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Review of the Literature on Jail Diversion Programs and Summary Recommendations for the
Establishment of a Mental Health Court and Crisis Center within Douglas County, Kansas
Margaret Severson, JD
Jason Matejkowski, PhD
In September 2014 and based in part on a referral from Dee Halley, corrections program specialist with
the National Institute of Corrections, Dan Rowe, President of Treanor Architects contacted University of
Kansas Professor Margaret Severson about a potential consultation related to the intake, housing, and
management of persons with mental illnesses who are admitted into the Douglas County Correctional
Facility (DCCF) in Lawrence, Kansas. Having worked on similar issues with Douglas County Sheriff Ken
McGovern for many years and with Sheriff Trapp before him, this consultation was pursued with the
hope of contributing objective and evidence supported information about established diversion
programs and services, including mental health courts and crisis intervention centers that might be
successfully implemented in Douglas County.
The review of the diversion literature that appears in the following pages was completed by Professors
Margaret Severson and Jason Matejkowski and, as requested, gives particular emphasis to identifying
the aspects of certain diversion programs that might be seen as keys to their success and/or
contributors to their partial or complete failure. Overarching principles and trends have been identified
in the literature and are reviewed in this document, as are the successes and failures experienced, which
are often site-specific. Thus, the elements of success and failure are also reported here and are often
related to the construction and management of the program itself in a particular jurisdiction.
In our review of the literature we kept in mind the current DCCF operation and the express interests of
Douglas County stakeholders, which include Douglas County elected and appointed officials, including
Sheriff McGovern, mental health and health agency administrators, local judges and attorneys, and
residents of the Douglas County community who participated in town hall meetings where information
was exchanged and ideas, questions, and hopes for the future of the community were solicited.
THE SITUATIONAL CONTEXT
That jails and prisons across the United States are struggling to manage persons with acute and chronic
mental health needs, not only by trying to identify best practices in corrections-based treatment
interventions but also by looking at effective strategies for total population management, is not new.
The challenges facing jails in terms of housing more and more persons with serious mental illnesses was
the focus of the first National Institute of Corrections’ seminar on the topic held in the mid-1980s. The
only national jail suicide studies were completed during the same period. By the late 1980s and well into
the 1990s, a mass of publications pointed to the reality and existence of a “criminalization” process,
where persons who might have previously been hospitalized in inpatient psychiatric units were, as a
consequence of state and local psychiatric hospital closures, instead detained for preventive detention
or arrested and held in the local county jail as a means of containment .
This burgeoning mentally impaired population, when combined with more severe arrest policies and
sentencing laws, resulted in an explosion of inmate populations at both local and state levels. To
complicate matters even more, an alarming increase in the rate of imprisonment of women, in facilities
ill-equipped – environmentally and programmatically – to attend to them, in some cases caused gridlock
inside correctional institutions. This influx served to thwart efforts to contemporize inmate classification
procedures consistent with constitutional mandates, so that operational efficiencies in housing and
program involvement could be achieved. In reality, many jails struggled with overcrowding and worse:
having empty beds in some specially designed housing units while in some general population units,
inmates could be found sleeping on the cell floors. Indeed, this classification / housing squeeze became
a management conundrum for nearly every jail manager in the country. Many counties and states
attempted to build their way out of the gridlock, but the relief offered by new and larger facilities was
In the late 1990s, jail diversion programs, many especially geared toward those with mental health
challenges, began to emerge around the country. New and modified diversion strategies have also been
implemented in the last 15 years. These are highlighted and reviewed in the pages that follow.
The Douglas County Correctional Facility shares the fate of many detention centers around the country.
Increases in its average daily population and average length of stay over time, dramatic increases in the
numbers of women prisoners being admitted into and staying in the jail, significant rates of mental
illness and substance use exhibited among its incarcerated population, and housing gridlock have all
impacted DCCF operations. At the same time, a robust reentry program, a mental health collaboration
initiative, and considerable programming opportunities have likely helped to mitigate some of the
common consequences of these population changes and challenges. Still, at the outset it is important to
keep in mind, as one reads the literature review presented in the following pages, that population
management and diversion strategies comprise two different challenges and call for two different types
of responses. Both sets of challenges must be addressed, but by using different strategies. To that end,
the literature review that follows is designed only to inform strategies that might result in more
effective diversion of persons with mental illnesses and co-occurring disorders from the jail system.
THE WORK PROCESS
To prepare for the literature search and review, several important inquiries were made. First, we set
out to define the problem to be explored in the literature review. There were three types of activities
pursued that were related to this process. First, over a period of several months, we met with key
county officials, including Sheriff McGovern, Commissioners Jim Flory or Mike Gaughan, Douglas County
administrator Craig Weinaug, David Johnson CEO of the Bert Nash Community Mental Health Center,
and representatives of Treanor Architects, to explore the challenges facing the DCCF with regard to
admitting and managing persons with serious mental illnesses. We identified the need to secure data
that would allow us to quantify, where possible, these challenges as well as provide us with a starting
place for exploring diversion options that already exist elsewhere in the United States.
Second, we engaged in key fact-finding activities, for example, talking with colleagues around the
country about their research and their knowledge of diversion programs. We also met with key Douglas
County jail and Bert Nash representatives and toured the DCCF in order to better understand the
existing and emergent population-related pressures impinging on the jail staff and on the jail
environment. Over time we met with city and district court personnel, including judges and
prosecutors, in order to listen to their perspectives and identify their interests in and questions about
jail diversion programs already underway in other areas of the state and country.
Third, we participated in site visits to other jurisdictions, exploring not only the operation and layout of
certain jail facilities, but also the development, design and operating procedures of mental health courts
and crisis intervention centers. In this regard, we made site visits to Bexar County, Texas and to Fayette
County, Kentucky. We also toured both the Rainbow Crisis Center located in Kansas City, Kansas and the
Valeo Crisis Intervention Center located in Topeka, Kansas.
In sum, this literature review is the product of a six-month process of interviews, discussions with
stakeholders, site visits, reviews of the relevant published peer-reviewed research, and perusals of the
contemporary practice literature.
Margaret Severson is a Professor at The University of Kansas School of Social Welfare, joining the faculty
in 1996. In the 1980s she developed and administered a comprehensive mental health and suicide
prevention program in the El Paso County Jail in Colorado Springs, Colorado. In the 1990s, while on the
faculty at the Louisiana State University School of Social Work, Professor Severson was appointed the
federal court expert in Hayes Williams v. McKeithen, a long standing civil rights case that resulted in
decades of federal court supervision over the operation and practices of all of Louisiana’s prisons and
local parish jails. She has provided technical assistance related to mental health and suicide prevention
for the US Department of Justice since 1990, for its National Institute of Corrections and the Civil Rights
Division. Professor Severson’s research scholarship is focused on mental health, suicide, incarcerated
women, and reentry – all within the context of the correctional environment.
Jason Matejkowski is an Assistant Professor at The University of Kansas School of Social Welfare, joining
the faculty in 2012. He has worked on a variety of projects involving justice-involved adults with serious
mental illness (SMI) and co-occurring substance use disorders. He has served as investigator on state
and federally-funded projects that examined integrated services for recently released inmates with SMI,
the relationships among SMI, criminal risk factors, and parole release decisions, and effective data
collection and information sharing between treatment and recovery services and the criminal justice
The sequential intercept model  provides a framework to study how people with mental illnesses
interact with the criminal justice system. The model identifies a series of intercept points in criminal
justice processing at which an intervention can be employed to divert individuals from penetrating
further into the criminal justice system. It is important to note that the developers of the sequential
intercept model assert that “an accessible, comprehensive, effective mental health treatment system
focused on the needs of individuals with serious and persistent mental disorders is undoubtedly the
most effective means of preventing the criminalization of people with mental illness” (p. 545). This
truism is reflected in the subsequent review of community crisis centers and the highlighting of
community support services necessary to buttress the remaining diversion programs discussed below.
Early interception points reflect law enforcement and emergency services and progress through
interception in jails, initial hearings and courts to community reentry and community supervision. The
adoption of the sequential intercept model by jurisdictions attempting to identify methods for
intervening with people who have mental health problems to reduce their justice involvement and jail
stays signals the appropriateness of the model for structuring this literature review. As such, we review
the intercept points in the following order:
1. Community crisis centers
2. Law enforcement
3. Post-booking intercepts in jails and at initial hearings
4. Mental health courts
Given the scope of our assigned work, i.e., to focus on diversion programs that may help to ease jail
overcrowding, reentry programs were not reviewed for this report.
A NOTE ABOUT “EVIDENCE”
The quality of the research supporting each category of diversion programs reviewed is highlighted by
identification of the associated research methodology. Research methodologies differ as to the extent
that they can provide the evidence to support causal relationships. Experimental designs that employ
randomization to treatment and control groups are most effective at providing evidence to support
whether or not some manipulation of “A” caused a change in “B”. Quasi-experimental designs may
employ a treatment and comparison group but lack the randomization of study participants to these
groups that would facilitate causal attribution. Therefore, studies that utilize quasi-experimental designs
provide a lower level of evidence than experimental designs (see figure below).
Lower still on the evidence hierarchy are pre-experimental designs that lack random assignment and
the control groups that are a central part of good experimental designs. Due to the dubious nature of
the conclusions that can be drawn from pre-experimental designs, effectiveness research using these
designs is not reviewed here.
Research that systematically reviews and analyzes the data from multiple studies (preferably from
studies that have utilized experimental designs) can provide a summary of the state of the evidence on a
particular causal relationship and its generalizability to different contexts. These systematic reviews and
meta-analyses provide valuable sources of evidence that support the development of clinical guidelines.
It is important that when results from studies are reported that the research methodology be identified.
Doing so allows the reader to gain a better understanding of the veracity of the findings. For example, if
findings from a study of a mental health court that utilized randomization of study participants to a
mental health court or to usual criminal justice processing found that those in the mental health court
condition had fewer subsequent arrests than those in the usual processing group, then we could be
fairly certain that the mental health court was responsible for (i.e., caused) the reduction in arrests. If
similar findings were reported from a study that did not utilize randomization to a treatment or control
group (i.e., that used a quasi-experimental design) or compared arrest days pre- and post-participation
in a mental health court (i.e., a pre-experimental design), then we would have less confidence that the
reduction in arrests was due to participation in the mental health court.
(1) COMMUNITY CRISIS CENTERS
Mental health crisis centers have long been available to the public and to law enforcement as a place for
assessment of individuals in need of psychiatric attention as a result of displaying behavior perceived to
have potential for harming themselves or others . Core elements of crisis centers have been proposed
by the Substance Abuse and Mental Health Services Administration (SAMHSA) ; however, these
guidelines are not specific to crisis centers that have been established primarily to support jail diversion
efforts. Steadman and colleagues  identify these more “specialized crisis response sites” as an integral
component of pre-booking jail diversion programs for people with psychiatric and substance use
disorders. While admitting at the time of their report (2001) that no client outcome data were available
to measure the impact of these programs on recidivism or engagement with treatment services,
Steadman et al., identify basic elements of these crisis response sites to include the following features.
A central drop-off site available 24-hours daily that serves as a point of entry into the substance
abuse and mental health services systems and provides linkages to community services. A
survey of experts on crisis intervention services  reported that 87% of those surveyed
considered 24/7 availability of mental health services to be a “very important” component of
Single group pre- to post-test designs (and
other pre-experimental designs)
pre-booking diversion programs for people with mental illnesses. The same survey found 55% of
experts thought that a single point of entry to mental health services was a very important
component of prebooking diversion programs and 60% reported that referral to outpatient
community treatment providers was a very important feature of these programs.
A “no refusal” policy that expedites the officers’ immediate return to their duties. This policy
recognizes the likelihood that officers will be deterred from bringing an individual to a crisis
center (and, instead, make an arrest) if they believe the person in custody will not be accepted
for evaluation by center staff. Eighty percent of crisis intervention experts surveyed identified
having a no-refusal policy as a very important component of a police diversion program . It
should be noted however, that a survey of 54 police departments from the U.S., Canada, the
U.K., and Australia reported that no-refusal policies were rarely available to pre-booking
diversion programs serving people with mental illnesses .
A streamlined intake process that minimizes officer time at the center and maximizes patrol
time. Slightly more than 85% of experts surveyed reported rapid transfer of responsibility as
being a very important component of mental health services supporting a pre-booking diversion
A legal foundation that allows the crisis center to accept and detain a person who may or may
not have pending criminal charges . Two-thirds (67%) of experts identified legal grounds for
detention as an important component of mental health services supporting police diversion
According to Compton et al. , there is consensus in the field that a designated emergency mental
health drop-off site with a no-refusal policy is crucial to improving officers’ linking of people with
mental illnesses to needed services. However, the lack of specific research makes it unclear the impact
that crisis centers, independent of the diversion programs discussed below, have on engaging in services
and reducing the incarceration of people with mental illnesses. The research reviewed below, while
identifying referral to services as an outcome, does not track individuals beyond the initial crisis drop-off
point to evaluate whether these crisis services are effective at keeping an individual engaged in
treatment or out of jail.
Indeed, there is some debate as to whether mental health services can actually reduce the criminal
involvement of most offenders with mental illnesses. Mental health treatment approaches aimed at
reducing psychiatric symptoms have often been employed with offenders who have mental illnesses
under the premise that symptom amelioration will reduce criminal involvement . This approach is at
the heart of the diversion-to-treatment programs reviewed here. However, research has shown that
employing with justice-involved individuals those evidence-based practices that have been effective at
reducing psychiatric hospitalizations and psychiatric symptoms does not translate to reductions in
criminal behavior and incarceration [10-14]. This has led some to suggest that mental illness plays a
minor role in the criminal involvement of this population and that services for offenders with mental
illness should focus on addressing other factors that are more strongly related to criminal behaviors [9,
The predominant, evidence-based approach in offender rehabilitation today is based upon the risk-
needs-responsivity model [RNR; 16]. This model asserts that: (1) an offender’s level of risk for criminal
behavior can be assessed and that offender treatment services should be proportional to this risk level;
(2) this treatment should be focused on removing those dynamic risk factors (termed criminogenic needs)
that are directly related to criminal behavior [mental illness is not a criminogenic need]; and, (3) this
treatment should be responsive and tailored to an individual’s personal characteristics that facilitate
learning new behaviors and cognitions. Criminogenic needs are the same for individuals regardless of
whether they have a mental illness [17-19] and include antisocial cognitions, antisocial peers, substance
abuse and lack of involvement in school and/or work. However, the presence of a mental illness is a
personal characteristic to which programs targeting criminogenic needs must be responsive. Research
has indicated programs that adhere to the RNR principles can reduce offender recidivism by up to 35%
In the end, if reduction in criminal behavior and incarceration is the aim, then services should: 1) be
provided at an intensity commensurate with an individual’s level of need, 2) target criminogenic needs,
and 3) be delivered in a way that is responsive to an individual’s health and mental health conditions.
There is nothing fundamentally at odds with providing needed mental health services while adopting an
RNR approach with those clients who are engaging in criminal behaviors.
In the absence of peer-reviewed literature on the effectiveness of crisis centers at reducing jail stays or
days, the authors visited two nearby crisis centers; one in Wyandotte County and one in Shawnee
County. One author also visited a crisis center in Bexar County, Texas.
Rainbow Services Inc.
Rainbow Services Inc. in Wyandotte County is a 24-hour facility that offers assessment and triage, crisis
observation, a sobering unit, and a short-term crisis stabilization unit. According to the Executive
Director, RSI serves as a resource to individuals, families and law enforcement, and to prevent
unnecessary hospitalization or incarceration of persons who can benefit from community-based
resources . The RSI sobering unit serves individuals who are intoxicated or impaired from substance
abuse. Diverting such individuals from hospital emergency rooms and jails, the unit provides brief stays
(no longer than 10 hours) for up to 10 persons at a time. At the conclusion of their stay, sobering unit
consumers may be transferred to local detoxification facilities or discharged to community-based
services, or the individual may simply exit the facility without a service plan.
The RSI observation unit is staffed by a multi-disciplinary team of professionals providing clinical
assessments, treatment, and observation lasting up to 23 hours per admission). The unit has a capacity
to serve 10 persons at a time. Individuals may be discharged to community-based services, admitted to
an inpatient psychiatric hospital, or transferred to RSI’s crisis stabilization unit. The crisis stabilization
unit provides short term care (up to 10 days) for up to 10 clients. Upon completion of their stay,
individuals may be referred to co-occurring substance abuse or other community-based services or
admitted to an inpatient psychiatric hospital.
Written RSI materials suggest that 45% of the persons referred to their services are accompanied by law
enforcement, 19% are self-referrals, 25% are accompanied by family or friends, and others are brought
in by community mental health centers (Wyandot Center/Johnson County Mental Health) or other
community agencies. The RSI protocol is to quickly process all law enforcement referrals so that officers
can immediately return to their patrol duties. Between April and August 2014, RSI served a total of 559
individuals; of those, 516 were unduplicated. Though it is unclear how the following figures were
obtained, RSI reports that had their services not been available 17% of RSI clients would have been
transported to a state hospital (91 individuals), 48% would have been seen in local hospitals (262
individuals), 11% would have gone to jail (61 individuals) and 24% to other community mental health
Since its inception, RSI has operated primarily with funding allocated by the State of Kansas’s
Department of Aging and Disability Services. This funding will extend three years after which RSI must
become self-supporting, relying on grants and donations for its operation.
Opened in October 2014, Valeo’s Regional Center for Mental Health Emergency Care consolidates crisis
services that were dispersed over eight locations into one central location . Services include crisis
intake and assessment as well as screening for state or local hospital admissions, counseling, and crisis
stabilization. In regards to the latter, Valeo has 26 crisis stabilization beds that are available for stays up
to 5 days. Valeo also provides crisis intervention training to local law enforcement agencies.
In an adjacent facility, Valeo provides 11 beds for substance detoxification services lasting between four
and five days. For those individuals for whom long-term treatment is indicated, Valeo operates a 50-bed,
long-term (i.e., 3 to 4 week) residential substance abuse treatment facility.
The Valeo facilities offer law enforcement officers a quick assessment/acceptance policy that allows
officers to return to their patrol duties within a very short period of time. Only persons physically
violent or deemed to be at imminent risk for violence are refused admission at the center.
Valeo officials report that approximately 40 percent of people brought to its crisis facility in the midst of
a mental health crisis come by way of the Topeka Police Department . It is noted that Valeo’s
budget for this crisis facility is dependent in part on the referral of persons from law enforcement
agencies outside of Shawnee County, including referrals from the Bert Nash Mental Health Center and
transports by the Lawrence Police Department. Indeed, it is clear that as other jurisdictions plan the
development of crisis intervention services, Valeo’s budget will be negatively impacted. The Valeo crisis
center operates on a profit-making basis, i.e., it is designed to be self-supporting. Part of the budget
design includes an expectation of receipt of payments for services offered to residents of other counties.
Private health insurance, Medicaid, and other payment sources are billed for services rendered.
Having been open for approximately only eight months at the times of our visit, Valeo could not provide
any data on the new crisis center’s current or potential impact on the justice involvement of the clients
it has served. It is important to note that Valeo has a very high staff turnover rate. Clearly, the intensity
of the needs among the population served takes its toll on staff. The potential for violence in the center,
the potential for personal injury, and the difficulty inherent in managing a large population of persons in
crisis all play out in staff turnover.
The Crisis Care Center (CCC), the crisis intervention center in Bexar County, Texas, serves the city and
suburbs of San Antonio – a metropolitan population of almost 1.9 million - in several physical locations,
with additional site expansion planned for the future. A site visit was made to the near-downtown
location, which consists of a complex of buildings that provide crisis intervention, chemical dependency,
health, and homelessness services for thousands of people each year. The complex is operated under
the collaborative auspices of Texas’s Center for Health Care Services and other state funded agencies,
and is one component of a menu of specialty programs – including a variety of therapeutic justice
programs - available to Bexar County justice-involved residents. This is a very expensive and largely
privately and grant-funded enterprise.
The Crisis Care Center is also a jail diversion resource available in the county, and provides a panoply of
professional staff (medical, psychiatric, social work) round-the-clock, enabling a “drop off” response
system that allows law enforcement officers to return to their duties immediately after bringing
someone to the physical crisis center location. In addition to providing mental health assessments and
treatment, the CCC also provides a sobering area and an inpatient detoxification unit . Further, in a
separate building on adjacent grounds, the Haven of Hope center provides structured interventions for
homelessness, focused on identifying and treating the root causes of homelessness. The Hope Haven
safe shelter (the ”courtyard”) sometimes sees a nighttime population of more than 600 people who
sleep outside in a secure area.
One published report  indicates that in a 12 month period during 2010-2011, 5,100 persons were
screened, referred, or received some level of services in the CCC and 8,000 people used the drug-related
services available on the same grounds.
There are no known peer-reviewed and published evaluations of the Bexar County diversion programs.
While these programs have received considered attention in the trade literature and from the
constituents of communities across the country that struggle with the same issues of mental illness,
addictions, homelessness, and poverty, independent reports of treatment and fiscal outcomes, including
resource savings, were not found in the refereed literature. However, Dr. Tony Fabelo, the research
division director for the Justice Center, Council of State Governments (CSG), summarizing the recent CSG
activity in Bexar County, provided this feedback about the Bexar County program outcomes:
Bexar County has good CIT training for police and the police uses (sic) their restoration center
and Havens for Hope programs to take mentally ill persons there instead of booking. So this is
good. However, they do a very poor job of screening, assessing and diverting mentally ill
persons to treatment programs at booking. They also do not have enough program capacity,
nor do they do a good job in retaining those that are diverted to treatment. … the mental health
system is very deficient and does not have capacity to address many of the needs of mentally ill
people in general, but in particular, those in the justice system (personal communication July 24,
There are several critical lessons to be learned from the literature and from the experiences of other
crisis intervention centers. First, no one ventures down this road without a fervent wish for
success. These desires can often yield inflated appraisals of “success” and estimated conclusions of
positive outcomes. The evidence, however, of both success and failure is missing. There are no known,
peer-reviewed, and published empirical studies using random assignment and there are also no quasi-
experimental studies reporting the impact of crisis centers on the justice-involved population to be
found in the literature. In part or in full, this total absence of good, trustworthy evaluations is a result of
not developing an evaluation strategy concurrent with the development of the crisis intervention center
itself. In essence, we have only stories and obscure percentages of success and failure to rely on. This
does not mean that crisis intervention centers are ineffective; it only means that we do not know which
are and which are not and why either is the case.
Second, mental health intervention alone may not have a significant impact on the total jail population;
we simply do not know for sure. Once referred individuals enter into the mental health system, they fall
off the radar screen. There are no known rigorous national studies that follow people referred to crisis
centers to identify their outcomes, including their future interface with the mental health system and
with law enforcement and the criminal justice system. As identified above, some scholars suggest that
mental health interventions may have limited impact on the criminality of people with SMI who are
justice-involved. The lesson here is one of prioritizing what needs to be addressed in an intervention
system. Mental health needs are one set of potentially many needs to be addressed and targeting
criminogenic needs may provide more positive and enduring justice-related outcomes. Both can be
targeted in a crisis intervention center, but often are not.
Nationwide, some 80% of justice-involved persons has a substance use problem. Estimates in Douglas
County echo this finding. Many of these persons also have co-occurring mental disorders that will be
difficult to assess and treat until the person is sober and stable. Thus, a crisis center is not just a mental
health venue; it must also be a venue to provide sobering and addiction treatment services.
Relatedly, the crisis intervention center must be developed to serve the entire community; not just the
law enforcement community. Not only will this encourage widespread support for its development and
services, crisis intervention centers have the potential to divert non-justice involved persons from
becoming involved in the justice system because of their mental conditions.
Finally, thinking about sustainability in the developmental stages is critical. Fiscal sustainability as well
as staff sustainability must be considered when designing the physical and ambient environment of the
(2) LAW ENFORCEMENT RESPONSES
There are frequent references in the professional and trade literature to the many calls for police
officers to respond to scenes involving individuals experiencing a mental health crisis. Consequently,
law enforcement officers play an important role in determining whether to resolve these situations with
arrest and incarceration or with diversion of the individual into treatment services [25-27]. Key members
of the Lawrence and Douglas County communities (i.e., the Sheriff, Police Chief, and Municipal Court
Judge) report the same trends in this jurisdiction, though evidence of the extent of this activity is not
readily available. Nationally, the most common law enforcement-based specialized response program is
the Crisis Intervention Team (CIT) model . The CIT model was developed in Memphis, Tennessee and
involves the training of police officers to de-escalate crises and, when appropriate, to divert to
treatment services instead of arresting individuals who are in the throes of a mental health crisis .
Essential elements of officer-based diversion programs are outlined in the literature [30, 31]. These
include specialized training of officers and dispatchers, and meaningful collaborations among criminal
justice and mental health professionals to support planning and implementation of the CIT program and
custodial transfers to comprehensive and effective community-based treatment, supports, and services
Training. The Memphis CIT model involves 40 hours of training for police officers to learn and master
crisis intervention skills . Supplemental training can also be provided to emergency dispatchers to
facilitate their identification of calls for service that may require a CIT response [31, 33]. During the
training, officers interact with individuals who have lived experiences in order to develop a better
understanding of challenges associated with mental illness; are instructed on mental health diagnoses,
psychiatric medications, and drug abuse and dependence; and receive intensive training in verbal de-
escalation skills . Qualitative and pre-experimental research involving officers trained in CIT has
found these officers to express greater understanding of mental illnesses and increased empathy and
patience towards people with mental illnesses, and to consider more options (e.g., redirection away
from jail) when deciding the outcomes of crisis calls [35-38].
Quasi-experimental research on the impact of the 40-hour CIT training has indicated that training
increases officers’ sense of self-efficacy and preparedness in effectively responding to the needs of
individuals with mental health problems [39-41]. In one study, Compton and colleagues  compared
CIT-trained officers to non-CIT-trained officers in their perceived need to use force in response to a
series of vignettes depicting an escalating crisis situation involving a person with psychotic symptoms.
The responses of CIT-trained officers to these scenarios reflected less escalation and a lower
endorsement of the use of physical force in responding to the individual experiencing psychosis .
Additionally, CIT training appears to reduce feelings of social distance and stigma toward the population
of persons with mental illnesses who come to the attention of the police [39, 41, 43, 44]. Retention of
knowledge gained from CIT training has been shown not to differ based upon age, gender, level of
education, or whether the officer volunteered for training .
Behavioral health partners. Behavioral health partners are a critical ingredient of the CIT model of
diversion . Mental health and substance abuse treatment professionals provide the necessary crisis
treatment and support services that function as an alternative to jail and they also provide the training
described above to officers and criminal justice personnel . It is important that, to maximize officer
presence in the community, mental health partners provide quick handoffs to supportive and crisis
services . Crisis services (usually a dedicated crisis center) should have a no refusal policy and accept
all referrals regardless of diagnosis or financial status . However, police should receive training on
who is appropriately safe for diversion to these crisis centers. For example, individuals whose crisis
resulted in injury to self or others or who remain agitated and potentially violent are not good
candidates for diversion to noncustodial, nonmedical crisis centers. Policies should be set to ensure
minimal turnaround time for the CIT Officers, so that it is less than or equivalent to the turnaround time
necessary in transporting a person and processing him into jail . Additionally, the facility will need
access to a wide range of emergency health care services and disposition options, as well as alcohol and
drug emergency services. The importance of effective mental health partnerships cannot be overstated.
Simply put, by Watson and colleagues ,
In order to divert individuals with mental illness to the mental health system, officers must
interact with providers from the mental health system. This can only occur if responsive mental
health services exist; and if officers are able to efficiently link individuals to treatment to resolve
a mental health call. Police must also have access to community mental health resources to
respond to individuals who are in need of services but do not meet criteria for emergency
evaluation at the hospital (p. 364).
Quasi-experimental research examining disposition outcomes involving CIT is sparse. One study
comparing the characteristics and psychiatric dispositions of individuals referred to mental health crisis
services by CIT officers, by family members or through self-referral concluded that CIT police officers
were able to adequately identify appropriate people for referral to emergency psychiatric services .
In another study involving 180 officers (91 with CIT training and 89 without) in six departments across
the State of Georgia, Compton et al.  found that among 1063 encounters CIT officers did not
generally differ from non-CIT officers in the use of force, nor did they differ in the percentage of calls
that was resolved on-site (about half for each group). However, referral to services was significantly
more likely and arrest was significantly less likely for those individuals in crisis who encountered a CIT-
trained officer versus a non-CIT-trained officer .
Research comparing outcomes of calls responded to by either CIT officers, a co-responder (CR) pairing of
an officer and a mental health professional, or a civilian community service officer (CSO) trained in social
work or related fields  found percentages of arrest dispositions varied from 2% (CIT) to 13% (CSO). In
75% of cases responded to by CIT officers the individual in crisis was transported to treatment; this
disposition occurred in 42% of CR responses and 20% of CSO responses. The authors suggest that the
large differences in treatment disposition were due to the availability of a crisis drop-off center in the
jurisdiction served by CIT officers .
Other quasi-experimental research has shown CIT training to increase direction to mental health
services and, to a lesser extent, reduce arrest and use of force with those individuals in a psychiatric
crisis who are brought to the attention of the police [51-53]. In comparing CIT to non-CIT officers in
Chicago policing districts with high/low mental health resources, Watson and colleagues  found no
effect of either CIT training or resource availability on arrest but did observe CIT trained officers were
more likely to direct individuals to mental health treatment than non-CIT trained officers. However, the
effect was moderated by the availability of mental health services. In districts with high levels of mental
health resources the relationship persisted while in low resource districts, the relationship between CIT
training and referral to services was nonsignificant; highlighting again the need for adequate mental
health support services for diversion efforts to be effective.
It is important to note that the studies reviewed here looked specifically at the actions of CIT vs. non-CIT
trained officers. The studies did not include investigations of what occurred after referrals to mental
health and support services were made, e.g., whether the person actually accessed services on an
No studies utilizing an experimental design were located.
Systematic reviews and meta-analysis
Two systematic reviews have been conducted of the research examining the effectiveness of CIT on
various outcomes. In 2008, Compton and colleagues  conducted a qualitative review of the extant
research that included evaluations, surveys and outcome studies involving CIT. They identified three
studies reporting on dispositions of calls eliciting a CIT response (all were reviewed above; [48, 50, 52]).
While noting “serious methodological limitations” (p. 53), the authors concluded the evidence provides
preliminary support for CIT as an effective method for connecting to mental health services those
individuals experiencing a psychiatric crisis and who come to the attention of the police.
A more recent quantitative meta-analysis by Taheri  focused specifically on studies that reported on
arrests, use of force and officer injury. The review was limited to available quasi-experimental or
experimental research. Seven studies were included in the meta-analysis. Again, no studies utilizing an
experimental design were located. The five studies that were able to be pooled for meta-analysis
resulted in a nonsignificant difference in arrests between CIT and non-CIT officers; though the average
number of arrests for CIT officers was lower. Similarly, the five studies that were able to be pooled for
meta-analysis resulted in a nonsignificant difference in use of force between CIT and non-CIT officers;
though results favored the non-CIT group on average. Only two studies reported on officer injury and
therefore no pooled analysis was possible on this outcome. Findings led Taheri to conclude that,
There appears to be some evidence that CIT has no effect on outcomes of arrest, nor on officer
use of force, with the overall findings being mixed. Paired with findings from the Compton et al.
(2008) review, these results raise some concern about the widespread implementation of CITs
That there are no published, peer-reviewed experimental and few quasi-experimental studies
completed on the outcomes of CIT training for officers should not be overlooked when considering
implementation of a widespread CIT program. Certainly, increasing one’s understanding of mental
illness and of effective ways to interdict in crises is significant in its own right. That said, it is important
not to conflate knowledge acquisition with actual outcomes. If the purpose of implementing CIT
training is to increase officers’ understanding of mental health crisis, CIT is clearly an appropriate
strategy to employ. If, however, the purpose is instead to reduce arrests and subsequent incarceration
and substantially improve people’s access to mental health resources, CIT has not yet been firmly
established as a viable method to do so.
In recent years, the CIT program originally developed at the University of Memphis has morphed into
something more abbreviated than the original and well-known 40 hour copyrighted course. Correction
officers, for example, may now take a 1 or 2-day crisis resolution course [e.g., 57]. These abbreviated
curricula have not been subject to rigorous evaluation.
What is consistently clear in the research that has been published is the importance of the mental
health resources in the community to which CIT trained and non-CIT trained officers can refer. Further,
these resources, including crisis centers, must have the capability to quickly assume physical
responsibility for the person referred, so the officer can return to his/her patrol duties in a timely
manner. Additionally, “mental health” should be interpreted broadly, to include crisis detox services for
persons severely intoxicated who are detained by law enforcement for their protection or whose
families are unable to manage the intoxicated person safely.
Finally, there simply isn’t enough research published to make definitive statements about the best
structure of a CIT program. Whether CIT is more effective when responses are made by CIT trained
officers alone or in dyads with mental health co-responders has not been established. At present, in
most communities, the availability of human and service resources will determine the program model.
(3) POST-BOOKING DIVERSION STRATEGIES
Post-booking diversion programs often begin with screening and, when indicated, assessment to identify
individuals with mental illness who may be appropriate for diversion to treatment services [58, 59].
Diversion may take the form of transfer to a secure forensic treatment setting, conditional release to
treatment services or release to treatment with charges dropped [59, 60]. Individuals eligible for
diversion are typically those who have been charged with a nonviolent misdemeanor or low-level felony
offense; those with other charges may be admitted depending on the program-specific criteria .
Post-booking diversion programs may be categorized based upon their administration and location as
either jail-based diversion, court-based diversion, and specialized diversion courts [62, 63]. Only the first
two models are discussed here, while the third, mental health courts, are discussed separately below.
Jail-based diversion programs are often operated by pretrial or specialty jail or mental health personnel
who screen and assess for diversion individuals booked into the jail. Identification of who meets
eligibility and is offered diversion to treatment and support services is determined in conjunction with
the prosecutor, defense attorney and judge . In some cases community supervision may accompany
diversion; in others, diversion to treatment and support services ends the individual’s episode of justice
involvement . Postarraignment, court-based diversion can occur at any stage in the criminal justice
process prior to sentencing. Court-based diversion programs vary in degree of court monitoring and
type of sanction imposed, but are typically decentralized, with diversion staff working in multiple courts
and in the community, providing case management and/or a liaison role between community service
providers and the court . Again, here, the focus is court-based diversion programs that have little to
no involvement beyond the initial screening and referral. Models with more extensive court oversight
(i.e., problem-solving courts, mental health courts) are discussed separately below.
Quasi-experimental evidence of effectiveness
Prearraignment programs. Hoff and colleagues  compared 314 offenders with a SMI who had been
enrolled in a diversion program between December 1994 and March 1997 to 124 individuals who were
eligible for diversion but were not diverted during the same time period. In the year after the index
arrest, those diverted had significantly reduced jail days compared to those who had not been diverted
(40.51 versus 172.84 days). However, this relationship was moderated by seriousness of the index
offense. That is, diversion only reduced subsequent days in jail among those initially charged with more
serious offenses (low-level felonies and high-level misdemeanors) compared to those who were charged
with moderate to low-level misdemeanors. Another quasi-experimental evaluation of jail-based
diversion programs in Arizona, Hawaii and New York, compared persons released from jail through
prearraignment diversion and those who were released without diversion, on the number of arrests and
on having any arrests during the past 30 days at three and 12 months post-release, and found no
significant differences between the two groups .
Postarraignment programs. Included in the report on the outcomes of eight jail diversion programs
cited above was the evaluation of one diversion program in Connecticut that was conducted during the
arraignment phase of criminal justice processing . Comparisons of 3- and 12-month outcomes of
those diverted and those not diverted resulted in no significant differences between the two groups in
whether individuals had been arrested or in each group’s average number of arrests during the past 30
days. Another study conducted in Connecticut with a smaller sample that included individuals not
diverted and individuals participating in a court-based diversion program found no difference between
the two groups in arrest rates or time to arrest; however, the diversion group spent significantly fewer
days incarcerated in the year following the index arrest, and were also less likely to be re-incarcerated
Rivas-Vasquez and colleagues compared arrest outcomes of individuals diverted, at arraignment, to an
integrated health/mental health and relationship-based care program to the outcomes of individuals
diverted to a variety of standard (non-integrated, not relationship focused) programs . Individuals in
the relationship focused program were encouraged (through the professionals’ concerted use of
empathy, respect and connectedness) to develop relationships with staff and each other as well as with
their health care network. Those in the standard diversion programs did not evidence a reduction in
number of arrests in the year following diversion. Individuals in the enhanced diversion programs had a
lower average number of arrests compared to the year prior to diversion and compared to the
individuals who received standard care.
Either pre- or postarraignment programs. A study by Shafer and colleagues’  included individuals
with SMI and substance use disorders who had been arrested and booked for misdemeanor offenses.
Diverted individuals included those who were released on conditions prior to trial, who received
deferred prosecution, or who received summary probation and court monitoring. These participants’
violent and criminality outcomes at 3 and 12 months were compared to those of similarly situated
nondiverted participants. Analyses found no main effects for diversionary status or time on having been
arrested or self-reported perpetration of violent acts at both follow-up points.
Within the New York City LINK diversion program, Broner and colleagues  compared the 3- and 12-
month outcomes of individuals diverted through the program’s prearraignment, jail-based diversion
track (the nonmandated track) to the outcomes of individuals diverted through the program’s
postarraignment, court-based track (the mandated track). Those in the nonmandated track were
diverted from jail and received case management without specific court involvement or any mandated
sanctions. Those in the mandated track were diverted through the court with diversion conditioned on
treatment involvement, mandatory case management reporting, and with court sanctions for
noncompliance. In addition to each other, group outcomes were compared to another group of similar
offenders who did not receive diversion. Findings suggest that mandated diversion is more effective
than nonmandated diversion or standard criminal justice processing “in terms of reducing the number
of days incarcerated in prison, increasing the number of days spent in the community (not in a hospital
or incarcerated), reducing drug use during the course of a year, and effectively creating treatment
linkages.” (p. 43).
Experimental evidence of effectiveness
No studies utilizing an experimental design were located.
Systematic reviews and meta-analysis of effectiveness
Lange and colleagues  conducted a systematic review of the research on jail-based diversion
programs for adults in North America and published between 1995 and 2011. They concluded that jail-
based (prearraignment) diversion has “a high degree of effectiveness in reducing recidivism … and
moderate effectiveness in reducing the number of days incarcerated” (p. 210). They also concluded that
court-based diversion (postarraignment) programs evidenced “moderate effectiveness for reducing
recidivism … [and] the number of days incarcerated.” However, these conclusions were based upon the
inclusion in their review of questionable findings from several pre-experimental research studies (e.g.,
[71-73]). Higher quality studies that were included in their review only partially supported their
conclusions (all of these studies were referenced above in the section entitled “Quasi-experimental
evidence of effectiveness”).
Ryan et al. reviewed the literature published between 1999 and 2008 examining postbooking diversion
programs targeting individuals with serious mental illness . Unfortunately, results reported conflate
mental health court outcomes (discussed separately below) with outcomes of diversion programs that
are not court-based. However, quasiexperimental studies included in the review by Ryan and colleagues
are summarized above.
While not an approach taken to specifically reduce the numbers of individuals with SMI in jail, it is worth
noting here the attention that no-bail programs have been receiving across the country as a method to
reduce jail populations. For example, in 2010, Human Rights Watch called for implementation of
policies that prevent the incarceration of misdemeanants because of their inability to afford financial
conditions of release imposed to secure their appearance at a subsequent court date . The group
suggests a number of policies that could be implemented by prosecutors, judges and defense counsel
that eliminate bail in most cases and that, when necessary, promote financial conditions that are
affordable to the defendant. The policies called for by Human Rights Watch are now being implemented
. For example, according to the New York Times, bail reform has been enacted to reduce jail
overcrowding as well as facilitate access to behavioral health treatment for those in need:
Reducing the population to make the jail complex more manageable was one of the central
objectives, and along with the bail changes, the city is also expanding public health services and
other programs for people with mental health and substance abuse problems .
In Washington, D.C., bail has been essentially eliminated. Eighty percent of defendants are released
without financial bonds and 15% are held without bond. The remaining 5% are held on a financial bond,
and upon request from the defendant, receive credit for time served if convicted . The Pretrial
Services Agency for the District of Columbia reports that 88% of released defendants (many of whom
are supervised in the community) make all court appearances, and the same percentage complete the
pretrial release period without any new arrests . Similar rates of success have been reported in
other jurisdictions that have employed risk assessment tools to identify individuals appropriate for
pretrial release [80-82]. In one study of state court felony defendants in the 75 largest counties in the
United States , failure to appear rates were slightly higher releases on recognizance than for those
on conditional releases (26% and 22% respectively), and rearrest rates (17% and 15%) were similar to
those of jurisdictions cited in this paragraph. Defendant characteristics associated with pretrial
misconduct include being male or a racial minority, having a prior arrest record or current drug offense
[83, 84]. Supervision of the defendant upon release is also associated with decreased arrest and
increased court appearance rates .
While once again we were unable to find any published experimental studies related to bail reform, it is
a strategy to be considered in any endeavor that seeks to reduce the total jail population. Its potential is
perhaps best summarized In a recent report on pretrial release programs , where the National
Association of Counties found that that the majority of people held in county jails is of pretrial status
and of low risk to public safety. Their report recommends expanded use of pretrial release and pretrial
supervision and concludes with a call to action for county boards:
County boards have the convening power of all the parties in the pretrial system and courts
have the authorizing power over pretrial release. Any long term sustainable solution for pretrial
release requires collaboration across the county justice system, including local law enforcement,
the court and corrections system. Counties are in a strong position to lead the way in pretrial
release, developing strategies and leveraging resources that not only assist in managing the
county jail population, but safeguarding public safety .
MENTAL HEALTH COURTS
Because unmanaged psychiatric impairment can be the primary contributing factor in some criminal
acts, standard criminal justice responses may be viewed as scientifically and therapeutically baseless.
For these individuals, a model that incorporates both criminal justice supervision and structured
therapeutic intervention may be more effective for addressing the dual objectives of public health and
public safety. Mental health courts (MHCs) are specialized dockets for defendants with mental illnesses
that seek the adjudication of criminal charges and municipal code violations by using a problem solving
model. Eligible clients voluntarily participate in a judicially supervised course of treatment developed by
a team that includes mental health professionals. Modeled after drug treatment courts, MHCs provide
an alternative to incarceration for mentally ill individuals charged with criminal offenses. The number of
MHCs has expanded since their inception in 1997 to the point that there are now approximately 350
such courts operating in the U.S. .
It is important to note that there is no consensus on what constitutes a mental health court; they are
developed in the context of community need and they function differently based upon the range and
availability of treatment and court resources in that community and service catchment area [88-90]. As
such, the following descriptions of populations served, court structures and resources should be viewed
as guidelines and generalizations about their effectiveness should be approached with caution.
Population and eligibility
Mental health courts typically target individuals with SMI [91-93]. Co-occurring substance use disorders
are common among this population as well [91, 92, 94]. However, the target populations of MHCs can
vary and are “often shaped by state mental health ‘priority population’ definitions because these
definitions affect the relative availability of treatment services that community providers can offer and
be reimbursed for by the state or federal government” . Arraignment for a nonviolent violence is
often a requirement for admittance to a MHC , though involvement of individuals charged with a
violent offense or history of violence may be considered on a case-by-case basis [91, 97]. Mental health
courts may serve individuals with both misdemeanor and felony charges [93, 94]. As in regular court
proceedings, defendants must be competent to proceed and capable of providing consent to voluntarily
participate in the MHC ; though the question of whether the voluntary nature of participation is
always clear to defendants is an ongoing one .
While enrollment in a MHC is presumed to be a voluntary choice, once admitted, the participant’s
adherence to the court-imposed treatment plan is leveraged through the threat of sanctions and the
possibility of reinstatement to standard criminal justice processing for the criminal charges that initially
brought the individual to the attention of law enforcement. The extent to which such mechanisms of a
MHC are perceived to be coercive can depend upon 1) the transparency of the defendant’s consent and
enrollment process, 2) the ability of the defendant to withdraw from the MHC and to refuse treatment
without additional penalties and 3) the defendant’s experience of procedural justice within the MHC.
Regarding the first point, mental health advocates  recommend that an individual’s decision to
participate in a MHC should involve the same level of choice as that of a criminal plea; that terms of
participation should be discussed and documented and the decision to participate should not be made
until after advisement from competent legal counsel has been offered. Making explicit to defendants
that they have a choice to participate in MHC can significantly reduce feelings of coercion among MHC
participants . Similarly, an individual’s choice to refuse a particular treatment or to withdrawal from
a MHC should not engender undue duress. Advocates have recommended that MHCs establish a
process for the review of treatment refusals by MHC participants “so that any decision to reinstate
charges is made in an informed manner after all reasonable alternatives have been exhausted” .
It has also been suggested that feelings of coercion can be minimized when the use of rewards and
sanctions to promote treatment adherence occurs in the context of a therapeutic relationship . In
MHCs, the relationship of focus tends to be the one between the judge and the MHC participant and the
quality of this relationship often involves the participant’s sense of procedural justice . Indeed,
procedural justice, or participants’ perceived fairness of legal procedures , can have substantial
impact on his/her satisfaction and compliance with MHC [99, 101]. As such, communication with MHC
participants that imparts knowledge of court procedures and that promotes involvement of clients in
determining sanctions and rewards can minimize feelings of coercion, increase perceived procedural
justice and improve MHC outcomes [99, 101, 103].
Mental health courts provide a post-booking alternative to the incarceration of mentally ill individuals
charged with criminal offenses. Offenders may enter mental health courts prior to pleading to their
charge(s) or may enter the MHC post-arraignment or post-adjudication . Some MHCs require
participants to plead guilty to their charged offense(s) in order to participate, with record expungement
upon graduation. Other MHCs may not require a guilty plea, will dismiss or reduce charges upon
graduation and will pursue charges for those that are unsuccessful in the MHC structure. It should be
noted that some critics view the requirement of a guilty plea as precluding the earliest possible criminal
justice diversion and as contributing to the further criminalization of this population .
Although these courts may differ somewhat in structure, objectives, and function by jurisdiction ,
the essential elements of MHCs include: multidisciplinary planning and administration, clear terms of
participation and informed choice to participate, confidentiality safeguards and, among others,
increasing participants’ access to evidence-based treatments and services as well as monitoring of
participants’ adherence to court conditions and incentives for adherence [105, 106]. In a survey of 90
MHCs in 2005, the median number of active clients being served at the time of the survey was 36 and
the mode was 30 .
The typical MHC team includes the Judge, court administrator/coordinator, treatment providers/case
managers, prosecuting and defense attorneys  and often (in the case of post-adjudication, felony
admitting MHCs ) probation officers . Given the emphasis on non-adversarial court
proceedings, the roles of attorneys appear to be minor during hearings . Attorneys play supportive
and collaborative roles, with the defendant’s success mutually embraced as the MHC goal. The average
length of expected participation in a mental health court program is 12-18 months , with 12 months
most common .
Judge/court. The majority of MHCs surveyed in 2005 had clients return to court either weekly or
monthly in the beginning period of their participation . Participants move through phases that
gradually require less frequent status hearings before the judge . During court, each participant
speaks with the judge and the judge receives updates on whether the participant met mental health
service and court obligations for the week or for the period between court meetings. In one process
evaluation, status hearings averaged 4.1 minutes per client . Conversations between the judge and
defendant tend to focus on treatment-related issues . Praise is offered for those who have met
obligations and encouragement for those struggling to get theirs met. Praise is offered more often than
sanctions . However, a variety of sanctions may be meted out for noncompliance, in graduated
fashion ranging from adjustments to treatment plans to written assignments to community service to
more frequent status hearings to jail time . Research suggests that the judge is instrumental in
promoting procedural justice (i.e., a sense of fairness in the application of rewards and sanctions) among
court clients, in part, through the use of transparent and collaborative decision-making with clients and
treatment providers .
Treatment and support services. Case managers are responsible for evaluating eligible defendants,
developing treatment plans and linking clients with necessary community support services including
mental health treatment services. As mentioned above, those courts that utilize a post-adjudication
model and that admit felony and/or violent offenders, may also incorporate probation officers into
supervision and support services . In a systematic review of MHC effectiveness studies, Cross found
that services provided though the MHCs varied but often included clinical counseling, case management,
substance abuse treatment, money management education, employment counseling, entitlement
program assistance, and self-help and support groups . The availability and quality of mental health
and supportive services, or lack thereof, have been identified as limiting factors in the effectiveness of
the MHC model [92, 110].
Quasi-experimental evidence of effectiveness
As mentioned above, quasi-experimental designs lack the randomization of study participants to
treatment (e.g., MHC) and control groups (e.g., traditional court processing) that equalizes the
characteristics of participants in the two groups and facilitates causal attribution of observed outcomes
to the intervention (i.e., MHC). Some designs will use statistical methods that attempt to equalize the
experimental and comparison groups (e.g., propensity score matching), while others will simply assign
those that opt out of the intervention (or who are wait-listed) to the comparison group. In either case,
there remain differences between participants in the experimental and comparison groups that can
explain differential outcomes between the two groups (e.g., MHC participants could be more motivated
to treatment). With this in mind, the results of several quasiexperimental studies are summarized
Research utilizing matched sample comparisons found that participants in MHCs displayed a lower
overall rate of recidivism (10% vs. 28% within 12 months following the index offense that led them to
court) and longer time to rearrest (11.3 vs. 9.6 months) for a new charge . Similarly, compared to a
matched sample of individuals diagnosed with a mental disorder receiving usual processing through the
San Francisco jail, MHC participants experienced a longer time without incurring any new criminal
charges or new charges for violent crimes . However, using a matched sample of misdemeanor
court defendants with mental illnesses, Christy and colleagues  found no significant differences
between the two groups in percentage rearrested or in time to rearrest in the 1 year study period. The
authors suggest this non-effect was due to a lack of additional funding for the local mental health
system to support the expanded demand that resulted from the newly developed MHC .
Using a nonequivalent comparison group design Moore and Hiday  found MHC participants,
compared to traditional court participants with mental illnesses, had fewer arrests and were arrested
for less severe crimes during the twelve months following entry into either the mental health or
traditional court. In a multi-site study evaluating four MHCs with a nonequivalent comparison group of
subjects who were eligible for the MHC but were never referred to it or were never rejected from the
MHC, Steadman and colleagues  observed MHC participants to be significantly less likely to be
rearrested than comparison group participants in the 18 months following enrollment (MHC) and jail
admission (comparison group).
Using non-equivalent comparison groups, Frailing  found MHC participants had reduced jail days,
decreased hospitalizations and decreased positive drug and alcohol tests while Boothroyd and
colleagues found increased utilization of mental health services  compared to non-MHC participants.
Similarly, comparing MHC opt-in participants to a nonequivalent group of opt-out referrals in two
Washington state MHCs, Trupin and Richards  found a medium effect of MHC participation on both
decreased bookings and decreased annualized jail days. Using non-equivalent samples, other
researchers [116, 117] have found relative reductions in the incidence of arrest among mental health
court participants. Indeed, aside from a recent study by Campbell et al., which found mental health
court completers had a similar rate of new charges to comparisons not enrolled in mental health court
, the quasiexperimental evidence has generally shown a positive relationship between MHC
participation and criminal justice and clinical outcomes.
Experimental evidence of effectiveness
In one of the only two experimental studies of a mental health court, Cosden and colleagues  found
that participants in mental health court had similar gains to participants receiving traditional court
processing in measures reflecting life satisfaction and alcohol use. In addition, a similar proportion of
clients in each condition had been booked at least once and spent some time in jail. However, MHC
participants showed greater improvements in level of distress, independent functioning, and drug use
over time. And a lower percentage of MHC participants, than traditional court participants, were
convicted of a new crime. There was also evidence that study participants processed in traditional
courts were convicted of more serious charges than those MHC participants who received a conviction.
It should be noted that MHC participants were supported by an assertive community treatment (ACT)
team during their court tenure which included the 6- and 12-month follow up data collection points
summarized here. ACT is a highly intensive treatment model involving a multidisciplinary team of
professionals supporting people with SMI/SPMI in the community.
In another experimental study conducted in Butte County, CA, mentally ill adults who committed a
qualifying offense (nonviolent, not a serious felony) were randomly assigned to either enhanced
treatment, which had as its centerpiece a MHC, or to the community’s usual standard of care .
Within a six-month follow-up period, 22.2% of MHC participants compared to 46.2% of non-MHC
participants were booked into jail at least once. On average, MHC participants also spent five fewer days
in jail. Due to the small sample (18 MHC and 26 non-MHC), statistical significance tests were not
conducted. A larger sample was available for testing clinical outcomes. The researchers found
statistically significant improvements over the control group in each of the standardized measurements
of client functioning and symptomatology .
Systematic reviews and meta-analysis of effectiveness
In a meta-analytic review of 18 studies published prior to 2009 and that contained quantifiable
recidivism data on MHC participants in the United States, Sarteschi and colleagues  found a
significant effect of MHC participation on recidivism reduction (with a moderate effect size; g = -.54).
Sarteschi et al. found too much heterogeneity in mental health outcomes to allow for pooling of study
results; likely reflecting the variability of mental health services availability at study sites .
A meta-analysis conducted by Cross  reviewed 20 experimental or quasi-experimental studies
published between 1997 and 2011 that reported at least one quantifiable indicator of recidivism or a
clinical outcome for adult MHC participants in the U.S.. This review differed from Sarteschi’s in that it
excluded pre-experimental studies and multiple studies using the same sample (in the case of the latter,
the most recent study was included). Mental health courts were found to have a significant but small
effect (d = 0.32) on reducing recidivism and a nonsignificant effect on clinical outcomes. Effect sizes for
recidivism outcomes did not differ based upon an indicator of the methodological quality of the study,
whether the study was published or not, or whether the study experienced greater than 10% attrition of
study participants. However, studies that used comparison groups comprised of individuals who had
opted-out of the MHC, had higher effect sizes than studies which utilized matched sample comparisons
receiving treatment as usual; the latter being a more rigorous design feature than the former.
The Washington State Institute for Public Policy  analyzed studies of MHC outcomes that utilized
experimental or quasiexperimental designs. They did not include in their meta-analysis studies that had
only MHC completers in their treatment group (i.e., they included only studies that utilized outcomes for
all individuals originally enrolled in the treatment condition). The six studies had a small but significant
pooled effect in favor of MHC on recidivism (ES = -.22). The focus of this meta-analysis however, was on
cost-savings to be gained through MHCs. Their results indicate a benefit-to-cost ratio of 6.96. That is, for
every dollar spent on MHCs, tax payers and others (e.g., those not victimized by crime) reap nearly
seven dollars in savings .
Factors related to outcomes among mental health court participants
Completion. Gender has not been found to influence MHC completion [117, 121-125]. Prior criminal
behaviors (particularly a felony versus a non-felony ) and failure to appear, drug use and
noncompliance with the conditions of the court positively predict noncompletion of a MHC program
[116, 122, 123] as has residential instability . Mixed findings have been observed with older age;
having been found associated with completion  as well as found not associated with completion
Recidivism. The factor most commonly observed to determine recidivism of MHC participants is
graduation status, with MHC graduates much less likely to reoffend compared with nongraduates [92,
112-114, 117, 121, 122, 126]. The number of prior arrests has also been shown to be positively related
to number of arrests and jail days during follow-up , so that individuals who have a greater history
of arrests are more likely to have a greater number of arrests and jail days during the follow up period.
Research has also found “perceptions of ‘negative pressures,’ a component of coercion, were important
predictors of criminal justice involvement in the 12 month period following MHC admission, even when
controlling for other factors that were related to criminal justice outcomes” . In one study, MHC
defendants charged with a misdemeanor had a significantly higher occurrence of rearrest, relative to
those charged with a felony, but those charged with violent and nonviolent offenses did not differ on
any recidivism outcomes . Gender has not been found to be associated with rearrest outcomes
among MHC participants [113, 117, 121, 126].
Summary of the Research
The paucity of experimental research with MHCs precludes its status as an evidence-based practice .
However, the mounting evidence of the efficacy of these courts in reducing re-arrest and days in jail is
promising. The table (Recidivism Rates of Mental Health Court Participants) on the next page
summarizes the (pre-experimental and quasi-experimental) research that provides findings related to
recidivism rates of mental health court participants. For example, in the first row, Steadman and
colleagues (2010) observed that 49% of MHC participants were rearrested within 18 months of their
entry into the MHC program. Recent research has indicated that reductions in costs associated with
justice system processing may not be offset by the increased behavioral services costs associated with
participation in a mental health court .
Site visits to two jurisdictions were made during the period when this consultation was delivered and
this literature review was underway. Each jurisdiction differed in its approach to building its MHC and
also in its length of experience. Both jurisdictions boast good MHC outcomes, but details about these
outcomes and the methodologies used to determine them were not forthcoming. In both cases,
however, the real numbers of persons served (relative to the county population and the jail average
daily population) suggests that significant positive impacts on jail inmate population reductions, if any,
would be difficult to substantiate.
Bexar County, Texas Mental Health Court
Initiated in 2008, the Bexar County MHC is described as:
A voluntary 12 month program of supervised probation. Persons accepted into the program will
receive treatment and medications, intensive case management services and supervision based
on their treatment and supervision plan. There is ongoing collaboration among the Judge,
Mental Health Court staff, probation and treatment providers to monitor and support
defendants’ compliance with treatment and medications, abstinence from drugs and alcohol
and successful completion of probation conditions (see: ).
Mental health court participants, limited to a maximum of 250 at any given time, may have been
arrested on misdemeanor charges, with acceptance into the court of those with violent charges being
made on a case-by-case basis. The MHC team consists of the judge, the prosecuting attorney, a mental
health case manager, and a probation officer. Defense attorneys play minimal roles in the MHC, not
unlike other court models reviewed.
Recidivism Rates of Mental Health Court Participants
Percentage who are …
Steadman, et al., 2010 
18 months post-entry to MHC
Moore & Hiday, 2006 
12 months post-entry to MHC
Hiday & Ray, 2010 
Completed program = 28%
Ejected from program = 81%
2 years of exiting a MHC
Cosden, et al., 2003 
76% booked at least once
and spent some time in jail
12 months post-enrollment
Christy, et al., 2005 
12 months following the initial court
appearance from which they were
recruited into the study
Dirks-Linhorst & Linhorst, 2012 
positive terminators = 14.5%;
chose not to participate = 25.8%;
negative terminators = 38.0%
12 months of discharge from the
Law & Policy Associates, 2013 
Completers in-program = 42.4%;
Completers 2-yrs post-program = 24.2%
Non-completers in-program = 100%;
Completers 2-yrs post-program = 95%
Bess Associates, 2004 
6 months after point-of-exit
Herinckx, et al., 2005 
12 months postenrollment
Comartin, et al., 2015 
12 months following MHC discharge
Anestis & Carbonell, 2014 
12 months after the index offense
McNiel & Binder, 2007 
Probability of any new charge at:
6 months = .23
12 months = .34
18 months = .42
24 months = .46
While the MHC is seen as part of the larger Bexar County system of mental health resources, it is unclear
how responsive these resources are to MHC referrals and how well the involved agencies interface with
each other. A recent initial evaluation of the Bexar County mental health system found that there are
low numbers of persons with mental illnesses diverted into treatment after being booked into the jail;
there are “deficient screening, assessment, and diversion protocols” for these persons; there are high
recidivism rates among people with mental illness, and a “shortage or inadequate use of” behavioral
health services among diverted persons .
Fayette County, Kentucky Mental Health Court
Initiated in 2014 after several years of planning, the Fayette County MHC is truly a “home-grown” effort,
with officials having foregone technical assistance and federal grant funding in order to fashion, build,
and implement their own vision of a properly functioning court. Serving only 15 persons at present,
with little or no expansion in capacity seen in the near-term, the Fayette County MHC Judge reports
using case conferences, weekly (initially) meetings with defendants, and linkages to mental health
services particularly those offered through the National Alliance on Mental Illness, Lexington, which is a
direct provider of many mental health services in Kentucky.
As with Bexar County, the MHC team consists of the judge, the prosecuting attorney, a mental health
case manager, and a probation officer. The input of others may be received, depending on the case.
One person who is regularly involved in these cases is the Fayette County homelessness coordinator
who works to find secure housing when needed, for court participants.
The judge and mental health court staff emphasized the importance of having key thinkers and
supporters at the table when planning and implementing the court. In the Fayette County case, a
specific member of NAMI Lexington pushed for the development of a court, and remained active in the
planning stage to shepherd the system collaborations that would assure that the services needed would
be available to MHC participants. In addition, while there is not a crisis center in Lexington, there are
hospital systems, including one state hospital, located in the area and willing to complete the initial
evaluations on persons brought to them by law enforcement.
While the experimental and quasi-experimental research is limited, particularly given the number of
specialty courts in the United States, there are some promising results from those studies that have
been published. We can say with some confidence that the outcomes of MHCs appear to be equal
across gender lines, that there is some measurable, though perhaps small, reductions in recidivism rates
among those defendants involved in a MHC, at least in the 12 month period following court
There are common and important elements to the structure, composition, and operation of MHCs found
across the country. Each offers defendants a range of rewards and sanctions in order to capture their
attention and shape behavior going forward. There is generally a graduated reduction in the frequency
of status hearings, progressively decreasing the amount of court appearances as the defendant’s
compliance with the court orders strengthens. In every court, the role of the judge in promoting
procedural justice is central to the process: the judge directs both the court process and the defendant’s
case plan. The latter then is facilitated and monitored by the MHC team, which generally includes the
prosecutor, a case manager, and a probation officer.
The existing research reports and narratives about MHCs provide cautions about their operations and
their outcomes as well. While the development of MHCs has been largely subsidized by the federal
government, they are not inexpensive to operate, especially when one considers the average number of
persons that can be followed by the court at any given time. Perhaps the best philosophical approach
when considering the development of a MHC is to consider the benefits of it in support of maintaining
and promoting the dignity and health of the consumer, leaving the goals of jail population reductions
and cost reductions out of the equation.
Further, jurisdictions with MHCs report that, similar to the experience of CIT programs, without a range
of community resources to which defendants can be referred and treated, the MHC will have little
impact. The judge must have the resources with which a treatment plan can be devised. The research
points especially to the need for ACT services, i.e., intensive, multi-disciplinary mental health teams that
carry small caseloads and provide ongoing, often daily services to consumers. There are currently no
ACT services in operation in Douglas County.
While recidivism rates among defendants involved in a MHC appear to be lower than those among non-
MHC participants, these reductions will not necessarily yield reductions in total jail populations. In many
ways, recidivism rates among one group have nothing to do with arrest rates of another group of
persons with similar characteristics. Thus, when thinking about designing a system that will address the
challenges that come with managing persons with SMIs and co-occurring disorders and reducing jail
populations, MHCs should be seen as one of several strategies that must be simultaneously in operation.
It calls for a tripartite approach: Well-staffed courts, community resources, and smart arrest and
diversion policies and procedures.
The literature reviewed for this report, the fact-finding activities undertaken, including data gathering
and review, and the site visits completed over the last six months, point to several important
components of diversion processes that we believe are fundamental to the effective operation of a crisis
center or mental health court and that could assist jail diversion efforts for people with serious mental
illness who become justice-involved in Douglas County.
The crisis center should belong to the community; that is, not solely used for jail diversion by law
enforcement (e.g., CIT). The crisis center should be open to individuals seeking assistance with
behavioral health needs for themselves and for their friends and family members. This open door
policy will encourage widespread support for its development and continued services. The open
door policy also has the potential to divert non-justice involved persons from becoming involved in
the justice system because of their mental conditions.
When the safety of staff and the individual in crisis can be managed, the crisis center should
maintain a “no refusal” policy that maximizes the potential for individuals with behavioral health
needs to access and engage with needed services. Risk of violent behavior should be assessed on
the basis of knowledge of the person’s history of violence and on the viability of a person’s threats
of violence. Personal safety, while never a guarantee, can be optimized via quick handoffs by law
enforcement (who may be the trigger for aggressions) and the presence of capable behavioral
health personnel trained in verbal de-escalation techniques.
The crisis center should have policies in place for law enforcement referrals (e.g., CIT) that expedite
handoff to the crisis center staff and officers’ return to duty. No refusal and quick handoff policies
will reduce the likelihood that law enforcement officers will be deterred from bringing an individual
to the crisis center (due to beliefs that the person in custody will not be accepted for evaluation by
the center or that transfers at the center will take longer than at the jail).
The mental health crisis observation unit should be staffed by qualified mental health professionals
who can provide 24-hour services, including clinical assessments, treatment (including trauma-
informed care) and observation. For those determined to be in need of longer-term stabilization
(e.g., 5 – 10 days), an appropriate number of short-term stabilization beds should be provided. The
number of beds dedicated to stabilization should be determined by a structured community needs
In addition to mental health treatment and referral, the design and implementation of the crisis
center should include the space and personnel to accommodate both males and females
experiencing a crisis and provide sobering and addiction treatment services. Consultation with local
addiction treatment providers is essential to cull their knowledge on the appropriateness and
magnitude of these services when offered within a local crisis center. Visits to neighboring crisis
centers suggest that the inclusion of a sobering unit that provides brief stays (up to 10 hours) is a
minimal requirement for inclusion in the crisis center.
The crisis center should provide linkages to community services. Upon completion of their stay,
individuals should be linked to appropriate services including stabilization beds, inpatient psychiatric
services, detoxification facilities, co-occurring substance abuse treatment, long term/residential
addictions treatment or other community-based services that target behavioral health and
Ongoing evaluation of the effectiveness of the crisis center at meeting its objectives (e.g., reduced
jail stays, reduced hospitalizations, increased treatment access and engagement) is essential. There
are no known rigorous national studies that follow people referred to crisis centers to identify their
outcomes. It cannot be assumed that the development of a crisis center that provides the above-
identified services will produce deisred outcomes. Regular assessment of outcomes and subsequent
service modifications and enhancements will be necessary to effectively incorporate the crisis
center within the existing community mental health service system.
Mental Health/Problem-Solving Court
Extensive development work remains before a mental health (or other problem-solving) court can
be implemented in Douglas County. Continued planning activities should be conducted with
municipal and district court staff and officials to identify non-duplicative, court-based diversion
efforts that can most efficiently reach those individuals identified as being potentially eligible for a
mental health court, as outlined by the recent report submitted by Huskey and Associates.
While in the pages of this literature review we identify common elements of mental health courts,
these are truly flexible and dynamic entities, that is, the city of Lawrence and Douglas County have
the freedom to design one or more mental health courts in ways thought most likely to satisfy
clearly articulated objectives. Evaluative feedback mechanisms should be simultaneously
implemented with the court(s) so that modifications, if implicated, can be made quickly and with
The Huskey report identifies potential eligibility criteria for a mental health court as well as length of
stay in the program. However, screening, referral and admission mechanisms to the court-based
program will need to be developed. Criteria for progression through and graduation from the
mental health court program as well as mechanisms for transfer to appropriate community based
services still need to be established.
Recruitment to and enrollment in the mental health court should minimize the potential for
coercion. An individual’s decision to participate in a mental health court should be informed and
should only be provided after advice from competent legal counsel has been offered. Participants’
decision to withdraw from the mental health court or to refuse treatment should not encumber
additional penalties. Transparent and collaborative decision-making with clients and treatment
providers should occur throughout an individual’s participation in the court.
Quality mental health and supportive services must be integrated into the mental health court
program. These services, at the very least, must include ongoing clinical assessment, clinical
counseling, psychopharmacology where indicated, case management, and substance abuse
treatment and should also include programs targeting criminogenic needs, housing assistance,
money management education, employment counseling, entitlement program assistance, and self-
help and support groups. Given the need to alleviate female overcrowding at DCCF (as well as the
higher rates of SMI among female inmates), it is likely that many women will be identified as eligible
for MHC. Therefore, MHC services should be able to address the histories of trauma that are
common among this population. Intensive and integrated supportive services that can address the
complex needs of the population typically seen in a mental health court are recommended (i.e.,
assertive community treatment or other intensive, community based wraparound services).
As with crisis centers, ongoing evaluation will be indispensible for assessing the effectiveness of the
mental heath court program at achieving progam objectives and for informing enhancements to the
program that can improve outcomes.
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