and
taken to a police station can also subsequently be assessed by mental health care professional"; "[The decision to
divert is done on a] case by case basis, depending on the incident at hand, the input from the victim (or property
owner if property crime) input from mental health staff"; "Diversion is completely ad-hoc, done on a case by case
basis."
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Theme 2: Training
As might be expected, the current mental health training for police officers encompasses a wide spectrum; several
respondents (particularly those with formal diversion programs) report intensive training in mental health issues (up
to 40 hours of CIT curricula), while 16 (29.6%) of respondents indicate that officers receive no special training
in mental health issues at all. Not surprisingly, therefore, 32 (59.2%) of the respondents noted that more training
is needed. Generally, the additional training perceived as necessary concerns diagnostic issues and deescalation of potentially volatile situations. The following comments are indicative of the range of suggestions:
"Training needed related to dual diagnoses issues. When the crisis unit is called, it is very rare for the client to be
admitted to hospital. The police are left to deal with a mentally ill client, who is usually off their prescribed
medication and causing problems in the community. The police need training on the quickest way to resolve a
situation and assist the client with the best solution possible, always trying to prevent arrest"; "1. Learning how to
interact with [PMI]. 2. knowing and observing behavior. 3. Knowing how to articulate your observations correctly to
health care professionals"; "Because it is difficult for small, rural police departments to send more than two officers
at a time to a week-long training, we feel the need to offer a one day basic course so that all officers have some
training, awareness and skills to respond to this population."
Theme 3: Outcomes and Monitoring
Thirty respondents (55%) indicated that they do not have specific criteria to monitor the diversion
program's success. Of those who responded affirmatively, outcomes revolved around the following factors:
Increasing the number of officers trained to deal with mental health issues;
Increasing the percentage of PMI diverted from jail to treatment;
Decreasing the percentage of use-of-force incidents when dealing with the mentally ill;
Reduced recidivism in identified PMI;
Comparing percentage of diversions from jail to treatment with previous year, and by CIT and non-CIT
members;
Number of arrests of the mentally ill to the previous year.
Theme 4: Services and Referral Options
Twenty-four respondents (44%) did not identify services or agencies to which their departments divert PMI. Of
those who did respond, below are the most common agencies or services provided to clients (proportion of
respondents accompanies each category):
Crisis intervention 42%
Case management services 35%
Risk assessment 29%
Assistance obtaining medical care 25%
Medication management 21%
Housing assistance 19%
Assistance obtaining financial aid 15%
Assistance with other benefits 15%
Day treatment 15%
Individual therapy 13%
Group therapy 10%
Money management 8%
Frequently mentioned 'other' categories of treatment or service include:
Substance abuse 31%
Acute care hospitalization 25%
Family therapy 17%
Safe beds / crisis beds 17%
Long-term care hospitalization 13%
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Seventeen respondents (31%) noted that other services should be available. Of these, the availability of, and
access to, treatment facilities and appropriate programs was most frequently noted. The following
comments are typical:
A locked facility that that is neither a jail or hospital and can be accessed voluntarily by those with a mental illness.
It would provide a place of safety to the individual"; "Our mental health services are seriously under-funded, relative
to the need. There is request for increased services in our local regional jail for persons who are not diverted";
"Department should have access to a safe bed/crisis bed program outside of the local hospital emergency room";
"Emergency beds"; "Housing and home care are sadly lacking for individuals with MH issues. Shelters are virtually
non-existant, immediate 'almost' emergency care other than the hospital emergency room does not exist.
Drug/alcohol treatment for those who are dually addicted isn't accessible. Emegency assistance with essentials
such as food and general hygiene is also scarce"; "In this county we have a deficit of beds available for: children
and teen-agers, dual diagnoses patients, people who need alcohol detox, locked long-term psychiatric
hospitalization, and subacute care."
Finally, despite the clear convergence in the literature on the importance of local mental health facilities
with a 'no refusal' police for police cases, only 10 (18%) of respondents reported the existence of such a
policy in their jurisdictions.
Similarly, only 17 (31%) of respondents noted having established formal memoranda of understanding with
other community agencies. A sample from the London Police Services and London Mental Health Crisis
Service, who permitted the inclusion of their MOU, is included as Appendix IX. On a state level, a portion of
the MOU between Tasmania’s Department of Health & Human Services and Tasmania’s Police Department
is also included in Appendix IX. The remainder of the document is available at :
http://www.dhhs.tas.gov.au/ partnerships/ strategicpartnerships/#police.
Theme 5: Costs and Cost Effectiveness
Only 11 respondents (20%) were able to provide an estimate of their program's annual budget. Responses ranged
from a low of $3,000 to a high of $3,000,000. Since existing institutions (i.e., police departments) tend to
encompass pre-booking diversion programs, it is likely that respondents were unable to easily distinguish the direct
and indirect costs of their diversion programs. Funds tend to be provided predominantly by state or county
governments and/or agencies.
b. Court Diversion Programs
Of the 43 diversion programs to respond, 16 were from the U.S., 17 were from Canada, eight from the United
Kingdom and two from Australia. Estimates of the programs' annual volume ranged from a low of 10 divertees per
year to a high of 360.
Theme 1: Training
Twenty (46.5%) of the respondents noted that legal team members associated with the program have received
training in mental health services, while 8 (18%) did report such training. Following are some typical comments:
"It varies according to the position of the staffing team. Some participants are mental health case managers while
others need to know only the basics"; "We have working relationship with legal counsel in the community but no
direct legal team. They would have access to a large number of mental health related training if interested";
"Regular meetings with Municipal Court Judges on activities, outcomes and problem solving. Make modifications in
format and referral / follow-up procedures"; "The Coordinator of the Diversion Program receives ongoing mental
health training on a variety of topics, e.g., mental illnesses, concurrent disorders, forensic conferences, in-service
workshops."
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The current amount of training for legal team members ranges between one to 24 hours, with the average being
eight hours. Nevertheless, 12 (27%) of the respondents noted that more training is needed. Generally, the
additional training perceived as necessary concerns more uniform education about basic mental health
issues. The following comments are indicative of the range of suggestions:
"It would be helpful for prosecutors, defense, and judges to have some standard mental health training";
"Understanding of mental health problems, limitations of treatment, knowledge of Mental Health Act"; "Ongoing
training would be helpful to legal firms in the community about the diversion program and issues concerning
mental illness. Training for staff in the diversion program could include overviews of the system and methods of
presentation to Crown to assure that charges would be divertable"; "Overview of Mental Health Services and which
disorders seem to respond better to treatment. Also some intervention techniques may be helpful"; "Lawyers should
be given an annual overview of SMI's, i.e. mood & thought disorders and of the CMHA's Justice Support Services
program."
Twenty-four respondents (55.8%) noted that diversion workers received training in mental health law and/or court
procedures. However, sixteen (37%) also note that more training for diversion workers is needed. As is the case
with mental health courts, most comments in this category suggest that more formalized and intensive legal
training would be beneficial:
"More cross-training would be helpful to all team members. Most of the current training is "hands on" in the court
room"; "Basic law and how the system works"; "Better understanding and legal language, different procedures
within legal system"; "Court procedures, language of the courts, approach to Crown for Diversion of difficult
charges, dealing with police."
Theme 2: Outcomes and Monitoring
Twenty-one respondents (48.8%) noted that they had established outcomes for the programs's clients. In general,
these outcomes revolved around factors such as compliance with the treatment program, reduced
recidivism, and reduced days in jail. As well, 25 respondents (58%) noted that they had established methods of
monitoring clients' outcomes. These methods tended to include reports from treatment/service providers,
regular staff meetings, and reports from case managers.
Theme 3: Memoranda of Understanding
Despite the importance of formal memoranda of understanding identified in the literature, only 13 respondents
(30%) noted having established such agreements. Some programs, however, did forward copies of their formal
memoranda of understanding to us. As with mental health courts, these tend to specify the exact nature of
services and obligations (including financial) among participating agencies (See Appendix X for an example
of such an agreement, from the Chesterfield/Colonial Heights Community Corrections Services, who permitted the
inclusion of their MOU).
Theme 4: Treatment Options
Only 10 respondents (23%) note the availability of on-site psychiatrists or psychologists to conduct fitness
or competence assessment. Conversely, 16 respondents (37%) note that such services are available offsite.
Below are the most common agencies or services provided to respondents' clients (proportion of respondents
accompanies each category):
Crisis intervention 75%
Housing assistance 72%
Case management services 69%
Risk assessment 66%
Assistance with other benefits 59%
Referral for other therapy 59%
Assistance obtaining financial aid 50%
Money management 50%
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Assistance obtaining medical care 63%
Individual therapy 63%
Medication management 63%
Group therapy 38%
Day treatment 25%
Frequently mentioned 'other' categories of treatment or service include:
Substance abuse 63%
Acute care hospitalization 56%
Safe beds / crisis beds 31%
Emergency room treatment 28%
Fifteen respondents (34%) noted that other services should be available. Of these, increased housing,
more treatment facilities and community services were mentioned most frequently. The following comments
are typical:
"A psychiatrist on site at the court house"; "Forensic beds easily accessible in an emergency"; "More direct
intervention should be provided for those who are not so ill as to warrant immediate hospitalization"; "Integrated
inpatient substance abuse/mental health treatment. Crisis beds. Access to medication in a timely fashion upon
release from jail"; "More money for housing, day treatment"; "On site court diversion worker at the court house
would be very helpful."
Interestingly, only one respondent noted the Psychosocial Rehabilitation Toolkit as a key means of monitoring
clients’ progress and outcomes.
Theme 5: Costs and Cost Effectiveness
16 respondents (37%) were able to provide an estimate of their program's annual budget. Responses ranged from
a low of $50,000 (U.S.). to a high of 2,600,000 pounds (AUS). The average cost reported was roughly $100,000
(US). Respondents were generally unable to provide information about the cost effectiveness of their programs.
Funds tend to be provided predominantly by state or county governments and/or agencies.
Mental Health Courts
Of the 28 mental health courts to respond, more than 90% identify themselves as dedicated courts. Twenty-six of
the courts were from the U.S., one from Canada and one from Australia. Sixteen of the respondents noted that
their courts meet once a week, two meet for half a day each week, and four of the courts meet two, three, five and
seven days a week respectively.
Theme 1: Training
Twenty-one (75%) of the respondents noted that legal team members associated with the court have received
training in mental health services. Following are some illustrative comments:
"All team members have received training on the history of mental health courts, goals and objectives, and signs
and symptoms of mental illness"; "[Our training consists of] conferences, workshops, in-services. Most of our team
have graduate degrees in Psychology or Social Work so they already have considerable mental health knowledge";
"We are designing some special legal mental health training through University of South Florida for the near future
as the Public Defender's office request";
The current amount of training for legal team members ranges between one to 28 hours, with the average being
about ten hours. Nevertheless, 22 (78.5%) of the respondents noted that more training is needed. Generally, the
additional training perceived as necessary concerns diagnostic criteria and more intensive crosstraining.
The following comments are indicative of the range of suggestions:
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"Additional training in the area of co-occurring disorders (mental health/substance abuse) and treatment modalities,
traumatic brain injuries, and fetal alcohol spectrum disorders"; "Could benefit from updates on best practice clinical
models; current medications and side effects; trends and practices in other jurisdictions and countries"; "Currently
a curricula is being developed regarding judicial education and education for criminal justice partners concerning
mental health courts and other collaborative justice courts, and court principles/practices that can be integrated into
the larger court system"; "Diagnosis and behavior patterns, treatment and best practices"; "Information dealing with
DSM IV criteria and medications. I believe there also needs to be more comprehensive cross-systems training."
Seventeen of the responding courts (60.7%) noted that mental health team members of the court received training
in mental health law and/or court procedures. The majority of this training, however, appears to occur on an
informal or ad hoc basis, as the following responses suggest:
"All of our team have been involved in the court and legal systems for many years"; "Once in position, training on
an ad hoc basis as per needs of individual and specifics of population in question. Members are selected because
of their background in mental health issues, so expected to have prior knowledge."
Again, however, 17 respondents (60.7%) noted that more training for mental health court team workers is needed.
As the following comments indicate, most comments in this category suggest that more formalized and
intensive legal training would be beneficial:
"Could benefit from updates on developments and emerging trends in problem-solving courts"; "Court process and
proceedings, outcomes of criminal prosecutions, normative response to illness: consumer and family, staffing
procedures"; "Court process and proceedings, probation responsibilities, outcomes of criminal prosecutions,
normative response to illness: family and consumer, staffing procedures"; "How court system works, sentencing
guidelines."
Theme 2: What the Court Does
Twenty-two (78.5%) of respondents estimated that roughly only 10% of the court's time is spent on fitness
assessments, and 5% on involuntary inpatient commitment or treatment orders. Twenty-one (75%) of
respondents indicated that the preponderance of the court's time was spent on developing treatment
dispositions and monitoring offender's compliance with court directives. The most common sanctions for
non-compliance with treatment included increased monitoring and withdrawal from the program. Twenty-two
(78.5%) of the respondents noted that jail time is also used as a sanction for non-compliance. Bench warrants are
the most common judicial responses to failure to appear.
Most respondents indicate that mentally ill clients may spend up to a week in jail waiting for an initial
hearing (two courts noted that clients may spend up to a month waiting for a hearing), up to two weeks in
jail waiting for a fitness assessment, and up to a week in jail waiting for a treatment plan to be put into
place. The longest jail time was identified as waiting for forensic care beds or acute care hospital beds
(responses in this category generally ranged from two to three weeks, with one court noting a wait of 182
days). When asked to identify ways of shortening jail time for mentally ill clients, most respondents suggested that
more active case finding measures should be undertaken. When asked to identify obstacles to decreasing jail
time, responses tended to include a shortage of forensic beds, residential drug and alcohol treatment
facilities, housing and community services.
Theme 3: Outcomes and Monitoring
Twenty respondents (71%) noted that they had established outcomes for the court's clients. In general, these
outcomes revolved around factors such as successful completion of the treatment program, reduced
recidivism, reduced incarceration, and reduced time in psychiatric hospitals. As well, 22 (78.5%) of
respondents noted that they had established methods of monitoring clients' outcomes. These methods tended to
20
include reports from treatment/service providers, probation officers, court reviews, and conferences
among mental health court team members.
Theme 4: Memoranda of Understanding
Despite the importance of formal memoranda of understanding identified in the literature, only 11 responding
courts (39%) noted having established such agreements. Some courts forwarded copies of their formal
memoranda of understanding to us. These tend to specify the exact nature of services and obligations
(including financial) among: the mental health court, local or community service providers (drug and
alcohol treatment facilities were sometimes included), and the police (See Appendix XI for an example of
such an agreement, from the Mendocino County Mental Health Court, who permitted the inclusion of their MOU in
this report).
Theme 5: Treatment Options
Ten respondents (35.7%) note the availability of on-site psychiatrists or psychologists to conduct fitness or
competence assessment. Conversely, 24 (85.7%) respondents noted that such services are available offsite (71% of respondents note that the foregoing off-site professionals are available to provide treatment;
the same percentage - 71% - note that case management services are provided for clients).
Among the groups for whom the provision of services has been most challenging are: the non-compliant,
homeless, those with co-occurring illnesses, and the newly diagnosed. Others mentioned include sex offenders,
youth (under 17) and individuals with traumatic brain injuries.
Below are the most common agencies or services provided to MHC clients (proportion of respondents
accompanies each category):
Housing assistance 87%
Case management services 84%
Medication management 84%
Assistance obtaining medical care 77%
Crisis intervention 77%
Group therapy 77%
Risk assessment 77%
Assistance obtaining financial aid 74%
Assistance with other benefits 74%
Individual therapy 74%
Day treatment 68%
Money management 65%
Referral for other therapy 58%
Frequently mentioned 'other' categories of treatment or service include:
Substance abuse 84%
Safe beds / crisis beds 61%
Acute care hospitalization 55%
Seventeen respondents (60%) noted that other services should be available. Of these, housing or
accommodation was mentioned most frequently. The following comments are typical:
"Improved availability of special housing"; "Because all defendants are case managed, they have availability to an
array of services through the mental health provider. However, our providers are poorly compensated resulting in a
shortage of best practice, appropriate services, especially housing and long term care"; Better access to crisis
services, acute care, residential treatment, co-occurring treatment and evaluation, and housing"; "better access to
housing (not shelter based)"; "Better quality and consistency of follow up; supported accommodation as an
alternative to hospital, supported and secure accommodation options for high risk category patients."
Theme 5: Costs and Cost Effectiveness
As reported in the literature, data regarding the cost and cost-effectiveness of mental health courts has proven to
be elusive. Consistent with this observation, a minority of respondents were able to provide clear and up-to-date
21
information about matters related to funding. Of the 28 courts that responded to our survey, only one answered all
questions related to funding. Only 14 of the 28 responding courts attempted to answer a portion of the survey's
questions related to funding or costs. In terms of the court's annual budget, responses ranged from a high of
$5,600,000 (U.S.) to a low of $50,000. Funds tend to be provided predominantly by state or county governments
and/or agencies.
Summary
The literature surrounding mental health diversion cannot answer many of the key questions that predicated this
review. In particular, questions about evidence-based practices - including areas such as policy, planning,
evaluation, funding, training, staffing levels and clinical interventions -have so far not been researched extensively
enough to reach definitive conclusions. While descriptive studies are prominent and reflect the recent innovation
that diversion represents, process and outcome evaluations are beginning to emerge. Our Web-based survey
identified that key ingredients of diversion programs were mental health personnel and community treatment
options and key barriers were the converse: insufficient mental health personnel and community treatment options.
Memoranda of Understanding between mental health and criminal justice agencies are presented that may assist
communities beginning or refining diversion programs. To illustrate recent developments of court diversion
programs in Ontario, for the first time a listing or programs is provided in Appendix VI.
11. Recommendations
In the absence of evidenced-based practices in the literature, responses to our international web-based survey and
reports in the literature indicate that communities have proceeded to develop organized responses to the issue of
criminalization of mental illness. It is recognized that the province of Ontario cannot wait for the requisite research
in order to take steps to further develop programs to decriminalized mental illness. In addition to supporting earlier
recommendations of the Forensic Mental Health Services Expert Advisory Panel, it is therefore recommended that:
A. Overarching:
1. Enhanced capacity of community mental health agencies and housing be funded through the Ministry of
Health and Long-term Care, as the primary method of diverting persons with mental illness from the criminal
justice system.
Rationale: Research demonstrates that lack of housing is a strong predictor of recidivism. Experts agree
that the criminal justice system becomes the default system when there are insufficient community mental
health services available.
2. a. The Provincial Human Services and Justice Coordination Committee comprised of staff, in senior
positions comparable to the previous committee, of the Departments of Health & Long-term Care, Attorney
General, Community Safety and Correctional Services, and Community and Social Services be reconstituted at a provincial level to provide leadership and direction to policy and program development using
pooled funding for diversion of mentally ill persons from the criminal justice system. These members should
be senior enough to act as boundary spanners within their departments. For example, substantial
interdepartmental investigation is required to ascertain the direct and indirect costs of court diversion and
mental health courts in Ontario.
Rationale: Interdepartmental leadership and coordination is required and in its absence over the past few
years, progress on local initiatives has been inconsistent.
b. Local, and regional networks of, human services and justice services coordinating committees be formed
to examine and resolve barriers to service at the interface of the mental health and criminal justice system,
to implement provincial polices and to develop responses and monitoring of pre-arrest diversion programs.
Rationale: Implementation and adaptation of policies developed by the former and reconstituted provincial
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Inter-ministerial Human Services and Justice Coordination Committee is required with regular meetings of
key personnel from local agencies.
3. With the advent of the new provincial local health integration networks (LHINs), a close examination of
the interface between proposed new health regions and existing regional forensic programs, local Human
Services and Justice Coordinating Committees and other government department boundaries be proposed,
and that boundary spanners at the local level be appointed, to ensure that boundaries are contiguous.
Rationale: Re-organization of health regions, if that occurs through LHINs, can have direct impact on service
delivery if other pre-existing boundaries are not carefully considered.
B B. Police Pre-Arrest:
1. Training:
a. Stand-alone, accredited, in-service education such as the police training educational module Not Just
Another Call…Police Response to People with Mental Illness in Ontario (Hoffman & Putnam, 2004) be
offered by the Ontario Police College to all uniformed officers within three years of basic training.
Rationale: Enhanced training in mental health is required in order for police to recognize and efffectively
assist persons with mental illness who come in contact with them as was recommended by the Ontario
Chiefs of Police resolution in 2003.
2. Services:
a. Police pre-arrest/prebooking diversion programs be supported by a free-standing, community mental
health crisis and short-term intervention agency containing crisis safe beds with a formal "no refusal" policy
for police referrals of voluntary clients.
Rationale: Research reports an association between drop-off centers with no-refusal policies and decreased
arrest rates and increased treatment rates.
b. In order to ensure the equitable application of mental health diversion according to principles of
therapeutic jurisdprudence, standardized protocols for police pre-arrest/prebooking diversion programs
should be developed by the Ontario Association of Chiefs of Police in consultation with mental health
professionals.
Rationale: Currently, many police responses to calls involving persons with serious mental illness rely on
individual officer's discretion and may result in inequitable responses.
c. Local police and mental health services agencies be encouraged to develop an organized mental health
response for police, such as mobile crisis response or specialized police-mental health worker teams.
Rationale: Research indicates increased pre-arrest diversion rates occur when police are educated about
mental health problems and when an organized community mental health response is available to them.
d. Police Services adopt the London Police Services method of enumerating contacts and dispositions of
persons with mental illness and police.
Rationale: Pre-arrest diversion should result in fewer arrests of persons with mental illness but without
enumeration of contacts and dispositions, outcomes of pre-arrest are difficult to measure.
3. Research:
a. Inter-provincial funding of evaluation of models of pre-arrest diversion programs be sought.
Rationale: In the absence of research it is not possible to know which model is most cost-effective.
C. Court Diversion:
1. Training
a. The delineation of the roles of Court Support Workers (CSW) in diversion programs and mental health
courts developed by the Consortium on Mental Health Services in Toronto Courts be discussed for adoption
across the province.
23
Rationale: Background preparation and skills of court support workers vary widely and a standard role
description would help to ensure equity of service delivery.
b. Training of court support workers in forensics and mental health law should be standardized. Consistent
with recommendations offered by previous studies (e.g., MacFarlane et al, 2002), such training would likely
be best undertaken annually by a single, pan-provincial body such as the Centre for Addiction & Mental
Health. Training could be offered at different sites in the province.
Rationale: Court support workers more often have preparation in mental health and lack background in
forensics and legal issues.
c. Training of defense counsel in mental health law be provided annually by the Centre for Addiction and
Mental Health and paid for by Legal Aid. Training could be offered at different sites in the province.
Rationale: While training in mental health law is available for judges through the National Judicial Institute
soon-to-be released Electronic Bench Book “Mentally Disordered Offenders” and for Crown Attorneys at the
Ontario Crown Attorneys' Association Summer School, defense counsel, who are most often paid by Legal
Aid, have no additional training in mental health law. In many smaller jurisdictions where the hiring of
dedicated duty counsel is not warranted, some defense counsel and duty counsel seem to specialize in
representing persons with mental illness and could benefit by additional training.
d. Judges, Crown Attorneys and Justices of the Peace involved in diversion and mental health courts be
encouraged to attend continuing education sessions in mental health law and mental illness.
Rationale: Continuing education, such as will soon be available through the National Justice Institute
Electronic Bench Book for judges, is required to keep current on issues in mental health law and to learn
about manifestations of mental illness, current treatment and community services available.
2. Services:
a. Active case finding should be supported by ensuring that court support workers have access to potential
clients, and to their mental health condition and history, as early as possible. This includes attendance at
bail hearings, access to cells, liaison with duty counsel, liaison with remand center, etc.
Rationale: Research has linked early case finding with lower incarceration and recidivism rates and higher
treatment compliance rates.
b. Active case finding should be done by a court diversion/mental health court support worker according to
an established protocol, such as outlined in the Consortium on Mental Health Services in Toronto Courts’
Policies and Procedures Manual.
Rationale: The current Crown Manual on court diversion provides direction for the Crown but direction for
court support workers is out of scope. Redundant efforts at a local level may be avoided if the work
conducted by the Consortium is examined for use.
c. To facilitate active case finding, court support workers should be on-site at the court. At minimum, this
means office space equipped with standard office information technology.
Rationale: On-site court support workers can act as boundary spanners between mental health and criminal
justice systems. Paging the court support worker off-site does not facilitate active case finding and on-going
dialogue with counsel and Crown about potential referrals.
d. Active case finding should be supported by ensuring that court support workers have access to collateral
information such as record of arrest, synopsis of alleged offense and other court documents.
Rationale: Delay in access to collateral information inhibits active case finding.
e. A standardized, computerized management information system to track intake information, treatment
plans, monitoring time and outcomes should be funded and implemented provincially.
Rationale: A management information system will enable intra-provincial comparison of client
demographics, volume of cases and outcomes to aid in resource allocation decisions, and information to
determine strategies to enhance service delivery.
f. Agencies employing court support workers are encouraged to develop Memoranda of Agreement with
community mental health, hospital and housing agencies regarding: (a) the provision of services for mentally
ill persons referred from the court, (b) priority access to services (e.g. housing, hospitalization, and case
24
management, etc), and (c) development of treatment plans and monitoring.
Rationale: Diversion cannot occur in the absence of community services; the alternative, jail, is nontherapeutic and often results in increased symptamotology.
g. That a provincial network of court support workers be established and funded through the Ministry of
Health and Long-term Care for the purposes of communicating and meeting regularly for in-service
education and opportunities to share solutions.
Rationale: Many court support workers work in isolation from each other. The list of programs contained in
Appendix VI will aid in the formation of a network. The Canadian National Committee for Police and Mental
Health liaison provides such a forum for pre-arrest personnel.
3. Research:
a. Workload measurement of court support workers be performed in each court diversion program to
determine their primary function and to assess the proportion of time spent in activities related to direct
diversion of mentally ill clients as opposed to court support activities. This could take the form of activity logs
kept by the workers.
Rationale: Since court support workers are funded from the Ministry of Health and Long-Term Care, their
primary function should be activities related to direct diversion.
b. Since court diversion programs are not established throughout the province yet, randomized controlled
trials be funded to assess the efficacy of court diversion.
Rationale: At present, the literature does not yield sufficient information to determine the efficacy of court
diversion. Benchmarks concerning the reduction of negative outcomes for diverted and non-diverted
persons are required and it is still possible to conduct ‘natural experiments’ in Ontario.
D. Mental Health Courts
1. Services:
a. Further in support of the recommendations of the Forensic Task Force and regional Mental Health
Implementation Task Forces, that regional forensic facilities be supported to enhance their ability to meet their
regional mandates by developing telepsychiatry capacity/linkages, it may be beneficial to replicate the
November 1, 2003 agreement between the Ministry of the Attorney General and The Centre for Addiction and
Mental Health (CAMH) with regional forensic facilities. In the interim, in jurisdictions where forensic
psychiatrists or telepsychiatry are unavailable, CAMH may be asked to assist with the conduct of timely
fitness assessments. This may take the form of expanding the November 1, 2003 agreement between the
Ministry of the Attorney General and CAMH for sessional fees for forensic psychiatrists or CAMH-trained local
psychiatrists or forensically trained physicians. Telepsychiatry linkage between CAMH forensic psychiatrists
at 102 Court and local correctional facilities/courts could also be explored.
Rationale: In the absence of a change to the Criminal Code allowing psychologists to perform fitness
assessments, currently, by legislation, only physicians can conduct fitness assessments. Many local courts
are unable to affect timely fitness assessments because of a shortage of available
physicians/psychiatrists/telepsychiatry linkages and provincial coordination by CAMH could be of interim
assistance. Most courts in Ontario are equipped with video-conferencing equipment for bail hearings and
extending the use of this technology to fitness assessments is feasible.
b. Standards for waiting periods for transfer to forensic beds for should be established and monitored
provincially in order to facilitate access.
Rationale: Waiting periods for transfer to forensic beds may vary markedly from one area of the province to
another and may represent inequitable access.
c. Where volume does not warrant a dedicated mental health court, application of the principles of
therapeutic jurisprudence support the establishment of a mental health docket.
Rationale: Many courts cannot identify the number of charged mentally ill persons and yet processing
mentally ill persons accused of minor offenses through the normal adversarial court process is nontherapeutic. Early case finding combined with a dedicated docket enhances coordination for fitness
25
assessment and treatment.
d. Where possible, dedicated or specially trained judges, duty counsel, Crowns and court support workers
should be scheduled for the docket.
Rationale: Court personnel trained in mental health law and issues around mental illness will likely result in
more equitable application of therapeutic jurisprudence.
2. Research
a. Consensus on the identification and definition outcomes of pre-arrest court diversion and mental health
courts is required for research studies and for monitoring programs. Rationale: In the literature, a wide
variety of outcomes have been used: (a) Recidivism, (b) Treatment compliance, (c) Treatment effectiveness,
(d) Independent living skills, (e) Re-hospitalization, (f) Housing/homelessness, (g) Community integration,
(h) Co-occurring disorders, such as alcohol and drug addition, (i) Incarcertation rates, (j) Quality of life, (k)
Symptomatology.
Rationale: Comparison of outcomes across settings is not possible until consensus is reached on standard
indicators/benchmarks/outcomes.
b. That the Ontario Ministry of Health and Long-term Care fund research into the satisfaction of inmates
receiving fitness assessments via telepsychaitry and psychiatrists/physicians conducting fitness
assessments via telepsychiatry.
Rationale: While research into telepsychiatry with inmates for psychiatric assessment and treatment has
been conducted, no research into telepsychiatry for fitness assessments has been conducted.
c. The Ontario Ministry of Health and Long-Term Care investigate general psychiatric assessment to
support diversion of persons with mental illness who are arrested and found fit, or who are obviously fit.
Rationale: Many persons with mental illness are not connected to services and require psychiatric
assessment, development of a care plan, risk assessment, etc. and with these services many could be
eligible for court diversion, or a bail/probation order from a mental health court/docket.
26
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32
Appendix I: Literature Review Methodology
To recover peer-reviewed articles from the scholarly literature, we conducted free-text searches of the following
databases: Web of Science, Medline, PubMed, PsychInfo, Sociological Abstracts, Cinahl, Criminal Justice
Abstracts, Social Work Abstracts, Index to Legal Periodicals and Books, LegalTrac, ProQuest, Dissertation
Abstracts International, LexisNexis and The Cochrane Library, among others. To ensure the broadest possible
retrieval set and to accommodate variations in controlled vocabulary between databases, we employed
combinations of the terms “diversion,” “diversion programs,” “mental health” and “mental health courts,” using
truncation and proximity operators as necessary. After retrieving and evaluating a substantial corpus of texts, we
examined their bibliographies to locate relevant items that had not been identified in previous database searches.
To recover gray literature, we conducted extensive searches of the Internet for electronically published documents
and for references to unpublished items. In addition to search engines such as Google, we used Internet resources
specifically designed to retrieve items from government and academic sites; these include Scirus, Infomine,
Academic Info, and Teoma. Relevant documents were retrieved from Web sites associated with universities,
advocacy groups, information clearinghouses and all levels of government, as well as existing mental health courts
and diversion programs throughout North America, Great Britain and Australasia. Finally, the project’s investigators
drew on their professional backgrounds and knowledge of relevant literature to note additional items of importance,
which were incorporated into the review. Ultimately, we recovered 519 items (available in Reference Manager
format).
33
Appendix II: Survey Methodology
In response to the RFP, a research team led by Dr. K. Hartford outlined three methods: a) an extensive literature
review from which a program assessment instrument would be developed, b) site visits, and c) a survey to be used
to interview key informants. The program assessment instrument was to be used during the site visits and for a
telephone survey/interview of key informants. The research team (Appendix XIl) was composed of persons working
in the fields of diversion and family members of persons who had experienced diversion.
Based on their areas of expertise, the team assessed 519 articles using a standard grid to summarize the findings
(Appendix XlIl). The research associates (RAs) and the principal investigator (PI) then drafted a survey intended to
capture data from practitioners that was missing in the literature. As an adjunct to developing the survey, site visits
to four Toronto Ontario courts and interviews with mental health agencies were conducted (Appendix VIII). It was
then decided that the efficiencies of a web-based survey (no paper, no postage, no phone charges or keyboard
data entry) would enable us to conduct an international cross-sectional survey of practitioners and researchers.
Dillman (2000) reports email response rates of 48%, with more complete responses although coverage errors are
problematic. Rather than sampling, it was anticipated that because potential respondents all had business email
addresses, the entire population could be surveyed with minimal additional costs.
Pretesting: The survey was pre-tested with police and community mental health agencies providing diversion (see
Appendix VIII). The survey was also pre-tested with the research team and sent to the Ministry of Health and
Long-Term Care liaison personnel for review. Comprehension, ease of administration and time for completion were
assessed. Ethical approval was granted from the University of Western Ontario’s Health Sciences Research Ethics
Board.
Survey: Three surveys were developed: (a) the mental health court survey that consisted of 60 questions, (b) the
court diversion survey with 41 questions, and (c) the police survey with 38 questions (Appendix XlV).
Commonalities included demographic information, personnel and funding, referral community agencies and
interagency memoranda of agreements, program monitoring criteria, annual volume, current training and future
needs for training in mental health or legal issues. The survey was converted by the LHSC web designer to a webbased format accessible by web browsers . Additionally, pdf , Word and Wordperfect documents were also
attached providing respondents with a range of software options. A covering letter with the University of Western
Ontario and Lawson Health Research Institute logos explained the reason for and nature of the survey and
provided assurances of confidentiality (Appendix XV). Respondents were directed to click on the highlighted web
address and to select the appropriate survey. Respondents were asked to indicate if they wanted a copy of the final
report. Individuals were able to cut and paste existing documents into the survey, send them as an email
attachment or fax them. The web-based survey enabled the use of color, drop down boxes and closed-ended
questions. It was designed as a single unit so that respondents could scroll through the entire questionnaire; an
automatic thank you was sent when completed. With the other attachments, an email thank you was sent.
Sample selection: Identifying the sample was a multi-stage effort. The first step was identifying published email
addresses. The U.S. NAMI (2004) and Council of State Governments (n.d.) documents provided email listing of
228 police, court diversion and mental health courts. After consideration of the new federal privacy legislation, the
Canadian Association of Chiefs of Police released their membership directory to us that contained 129 email
addresses. The second step involved Web searches. Police email addresses or fax numbers in Australia and New
Zealand were located, but UK police and court email addresses were not available. Contacts with the Home Office
did not identify email addresses. The third step involved using literature, personal contacts and extensive searches
on the Internet. Email addresses of 473 individuals from Canadian, UK, Australian and New Zealand police, court
diversion and mental health courts were identified. A convenience sample of 850 persons/organizations was
assembled. The forth step was to try and identity addresses that proved incorrect on the initial mailing by phoning
the organization. This left 266 usable addresses.
34
Survey Results:
Response Rate: Four waves of surveys were sent between May 24 and July 7, 2004. All UK National Health
Services emails were rejected by their spam filter and a different email address was used to resend these 117
emails. Many individuals responded that they were not the correct person to complete the survey; we attempted to
have them identify the correct individual. The overall response rate was 47%. The distribution of responses by
country, type of survey and type of format are displayed in Table 1. Although the response rate is typical for Webbased surveys, the rate might have been higher but: (a) time did not permit the sending of a prior letter informing
respondents that the survey was forthcoming as advised by Dillman (2000), (b) identifying accurate email
addresses through web searches was problematic, (c) researchers who had previously conducted surveys in the
UK and US had either not retained the addresses or did not feel the addresses were current and (d) when Dillman
was conducting his research on email-based surveys in the late 1990s, the volume of email that employees
received was lower. Increased volume and the problems associated with spam make it easier for respondents to
delete unexpected email (and we would include the prior letter in this) and for individual and corporate spam filters
to eliminate unexpected email.
Table 1. Surveys received by country
Country
Australia
Mental Health Court
Web *Doc Fax Mail
1
0
0
0
Survey Type
Court Diversion
Web *Doc Fax Mail
1
1
0
0
Canada
1
0
0
0
10
3
4
United Kingdom
0
0
0
0
7
0
New Zealand
0
0
0
0
0
United States
24
2
0
0
Total
26
2
0
0
Responses
Web
1
Police
*Doc Fax
1
0
Mail
0
5
0
19
8
2
1
48
0
1
6
0
0
0
14
0
0
0
0
0
0
0
0
12
4
0
0
14
2
0
0
58
30
8
4
1
40
11
2
1
125
* Surveys received in various formats provided: Word, WordPerfect, and Pdf.
Survey Analysis:
The web-based survey automatically tallied the quantitative responses and a research assistant entered the
qualitative responses and non-web-based surveys into Nudist, a qualitative analysis program.
35
Appendix lll: Experimental Designs
1. Qualitative designs
2. Non-experimental quantitative designs
3. Quasi-experimental designs
4. Experimental designs
These include field studies, ethnographies or
historical analyses. Such designs do not produce
the kind of generalizable conclusions on which
evidence-based practice depends.
These include correlational, case study and
descriptive designs. By themselves, such studies
are usually insufficient bases for evidence-based
practice insofar as they lack the controls necessary
to establish causal relationships among variables.
Considered less rigorous than experimental designs,
these involve manipulation of an independent
variable but lack either a control group or random
assignment.
These are considered to be of greatest importance
in identifying evidence-based practice. While
experimental designs vary in complexity, they
generally allow researchers to: establish a temporal
relationship among variables; to control for
confounding variables; and to establish a statistical
association among variables.
36
Appendix lV: Formative and Summative Evaluation
Formative
Summative
Primarily prospective
Primarily retrospective
Analyze strengths and weaknesses towards improving
Document achievement
Shape direction of programs
Show results of programs
Provide feedback
Provide evidence
Source: Palys, T. 1997. Research Decisions: Quantitative and Qualitative Perspectives. Toronto:
Harcourt Brace.
37
Appendix V: Differences Between Traditional and Problem-Solving Courts
Table 1: Roles and functions of traditional and mental health courts:
Actors/Activities
Traditional courts
TJ, Problem-solving courts
Proceedings
Adversarial in nature/Formal
Non-adversarial, collaborative, cooperative/less formal
Judge
Impartial arbiter, central role
Team integrated role/compromise
orientation/fact finder
Crown/Prosecution
Argue the victim’s/state’s case
Team integrated role/compromise
orientation/fact finder
Attorney
Argue the offender’s case/duty of Team integrated role/compromise
loyalty only toward client
orientation/fact finder
Mental health professionals
N/A
Team members/bring their expertise
Social workers
N/A
Team members/linking offenders to
services in the community
Intervention
Usually postponed because of
Immediate intervention
longer proceedings
Outcome
Guilty/Not guilty
Treatment programs with clear rules
and structured goals
Table 2: A Comparison of transformed and traditional court process
Traditional Process
Transformed Process
Dispute resolution
Problem-solving dispute avoidance
Legal outcome
Therapeutic outcome
Adversarial process
Collaborative process
Claim-or case-oriented
People-oriented
Rights based
Interest-or needs-based
Emphasis placed on adjudication
Emphasis placed on postadjudication and
alternative dispute resolution
Interpretation and application of law
Interpretation and application of social science
Judge as arbiter
Judge as coach
Backward looking
Forward looking
Precedent-based
Planning-based
Few participants and stakeholders
Wide range of participants and stakeholders
Individualistic
Interdependent
Legalistic
Common-sensical
Formal
Informal
Efficient
Effective
38
Appendix Vl: Court Diversion Programs in Ontario
Organization
Province/ Territory
Ontario
Canadian Mental Health Association, Thunder Bay
CMHA, Sudbury
CMHA Sudbury/Espanola Mental Health Clinic, Little Current
CMHA, Essex County, Windsor
CMHA, Ottawa
CMHA, Barrie-Simcoe
Frontenac Community Mental Health Services, Kingston
CMHA, Nipissing Regional Branch
Regional Mental Health Care, St.Thomas
Regional Mental Health Care, London
CMHA Leeds/Grenville, Brockville
CMHA, Cochrane-Timiskmaming
CMHA, Waterloo-Kitchener
CMHA, Newmarket
CMHA, Toronto, East Metro Court & East Mall Court
CMHA, Peel
COTA Comprehensive Rehabilitation and Mental Health
Services, Toronto
Community Resources Consultants, Toronto
39
Appendix VII: Legislation from Other Countries
New Zealand: While no mental health court exists in New Zealand, the legal frameworks for fitness assessment
and court diversion (known as court liaison service) are the Criminal Justice Act of 1985, No. 120 (CJA), and the
Mental Health (Compulsory Assessment and Treatment) Act 1992, (MHA, N.Z.) amended in 1999. The CJA
enables alleged offenders who have been found unfit to be involuntarily committed for treatment in hospital or jail
(Section 115, 118, 121(1) and (2). The MHA – N.Z. (1992) defines mental illness and requires respect for cultural
identity. Section 9 defines the terms for an assessment examination. Police can detain the proposed patient for up
to six hours or the time it takes to conduct the examination, whichever is shorter, according to Section 109(3).
Section 110A provides for the powers of the police when urgent assistance is required by a medical practitioner. In
relation to forensic services, compulsory treatment orders are the most commonly used MHA – N.Z. provisions.
Section 29 requires a person to attend a certain place for treatment and accept that treatment while Section 30
requires a person to be detained in or go to a specified hospital for treatment and to accept that treatment.
Court liaison service: The Forensic Court Liaison Service provides advice, assessments, reports and
recommendations to the judiciary. It also consults and liaises with Adult Mental Health Services (AMHS), prisons,
community probation and police. Within the courts, the principal role of forensic services is to provide triage and
advice. Forensic court liaison staff also acts as gatekeepers to ensure that court referrals to mental health services
are appropriate. Thus staff ensures access to treatment and assists fair representation through the justice system.
New Zealand Police: Police have powers to arrest a person when they suspect a criminal offence has been
committed. If the police think the person is “mentally disordered” they may ask for a psychiatric assessment or, if
the crime is minor, they may not press charges and instead may call in the AMHS. It is for the courts, not the police,
to make judgments about whether a person’s mental state needs to be taken into account in any trial process or in
sentencing (New Zealand Mental Health Commission, 2003).
Australia
Australia has no federal legislation regarding mentally ill persons. Rather, individual states are governed by specific
mental health legislation. For instance, most states have compulsory community treatment orders (Kisley & Xiao,
2002). In Queensland, the only Australian state with a specialized MHC, mental health matters are legislated by
Mental Health Act (Q.C.A Mental Health Act 2000, Queensland, AU.). The purpose of this Act “is to provide for the
involuntary assessment and treatment, and the protection, of persons (whether adults or minors) who have mental
illnesses while at the same time safeguarding their rights.” An established Mental Health Review Tribunal reviews
all decisions relating to involuntary patients issued by the Queensland MHC. The entire process of considering,
admitting, and discharging potential qualified offenders is regulated by this new law.
In the other states, court diversion programs are in place using legal dispositions contained in state mental health
laws or in codes or regulations. The corresponding laws in other Australian states are as follows: Criminal Justice
(Mental Impairment) Act 1999, Act No. 21, Tasmania, AU.), Criminal Law Consolidation Act 1935, South Australia,
AU.), Criminal Law (Mentally Impaired Defendants) Act 1996, Western Australia, AU.), Mental Health Act (V.C.L.,
Mental Health Act 1986, Act No. 59, Victoria, AU.), Mental Health Act (N.S.W. C. A., Mental Health Act 1990, New
South Wales, AU)., Mental Health Act 1993 (SA), Mental Health Act (T.C.A., Mental Health Act 1996, Act No. 31,
Tasmania, AU.), Mental Health Act (W.A.C.A., Mental Health Act 1996, Western Australia, AU.)., Mental Health
and Related Services Act (N.T. C. A., 1998, Northern Territory, AU.)., Mental Health (Treatment and Care) Act
1994 (A.C.T. C. A. 1994, Australian Capital Territory, AU.).
In New South Wales, court liaison services work closely with magistrates when persons with mental illness appear
before the court. “Forensic psychiatrists and nurses work with magistrates, lawyers and police to assess people
with suspected mental illness and divert them from the criminal justice system into mental health services, hospitals
or community settings. Where these options are not feasible for the individual, the Service facilitates referral to
40
clinical care within the prison system” (Henderson, 2003). These programs show potential with “the service reports
promising outcomes on court through-put, referral rates and mental health assessments” (Henderson, 2003). In
South Australia, “the Magistrates Court Diversion Program was established in June of 1999 as a South Australian
Cabinet-funded pilot project. In the June 2001 budget, the Attorney-General announced that funding to continue its
operation and expansion” (Henderson, 2003).
United Kingdom
Courts: The principal act governing people with mental illnesses in the UK is Mental Health Act (Mental Health Act
1983, U.K.) (MHA) which allows for, among other things, a fitness assessment report under Section 35 and for a
Crown Court to send a person to hospital for psychiatric treatment rather than remanding them to prison (Section
36). Sections 2 and 3 allow for compulsory treatment for specific time periods. In the United Kingdom, which
includes England, Wales, Scotland, and Northern Ireland, specific acts of legislation may sometimes apply to only
one or other of these divisions (Ferencz et al, 2000). In Scotland, the first court diversion scheme was established
in 1984 at the Douglas Inch Centre in Glasgow. In the diversion procedure, “the clinician attempts to provide the
procurator fiscal [the prosecution representative] with a greater understanding of the processes which underpinned
the alleged offence” (Cooke, 1994, p. 212). The procurator fiscal has a considerable discretion to decide whether to
proceed with the charges against a person, stay the charges, or remove accused people from the normal process
of prosecution if he believes that their offences were linked to psychological disturbances (Cooke, 1991). Cooke
conducted a study describing the persons usually referred for diversion. “[T]he quality of the information provided
by the arresting officer is fundamental to the procurator’s fiscal ability to divert a case for treatment” (Cooke, 1994,
p. 222). In addition, because of the decisive influence of the police report in the diversion process, the author
believed that the process of diversion in Scotland may be discriminatory without “systematic information in police
reports” in the future (Cooke, 1994).
In the London area, a court psychiatric service covering five London boroughs was established in 1994, using a
scheme in existence since 1989 (James et al, 1997). All the London Magistrates’ Courts, remand mentally ill
offenders to Horseferry Road Court rather than to prison for psychiatric assessment where they had spent “…more
than 7 weeks in custody between arrest and admission to hospital” (James & Hamilton, 1993). Through the
Horseferry court scheme, 85% of offenders were “admitted to psychiatric hospitals through assessment at courts or
prisons,” (James & Hamilton, 1992). As a result, the time spent in jail by mentally ill charged with minor offences
was considerably reduced.
A circular of the Home Office, 66/1990, encouraged establishing of psychiatric liaison schemes, to divert mentally ill
wherever possible. Magistrates’ courts, being of less formal character than Crown courts, made it easier for
psychiatrists to give “opinions in brief forms, stating the diagnosis and suggested disposal.”(James and Hamilton,
1992) James and Hamilton also suggested that “diversion to hospital is possible without using the Mental Health
Act”, courts being able “to remand people on bail with a condition of attendance at or residence in a psychiatric
hospital.” (James & Hamilton, 1992)
Police: Powers for apprehension of PMIs are specified under the MHA, 1983. An approved social worker can
apply to a Justice of the Peace for a warrant to allow police to enter premise (by force if necessary) to search for a
person with mental health problems and take them to a place of safety (MHA 1983, Section 135). The police officer
who attends, and if necessary, breaks into premises in accordance with the warrant, must be accompanied by an
Approved Social Worker [ASW] and a doctor. This Section also provides for a police officer (rather than an ASW) to
obtain a warrant to enter premises when seeking to re-take a patient who is already Sectioned and liable to be
detained, but who is absent without leave. In this case the police officer may be accompanied by an Approved
Social Worker [ASW] and a doctor, but this is not compulsory.
United States
41
Mental Health Courts: No federal legislation guides the legal framework for diversion, rather federal legislation
provides funding for mental health courts. Lurigio et al. (2000) describes how within the US judicial system, mental
health courts were preceded by drug courts. In the late 1990s specialized MHCs were established in the US,
beginning with Broward County, Florida. This court has jurisdiction over mentally ill defendants, charged with nonviolent, low-level misdemeanor offences, with driving under influence and domestic violence crimes being excluded
(Lurigio et al, 2000). Defendants are initially evaluated for competency, and based on their status they can be sent
to in patient or outpatient programs in the community. Treatments are proposed and followed up by a professional
team. In October 2000, US Congress decided to support establishment of new MHCs: “A bill to provide grants to
establish demonstration mental health courts” became America's Law Enforcement and Mental Health Project
(Public Law No: 106-515 of 2000, 106th Congress). In 2002, 23 projects in 17 states received federal funds through
Bureau of Justice Assistance (BJA); in 2003, 14 sites in 12 states were awarded funding from the 2002 Congressapproved federal funds. The Consensus Project estimates that these 37 courts represent half of the MHCs in the
US. In the last decade, in many US states important changes to legislation have been made to allow mentally ill
offenders to get access to treatment (Council of State Governments, 2001)
Some states such as Massachusetts do not have a formal diversion programs or a MHC, their legislation allows for
legal representation in a commitment hearing, timely disposition, timely adjudication of treatment decisions and
criteria for civil commitment (Mass. Gen. Laws ch. 123, § 1 through 36B). The result is both diversion and a
treatment court, but on an ad hoc basis. Because court clinicians are attached to courts, at the arraignment stage
they can perform a quick competency assessment and send the defendant to a mental hospital for a 20-day
evaluation.
42
Appendix VllI: Acknowledgements
We thank the individuals involved in the site visits and others who contributed to this study:
Court
Toronto Provincial 102
Court
Date
April 16, 2004
Brampton Provincial
Court and CMHA Peel
April 22, 2004
Persons interviewed
1.Darlene Minor
2. Margaret Creal
3. Richard D. Schneider
4. Joe Wright
5. Dr. Ian Swayze
1. Sandy Milakovic
2. Courtenay McGlashen
Etibicoke Provincial
Court
Scarborough Provincial
Court
April 27, 2004
April 27, 2004
3. Stephen Laufer
4. Dr. Bruce Menchions
1. Andrea Faveri
2. Lori Hamilton
1. Cathy Chau
2. Frank Sirotich
3. Dr. David Boyers
Dr. Howard Barbaree
Clinical Director, Law and Mental Health Programs
Center for Addiction & Mental Health
Gail Czukar,Executive Vice President, Policy and
Planning, General Counsel
Centre for Addiction and Mental Health
Toronto, Ontario
Mary Doyle,Lecturer, Faculty of Information & Media
Studies
University of Western Ontario
London, Ontario
Dr. Virgina Aldige Hiday
Professor, Department of Sociology
North Carolina State University
Raleigh, North Carolina, USA
Justice McLeod
Brampton Provincial Court
Brampton, Ontario
Jillian Romanko
CMHA Mental Health Court Support Worker
Sudbury, Ontario
Position
CRCT CSW
Assistant Crown Attorney
Judge
Duty counsel
Psychiatrist
CMHA Peel – Executive
Director
Manager, Court Support
Services
Assistant Crown Attorney
Psychiatrist
CMHA CSW
Assistant Crown Attorney
MHCD Coordinator
MHCD Team leader
Psychiatrist
Peter Cuthbert
Canadian Association of Chiefs of Police
Ottawa, Ontario
John Dawson
Professor, Faculty of Law
University of Otago
Dunedin, New Zealand
Gail Hankinson Web Designer
London Health Sciences Center
London, Ontario
Steve Lurie, Executive Director
CMHA Toronto Branch
Toronto Ontario
Susan McDonald, Research Analyst
Department of Justice Canada
Ottawa, Ontario
Dr. Sandy Simpson
Clinical Director
Regional Forensic Services
Auckland, New Zealand
Clare J. Wiersma
Inspector, Operational Support Branch
Chatham-Kent Police Service
Chatham, Ontario
George F. Tomossy
Associate Lecturer, Faculty of Law,
University of Sydney
Sydney, Australia
43
Lesley Bell, Clinical Nurse Specialist
Forensic Services
Regional Mental Health Care-St. Thomas
467 Sunset Avenue
St. Thomas, Ontario
Dr. Jack Ellis, Physician Leader
Forensic Services
Regional Mental Health Care-St. Thomas
467 Sunset Avenue
St. Thomas, Ontario
Robin Daly
Mental Health Consultant
Toronto Region
Ministry of Health and Long-Term Care
University of Western Ontario students who worked on this project:
Briane Browne
Thurikah D'Nathan
Markus Juodis
Magda Lukasiewicz
44
Appendix IX: Memorandum of Understanding - Police Services
A) PROTOCOL BETWEEN LONDON (ONTARIO) MENTAL HEALTH CRISIS SERVICE AND LONDON POLICE
SERVICES
Calls from London Police to London Mental Health Crisis Service:
Effective February 21, 2003 the Police Dispatch Centre will contact the crisis service and request assistance on
behalf of an officer who is involved with a persons possibly needing our assistance including Mobile Services.
LMHCS phone staff will be given the name and date of birth to determine if the person is on file with us.
LMHSC Mobile staff is then to be contacted and given the relevant information. AS POLICE WILL BE ON SITE,
THEY MAY ATTEND ALL REQUESTS.
NO CALLS ARE TO BE DEVLINED AS THIS IS A NEW PROCESS FOR ALL INVOLVED AND COOPERATON IS
ESSENTIAL.
All Police contacts are to be reviewed the following business day by the face-to-face LMHCS counselor who was
involved in the call or on site.
Calls from LMHCS to London Police:
If LMHCS Phone staff feels the need to contact police to attend a client, the LMHCS Mobile Team also is sent out
at the same time.
February 17,2003
Inspector Ian Peer
London Police Services
P.O. Box 3419
London, ON N6A 4K9
Dear Inspector Peer,
I would like to review and update the agreement between the London City Police and the London Mental Health
Crisis Service.
If there are any modifications, additions, etc. needed, please contact me at London Mental Health Crisis Service
(telephone 433-2106 or fax 438-5808) to ensure the necessary changes are made.
Any emergency contact with Police is initiated by using 911;
The Police will respond to any situation where danger to person or property is observed or believed imminent;
It is understood that when Police proceed to a site at the request of Crisis Service Staff, the Police attending are
in charge of the situation and at their discretion may or may not confer or consult with Crisis staff;
Police respect the limitation of Crisis Service staff to disclose confidential information as detailed by the Mental
Health Act;
Crisis Service Staff will be familiar with the terms of the Mental Health Act, specifically with regard to situations
whereby the Police provide direct intervention;
45
With regard to the Crisis Service, only in situations where the police arrest under the terms of the Mental Health
Act will they transport person or persons to hospital;
It is understood that in other situations a request for an ambulance would be the appropriate response both for
site attendance and for transportation;
While the London Mental Health Crisis Centre has a mandate to respond to specific persons and situations (as
detailed in the attached brochure) the Police may choose to refer to or consult with the Crisis Centre any adult
with a non-medical crisis, including persons directly served by P.A.C.T.;
Police Dispatch will contact the Crisis if and when Officers respond to a call, which in their opinion warrants the
assistance of the Crisis Mobile Team;
The Mobile Team will assist the Officers and will collaborate agree on the disposition of the call;
The Crisis Service will also respond to the Police Services when the Officers managing the holding cells make a
request;
In summary, this reflects what I believe to be the key points of the agreement. On behalf of all those involved with
the provision of this crisis service, I appreciate your interest and desire to ensure the best possible
relationship
between the London Police and the Crisis Service.
I understand that you will be the principle contact at the Police Department, and that I will be the contact person for
the Crisis Service.
Sincerely
Kristine Diaz R.N. M.Ed.
Director
KD/sm
B) Memorandum of Understanding and Working Protocol Tasmania Police Service and
Department of Health and Human Services
Tasmania Police Service and the Department of Health and Human Services often provide services to the same
clients. The work of both sectors needs to be co-operatively linked, where appropriate, and
undertaken with a clear understanding and agreement about the roles and responsibilities of each in providing
services to these clients.
Following extensive consultation, this Memorandum of Understanding has been developed by a working party
consisting of officers from both Agencies, and community representation. It is supported by a working protocol for
Police and Health and Human Services staff who are required to provide services to people with disability, including
those with mental illness and/or intellectual disability.
This document is a working agreement to be implemented at all levels in both agencies, and covers the following
areas:
• Communication between the two agencies;
• Training;
46
• Review process;
• Police request for assistance from mental health and disability services;
• Department of Health and Human Services request for assistance from
Tasmania Police Service;
• Request for police attendance at an inpatient, residential or community
facility;
• Joint management;
• Sharing of information;
• Firearms Act 1996;
• Transport;
• Approved hospitals;
• Authorised officers;
• Approved medical practitioners; and
• Consumer rights and responsibilities.
[The remainder of this 40-page document can be found at <URL:http://www.dhhs.tas.gov.au/
partnerships/strategicpartnerships/index.html#police]
47
Appendix X: Chesterfield/Colonial Heights Memoranda of Understanding - Court Diversion
Memorandum of Agreement
Chesterfield/Colonial Heights Community Corrections Services
Chesterfield County Community Corrections – Day Reporting Center has been awarded a Substance Abuse Mental
Health Services Administration grant for a renewable period of up to three years. The funding will be used to
implement a dual diagnosis track, open to offenders under pretrial status. Traditionally, these offenders would
spend time incarcerated until trial, due to a lack of resources and stability. This funding will allow the Day Reporting
Center to implement a new track to identify and serve offenders diagnosed with a substance abuse addiction and
other mental health disorders. The implementation of these new services includes a contractual agreement
between Community Corrections – Day Reporting Center – Dual Treatment Track (CCS-DRC-DTT) and the
Community Services Board (CSB). The CSB will provide one senior clinician and one clinician to staff the program
to provide services to this targeted population. The CCS-DRC-DTT will financially compensate the CSB for the
clinical staff and their supervision according to grant stipulations and the continuation of funding.
Staffing
The CSB will hire one senior clinician with minimally a Masters Degree in counseling, social work, or related human
services field and three years experience of direct service. Emphasis will be placed on candidates who have
experience working with individuals with co-occurring disorders. In addition, the CSB will hire one clinician with
minimally a Masters Degree in counseling, social work, or related human services field and one year experience of
direct service. Emphasis will be placed on candidates who have experience working with individuals with cooccurring disorders. Grant allowable salaries may not exceed $40,000 and $35,000 respectfully in addition to
allowable fringe benefits as outlined by the County. The hiring and salary negotiation will be done in conjunction
with the Project Director, who will be providing the daily direct supervision to these employees. The Project
Administrator and Project Director maintain final approval of the clinical staff. Both positions will be housed at the
CCS-DRC-DTT office but will maintain status as employees of the CSB and will participate in CSB training and
clinical supervision as required. All employees must have successfully completed a background check.
Service Delivery
The CSB will provide outpatient services to the CCS-DRC-DTT by assigning one qualified senior clinician and one
qualified clinician on a full-time basis to provide the services as outlined below, on-site at the CCS-DRC-DTT .
· Assessments
· Group Therapy
· Individual Therapy
· Treatment planning
· Referrals
· Case staffing
· Evaluations
· Other duties as assigned
Evaluation of the CCS-DRC-DTT track serving dual-diagnosed offenders will be completed in compliance with the
SAMHSA grant requirements. Clinical staff are required to participate and on a daily basis gather and maintain data
for evaluation purposes. All data gathered will be stripped of identifiers and provided to the evaluator on contract
with the grant.
Operational Provisions
48
Clinical staff will be provided appropriate office space that allows privacy as well as treatment group space, basic
office furnishings, office supplies, telephone services, and computers.
Payment for Services
Request for payment will be processed by use of the Chesterfield County Inter-Departmental Transfer. This transfer
will occur at the end of each quarter for the services preformed during that quarter. If one or both of these positions
experience a vacancy the quarterly IDT amount will be altered to reflect the actual expense that the CSB incurred.
The amount will not be greater then $75,000 in CY03 in addition to applicable fringe benefits at established county
rates. Anticipated start date is January 1, 2003 with the county fiscal year ending June 30, 2003, so the annual
transfer on the county’s fiscal schedule should not be more then $37,500 and the amount of all applicable fringe
benefits
Contract Conditions
This contract is automatically renewable for two consecutive years after the first year, providing both parties are
satisfied with the service delivery and terms. Should either party be dissatisfied with the services provided, this
contract may be terminated by providing a 30-day written notice of such termination.
By signing below, parties mutually agree to the terms of the agreement and the roles and responsibilities as they
have been described.
______________________________ ______________________________
George Braunstein Glen Peterson
Community Services Board Community Correction Services
Director Director
_____________________________ _______________________________
Date Date
Memorandum of Agreement
Chesterfield/Colonial Heights Community Corrections Services
Day Reporting Center-Dual Treatment Track
And
Chesterfield Community Service Board
Substance Abuse Services Program
Chesterfield County Community Corrections – Day Reporting Center – Dual Treatment Track has been awarded a
Substance Abuse Mental Health Services Administration grant for a renewable period of up to three years. The
funding will be used to implement a dual diagnosis track, open to offenders under pretrial status. Traditionally,
these offenders would spend time incarcerated until trial, due to a lack of resources and stability. This funding will
allow the Day Reporting Center – Dual Treatment Track to implement a new track to identify and serve offenders
suffering from substance abuse addiction and other mental health disorders. The implementation of these new
services includes a contractual agreement between Community Corrections – Day Reporting Center-Dual
Treatment Track (CCS-DRC-DTT) and the Community Services Board (CSB). The CSB will provide eight (8) hours
a week of a psychiatrist’s time and five (5) hours a week of nursing support services. The CCS-DRC- DTT will
financially compensate the CSB for the hours according to grant stipulations and the continuation of funding.
49
Staffing
The CSB will provide eight (8) hours a week of a licensed psychiatrist on staff at the CSB. Preference is given to
qualified individuals who have a history of working with dual diagnosed clients involved in the criminal justice
system. In addition, the CSB will provide five (5) hours a week of nursing support services. Preference is given to
qualified individuals who have a history of working with dual diagnosed clients involved in the criminal justice
system. Grant allowable rate for the contracted hours is as follows:
Psychiatrist @ $70 an hour for eight (8) hours a week, 52 weeks a year. Nursing support services @ $20 an hour
for five hours a week, 52 weeks a year.
The designation of staff should if at all possible be one individual to provide each service and available during the
same time periods each week. This procedure will improve relationship building and a working knowledge base of
the CCS-DRC-DTT. The Project Director, who will provide the daily direct supervision of this program, maintains
the right to approve the designation of the CSB employees. In addition, the Project Director is the point of contact
for the operational purposes. Both positions will be housed at the CSB. The psychiatrist on contract is responsible
for at least four (4) hours of on-site training with the program staff. In addition, initial set – up will include several
required meetings that will be within the eight (8) hours allowed each week. All contractual service providers must
have successfully completed a background check.
Service Delivery
The CSB psychiatric service contract will provide the following during the eight- (8) hours allotted each week:
· Psychiatric Evaluations
· Medication Management visits
· Face to face staff consultation with the DTT staff re: diagnosis, treatment planning, interventions,
medical/psychiatric aspects of treatment
The Nursing support service contract will provide the following during the five- (5) hours allotted each week:
· Patient Education re. medication administration, effects, side-effects, compliance issues
· Pharmacy Administration (indigent care program enrollment, access to State Pharmacy medications, medication
delivery)
· Injections, blood samples, etc.
· Physician support (responding to phone calls, patient prep. during visits, assistance with record keeping/charting.
· Liaison with non-medical program staff
Evaluation of the CCS-DRC-DTT track serving dual-diagnosed offenders will be completed in compliance with the
SAHSHA grant requirements. All staff are required to participate and on a regular basis gather and maintain data
for evaluation purposes. All data gathered will be stripped of identifiers and provided to the evaluator on contract
with the grant.
Payment for Services
Request for payment will be processed by use of the Chesterfield County Inter-Departmental Transfer (IDT). The
IDT will be sent by the CSB at the end of a quarter for the services provided during that quarter. This contracted
amount will be based on the maximum hours set forth in the staffing section of this memorandum. If the CSB is
unable to provide 8 hours and 5 hours respectively, the IDT amount will be altered to reflect the available hours.
The amount will not be greater then $29,120 in CY03. Anticipated start date is January 1, 2003.
50
Contract Conditions
This contract is automatically renewable for two consecutive years after the first year, providing both parties are
satisfied with the service delivery and terms. Should either party be dissatisfied with the services provided, this
contract may be terminated by providing a 30-day written notice of such termination.
By signing below, parties mutually agree to the terms of the agreement and the roles and responsibilities as they
have been described.
George Braunstein Glen Peterson
Community Services Board, Director Community Correction Services, Director
_____________________________ ______________________________
Date Date
51
Appendix XI: Mendocino County Memorandum of Understanding - Mental Health Court
MEMORANDUM OF UNDERSTANDING
DIVISION OF ALCOHOL AND OTHER DRUG PROGRAMS AND THE MENDOCINO COUNTY SHERIFF’S
OFFICE
(5-9-02)
The Mendocino County Department of Public Health, Division of Alcohol and Other Drug Programs (AODP) and the
Mendocino County Sheriff’s Office (MCSO) enter into this Memorandum of Understanding. This Memorandum of
Understanding stands as evidence that the MCSO and AODP work together toward the goal of providing Mentally
Ill Offenders Court Program services for eligible mentally ill offenders residing in Mendocino County.
Under judicial supervision provided by the Mendocino County Superior Court, the Mendocino County Mentally Ill
Offenders Court Program (MIOCP) program includes intensive mental health treatment, substance abuse
treatment, mandatory drug testing, and use of graduated sanctions.
TERM: This Memorandum of Understanding remains in effect for the duration of the California State Board of
Corrections Mentally Ill Offenders Crime Reduction Grant hereinafter known as MIOCRG given under the statutory
authority of Chapter 501, Statutes of 1998. The term of this Memorandum of Understanding shall begin on July 1,
2001. The project must be completed by June 30, 2004.
GENERAL PROVISIONS:
Each party agrees to the following:
1. The amount awarded to AODP through the MIOCRGrant. (See page 6: Grant Budget.)
2. The amount awarded to the Inland Enhancement Adult MIOCP Grant (Award # 2000-DC-VX-0016) is $299,507,
approximately 46% of the total cost of operations ($647,675) for this period of time (October 1, 2000 – September
30, 2002). (See page 7: Grant Budget.)
3. Maintain line item detail of this grant’s funding sufficient to meet the auditing requirements set forth in the U.S.
Department of Justice publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative
Requirements for Grants and Cooperative Agreements to State and Local Governments and U.S. Department of
Justice, Office of Justice Programs, Office of the Comptroller Financial Guide, as interpreted by the Court Fiscal
Manager.
4. Meet on an as-needed basis for the purpose of monitoring expenditure patterns, fund depletion, budget
discussion and cost projections. Based upon the results of such financial analysis, parties may agree to modify,
restrict, adjust and/or discontinue MIOCP activities until such time as adequate funding is identified and secured.
5. Recognize that funding commitments are intended to be stable during any given fiscal year/grant period. If the
number of participants is consistently below the commitments made in the grant applications, the issue will be
presented to the Therapeutic Courts Management Team to discuss possible options and recommendations for
submission to the funding source if needed.
6. Participate in OJP-sponsored technical assistance workshops and obtain prior approval from the OJP MIOCPs
Program Office before using Federal funds to travel to other MIOCPs or to any non-OJP conferences
7. Abide by the Code of Federal Regulations regarding confidentiality as found in CFR 42, Part 2.
52
THE MENDOCINO COUNTY SHERIFF’S OFFICE WILL
1. Have sole authorization for the official signature and will complete inter-fund transfers for authorized
reimbursement to AODP upon receipt of quarterly invoices reflecting actual costs incurred approved by the
Therapeutic Courts Administrator and the Court’s Fiscal Manager.
2. Assess a one-time only, “court administration fee” of $35 on each MIOCP participant to cover costs of
processing accounts receivable as determined by Penal Code 1205 (D).
• The Court Collections office is responsible for the collection of this fee.
3. Monitor payment of MIOCP “participant fees,” loan re-payment plans, past-due fees and fines and use of
Community Service in lieu of payment.
4. Utilize the sliding fee scale established by the Therapeutic Courts Management Team of a maximum charge of
$217 per month per participant for non Medi-Cal eligible individuals to charge and collect “participant fees.”
5. Vest with AODP all expendable and non-expendable personal property purchased with grant funds:
Upon verification by the Therapeutic Courts’ Administrator that AODP is a service provider in good standing with
the Mendocino County Sheriff’s Office; and
If written certification is made to Therapeutic Courts’ Administrator that the property will continue to be used for
USDOJ/OJP/DCPO grant related purposes.
THE ALCOHOL AND OTHER DRUGS PROGRAM WILL
1. Serve the Mendocino County Adult MIOCP as the primary treatment provider. In the event that a private provider
is utilized to maximize individual treatment planning, AODP will serve as Quality Assurance Monitor for the MIOCP
and act as liaison to the other providers.
2. Provide timely, accurate and authorized expenditure invoicing with supporting documentation (i.e., invoices, bills,
journal entries, management reports) of grant-funded positions and in-kind contributions. Supporting documentation
is required to guarantee reimbursement. Timesheets that are less than 100% funded by a single grant must show
time charged by grant or program for actual time to be billable. (Samples provided pages 7-12.)
3. Provide line item detail sufficient to meet the auditing requirements set forth in the U.S. Department of Justice
publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative Requirements for Grants
and Cooperative Agreements to State and Local Governments and U.S. Department of Justice, Office of Justice
Programs, Office of the Comptroller Financial Guide as interpreted by the Court Fiscal Manager
4. Submit invoices reflecting actual costs incurred quarterly with line item detail. This detail will support any
requested transfer of funds.
a. Assure proper supporting documentation with verification that includes cross-reference checks of requested
reimbursement aligned with supporting documentation for both grant reimbursed expenses or those being
contributed as in-kind.
b. Utilize a cover sheet consolidating employee (s) hours, rate of pay, percentage of benefits and total amount
being charged or contributed as in-kind to expedite the reimbursement process. (Samples provided on page 7, 8,
9,11, & 12.)
53
5. The billing due dates are as follows:
• Report Period • Billing Due to MIOCP Office • 269A Due to DCPO
• October 1, 2000 - December 31, 2000 • February 1, 2001 • February 15, 2001
• January 1, 2001 - March 31, 2001 • May 1, 2001 • May 15, 2001
• April 1,2001 - June 30, 2001 • August 1, 2001 • August 15, 2001
• July 1, 2001 - September 30, 2001 • November 1, 2001 • November 15, 2001
• October 1, 2001 - December 31, 2001 • February 1, 2002 • February 15, 2002
• January 1, 2002 - March 31, 2002 • May 1, 2002 • May 15, 2002
• April 1, 2002 - June 30, 2002 • August 1, 2002 • August 15, 2002
• July 1, 2002 - September 30, 2001 • November 1, 2002 • November 15, 2002
• Invoices submitted after the above-mentioned dates may result in a change in the time and/or method of payment.
6. Receive approval from the Therapeutic Courts Management Team and the U.S. Department of Justice’s
MIOCPs Program Office (DCPO) Grants Manager prior to the obligation and expenditure of funds outside of the
approved grant budgets.
7. Submit verification of use of time as part of the quarterly invoices for OPTIONS Program staff. Required
documentation for payroll includes time card(s) with hours delineated to specific grant and provision of payroll
management reports with pay periods identified for cross-referencing purposes.
8. Provide information required to complete the mandated MIOCP Grantee Data Collection Survey.
9. Provide documentation of funds including those collected on behalf of Medi-Cal eligible MIOCP Program
participants that are a part of the Local Match.\
10. Submit one copy of all reports and proposed publications resulting from this grant award thirty (30) days prior to
public release.
a. Any publications (written, visual, or sound), whether published at the grantee’s or government’s expense, shall
contain the following state: “ This project was supported by Grant #2001-DC-VX-0001 awarded by the MIOCPs
Program Office, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those
of the author and do not necessarily represent the official positions or policies of the U.S. Department of Justice.”
b. NOTE: This excludes press releases, newsletters, and issue analysis.
The Mendocino County Sheriff’s Office and the Public Health Department, Division of Alcohol and Other Drug
Programs agree upon these protocols and procedures on this ___________ day of the month of ___________,
2002
We hereby agree to this Memorandum of Understanding and certify the agreements made will be honored.
__________________________________ ______________________________
Eric Labowitz, Judge, Mentally Ill Offenders Carol Mordhorst, Administrator
Court Program Mendocino County Department of
54
Mendocino County Sheriff’s Office Public Health
Date:___________________ Date: ___________________
_____________________________ ______________________________
Ron Brown, Presiding Judge Ned W. Walsh, M.Ed.,
Mendocino County Sheriff’s Office Administrator
Mendocino County Division of Alcohol and Other Drugs Program
Date:___________________ Date:___________________
___________________________________ ______________________________
Tania Ugrin-Capobianco, James Anderson,
Court Executive Officer Mendocino County Administrator
Mendocino County Sheriff’s Office
Date:____________________ Date:___________________
MEMORANDUM OF UNDERSTANDING: DIVISION OF ALCOHOL AND OTHER DRUG PROGRAMS AND THE
MENDOCINO COUNTY SHERIFF’S OFFICE
(5-9-02)
The Mendocino County Department of Public Health, Division of Alcohol and Other Drug Programs (AODP) and
the Mendocino County Sheriff’s Office (MCSO) enter into this Memorandum of Understanding. This Memorandum
of Understanding stands as evidence that the MCSO and AODP work together toward the goal of providing
Mentally Ill Offenders Court Program services for eligible mentally ill offenders residing in Mendocino County.
Under judicial supervision provided by the Mendocino County Superior Court, the Mendocino County Mentally Ill
Offenders Court Program (MIOCP) program includes intensive mental health treatment, substance abuse
treatment, mandatory drug testing, and use of graduated sanctions.
TERM: This Memorandum of Understanding remains in effect for the duration of the California State Board of
Corrections Mentally Ill Offenders Crime Reduction Grant hereinafter known as MIOCRG given under the
statutory authority of Chapter 501, Statutes of 1998. The term of this Memorandum of Understanding shall begin on
July 1, 2001. The project must be completed by June 30, 2004.
GENERAL PROVISIONS:
Each party agrees to the following:
55
1. The amount awarded to AODP through the MIOCRGrant. (See page 6: Grant Budget.)
2. The amount awarded to the Inland Enhancement Adult MIOCP Grant (Award # 2000-DC-VX-0016) is
$299,507, approximately 46% of the total cost of operations ($647,675) for this period of time (October 1, 2000 –
September 30, 2002). (See page 7: Grant Budget.)
3. Maintain line item detail of this grant’s funding sufficient to meet the auditing requirements set forth in the U.S.
Department of Justice publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative
Requirements for Grants and Cooperative Agreements to State and Local Governments and U.S. Department of
Justice, Office of Justice Programs, Office of the Comptroller Financial Guide, as interpreted by the Court Fiscal
Manager.
4. Meet on an as-needed basis for the purpose of monitoring expenditure patterns, fund depletion, budget
discussion and cost projections. Based upon the results of such financial analysis, parties may agree to modify,
restrict, adjust and/or discontinue MIOCP activities until such time as adequate funding is identified and secured.
5. Recognize that funding commitments are intended to be stable during any given fiscal year/grant period. If the
number of participants is consistently below the commitments made in the grant applications, the issue will be
presented to the Therapeutic Courts Management Team to discuss possible options and recommendations for
submission to the funding source if needed.
6. Participate in OJP-sponsored technical assistance workshops and obtain prior approval from the OJP
MIOCPs Program Office before using Federal funds to travel to other MIOCPs or to any non-OJP conferences
7. Abide by the Code of Federal Regulations regarding confidentiality as found in CFR 42, Part 2.
THE MENDOCINO COUNTY SHERIFF’S OFFICE WILL
1. Have sole authorization for the official signature and will complete inter-fund transfers for authorized
reimbursement to AODP upon receipt of quarterly invoices reflecting actual costs incurred approved by the
Therapeutic Courts Administrator and the Court’s Fiscal Manager.
2. Assess a one-time only, “court administration fee” of $35 on each MIOCP participant to cover costs of
processing accounts receivable as determined by Penal Code 1205 (D).
• The Court Collections office is responsible for the collection of this fee.
3. Monitor payment of MIOCP “participant fees,” loan re-payment plans, past-due fees and fines and use of
Community Service in lieu of payment.
4. Utilize the sliding fee scale established by the Therapeutic Courts Management Team of a maximum charge
of $217 per month per participant for non Medi-Cal eligible individuals to charge and collect “participant fees.”
5. Vest with AODP all expendable and non-expendable personal property purchased with grant funds:
Upon verification by the Therapeutic Courts’ Administrator that AODP is a service provider in good standing with
the Mendocino County Sheriff’s Office; and If written certification is made to Therapeutic Courts’ Administrator that
the property will continue to be used for USDOJ/OJP/DCPO grant related purposes.
THE ALCOHOL AND OTHER DRUGS PROGRAM WILL
56
1. Serve the Mendocino County Adult MIOCP as the primary treatment provider. In the event that a private
provider is utilized to maximize individual treatment planning, AODP will serve as Quality Assurance Monitor for the
MIOCP and act as liaison to the other providers.
2. Provide timely, accurate and authorized expenditure invoicing with supporting documentation (i.e., invoices,
bills, journal entries, management reports) of grant-funded positions and in-kind contributions. Supporting
documentation is required to guarantee reimbursement. Timesheets that are less than 100% funded by a single
grant must show time charged by grant or program for actual time to be billable. (Samples provided pages 7-12.)
3. Provide line item detail sufficient to meet the auditing requirements set forth in the U.S. Department of Justice
publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative Requirements for Grants
and Cooperative Agreements to State and Local Governments and U.S. Department of Justice, Office of Justice
Programs, Office of the Comptroller Financial Guide as interpreted by the Court Fiscal Manager.
4. Submit invoices reflecting actual costs incurred quarterly with line item detail. This detail will support any
requested transfer of funds.
a. Assure proper supporting documentation with verification that includes cross-reference checks of requested
reimbursement aligned with supporting documentation for both grant reimbursed expenses or those being
contributed as in-kind.
b. Utilize a cover sheet consolidating employee (s) hours, rate of pay, percentage of benefits and total amount
being charged or contributed as in-kind to expedite the reimbursement process. (Samples provided on page 7, 8,
9,11, & 12.)
5. The billing due dates are as follows:
• Report Period • Billing Due to MIOCP Office • 269A Due to DCPO
• October 1, 2000 - December 31, 2000 • February 1, 2001 • February 15, 2001
• January 1, 2001 - March 31, 2001 • May 1, 2001 • May 15, 2001
• April 1,2001 - June 30, 2001 • August 1, 2001 • August 15, 2001
• July 1, 2001 - September 30, 2001 • November 1, 2001 • November 15, 2001
• October 1, 2001 - December 31, 2001 • February 1, 2002 • February 15, 2002
• January 1, 2002 - March 31, 2002 • May 1, 2002 • May 15, 2002
• April 1, 2002 - June 30, 2002 • August 1, 2002 • August 15, 2002
• July 1, 2002 - September 30, 2001 • November 1, 2002 • November 15, 2002
• Invoices submitted after the above-mentioned dates may result in a change in the time and/or method of
payment.
6. Receive approval from the Therapeutic Courts Management Team and the U.S. Department of Justice’s
MIOCPs Program Office (DCPO) Grants Manager prior to the obligation and expenditure of funds outside of the
approved grant budgets.
7. Submit verification of use of time as part of the quarterly invoices for OPTIONS Program staff. Required
documentation for payroll includes time card(s) with hours delineated to specific grant and provision of payroll
management reports with pay periods identified for cross-referencing purposes.
8. Provide information required to complete the mandated MIOCP Grantee Data Collection Survey.
9. Provide documentation of funds including those collected on behalf of Medi-Cal eligible MIOCP Program
participants that are a part of the Local Match.
57
10. Submit one copy of all reports and proposed publications resulting from this grant award thirty (30) days
prior to public release.
a. Any publications (written, visual, or sound), whether published at the grantee’s or government’s expense,
shall contain the following state: “ This project was supported by Grant #2001-DC-VX-0001 awarded by the
MIOCPs Program Office, Office of Justice Programs, U.S. Department of Justice. Points of view in this document
are those of the author and do not necessarily represent the official positions or policies of the U.S. Department of
Justice.”
b. NOTE: This excludes press releases, newsletters, and issue analysis.
The Mendocino County Sheriff’s Office and the Public Health Department, Division of Alcohol and Other Drug
Programs agree upon these protocols and procedures on this ___________ day of the month of ___________,
2002.
We hereby agree to this Memorandum of Understanding and certify the agreements made will be honored.
__________________________________ ______________________________
Eric Labowitz, Judge, Mentally Ill Offenders Carol Mordhorst, Administrator
Court Program Mendocino County Department of
Mendocino County Sheriff’s Office Public Health
Date:___________________ Date: ___________________
__________________________________ ______________________________
Ron Brown, Presiding Judge Ned W. Walsh, M.Ed.,
Mendocino County Sheriff’s Office Administrator
Mendocino County Division of Alcohol and Other Drugs Program
Date:___________________ Date:___________________
___________________________________ ______________________________
Tania Ugrin-Capobianco, James Anderson,
Court Executive Officer Mendocino County Administrator
Mendocino County Sheriff’s Office
Date:____________________ Date:___________________
58
Appendix XIl: Research Team Members
Name
1.Dr. Kathleen Hartford
2.Simon Davies
3. Chris Dobson
4.Carolyn Dykeman
5.Brenda Furhman
6.John Hanbidge
7.Donna Irving
8.Elizabeth McIntosh
9.Dr. Jim Mendonca
10. Ian Peer
11. Mike Petrenko
12.Veronica Voigt
13. Dr. Stephen State
14.Janice Vandevooren
15. Dr. Robert Carey
16. Alexandru Craciunescu
Title/Position
Scientist-Epidemiologist,
Associate Professor (UWO)
Area Director, Legal Aid
Ontario
Criminal Lawyer
Family member of consumer
survivor
Coordinator, Mental Health
Programs, London Health
Sciences Centre/Lawyer, Duty
Counsel
Assistant Crown Attorney,
Elgin/Middlesex Court House
Family member of consumer
survivor
Coordinator, London ACT +
Diversion Services, RMHC-L,
St. Joseph
Clinical Psychologist/
Professor, Dept. of Psychiatry
(UWO)
Inspector, London Police
Services
Executive Director, CMHALondon Middlesex
Regional Mental Health Care,
Elgin/Middlesex Mental Health
Court Diversion Services
Coordinator, Department of
Family Medicine, UWO
Coordinator, SAS,
PACT/Elgin,Regional Mental
Health Care, St. Thomas
Lawson Health Research
Institute
Lawson Health Research
Institute
59
Role
Principal Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Co-Investigator
Research Associate
Research Associate
Appendix XlIl: Standardized Literature Review Grid
Literature Review Table
Reviewer’s name:
Title, author(s) & year:
Purpose:
Research method/design:
N(numbers) & measures used or sources of data and evidence:
Findings:
Author’s conclusions:
Reviewer’s comments/contact information:
Conceptual/methodological problems:
This literature review table template is provided to enable reviewers to articulate very briefly the main points of
the article or report which they are examining. A digital copy will be emailed to you so that you can enter the
material on screen. Many of the details will be available in the abstract if one is included with the article.
60
If the article discusses a person, program, or institution you think we should interview or include in our
survey, please note any available contact information in the “Reviewer’s comments” box.
Please don’t be intimidated by the structure of the template. In a nutshell, what we want is your feedback on
written material that you agree to review.
***
Findings: The following list is intended to help you categorize any findings you identify in the articles you
review. You may encounter findings that do not appear in this list; if so, please note these as well.
Early identification-referral mechanisms
Case management: screening & needs assessment
Case management: counseling and discharge planning
Case management: liaison with criminal justice system
Case management: treatment and monitoring in the community
Case management crisis intervention
In-jail counseling
Services for homeless mentally ill offenders
Substance-abuse services
Diversion mechanisms and clear guidelines
Triage and diversion by police
Triage by specialized staff or team
-on site or immediate availability (e.g. drop-off)
-available on referral
Training/education of police
Training/education of attorneys
Program evaluation or review
Inter-agency agreements and partnerships
Integrated systems between criminal justice, mental health & social services agencies
Regular meetings of key players
Creation of 'boundary spanners': key staff positions to link criminal justice and mental health agencies or link
systems involved in diversion
61
Appendix XlV: Diversion Survey
A. Police Diversion
Introduction
This portion of the survey is concerned with pre-arrest or police diversion. Again, thank you for agreeing to
participate.
Before you begin, it would be helpful to know the following:
P1. Your department’s name:
P2. City:
P3. Province/State/Territory:
P4. Country:
P5. Zip Code / Postal Code:
P6. If you would like a final copy of the report, please provide a contact name in the space below:
P7. Police have some discretion in laying a charge involving a person thought to have mental illness. We
are interested in learning more about this.
P8. Does your department have:
A formal pre-arrest diversion program?
__ Yes
__ No
P9. If yes, please describe the program in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
P10. Does your department have:
62
An informal pre-arrest diversion program?
__ Yes
__ No
P11. If yes, please describe the program in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
P12. Does your department have written criteria that officers use to assess whether an individual is an
appropriate candidate for pre-arrest diversion?
__ Yes
__ No
P13. If yes, please provide these criteria in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
P14. If no, please explain how officers decide whether an individual is an appropriate candidate for
diversion.
63
P15. Does your department’s program involve a Crisis Intervention Team?
__Yes
__ No
P16. Is your department associated with a mobile response agency for the purpose of mental health
diversion?
__ Yes
__ No
Training
P17. Has your department provided training for all members specifically for mental health issues (i.e.,
beyond the basic and advanced patrol training)?
__ Yes
__ No
P18. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
P19. How many hours does this training take?
__Hours
P20. How often is this training offered to your department’s members?
a. Every year
b. Every two years
c. Every three years
d. Data not kept
e. Don’t know
f. Other (please specify).
P21. Is more training needed?
__ Yes
__ No
64
P22. Please describe the training needed.
Outcomes and Monitoring
P23. How many individuals with mental illness did your department divert last year?
__Number/Last year
__Data not kept
P24. Does your department have specific criteria to monitor the pre-arrest diversion program’s success?
__Yes
__ No
P25. If yes, please explain these criteria in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
Treatment
P26. Which of the following agencies/services does your department divert people with mental illness to?
(Check all that apply):
Risk assessment
Medication management
Case management services
Housing assistance
Assistance obtaining financial aid
Assistance obtaining medical care
65
Assistance with other benefits
Money management
Crisis intervention
Group therapy
Individual therapy
Day treatment
Referral for other therapy (please specify):
Substance abuse
Guardianship
Family therapy
Acute care hospitalization
Long-term care hospitalization
Emergency room treatment
Safe beds / crisis beds
Other (please explain)
P27. Should other services be available?
__ Yes
__ No
P28. If yes, please explain in the space below.
P29. Do any local mental health treatment facilities with beds have “no refusal” policies for police referrals?
__ Yes
__ No
P30. Does the department have formal agreements or memoranda of understanding with community
agencies or services?
__ Yes
__ No
P31. If yes, please provide these agreements or memoranda in the space below. Feel free to cut and paste
from the relevant sections of any policy documents to which you have access. Alternatively, you can
forward these documents as an attachment to [email protected], or mail them to the address
noted at the beginning of this document.
66
Funding
P32. What is the pre-arrest diversion program’s annual budget?
_________$/Year
_________ Don’t know
P33. Please identify the funds allocated to the following categories. Please identify as well the source of
these funds in the space provided (e.g., Attorney General, Department of Health). For categories (a) and
(b), note the number of equivalent full time positions included.
a. Professional salaries and benefits
__ $/Year
Source of funds:
No. of equivalent full time positions:
b. Administrative/clerical salaries
__ $/Year
Source of funds:
No. of equivalent full time positions:
c.
Rent
__ $/Year
Source of funds:
d. Utilities
__ $/Year
Source of funds:
e. Equipment/supplies
__ $/Year
Source of funds:
67
f.
Parking
__ $/Year
Source of funds:
g. Other (please explain)
__ $/Year
Source of funds:
P34. How would you rate the adequacy of the program’s funding?
a. Poor
b. Fair
c. Good
d. Excellent
P35. If rated fair or poor, how would you modify the funding structure of the program to improve its overall
effectiveness and/or efficiency?
Conclusion
P36. In conclusion, what are the program’s key strengths?
P37. What are the program’s key weaknesses?
P38. How might the program be improved?
68
P39. Please provide any additional comments you think might be helpful.
P40. Finally, for follow-up purposes, it would be extremely helpful for us to know:
________________________________ Your name.
________________________________ E-mail address.
________________________________ Telephone number.
Thank you for your participation.
B. Court Diversion
Introduction
69
This portion of the survey is concerned with court diversion programs. In some jurisdictions, a court
diversion program exists to divert an individual with mental illness into appropriate treatment. We are
interested in learning more about this. Again, we thank you for agreeing to participate.
Before you begin, it would be helpful to know the following:
C1. Your agency’s name:
C2. City:
C3. Province/State/Territory:
C4. Country:
C5. Zip Code / Postal Code:
C6. If you would like a final copy of the report, please provide a contact name in the space below:
____________________________________________________________
Training
C7. Have legal team members associated with the diversion program received any training in mental
health services?
__ Yes
__ No
C8. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
C9. How many hours does this training take?
__Hours
C10. How often is this training offered to your program’s members?
a. Every year
70
b.
c.
d.
e.
f.
Every two years
Every three years
Data not kept
Don’t know
Other (please specify).
C11. Is more training needed?
__ Yes
__ No
C12. Please describe the training needed in the space below.
C13. Have mental health team members associated with the diversion program received any training in
mental health law and/or court procedures?
__ Yes
__ No
C14. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
C15. How many hours does this training take?
__Hours
71
C16. How often is this training offered to your program’s members?
a. Every year
b. Every two years
c. Every three years
d. Data not kept
e. Don’t know
f. Other (please specify).
C17. Is more training needed?
__ Yes
__ No
C18. Please describe the training needed in the space below.
Outcomes and Monitoring
C19. Has the diversion program established a set of outcomes for clients?
__ Yes
__ No
C20. If yes, please explain these outcomes in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
C21. Does the program monitor clients’ outcomes?
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__Yes
__ No
C22. If yes, please explain how the program monitors clients’ outcomes in the space below. Feel free to cut
and paste from the relevant sections of any policy documents to which you have access. Alternatively, you
can forward these documents as an attachment to [email protected], or mail them to the
address noted at the beginning of this document.
Treatment
C23. Does your diversion program have formal agreements or memoranda of understanding with
community agencies?
__Yes
__ No
C24. If yes, please describe these agreements in the space below. Feel free to cut and paste from the
relevant sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
C25. Does your diversion program have on-site psychiatrists, psychologists, or social workers to conduct
fitness or competence assessments?
__ Yes
__ No
C26. Does your diversion program have on-site psychiatrists, psychologists, or social workers to assess
psychiatric diagnoses?
__ Yes
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__ No
C27. Does your diversion program have off-site psychiatrists, psychologists, or social workers to provide
treatment and follow-up?
__ Yes
__ No
C28. Please note the agencies/services provided to clients (check all that apply):
Risk assessment
Medication management
Case management services
Housing assistance
Assistance obtaining financial aid
Assistance obtaining medical care
Assistance with other benefits
Money management
Crisis intervention
Group therapy
Individual therapy
Day treatment
Referral for other therapy (please specify):
Substance abuse
Guardianship
Family therapy
Acute care hospitalization
Long-term care hospitalization
Emergency room treatment
Safe beds / crisis beds
Other (please explain)
C29. Should any other services be available?
__ Yes
__ No
C30. If yes, please explain in the space below.
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C31. Please estimate how many mentally ill clients the diversion program has dealt with in the last year
___Clients/Last year
___ Data not kept
C32. Do your program’s diversion policies exist in written form?
__ Yes
__ No
C33. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any
policy documents to which you have access. Alternatively, you can forward these documents as an
attachment to [email protected], or mail them to the address noted at the beginning of this
document.
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Funding
C34. What is the diversion program’s annual budget?
_________$/Year
C35. In the tables below, please identify the funds allocated to each category. For categories (a) and (b),
note the number of equivalent full time (EFT) positions included and provide a job description for each
position (Feel free to cut and paste from the relevant sections of any policy documents to which you have
access. Alternatively, you can forward these documents as an attachment to [email protected],
or mail them to the address noted at the beginning of this document). Please identify as well the source of
funds in the space provided (e.g., Attorney General, Department of Health).
a. Professional Salaries and Benefits
Job Title
EFT
Total
Salary/Benefits
Source of Funds
Prosecutor/Crown
Prosecutor/Crown’s Job Description
Defender/Counsel
Defender/Counsel’s Job Description
Social Worker
Social Worker’s Job Description
Diversion Worker
Diversion Worker’s Job Description
Mental Health Worker
Mental Health Worker’s Job Description
Nurse
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Nurse’s Job Description
Other (Please explain):
Job Description
b. Administrative/clerical salaries
Title
EFT
Total
Salary/Benefits
Source of Funds
Court Clerk
Court Clerk’s Job Description
Court Monitor
Court Monitor’s Job Description
Coordinator
Coordinator’s Job Description
Other (please
explain)
Job Description
c. Rent
__ $/Year
Source of funds:
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d. Utilities
__ $/Year
Source of funds:
e.
Equipment/supplies
__ $/Year
Source of funds:
f.
Parking
__ $/Year
Source of funds:
g. Other (please explain)
__ $/Year
Source of funds:
C36. How would you rate the adequacy of the program’s funding?
a. Poor
b. Fair
c. Good
d. Excellent
C37. If rated fair or poor, how would you modify the funding structure of the program to improve its overall
effectiveness and/or efficiency?
Conclusion
C38. In conclusion, what are your program’s key strengths?
C39. What are your program’s key weaknesses?
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C40. How might your program be improved?
C41. Please provide any additional comments you think might be helpful.
C42. Finally, for follow-up purposes, it would be extremely helpful for us to know:
________________________________ Your name.
________________________________ e-mail address.
________________________________ telephone number.
Thank you for your participation.
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C. Mental Health Courts
Introduction
This portion of the survey is concerned with mental health courts. In some jurisdictions, a mental health
court exists to divert an individual with mental illness from jail into appropriate treatment programs. We are
interested in learning more about this. Again, we thank you for agreeing to participate.
Before you begin, it would be helpful to know the following:
M1. Your court’s name:
M2. City:
M3. Province/State/Territory:
M4. Country:
M5. Zip Code / Postal Code:
M6. If you would like a final copy of the report, please provide a contact name in the space below:
M7. Is your court a dedicated mental health court?
__ Yes
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__ No
M8. If you answered yes, please continue with the survey. If you answered no, thank you for your time.
M9. How often does your mental health court sit?
__ days per week
__ days per month
Training
M10. Have legal team members of the mental health court received training in mental health services?
__ Yes
__ No
M11. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
M12. How many hours does this training take?
__Hours
M13. How often is this training offered to your court’s members?
a.
b.
c.
d.
e.
f.
Every year
Every two years
Every three years
Data not kept
Don’t know
Other (please specify).
M14. Is more training needed?
__ Yes
__ No
M15. Please describe the training needed in the space below.
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M16. Have mental health team members of the mental health court received training in mental health law
and/or court procedures?
__ Yes
__ No
M17. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
M18. How many hours does this training take?
__Hours
M19. How often is this training offered to your court’s members?
g.
h.
i.
j.
k.
l.
Every year
Every two years
Every three years
Data not kept
Don’t know
Other (please specify).
M20. Is more training needed?
__ Yes
__ No
M21. Please describe the needed training needed in the space below.
Policies and Procedures
M22. Please estimate what proportion (per cent) of the court’s time is spent on the following:
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a. Assessing fitness or competence to stand trial
__ %
b. Involuntary inpatient commitment / treatment order
__ %
c. Monitoring offender’s compliance with the court’s directives
__ %
d. Developing treatment dispositions
__ %
e. Other (please explain)
__ %
M23. Would you recommend changes to improve the quality of information available at mentally disordered
offenders’ hearings?
__ Yes
__ No
M24. If yes, please explain in the space below.
M25. Please estimate the average time (in days) a mentally ill client spends in jail for the following reasons:
a. Waiting for initial hearing
__ days
b. Waiting for fitness or competence assessment
__ days
c. Waiting for treatment plan to be put into place
__ days
d. Waiting for a forensic bed
__ days
e. Waiting for an acute care hospital bed
__ days
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f.
Other (please explain)
__ days
M26. Can your court take steps to reduce jail time for mentally ill clients?
__ Yes
__ No
M27. If yes, please explain in the space below.
M28. If no, what obstacles exist to reductions in jail time?
M29. Does your court require the client to sign a contract or agreement that specifies:
a. The conditions of treatment
__ Yes
__ No
b. The consequences of non-compliance
__ Yes
__ No
M30. What sanctions does your court employ to deal with non-compliance with treatment?
a. More frequent court monitoring
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b.
c.
d.
e.
Jail time
Withdrawing the client from the program
Fines
Other (please explain)
M31. What sanctions does your court employ to deal with failure to appear?
Outcomes and Monitoring
M32. Does the court have an established a set of outcomes for clients?
__ Yes
__ No
M33. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any
policy documents to which you have access. Alternatively, you can forward these documents as an
attachment to [email protected], or mail them to the address noted at the beginning of this
document.
M34. Does the court have a method for monitoring client's outcomes?
__Yes
__ No
M35. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any
policy documents to which you have access. Alternatively, you can forward these documents as an
attachment to [email protected], or mail them to the address noted at the beginning of this
document.
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Treatment
M36. Does your court have the authority to require community services to provide treatment for the court’s
clients?
__ Yes
__ No
M37. Does the court have formal agreements or memoranda of understanding with any service providers?
__ Yes
__ No
M38. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any
policy documents to which you have access. Alternatively, you can forward these documents as an
attachment to [email protected], or mail them to the address noted at the beginning of this
document.
M39. Please estimate the timeliness of mental health treatment services (average time between initial
referral for treatment and the first day of treatment)
a. Within 24 hours
b. Within 2 days
c. Within 7 days
c. Other (please specify)
M40. Does your mental health court have on-site psychiatrists, psychologists, or social workers to conduct
fitness or competence assessments?
__ Yes
__ No
M41. Does your mental health court have on-site psychiatrists, psychologists, or social workers to assess
psychiatric diagnoses?
__ Yes
__ No
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M42. Does your mental health court have off-site psychiatrists, psychologists, or social workers to provide
treatment and follow-up?
__ Yes
__ No
M43. Are case management services provided for clients?
__ Always
__ Never
__ Sometimes
M44. Please identify the groups for whom coordinating necessary treatment services has been especially
challenging.
a. Homeless
b. Co-occurring illness
c. Newly diagnosed
d. Non-compliant with medication
e. Non-English speaking clients
f. Culturally diverse populations
g. Other (please explain)
M45. Please note the services provided to clients (check all that apply):
Risk assessment
Medication management
Case management services
Housing assistance
Assistance obtaining financial aid
Assistance obtaining medical care
Assistance with other benefits
Money management
Crisis intervention
Group therapy
Individual therapy
Day treatment
Referral for other therapy (please specify):
Substance abuse
Guardianship
Family therapy
Acute care hospitalization
Long-term care hospitalization
Emergency room treatment
Safe beds / crisis beds
Other (please explain)
87
M46. Should any other services be available?
__ Yes
__ No
M47. If yes, please explain in the space below.
M48. Please estimate how many mentally ill clients the court dealt with last year
__Number/Last year
__Data not kept
M49. Do your court’s policies exist in written form?
__ Yes
__ No
M50. If yes, please provide these policies in the space below. Feel free to cut and paste from the relevant
sections of any policy documents to which you have access. Alternatively, you can forward these
documents as an attachment to [email protected], or mail them to the address noted at the
beginning of this document.
M51. Are these policies comprehensive enough to cover the majority of situations encountered by you as a
member of the MHC team?
__ Yes
__ No
M52. If no, please explain how the policies could be improved.
88
Funding
M53. What is your court’s annual budget?
_________$/Year
M54. In the tables below, please identify the funds allocated to each category. For categories (a) and (b),
note the number of equivalent full time (EFT) positions included and provide a job description for each
position (Feel free to cut and paste from the relevant sections of any policy documents to which you have
access. Alternatively, you can forward these documents as an attachment to [email protected],
or mail them to the address noted at the beginning of this document). Please identify as well the source of
funds in the space provided (e.g., Attorney General, Department of Health).
a. Professional Salaries and Benefits.
Job Title
EFT
Total
Salary/Benefits
Source of Funds
Judge
Prosecutor/Crown
Prosecutor/Crown’s Job Description
Defender/Counsel
Defender/Counsel’s Job Description
Social Worker
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Social Worker’s Job Description
Diversion Worker
Diversion Worker’s Job Description
Mental Health Worker
Mental Health Worker’s Job Description
Nurse
Nurse’s Job Description
Other (Please explain):
Job Description
b. Administrative/Clerical
Title
EFT
Total
Salary/Benefits
Source of Funds
Court Clerk
Court Clerk’s Job Description
Court Monitor
Court Monitor’s Job Description
Coordinator
90
Coordinator’s Job Description
Other (please
explain)
Job Description
c.
Rent
__ $/Year
Source of funds:
d. Utilities
__ $/Year
Source of funds:
e. Equipment/supplies
__ $/Year
Source of funds:
f.
Parking
__ $/Year
Source of funds:
g. Other (please explain)
__ $/Year
Source of funds:
M55. How would you rate the adequacy of the program’s funding?
a. Poor
b. Fair
c. Good
d. Excellent
M56. If rated fair or poor, how would you modify the funding structure of the program to improve its overall
effectiveness and/or efficiency?
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Conclusion
M57. Finally, what are your court’s key strengths?
M58. What are your court’s key weaknesses?
M59. How might your court be improved?
M60. Please provide any additional comments you think might be helpful.
M61. Finally, for follow-up purposes, it would be extremely helpful for us to know:
________________________________ Your name.
________________________________ e-mail address.
________________________________ telephone number.
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Thank you for your participation.
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Appendix XV: Survey cover letter
Survey of Evidence-Based Practices in Diversion Programs
for Persons with Serious Mental Illness
Who are in Conflict with the Law
Dear Colleague,
You are invited to take part in this survey, conducted by researchers at the University of Western Ontario
and the Lawson Health Research Institute in London, Ontario, Canada, on behalf of the Ontario Ministry of
Health and Long-Term Care.
About the survey
The purpose of the survey is to understand how persons with serious mental illness are diverted from the
criminal justice system. Our goal is to identify the key elements of successful diversion practices in three
categories:
1) Pre-arrest or police diversion;
2) Court diversion programs;
3) Mental Health Courts.
Participation is sought from colleagues in Canada, the United States, Great Britain, Australia and New
Zealand. Because of its international scope, we believe this survey will lead to a comprehensive
assessment of current diversion practices. Your participation is very important if the survey is to be as
inclusive as possible. We would be happy to send a copy of the final report you.
Participation is voluntary, but we hope you will agree to contribute to our understanding of diversion
programs. Any information you provide will be administered in accordance with the Privacy Act of Canada.
The researchers will maintain all responses as confidential, and no individuals will be identified in
published reports.
If you have questions about your rights as a research participant, please contact the University of Western
Ontario's Office of Research Ethics ([email protected]) or country code 01-519-661-3036.
Instructions
The survey is available at the Web address noted below. We would appreciate your responding before July
9, 2004. We estimate that the survey will take no longer than 20 minutes to complete (based on previous
responses).
There are three ways to access the survey:
1) Through a secure site on the Internet. If you choose to complete the Web-based survey, it must be
completed in one sitting; you will not be able to save your responses and complete the survey later. If you
do not have time to complete the survey in one session, please choose option 2) or 3) below.
94
2) You may download a writable .PDF file from here. If you choose this option, you can save the file to your
computer and complete the survey at your leisure. If you are completing the .PDF version, Part A (Police
Diversion) begins on page 1, Part B (Court Diversion) begins on page 10, and part C (Mental Health Courts)
begins on page 21.
3) Finally, you may also download the survey in Word or WordPerfect formats. If you choose this option you
must save the file to your computer and complete the survey at your leisure. If you are completing the
Word or WordPerfect versions of the survey: Part A (Police Diversion) begins on page 1, Part B (Court
Diversion) begins on page10, and Part C (Mental Health Courts) begins on page 22.
If you choose options 2) or 3), lease make sure to send the completed survey as an attachment to
[email protected].
An important note
Some of the survey questions will require you to provide information about program statistics, and about
policy and planning. You may wish to consult others in your organization. If the answers to any questions
are contained in your agency's documents, please feel free to use the cut and paste function to insert these
into the appropriate sections of the survey. Or, if you prefer, you can mail copies of the relevant documents
to us in care of:
Dr. Kathleen Hartford
375 South Street, NR A220
London, Ontario, Canada
N6A 4G5
E-mail: [email protected]
Phone: Country code 01-519-685-8000, ext. 77035
Fax: Country code 01-519-432-7367
If you are completing the Web-based version of the survey, click on the relevant link below:
Police Diversion
Court Diversion
Mental Health Courts
You need only complete the section of the survey that corresponds to the type of diversion with
which you are involved.
Thank you.
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