Program Profile: San Francisco (Calif.) Behavioral Health Court

The court aims to connect defendants with serious mental illness to community treatment services, to find dispositions to their criminal charges that take into account their mental illness, and to decrease the chances they return to the criminal justice system. The program is rated Promising. The study showed participants were statistically significantly less likely to be charged with a new offense and had a longer time without a new violent charge compared with the comparison group.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals

The San Francisco Behavioral Health Court (BHC) is a mental health court established in early 2003 in response to the increasing numbers of mentally ill defendants cycling through the jails and courts. The court aims to intensely monitor a subset of mentally ill persons whose criminal behavior is directly linked to their mental illness. The mission of the BHC is to:

• Connect criminal defendants who have serious mental illness to treatment services
• Find disposition to their criminal charges that take mental illness into consideration
• Ensure public safety by decreasing recidivism through appropriate mental health treatment and intensive supervision

Target Population/Eligibility

Participation in BHC is voluntary, and in many instances, the defendant does not have to enter a guilty plea to criminal charges in order to enter the program. To qualify for participation in the BHC, defendants must be diagnosed as having an axis I mental disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) or, in some circumstances, developmental disabilities. Defendants must also be amenable to treatment in the community mental health system. The gravity of the criminal charges against a defendant is also considered, although BHC does accept a substantial proportion of defendants who are charged with felony offenses.

Services Provided

The BHC provides services to participants through a continuum of care, beginning with in-jail services, transitional care prior to release, and early release into the community. The court has adopted several practices for treating mental ill persons, including Forensic Assertive Community Treatment, Illness Management and Recovery, Trauma Informed Care, Integrated Dual Diagnosis Treatment, Dialectical Behavior Therapy, and the Supported Employment Program. The BHC has also adopted the Women’s Integrated Skills and Health (or WISH) Project, which diverts in-custody females with co-occurring disorders to appropriate community mental health treatment services. The BHC is one of the only mental health courts in the country to develop gender specific treatment.

Key Personnel

The BHC involves collaboration between the Superior Court, the Public Defender’s Office, the District Attorney’s Office, the Sheriff’s Department, the Haight Ashbury Free Clinic’s Jail Psychiatric Services, the University of California, San Francisco’s Citywide Case Management, and the city’s Department of Public Health. The judge and lawyers work closely with mental health providers, who provide intensive case management that centers around the client’s diagnosis and psychosocial needs rather than his or her criminal charges. The court anticipates that relapses may occur, and it emphasizes positive reinforcement for successes rather than sanctions for failure. Participants who successfully maintain a sustained period of stability “graduate” from the mental health court.

Study

McNiel and Binder (2007) used a retrospective observational design with nonrandom assignment to compare the occurrence of new criminal charges to people who entered the San Francisco Behavioral Health Court (BHC) after arrest to other adults with mental disorders who were booked into an urban county jail after arrest. The primary research objective was to determine whether participation in BHC was associated with a longer time without recidivism compared with treatment as usual.

A total of 8,325 individuals 18 years of age or older who were diagnosed as having a mental disorder entered the San Francisco jail during the study period. Of these, the study looked at 170 individuals for whom complete data was available, including at least 6 months of follow-up. The comparison group consisted of 8,067 persons who did not participate in the BHC and received treatment as usual. Data was obtained from the administrative database associated with the San Francisco county court and jail systems.

For the treatment group, the baseline period was defined as the 12 months before the date of entry to the program. For the comparison group, the baseline period was defined as the 12 months before the date of the first arrest (the index arrest) that occurred between Jan. 14, 2003, and Nov. 19, 2004. Follow-up data for both groups were obtained through May 27, 2005.

The outcome variable was recidivism, which was measured as rearrest for two categories of new charges: any offense and violent crimes. The study used a propensity weighting procedure to create a sample of treatment cases comparable to those in the control group to account for differences in baseline characteristics between the treatment and control group. The statistical approach involved time-to-event analysis (i.e., survival analysis) using the Cox proportional hazards model. The primary survival analyses used intent-to-treat analyses to compare those in the mental health court group with those in the treatment-as-usual group without distinguishing whether individuals graduated from the mental health court program or not. The survival analyses also included comparing recidivism after graduation (for those who graduated from the program) with recidivism in the treatment-as-usual group to determine whether the changes associated with mental health court participation were maintained after successful completion of the program.

A 2009 cost–benefit analysis of the Behavioral Health Court (BHC) found that in the third year after participants entered the program, criminal justice and mental health treatment savings completely offset annual BHC operating costs and resulted in a net benefit of $277,000. Using an average annual BHC caseload of 206 clients, the study authors estimated that operating costs per person were approximately $12,101 (Lindberg 2009).

McNiel and Binder (2007) reported that statistically significant positive outcomes were also associated with completion and graduation from the Behavioral Health Court (BHC). For example, BHC graduates continued to show a longer time before incurring any new charges after graduating, compared with individuals who received treatment as usual. At 18 months, BHC graduates were 39 percent less likely to have been charged with a new offense, compared with the treatment-as-usual group and a longer time before incurring any new violent charges after graduating from the program. In addition, BHC graduates were 54 percent less likely to have been charged with a new violent offense, compared with the treatment-as-usual group.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

County of San Francisco, Superior Court of California. 2010. “Behavioral Health Court.” Accessed Dec. 20, 2010.

http://www.sfsuperiorcourt.org/Modules/ShowDocument.aspx?documentid=2178

Lindberg, Arley. 2009. Findings From Examining Program Costs and Outcomes of San Francisco’s Behavioral Health Court. San Francisco, Calif.: San Francisco Collaborative Courts, Administrative Office of the Courts, Collaborative Justice Unit.

http://38.106.4.177/Modules/ShowDocument.aspx?documentid=2422

Following are CrimeSolutions-rated programs that are related to this practice:

Adult Mental Health Courts

Specialized, treatment-oriented, problem-solving courts that divert mentally ill persons away from the criminal justice system and into court-mandated, community-based treatment programs in order to reduce recidivism and decrease the amount of contact that mentally ill individuals have with the criminal justice system. The practice is rated Promising for reducing recidivism but rated Ineffective on measures of clinical outcomes.

Evidence Ratings for Outcomes

	Crime & Delinquency - Multiple crime/offense types
	Mental Health & Behavioral Health - Multiple mental health/behavioral health outcomes

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?