The role of gender in mental health court admission and completion.

• Author: Ennis, Andrea R.
• Position: Canada

Since the advent of deinstitutionalization (i.e., the movement to relocate patients from psychiatric hospitals back to the community) in the late 1950s and early 1960s, the prevalence of mental illness within the criminal justice system has been growing (Lange, Rehm, and Popova 2011). The deinstitutionalization movement saw a broad scale downsizing and restructuring of formal mental health care services and hospitals throughout North America (Steadman, Morris, and Dennis 1995). Despite the intention to redirect patients with mental illness toward enhanced community-based treatment options, over time, adequate mental health services became increasingly scarce (Lurie 2009). Money saved from the closure of psychiatric institutions typically was not reinvested in community treatment. Reductions in governmental expenditures in the 1990s exacerbated the downsizing of health care and social programs, leaving mental health services underfunded (Schneider, Bloom, and Heerema 2007).

Across North America, the shortage of resources for treating mental illness has spurred an increase in the number of untreated persons with mental illness in the community (Lurigio and Harris 2007). According to Canadian researchers Hoch, Hartford, Heslop, and Stitt (2009), persons with mental illness are three times more likely to interact with police than members of the general population. In 2005, these same authors found that people with mental illness had higher arrest and incarceration rates than the general population, even for minor, nuisance-type offences (e.g., public disturbances) that are minimally harmful to others (Hartford, Heslop, Stitt, and Hoch 2005). Similarly, American researchers Lurigio and Harris (2007) found that individuals suffering from mental illness are more likely to be incarcerated for minor offences than individuals without mental illness charged with similar offences. These results indicate that people with mental illness are more apt to be incarcerated for minor, non-violent offences (Schneider 2008). Although most people with mental illness do not enter the criminal justice system, these individuals are over-represented within Canada's criminal justice system (Canadian Institute for Health Information 2008).

Overall, the prevalence of persons with mental illness being processed through the criminal justice system has increased at least 10% per year for the past decade in most North American jurisdictions (Schneider 2010). Canadian statistics indicate that, between 1997 and 2008, the number of offenders with mental illness entering federal correctional facilities nearly doubled. Rates of offenders presenting with a mental health diagnosis at intake increased from 7% to 13% for male offenders and from 13% to 29% for female offenders, with 15% of incarcerated men and 30% of women having prior histories of hospitalization for psychiatric reasons (Office of the Correctional Investigator 2012; Stewart, Harris, Wilton, Archambault, Cousineau, Varrett, and Power 2010). The sum of these findings illustrates the growing role of prisons as "surrogate" institutions for persons with mental illness (Cosden, Ellens, Schnell, Yamini-Diouf, and Wolfe 2003). This trend is often referred to as the "criminalization of the mentally ill" (Abramson 1972: 102), a phenomenon by which the responsibility for providing mental health care services has shifted toward the criminal justice system (Schneider 2010).

As the Canadian inmate population grows, it is expected that the rates of mental illness within the correctional system will continue to grow (Kaiser 2011). The impact of this growth may be more substantial for women, as the greater increase in rates of mental illness among female (vs. male) offenders is concomitant with an escalating rate of incarceration of women. In Canada, as of time of writing, the number of incarcerated women has increased by 66% since 2005, compared to an overall increase in the Canadian inmate population of 17.5% (Office of the Correctional Investigator 2014).

Fuelled by the shortage of mental health services in both the community and correctional institutions, as well as the potential for incarceration to exacerbate mental health symptoms, mentally disordered offenders often cycle through the criminal justice system (Dumont, Allen, Brockmann, Alexander, and Rich 2013). Over the past decade, numerous initiatives have been developed to halt or at least slow this "revolving door" (Schneider et al. 2007: 2) and to divert individuals into treatment. These initiatives are predicated on the notion that many people with mental illness who come into contact with the law would be better served (thereby increasing rehabilitation and reducing risk) by providing mental health services rather than correctional services. This is the fundamental premise of therapeutic jurisprudence--the concept upon which diversion programs, such as Mental Health Courts, are based (Slinger and Roesch 2010).

Mental Health Courts (MHCs) are specialized problem solving courts that link criminally accused individuals with community-based services, with the goal of treating their underlying issues--be it mental illness, substance abuse, or both--with the intent of preventing or thwarting the accused from cycling through the criminal justice system (Steadman, Deane, Morrissey, Westcott, Salasin, Shapiro 1999). MHCs provide an alternative to traditional criminal sanctions by diverting low-risk justice-involved persons with mental illness to judicially supervised, community-based rehabilitative treatment. The ultimate goal of MHCs is to reduce the number of people entering prisons primarily because of mental illness (Ministry of Health and Long-term Care 2006).

Generally, MHC participation is voluntary and candidates must have a significant and persistent mental illness (e.g., schizophrenia or other psychotic disorders, bipolar disorder, or major depression) that is judged to be a primary contributing factor in their criminal behaviour. MHCs are not intended for those whose offence is exclusive of their mental health issues (Kaiser 2011). Mental health needs must be weighed against public safety; therefore, some offences (i.e., more violent offences) may be deemed inappropriate for diversion via MHCs (Toronto Mental Health Court 2008) or may fall outside the jurisdiction of the provincial court (i.e., certain indictable offences, such as murder [Nova Scotia Justice 2010]). In all MHCs, public safety, including the safety of the client, is the paramount concern and central tenet of diversion. The Crown Attorney has the authority to refer the matter to the originating court if the accused is not considered a suitable candidate (i.e., there is a Crown veto). While participating in MHC diversion, clients must adhere to specific conditions and treatment recommendations. Compliance is monitored through regular court review hearings and direct community supervision. Compliance and completion of the MHC program is generally rewarded through legal incentives, such as dismissed charges and avoidance of incarceration (Saint John Mental Health Court 2010; Steadman et al. 1995).

There exists a paucity of research examining the effectiveness of MHCs in decriminalizing the mentally ill. Most of the extant research focuses on whether MHCs reduce recidivism (reoffending). Early research yielded positive results, suggesting that MHC participants were less likely to offend following the program than they were before entering the MHC (Christy, Poythress, Boothroyd, Petrila, and Mehra 2005; Cosden, Ellens, Schnell, and Yamini-Diouf 2005). Subsequent research has also revealed a reduction in the number and severity of rearrests among MHC participants who completed their programs as compared to a randomly assigned (Cosden et al. 2003) or matched (Moore and Hiday 2006) group of traditional criminal court defendants (Cosden et al. 2003; Hiday 2006; Moore and Hiday 2006).

Research examining the effectiveness of Canadian MHCs is even more limited. In an evaluation of the Saint John (SJ) MHC completed by Campbell, Canales, Wei, Moser, and Joshi (2011), it was determined that over 90% of participants admitted to the SJ-MHC completed the program, indicating a high retention rate. Those who completed the MHC program showed significant improvements in mental health functioning and lower rates of reoffending in the year following discharge from MHC relative to those who were not admitted or who failed to complete the MHC program.

The evaluation of MHCs may be influenced by gender variations in criminal behaviour and mental illness. Differences in rates and types of criminal behaviour between the general offender population and mentally disordered offenders have led to some interesting findings in relation to gender. In the general offender population, men are much more likely to have engaged in violent and criminal behaviour than women (Bonta, Law, and Hanson 1998; Collins 2010; Gendreau, Little, and Goggin 1996). Some studies, however, have found that, in samples of psychiatric patients, men were no more likely than women to exhibit violent behaviour (Hiday, Swartz, Swanson, Borum, and Wagner 1998; Robbins, Monahan, and Silver 2003; Sirotich 2009). These findings raise the possibility of an interaction between gender and mental illness in the prediction of criminality. This is consistent with a growing body of literature exploring gender variations in pathways to crime, in which higher rates of physical and sexual abuse (particularly within familial and intimate relationships) among female offenders (versus male offenders and/or female non-offenders) have been linked with substance abuse, mental illness, poverty, and crime (Bloom, Owen, and Covington 2003). These findings have highlighted a need for further investigation into how gender may affect the relation between mental illness, violence, and crime, and have inspired studies examining gender effects in...