Deciding to Participate in Mental Health Court: Exploring Participant Perspectives

Abstract

As the number of mental health courts (MHC) expands across the United States, so does the body of research demonstrating its effectiveness in reducing criminal recidivism. While there has been considerable research conducted on MHC operations, less is known about how individuals decide to participate in MHCs. Data from in-depth interviews with 26 MHC participants from two MHCs in the United States were analyzed using grounded dimensional and thematic analyses. Results suggest that individuals participated in MHC to avoid incarceration and obtain treatment. Participants understood the court to function in four distinct ways: 1) to help through service provision, 2) to structure a judicial agreement allowing MHCs to make treatment decisions in exchange for community living, 3) to protect people from risks within the criminal justice system, and 4) to reward participants for treatment adherence. Findings can be used to guide the need for policy and practice for those referring to MHCs.

1.1. Introduction

There are an estimated 350 adult mental health courts (MHCs) operating across the United States (GAINS Center, 2017). These specialized problem-solving or therapeutic criminal court dockets began in the 1990s, offering a court-based diversionary response intended to reduce the over-representation of people with serious mental illnesses entering and continuously cycling through the criminal justice system. Implementation of MHCs also aimed to increase public safety, improve quality of life and access to treatment for people with serious mental illnesses involved in the legal system, and reduce corrections- and court-related costs (Almquist & Dodd, 2009). Initially, MHCs primarily targeted people who committed low-level and quality of life offenses (e.g., panhandling, trespassing, shoplifting), but courts are now shifting their focus to assisting people with felony offenses (Trawver & Rhoades, 2013).

While MHCs may vary based on local needs and available resources, they share common goals and a set of core essential elements across programs (Thompson, Osher, & Tomasini-Joshi, 2007). Core MHC elements include a specialized criminal court docket staffed by a legal, behavioral health, and probation team that offers participants coordinated access to community-based treatment and other social services in lieu of traditional legal sanctions (e.g., prison time, restitution, community service). Regular monitoring and court status hearings provide MHC participants with close supervision, support, and encouragement, as well as the ability for the team to quickly identify individual issues and engage in problem-solving. The court team employs the use of graduated incentives (e.g., applause, less frequent court appearances, gift cards) and sanctions (e.g., short stays in jail, community service, program termination) for adherence or non-adherence to court ordered conditions. Generally, MHCs offer participants an incentive of a better legal outcome for program completion, such as a reduced sentence or case dismissal. Despite these core elements, however, there is significant variation in MHC procedures and policy, program length of time, acceptance criteria, treatment planning, and treatment options (Canada, Barrenger, & Ray, 2019).

There is mounting evidence that MHCs are meeting their goals and can safely divert people with mental illnesses from serving time in prison. A meta-analysis of MHC studies concludes participation can reduce criminal recidivism during and following mental health court although effect sizes for recidivism is considered small (Lowder, Rade, & Desmarais, 2018; Sarteschi, Vaughn, & Kim, 2011). One limitation to this body of literature is the relatively large black box that precedes MHC participation. That is, there are multiple decision points about who is eligible for MHC, who is selected to participate, and who decides to take part in the program.

In order to fully understand MHC effectiveness and to extend the MHC literature, a critical next step involves examining decision points leading to MHC participation to better understand this small pool of participants served by MHC and whether or not biases interfere with decisions of who is selected and referred, and ultimately who opts into MHC. The current project aims to generate new knowledge about decisions to participate in the MHC and what factors may play an important role in participant decision making. Results gained from this work aid in understanding the complex factors that intersect with MHC admission and questions the need for targeted policy to address bias in the referral and selection process.

2.1. Background & Significance

The body of work examining MHCs is expanding. The majority of what is known about MHCs involves the impact of this intervention on criminal recidivism for people who are referred, accepted, and opt-in to MHC. Much less is known about the processes that occur prior to MHC acceptance. That is, little is known about the factors that influence people when referring to MHC (i.e., when to make a referral; deciding who should be referred), the formal and informal processes MHCs use to find a person eligible for MHC (i.e., the actual decision-making process), and reasons why a person chooses to take part in an MHC or not. Figure one outlines these multiple decision points that filter potential participants away from MHCs, leaving the pool of people who are actually served by MHCs to be a fraction of the total population. Understanding each of these decision points is essential in order to accurately examine MHC effectiveness and to explore the potential biases toward who is served by MHCs.

Figure 1 identifies the path toward MHC involvement. This pathway begins with a population (i.e., people with mental illnesses who are eligible for MHC) and ends with a subsample of people from this population who are accepted and opt-in to MHC. There are multiple decision points located along this path which impacts who will ultimately have access to MHCs. The boxes are shaded to depict the degree of knowledge we have in each of these areas with black boxes indicating a void in knowledge and white boxes indicating, at a minimum, a preliminary understanding. The first box in Figure 1 represents the population of people with mental illnesses who are involved in the legal system. An extensive body of research supports that this population is overrepresented in the legal system compared to community samples (e.g., Bronson & Berzofsky, 2017; Fazel, Hayes, Bartellas, Clerici, & Trestman, 2016), tend to fare worse when incarcerated (Human Rights Watch, 2003), and has a disproportionate risk of criminal recidivism when released (Skeem, Emke-Francis, & Louden, 2006). The first black box in Figure 1 represents the lack of understanding about the role of gatekeepers (i.e., the people who determine whether or not a person should be referred to the MHC team) to MHC participation. The next box represents the decision point in determining whether or not someone is eligible for MHC (i.e., accepted into the MHC). This box is gray because there is some knowledge regarding this decision point but important questions, such as what role does bias play in decision making, remain. The following box is the decision about whether to participate in MHC once accepted. Some participants opt out of MHC participation while others opt in. The final box is MHC participants, representing the literature we have on how MHC works for people who are referred, accepted, and opt-in to the MHC.

Figure 1.

Decision Points & MHC Black Boxes of Knowledge

In the following section, the state of the literature for each of the decision points noted in Figure 1 is summarized.

2.2. Determining Who is Referred

In order for a person to take part in an MHC, they must first be referred. Possible referral sources include attorneys, judges, jail staff, community providers, police officers, and family members (Steadman, Redlich, Griffin, Petrila, & Monahan, 2005). Some MHCs allow for self-referrals. In a study on seven MHCs, Steadman and colleagues (2005) identified public defenders as the primary referral source for five out of seven courts. Other studies find specialized police officers and judges to be primary referral sources (Dirks-Linhorst & Linhorst, 2012). The literature on how attorneys and others determine who should be referred to MHC is lacking. Wolff and colleagues (2011) find “support” for the MHC from attorneys and/or the jail staff could impact who is referred, while Luskin (2001) argues referrals will not be accepted without the prosecutor’s agreement. Neither study, however, explores how each of these stakeholders determine who is referred.

Steadman and colleagues (2005) offer one of the few findings surrounding differences between the pool of people referred to MHCs and the broader jail population. Across study sites, they find people referred to MHCs are more likely older White women, which is significantly different from the predominant jail population that includes younger Black men. In a broader study on jail diversion referrals, Naples and colleagues (2007) examined referrals to 21 different jail diversion programs. In comparison to the general population of people arrested, diversion programming referrals were of older age, included more women, and included more non-Hispanic White people. Although Naples and colleagues (2007) did not specifically focus on MHC referrals, findings are informative to potential trends within MHCs. In sum, it is likely that the demographics of MHC referrals vary across sites due to the diversity in communities served by MHCs; however, these differences could also be an indication of bias or racial disparity in deciding who will be referred.

2.3. Acceptance into MHC

Studies on the acceptance rates of referrals to MHCs show variation from court to court. As an example, the seven courts surveyed by Steadman and colleagues (2005) had acceptance rates that varied from 20% to 100% across the seven courts. Although some courts have a formalized approach to assessing potential participants, which may reduce the introduction of bias to the process, other courts are more informal in their assessment (Wolff, Fabrikant, & Belenko, 2011), allowing the team to examine participants on an individualized basis. Wolff and colleagues (2011, p. 3) assert, “Even when found eligible for the court, issues of treatability, motivation, convictability, and support from victims and the defense attorney may independently impact selection and recruitment of clients.”

Recent work conducted by Castellano (2017) explored the micro-politics of MHC referrals and how the team decided on who was accepted. Castellano analyzed cases that were eligible for MHC but ultimately rejected and cases that were not eligible but ultimately accepted and found that teams determine eligibility based on their own internal and external pressures as well as constraints and resources within the community. Three examples of processes utilized by teams included 1) expanding definitions of mental illness or minimizing blame to accept participants who technically fall outside eligibility criteria, 2) enforcing the scope of MHC referral for people who are “too sick or too well,” and 3) retooling problems from treatable to deviant when rejecting an eligible participant (Castellano, 2017). These processes may be more present within teams who utilize informal strategies for decision making; however, it is an empirical question that has yet to be examined and an important area for future research.

Variations in screening procedures or other sources of bias may contribute to differences in who is accepted into an MHC and who is found ineligible. For example, in Indiana, Luskin and Ray (2015) found people without warrants, with diagnoses other than depression, with no recent drug use, and who were more motivated for treatment were more likely to be accepted into the MHC. Frailing (2011) found committing a crime against a person or the community and being male predicted rejection from Washoe County MHC; age, race, and referral source did not predict acceptance or rejection into the court.

2.4. Who Chooses MHC and Why

Once a person is accepted into an MHC, they have the right to choose to participate in the program (i.e., “opt in”) or not (i.e., “opt out”). There is mixed evidence on the percentage of participants who opt out of MHC—one study found around 1% (Steadman et al., 2005) and another found over 50% (Trupin & Richards, 2003) of accepted participants opt out. The decision to participate is likely influenced by a number of factors including attorneys, legal outcomes, and alternative options. The “choice” may be participating in MHC or serving time in prison, which may not feel like a choice. Certain eligible participants may be more or less motivated to participate in MHC because of the legal impacts of MHC completion, which act as incentives or disincentives to participate (Wolff et al., 2011). Wolff and colleagues (2011) concluded that participants who opt in to MHC because of legal incentives of the court (e.g., charges will be dropped or reduced) may be less intrinsically motivated for treatment. Alternatively, MHC participants with misdemeanor charges, for example, who face little to no prison time may be more motivated for treatment since they are under supervision longer than if they chose not to participate.

An important caveat to consider arises from Redlich and colleagues’ (2010a) work on the knowledge MHC participants have about the MHC being a voluntary program. The majority of participants in their study perceived the judge or other legal decision makers to have the final say in whether or not they participate in MHC. Researchers concluded that although there were some indicators that the majority of MHC participants voluntarily opted in to MHC, other indicators signaled that participants may not fully understand their decision and the implications of their decision. Specifically, more than half of participants reported they did not know the MHC was voluntary prior to opting in, were not fully aware of the requirements of MHC, did not know they had the final say in participating, did not know they could quit at any time, and were unable to identify any personal disadvantages to participating in MHC.

2.5. The Intervention: MHC Literature

A large body of literature provides support for MHCs in reducing criminal recidivism among its court participants (Burns, Hiday, & Ray, 2013; Campbell et al., 2015; Comartin et al., 2015; Cosden et al., 2003; Dirks-Linhorst & Linhorst, 2012; Frailing, 2010; Hiday & Ray, 2010; Hiday, Wales, & Ray, 2013; Lim & Day, 2016; Lowder, Desmarais, & Baucom, 2016; McNiel & Binder, 2007; Moore & Hiday, 2006; Ray, 2014; Ray, Kubiak, Comartin, & Tillander, 2015; Sarteschi et al., 2011; Steadman et al., 2011; Trupin & Richards, 2003). Research on MHCs also finds reductions in violence (McNiel & Binder, 2007), reductions in the number of days in psychiatric hospital care (Frailing, 2010), and increases in access to and/or utilization of behavioral healthcare treatment and services (Boothroyd, Poythress, McGaha, & Petrila, 2003; Cosden et al., 2005; Keator, Callahan, Steadman, & Vesselinov, 2013; Luskin, 2013; Redlich et al., 2010b; Trupin & Richards, 2003). Studies consistently demonstrate that participants who stay engaged with the court and graduate from MHC experience the most positive outcomes (Burns et al., 2013; Dirks-Linhorst & Linhorst, 2012; Hiday & Ray, 2010; Hiday et al., 2013; Lowder et al., 2016; McNiel & Binder, 2007; Moore & Hiday, 2006; Ray et al., 2015).

More recent research suggests mixed results for the impact of MHC participation on mental health. MHC participation was associated with a decreasing need for high-intensity behavioral health care services in one study (Comartin et al., 2015), but in another, MHC participation had no effect on the use of crisis or emergency room services (Keator et al., 2013). Results are also mixed when assessing the potential role MHCs play in reducing participant substance use (Cosden et al., 2005; Frailing, 2010; Sarteschi et al., 2011) and improving participant functioning (Cosden et al., 2005; Turpin & Richards, 2003). Studies have yet to find that MHC participation improves participants’ psychiatric symptom severity (Boothroyd, Mercado, Poythress, Christy, & Petrila, 2005; Sarteschi et al., 2011).

Although the body of outcome-related research on MHCs is slowly growing, there is considerably less evidence on MHC participants’ experiences and what impact these experiences have on individual outcomes. Researchers have explored the role of procedural justice during court proceedings and within the exchanges between participants and MHC staff. Participants experience procedural justice when they feel they have been treated with dignity and respect, understand the court process, have a voice in the proceedings, and trust that case decisions are made neutrally (Center for Court Innovation, 2017). Researchers utilized court observations, individual interviews, and administration of standardized measures to assess factors related to MHC and participant-experienced procedural justice. This body of evidence suggests that MHC participants experience low levels of coercion and high levels of procedural justice (Canada & Hiday, 2014; Canada & Watson, 2013; Kopelovich, Yanos, Pratt, & Kowener, 2013; Munetz, Ritter, Teller, & Bonefine, 2013; Poythress, Petrila, McGaha, & Boothroyd, 2002; Ray & Dollar, 2014; Redlich & Han, 2014; Wales, Hiday, & Ray, 2010). Perceiving procedural justice has been positively associated with participants’ views of recovery and feelings of hope and empowerment (Kopelovich et al., 2013), treatment adherence and program retention (Canada & Hiday, 2014), and successful completion of MHC (Redlich & Han, 2014).

Beyond procedural justice, an even smaller body of work explores other MHC participant experiences. For example, Ray and Dollar (2014) found participants perceive low levels of stigmatizing shame from the MHC staff. Norberg (2015) reported MHC participants enhanced their coping skills and felt supported through the MHC process. Finally, Canada and Ray (2016) discussed MHC participants’ experiences of improved psychiatric stability and relationships, sobriety, increased engagement in life, and improvement in mental health that MHC participants believe resulted from MHC involvement.

With the exception of one study by Cosden and colleagues (2003; 2005), MHC research has relied on quasi-experimental designs to examine outcomes in which participants may be matched to a comparable group or evaluated before and after MHC. These research designs are unable to address the multiple layers of bias that are inherent in the selection process of entering MHC. Even when matching court participants to people who were eligible or could be eligible if the county had a MHC, it does not address bias as these comparison groups did not actually enter the MHC—they were not chosen to participate nor did they choose to participate. In order to move the MHC research forward, it is important to understand who ends up in MHC and thus who is represented in the MHC literature. Luskin (2001) provides an example of how many people with mental illnesses are filtered out through the process of MHC acceptance from a project conducted in Marion County. A psychiatric social worker in the county jail determined 1,152 people met criteria for a mental health condition. From that pool, 25% or 299 people were referred to the MHC team for screening. Approximately 14% or 43 people who were referred were eventually accepted into the MHC. That is, 3.5% of the people who have a mental illness in the county jail were accepted into MHC. Understanding how this group differs from the larger population and how people were selected at each decision point is understudied and not well understood in the current body of MHC literature.

The current research project is a first step towards understanding the various decisions that take place prior to MHC involvement. The purpose of this research is to explore one component of the process that precedes MHC involvement by examining how a group of MHC participants from two different MHCs were referred to the court and how they ultimately decided to take part in MHC. The research aimed to answer three questions: How were MHC participants referred to the MHC? Why did they decide to participate (i.e., what factors did they consider)? What conditions, processes, and themes surrounded decisions to participate? Answers to these questions produce a greater understanding of who enters MHC and why. This knowledge is needed to better understand MHC effectiveness, bias in decision making, and disproportional access to and use of MHCs.

3.1. Method

The analysis presented in this manuscript is part of a larger research project on the impact of MHCs from participant perspectives. Research questions in the larger study were answered using a concurrent triangulation mixed-method design, which allows for exploration of a phenomena and testing of relationships between factors (Creswell, Plano Clark, Gutmann, & Hanson, 2003). Research questions specific to this analysis relate to the qualitative portion of the study, which is discussed in detail below. The remainder of this section presents information only on the sub-study. Information on the larger study is presented elsewhere (Canada, 2013).

3.2. Setting

Study participants were recruited from two Midwestern MHCs between September 2010 and October 2011. Both MHCs are well established and included all 10 essential elements as outlined by Thompson, Osher, and Tomasini-Joshi (2007). The two courts differed in the size of the counties they served, charges accepted, and service provision. For example, one court serves a county that incorporates a large metropolis and suburban area, while the other serves a smaller city and rural area. The court that serves the larger metropolis and suburban area accepts felony charges only and contracts with mental health providers from the community for service provision. Case managers are a part of the MHC team. They broker services for MHC participants and provide some direct services as people approach graduation. The court serving a smaller city and rural area accepts both misdemeanor and felony charges. Services are provided directly by a community provider who is also a part of the MHC team. Participants in both courts are in the MHC between 18 and 24 months as long as there are no additional charges or multiple violations. Both courts include pre- and post-adjudication cases. Eligible participants for both MHCs include adults with a primary mental illness diagnosis, no charges involving sexual misconduct, and victim approval of diversion, if applicable. Many participants also have co-occurring substance use disorders and most lived below the state poverty line.

Both courts were also relatively similar in the frequency of engagement with participants and the requirements around service utilization. Participants were required to meet with the judge once per week for the majority of the first six to eight months in the MHC. In addition, participants met with probation and treatment providers weekly at both MHCs. Service engagement was required as soon as participants entered the MHC. Services were readily available for participants in both settings; however, in the larger metropolis, some participants did have wait times before they were admitted into inpatient or residential treatment services. Required treatment varied by participants rather than the court location. The treatment providers ultimately developed a treatment plan for court participants but other MHC team members were able to request or suggest services as they saw a need arise.

3.3. Sampling

Eligible participants for this study were legally competent adults (18 years or older) who were MHC participants, not currently in custody, and willing to participate in the study. Participants were recruited between their 2nd and 18th month in the MHC. This range was selected because of the research aims of the larger study. Two months appeared to be a conservative estimate in order for potential study participants to be linked and involved with treatment and have a baseline understanding of the MHC. All MHC participants who met eligibility criteria were invited to participate in the larger study. Ninety-three participants were invited and 80 participants completed the consent process (40 from each of the 2 courts). The 13 eligible participants who did not participate were not consented for the following reasons: researcher phone calls to set up an interview were not returned (n = 5), phone numbers left on researcher voicemail did not work (n = 5), incarcerated throughout the entire study period (n = 2), and participant was too delusional to consent (n = 1).

For purposes of the analysis presented in this manuscript, a subsample of 35 consenting participants was recruited from the original pool (n = 80) using maximum variation purposive sampling. Maximum variation purposive sampling occurs when the researcher selects cases strategically to provide depth into the phenomenon under study; the cases selected were meant to include study participants with a range of experiences who were most able to engage in a dialogue regarding their experiences with the MHC (Kemper, Stringfield, & Teddlie, 2003). The subsample was selected based on court (i.e., the sample includes participants from both courts), sex, criminal history, mental illness diagnosis, and substance use severity, as some of these factors have impacted recidivism and program engagement in previous studies (Bonta, Law, & Hanson, 1998; Hartwell, 2004). The intent of the sampling strategy was to end with a sample of participants with varying criminal, substance use, and mental illness severity and to include both men and women from both courts under study.

Participants were invited via phone to participate in a second interview. Of the 35 individuals sampled, 26 consented to participate. The nine people who declined participation did not show up to the scheduled interview (n = 2), did not return the researcher’s phone call when being invited (n = 6), and did not have a working phone number (n = 1). The final sample of 26 participants includes an even split between the two courts.

As a result of the sampling strategy, the sample of 26 participants represents a wide range of MHC participants. This sample does not demographically reflect the larger population of MHC participants from these two courts but rather includes variation to explore diverse perspectives. Table one outlines demographic and background variables describing the sample.

3.4. Procedures

Participants completed a single face-to-face interview with the first author in locations convenient for the participants (e.g., local coffee shops, the public library). Audio-recorded interviews lasted between 60 and 90 minutes. A protocol of questions guided the interview, but interviews were intended to be conversational. Questions focused on gaining an understanding of participants’ expectations of the MHC, how they got involved in it, and why they wanted to participate. Some of the questions prompted participants to think back to when they made the decision to participate and discuss what led to their decision. There are limitations to this strategy. However, during interviews, researchers used strategies to help with recall. These strategies include discussing events that led up to participation in MHC, helping them think through the timeline of events using a paper calendar, and talking through the specific events that occurred after their arrest that was associated with MHC participation. Participants were compensated $25 in cash in exchange for their time. All procedures were approved by the University Institutional Review Board.

3.5. Analysis

Interviews were transcribed verbatim and proof-read prior to analysis. A combination of analytic tools were utilized, including Schatzman’s (1991) grounded dimensional approach to analysis and thematic analysis as outlined by Braun and Clarke (2006). Grounded dimensional analysis is a variation of grounded theory and allows the researcher to utilize an overarching, interactionist framework to guide the analysis and uncover meaning. A model outlined by Kools and colleagues (1996) was followed, which identifies the context (i.e., studying MHC participants who are already participating in the MHC), conditions (i.e., factors that impact decisions to participate in MHC), processes (i.e., what led to or influenced decision making), and consequences (i.e., the decision to participate) of the phenomenon under examination. In using this approach, codes are generated inductively by reading each line of the transcript several times through to better understand MHC participants’ decisions to participate. The grounded dimensional analysis was first utilized to identify the conditions and processes surrounding decisions to participate and then thematic analysis was utilized to explore and better understand conditions and processes. Thematic analysis is used to identify, organize, interpret, and present patterns or themes within data (Braun & Clarke, 2006). In this study, data were considered a theme when there was a clear pattern across participants. Data were deconstructed into components through coding using both open coding and the overarching framework and eventually grouped together based on thematic similarities. Once chunks of data were grouped, they were compared, contrasted, and synthesized. The conclusions presented below were conceptualized in an iterative fashion by defining themes, challenging themes based on existing theory and research, comparing themes across participants and courts, and challenging results with alternative explanations until themes were clearly conceptualized, defined, and distinctive from one another. Because this work is exploratory, any theme that occurred across participants, regardless of size (i.e., how many participants referenced it), was included as a result. The analysis was organized using NVivo software, version 11.

4.1. Results

Outlined below are the experiences of how current MHC participants entered the program, including who referred them to the MHC, how the MHC was introduced to them, and why they decided to participate. Decisions to participate in MHC likely vary across people and may be influenced by several factors. The results presented below are based on the experiences of participants in the two MHCs in this study. The results include a description of the conditions under which MHC participants learned about the MHC and the processes and themes surrounding their decisions to participate. Each of the conditions, processes, and themes that emerged within and across interviews are explained below. The researchers’ interpretation of the data is discussed alongside study participants’ direct quotes and key literature offering insights into the study findings.

4.2. Referral to MHC

Most participants were introduced to the MHC through their public defenders. This information was provided by participants and not cross-validated with court data so it is possible that participants were not actually served by a public defender. However, the counties that housed the two MHCs in this study do have public defender programs for people who are indigent. One participant in the current study reported having a private attorney who she said advocated for her to “get help” rather than be incarcerated. Another participant recalled “He [public defender] could look at me and tell something was the matter with me…He was a smart lawyer and he helped me out…He knew my problem.” Participants remembered public defenders describing the MHC as a way to get treatment, including a therapist once a week and a psychiatrist once a month, a program that “would be more better for me” than jail and “just a thing to turn my life around.” Some public defenders first referred participants to the drug court but upon referral and review were found ineligible due to either being on psychiatric medications or having a history of using psychiatric medications. The drug court judges subsequently referred these participants to the MHC.

Other participants recalled that a judge in a traditional court advocated for participation in the MHC. One participant reported the judge suggested he get treatment because “he’s sent me to jail and prison many times, and he felt that it was, due to the charge being so petty, you know, he figured, ‘Well, let’s get him treatment’.” Multiple participants recalled the judges in a traditional court asking if they would like to receive treatment for a drug addiction and mental illness. One participant reported the judge said, “Well you can either accept this help or you can try to fight this case but I guarantee you’re going to go to the penitentiary if you do.” Several participants were referred to the MHC through mental health workers in the jail or probation officers. Participants recalled that jail-based mental health workers described the MHC to them as a court program that is run through a community treatment center, a way to avoid going to prison, and a way to receive treatment.

Some participants’ family members played a key role in their referral to MHC. Family members including parents and adult children spoke to public defenders shortly after the arrest to offer information about problems with the participants’ mental health. One participant recalled family members notifying the public defender that he was prescribed psychiatric medication and committed the current crime due to non-adherence with treatment. In these cases, the public defender referred participants to the court but these referrals may have been prompted by family members’ advocacy.

In this study, public defenders and judges for many participants enacted the first tier of gatekeeping by making a decision to refer participants to the MHC. Most participants in the current study reported they were referred through a public defender, a profession that does not typically receive training on recognizing mental illness symptoms. Professionals without clinical training are thus making decisions regarding who needs the intensive treatment offered through MHCs and who should not be offered this alternative to traditional retribution. To date, research does not fully explore what prompts judges and lawyers to make referrals to MHC, including the kinds of information used to determine if a person should be referred or not. It is not clear if referrals are based on externalizing symptoms as participants in this study discussed (e.g., “He could look at me and tell something was the matter with me”) or if other factors are more important (e.g., family members’ reports; community risk) in making these determinations.

4.3. Introduction to MHC

About half of participants discussed how MHC was introduced to them. Three patterns were identified: “rehab court,” “a second chance,” and a “get out of jail free card.” Participants were not explicitly asked to provide this information; rather, participants were asked to discuss their experiences as they entered the MHC. Most participants who discussed their introduction to MHC recalled it was described as “rehab court.” For example, it was portrayed as “…a program that addresses both of your needs, your health issues which addiction is a health problem too and then along with it, it addresses your mental illness” and “…it gives people a chance to rehabilitate themselves and teach them responsibility.” Rehab court, for participants, meant an intervention that provides assistance and treatment for both mental health and substance use needs. Participants also identified rehab court to mean obtaining services that they would not get while incarcerated. Participants believed the MHC would teach them responsibility.

Rehabilitation, to some participants, also meant learning how to participate in society and gain independence through self-care. As such, MHC was perceived as a means for some people to gain access to services needed to address mental health and problems with substance use. The interventions that MHCs provide, from participants’ perspectives, were services to address their psychological problems; participants did not discuss the perception that MHCs could address issues related to social disadvantage (i.e., poverty, living in high crime neighborhoods, stabilizing housing) or criminogenic needs.

A smaller portion of participants talked about MHCs being described as “a second chance, a third, even fourth, fifth, sixth, seventh” chance for people with mental illness. A second chance to these participants meant they were being given an opportunity to stay out of prison because the court sees them as someone who needs help rather than punishment. Viewing the MHC as an opportunity elicited feelings of gratitude among participants who perceived it this way, which could shape their experiences as they progress through the program. One study participant recalled receiving multiple messages about MHC including that it was an opportunity to receive treatment (i.e., “rehab court) and a second chance.

A few participants recalled being told the MHC was a “get of out jail free card.” These participants understood the MHC to be just “like jail” but people are living “without bars” and “wearin’ clothes.” Participants reported the MHC required compliance to treatment and probation while they lived in the community. These participants reported that they were told the program would be intense and would require participation in treatment and court monitoring. One participant recalled he was told “[case managers] would tell me where to live, that I would be reporting regularly for drops, that I would be reporting regularly to the judge…to see how I was doing.” Another study participant said MHC required “…stay[ing] clean, comin’ to court when you’re told, meet your probation officer when you’re told and any other appointments.”

In sum, understanding how MHC is portrayed to potential participants and the impact that has on decisions to participate in MHC was not the central aim of this work. However, in half of participant interviews, this initial introduction to MHC was a factor they perceived to be part of their decision-making process. Given participants were asked to recall this information, further study is warranted in order to gather information when participants enter the program.

4.4. Decision to Participate

Decisions to participate in the MHC involved consideration of participants’ needs, past experiences, and how they perceived the MHC could help them. These decisions, about whether or not to participate, were made within the context of how a person perceived the MHC would impact them, the costs and benefits to participation, and how MHC professionals would intersect with their daily life. During interviews, researchers asked participants to think back to when they entered MHC and discuss the factors they considered when making decisions. It is possible that what participants recalled may be clouded by their current experience and it is also possible that these perceptions change over time (Eschbach, Dalgin, & Pantucci, 2019). Despite these limitations with recall, participants discussed distinct perceptions that shaped their decisions.

4.4.1. Conditions of participation

Participants decided to take part in MHC because they wanted to avoid spending time in prison, they needed access to treatment, or a combination of these two factors. Patterns were equally salient with participants proportioned equally across the three conditions. For people who participated to avoid spending time in prison, an important condition surrounding this decision was having spent time in prison before. For example, one participant reported,

I knew it [MHC] wasn’t gonna be easy…it wasn’t really meant to be easy, you know, because you’re takin’ a cop out. I mean, to me – I mean, to me, it’s easy. I mean, if you’ve ever been in prison, or you’ve ever spent any time in jail, it’s easy…Goin’ to prison is hard, you know? This is easy, you know, havin’ to get up and come down here and go to [treatment] that’s easy, staying clean, that’s easy. You can either stay clean out here and, you know, live your life, or you can go to jail and be forcibly to stay clean and be cooped up.

Another participant stated that she initially decided to participate in MHC because she never wanted to be incarcerated again, but now she sees some benefit in the treatment portion of the program. “…I’m one of them because I didn’t want to go to prison. I’ve been before….now that I understand the program, it’s benefitted me a lot. I’m on…the right medication…I really got stable.” Other participants decided that both getting out of prison and participating in treatment were important reasons to participate in the MHC. For example, one participant said, “Well one, I wanted out of jail, and two, I thought it’ll be a good way to get sober.”

Other participants decided to participate in the MHC because of a need for change or the desire for treatment. This theme includes references made regarding wanting treatment, wanting to change one’s lifestyle through treatment, or deciding the MHC was a way to obtain resources needed for recovery. One woman shared that she was presented with the option to participate in the drug court and MHC a number of times in the past. She decided to participate this time because she needed additional resources to help her maintain her sobriety, such as treatment, support from staff, and guidance: “I knew somewhere that I would be getting my life back on track” with the MHC. Other study participants recalled the decision to participate in the MHC was impacted most heavily by their desire for treatment. One participant said, “But I was like, ‘Well maybe I need to try it this way ‘cause I do need treatment.’ It’s like I put it on a scale and I weighed it out. This is what I wanted to do; come to treatment.”

An important condition influencing participants’ decision to take part in the MHC is limited or no access to mental health treatment due to lack of insurance or the high cost of their medical care (i.e., high co-pays for medications or doctors). One participant reported,

So, I decided to take it. Also, that I would be seeing a therapist every week. Now, I had insurance last year but my insurance had ended with my husband’s divorce, so it was kind of good. I was paying out of my pocket to see my psychiatrist, so this worked out well. I’m seeing a therapist once a week. I’m going to group. They’re paying for my medicine right now, because my mother was paying for it and it was very expensive.

Another participant said his decision to participate in the MHC was because it was a way for him to get his medications: “[I] don’t have the funding right now to pay for it—or Medicaid.” After losing her insurance, another participant tried a number of ways to obtain treatment for her bipolar disorder but was unsuccessful. She stated,

…my symptoms were not bad enough to be accepted into the program [free county mental health program] because I had no insurance…without insurance you can’t do anything. When I’m off my meds I definitely can’t work because I never know what’s going to happen in the next five minutes. So, with already having a felony charge people wouldn’t –they won’t hire you…it’s too bad it took a second felony to get somebody to listen to what I was saying. ‘Hello? I need help.’

Studies find low perceived coercion as it relates to freedom, choice, and control about the actual decision to enter the MHC (Poythress et al., 2002) and regarding interactions with the judge while in the MHC (Wales et al., 2010; Munetz et al., 2013), However, the pressure participants identified in this study is a distinctly different and has yet to be explored within MHC research. Even though participants are making the choice to participate in MHC, this choice is influenced by financial hardships, lack of access to mental health care, and a desire to engage in treatment.

Even if a person is disabled by their mental illness, it is no guarantee that they will be able to access Medicaid or Medicare. There are numerous barriers to applying for Medicaid including complicated applications, lack of understanding or confusion about the application, no permanent address or access to a phone, and access to required documentation (Stuber, Maloy, Rosenbaum, & Jones, 2000). As noted by participants in this study, gaining access to treatment meant paying out-of-pocket or participating in MHC. Safety-net providers (e.g., free clinics) existed in the areas surrounding both of these MHCs; however, participants in this study did not see those services as viable options for consistent mental health care. The two MHCs in this study did not require participants to have insurance upon entering the MHC. Caseworkers working with the MHC assisted participants in applying for Medicaid once they entered the MHC, which was also a service welcomed by MHC participants. Participants who could not afford care or who were unable to access consistent treatments were left with a decision to make about whether or not consenting to the requirements of an intensive, approximately 2-year program was worth the access they gained to treatment.

Decisions to participate in MHC rest within a broader understanding and context, which could be shaped by a number of factors including those already discussed above like who referred them to the MHC (e.g., judge, public defender, family member) and how MHC was introduced to them. Although avoiding prison and accessing treatment were salient reasons to participate in MHC, participants also discussed their perception of how MHCs function as yet another condition that surrounded their decision to participate in MHC. At the time of their interviews, participants were already in the MHC. It’s unclear if and by how much their understanding of the MHC shifted since entry and whether the themes identified actually impacted their decision making. Given these caveats, patterns existed regarding perceptions of how MHCs are intended to function. Two prominent and two obscure patterns were identified. Prominent patterns that arose across many participants include understanding MHC to be a program (1) designed to help people with mental illnesses and addictions through service provision and (2) that provides the structure for a judicial agreement to allow court and treatment staff to make decisions regarding one’s life in exchange for freedom from prison and for treatment and services. Two other important but less prominent themes are that MHCs are designed to protect people with mental illnesses from the risks they may face in the criminal justice system and a formalized way for the courts to reward participants for complying with treatment. Given the exploratory nature of this work, both prominent and obscure themes are discussed. Each theme is explicated individually; contextual factors that influenced participant perceptions of the function of MHCs are also addressed below.

4.4.2. “Help sick people”

Participants described MHCs as a tool for helping or intervening with people who have mental health and/or substance use needs. MHC was described as a program to “help sick people.” MHCs were understood to be a mechanism for service provision to individuals who have mental illnesses, substance use problems, or are generally unable to take care of themselves. For example, one participant reported, “They help people that can’t help they self. They sick and they can’t help they self,” while another participant found the MHCs “help somebody with mental illness overcome their addictions and be straight with their illness, as well as stay clean.” Other participants said that the MHC was designed to “help us get through sobriety and work with our mental illness” and assist participants in “working through the mental health system.” One participant noted that MHCs are designed to provide treatment but also supervise treatment adherence: “It’s to monitor the people with real mental illness, you know, that are really—really need help with makin’ sure they take their meds, makin’ sure they have a safe environment where they could recover if they wanted to.”

When discussing the function of the MHC, participants found a lack of treatment to be a major contributor to arrest and criminal justice involvement. For example, one participant reported that the MHC was designed to

basically to give—give people with a mental illness a chance to recover through actually taking their meds other than just shippin’ ‘em off to jail or put ‘em in their –actually givin’ ‘em a chance, pretty much…There’s a lotta people in jail or in prison that really shouldn’t be there because they’re not—either not on the right meds or never—you know, never been diagnosed.

Another participant echoed this by saying, “…because mostly for people with mental health and drug abuse issues that’s mostly why we go to jail. If it were not for these issues, we wouldn’t be getting arrested. So, it’s to treat those issues to reduce the recidivism rate.” One participant found the MHC to be a way for individuals to receive treatment and to explore the reasons for criminal justice involvement: “…they’re trying to get you to see why you committed the crime, what led up to it, what all played a part in you committing the crime.”

Treatment provided by MHCs was also described as services to help people reintegrate into the community. The language participants used conveys a perspective that people with mental illnesses and criminal justice involvement may not be integrated into the larger social order and that with assistance, participants may once again be a part of society. For example, one participant stated, “…the court tried to help that person instead of giving them years in jail, it gives them probation and also gives them the opportunity to get back into society through [mental health program],” while another participant shared that the MHC “…allows them a chance at recovering their lives, becoming citizens—productive citizens again…while providing them with the services that the court feels that they need in order to, um, reach that goal.” Integration into society, for participants, appears to involve both gaining insight into one’s mental illness and engaging in treatment. Another MHC participant shared that the MHC was “…designed to correct my errors that I’m doing and get my life back in order, and recognize my dual diagnosis that I have and what does the disease enable me to do, and what could I learn from it and do about my dual diagnosis.” Similarly, another participant stated, “…it can nurse you back to health or help you to learn how to live life right.” In summary, MHCs are designed to help sick people, according to participants, which means the MHC functions as a way of diverting people from incarceration to needed services in order to promote recovery. MHCs help people through service provision to address mental health needs and substance use problems as well as teach participants about mental illnesses and ways to reengage with the community.

4.4.3. Judicial agreement

A second prominent pattern captures the belief that MHC is essentially a judicial agreement or contract in which participants relinquish their rights to make decisions about their life in exchange for freedom and, in some cases, dropped or reduced charges. Rather than participants making decisions, the legal and treatment teams are primarily responsible for decision-making. For example, one participant said that MHCs were intended “…to help us so our charges will be dropped. They said our charges will be dropped if we complete the court, and we’re just supposed to do everything the court tells us to do. I mean, no drinking, no drugs, and just abide by what the court tell you to do.” Another participant stated, “I believe it’s to make my life harder. [Laughs] But no, I believe it’s designed to give people with mental illness and drug abuse some accountability. You know, making sure that I make my appointments, take my medications.” Similarly, another participant reported, “I can’t get into no trouble. Like no smoking, no drinking, no selling drugs, no fighting…my charges could be dropped.” Many participants recalled the judges informing them of the intensity of the judicial agreement inherent in MHCs. For example, one MHC participant remembered the judge said the MHC was designed to “…pretty much take your life over and that’s it. You’ve got to do what we say to do and live where we say live and we just take over your whole life.” The participant went on to say, “…which is better than the penitentiary. I’m willing to try that. Then maybe I don’t have to go to the penitentiary no more after this.”

Some participants, particularly those who felt they were “blessed” to have the MHC and those who felt the staff cared about them or provided support, did not explicitly express or use language that suggests their agreement with the MHC was problematic for them. According to one participant:

You just got to go to court and be good. As long as you be good they really nice especially the judge…Then you want to do good for them…I be willing to do good for them because they trying to help me out all the time.

Other participants talked about their experience in working with the MHC staff to fulfill treatment obligations. For example, one participant, who is “grateful” for the MHCs, described her experience in working with the staff to fulfill her probation and treatment requirements:

I’m very grateful for the courts. I’m very, very grateful for mental health probation, my [MHC] worker, my probation officer. I’m grateful for all these supportive peoples, but they’re very caring. They’re making me feel like they really care, they actually care about my well-being.

Another participant, who also felt “blessed” and supported, described his experience in working with the MHC as follows:

My counselor works overtime; he’s a very busy man and he does a lot for me and I really appreciate it and my counselor over here is workin’ overtime to get me out, so everybody has been very cooperative in gettin’ me out and because they’ve seen that I wanna cooperate and I want to get out and I want to have a normal life and I’m ready to face responsibilities, I mean, I did the crime, I should do the time. I should’ve been doin’ it a lot more than right now but all I can say is I’ve been divinely blessed for one and my team has been working for me, too.

Despite engaging in an agreement or contract to abide by the courts’ rules and requirements in exchange for freedom and services, some participants described their experience with gratitude, perceptions of caring and support, and engagement. Factors such as feeling “blessed” and supported may shape participants’ understanding and perceptions of the MHC.

Some MHC participants found the contractual design of MHCs to function as a means of obligating participants to give up control over their lives. The perception that MHCs are designed to exert control over participants is one context that appears to shape how participants come to understand the function of MHCs. For example, one participant said, “I asked for help, but I didn’t ask for total domination…telling me how I can live now after I did what you asked me to do.” Another participant echoed by stating,

…I knew that it would mean relinquishing control, autonomy, power over my life…I have wondered on several occasions if it would’ve been easier to just do my time in the penitentiary and get it over with and come out, because it can be very taxing having someone basically running your life and you’re an adult.

Participants managed the feelings of being controlled in a number of different ways. One participant identified the choices he was able to make and essentially described how he is putting his life on hold until he completes the program. He stated,

It kind of sucks, but it is what it is…I took the program…I’ve either got to deal with it…or I go back to jail…I choose to deal with it…And I ain’t going to lie to you…the day I get off [MHC] I ain’t gonna tell you I’m not going to go out and get high.

Other participants appeared to manage the obligations of their contract despite feelings of being controlled by the MHC staff. However, participants consistently reported frustration or anger when the control became “too personal.” For numerous participants, the control crossed the line when they were faced with giving up control over their finances. One participant described his experience:

They tell me how to budget my money. And I don’t think that’s right. I can spend my money the way I wanna…they tell me I have to go to this agency where they make them be my payee…It makes me frustrated, real frustrated…I wish I could wake up tomorrow and my probation would be over with. Or they could terminate it, you know, unsatisfaction, you know? I’ve been trying to figure out a way to do that.

Another participant addressed MHC crossing the line, leveraging the power of other actors involved in his care:

So that was my final string, you know. They tried to have the judge order me to have a payee, and just all kinds of stuff that I really don’t need. And I asked my public defender, and my—my public defender and my [community treatment provider], you know, convinced the judge, he don’t need a payee. He’s never had one, and that doesn’t seem to be his problem.

Contextual factors play a particularly important role in shaping perceptions of how MHCs function. Specifically, participants may find their judicial agreement to be a “blessing” or they may feel that they are lucky to have the opportunity to participate in the MHC. For these participants, the contract seems to be experienced as less coercive and viewed as a factor promoting recovery. Language used by participants evokes a sense that staff members are trusted to provide oversight and direction in one’s life. Other participants view participation in the MHC as surrendering complete control over their lives. Perceiving that the staff is controlling can shape the ways that participants understand the MHC to function and may ultimately elicit feelings of coercion. Some participants try to regain control through various techniques like advocacy or disengagement.

4.4.4. Protect people with mental illnesses and reward compliance

Two additional less prominent themes were also identified. Although there were fewer instances, these two themes appeared across several interviews. Participants identified the MHC as a protective mechanism and an “advocate” for people with mental illnesses to help keep them out of the risky prison environment. Participants discussed the importance of the MHC in relation to the threats people with mental illnesses face while in custody. One participant said, “…you get to jail, they don’t care if they’re taking their medications, and things escalate and get worse.” Participants understood the MHC’s function as a means for protecting people with mental illnesses through advocacy and keeping them out of prison. However, the protective function of MHCs appears to work through the act of diverting people from prison. It is unclear how, if at all, the MHC acts as a protective agent in other ways. Finally, participants described MHCs as a program that rewards individuals for treatment adherence and compliance. Although similar, rewarding compliance is different than the idea that MHCs are designed to facilitate a judicial agreement or contract. Participants who described MHCs as a program that rewards people for compliance do not use language that suggests they are engaging in a contract or agreement with the MHC. Rather, they suggest MHCs are designed to encourage and motivate compliance through reinforcement. Participants reported the MHC uses reinforcers, like dropping charges, to foster motivation among participants to adhere to treatment and follow court orders. For example, one MHC participant reported, “…it’s designed to motivate you to do better….and there’s a lot of motivational things…just gives you a little bit of a boost to, you know, try to—you know…if you graduate, it’s not gonna be on your record.” MHCs, based on these participant perspectives, utilize behavioral strategies to encourage self-regulation and ultimately program adherence. Rather than the courts exerting control overtly, participants are encouraged to model behaviors in line with court orders.

5.1. Discussion

This study begins to build the knowledge base regarding decision points leading up to and including why participants decided to opt-in to MHC. Specifically, the grounded dimensional and thematic analyses explicated dimensions of the participant experience in referral to MHC and decisions to participate and the contexts by which these experiences are shaped and derived. Collectively, participant experiences point to the understanding that MHC programs divert people from incarceration and provide treatment that is intended to address substance use and mental health needs. When offered MHC, participants understood the program would provide treatment and assistance while also keeping participants out of prison. However, participants identified one reason they opted-in to MHC was to avoid spending time in prison. It may be that, at least for some participants, avoiding a prison sentence was so important that participating in treatment, regardless of desire, would be worthwhile.

Participants understood the MHC to help them avoid incarceration and access treatment for substance use and/or mental health problems. Although MHCs aim to reduce criminal recidivism, past research demonstrates that criminal justice involvement is often caused by a more complex mix of factors, like poverty and structural racism, rather than simply untreated mental illness (Draine, Salzer, Culhane, & Hadley, 2002; Fisher, Silver, & Wolff, 2006). Results from this study did not reveal an expectation from participants that MHC could help address these more complex issues related to social disadvantage and the broader social environment.

It is notable that participants identified a lack of health insurance as a contributing factor to opting in to MHC. This suggests a type of push to participate that has yet to be explored in the MHC literature but one that is needed in future research. As outlined in Table 1, 54% of participants had Social Security Disability (SSDI) or Supplemental Security Income (SSI) at the time of their interview. Although having SSDI or SSI is not a guarantee these participants had Medicaid, most were living below the poverty line making them eligible for Medicaid in the state where the two MHCs are located. However, participant interviews took place after MHC enrollment; they may not have had disability at the time they made the decision to participate in the MHC. If people perceive the MHC to be a mechanism by which they can access consistent mental health care, for some through the acquisition of healthcare insurance, it may shape their appraisal of the utility and judicial fairness of the MHC. That is, people who are economically disadvantaged may be more prone to accept MHC as a pathway into mental health care.

Table 1.

Background and Demographic Variables of Sample (n = 26)

Variables	Categories	%*	n	M	SD
Sex	Female	50	13
Race	African American	50	13
	Bi-racial	4	1
	Caucasian	42	11
	Latino	4	1
	Native American	0	0
Relationship Status	Single	42	11
	In a relationship, not married	46	12
	Married	4	1
	Div/Widowed	8	2
Substance Use Diagnosis		77	20
Receiving SSI or SSDIy		54	14
Primary Mental Illness	Bipolar	62	16
Diagnosis	Schizophrenia Spectrum	19	5
	Major Depression	4	1
	Anxiety/Dep.	12	3
	ADHD	4	1
Felony Charge		81	21
Charge Leading to MHC	Drug Related	27	7
Participation	Theft	42	11
	Forgery	8	2
	Trespassing	8	2
	Prostitution	4	1
	Driving with Revoked License	4	1
	Battery	8	2
Age (range 22 – 61 yrs)				42.1	9.9
Education (range 7 – 16 yrs)				12.2	2.3
Annual Income at time of interview ($0 – 19,200)				6614	6076
Months in MHC at time of study participation (range 2 – 17)				7.2	4.2
Arrests in two years prior to MHC (range 1 – 8)				2.4	1.8

^*Categories may not equal 100% due to rounding

Existing policies surrounding MHC and eligibility do not address the complex and potentially competing factors inherent in decision-making based on access to resources. Lawyers provide counsel surrounding participants’ decisions to take part in MHC, helping them weigh their options between taking part in an intensive, community-based program or serving time in prison but no one counsels them on alternative options for access to mental health treatment. County or program policy may be a beneficial intervention to guide the types of information that should be offered when lawyers or MHC administrators are assessing a person’s fit for MHC to help them make informed decisions about MHC participation. In 40% of courts surveyed, supervised treatment was longer in the MHC than the sentence would have been in a traditional court (Bernstein & Seltzer, 2003). Future research is needed to determine if people are knowingly making these decisions in order to access treatment or avoid incarceration and if they are consenting to MHC without fully understanding the potential inequity in supervised time (Johnson & Flynn, 2017). If a person could access treatment without the MHC or knew about options outside of MHC for obtaining mental health care, would they be more inclined to decline or opt-out of MHC? This is an important question that could be addressed in future research.

Another notable finding is the duality of experience around the judicial agreement. While some individuals felt blessed at relinquishing decision-making control of their lives and felt MCH staff have their best interests in mind, other participants felt that MHC was too controlling and asking them to comply with unnecessary treatment conditions, like having a representative payee. There are a variety of variables that could account for the vast experiences of participants, including individual (diagnosis), interpersonal (relationship with MHC staff), or structural (perception of procedural justice). Despite the similarities of the two courts in this study, there is great variation in MHC procedure and policy. Programmatic policy that influences the decision-making rights of the MHC team may perceptions of feeling controlled versus cared for. This finding may also point to another black box of MHCs—how decisions around treatment expectations and sanctions are made. These decision-making processes may operate under similar internal and external pressures and be sensitive to the same constraints and resources that can determine who is eligible for MHC, as Castellano’s (2017) research showed.

While most participants’ understanding of MHCs was in alignment with the stated goals of these courts, motivation to avoid incarceration was cited as a factor for participation. In general, the court system is designed to be adversarial, but this stance gets murky in MHCs in which taking psychotropic medications, engaging in counseling, and having a representative payee can be requirements for avoiding incarceration. Individuals have the right to refuse medical and psychiatric treatment unless they pose an immediate danger to themselves or others, which is not the case for those participating in MHCs. Because MHCs occupy this liminal space between individual rights and punishment, there is a need for improved policy to require more transparency about how decisions are made around eligibility, treatment requirements, sanctions, and anticipated program length. However, because of the variability in individual cases, effectiveness of different types of treatments, and resources available to MHCs, it is difficult to enact strict policy or practice recommendations across MHCs. Instead, having a better understanding of these processes and establishing policies surrounding guidelines for decision-making may help to ensure more equitable and ethical treatment for participants.

As the body of MHC research continues to expand, the role of the gatekeepers (i.e., people making referrals) and others involved in admission decision-making requires close consideration and investigation. The black boxes of knowledge preceding MHC need to be addressed in order to understand the points of potential bias and to better understand the population of people served by MHCs. Through research, we will be able to determine the need for targeted policies regarding referral and assessment for MHC and other diversion programs. Future research is also needed to determine whether MHC participants’ perspective on the function of the MHC (i.e., an avenue for treatment or judicial contract) impacts program engagement, retention, and outcomes. It is also essential for future research to examine the nuances of why people might opt-in as a means to access treatment and what might happen upon graduation from MHC when these services may no longer be accessible.

5.2. Limitations

When interpreting the results of this study, key limitations are important to consider. The aim of this analysis was to utilize in-depth interviews to understand complicated phenomena and to begin to understand these decision processes. The findings are not intended to represent all of MHC participants or to generalize. Further research with different methodologies are required to examine the extent to which these findings represent the experiences of the population of MHC participants. This study relied on recall of events that occurred when participants entered the MHC. While we utilized several strategies in the interviews to improve recall, retrospective accounts can be flawed and current events may impact memories of past events. This research also assumed that participants “chose” to participate in the MHC. This may not be the case for all participants, given findings from Redlich and colleagues’ (2010a) work. Further, given participants had been in the MHC between 2 and 18 months, it is likely that their perceptions of the program shifted with time (Eschback et al., 2019) and these experiences may have shaped their responses. In particular, recalling how the MHC was introduced to participants may be slanted based on their current experience with the court.

Although in-depth interviews provide context and depth into complicated phenomena, it does not help guide us in developing and defining specific policies for individual MHCs to use in practice. This study does identify a need for MHCs to develop policy surrounding decision-making points; however, the findings cannot be generalized across all MHCs. Future research is needed to examine whether these findings hold true across court jurisdictions. Finally, although the methods used in this study adequately answers the research questions that were posed, the study is unable to explicate why participants perceived the MHC in the way they did. That is, additional perspectives from others involved in these processes (e.g., judges, lawyers) were not collected as data points. Additional research would benefit from including additional perspectives which can be compared and contrasted with participant perspectives and to assess if these factors impact participants’ clinical or legal outcomes.

6.1. Conclusion

As interventions like MHC continue to expand and utilize diminishing mental health resources, it is important to understand how people enter this system, if bias exists in referral, and how the population currently served by MHCs compares to the population of people who may be eligible but never referred or accepted. Examining the black boxes of MHC research and the function of gatekeepers to MHC services is an important step in expanding the knowledge base about MHCs.