Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are

Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are in Conflict with the Law: Literature Review and Synthesis Prepared for Ontario Mental Health Foundation and Ontario Ministry of Health and Long-Term Care* Funded by Ontario Mental Health Foundation November, 2004 B Investigators: Dr. Kathleen Hartford Simon Davies Chris Dobson Carolyn Dykeman Brenda Furhman John Hanbidge Donna Irving Elizabeth McIntosh Dr. Jim Mendonca Ian Peer Mike Petrenko Veronica Voigt Dr. Stephen State Janice Vandevooren Project Staff: Dr. Robert Carey Alex Craniescu *All views, positions and conclusions expressed in this report are solely the authors and are not endorsed by the Ontario Ministry of Health and Long-term Care.

Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are in Conflict with the Law: Literature Review and Synthesis

CONTENTS

Main Messages i Executive Summary ii 1. Introduction 1 2. Methods 1 3. Evidence-Based Typology 1 4. Mental Health Diversion: Definitions and Context 2

Types of diversion 2 The Consensus Project 2 Diversion in Ontario 2

5. Legal Issues Surrounding Mental Health Diversion 3 The criminalization of mental illness 3 Therapeutic jurisprudence 4 Overview of Diversion and Mental Health Law in Canada 5

6. Pre-Arrest diversion 6 7. Court Diversion 9 8. Mental Health Courts 11 9. Site Visits 13 10. Survey Results 14

11. Recommendations 22 References 27

Appendices 33 Appendix I: Literature Review Methodology 33 Appendix II: Survey Methodology 34 Appendix lll: Experimental Designs 36 Appendix lV: Formative and Summative Evaluation 37 Appendix V: Differences Between Traditional

and Problem-Solving Courts 38 Appendix VI: Court Diversion Programs in Ontario 39 Appendix VII: Legislation from Other Countries 40 Appendix VIII: Acknowledgements 43 Appendix IX: London Police and Mental Health Crisis

Service Memorandum of Understanding 45 Appendix X: Chesterfield/Colonial Heights

Memoranda of Understanding for Court Diversion 48

Appendix XI: Mendocino County Memorandum of Understanding for Mental Health Court 52

Appendix XII: Research Team Members 59 Appendix XIII: Standardized Literature Review Grid 60 Appendix XIV: Diversion Survey 62 Appendix XV: Survey cover letter 94

Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are in Conflict with the Law: Literature Review and Synthesis KEY MESSAGES Rationale The criminalization of persons with mental illness (PMI) for minor offenses has been reported to be an unintended consequence of deinstitutionalization and inadequate community-based treatment. Diversion of PMI who are in contact with the law into appropriate treatment is an integral element of a humane mental health system. Research Question The key question posed by the Ministry of Health and Long-Term Care is: what standards, benchmarks, indicators, and evidence-based practices regarding mental health diversion exist?

Methods A multi-method approach was used that included: a literature review, including both published and grey literature; site visits and key informant interviews; and an international Web-based survey of existing diversion programs. Key Findings Literature on mental health diversion has been primarily limited to descriptive accounts, and with the exception of basic program statistics such as the numbers of people diverted, there remain few outcome data in published studies. There is no information on optimal staffing or funding levels; nor does the literature offer rigorous evidence on which to base decisions surrounding policy, planning, or training. Nevertheless, the literature is extensive enough to suggest that the following are key themes in the development and maintenance of successful diversion programs: •Inter-agency/governmental collaboration •Regular meetings among key personnel •Steamlined services

•Formal case-finding procedures •Enhanced community resources • Increased awareness among key players

Recommendations Our overarching recommendations are: 1) That enhanced capacity of community mental health agencies and housing be funded through the Ministry of Health and Long-term Care; 2) That the inter-ministerial Human Services and Criminal Justice System Coordinating Committee be re-constituted at a provincial level; 3) That, with the advent of the new provincial local health integration networks (LHINs), a close examination of the interface between proposed new health regions and existing regional forensic programs, as well as local and other government department boundaries be proposed.

a) standardized training for police, court support workers (CSW), lawyers, justices of the peace and judges; b) enhanced community mental health services, including housing and treatment facilties; c) streamlined services, including telepsychiatry for fitness assessments, court docket for PMI, and Memoranda of Understanding between mental health and criminal justice agencies; d) increased research, focusing particularly on randomized controlled trials, program evaluation and the development of uniform outcome measures.

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Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are in Conflict with the Law: Literature Review and Synthesis EXECUTIVE SUMMARY Rationale The criminalization of persons with mental illness (PMI) for minor offenses has been reported to be an unintended consequence of deinstitutionalization and inadequate community-based treatment. Diversion of PMI who are in contact with the law into appropriate treatment is an integral element of a humane mental health system.

With publication of the Making it Happen reports, Ontario embarked on major restructuring of mental health services. This review of evidence-based practices in mental health diversion was funded by the Ministry of Health and Long-Term Care (MOHLTC) as a contribution to that effort. Research Questions: This report addresses the following research questions posed by the MOHLTC: 1. What standards exist for diversion programs for persons with serious mental illness? 2. What evidence-based practices - including areas such as policy, planning, evaluation, funding, training, and clinical interventions - are characteristic of successful diversion programs? 3. What benchmarks - including staffing and funding levels - exist for diversion programs? 4. What performance standards and performance indicators exist for the provision of specific diversion programs? 5. What criteria and factors should be considered in the development of standards?

Methods A multi-method approach was used that included: a literature review, including both published and grey literature; site visits and key informant interviews; and an international Web-based survey of existing diversion programs.

Defining mental health diversion Diversion is a process where alternatives to criminal sanctions are made available to PMI who have come into contact with the law. The objective is to secure appropriate mental health services without invoking the usual criminal justice control of trial and/or incarceration. Mental health diversion programs take one of three forms: (a) Police pre-arrest, or pre-booking diversion; (b) Court diversion and; (c) Mental Health Courts (MHCs). Key Findings Literature on mental health diversion has been primarily limited to descriptive accounts, and with the exception of basic program statistics such as the numbers of people diverted, there remain few outcome data in published studies. There is no information on optimal staffing or funding levels; nor does the literature offer rigorous evidence on which to base decisions surrounding policy, planning, or training. Nevertheless, the literature review, our site visits, and the responses to our survey, suggest the following are key themes in the development and maintenance of successful diversion programs:

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• All relevant mental health, substance abuse and criminal justice agencies were involved in program development from the start. • Regular meetings between key personnel from the various agencies were held. • Streamlining services through a treatment centre with a no-refusal policy for police cases is frequently seen as crucial. • A key theme in the integration of services is that of a liaison person or "boundary spanner" with a mandate to effect strong leadership in the coordination among agencies. • Awareness of the pre-trial diversion option among lawyers and court staff is crucial. • Formal case finding procedures are important for the early identification of mentally ill offenders in need of services. • Diversion is a realistic enterprise only to the extent that adequate resources exist in the community. • Extended mental health treatment combined with active case management improves compliance and reduces the likelihood of recidivism. Housing is frequently cited as a key issue.

Recommendations In the absence of evidenced-based practices in the literature, the responses to our international web-based survey and reports in the literature indicate that communities have proceeded to develop organized responses to the issue of criminalization of mental illness. It is recognized that the province of Ontario cannot wait for the requisite research in order to take steps to further develop programs to decriminalized mental illness. Our three overarching recommendations, therefore, are: 1) That enhanced capacity of community mental health agencies and housing be funded through the Ministry of Health and Long-term Care, as the primary method of diverting persons with mental illness from the criminal justice system; 2) That the Human Services and Criminal Justice System Coordinating Committee, comprised of senior staff of the Ministries of Health & Long-term Care, Attorney General, Community Safety and Correctional Services, and Community and Social Services be re-constituted at a provincial level to provide leadership and direction to policy and program development for diversion of mentally ill persons from the criminal justice system. For example, substantial interdepartmental investigation is required to ascertain the direct and indirect costs of court diversion and mental health courts in Ontario; 3) That, with the advent of the new provincial local health integration networks (LHINs), a close examination of the interface between proposed new health regions and existing regional forensic programs, local Human Services and Justice Coordinating Committees and other government department boundaries be proposed, and that boundary spanners at the local level be appointed, to ensure that boundaries are contiguous.

We also propose that Ontario take a leadership role in the development of the following areas:

a) standardized training for police, court support workers (CSW), lawyers, justices of the peace and judges. Highlights include: • Stand-alone, accredited, in-service education such as the police training educational module Not Just Another Call… Police Response to People with Mental Illness in Ontario (Hoffman & Putnam, 2004) be offered by the Ontario Police College to all uniformed officers within three years of basic training.

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• Training of court support workers in forensics and mental health law should be standardized. Consistent with recommendations offered by previous studies (e.g., MacFarlane et al, 2002), such training would likely be best undertaken annually by a single, pan-provincial body such as the Centre for Addiction & Mental Health. Training could be offered at different sites in the province. • Judges, Crown Attorneys and Justices of the Peace involved in diversion and mental health courts be encouraged to attend continuing education sessions in mental health law and mental illness. b) enhanced community mental health services, including housing and treatment facilties. • Police pre-arrest/prebooking diversion programs be supported by a free-standing, community mental health crisis agency with a formal "no refusal" policy for police referrals of voluntary clients. • Local police and mental health services agencies be encouraged to develop an organized mental health response for police when dealing with mentally ill persons which results in increased pre-arrest diversion. • Local human services and justice services coordinating committees be formed to examine and resolve barriers to service at the interface of the mental health and criminal justice system. •Active case finding should be supported by ensuring that court support workers have access to potential clients, and to the mental health condition and history of potential clients, as early as possible.

c) streamlined services, including telepsychiatry for fitness assessments, court docket for PMI, andMemoranda of Understanding between mental health and criminal justice agencies. •Agencies employing court support workers are encouraged to develop Memoranda of Agreements with community mental health, hospital and housing agencies. •Regional forensic facilities be encouraged to enhance their ability to meet their regional mandates by developing telepsychiatry capacity/linkages, and, in the interim, in jurisdictions where forensic psychiatrists or telepsychiatry are unavailable CAMH, may be asked to assist with the conduct of timely fitness assessments . •Where volume does not warrant a dedicated mental health court, application of the principles of therapeutic jurisprudence support the establishment of a mental health docket.

d) increased research, focusing particularly on randomized controlled trials, program evaluation and the development of uniform outcome measures. •Inter-provincial funding of evaluation of models of pre-arrest diversion programs be sought. •Workload measurement of court support workers be performed in each court diversion program to determine their primary function and assessing the proportion of time spent in activities related to direct diversion of mentally ill clients as opposed to court support activities. •Since court diversion programs are not established throughout the province yet, randomized controlled trials be funded to assess the efficacy of court diversion. •Consensus on the identification and definition outcomes of pre-arrest, court diversion and mental health courts is required for research studies and for monitoring programs. •The Ontario Ministry of Health and Long-Term Care investigate clinical diversion of persons with mental illness who are arrested and found fit, or who are obviously fit.

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Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness Who are in Conflict with the Law: Literature Review and Synthesis 1. Introduction A fundamental principle arising from Making It Happen, Ontario's Ministry of Health and Long-Term Care's (MOHLTC) plan for mental health reform, is that effective diversion for persons with serious mental illness (PMI) who are in contact with the law is an integral elemental of the mental health system (Ontario Ministry of Health and Long-Term Care, 1999). Accordingly, the MOHLTC has embarked on a program of research to identify evidence-based practices in mental health diversion. In addition to its own activities, the Ministry has funded a review and synthesis of all relevant published and unpublished literature. We addressed the Ministry's following research questions: 2. MeThis reassocimateriAustrasuch aAfter ritems textensFinallynote a(availa In addconduScarbodiversirepresII). Thliteratuanalyz 3. EvidThe abliteratuthe chquanticategoSince evaluadevelofor som

1. What standards exist for diversion programs for persons with serious mental illness? 2. What evidence-based practices - including areas such as policy, planning, evaluation, funding, training, and clinical interventions - are characteristic of successful diversion programs? 3. What benchmarks - including staffing and funding levels - exist for diversion programs? 4. What performance standards and performance indicators exist for the provision of specific diversion programs? 5. What criteria and factors should be considered in the development of standards?

thods port adopted a multi-faceted approach to the identification and analysis of the evidence-based practices ated with diversion programs. Our literature review encompassed several strategies and focused primarily on al about pre-arrest, court diversion programs and mental health courts in Canada, the United States, lia, New Zealand and the United Kingdom (see Appendix l). Based on the Ministry's directives, subjects s co-occurring disorders, youth diversion, and forensic treatment were excluded from the literature search. etrieving and evaluating a substantial number of texts, we examined their bibliographies to locate relevant hat had not been identified in previous database searches. To recover grey literature, we conducted ive searches of the Internet for electronically published documents and for references to unpublished items. , the project’s investigators drew on their professional backgrounds and knowledge of relevant literature to dditional items of importance, which were incorporated into the review. Ultimately, we recovered 519 items ble in Reference Manager format).

ition to the literature review, we employed two other methods to identify best practices in diversion. First, we cted site visits to mental health courts or court diversion programs in Toronto, Brampton, Etobicoke and rough. During these visits, we interviewed key informants, including crown attorneys, duty counsels,

on workers and judges. Second, we developed and distributed a Web-based survey to more than 734 entatives of diversion programs in North America, Great Britain, Australia and New Zealand (See Appendix e survey was designed to elicit descriptive data about aspects of diversion that do not appear in the re, such as policy, planning, evaluation, funding, training, and treatment options. Responses were coded and ed using a qualitative data analysis software called Nud*ist.

ence-Based Typology ility to identify evidence-based practices in diversion depends on the strength of the research design in the re. Generalizing from anecdotal accounts may be misleading because certain contextual factors, such as aracteristics of legal and mental health systems, may vary from site to site. Accordingly, insights arising from tative research are usually considered the "gold standard" in identifying evidence-based practice. We have rized the mental health diversion literature according to the research hierarchy represented in Appendix III. much of this literature is evaluative, it is important to note the difference between formative and summative tion. Formative evaluations are undertaken during the initial phase of a program to gain insight into further pment. Summative evaluations, on the other hand, are often carried out when a program has been in place e time; the purpose here is to study the program's effectiveness and to judge its overall value. Summative

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evaluations are typically used to determine how resources should be allocated, or to enhance public accountability (Palys, 1997). Summative evaluation is more likely to lead to the kind of insights necessary to support evidence-based practice (see Appendix IV). 4. Mental Health Diversion: Definitions and Context a. Types of diversion Diversion is a process where alternatives to criminal sanctions are made available to PMI who have come into contact with the law for minor offenses. The objective is to secure appropriate mental health services without invoking the usual criminal justice control of trial and/or incarceration. Treating the mental disorder, it is hoped, reduces the likelihood of further offending and the focus is on helping individuals to access community support and treatment. In general, mental health diversion programs take one of three forms: (a) police pre-arrest, or pre-booking diversion; (b) court diversion and; (c) mental health courts (MHCs). Arrest diversion allows the police to use their discretion in laying charges. Court diversion programs, on the other hand, are post-booking, pre-arraignment programs that involve staying charges for eligible offenses if the person agrees to treatment. In addition to the mentally ill defendant and her or his family, MHCs involve a dedicated judge, crown, defence, and court support worker (CSW). Characteristics of MHCs include: (a) all identified mentally ill defendants are handled in a single court/docket, (b) the use of a collaborative team which includes a clinical specialist who recommends and makes linkages to treatment, (c) assurance of availability of appropriate clinical placement prior to the judge making a ruling, and (d) specialised court monitoring with possible sanctions for noncompliance (Steadman, Davidson & Brown, 2001). b. The Consensus Project The public profile of mental health diversion in the criminal justice system was advanced markedly by the Criminal Justice/Mental Health Consensus Project (Council of State Governments, 2001) undertaken in 1999 by the U.S. Council of State Governments (CSG) in response to requests from state government officials for recommendations to improve the criminal justice system's response to PMI. To address the numerous issues related to PMI in all phases of the criminal justice system, the CSG collaborated with six organizations: the Police Executive Research Forum (PERF), the Pretrial Services Resource Center (PSRC), the Association of State Correctional Administrators (ASCA), the National Association of State Mental Health Program Directors (NASMHPD), the Bazelon Center for Mental Health Law, and the Center for Behavioral Health, Justice Public Policy. The resulting Consensus Project Report <URL:http://consensusproject. org/> provides 47 policy statements intended to improve the criminal justice system's response to PMI. Following each policy statement is a series of specific recommendations that highlight the practical steps that should be taken to implement the policy. The report contains examples of programs, policies, or elements of state statutes that illustrate one or more jurisdiction's attempt to implement a particular policy statement. Although the Consensus Project is a milestone in mental health diversion, many of the initiatives it advocates are so new that they have yet to be evaluated to assess their impact on individuals and systems. c. Diversion in Ontario In Ontario, two initiatives created by the MOHLTC sparked further interest in diversion. First, the Ministry established a Forensic Mental Health Services Expert Advisory Panel in 2001 to advise the government on a provincial strategy for the implementation of a comprehensive forensic mental health service system. The panel’s final report, entitled Assessment, Treatment, and Community Reintegration of the Mentally Disordered Offender (Ontario Ministry of Health and Long-Term Care, 2002) advocated a comprehensive and coordinated system of services and supports to meet the needs of PMI who come in contact with the law. Among the panel’s specific recommendation are: (a) increased community services – such as housing and forensic beds – to support PMI who are undergoing diversion; (b) enhanced training and support for police officers to support pre-arrest diversion programs; (c) revision to the Crown policy on mental health diversion, and (d) special training and support for Crown prosecutors to allow them to offer formal diversion programs. One of the panel's key observations is that

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earlier intervention is necessary if the mentally ill person's engagement with the criminal justice system is to be minimized in favor of treatment and community support. Consequently, the panel placed a great deal of emphasis on the need to enhance pre-arrest diversion and other preventative measures. Additionally, the task force recommended the use of telecommunications for forensic assessments (i.e., telepsychiatry) in order to expedite assessments, make better use of clinical personnel and to decrease potentially unnecessary admissions to regional forensic programs. This recommendation is supported by studies such as Monnier,Knapp and Frueh (2003) and Brodey et al. (2000). Zaylor et al. (2001) conclude that telepsychiatry is an effective means of delivering mental health services to the prison population. Second, the Ministry established nine regional task forces in 2000 and 2001 whose mandate was to develop recommendations for regional and local improvements to provincial mental health services. Accordingly, the final report of the Provincial Forum of Mental Health Implementation Task Force Chairs, entitled Making It Happen: Implementation Plan for the Reformed Mental Health System (Ontario Ministry of Health and Long-Term Care 2002) advocated a broad range of strategies intended to support a community-based system of care. Key among these was new training for justice sector workers such as police, lawyers, judges, diversion workers and social service workers in the justice system. Although not all task forces dealt substantially with forensic issues, most of the reports reflect a belief that mental health diversion is advisable. Among the specific themes that recurred among the task forces' reports are: (a) increasing the number of court diversion workers; (b) improving collaboration among regional diversion workers; (c) enhancing inter-agency and inter-governmental collaboration; (d) the need for more accessible pre-trial assessment services; (e) increasing the number of available forensic psychiatrists or forensic community consultants, and (f) enhancing pre-arrest diversion initiatives. Ultimately, the task forces' recommendations regarding diversion converged on three elements: (a) more effective integration of services among various organizations within the criminal justice and mental health systems;(b) standardized policies and procedures, and (c) interagency agreements. Most of the regional reports echo the Forensic Mental Health Services Expert Advisory Panel's conclusion that the diversion of low risk offenders to the human service system as soon as possible is critical. The report issued by the Champlain District Mental Health Implementation Task Force (2002) for example, states that "police diversion is the most effective form of diversion, since it ensures minimal contact with the criminal justice system." From an evidence-based perspective, however, the confidence with which one can assert that a particular initiative is "effective" depends at least in part on the extent and nature of the available evaluative research. Importantly, it was not within the provincial advisory panel's or the regional task forces' scope to establish benchmarks regarding funding and staffing levels for various elements of mental health diversion. 5. Legal Issues Surrounding Mental Health Diversion a. The Criminalization of Mental Illness The term 'criminalization' was first used in relation to mental illness by Abramson (1972). In this classic formulation, the term refers to a social dilemma posed by the deinstutionalization of the mentally ill: "If the entry of persons exhibiting mentally disordered behavior into the mental health system of social control is impeded, community pressure will force them into the criminal justice system of social control" (Abramson, 1972, p. 103). In effect, Abramson argues that the criminal justice system reinstitutionalizes PMI by subjecting them to criminal prosecution for relatively minor offences. The criminalization of PMI, therefore, is at least partly understood as an unintended consequence of deinstitutionalization and inadequate community-based treatment. More formally, three factors are thought to contribute to the criminalization of mental illness: (a) increased numbers of persons with PMI residing in the community, (b) police handling of PMI, and (c) PMI being unable to gain access to treatment. As a result of complex structural changes to the delivery of mental health care - predicated both on fiscal necessity and a philosophical inclination toward deinstitutionalization - community-based care is now a preferred treatment modality for most PMI (Bachrach, 1978; DiCataldo, Greer & Profit, 1995). In Canada, the current round of deinstitutionalization began in earnest in the mid-90s when, as Sealy and Whitehead (2004) point out, average

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days of care in psychiatric hospitals and psychiatric units in general hospitals began to decrease, primarily due to bed closures. The movement of PMI out of hospitals and into the community led to a proliferation of PMI residing in the community without adequate supports (Sealy & Whitehead, 2004). Among the recommendations for improvement to the mental health system in Ontario are: (a) intensive case management; (b) 24-hour crisis intervention; (c) housing, and (d) supports planned and run by consumers/survivors and families (Ontario Ministry of Health, 1993; Ontario Ministry of Health and Long-Term Care, 2002). And yet, despite a general preference among mental health professionals for community-based treatment, PMI may still face a dearth of community resources because community mental health agency budgets have essentially remained static in Ontario since the early 90s. Between 1994-1995 and 1998-1999, for example, the percentage of expenditures for community-based psychiatric services (as a proportion of all expenditures) only increased from 25.8% to 27.4% (Ontario Ministry of Finance, 1995, 1999). Appelbaum (2002) notes a similar trend in the U.S. Moreover, by 2003, Ontario was to spend 40% of its mental health budget on institutional care and 60% on community services, as compared with an approximate 80/20 split in 1992/1993 (Ontario Ministry of Health, 1993, p. 28). This tangible goal has not been achieved. b. Therapeutic Jurisprudence Therapeutic jurisprudence (TJ) describes a non-traditional approach to criminal justice. Developed by Pound (1942) and revisited by Wexler (1992) and Winick (1994) who suggested that the justice system should balance two key objectives when sentencing offenders. That is, it must consider the nature of the sentence imposed and the degree to which it serves punishment and deterrence mandates, while also attending to the potential therapeutic consequences for the offender’s physical and mental well-being, and the eventual impact on society at large (Slate, 2003). Therapeutic jurisprudence represents a significant innovation for the justice system. In a traditional court, the central position is occupied by a judge (Petrila, 2003). By contrast, problem-solving courts have judges, prosecutors, defense counsel and mental health professionals, playing a more collaborative role in a more informal atmosphere. Greater emphasis is placed on offender treatment issues and problem-solving. Tables 1 and 2 in Appendix V outline some of the key differences between traditional courts and problem-solving courts informed by the principles of TJ. The advent of TJ in the American adversarial system, while welcomed by many, was equally criticized, for allegedly compromising the integrity of the criminal justice system. For example, in two situations - opponents argue - involuntary civil commitment and juvenile justice, the jurisprudence is based on the state’s parens patriae authority (Haycock et al., 1994, p. 304). Thus, “…the criminal justice system does not function on behalf of the individuals, but rather on behalf of the social order” (Haycock, 1994, p. 304). Haycock (1994) refers to TJ being perceived as a method “to stray from rights-based perspectives” which comes with “grave risks” (p. 315). Critics argue that MHCs use preferred selection in that candidates are among those with limited risks, because the new established courts’ survivability requires positive outcomes (Wolff, 2002, p. 431). Also, among other unintended consequences, the same author argues that MHCs add to demand for treatment. The consequences will be either to “cut back on the services already provided…or discharge some current clients”(Wolff, 2002, p. 433). Another negative aspect is that using the court’s powerful position, some clients will “effectively jump queues or circumvent access barriers”(Wolff, 2002, p. 433). Others are afraid that by moving services into the criminal justice system the stigma of mental illness will increase (Watson et al., 2000). Alternatively, some advocates favor of allocating resources to provide services to people before they become involved in the criminal justice system. Also controversy exists between rights discourse and TJ application. Some jurisdictions recognize a person with mental illness’s right to refuse treatment (Winick, 1994; Greer & Appelbaum, 1993). In diversion programs, clients forfeit the right to a trial by voluntarily entering the program. An innovative solution to potential conflicts between individual liberty and therapeutic interest is postulated through a constraint or balancing approach:

When therapeutic interests conflict with individual liberty, one can advocate either of two plausible relationships between the competing values. First, one can grant a priority to one value over the other such that the first serves as a constraint on the second. According to this approach, for example,

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liberty might constraint therapeutic efforts such that any therapeutic program must give way when it conflicts with protective liberty, regardless of the magnitude of the potential gains or losses to each value. Alternately, one can balance the two competing values, […] deciding a case by weighing the relative gains and losses to each value in the circumstances (Schopp, 1993, p. 517).

Informed consent and voluntariness of participation are pillars of diversion. The issue of offenders’ rights needs to be analyzed carefully in the context of diversion, especially in jurisdictions where a guilty plea is a prerequisite for acceptance into the program.

c. Overview of Diversion and Mental Health Law in Canada

Canada

Federal legislation: The Canadian Criminal Code (R.S. 1985, c. C-46) regulates matters involving mentally ill persons in contact with the criminal justice system. Section 672.11, in particular, gives the court power to “order an assessment of the mental condition of the accused, if it has reasonable grounds to believe that such evidence is necessary to determine” whether the accused is unfit to stand trial, or whether the accused was, at the time of the commission of the alleged offence, suffering from a mental disorder so as to be exempt from criminal responsibility. The court may make an assessment order at any time during the proceedings on its own motion, at the request of the accused, or at the request of the prosecutor. Such an assessment order will contain information about who is to be assessed and where the assessment will be made, whether or not the accused will be in custody during this period of time, and the period of time for which the order is in place. Section 672.38 of the same Act also provides for establishment of Review Boards in each province that are able to “make or review dispositions concerning any accused in respect of whom a verdict of not criminally responsible by reason of mental disorder or unfit to stand trial is rendered.”

Provincial legislation: Provincial mental health legislation puts into effect the way in which the Criminal Code (R.S. 1985, c. C-46) is applied. Inter-provincial variations in legislation exist in the: (a) time that a person can be held for a fitness assessment, and (b) criteria under which an individual can be detained. “[The Provinces of] Ontario and Saskatchewan have included provisions within their mental health acts that require the services necessary to support [community treatment orders] CTOs [that are] to be available in the community and require the patient to be capable of complying with the mandated treatment.” (O’Reilly, 2003). In Ontario, CTOs are implemented by the Mental Health Act (R.S.O. 1990, c. M. 7, s.33) and in Saskatchewan by the Mental Health Services Act (S.S. 1984-85-86, c. M 13.1, s. 24.3, S.S., 1989-90, c.54; 1992, c.A-24.1; 1993, c.59; 1996, c.9 and 17; 1997, c.12; and 2002, c.R-8.2). It should also be noted that most provinces have acts regulating consent to treatment such as the Ontario Health Care Consent Act, 1996.

Fitness Assessment and Involuntary Commitment in Ontario: In Ontario, a justice of the peace can issue an order for psychiatric examination under specified conditions involving threatening or imminent harm to self or others. Mental Health Act (R.S.O. 1990, c. M. 7) allows a judge to send a person suffering from a mental illness to psychiatric facility for not more than 2 months, with the consultation of a psychiatrist. Under certain conditions (Section 20. (1.1) of the Act, based on a psychiatric examination, “The attending physician shall complete a certificate of involuntary admission or a certificate of renewal.” Sections 21 and 22 of the Act provide for conditions under which a judge can make orders for the examination and admission to a psychiatric hospital (for a period not to exceed two months) of a person who appears before him or her charged with or convicted of an offence and who suffers from mental disorder.

Court Diversion Policy: The Criminal Code of Canada (R.S. 1985, c. C-46, s. 717) allows for the use of "alternative" measures. In the case of a PMI, alternative measures could include treatment. Inter-ministerial agreements have guided the development of court diversion programs in Canada (Quebec and Alberta are the only

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other provinces that have a formal court diversion program.). Based on protocols between the Ontario Ministries of HLTC and Attorney General, court diversion can be conducted at the provincial level. In 1995, the Crown Policy Manual for Diversion of Mentally Disordered Offenders (Ontario Ministry of the Attorney General, 1995) was released. When the accused suffers from a mental illness that the Crown Prosecutor believes is the underlying cause of the criminal conduct, the accused is seen as a suitable candidate for diversion. Usually violent crime renders the offender ineligible for diversion. In Ontario diversion is offered mainly for Class I offences; these may include joy riding, theft, or fraud under $5000 in damages. Diversion may also be offered for Class II offences – such as uttering threats, public mischief, break and enter – in which there are extenuating circumstances not involving violence. An accused with criminal record or who was previously diverted is not automatically precluded from diversion. As of February 4, 1998, offenders with developmental disabilities were included in the diversion protocol. We are aware that the Crown Policy manual has been under review and is slated for imminent release; unfortunately the Ministry of the Attorney General, citing protocol, declined to make a copy available for use in this study. Outside of Toronto, court diversion programs often operate in isolation. We provide, for the first time, a listing of Ontario Court Diversion Programs in Appendix Vl obtained from our survey.

Mental Health Courts: In a comprehensive review, Hanbidge (2003) notes that no new legislation has been required for the development of MHCs in Canada. Two MHCs exist currently: 102 Court established in Toronto in 1998 where psychiatrists conduct in-court fitness/not criminally responsible assessments, as well as facilitating fitness/treatment orders, and certifiability issues off site. Similarly, the MHC in Saint John, New Brunswick, established in November 2000, conducts fitness assessments and considers eligibility for diversion.

Police: In Ontario, police powers under the Mental Health Act, Section 17, allow a police officer, under certain conditions, to take a person in custody to an appropriate place for examination by a psychiatrist. The conditions under which police may apprehend the person are indicated. As well adequacy standards exist under the Police Services Act that indicates required provincial services. For example, O. Reg. 3/99, s. 13. 1, under the Police Services Act, stipulates: “Every chief of police shall establish procedures and processes in respect of, (g) police response to persons who are emotionally disturbed or have a mental illness or a developmental disability.” Other Countries: For an elaboration on legislation and policies related to all aspects of diversion in other countries involved in the survey, see Appendix VII. In these countries, the following legislation regarding diversion was found. (a) New Zealand’s federal Criminal Justice Act (Criminal Justice Act of 1985, No. 120, 1986 No. 83, 1987 No. 25, 85, and 168, 1989 No. 20, and 91, 1993 No. 43, and 93, 1994 No. 28, 1995 No. 69, 1997 No. 40, and 94, 1998 No. 37, and 78, 1999 No. 9, and 78, 2001 No. 60) and the Mental Health Act (Mental Health Act 1992, No. 46, 1999 No. 140, and 2003 No. 85), provide the legal framework for defining mental illness, compulsory assessment and treatment, police involvement and court liaison services. (b) In Australia, individual state mental health legislation governs definitions of mental illness, informed consent, assessment, voluntary admissions, and compulsory treatment and community orders. The Queensland Mental Health Act (Q.C.A Mental Health Act 2000) also provides the framework for Australia’s only MHC. Court diversion in New South Wales and the other Australian states is described in Appendix VII. (c) Similarly, in the UK, Mental Health Act (Mental Health Act 1983) defines mental illness, fitness assessment, compulsory treatment, police powers, etc. Criminal justice mental health liaison is discussed by Cooke (1991) and an evaluation of the court psychiatry program in the five London boroughs, supported by a Home Office circular, 66, 1990, is reported by James and Hamilton (1992). (d) Mental Health legislation in the US is governed by the individual state, and a review exceeds our mandate. However, federal funds have supported the establishment of 37 MHCs in 2002-2003.

6. Pre-Arrest Diversion a. Introduction In a definition proposed by Steadman, Morris & Dennis (1995), pre-arrest diversion involves the police using their discretion in laying a charge for minor offenses against an offender thought to have mental illness. As Teplin and Pruett (1992) note, involvement of the police with the mentally ill is based on two principles: (a) the protection of the

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public; (b) parens patriae, which involves the protection of the disabled citizen. Increasingly, the police are seen as the first entry point into the mental health system for PMI (Lurigio and Swartz, 2000). Pre-booking diversion, however, is a complex process that frequently involves informal assessments by the officer on the scene; in a study of 1,396 police-citizen encounters, for example, Teplin and Pruett found that police tend not to rely on conventional mental health resources or arrest, but prefer informal dispositions because it requires "neither paperwork not unwanted downtime (time off the streets)" (Teplin & Pruett, 1992, p. 152). Increasingly, police responses to PMI are becoming more formalized. Many police services are organizing so that community mental health agencies can be contacted to help with calls involving mentally ill persons and, rather than charge the individuals, assist them to obtain treatment. For example, in a study intended to identify best practices between the criminal justice system and the mental health system in four cities in Southwestern Ontario (Hartford, 2003), systemic police responses to interactions with PMI ranged from: (a) modest in-service education on mental health issues, (b) 40 hours of additional training in mental health issues for officers who would then be first responders to calls involving PMI; (c) a service agreement with a mobile mental health crisis service to attend calls from the police, and (d) a mobile crisis team consisting of mental health professionals and police officers specially trained in mental health issues. Only one study has documented a method for identifying the numbers of PMI in contact with police: an important outcome measure for assessing the effectiveness of pre-arrest diversion over time (Hartford, Heslop, Stitt & Hoch, in press). b. Synthesis and Evaluation of the Pre-Arrest Literature Of the 519 items identified in the literature review, 92 are concerned specifically with some form of pre-arrest diversion. The preponderance of these - 53 - arise from the United States. The sample of 92 articles includes no experimental studies. Most are accounts of various programs containing descriptive statistics. Thus, while quantitative evaluation of specific programs has been undertaken, the literature does not yet convey a clear and consistent picture of best practices in pre-booking diversion. Since diversion programs have only developed recently, it is unsurprising that the literature is mainly descriptive and not evaluative. Since few randomized, controlled trials have been undertaken, little is known of short- or long-term outcomes of pre-arrest diversion programs. Research tended to focus on various aspects of police training as a means of lowering arrest rates of mentally ill offenders. Such research suggested that law enforcement personnel maintained negative attitudes toward PMI and that this bias was due to lack of information (Cotton, 2004). Thus, it was proposed that police should be trained in issues related to mental illness and crisis intervention so they could better serve this population. In a survey of major U.S. police departments, 88% of the responding agencies reported that they offered some form of training for their officers in how to deal with PMI (Deane et al., 1999). Early evaluations of such training employed three primary outcome measures: knowledge of mental illness, attitudes toward PMI and changes in job-related behaviour and performance (Godschalx, 1984). These early studies provide some limited support for the ability of educational intervention to improve officers' knowledge of mental health issues. Similarly, Mulvey & Repucci (1981) examined the effectiveness of crisis intervention training for police, but found no significant differences between trained officers and a control group in terms of officers' attitudes, knowledge or performance. Despite the inconclusiveness of this early research, several distinct models of pre-booking diversion programs have since emerged. These include: 1. The Crisis Intervention Team (CIT) model, first implemented in Memphis, Tennessee in 1988. This program is staffed by officers with 40 hours of special training in mental health issues (Borum, 2000). In situations with PMI, CIT officers have a chance to defuse the situation before it escalates. Memphis CIT officers respond to approximately 7,000 calls a year. According to Borum (2000), the Memphis CIT model shows a low arrest rate for police calls involving PMI, a rapid response time, and frequent referrals for treatment. This type of program has since been adopted in Portland, Oregon; San Jose, California; and Seattle, Washington, among others. In Canada, the CIT model has been adapted by police departments in Vancouver, Camrose, Chatham and Calgary. 2. The Psychiatric Emergency Response Team (PERT) model, which has been operating in San Diego, California since 1996. The program pairs licensed mental health professionals with police officers, both of whom response to situations involving PMI. The mental health professionals and the police officers receive 80 hours of training over a four week period. According to the Council of State Governments (2001), the San Diego PERT program has

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responded to 3,000 calls since 1996, with only 1% resulting in incarceration. A similar model has been adopted in Hamilton. 3. The Crisis Mobile Team (CMT) model operates in Santa Fe, New Mexico. It is comprised of behavioural health experts who help police officers at the scene decide a course of action in incidents involving mentally ill offenders. Case managers may refer the person to an appropriate outpatient facility. Unfortunately, evaluative literature about this model remains sparse, although the program has been adapted in Canada by departments in London, New Westminister, Gatineau and Halifax, among other sites. One study has compared the three models. Steadman et al. (2000) found that the Memphis CIT model resulted in lower arrest rates (2%, compared to 5% and 13% for the other study sites), and more incidences of a PMI being taken to a treatment location (75% in Memphis, compared to 20 and 40% for the other sites). The authors attribute the difference in part to the existence in Memphis of a mental health facility with a "no refusal" policy for police cases. c. Strengths and Weaknesses of the Pre-Arrest Literature Literature on pre-arrest diversion programs has been primarily limited to descriptive accounts, and with the exception of basic program statistics, such as the numbers of people diverted by the police, there remains few outcome data in published studies. Most evaluations of pre-arrest diversion programs have taken on a formative aspect whose purpose is to identify and describe process elements, rather than analyze program strengths and weaknesses with an eye to improvement or replicability or to gauge outcomes. Consequently, the paucity of generalizable evidence about pre-arrest diversion schemes precludes definitive statements about their overall effectiveness. This implies a substantial need for further evaluative research. Moreover, the literature surrounding pre-arrest diversion provides little insight into some of the key questions behind this literature review. Other than the program descriptions noted above, there is virtually no information on optimal staffing or funding levels; nor does the literature offer rigorous evidence on which to base decisions surrounding policy, planning, or training. Nevertheless, a key strength of the extant literature is its rich descriptive nature; among the themes to arise from the literature review, there appears to be strong consensus that the following four key elements are associated with programs that were perceived to be successful. First, all relevant mental health, substance abuse and criminal justice agencies were involved in program development from the start. Numerous authors have noted that most forms of the diversion represent a profound administrative challenge, insofar as such programs necessarily require collaboration among agencies with diverse goals and objectives. For example, Steadman et al. (2001) studied a pre-arrest programs in three communities using a primarily descriptive design and concluded that collaboration among stakeholders was a fundamental element of the program's survival. In an earlier study, Steadman et al. (1995) noted that interagency agreements or memoranda of understanding (MOU), in which agencies specify the availability of services to one another, were essential for success. Second, regular meetings between key personnel from the various agencies were held. Deane et al. (1999) conducted case-study analyses of two pre-booking diversion programs and concluded that the teams benefited from frequent inter-agency contact in making disposition decisions. The trained officers provided security, transportation, law enforcement field resources and knowledge about handling violence. The mental health specialists provided knowledge about mental illness and experience in diagnosis, crisis evaluation, and interacting with psychiatric patients. Overall, the teams increased the percentage of PMI who had access to the mental health systems. Third, streamlining services through the creation of a dropoff center with a no-refusal policy for police cases is seen as crucial. For example, in their 2000 study comparing various models of police response,

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Steadman at al (2000) attribute differences in arrest rates and referral to treatment to the availability in Memphis of a crisis triage center with a no-refusal policy for police cases. This specialized crisis response site allows police to drop off individuals in psychiatric crisis and return to their regular patrol duties. The authors note several principles that are important to the operation of these crisis response sites: having a single point of entry; having a streamlined intake and a "no refusal" policy for police cases; and linking clients to community services. A fourth related theme in the integration of services is that of a liaison person or "boundary spanner" with a mandate to effect strong leadership in the coordination of various agencies (Steadman et al., 1999, p. 1620). Whether or not a specific position is created, an experienced individual who has the trust and recognition of people from each of the systems involved can bridge administrative difficulties inherent in interagency collaboration. In a descriptive account, James (2000) argues that diversion schemes in the U.K. suffered because of the "disparity between the role that each agency is supposed to perform and the reality of its training and availability" (p. 535), a problem compounded by the lack of any effective coordination between the agencies involved, or the lack of any professional with a specific mandate to pursue such coordination. 7. Court Diversion a. Introduction Pre-trial court diversion generally refers to the crown's decision not to prosecute eligible offenses if a charged offender with mental illness agrees to treatment. Often, such programs are known as post-booking, pre-arraignment schemes (Steadman et al., 1995). In Ontario, crown attorneys who wish to implement some form of diversion are guided by the Crown Policy Manual (Ontario Ministry of Attorney General, 1995). Requests for diversion may come from the defense counsel, the police, various mental health services, diversion workers, court staff, or from citizens. The Criminal Justice / Mental Health Consensus Project Report (Council of State Governments, 2001) identifies four elements of the pre-trial court diversion process. These include: (a) appointment of counsel; (b) assessment of the offender; (c) consultation with the victim, and (d) prosecutorial review of charges (including the decision to divert). While most pre-trial diversion programs tend to consist of the same general procedures, they may vary enormously in terms of staff and resources. For example, the diversion team for a pilot program associated with the Adelaide Magistrates Court in Australia consisted of a coordinator with a background in mental health and disability issues, a clinical psychologist who oversaw assessments, and a mental health liaison officer responsible for advising mental health service providers (Burvill et al., 2003). In Ontario, however, diversion teams in smaller or rural communities may consist of a single psychiatric nurse (Swaminath et al., 2002). b. Synthesis and Evaluation of the Court Diversion Literature Unfortunately, little is known of the long-term outcomes of pre-trial diversion programs. Few studies follow up and evaluate the outcomes of pre-trial diversion of adult offenders with mental illness. Moreover, it is difficult to gauge the overall effectiveness of court diversion programs due to jurisdictional/regional variations in treatment and resources, and to varying conceptualizations of "effectiveness," which preclude the meaningful comparison of study findings. Terminological confusion notwithstanding, such evaluative literature as exists tends to focus on the following process and outcome variables: recidivism, compliance, monitoring/case management and treatment/community services. In a study of court diversion programs in two Ontario communities, Swaminath et al. (2002) found low recidivism rates (2% and 3%) one year after diversion. The authors caution, however, that selection bias may account for this insofar as the Crown Attorneys may have screened out offenders with criminal histories. Furthermore, diversion was not recommended if a program of treatment was unavailable or could not be monitored. In their study of a Los Angeles court diversion program, for example, Lamb et al. (1995) defined an unsuccessful outcome if, during a

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year after arrest, a study subject had been psychiatrically hospitalized or arrested, had committed physical violence against others, or was homeless. The authors found that 46% of those who had participated in the program had a successful outcome, whereas 54% did not. In a U.K. study of 65 mentally disordered offenders, Chung et al. (1998) found little difference in the quality of offenders' lives six months and one year after diversion. The authors caution, however, that the results may not be generalizable due to the due to the highly transient nature of study subjects, and due to the nature of treatment options available. The authors found that few of the subjects had stable accommodation within the year-long measurement period. Additionally, none of the subjects' treatment was monitored, nor were they assigned case managers. Only 14% had regular contact with social workers and only 13% had regular contact with a physician; the authors surmise that compliance would have improved with secure accommodation and monitored treatment. According to Hiday (2003), homelessness is a strong predictor of recidivism, a finding echoed by Australian researchers Hunter & McRostie (2001). Few studies actually investigate the effect of specific aspects of court diversion programs on treatment or other outcomes. For example, in terms of pre-trial diversion, only Steadman et al. (1999) studied measures to improve diversion rates. These authors suggest that active case finding - noted in 8 of the 13 diversion programs studied - tends to result in offenders being linked more quickly to diversion programs and to mental health services. As is the case with many field studies, however, this article is insufficiently controlled to rule out confounding variables. c. Strengths and Weakness of the Court Diversion Literature In conclusion, the long-term outcomes of pre-trial diversion are vastly understudied phenomena. The preponderance of literature consists of program descriptions or evaluations whose focus on outcomes is limited primarily to the collection of descriptive statistics regarding program enrolment and completion. With the exception of the studies noted above, there has been little effort to gauge the effect of diversion on recidivism, or on quality of life. Nor has there been much systematic effort to delineate factors that contribute to successful diversion. Despite this, the literature on pre-trial court diversion tends to support the following themes: Some studies of diversion programs note difficulties in creating awareness of the pre-trial diversion option among lawyers and court staff, who may not be aware of mental health issues (James, 1999). Swaminath et al. (2002) found that some lawyers were not aware of the diversion procedure or found it cumbersome. In other studies, the application to divert was made by professional staff who were knowledgeable about mental health issues (Chung et al., 1998). Lamb et al. (1996) suggest it is crucial for nonclinicians in the criminal justice system to have assistance in recognizing mental illness.

Formal case finding procedures are important for the early identification of mentally ill offenders in need of services. In the U.S., court diversion workers are able to make rapid and regular use of both mental health and criminal justice information systems to learn more about an individual's history (Steadman et al., 1995). While similar links between criminal justice and mental health information systems may not be practicable in all jurisdictions, some accounts of diversion programs suggest that, at minimum, program staff check daily rosters of jail and remand inmates to find clients, interview them, recommend diversion if appropriate, and link them to mental health treatment (Macfarlane et al., 2002). Diversion is a realistic enterprise only to the extent that adequate resources exist in the community. The few long-term studies support the proposition that stable accommodation enhances the possibility that the divertee will remain in regular contact with her or his treatment provider (Chung et al.,1998; Lamb et al., 1996; Hiday, 2003). Moreover, lawyers or court workers may be reluctant to apply for the diversion option if a program of treatment is unavailable. There is a general consensus in the literature that extended mental health treatment combined with active case management improves compliance and reduces the likelihood of recidivism (Cervantes et al., 1987;

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Steadman et al., 1999). Case managers perform critical functions, including client identification and outreach, evaluation, direct consultation to the courts, and the development of an appropriate treatment plan, among others. An equally important function, however, is that of monitoring the client's treatment to determine whether services are in place and whether the client is compliant. 8. Mental health courts a. Introduction In MHCs, judges and attorneys work with clinicians and defendants to fashion treatment alternatives to trial (Haimowitz, 2002). The oldest extant MHC in the United States was established in Broward County, Florida, in May, 1997. The Broward County program involves a specialized court dedicated to handling PMI accused of nonviolent, low-level misdemeanor offenses, excluding driving under the influence and domestic violence. The court was created specifically to balance issues of treatment and punishment for defendants with mental illness and was modeled after the drug court introduced in 1989 in Dade County, Florida (Steadman et al., 2001). Funding for the $2 million program was provided through the budgets of state and county governments and miscellaneous sources (Lurigio & Schwartz, 2000). King County's mental health court was modeled after the Broward County program. Beginning operation in February, 1999, this program is funded by the Bureau of Justice Assistance, and local criminal justice and mental health systems. The annual cost of the program is $900,000, most of which is spent on treatment. b. Mental Health Courts in Canada Currently, there are two MHCs operating in Canada. Court 102 in Toronto began operation in 1998, sponsored by the Attorney General, the Ministry of Health and Long-Term Care, and the Solicitor General (MacFarlane et al., 2002). The creation of this dedicated court was motivated by factors such as the perception of an increased number of mentally disordered accused in the criminal justice system, and the inability of regular courts to provide an appropriate response to this population, as well as the slow rate of processing these cases. The features of Court 102 include: shared spaced with the Ontario Review Board to facilitate fitness assessments; a psychiatrist on site five afternoons a week to conduct assessments; mental health workers and a case manager; adjoining cells, dedicated duty counsels, crown attorney and judges. As Court 102 has evolved, it has come to function primarily as a fitness assessment court, although other support services are available (MacFarlane et al., 2002). The mental health court in Saint John, New Brunswick, began in November, 2002. The court was initiated by a judge and crown prosecutor as a response to an apparent increase in the number of mentally ill offenders appearing in provincial court. The current court team consists of representatives from three sectors: (a) officers of the court - judge, crown prosecutors, Legal Aid defense counsel, and probation officers; (b) clinical professionals - psychiatrists, psychologist and mental health nurses; (c) community-based residential services - the Salvation Army and special care homes (Goggin et al., 2003). The initiative was funded under the Legal Aid Initiative. There are two main phases in the St. John Mental Health Court process: (a) the Admission phase consists of four components: Presentation, Eligibility, Compliance and Acceptance, and; (b) the Program phase during which an accused participates in a judicially monitored program. This phase continues until the accused graduates, voluntarily withdraws or is removed from the program. c. Synthesis and Evaluation of the Mental Health Court Literature Although the Broward County program has been a highly influential model for subsequent mental health courts, no single conceptual model common to all MHCs has yet been established (Slate, 2003; Petrila, 2003). Consequently, much literature surrounding MHCs is less evaluative than normative. As Steadman et al. (2001) point out, "almost any effort by the courts to better address the needs of PMI who engage with the criminal justice system can qualify as a mental health court […]. In its confusion, the concept has come to have little meaning" (p. 458). Several scholars have attempted to redress this conceptual confusion by delineating the necessary constituents of an MHC. Among the most thoughtful of these efforts are Steadman et al. (2001), Slate (2003) and Goldkamp & Irons-Guyn (2000). Following are common elements of MHCs, culled from the work of these authors:

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• All PMI identified for referral to community-based services are handled on a single court docket; • A courtroom team approach is used to arrive at recommended treatment and supervision plans; • Assurance of the availability of appropriate treatment is necessary before the judge rules; • Appropriate monitoring occurs under the aegis of the court, with possible sanctions for noncompliance such as reinstituting charges for sentences; • Court staff, including judges, function in accordance with principles of therapeutic jurisprudence; • Participation of all key players from the initial planning process of the mental health court to periodic meetings and evaluation after the court is operating; • Much of the courtroom process is aimed at making an initial assessment of an individual for mental illness, and then moving the person with mental illness out of jail and voluntarily into treatment as expeditiously as possible; • A linkage to a varying range of treatment and support services, underpinned by inter-agency cooperation and collaboration. Despite these common elements, MHCs may vary in the way they deal with mentally ill offenders. Griffin et al. (2002) found that some courts tended not to accept a plea and to withhold adjudication, whereby charges would be dismissed upon successful completion of requirements (i.e., treatment) set by the court. In other courts, an individual would be convicted and then placed on probation, sometimes via a deferred or suspended sentence. Many of the courts stayed charges once the treatment program had been successfully completed. In one jurisdiction, after successful complete of a treatment program, the guilty plea can be withdrawn. In another court, once charges are dismissed, a request for expungement of the arrest from the record can be made (Griffin et al., 2002). Varying methods of supervision also exist. Supervision may be maintained by representatives from area community treatment providers, probation officers or MHC staff, or teams composed of both mental health and probation personnel. These personnel can also be utilized in hearings to assist the court in monitoring the progress of those under supervision by the court (Lurigio & Swartz, 2000; Petrila, 2003). Relatively few courts resorted to jail confinement as a sanction for noncompliance. Employees under the MHC's control can also function as boundary spanners or resource brokers to ensure that PMI who appear before the court can be linked to services such as treatment, benefits, housing, or employment opportunities (Steadman et al., 2001). Boothroyd et al. (2003) studied the case outcomes of Broward County's Mental Health Court over a two-year period. They found that at the conclusion of the initial hearings, the defendant's legal case remained open in about one-third (36%) of the cases. These cases were usually scheduled for a "status hearing" several weeks later at which the court would receive information about the defendant's participation in treatment, and would reconsider the legal status of the case. d. Strengths and Weaknesses of the Mental Health Court Literature As is the case with pre-arrest and court diversion schemes, the effectiveness of MHCs in reducing future contacts with the legal and medical systems (i.e., arrests, convictions, hospitalizations, etc.) has not yet been evaluated rigorously (Steadman et al., 2001). Although MHCs have been studied, this work tends to be primarily descriptive, and is hampered by an absence of data regarding participants, the services employed, or outcomes (Goldkamp & Irons-Guynn, 2000). Nevertheless, several evaluations have been undertaken, and we discuss these below. In evaluating the effectiveness of the Seattle MHC, Trupin & Richards (2003) used a pre-test, post-test design in which they studied charge, detention and mental health data for participants before and after their contact with the MHC. In most cases (n=65), the measured effects were in the direction expected for programs intended to reduce crime and criminal justice sanctions. Evidence for increased treatment referral and treatment compliance was unequivocal. The authors acknowledge, however, that in the absence of a comparison group, some of the indications of effectiveness used in the study - charge severity, global assessment of functioning ratings, and booking rates - may arise from elements in the criminal justice system other than the MHC (such as police handling and the nature of treatment).

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Boothroyd et al. (2003) found that participants (n=95) in the Broward County MHC were more likely to become engaged in the mental health treatment system that participants in a regular court (Hillsborough County, n=97) over the eight months after their initial court appearance. Additionally, regular court defendants were 50% more likely to stop receiving treatment after their court appearances relative to MHC defendants. In a related study, Poythress et al. (2002) found that offenders participating in the Broward County MHC did not experience their involvement in the court to be coercive. Cosden et al. (2003) compared the results of an MHC in Santa Barbara that employed an assertive community treatment (ACT) model of case management (n=137) with treatment as usual (TAU, n=98). The ACT model consisted of frequent contact with case managers, transportation to meetings, housing assistance, vocational training, and group skills training. TAU consisted of adversarial criminal processing and referral to the long-term care team associated with local mental health services, where PMI received housing assistance and some vocational training. Considerable variation was found in services received by clients in the latter model, although both groups experienced similar gains in quality of life self-assessments. Moreover, both groups experienced less self-reported distress at the end of 12 months of treatment. In terms of criminal activity, clients in TAU were significantly more likely to commit and be convicted of a new crime during the 12 months subsequent to their beginning the TAU program. Finally, participant in the MHC treatment program demonstrated greater self-reported gains in developing independent living skills and reducing problems with drugs and/or alcohol. Again, factors confounding these results are the validity of the self-report measures. Thus, while there is some indication that mentally ill offenders benefit from their participation in mental health courts, the evaluative literature has not year achieved the "critical mass" necessary to create generalizable, evidence-based knowledge. In an evaluation of the King County MHC, Neiswender (2003) found that during the year after their initial court appearance: 75% of the program's graduates did not commit a crime during the following year; jail time was reduced by 90%; and fewer than 10% committed a violent crime. Neiswender concludes that the "King County Mental Health Court significantly reduces criminal activity" (p. 10). Since this report does not include a control group, it is likely that the term "significant" is best interpreted in a colloquial rather than statistical sense. In his assessment of the Maricopa County MHC, Stodola (2004) uncovers similar indications of effectiveness as Neiswender, but since Stodola's observation period encompasses only three months and since his sample includes only 14 offenders, comparisons are difficult. Stodola is the only researcher to consider whether MHCs are more cost effective than traditional courts, but concludes that insufficient data exists to answer the question. 9. Site Visits a. Context of the Site Visits Rather than conducting site visits after the survey was developed as originally proposed, the site visits were used to develop the survey. Since the principal investigator was familiar with courts in Southwestern Ontario (Hartford, 2003), four site visits in Toronto were conducted in April, 2004 and key informants in these settings were interviewed in person or by phone (Appendix VlIl). It should be noted that Mount Sinai Hospital, which was not included in our site visits, provides court support services for the Black and Asian communities in Toronto. In 2002, a review of five court support services was conducted (MacFarlane, 2002). The report identified Toronto has having a mixed model of mental health services in the courts with one dedicated MHC (which conducted mostly fitness assessments although support services were available at theToronto mental health court) and mental health services that operate in courthouses with no dedicated mental health court (we noted that one court that we visited had since dedicated a docket to mental health). Among many recommendations was the need for the development of a program, protocols, outcome measures, etc. Also an internal review of the two CMHA court support teams was conducted in 2004 which provides a detailed description of the two programs’ similarities and unique differences. Direct program costs were calculated from approved budgets and data such as number of clients served, proportion of time spent in consultation/case management, client demographics, previous history, pending charges, etc. were abstracted from an established database. While more linkages with community

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agencies were identified as a service need, the need for a common management information system (MIS) data system was also identified. In Janurary, 2003, the Consortium on Mental Health Services in Toronto Courts was formed. It was composed of the Executive Directors of CMHA-Toronto, COTA Comprehensive Rehabilitation and Mental Health Services, Community Resource Consultants of Toronto, and representatives of CAMH and the Ministry of the Attorney General. To date, the Consortium has produced: (a) Vision and Mission Statement; (b) Court Support Worker Activities Statement; and (c) Policies and Procedures. Dialogue with key informants at the Centre for Addiction and Mental Health (CAMH) and the Canadian Mental Health Association (CMHA) -Toronto identified further resources such as an Agreement between the Ministry of the Attorney General and CAMH for forensic services. b. Findings from Site Visits Observations resulting from our site visits included: (a) mental health personnel connected to the court have a wide variety of background preparation in mental health and criminal justice issues. Most were operating with no formal education/training in criminal justice issues; rather they had learned on the job. (b) Mental health personnel were all paid by community mental health agencies. Their ability to quickly access community resources varied widely, e.g. access to Schedule 1 beds, supportive housing, etc. (c) Psychiatrists’ time was reimbursed by the Attorney General’s Department through an agreement with CAMH; one psychiatrist was reimbursed by CMHA. One court had a community psychiatrist who would accept referrals. (d) Mental health personnel connected to the court identified eligible clients in a variety of ways that seemed dependent upon their relationship with the Crown. Close, established relationships saw CSW case-finding in the cells, at bail court, with police, etc. When this relationship was not as established, the crown referred cases to the CSW. As the relationship evolved, more “difficult” clients were referred, i.e., multiple offenses, more severe offenses. (e) Not one court or agency could identify all the costs associated with the CSW and the court diversion process; two courts had identified direct costs for their internal report. (f) All courts had dedicated psychiatrist/s available for fitness assessment from 1 half day/week to 5 half day/s week. It should be noted that this does not occur in most of the province. Only one court had dedicated judges, legal aid defence counsels, mental health court workers, and case managers. (g) Office conditions ranged from cramped and dingy to small and new: office conditions seemed to be irrelevant to functioning. Access to the crown, defence counsel and private interviewing rooms were viewed as important. (h) In the Toronto area, there were movements underway to standardize forms, job descriptions, etc. (i) CSW’s duties ranged from direct contact with clients, crowns, psychiatrists and defence counsel, to indirect consultation to clients at the request of the judge (up to 60-70% of CSW time in one site). At one site, a fulltime dedicated court existed while in one other site a weekly docket was dedicated to mental health clients, but this wasn’t entirely satisfactory because the docket before it often spilled over into it. Frustrations mentioned included: (a) lack of access to Schedule 1 beds for acute clients, (b) clients’ deterioration in the cells or jail because of lack of timely assessment and treatment, (c) lack of dedicated defence counsel, dedicated crowns, dedicated court rooms and court dockets, lack of community psychiatrists for referral, lack of housing and case management. It was acknowledged that volume of cases did not always justify a dedicated court, and in these cases a dedicated docket, crown and defence counsel would be appropriate. Outcomes: Charges stayed represented a successful outcome in one court, letters of satisfaction in another, and reduced recidivism. In other instances, no outcomes were assessed. Monitoring of compliance with the diversion plan is done by phone at several courts. Some courts declined to stay the charges if the client didn’t comply with the diversion plan; some courts will not allow a person who re-offends to be diverted, while others do. All CSWs could provide the number of clients served annually, most knew whether re-offense had occurred in their jurisdiction but other outcomes were not known. 10. Survey Results Because of the difficulties involved in compiling a comprehensive sampling frame of all diversion programs in Canada, the United States, the United Kingdom, Australia and New Zealand, this survey was intended from the

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outset to yield a “snapshot” of mental health diversion as it is commonly practiced, rather than a statistically generalizable dataset (see Appendix II). Since the agencies to which we distributed the survey were compiled from numerous secondary sources – some of which proved to be obsolete or inaccurate – we are unable to assert that the 266 potential respondents represent the actual statistical population of all mental health diversion programs. Nevertheless, the survey provides a glimpse of common practices and concerns among the 125 respondents (47% response rate). In the field of mental health diversion that is not reflected in the literature. Specifically, we found that the following themes represent pervasive concerns in the field: •The need to link mental health diversion practices to housing and accommodation for PMI;

•The importance of enhanced community mental health services, and their integral connection to successful diversion programs;

•The advisability of intensive cross-training at all levels of mental health diversion practice; •The seemingly pervasive shortage of forensic beds and treatment facilities. Consistent with accepted practices of qualitative research, we present the key themes and illustrative raw data below. Key observations are noted in bold. a. Pre-arrest Diversion Of the 54 police departments and pre-arrest diversion programs to respond, 30 were from Canada, 16 from the United States, six from the United Kingdom and two from Australia. Theme 1: Type of Program Twenty-six respondents (48%) noted that they did not have a formal diversion program in place, while 15 (27%) responded affirmatively. Forty-three of the respondents (79.6%) were unable to indicate how many PMI they diverted in the previous year. Those departments and programs (n=9, 16%) who did respond to this question indicated a wide range of diverted PMI, from a high of 1,700 to 6. Twenty-one (38.8%) of the respondents noted that their department's program involves a Crisis Intervention Team, while an equal number note that their department's program is associated with a mobile response agency. Only 19 (35%) of respondents offered a brief description of their program; the following comments indicate the range of program types: "Advice given to custody staff on mental health issues and if it is the public interest to prosecute. This is dependant on the nature of the offence"; "[Our department] has a team of trained masters-level mental health specialists who provide 24/7 mobile, on-site crisis intervention to stabilize consumers and link them with community mental health resources - Mental Health Association, NAMI, Mental Health Center and Mental Health Court. In addition, the Crisis Unit trains all officers on defusing volatile situations"; "Community Service Officer Unit consists of civilian social workers, who work to assist officers in many situation involving a person with mental illness. This can include an emergency psychiatric evaluation"; "Crisis Intervention Team program. We provide 40 hours of experiential training to volunteer officers (25% of patrol) on mental illness and communication/active listening techniques. The objectives of the program are to help keep officers and mental health consumers safe by educating officers about mental illness and less physical tactics and techniques that have proven to be effective in helping officers de-escalate these difficult, potentially volatile situations involving individuals in serious mental health crises." Only 13 (24%) of respondents noted that their departments have written criteria that officers use to assess whether an individual is an appropriate candidate for diversion. The majority of respondents indicate that they rely on the officer's discretion on the scene, as the following comments suggest: "Officers have to use their own experience in making the initial assessment"; "People arrested for offences and taken to a police station can also subsequently be assessed by mental health care professional"; "[The decision to divert is done on a] case by case basis, depending on the incident at hand, the input from the victim (or property owner if property crime) input from mental health staff"; "Diversion is completely ad-hoc, done on a case by case basis."

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Theme 2: Training As might be expected, the current mental health training for police officers encompasses a wide spectrum; several respondents (particularly those with formal diversion programs) report intensive training in mental health issues (up to 40 hours of CIT curricula), while 16 (29.6%) of respondents indicate that officers receive no special training in mental health issues at all. Not surprisingly, therefore, 32 (59.2%) of the respondents noted that more training is needed. Generally, the additional training perceived as necessary concerns diagnostic issues and de-escalation of potentially volatile situations. The following comments are indicative of the range of suggestions: "Training needed related to dual diagnoses issues. When the crisis unit is called, it is very rare for the client to be admitted to hospital. The police are left to deal with a mentally ill client, who is usually off their prescribed medication and causing problems in the community. The police need training on the quickest way to resolve a situation and assist the client with the best solution possible, always trying to prevent arrest"; "1. Learning how to interact with [PMI]. 2. knowing and observing behavior. 3. Knowing how to articulate your observations correctly to health care professionals"; "Because it is difficult for small, rural police departments to send more than two officers at a time to a week-long training, we feel the need to offer a one day basic course so that all officers have some training, awareness and skills to respond to this population." Theme 3: Outcomes and Monitoring Thirty respondents (55%) indicated that they do not have specific criteria to monitor the diversion program's success. Of those who responded affirmatively, outcomes revolved around the following factors:

Increasing the number of officers trained to deal with mental health issues; Increasing the percentage of PMI diverted from jail to treatment; Decreasing the percentage of use-of-force incidents when dealing with the mentally ill; Reduced recidivism in identified PMI; Comparing percentage of diversions from jail to treatment with previous year, and by CIT and non-CIT members; Number of arrests of the mentally ill to the previous year.

Theme 4: Services and Referral Options Twenty-four respondents (44%) did not identify services or agencies to which their departments divert PMI. Of those who did respond, below are the most common agencies or services provided to clients (proportion of respondents accompanies each category):

Crisis intervention 42% Case management services 35% Risk assessment 29% Assistance obtaining medical care 25% Medication management 21% Housing assistance 19%

Assistance obtaining financial aid 15% Assistance with other benefits 15% Day treatment 15% Individual therapy 13% Group therapy 10% Money management 8%

Frequently mentioned 'other' categories of treatment or service include:

Substance abuse 31% Acute care hospitalization 25% Family therapy 17%

Safe beds / crisis beds 17% Long-term care hospitalization 13%

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Seventeen respondents (31%) noted that other services should be available. Of these, the availability of, and access to, treatment facilities and appropriate programs was most frequently noted. The following comments are typical: A locked facility that that is neither a jail or hospital and can be accessed voluntarily by those with a mental illness. It would provide a place of safety to the individual"; "Our mental health services are seriously under-funded, relative to the need. There is request for increased services in our local regional jail for persons who are not diverted"; "Department should have access to a safe bed/crisis bed program outside of the local hospital emergency room"; "Emergency beds"; "Housing and home care are sadly lacking for individuals with MH issues. Shelters are virtually non-existant, immediate 'almost' emergency care other than the hospital emergency room does not exist. Drug/alcohol treatment for those who are dually addicted isn't accessible. Emegency assistance with essentials such as food and general hygiene is also scarce"; "In this county we have a deficit of beds available for: children and teen-agers, dual diagnoses patients, people who need alcohol detox, locked long-term psychiatric hospitalization, and subacute care." Finally, despite the clear convergence in the literature on the importance of local mental health facilities with a 'no refusal' police for police cases, only 10 (18%) of respondents reported the existence of such a policy in their jurisdictions. Similarly, only 17 (31%) of respondents noted having established formal memoranda of understanding with other community agencies. A sample from the London Police Services and London Mental Health Crisis Service, who permitted the inclusion of their MOU, is included as Appendix IX. On a state level, a portion of the MOU between Tasmania’s Department of Health & Human Services and Tasmania’s Police Department is also included in Appendix IX. The remainder of the document is available at : http://www.dhhs.tas.gov.au/ partnerships/ strategicpartnerships/#police. Theme 5: Costs and Cost Effectiveness Only 11 respondents (20%) were able to provide an estimate of their program's annual budget. Responses ranged from a low of $3,000 to a high of $3,000,000. Since existing institutions (i.e., police departments) tend to encompass pre-booking diversion programs, it is likely that respondents were unable to easily distinguish the direct and indirect costs of their diversion programs. Funds tend to be provided predominantly by state or county governments and/or agencies. b. Court Diversion Programs Of the 43 diversion programs to respond, 16 were from the U.S., 17 were from Canada, eight from the United Kingdom and two from Australia. Estimates of the programs' annual volume ranged from a low of 10 divertees per year to a high of 360. Theme 1: Training Twenty (46.5%) of the respondents noted that legal team members associated with the program have received training in mental health services, while 8 (18%) did report such training. Following are some typical comments: "It varies according to the position of the staffing team. Some participants are mental health case managers while others need to know only the basics"; "We have working relationship with legal counsel in the community but no direct legal team. They would have access to a large number of mental health related training if interested"; "Regular meetings with Municipal Court Judges on activities, outcomes and problem solving. Make modifications in format and referral / follow-up procedures"; "The Coordinator of the Diversion Program receives ongoing mental health training on a variety of topics, e.g., mental illnesses, concurrent disorders, forensic conferences, in-service workshops."

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The current amount of training for legal team members ranges between one to 24 hours, with the average being eight hours. Nevertheless, 12 (27%) of the respondents noted that more training is needed. Generally, the additional training perceived as necessary concerns more uniform education about basic mental health issues. The following comments are indicative of the range of suggestions: "It would be helpful for prosecutors, defense, and judges to have some standard mental health training"; "Understanding of mental health problems, limitations of treatment, knowledge of Mental Health Act"; "Ongoing training would be helpful to legal firms in the community about the diversion program and issues concerning mental illness. Training for staff in the diversion program could include overviews of the system and methods of presentation to Crown to assure that charges would be divertable"; "Overview of Mental Health Services and which disorders seem to respond better to treatment. Also some intervention techniques may be helpful"; "Lawyers should be given an annual overview of SMI's, i.e. mood & thought disorders and of the CMHA's Justice Support Services program." Twenty-four respondents (55.8%) noted that diversion workers received training in mental health law and/or court procedures. However, sixteen (37%) also note that more training for diversion workers is needed. As is the case with mental health courts, most comments in this category suggest that more formalized and intensive legal training would be beneficial: "More cross-training would be helpful to all team members. Most of the current training is "hands on" in the court room"; "Basic law and how the system works"; "Better understanding and legal language, different procedures within legal system"; "Court procedures, language of the courts, approach to Crown for Diversion of difficult charges, dealing with police." Theme 2: Outcomes and Monitoring Twenty-one respondents (48.8%) noted that they had established outcomes for the programs's clients. In general, these outcomes revolved around factors such as compliance with the treatment program, reduced recidivism, and reduced days in jail. As well, 25 respondents (58%) noted that they had established methods of monitoring clients' outcomes. These methods tended to include reports from treatment/service providers, regular staff meetings, and reports from case managers. Theme 3: Memoranda of Understanding Despite the importance of formal memoranda of understanding identified in the literature, only 13 respondents (30%) noted having established such agreements. Some programs, however, did forward copies of their formal memoranda of understanding to us. As with mental health courts, these tend to specify the exact nature of services and obligations (including financial) among participating agencies (See Appendix X for an example of such an agreement, from the Chesterfield/Colonial Heights Community Corrections Services, who permitted the inclusion of their MOU). Theme 4: Treatment Options Only 10 respondents (23%) note the availability of on-site psychiatrists or psychologists to conduct fitness or competence assessment. Conversely, 16 respondents (37%) note that such services are available off-site. Below are the most common agencies or services provided to respondents' clients (proportion of respondents accompanies each category):

Crisis intervention 75% Housing assistance 72% Case management services 69% Risk assessment 66%

Assistance with other benefits 59% Referral for other therapy 59% Assistance obtaining financial aid 50% Money management 50%

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Assistance obtaining medical care 63% Individual therapy 63% Medication management 63%

Group therapy 38% Day treatment 25%

Frequently mentioned 'other' categories of treatment or service include:

Substance abuse 63% Acute care hospitalization 56%

Safe beds / crisis beds 31% Emergency room treatment 28%

Fifteen respondents (34%) noted that other services should be available. Of these, increased housing, more treatment facilities and community services were mentioned most frequently. The following comments are typical: "A psychiatrist on site at the court house"; "Forensic beds easily accessible in an emergency"; "More direct intervention should be provided for those who are not so ill as to warrant immediate hospitalization"; "Integrated inpatient substance abuse/mental health treatment. Crisis beds. Access to medication in a timely fashion upon release from jail"; "More money for housing, day treatment"; "On site court diversion worker at the court house would be very helpful." Interestingly, only one respondent noted the Psychosocial Rehabilitation Toolkit as a key means of monitoring clients’ progress and outcomes. Theme 5: Costs and Cost Effectiveness 16 respondents (37%) were able to provide an estimate of their program's annual budget. Responses ranged from a low of $50,000 (U.S.). to a high of 2,600,000 pounds (AUS). The average cost reported was roughly $100,000 (US). Respondents were generally unable to provide information about the cost effectiveness of their programs. Funds tend to be provided predominantly by state or county governments and/or agencies. Mental Health Courts Of the 28 mental health courts to respond, more than 90% identify themselves as dedicated courts. Twenty-six of the courts were from the U.S., one from Canada and one from Australia. Sixteen of the respondents noted that their courts meet once a week, two meet for half a day each week, and four of the courts meet two, three, five and seven days a week respectively. Theme 1: Training Twenty-one (75%) of the respondents noted that legal team members associated with the court have received training in mental health services. Following are some illustrative comments: "All team members have received training on the history of mental health courts, goals and objectives, and signs and symptoms of mental illness"; "[Our training consists of] conferences, workshops, in-services. Most of our team have graduate degrees in Psychology or Social Work so they already have considerable mental health knowledge"; "We are designing some special legal mental health training through University of South Florida for the near future as the Public Defender's office request"; The current amount of training for legal team members ranges between one to 28 hours, with the average being about ten hours. Nevertheless, 22 (78.5%) of the respondents noted that more training is needed. Generally, the additional training perceived as necessary concerns diagnostic criteria and more intensive crosstraining. The following comments are indicative of the range of suggestions:

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"Additional training in the area of co-occurring disorders (mental health/substance abuse) and treatment modalities, traumatic brain injuries, and fetal alcohol spectrum disorders"; "Could benefit from updates on best practice clinical models; current medications and side effects; trends and practices in other jurisdictions and countries"; "Currently a curricula is being developed regarding judicial education and education for criminal justice partners concerning mental health courts and other collaborative justice courts, and court principles/practices that can be integrated into the larger court system"; "Diagnosis and behavior patterns, treatment and best practices"; "Information dealing with DSM IV criteria and medications. I believe there also needs to be more comprehensive cross-systems training." Seventeen of the responding courts (60.7%) noted that mental health team members of the court received training in mental health law and/or court procedures. The majority of this training, however, appears to occur on an informal or ad hoc basis, as the following responses suggest: "All of our team have been involved in the court and legal systems for many years"; "Once in position, training on an ad hoc basis as per needs of individual and specifics of population in question. Members are selected because of their background in mental health issues, so expected to have prior knowledge." Again, however, 17 respondents (60.7%) noted that more training for mental health court team workers is needed. As the following comments indicate, most comments in this category suggest that more formalized and intensive legal training would be beneficial: "Could benefit from updates on developments and emerging trends in problem-solving courts"; "Court process and proceedings, outcomes of criminal prosecutions, normative response to illness: consumer and family, staffing procedures"; "Court process and proceedings, probation responsibilities, outcomes of criminal prosecutions, normative response to illness: family and consumer, staffing procedures"; "How court system works, sentencing guidelines." Theme 2: What the Court Does Twenty-two (78.5%) of respondents estimated that roughly only 10% of the court's time is spent on fitness assessments, and 5% on involuntary inpatient commitment or treatment orders. Twenty-one (75%) of respondents indicated that the preponderance of the court's time was spent on developing treatment dispositions and monitoring offender's compliance with court directives. The most common sanctions for non-compliance with treatment included increased monitoring and withdrawal from the program. Twenty-two (78.5%) of the respondents noted that jail time is also used as a sanction for non-compliance. Bench warrants are the most common judicial responses to failure to appear. Most respondents indicate that mentally ill clients may spend up to a week in jail waiting for an initial hearing (two courts noted that clients may spend up to a month waiting for a hearing), up to two weeks in jail waiting for a fitness assessment, and up to a week in jail waiting for a treatment plan to be put into place. The longest jail time was identified as waiting for forensic care beds or acute care hospital beds (responses in this category generally ranged from two to three weeks, with one court noting a wait of 182 days). When asked to identify ways of shortening jail time for mentally ill clients, most respondents suggested that more active case finding measures should be undertaken. When asked to identify obstacles to decreasing jail time, responses tended to include a shortage of forensic beds, residential drug and alcohol treatment facilities, housing and community services. Theme 3: Outcomes and Monitoring Twenty respondents (71%) noted that they had established outcomes for the court's clients. In general, these outcomes revolved around factors such as successful completion of the treatment program, reduced recidivism, reduced incarceration, and reduced time in psychiatric hospitals. As well, 22 (78.5%) of respondents noted that they had established methods of monitoring clients' outcomes. These methods tended to

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include reports from treatment/service providers, probation officers, court reviews, and conferences among mental health court team members. Theme 4: Memoranda of Understanding Despite the importance of formal memoranda of understanding identified in the literature, only 11 responding courts (39%) noted having established such agreements. Some courts forwarded copies of their formal memoranda of understanding to us. These tend to specify the exact nature of services and obligations (including financial) among: the mental health court, local or community service providers (drug and alcohol treatment facilities were sometimes included), and the police (See Appendix XI for an example of such an agreement, from the Mendocino County Mental Health Court, who permitted the inclusion of their MOU in this report). Theme 5: Treatment Options Ten respondents (35.7%) note the availability of on-site psychiatrists or psychologists to conduct fitness or competence assessment. Conversely, 24 (85.7%) respondents noted that such services are available off-site (71% of respondents note that the foregoing off-site professionals are available to provide treatment; the same percentage - 71% - note that case management services are provided for clients). Among the groups for whom the provision of services has been most challenging are: the non-compliant, homeless, those with co-occurring illnesses, and the newly diagnosed. Others mentioned include sex offenders, youth (under 17) and individuals with traumatic brain injuries. Below are the most common agencies or services provided to MHC clients (proportion of respondents accompanies each category):

Housing assistance 87% Case management services 84% Medication management 84% Assistance obtaining medical care 77% Crisis intervention 77% Group therapy 77% Risk assessment 77%

Assistance obtaining financial aid 74% Assistance with other benefits 74% Individual therapy 74% Day treatment 68% Money management 65% Referral for other therapy 58%

Frequently mentioned 'other' categories of treatment or service include: Substance abuse 84% Acute care hospitalization 55% Safe beds / crisis beds 61% Seventeen respondents (60%) noted that other services should be available. Of these, housing or accommodation was mentioned most frequently. The following comments are typical: "Improved availability of special housing"; "Because all defendants are case managed, they have availability to an array of services through the mental health provider. However, our providers are poorly compensated resulting in a shortage of best practice, appropriate services, especially housing and long term care"; Better access to crisis services, acute care, residential treatment, co-occurring treatment and evaluation, and housing"; "better access to housing (not shelter based)"; "Better quality and consistency of follow up; supported accommodation as an alternative to hospital, supported and secure accommodation options for high risk category patients." Theme 5: Costs and Cost Effectiveness As reported in the literature, data regarding the cost and cost-effectiveness of mental health courts has proven to be elusive. Consistent with this observation, a minority of respondents were able to provide clear and up-to-date

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information about matters related to funding. Of the 28 courts that responded to our survey, only one answered all questions related to funding. Only 14 of the 28 responding courts attempted to answer a portion of the survey's questions related to funding or costs. In terms of the court's annual budget, responses ranged from a high of $5,600,000 (U.S.) to a low of $50,000. Funds tend to be provided predominantly by state or county governments and/or agencies. Summary The literature surrounding mental health diversion cannot answer many of the key questions that predicated this review. In particular, questions about evidence-based practices - including areas such as policy, planning, evaluation, funding, training, staffing levels and clinical interventions -have so far not been researched extensively enough to reach definitive conclusions. While descriptive studies are prominent and reflect the recent innovation that diversion represents, process and outcome evaluations are beginning to emerge. Our Web-based survey identified that key ingredients of diversion programs were mental health personnel and community treatment options and key barriers were the converse: insufficient mental health personnel and community treatment options. Memoranda of Understanding between mental health and criminal justice agencies are presented that may assist communities beginning or refining diversion programs. To illustrate recent developments of court diversion programs in Ontario, for the first time a listing or programs is provided in Appendix VI.

11. Recommendations

In the absence of evidenced-based practices in the literature, responses to our international web-based survey and reports in the literature indicate that communities have proceeded to develop organized responses to the issue of criminalization of mental illness. It is recognized that the province of Ontario cannot wait for the requisite research in order to take steps to further develop programs to decriminalized mental illness. In addition to supporting earlier recommendations of the Forensic Mental Health Services Expert Advisory Panel, it is therefore recommended that:

A. Overarching: 1. Enhanced capacity of community mental health agencies and housing be funded through the Ministry of Health and Long-term Care, as the primary method of diverting persons with mental illness from the criminal justice system. Rationale: Research demonstrates that lack of housing is a strong predictor of recidivism. Experts agree that the criminal justice system becomes the default system when there are insufficient community mental health services available. 2. a. The Provincial Human Services and Justice Coordination Committee comprised of staff, in senior positions comparable to the previous committee, of the Departments of Health & Long-term Care, Attorney General, Community Safety and Correctional Services, and Community and Social Services be re-constituted at a provincial level to provide leadership and direction to policy and program development using pooled funding for diversion of mentally ill persons from the criminal justice system. These members should be senior enough to act as boundary spanners within their departments. For example, substantial interdepartmental investigation is required to ascertain the direct and indirect costs of court diversion and mental health courts in Ontario. Rationale: Interdepartmental leadership and coordination is required and in its absence over the past few years, progress on local initiatives has been inconsistent. b. Local, and regional networks of, human services and justice services coordinating committees be formed to examine and resolve barriers to service at the interface of the mental health and criminal justice system, to implement provincial polices and to develop responses and monitoring of pre-arrest diversion programs. Rationale: Implementation and adaptation of policies developed by the former and reconstituted provincial

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Inter-ministerial Human Services and Justice Coordination Committee is required with regular meetings of key personnel from local agencies. 3. With the advent of the new provincial local health integration networks (LHINs), a close examination of the interface between proposed new health regions and existing regional forensic programs, local Human Services and Justice Coordinating Committees and other government department boundaries be proposed, and that boundary spanners at the local level be appointed, to ensure that boundaries are contiguous. Rationale: Re-organization of health regions, if that occurs through LHINs, can have direct impact on service delivery if other pre-existing boundaries are not carefully considered. B B. Police Pre-Arrest: 1. Training: a. Stand-alone, accredited, in-service education such as the police training educational module Not Just Another Call…Police Response to People with Mental Illness in Ontario (Hoffman & Putnam, 2004) be offered by the Ontario Police College to all uniformed officers within three years of basic training. Rationale: Enhanced training in mental health is required in order for police to recognize and efffectively assist persons with mental illness who come in contact with them as was recommended by the Ontario Chiefs of Police resolution in 2003.

2. Services: a. Police pre-arrest/prebooking diversion programs be supported by a free-standing, community mental health crisis and short-term intervention agency containing crisis safe beds with a formal "no refusal" policy for police referrals of voluntary clients. Rationale: Research reports an association between drop-off centers with no-refusal policies and decreased arrest rates and increased treatment rates. b. In order to ensure the equitable application of mental health diversion according to principles of therapeutic jurisdprudence, standardized protocols for police pre-arrest/prebooking diversion programs should be developed by the Ontario Association of Chiefs of Police in consultation with mental health professionals. Rationale: Currently, many police responses to calls involving persons with serious mental illness rely on individual officer's discretion and may result in inequitable responses. c. Local police and mental health services agencies be encouraged to develop an organized mental health response for police, such as mobile crisis response or specialized police-mental health worker teams. Rationale: Research indicates increased pre-arrest diversion rates occur when police are educated about mental health problems and when an organized community mental health response is available to them. d. Police Services adopt the London Police Services method of enumerating contacts and dispositions of persons with mental illness and police. Rationale: Pre-arrest diversion should result in fewer arrests of persons with mental illness but without enumeration of contacts and dispositions, outcomes of pre-arrest are difficult to measure. 3. Research: a. Inter-provincial funding of evaluation of models of pre-arrest diversion programs be sought. Rationale: In the absence of research it is not possible to know which model is most cost-effective.

C. Court Diversion: 1. Training

a. The delineation of the roles of Court Support Workers (CSW) in diversion programs and mental health courts developed by the Consortium on Mental Health Services in Toronto Courts be discussed for adoption across the province.

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Rationale: Background preparation and skills of court support workers vary widely and a standard role description would help to ensure equity of service delivery. b. Training of court support workers in forensics and mental health law should be standardized. Consistent with recommendations offered by previous studies (e.g., MacFarlane et al, 2002), such training would likely be best undertaken annually by a single, pan-provincial body such as the Centre for Addiction & Mental Health. Training could be offered at different sites in the province. Rationale: Court support workers more often have preparation in mental health and lack background in forensics and legal issues. c. Training of defense counsel in mental health law be provided annually by the Centre for Addiction and Mental Health and paid for by Legal Aid. Training could be offered at different sites in the province. Rationale: While training in mental health law is available for judges through the National Judicial Institute soon-to-be released Electronic Bench Book “Mentally Disordered Offenders” and for Crown Attorneys at the Ontario Crown Attorneys' Association Summer School, defense counsel, who are most often paid by Legal Aid, have no additional training in mental health law. In many smaller jurisdictions where the hiring of dedicated duty counsel is not warranted, some defense counsel and duty counsel seem to specialize in representing persons with mental illness and could benefit by additional training. d. Judges, Crown Attorneys and Justices of the Peace involved in diversion and mental health courts be encouraged to attend continuing education sessions in mental health law and mental illness. Rationale: Continuing education, such as will soon be available through the National Justice Institute Electronic Bench Book for judges, is required to keep current on issues in mental health law and to learn about manifestations of mental illness, current treatment and community services available.

2. Services: a. Active case finding should be supported by ensuring that court support workers have access to potential clients, and to their mental health condition and history, as early as possible. This includes attendance at bail hearings, access to cells, liaison with duty counsel, liaison with remand center, etc. Rationale: Research has linked early case finding with lower incarceration and recidivism rates and higher treatment compliance rates. b. Active case finding should be done by a court diversion/mental health court support worker according to an established protocol, such as outlined in the Consortium on Mental Health Services in Toronto Courts’ Policies and Procedures Manual. Rationale: The current Crown Manual on court diversion provides direction for the Crown but direction for court support workers is out of scope. Redundant efforts at a local level may be avoided if the work conducted by the Consortium is examined for use. c. To facilitate active case finding, court support workers should be on-site at the court. At minimum, this means office space equipped with standard office information technology. Rationale: On-site court support workers can act as boundary spanners between mental health and criminal justice systems. Paging the court support worker off-site does not facilitate active case finding and on-going dialogue with counsel and Crown about potential referrals. d. Active case finding should be supported by ensuring that court support workers have access to collateral information such as record of arrest, synopsis of alleged offense and other court documents. Rationale: Delay in access to collateral information inhibits active case finding. e. A standardized, computerized management information system to track intake information, treatment plans, monitoring time and outcomes should be funded and implemented provincially. Rationale: A management information system will enable intra-provincial comparison of client demographics, volume of cases and outcomes to aid in resource allocation decisions, and information to determine strategies to enhance service delivery. f. Agencies employing court support workers are encouraged to develop Memoranda of Agreement with community mental health, hospital and housing agencies regarding: (a) the provision of services for mentally ill persons referred from the court, (b) priority access to services (e.g. housing, hospitalization, and case

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management, etc), and (c) development of treatment plans and monitoring. Rationale: Diversion cannot occur in the absence of community services; the alternative, jail, is non-therapeutic and often results in increased symptamotology. g. That a provincial network of court support workers be established and funded through the Ministry of Health and Long-term Care for the purposes of communicating and meeting regularly for in-service education and opportunities to share solutions. Rationale: Many court support workers work in isolation from each other. The list of programs contained in Appendix VI will aid in the formation of a network. The Canadian National Committee for Police and Mental Health liaison provides such a forum for pre-arrest personnel.

3. Research: a. Workload measurement of court support workers be performed in each court diversion program to determine their primary function and to assess the proportion of time spent in activities related to direct diversion of mentally ill clients as opposed to court support activities. This could take the form of activity logs kept by the workers. Rationale: Since court support workers are funded from the Ministry of Health and Long-Term Care, their primary function should be activities related to direct diversion. b. Since court diversion programs are not established throughout the province yet, randomized controlled trials be funded to assess the efficacy of court diversion. Rationale: At present, the literature does not yield sufficient information to determine the efficacy of court diversion. Benchmarks concerning the reduction of negative outcomes for diverted and non-diverted persons are required and it is still possible to conduct ‘natural experiments’ in Ontario.

D. Mental Health Courts 1. Services: a. Further in support of the recommendations of the Forensic Task Force and regional Mental Health Implementation Task Forces, that regional forensic facilities be supported to enhance their ability to meet theirregional mandates by developing telepsychiatry capacity/linkages, it may be beneficial to replicate the November 1, 2003 agreement between the Ministry of the Attorney General and The Centre for Addiction and Mental Health (CAMH) with regional forensic facilities. In the interim, in jurisdictions where forensic psychiatrists or telepsychiatry are unavailable, CAMH may be asked to assist with the conduct of timely fitness assessments. This may take the form of expanding the November 1, 2003 agreement between the Ministry of the Attorney General and CAMH for sessional fees for forensic psychiatrists or CAMH-trained localpsychiatrists or forensically trained physicians. Telepsychiatry linkage between CAMH forensic psychiatrists at 102 Court and local correctional facilities/courts could also be explored. Rationale: In the absence of a change to the Criminal Code allowing psychologists to perform fitness assessments, currently, by legislation, only physicians can conduct fitness assessments. Many local courts are unable to affect timely fitness assessments because of a shortage of available physicians/psychiatrists/telepsychiatry linkages and provincial coordination by CAMH could be of interim assistance. Most courts in Ontario are equipped with video-conferencing equipment for bail hearings and extending the use of this technology to fitness assessments is feasible. b. Standards for waiting periods for transfer to forensic beds for should be established and monitored provincially in order to facilitate access. Rationale: Waiting periods for transfer to forensic beds may vary markedly from one area of the province to another and may represent inequitable access. c. Where volume does not warrant a dedicated mental health court, application of the principles of therapeutic jurisprudence support the establishment of a mental health docket. Rationale: Many courts cannot identify the number of charged mentally ill persons and yet processing mentally ill persons accused of minor offenses through the normal adversarial court process is non-therapeutic. Early case finding combined with a dedicated docket enhances coordination for fitness

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assessment and treatment. d. Where possible, dedicated or specially trained judges, duty counsel, Crowns and court support workers should be scheduled for the docket. Rationale: Court personnel trained in mental health law and issues around mental illness will likely result in more equitable application of therapeutic jurisprudence.

2. Research a. Consensus on the identification and definition outcomes of pre-arrest court diversion and mental health courts is required for research studies and for monitoring programs. Rationale: In the literature, a wide variety of outcomes have been used: (a) Recidivism, (b) Treatment compliance, (c) Treatment effectiveness, (d) Independent living skills, (e) Re-hospitalization, (f) Housing/homelessness, (g) Community integration, (h) Co-occurring disorders, such as alcohol and drug addition, (i) Incarcertation rates, (j) Quality of life, (k) Symptomatology. Rationale: Comparison of outcomes across settings is not possible until consensus is reached on standard indicators/benchmarks/outcomes. b. That the Ontario Ministry of Health and Long-term Care fund research into the satisfaction of inmates receiving fitness assessments via telepsychaitry and psychiatrists/physicians conducting fitness assessments via telepsychiatry. Rationale: While research into telepsychiatry with inmates for psychiatric assessment and treatment has been conducted, no research into telepsychiatry for fitness assessments has been conducted. c. The Ontario Ministry of Health and Long-Term Care investigate general psychiatric assessment to support diversion of persons with mental illness who are arrested and found fit, or who are obviously fit. Rationale: Many persons with mental illness are not connected to services and require psychiatric assessment, development of a care plan, risk assessment, etc. and with these services many could be eligible for court diversion, or a bail/probation order from a mental health court/docket.

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Appendix I: Literature Review Methodology

To recover peer-reviewed articles from the scholarly literature, we conducted free-text searches of the following databases: Web of Science, Medline, PubMed, PsychInfo, Sociological Abstracts, Cinahl, Criminal Justice Abstracts, Social Work Abstracts, Index to Legal Periodicals and Books, LegalTrac, ProQuest, Dissertation Abstracts International, LexisNexis and The Cochrane Library, among others. To ensure the broadest possible retrieval set and to accommodate variations in controlled vocabulary between databases, we employed combinations of the terms “diversion,” “diversion programs,” “mental health” and “mental health courts,” using truncation and proximity operators as necessary. After retrieving and evaluating a substantial corpus of texts, we examined their bibliographies to locate relevant items that had not been identified in previous database searches. To recover gray literature, we conducted extensive searches of the Internet for electronically published documents and for references to unpublished items. In addition to search engines such as Google, we used Internet resources specifically designed to retrieve items from government and academic sites; these include Scirus, Infomine, Academic Info, and Teoma. Relevant documents were retrieved from Web sites associated with universities, advocacy groups, information clearinghouses and all levels of government, as well as existing mental health courts and diversion programs throughout North America, Great Britain and Australasia. Finally, the project’s investigators drew on their professional backgrounds and knowledge of relevant literature to note additional items of importance, which were incorporated into the review. Ultimately, we recovered 519 items (available in Reference Manager format).

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Appendix II: Survey Methodology In response to the RFP, a research team led by Dr. K. Hartford outlined three methods: a) an extensive literature review from which a program assessment instrument would be developed, b) site visits, and c) a survey to be used to interview key informants. The program assessment instrument was to be used during the site visits and for a telephone survey/interview of key informants. The research team (Appendix XIl) was composed of persons working in the fields of diversion and family members of persons who had experienced diversion. Based on their areas of expertise, the team assessed 519 articles using a standard grid to summarize the findings (Appendix XlIl). The research associates (RAs) and the principal investigator (PI) then drafted a survey intended to capture data from practitioners that was missing in the literature. As an adjunct to developing the survey, site visits to four Toronto Ontario courts and interviews with mental health agencies were conducted (Appendix VIII). It was then decided that the efficiencies of a web-based survey (no paper, no postage, no phone charges or keyboard data entry) would enable us to conduct an international cross-sectional survey of practitioners and researchers. Dillman (2000) reports email response rates of 48%, with more complete responses although coverage errors are problematic. Rather than sampling, it was anticipated that because potential respondents all had business email addresses, the entire population could be surveyed with minimal additional costs. Pretesting: The survey was pre-tested with police and community mental health agencies providing diversion (see Appendix VIII). The survey was also pre-tested with the research team and sent to the Ministry of Health and Long-Term Care liaison personnel for review. Comprehension, ease of administration and time for completion were assessed. Ethical approval was granted from the University of Western Ontario’s Health Sciences Research Ethics Board. Survey: Three surveys were developed: (a) the mental health court survey that consisted of 60 questions, (b) the court diversion survey with 41 questions, and (c) the police survey with 38 questions (Appendix XlV). Commonalities included demographic information, personnel and funding, referral community agencies and interagency memoranda of agreements, program monitoring criteria, annual volume, current training and future needs for training in mental health or legal issues. The survey was converted by the LHSC web designer to a web-based format accessible by web browsers . Additionally, pdf , Word and Wordperfect documents were also attached providing respondents with a range of software options. A covering letter with the University of Western Ontario and Lawson Health Research Institute logos explained the reason for and nature of the survey and provided assurances of confidentiality (Appendix XV). Respondents were directed to click on the highlighted web address and to select the appropriate survey. Respondents were asked to indicate if they wanted a copy of the final report. Individuals were able to cut and paste existing documents into the survey, send them as an email attachment or fax them. The web-based survey enabled the use of color, drop down boxes and closed-ended questions. It was designed as a single unit so that respondents could scroll through the entire questionnaire; an automatic thank you was sent when completed. With the other attachments, an email thank you was sent. Sample selection: Identifying the sample was a multi-stage effort. The first step was identifying published email addresses. The U.S. NAMI (2004) and Council of State Governments (n.d.) documents provided email listing of 228 police, court diversion and mental health courts. After consideration of the new federal privacy legislation, the Canadian Association of Chiefs of Police released their membership directory to us that contained 129 email addresses. The second step involved Web searches. Police email addresses or fax numbers in Australia and New Zealand were located, but UK police and court email addresses were not available. Contacts with the Home Office did not identify email addresses. The third step involved using literature, personal contacts and extensive searches on the Internet. Email addresses of 473 individuals from Canadian, UK, Australian and New Zealand police, court diversion and mental health courts were identified. A convenience sample of 850 persons/organizations was assembled. The forth step was to try and identity addresses that proved incorrect on the initial mailing by phoning the organization. This left 266 usable addresses.

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Survey Results: Response Rate: Four waves of surveys were sent between May 24 and July 7, 2004. All UK National Health Services emails were rejected by their spam filter and a different email address was used to resend these 117 emails. Many individuals responded that they were not the correct person to complete the survey; we attempted to have them identify the correct individual. The overall response rate was 47%. The distribution of responses by country, type of survey and type of format are displayed in Table 1. Although the response rate is typical for Web-based surveys, the rate might have been higher but: (a) time did not permit the sending of a prior letter informing respondents that the survey was forthcoming as advised by Dillman (2000), (b) identifying accurate email addresses through web searches was problematic, (c) researchers who had previously conducted surveys in the UK and US had either not retained the addresses or did not feel the addresses were current and (d) when Dillman was conducting his research on email-based surveys in the late 1990s, the volume of email that employees received was lower. Increased volume and the problems associated with spam make it easier for respondents to delete unexpected email (and we would include the prior letter in this) and for individual and corporate spam filters to eliminate unexpected email.

Table 1. Surveys received by country

Survey Type

Mental Health Court Court Diversion Police Country

Web *Doc Fax Mail Web *Doc Fax Mail Web *Doc Fax Mail

Responses

Australia 1 0 0 0 1 1 0 0 1 1 0 0 5

Canada 1 0 0 0 10 3 4 0 19 8 2 1 48

United Kingdom 0 0 0 0 7 0 0 1 6 0 0 0 14

New Zealand 0 0 0 0 0 0 0 0 0 0 0 0 0

United States 24 2 0 0 12 4 0 0 14 2 0 0 58

Total 26 2 0 0 30 8 4 1 40 11 2 1 125

* Surveys received in various formats provided: Word, WordPerfect, and Pdf.

Survey Analysis: The web-based survey automatically tallied the quantitative responses and a research assistant entered the qualitative responses and non-web-based surveys into Nudist, a qualitative analysis program.

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Appendix lll: Experimental Designs

1. Qualitative designs 2. Non-experimental quantitative designs 3. Quasi-experimental designs 4. Experimental designs

These include field studies, ethnographies or historical analyses. Such designs do not produce the kind of generalizable conclusions on which evidence-based practice depends. These include correlational, case study and descriptive designs. By themselves, such studies are usually insufficient bases for evidence-based practice insofar as they lack the controls necessary to establish causal relationships among variables. Considered less rigorous than experimental designs, these involve manipulation of an independent variable but lack either a control group or random assignment. These are considered to be of greatest importance in identifying evidence-based practice. While experimental designs vary in complexity, they generally allow researchers to: establish a temporal relationship among variables; to control for confounding variables; and to establish a statistical association among variables.

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Appendix lV: Formative and Summative Evaluation

Formative Summative

Primarily prospective Primarily retrospective

Analyze strengths and weaknesses towards improving Document achievement

Shape direction of programs Show results of programs

Provide feedback Provide evidence

Source: Palys, T. 1997. Research Decisions: Quantitative and Qualitative Perspectives. Toronto: Harcourt Brace.

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Appendix V: Differences Between Traditional and Problem-Solving Courts Table 1: Roles and functions of traditional and mental health courts: Actors/Activities Traditional courts TJ, Problem-solving courts Proceedings Adversarial in nature/Formal Non-adversarial, collaborative, co-

operative/less formal Judge Impartial arbiter, central role Team integrated role/compromise

orientation/fact finder Crown/Prosecution Argue the victim’s/state’s case Team integrated role/compromise

orientation/fact finder Attorney Argue the offender’s case/duty of

loyalty only toward client Team integrated role/compromise orientation/fact finder

Mental health professionals N/A Team members/bring their expertise Social workers N/A Team members/linking offenders to

services in the community Intervention Usually postponed because of

longer proceedings Immediate intervention

Outcome Guilty/Not guilty Treatment programs with clear rules and structured goals

Table 2: A Comparison of transformed and traditional court process Traditional Process Transformed Process Dispute resolution Problem-solving dispute avoidance Legal outcome Therapeutic outcome Adversarial process Collaborative process Claim-or case-oriented People-oriented Rights based Interest-or needs-based Emphasis placed on adjudication Emphasis placed on postadjudication and

alternative dispute resolution Interpretation and application of law Interpretation and application of social science Judge as arbiter Judge as coach Backward looking Forward looking Precedent-based Planning-based Few participants and stakeholders Wide range of participants and stakeholders Individualistic Interdependent Legalistic Common-sensical Formal Informal Efficient Effective

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Appendix Vl: Court Diversion Programs in Ontario

Organization Province/ Territory Canadian Mental Health Association, Thunder Bay CMHA, Sudbury CMHA Sudbury/Espanola Mental Health Clinic, Little Current CMHA, Essex County, Windsor CMHA, Ottawa CMHA, Barrie-Simcoe Frontenac Community Mental Health Services, Kingston CMHA, Nipissing Regional Branch Regional Mental Health Care, St.Thomas Regional Mental Health Care, London CMHA Leeds/Grenville, Brockville CMHA, Cochrane-Timiskmaming CMHA, Waterloo-Kitchener CMHA, Newmarket CMHA, Toronto, East Metro Court & East Mall Court CMHA, Peel COTA Comprehensive Rehabilitation and Mental Health Services, Toronto Community Resources Consultants, Toronto

Ontario

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Appendix VII: Legislation from Other Countries New Zealand: While no mental health court exists in New Zealand, the legal frameworks for fitness assessment and court diversion (known as court liaison service) are the Criminal Justice Act of 1985, No. 120 (CJA), and the Mental Health (Compulsory Assessment and Treatment) Act 1992, (MHA, N.Z.) amended in 1999. The CJA enables alleged offenders who have been found unfit to be involuntarily committed for treatment in hospital or jail (Section 115, 118, 121(1) and (2). The MHA – N.Z. (1992) defines mental illness and requires respect for cultural identity. Section 9 defines the terms for an assessment examination. Police can detain the proposed patient for up to six hours or the time it takes to conduct the examination, whichever is shorter, according to Section 109(3). Section 110A provides for the powers of the police when urgent assistance is required by a medical practitioner. In relation to forensic services, compulsory treatment orders are the most commonly used MHA – N.Z. provisions. Section 29 requires a person to attend a certain place for treatment and accept that treatment while Section 30 requires a person to be detained in or go to a specified hospital for treatment and to accept that treatment. Court liaison service: The Forensic Court Liaison Service provides advice, assessments, reports and recommendations to the judiciary. It also consults and liaises with Adult Mental Health Services (AMHS), prisons, community probation and police. Within the courts, the principal role of forensic services is to provide triage and advice. Forensic court liaison staff also acts as gatekeepers to ensure that court referrals to mental health services are appropriate. Thus staff ensures access to treatment and assists fair representation through the justice system. New Zealand Police: Police have powers to arrest a person when they suspect a criminal offence has been committed. If the police think the person is “mentally disordered” they may ask for a psychiatric assessment or, if the crime is minor, they may not press charges and instead may call in the AMHS. It is for the courts, not the police, to make judgments about whether a person’s mental state needs to be taken into account in any trial process or in sentencing (New Zealand Mental Health Commission, 2003). Australia Australia has no federal legislation regarding mentally ill persons. Rather, individual states are governed by specific mental health legislation. For instance, most states have compulsory community treatment orders (Kisley & Xiao, 2002). In Queensland, the only Australian state with a specialized MHC, mental health matters are legislated by Mental Health Act (Q.C.A Mental Health Act 2000, Queensland, AU.). The purpose of this Act “is to provide for the involuntary assessment and treatment, and the protection, of persons (whether adults or minors) who have mental illnesses while at the same time safeguarding their rights.” An established Mental Health Review Tribunal reviews all decisions relating to involuntary patients issued by the Queensland MHC. The entire process of considering, admitting, and discharging potential qualified offenders is regulated by this new law. In the other states, court diversion programs are in place using legal dispositions contained in state mental health laws or in codes or regulations. The corresponding laws in other Australian states are as follows: Criminal Justice (Mental Impairment) Act 1999, Act No. 21, Tasmania, AU.), Criminal Law Consolidation Act 1935, South Australia, AU.), Criminal Law (Mentally Impaired Defendants) Act 1996, Western Australia, AU.), Mental Health Act (V.C.L., Mental Health Act 1986, Act No. 59, Victoria, AU.), Mental Health Act (N.S.W. C. A., Mental Health Act 1990, New South Wales, AU)., Mental Health Act 1993 (SA), Mental Health Act (T.C.A., Mental Health Act 1996, Act No. 31, Tasmania, AU.), Mental Health Act (W.A.C.A., Mental Health Act 1996, Western Australia, AU.)., Mental Health and Related Services Act (N.T. C. A., 1998, Northern Territory, AU.)., Mental Health (Treatment and Care) Act 1994 (A.C.T. C. A. 1994, Australian Capital Territory, AU.).

In New South Wales, court liaison services work closely with magistrates when persons with mental illness appear before the court. “Forensic psychiatrists and nurses work with magistrates, lawyers and police to assess people with suspected mental illness and divert them from the criminal justice system into mental health services, hospitals or community settings. Where these options are not feasible for the individual, the Service facilitates referral to

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clinical care within the prison system” (Henderson, 2003). These programs show potential with “the service reports promising outcomes on court through-put, referral rates and mental health assessments” (Henderson, 2003). In South Australia, “the Magistrates Court Diversion Program was established in June of 1999 as a South Australian Cabinet-funded pilot project. In the June 2001 budget, the Attorney-General announced that funding to continue its operation and expansion” (Henderson, 2003). United Kingdom Courts: The principal act governing people with mental illnesses in the UK is Mental Health Act (Mental Health Act 1983, U.K.) (MHA) which allows for, among other things, a fitness assessment report under Section 35 and for a Crown Court to send a person to hospital for psychiatric treatment rather than remanding them to prison (Section 36). Sections 2 and 3 allow for compulsory treatment for specific time periods. In the United Kingdom, which includes England, Wales, Scotland, and Northern Ireland, specific acts of legislation may sometimes apply to only one or other of these divisions (Ferencz et al, 2000). In Scotland, the first court diversion scheme was established in 1984 at the Douglas Inch Centre in Glasgow. In the diversion procedure, “the clinician attempts to provide the procurator fiscal [the prosecution representative] with a greater understanding of the processes which underpinned the alleged offence” (Cooke, 1994, p. 212). The procurator fiscal has a considerable discretion to decide whether to proceed with the charges against a person, stay the charges, or remove accused people from the normal process of prosecution if he believes that their offences were linked to psychological disturbances (Cooke, 1991). Cooke conducted a study describing the persons usually referred for diversion. “[T]he quality of the information provided by the arresting officer is fundamental to the procurator’s fiscal ability to divert a case for treatment” (Cooke, 1994, p. 222). In addition, because of the decisive influence of the police report in the diversion process, the author believed that the process of diversion in Scotland may be discriminatory without “systematic information in police reports” in the future (Cooke, 1994). In the London area, a court psychiatric service covering five London boroughs was established in 1994, using a scheme in existence since 1989 (James et al, 1997). All the London Magistrates’ Courts, remand mentally ill offenders to Horseferry Road Court rather than to prison for psychiatric assessment where they had spent “…more than 7 weeks in custody between arrest and admission to hospital” (James & Hamilton, 1993). Through the Horseferry court scheme, 85% of offenders were “admitted to psychiatric hospitals through assessment at courts or prisons,” (James & Hamilton, 1992). As a result, the time spent in jail by mentally ill charged with minor offences was considerably reduced. A circular of the Home Office, 66/1990, encouraged establishing of psychiatric liaison schemes, to divert mentally ill wherever possible. Magistrates’ courts, being of less formal character than Crown courts, made it easier for psychiatrists to give “opinions in brief forms, stating the diagnosis and suggested disposal.”(James and Hamilton, 1992) James and Hamilton also suggested that “diversion to hospital is possible without using the Mental Health Act”, courts being able “to remand people on bail with a condition of attendance at or residence in a psychiatric hospital.” (James & Hamilton, 1992) Police: Powers for apprehension of PMIs are specified under the MHA, 1983. An approved social worker can apply to a Justice of the Peace for a warrant to allow police to enter premise (by force if necessary) to search for a person with mental health problems and take them to a place of safety (MHA 1983, Section 135). The police officer who attends, and if necessary, breaks into premises in accordance with the warrant, must be accompanied by an Approved Social Worker [ASW] and a doctor. This Section also provides for a police officer (rather than an ASW) to obtain a warrant to enter premises when seeking to re-take a patient who is already Sectioned and liable to be detained, but who is absent without leave. In this case the police officer may be accompanied by an Approved Social Worker [ASW] and a doctor, but this is not compulsory.

United States

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Mental Health Courts: No federal legislation guides the legal framework for diversion, rather federal legislation provides funding for mental health courts. Lurigio et al. (2000) describes how within the US judicial system, mental health courts were preceded by drug courts. In the late 1990s specialized MHCs were established in the US, beginning with Broward County, Florida. This court has jurisdiction over mentally ill defendants, charged with non-violent, low-level misdemeanor offences, with driving under influence and domestic violence crimes being excluded (Lurigio et al, 2000). Defendants are initially evaluated for competency, and based on their status they can be sent to in patient or outpatient programs in the community. Treatments are proposed and followed up by a professional team. In October 2000, US Congress decided to support establishment of new MHCs: “A bill to provide grants to establish demonstration mental health courts” became America's Law Enforcement and Mental Health Project (Public Law No: 106-515 of 2000, 106th Congress). In 2002, 23 projects in 17 states received federal funds through Bureau of Justice Assistance (BJA); in 2003, 14 sites in 12 states were awarded funding from the 2002 Congress-approved federal funds. The Consensus Project estimates that these 37 courts represent half of the MHCs in the US. In the last decade, in many US states important changes to legislation have been made to allow mentally ill offenders to get access to treatment (Council of State Governments, 2001)

Some states such as Massachusetts do not have a formal diversion programs or a MHC, their legislation allows for legal representation in a commitment hearing, timely disposition, timely adjudication of treatment decisions and criteria for civil commitment (Mass. Gen. Laws ch. 123, § 1 through 36B). The result is both diversion and a treatment court, but on an ad hoc basis. Because court clinicians are attached to courts, at the arraignment stage they can perform a quick competency assessment and send the defendant to a mental hospital for a 20-day evaluation.

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Appendix VllI: Acknowledgements

We thank the individuals involved in the site visits and others who contributed to this study: Court Date Persons interviewed Position Toronto Provincial 102 Court

April 16, 2004 1.Darlene Minor 2. Margaret Creal 3. Richard D. Schneider 4. Joe Wright 5. Dr. Ian Swayze

CRCT CSW Assistant Crown Attorney Judge Duty counsel Psychiatrist

Brampton Provincial Court and CMHA Peel

April 22, 2004 1. Sandy Milakovic 2. Courtenay McGlashen 3. Stephen Laufer 4. Dr. Bruce Menchions

CMHA Peel – Executive Director Manager, Court Support Services Assistant Crown Attorney Psychiatrist

Etibicoke Provincial Court

April 27, 2004 1. Andrea Faveri 2. Lori Hamilton

CMHA CSW Assistant Crown Attorney

Scarborough Provincial Court

April 27, 2004 1. Cathy Chau 2. Frank Sirotich 3. Dr. David Boyers

MHCD Coordinator MHCD Team leader Psychiatrist

Dr. Howard Barbaree Clinical Director, Law and Mental Health Programs Center for Addiction & Mental Health

Peter Cuthbert Canadian Association of Chiefs of Police Ottawa, Ontario

Gail Czukar,Executive Vice President, Policy and Planning, General Counsel Centre for Addiction and Mental Health Toronto, Ontario

John Dawson Professor, Faculty of Law University of Otago Dunedin, New Zealand

Mary Doyle,Lecturer, Faculty of Information & Media Studies University of Western Ontario London, Ontario

Gail Hankinson Web Designer London Health Sciences Center London, Ontario

Dr. Virgina Aldige Hiday Professor, Department of Sociology North Carolina State University Raleigh, North Carolina, USA

Steve Lurie, Executive Director CMHA Toronto Branch Toronto Ontario

Justice McLeod Brampton Provincial Court Brampton, Ontario

Susan McDonald, Research Analyst Department of Justice Canada Ottawa, Ontario

Jillian Romanko CMHA Mental Health Court Support Worker Sudbury, Ontario

Dr. Sandy Simpson Clinical Director Regional Forensic Services Auckland, New Zealand

George F. Tomossy Associate Lecturer, Faculty of Law, University of Sydney Sydney, Australia

Clare J. Wiersma Inspector, Operational Support Branch Chatham-Kent Police Service Chatham, Ontario

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Dr. Jack Ellis, Physician Leader Forensic Services Regional Mental Health Care-St. Thomas 467 Sunset Avenue St. Thomas, Ontario Robin Daly Mental Health Consultant Toronto Region Ministry of Health and Long-Term Care

Lesley Bell, Clinical Nurse Specialist Forensic Services Regional Mental Health Care-St. Thomas 467 Sunset Avenue St. Thomas, Ontario

University of Western Ontario students who worked on this project: Briane Browne Thurikah D'Nathan Markus Juodis Magda Lukasiewicz

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Appendix IX: Memorandum of Understanding - Police Services A) PROTOCOL BETWEEN LONDON (ONTARIO) MENTAL HEALTH CRISIS SERVICE AND LONDON POLICE SERVICES Calls from London Police to London Mental Health Crisis Service: Effective February 21, 2003 the Police Dispatch Centre will contact the crisis service and request assistance on behalf of an officer who is involved with a persons possibly needing our assistance including Mobile Services. LMHCS phone staff will be given the name and date of birth to determine if the person is on file with us. LMHSC Mobile staff is then to be contacted and given the relevant information. AS POLICE WILL BE ON SITE, THEY MAY ATTEND ALL REQUESTS. NO CALLS ARE TO BE DEVLINED AS THIS IS A NEW PROCESS FOR ALL INVOLVED AND COOPERATON IS ESSENTIAL. All Police contacts are to be reviewed the following business day by the face-to-face LMHCS counselor who was involved in the call or on site.

Calls from LMHCS to London Police: If LMHCS Phone staff feels the need to contact police to attend a client, the LMHCS Mobile Team also is sent out at the same time.

February 17,2003 Inspector Ian Peer London Police Services P.O. Box 3419 London, ON N6A 4K9 Dear Inspector Peer, I would like to review and update the agreement between the London City Police and the London Mental Health Crisis Service. If there are any modifications, additions, etc. needed, please contact me at London Mental Health Crisis Service (telephone 433-2106 or fax 438-5808) to ensure the necessary changes are made.

Any emergency contact with Police is initiated by using 911; The Police will respond to any situation where danger to person or property is observed or believed imminent; It is understood that when Police proceed to a site at the request of Crisis Service Staff, the Police attending are in charge of the situation and at their discretion may or may not confer or consult with Crisis staff; Police respect the limitation of Crisis Service staff to disclose confidential information as detailed by the Mental Health Act; Crisis Service Staff will be familiar with the terms of the Mental Health Act, specifically with regard to situations whereby the Police provide direct intervention;

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With regard to the Crisis Service, only in situations where the police arrest under the terms of the Mental Health Act will they transport person or persons to hospital; It is understood that in other situations a request for an ambulance would be the appropriate response both for site attendance and for transportation; While the London Mental Health Crisis Centre has a mandate to respond to specific persons and situations (as detailed in the attached brochure) the Police may choose to refer to or consult with the Crisis Centre any adult with a non-medical crisis, including persons directly served by P.A.C.T.; Police Dispatch will contact the Crisis if and when Officers respond to a call, which in their opinion warrants the assistance of the Crisis Mobile Team; The Mobile Team will assist the Officers and will collaborate agree on the disposition of the call; The Crisis Service will also respond to the Police Services when the Officers managing the holding cells make a request;

In summary, this reflects what I believe to be the key points of the agreement. On behalf of all those involved with the provision of this crisis service, I appreciate your interest and desire to ensure the best possible relationship between the London Police and the Crisis Service. I understand that you will be the principle contact at the Police Department, and that I will be the contact person for the Crisis Service. Sincerely Kristine Diaz R.N. M.Ed. Director KD/sm B) Memorandum of Understanding and Working Protocol Tasmania Police Service and Department of Health and Human Services Tasmania Police Service and the Department of Health and Human Services often provide services to the same clients. The work of both sectors needs to be co-operatively linked, where appropriate, and undertaken with a clear understanding and agreement about the roles and responsibilities of each in providing services to these clients. Following extensive consultation, this Memorandum of Understanding has been developed by a working party consisting of officers from both Agencies, and community representation. It is supported by a working protocol for Police and Health and Human Services staff who are required to provide services to people with disability, including those with mental illness and/or intellectual disability. This document is a working agreement to be implemented at all levels in both agencies, and covers the following areas:

• Communication between the two agencies; • Training;

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• Review process; • Police request for assistance from mental health and disability services; • Department of Health and Human Services request for assistance from Tasmania Police Service; • Request for police attendance at an inpatient, residential or community facility; • Joint management; • Sharing of information; • Firearms Act 1996; • Transport; • Approved hospitals; • Authorised officers; • Approved medical practitioners; and • Consumer rights and responsibilities. [The remainder of this 40-page document can be found at <URL:http://www.dhhs.tas.gov.au/ partnerships/strategicpartnerships/index.html#police]

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Appendix X: Chesterfield/Colonial Heights Memoranda of Understanding - Court Diversion Memorandum of Agreement Chesterfield/Colonial Heights Community Corrections Services Chesterfield County Community Corrections – Day Reporting Center has been awarded a Substance Abuse Mental Health Services Administration grant for a renewable period of up to three years. The funding will be used to implement a dual diagnosis track, open to offenders under pretrial status. Traditionally, these offenders would spend time incarcerated until trial, due to a lack of resources and stability. This funding will allow the Day Reporting Center to implement a new track to identify and serve offenders diagnosed with a substance abuse addiction and other mental health disorders. The implementation of these new services includes a contractual agreement between Community Corrections – Day Reporting Center – Dual Treatment Track (CCS-DRC-DTT) and the Community Services Board (CSB). The CSB will provide one senior clinician and one clinician to staff the program to provide services to this targeted population. The CCS-DRC-DTT will financially compensate the CSB for the clinical staff and their supervision according to grant stipulations and the continuation of funding. Staffing The CSB will hire one senior clinician with minimally a Masters Degree in counseling, social work, or related human services field and three years experience of direct service. Emphasis will be placed on candidates who have experience working with individuals with co-occurring disorders. In addition, the CSB will hire one clinician with minimally a Masters Degree in counseling, social work, or related human services field and one year experience of direct service. Emphasis will be placed on candidates who have experience working with individuals with co-occurring disorders. Grant allowable salaries may not exceed $40,000 and $35,000 respectfully in addition to allowable fringe benefits as outlined by the County. The hiring and salary negotiation will be done in conjunction with the Project Director, who will be providing the daily direct supervision to these employees. The Project Administrator and Project Director maintain final approval of the clinical staff. Both positions will be housed at the CCS-DRC-DTT office but will maintain status as employees of the CSB and will participate in CSB training and clinical supervision as required. All employees must have successfully completed a background check. Service Delivery The CSB will provide outpatient services to the CCS-DRC-DTT by assigning one qualified senior clinician and one qualified clinician on a full-time basis to provide the services as outlined below, on-site at the CCS-DRC-DTT . · Assessments · Group Therapy · Individual Therapy · Treatment planning · Referrals · Case staffing · Evaluations · Other duties as assigned Evaluation of the CCS-DRC-DTT track serving dual-diagnosed offenders will be completed in compliance with the SAMHSA grant requirements. Clinical staff are required to participate and on a daily basis gather and maintain data for evaluation purposes. All data gathered will be stripped of identifiers and provided to the evaluator on contract with the grant. Operational Provisions

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Clinical staff will be provided appropriate office space that allows privacy as well as treatment group space, basic office furnishings, office supplies, telephone services, and computers. Payment for Services Request for payment will be processed by use of the Chesterfield County Inter-Departmental Transfer. This transfer will occur at the end of each quarter for the services preformed during that quarter. If one or both of these positions experience a vacancy the quarterly IDT amount will be altered to reflect the actual expense that the CSB incurred. The amount will not be greater then $75,000 in CY03 in addition to applicable fringe benefits at established county rates. Anticipated start date is January 1, 2003 with the county fiscal year ending June 30, 2003, so the annual transfer on the county’s fiscal schedule should not be more then $37,500 and the amount of all applicable fringe benefits Contract Conditions This contract is automatically renewable for two consecutive years after the first year, providing both parties are satisfied with the service delivery and terms. Should either party be dissatisfied with the services provided, this contract may be terminated by providing a 30-day written notice of such termination. By signing below, parties mutually agree to the terms of the agreement and the roles and responsibilities as they have been described. ______________________________ ______________________________ George Braunstein Glen Peterson Community Services Board Community Correction Services Director Director _____________________________ _______________________________ Date Date Memorandum of Agreement Chesterfield/Colonial Heights Community Corrections Services Day Reporting Center-Dual Treatment Track And Chesterfield Community Service Board Substance Abuse Services Program Chesterfield County Community Corrections – Day Reporting Center – Dual Treatment Track has been awarded a Substance Abuse Mental Health Services Administration grant for a renewable period of up to three years. The funding will be used to implement a dual diagnosis track, open to offenders under pretrial status. Traditionally, these offenders would spend time incarcerated until trial, due to a lack of resources and stability. This funding will allow the Day Reporting Center – Dual Treatment Track to implement a new track to identify and serve offenders suffering from substance abuse addiction and other mental health disorders. The implementation of these new services includes a contractual agreement between Community Corrections – Day Reporting Center-Dual Treatment Track (CCS-DRC-DTT) and the Community Services Board (CSB). The CSB will provide eight (8) hours a week of a psychiatrist’s time and five (5) hours a week of nursing support services. The CCS-DRC- DTT will financially compensate the CSB for the hours according to grant stipulations and the continuation of funding.

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Staffing The CSB will provide eight (8) hours a week of a licensed psychiatrist on staff at the CSB. Preference is given to qualified individuals who have a history of working with dual diagnosed clients involved in the criminal justice system. In addition, the CSB will provide five (5) hours a week of nursing support services. Preference is given to qualified individuals who have a history of working with dual diagnosed clients involved in the criminal justice system. Grant allowable rate for the contracted hours is as follows: Psychiatrist @ $70 an hour for eight (8) hours a week, 52 weeks a year. Nursing support services @ $20 an hour for five hours a week, 52 weeks a year. The designation of staff should if at all possible be one individual to provide each service and available during the same time periods each week. This procedure will improve relationship building and a working knowledge base of the CCS-DRC-DTT. The Project Director, who will provide the daily direct supervision of this program, maintains the right to approve the designation of the CSB employees. In addition, the Project Director is the point of contact for the operational purposes. Both positions will be housed at the CSB. The psychiatrist on contract is responsible for at least four (4) hours of on-site training with the program staff. In addition, initial set – up will include several required meetings that will be within the eight (8) hours allowed each week. All contractual service providers must have successfully completed a background check. Service Delivery The CSB psychiatric service contract will provide the following during the eight- (8) hours allotted each week: · Psychiatric Evaluations · Medication Management visits · Face to face staff consultation with the DTT staff re: diagnosis, treatment planning, interventions, medical/psychiatric aspects of treatment The Nursing support service contract will provide the following during the five- (5) hours allotted each week: · Patient Education re. medication administration, effects, side-effects, compliance issues · Pharmacy Administration (indigent care program enrollment, access to State Pharmacy medications, medication delivery) · Injections, blood samples, etc. · Physician support (responding to phone calls, patient prep. during visits, assistance with record keeping/charting. · Liaison with non-medical program staff Evaluation of the CCS-DRC-DTT track serving dual-diagnosed offenders will be completed in compliance with the SAHSHA grant requirements. All staff are required to participate and on a regular basis gather and maintain data for evaluation purposes. All data gathered will be stripped of identifiers and provided to the evaluator on contract with the grant. Payment for Services Request for payment will be processed by use of the Chesterfield County Inter-Departmental Transfer (IDT). The IDT will be sent by the CSB at the end of a quarter for the services provided during that quarter. This contracted amount will be based on the maximum hours set forth in the staffing section of this memorandum. If the CSB is unable to provide 8 hours and 5 hours respectively, the IDT amount will be altered to reflect the available hours. The amount will not be greater then $29,120 in CY03. Anticipated start date is January 1, 2003.

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Contract Conditions This contract is automatically renewable for two consecutive years after the first year, providing both parties are satisfied with the service delivery and terms. Should either party be dissatisfied with the services provided, this contract may be terminated by providing a 30-day written notice of such termination. By signing below, parties mutually agree to the terms of the agreement and the roles and responsibilities as they have been described. George Braunstein Glen Peterson Community Services Board, Director Community Correction Services, Director _____________________________ ______________________________ Date Date

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Appendix XI: Mendocino County Memorandum of Understanding - Mental Health Court MEMORANDUM OF UNDERSTANDING DIVISION OF ALCOHOL AND OTHER DRUG PROGRAMS AND THE MENDOCINO COUNTY SHERIFF’S OFFICE (5-9-02) The Mendocino County Department of Public Health, Division of Alcohol and Other Drug Programs (AODP) and the Mendocino County Sheriff’s Office (MCSO) enter into this Memorandum of Understanding. This Memorandum of Understanding stands as evidence that the MCSO and AODP work together toward the goal of providing Mentally Ill Offenders Court Program services for eligible mentally ill offenders residing in Mendocino County. Under judicial supervision provided by the Mendocino County Superior Court, the Mendocino County Mentally Ill Offenders Court Program (MIOCP) program includes intensive mental health treatment, substance abuse treatment, mandatory drug testing, and use of graduated sanctions. TERM: This Memorandum of Understanding remains in effect for the duration of the California State Board of Corrections Mentally Ill Offenders Crime Reduction Grant hereinafter known as MIOCRG given under the statutory authority of Chapter 501, Statutes of 1998. The term of this Memorandum of Understanding shall begin on July 1, 2001. The project must be completed by June 30, 2004. GENERAL PROVISIONS: Each party agrees to the following: 1. The amount awarded to AODP through the MIOCRGrant. (See page 6: Grant Budget.) 2. The amount awarded to the Inland Enhancement Adult MIOCP Grant (Award # 2000-DC-VX-0016) is $299,507, approximately 46% of the total cost of operations ($647,675) for this period of time (October 1, 2000 – September 30, 2002). (See page 7: Grant Budget.) 3. Maintain line item detail of this grant’s funding sufficient to meet the auditing requirements set forth in the U.S. Department of Justice publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments and U.S. Department of Justice, Office of Justice Programs, Office of the Comptroller Financial Guide, as interpreted by the Court Fiscal Manager. 4. Meet on an as-needed basis for the purpose of monitoring expenditure patterns, fund depletion, budget discussion and cost projections. Based upon the results of such financial analysis, parties may agree to modify, restrict, adjust and/or discontinue MIOCP activities until such time as adequate funding is identified and secured. 5. Recognize that funding commitments are intended to be stable during any given fiscal year/grant period. If the number of participants is consistently below the commitments made in the grant applications, the issue will be presented to the Therapeutic Courts Management Team to discuss possible options and recommendations for submission to the funding source if needed. 6. Participate in OJP-sponsored technical assistance workshops and obtain prior approval from the OJP MIOCPs Program Office before using Federal funds to travel to other MIOCPs or to any non-OJP conferences 7. Abide by the Code of Federal Regulations regarding confidentiality as found in CFR 42, Part 2.

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THE MENDOCINO COUNTY SHERIFF’S OFFICE WILL 1. Have sole authorization for the official signature and will complete inter-fund transfers for authorized reimbursement to AODP upon receipt of quarterly invoices reflecting actual costs incurred approved by the Therapeutic Courts Administrator and the Court’s Fiscal Manager. 2. Assess a one-time only, “court administration fee” of $35 on each MIOCP participant to cover costs of processing accounts receivable as determined by Penal Code 1205 (D). • The Court Collections office is responsible for the collection of this fee. 3. Monitor payment of MIOCP “participant fees,” loan re-payment plans, past-due fees and fines and use of Community Service in lieu of payment. 4. Utilize the sliding fee scale established by the Therapeutic Courts Management Team of a maximum charge of $217 per month per participant for non Medi-Cal eligible individuals to charge and collect “participant fees.” 5. Vest with AODP all expendable and non-expendable personal property purchased with grant funds: Upon verification by the Therapeutic Courts’ Administrator that AODP is a service provider in good standing with the Mendocino County Sheriff’s Office; and If written certification is made to Therapeutic Courts’ Administrator that the property will continue to be used for USDOJ/OJP/DCPO grant related purposes. THE ALCOHOL AND OTHER DRUGS PROGRAM WILL 1. Serve the Mendocino County Adult MIOCP as the primary treatment provider. In the event that a private provider is utilized to maximize individual treatment planning, AODP will serve as Quality Assurance Monitor for the MIOCP and act as liaison to the other providers. 2. Provide timely, accurate and authorized expenditure invoicing with supporting documentation (i.e., invoices, bills, journal entries, management reports) of grant-funded positions and in-kind contributions. Supporting documentation is required to guarantee reimbursement. Timesheets that are less than 100% funded by a single grant must show time charged by grant or program for actual time to be billable. (Samples provided pages 7-12.) 3. Provide line item detail sufficient to meet the auditing requirements set forth in the U.S. Department of Justice publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments and U.S. Department of Justice, Office of Justice Programs, Office of the Comptroller Financial Guide as interpreted by the Court Fiscal Manager 4. Submit invoices reflecting actual costs incurred quarterly with line item detail. This detail will support any requested transfer of funds. a. Assure proper supporting documentation with verification that includes cross-reference checks of requested reimbursement aligned with supporting documentation for both grant reimbursed expenses or those being contributed as in-kind. b. Utilize a cover sheet consolidating employee (s) hours, rate of pay, percentage of benefits and total amount being charged or contributed as in-kind to expedite the reimbursement process. (Samples provided on page 7, 8, 9,11, & 12.)

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5. The billing due dates are as follows: • Report Period • Billing Due to MIOCP Office • 269A Due to DCPO • October 1, 2000 - December 31, 2000 • February 1, 2001 • February 15, 2001 • January 1, 2001 - March 31, 2001 • May 1, 2001 • May 15, 2001 • April 1,2001 - June 30, 2001 • August 1, 2001 • August 15, 2001 • July 1, 2001 - September 30, 2001 • November 1, 2001 • November 15, 2001 • October 1, 2001 - December 31, 2001 • February 1, 2002 • February 15, 2002 • January 1, 2002 - March 31, 2002 • May 1, 2002 • May 15, 2002 • April 1, 2002 - June 30, 2002 • August 1, 2002 • August 15, 2002 • July 1, 2002 - September 30, 2001 • November 1, 2002 • November 15, 2002 • Invoices submitted after the above-mentioned dates may result in a change in the time and/or method of payment. 6. Receive approval from the Therapeutic Courts Management Team and the U.S. Department of Justice’s MIOCPs Program Office (DCPO) Grants Manager prior to the obligation and expenditure of funds outside of the approved grant budgets. 7. Submit verification of use of time as part of the quarterly invoices for OPTIONS Program staff. Required documentation for payroll includes time card(s) with hours delineated to specific grant and provision of payroll management reports with pay periods identified for cross-referencing purposes. 8. Provide information required to complete the mandated MIOCP Grantee Data Collection Survey. 9. Provide documentation of funds including those collected on behalf of Medi-Cal eligible MIOCP Program participants that are a part of the Local Match.\ 10. Submit one copy of all reports and proposed publications resulting from this grant award thirty (30) days prior to public release. a. Any publications (written, visual, or sound), whether published at the grantee’s or government’s expense, shall contain the following state: “ This project was supported by Grant #2001-DC-VX-0001 awarded by the MIOCPs Program Office, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the author and do not necessarily represent the official positions or policies of the U.S. Department of Justice.” b. NOTE: This excludes press releases, newsletters, and issue analysis. The Mendocino County Sheriff’s Office and the Public Health Department, Division of Alcohol and Other Drug Programs agree upon these protocols and procedures on this ___________ day of the month of ___________, 2002 We hereby agree to this Memorandum of Understanding and certify the agreements made will be honored. __________________________________ ______________________________ Eric Labowitz, Judge, Mentally Ill Offenders Carol Mordhorst, Administrator Court Program Mendocino County Department of

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Mendocino County Sheriff’s Office Public Health Date:___________________ Date: ___________________ _____________________________ ______________________________ Ron Brown, Presiding Judge Ned W. Walsh, M.Ed., Mendocino County Sheriff’s Office Administrator Mendocino County Division of Alcohol and Other Drugs Program Date:___________________ Date:___________________ ___________________________________ ______________________________ Tania Ugrin-Capobianco, James Anderson, Court Executive Officer Mendocino County Administrator Mendocino County Sheriff’s Office Date:____________________ Date:___________________ MEMORANDUM OF UNDERSTANDING: DIVISION OF ALCOHOL AND OTHER DRUG PROGRAMS AND THE MENDOCINO COUNTY SHERIFF’S OFFICE (5-9-02) The Mendocino County Department of Public Health, Division of Alcohol and Other Drug Programs (AODP) and the Mendocino County Sheriff’s Office (MCSO) enter into this Memorandum of Understanding. This Memorandum of Understanding stands as evidence that the MCSO and AODP work together toward the goal of providing Mentally Ill Offenders Court Program services for eligible mentally ill offenders residing in Mendocino County. Under judicial supervision provided by the Mendocino County Superior Court, the Mendocino County Mentally Ill Offenders Court Program (MIOCP) program includes intensive mental health treatment, substance abuse treatment, mandatory drug testing, and use of graduated sanctions. TERM: This Memorandum of Understanding remains in effect for the duration of the California State Board of Corrections Mentally Ill Offenders Crime Reduction Grant hereinafter known as MIOCRG given under the statutory authority of Chapter 501, Statutes of 1998. The term of this Memorandum of Understanding shall begin on July 1, 2001. The project must be completed by June 30, 2004. GENERAL PROVISIONS: Each party agrees to the following:

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1. The amount awarded to AODP through the MIOCRGrant. (See page 6: Grant Budget.) 2. The amount awarded to the Inland Enhancement Adult MIOCP Grant (Award # 2000-DC-VX-0016) is $299,507, approximately 46% of the total cost of operations ($647,675) for this period of time (October 1, 2000 – September 30, 2002). (See page 7: Grant Budget.) 3. Maintain line item detail of this grant’s funding sufficient to meet the auditing requirements set forth in the U.S. Department of Justice publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments and U.S. Department of Justice, Office of Justice Programs, Office of the Comptroller Financial Guide, as interpreted by the Court Fiscal Manager. 4. Meet on an as-needed basis for the purpose of monitoring expenditure patterns, fund depletion, budget discussion and cost projections. Based upon the results of such financial analysis, parties may agree to modify, restrict, adjust and/or discontinue MIOCP activities until such time as adequate funding is identified and secured. 5. Recognize that funding commitments are intended to be stable during any given fiscal year/grant period. If the number of participants is consistently below the commitments made in the grant applications, the issue will be presented to the Therapeutic Courts Management Team to discuss possible options and recommendations for submission to the funding source if needed. 6. Participate in OJP-sponsored technical assistance workshops and obtain prior approval from the OJP MIOCPs Program Office before using Federal funds to travel to other MIOCPs or to any non-OJP conferences 7. Abide by the Code of Federal Regulations regarding confidentiality as found in CFR 42, Part 2. THE MENDOCINO COUNTY SHERIFF’S OFFICE WILL 1. Have sole authorization for the official signature and will complete inter-fund transfers for authorized reimbursement to AODP upon receipt of quarterly invoices reflecting actual costs incurred approved by the Therapeutic Courts Administrator and the Court’s Fiscal Manager. 2. Assess a one-time only, “court administration fee” of $35 on each MIOCP participant to cover costs of processing accounts receivable as determined by Penal Code 1205 (D). • The Court Collections office is responsible for the collection of this fee. 3. Monitor payment of MIOCP “participant fees,” loan re-payment plans, past-due fees and fines and use of Community Service in lieu of payment. 4. Utilize the sliding fee scale established by the Therapeutic Courts Management Team of a maximum charge of $217 per month per participant for non Medi-Cal eligible individuals to charge and collect “participant fees.” 5. Vest with AODP all expendable and non-expendable personal property purchased with grant funds: Upon verification by the Therapeutic Courts’ Administrator that AODP is a service provider in good standing with the Mendocino County Sheriff’s Office; and If written certification is made to Therapeutic Courts’ Administrator that the property will continue to be used for USDOJ/OJP/DCPO grant related purposes. THE ALCOHOL AND OTHER DRUGS PROGRAM WILL

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1. Serve the Mendocino County Adult MIOCP as the primary treatment provider. In the event that a private provider is utilized to maximize individual treatment planning, AODP will serve as Quality Assurance Monitor for the MIOCP and act as liaison to the other providers. 2. Provide timely, accurate and authorized expenditure invoicing with supporting documentation (i.e., invoices, bills, journal entries, management reports) of grant-funded positions and in-kind contributions. Supporting documentation is required to guarantee reimbursement. Timesheets that are less than 100% funded by a single grant must show time charged by grant or program for actual time to be billable. (Samples provided pages 7-12.) 3. Provide line item detail sufficient to meet the auditing requirements set forth in the U.S. Department of Justice publication 28 CFR Part III, Chapter 19 (7-1-94 edition), Part 66 - Uniform Administrative Requirements for Grants and Cooperative Agreements to State and Local Governments and U.S. Department of Justice, Office of Justice Programs, Office of the Comptroller Financial Guide as interpreted by the Court Fiscal Manager. 4. Submit invoices reflecting actual costs incurred quarterly with line item detail. This detail will support any requested transfer of funds. a. Assure proper supporting documentation with verification that includes cross-reference checks of requested reimbursement aligned with supporting documentation for both grant reimbursed expenses or those being contributed as in-kind. b. Utilize a cover sheet consolidating employee (s) hours, rate of pay, percentage of benefits and total amount being charged or contributed as in-kind to expedite the reimbursement process. (Samples provided on page 7, 8, 9,11, & 12.) 5. The billing due dates are as follows: • Report Period • Billing Due to MIOCP Office • 269A Due to DCPO • October 1, 2000 - December 31, 2000 • February 1, 2001 • February 15, 2001 • January 1, 2001 - March 31, 2001 • May 1, 2001 • May 15, 2001 • April 1,2001 - June 30, 2001 • August 1, 2001 • August 15, 2001 • July 1, 2001 - September 30, 2001 • November 1, 2001 • November 15, 2001 • October 1, 2001 - December 31, 2001 • February 1, 2002 • February 15, 2002 • January 1, 2002 - March 31, 2002 • May 1, 2002 • May 15, 2002 • April 1, 2002 - June 30, 2002 • August 1, 2002 • August 15, 2002 • July 1, 2002 - September 30, 2001 • November 1, 2002 • November 15, 2002 • Invoices submitted after the above-mentioned dates may result in a change in the time and/or method of payment. 6. Receive approval from the Therapeutic Courts Management Team and the U.S. Department of Justice’s MIOCPs Program Office (DCPO) Grants Manager prior to the obligation and expenditure of funds outside of the approved grant budgets. 7. Submit verification of use of time as part of the quarterly invoices for OPTIONS Program staff. Required documentation for payroll includes time card(s) with hours delineated to specific grant and provision of payroll management reports with pay periods identified for cross-referencing purposes. 8. Provide information required to complete the mandated MIOCP Grantee Data Collection Survey. 9. Provide documentation of funds including those collected on behalf of Medi-Cal eligible MIOCP Program participants that are a part of the Local Match.

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10. Submit one copy of all reports and proposed publications resulting from this grant award thirty (30) days prior to public release. a. Any publications (written, visual, or sound), whether published at the grantee’s or government’s expense, shall contain the following state: “ This project was supported by Grant #2001-DC-VX-0001 awarded by the MIOCPs Program Office, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the author and do not necessarily represent the official positions or policies of the U.S. Department of Justice.” b. NOTE: This excludes press releases, newsletters, and issue analysis. The Mendocino County Sheriff’s Office and the Public Health Department, Division of Alcohol and Other Drug Programs agree upon these protocols and procedures on this ___________ day of the month of ___________, 2002. We hereby agree to this Memorandum of Understanding and certify the agreements made will be honored. __________________________________ ______________________________ Eric Labowitz, Judge, Mentally Ill Offenders Carol Mordhorst, Administrator Court Program Mendocino County Department of Mendocino County Sheriff’s Office Public Health Date:___________________ Date: ___________________ __________________________________ ______________________________ Ron Brown, Presiding Judge Ned W. Walsh, M.Ed., Mendocino County Sheriff’s Office Administrator Mendocino County Division of Alcohol and Other Drugs Program Date:___________________ Date:___________________ ___________________________________ ______________________________ Tania Ugrin-Capobianco, James Anderson, Court Executive Officer Mendocino County Administrator Mendocino County Sheriff’s Office Date:____________________ Date:___________________

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Appendix XIl: Research Team Members

Name Title/Position Role 1.Dr. Kathleen Hartford Scientist-Epidemiologist,

Associate Professor (UWO) Principal Investigator

2.Simon Davies Area Director, Legal Aid Ontario

Co-Investigator

3. Chris Dobson Criminal Lawyer Co-Investigator 4.Carolyn Dykeman Family member of consumer

survivor Co-Investigator

5.Brenda Furhman Coordinator, Mental Health Programs, London Health Sciences Centre/Lawyer, Duty Counsel

Co-Investigator

6.John Hanbidge Assistant Crown Attorney, Elgin/Middlesex Court House

Co-Investigator

7.Donna Irving Family member of consumer survivor

Co-Investigator

8.Elizabeth McIntosh Coordinator, London ACT + Diversion Services, RMHC-L, St. Joseph

Co-Investigator

9.Dr. Jim Mendonca Clinical Psychologist/ Professor, Dept. of Psychiatry (UWO)

Co-Investigator

10. Ian Peer Inspector, London Police Services

Co-Investigator

11. Mike Petrenko Executive Director, CMHA- London Middlesex

Co-Investigator

12.Veronica Voigt Regional Mental Health Care, Elgin/Middlesex Mental Health Court Diversion Services

Co-Investigator

13. Dr. Stephen State Coordinator, Department of Family Medicine, UWO

Co-Investigator

14.Janice Vandevooren Coordinator, SAS, PACT/Elgin,Regional Mental Health Care, St. Thomas

Co-Investigator

15. Dr. Robert Carey Lawson Health Research Institute

Research Associate

16. Alexandru Craciunescu Lawson Health Research Institute

Research Associate

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Appendix XlIl: Standardized Literature Review Grid

Literature Review Table

Reviewer’s name: Title, author(s) & year: Purpose: Research method/design: N(numbers) & measures used or sources of data and evidence: Findings: Author’s conclusions: Reviewer’s comments/contact information: Conceptual/methodological problems: This literature review table template is provided to enable reviewers to articulate very briefly the main points of the article or report which they are examining. A digital copy will be emailed to you so that you can enter the material on screen. Many of the details will be available in the abstract if one is included with the article.

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If the article discusses a person, program, or institution you think we should interview or include in our survey, please note any available contact information in the “Reviewer’s comments” box. Please don’t be intimidated by the structure of the template. In a nutshell, what we want is your feedback on written material that you agree to review.

*** Findings: The following list is intended to help you categorize any findings you identify in the articles you review. You may encounter findings that do not appear in this list; if so, please note these as well. Early identification-referral mechanisms Case management: screening & needs assessment Case management: counseling and discharge planning Case management: liaison with criminal justice system Case management: treatment and monitoring in the community Case management crisis intervention In-jail counseling Services for homeless mentally ill offenders Substance-abuse services Diversion mechanisms and clear guidelines Triage and diversion by police Triage by specialized staff or team -on site or immediate availability (e.g. drop-off) -available on referral Training/education of police Training/education of attorneys Program evaluation or review Inter-agency agreements and partnerships Integrated systems between criminal justice, mental health & social services agencies Regular meetings of key players Creation of 'boundary spanners': key staff positions to link criminal justice and mental health agencies or link systems involved in diversion

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Appendix XlV: Diversion Survey

A. Police Diversion Introduction This portion of the survey is concerned with pre-arrest or police diversion. Again, thank you for agreeing to participate. Before you begin, it would be helpful to know the following: P1. Your department’s name: P2. City: P3. Province/State/Territory: P4. Country: P5. Zip Code / Postal Code: P6. If you would like a final copy of the report, please provide a contact name in the space below: P7. Police have some discretion in laying a charge involving a person thought to have mental illness. We are interested in learning more about this. P8. Does your department have:

A formal pre-arrest diversion program? __ Yes __ No P9. If yes, please describe the program in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. P10. Does your department have:

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An informal pre-arrest diversion program?

__ Yes __ No P11. If yes, please describe the program in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. P12. Does your department have written criteria that officers use to assess whether an individual is an appropriate candidate for pre-arrest diversion? __ Yes __ No P13. If yes, please provide these criteria in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. P14. If no, please explain how officers decide whether an individual is an appropriate candidate for diversion.

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P15. Does your department’s program involve a Crisis Intervention Team? __Yes __ No P16. Is your department associated with a mobile response agency for the purpose of mental health diversion? __ Yes __ No

Training P17. Has your department provided training for all members specifically for mental health issues (i.e., beyond the basic and advanced patrol training)? __ Yes __ No P18. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. P19. How many hours does this training take? __Hours P20. How often is this training offered to your department’s members?

a. Every year b. Every two years c. Every three years d. Data not kept e. Don’t know f. Other (please specify).

P21. Is more training needed? __ Yes __ No

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P22. Please describe the training needed.

Outcomes and Monitoring P23. How many individuals with mental illness did your department divert last year? __Number/Last year __Data not kept P24. Does your department have specific criteria to monitor the pre-arrest diversion program’s success? __Yes __ No P25. If yes, please explain these criteria in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document.

Treatment P26. Which of the following agencies/services does your department divert people with mental illness to? (Check all that apply):

Risk assessment Medication management Case management services Housing assistance Assistance obtaining financial aid Assistance obtaining medical care

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Assistance with other benefits Money management Crisis intervention Group therapy Individual therapy Day treatment Referral for other therapy (please specify):

Substance abuse Guardianship Family therapy Acute care hospitalization Long-term care hospitalization Emergency room treatment Safe beds / crisis beds Other (please explain)

P27. Should other services be available? __ Yes __ No P28. If yes, please explain in the space below. P29. Do any local mental health treatment facilities with beds have “no refusal” policies for police referrals? __ Yes __ No P30. Does the department have formal agreements or memoranda of understanding with community agencies or services? __ Yes __ No P31. If yes, please provide these agreements or memoranda in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document.

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Funding P32. What is the pre-arrest diversion program’s annual budget? _________$/Year _________ Don’t know P33. Please identify the funds allocated to the following categories. Please identify as well the source of these funds in the space provided (e.g., Attorney General, Department of Health). For categories (a) and (b), note the number of equivalent full time positions included.

a. Professional salaries and benefits __ $/Year

Source of funds: No. of equivalent full time positions:

b. Administrative/clerical salaries __ $/Year

Source of funds:

No. of equivalent full time positions:

c. Rent __ $/Year

Source of funds:

d. Utilities

__ $/Year

Source of funds:

e. Equipment/supplies __ $/Year

Source of funds:

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f. Parking __ $/Year

Source of funds:

g. Other (please explain) __ $/Year

Source of funds: P34. How would you rate the adequacy of the program’s funding?

a. Poor b. Fair c. Good d. Excellent P35. If rated fair or poor, how would you modify the funding structure of the program to improve its overall effectiveness and/or efficiency?

Conclusion P36. In conclusion, what are the program’s key strengths? P37. What are the program’s key weaknesses? P38. How might the program be improved?

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P39. Please provide any additional comments you think might be helpful. P40. Finally, for follow-up purposes, it would be extremely helpful for us to know: ________________________________ Your name. ________________________________ E-mail address. ________________________________ Telephone number. Thank you for your participation. B. Court Diversion Introduction

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This portion of the survey is concerned with court diversion programs. In some jurisdictions, a court diversion program exists to divert an individual with mental illness into appropriate treatment. We are interested in learning more about this. Again, we thank you for agreeing to participate. Before you begin, it would be helpful to know the following: C1. Your agency’s name: C2. City: C3. Province/State/Territory: C4. Country: C5. Zip Code / Postal Code: C6. If you would like a final copy of the report, please provide a contact name in the space below: ____________________________________________________________ Training C7. Have legal team members associated with the diversion program received any training in mental health services? __ Yes __ No C8. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. C9. How many hours does this training take? __Hours C10. How often is this training offered to your program’s members?

a. Every year

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b. Every two years c. Every three years d. Data not kept e. Don’t know f. Other (please specify).

C11. Is more training needed? __ Yes __ No C12. Please describe the training needed in the space below. C13. Have mental health team members associated with the diversion program received any training in mental health law and/or court procedures? __ Yes __ No C14. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. C15. How many hours does this training take? __Hours

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C16. How often is this training offered to your program’s members? a. Every year b. Every two years c. Every three years d. Data not kept e. Don’t know f. Other (please specify).

C17. Is more training needed? __ Yes __ No C18. Please describe the training needed in the space below.

Outcomes and Monitoring

C19. Has the diversion program established a set of outcomes for clients? __ Yes __ No C20. If yes, please explain these outcomes in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. C21. Does the program monitor clients’ outcomes?

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__Yes __ No C22. If yes, please explain how the program monitors clients’ outcomes in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document.

Treatment C23. Does your diversion program have formal agreements or memoranda of understanding with community agencies? __Yes __ No C24. If yes, please describe these agreements in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. C25. Does your diversion program have on-site psychiatrists, psychologists, or social workers to conduct fitness or competence assessments? __ Yes __ No C26. Does your diversion program have on-site psychiatrists, psychologists, or social workers to assess psychiatric diagnoses? __ Yes

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__ No C27. Does your diversion program have off-site psychiatrists, psychologists, or social workers to provide treatment and follow-up? __ Yes __ No C28. Please note the agencies/services provided to clients (check all that apply):

Risk assessment Medication management Case management services Housing assistance Assistance obtaining financial aid Assistance obtaining medical care Assistance with other benefits Money management Crisis intervention Group therapy Individual therapy Day treatment Referral for other therapy (please specify):

Substance abuse Guardianship Family therapy Acute care hospitalization Long-term care hospitalization Emergency room treatment Safe beds / crisis beds Other (please explain)

C29. Should any other services be available? __ Yes __ No C30. If yes, please explain in the space below.

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C31. Please estimate how many mentally ill clients the diversion program has dealt with in the last year ___Clients/Last year ___ Data not kept C32. Do your program’s diversion policies exist in written form? __ Yes __ No C33. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document.

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Funding

C34. What is the diversion program’s annual budget? _________$/Year C35. In the tables below, please identify the funds allocated to each category. For categories (a) and (b), note the number of equivalent full time (EFT) positions included and provide a job description for each position (Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document). Please identify as well the source of funds in the space provided (e.g., Attorney General, Department of Health). a. Professional Salaries and Benefits

Job Title EFT Total Salary/Benefits

Source of Funds

Prosecutor/Crown

Prosecutor/Crown’s Job Description Defender/Counsel

Defender/Counsel’s Job Description Social Worker

Social Worker’s Job Description Diversion Worker

Diversion Worker’s Job Description Mental Health Worker

Mental Health Worker’s Job Description Nurse

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Nurse’s Job Description Other (Please explain):

Job Description

b. Administrative/clerical salaries

Title EFT Total Salary/Benefits

Source of Funds

Court Clerk

Court Clerk’s Job Description Court Monitor

Court Monitor’s Job Description Coordinator

Coordinator’s Job Description Other (please explain)

Job Description

c. Rent __ $/Year

Source of funds:

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d. Utilities __ $/Year

Source of funds:

e. Equipment/supplies

__ $/Year

Source of funds:

f. Parking __ $/Year

Source of funds:

g. Other (please explain) __ $/Year

Source of funds: C36. How would you rate the adequacy of the program’s funding?

a. Poor b. Fair c. Good d. Excellent C37. If rated fair or poor, how would you modify the funding structure of the program to improve its overall effectiveness and/or efficiency?

Conclusion C38. In conclusion, what are your program’s key strengths? C39. What are your program’s key weaknesses?

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C40. How might your program be improved? C41. Please provide any additional comments you think might be helpful. C42. Finally, for follow-up purposes, it would be extremely helpful for us to know: ________________________________ Your name. ________________________________ e-mail address. ________________________________ telephone number. Thank you for your participation.

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C. Mental Health Courts

Introduction This portion of the survey is concerned with mental health courts. In some jurisdictions, a mental health court exists to divert an individual with mental illness from jail into appropriate treatment programs. We are interested in learning more about this. Again, we thank you for agreeing to participate. Before you begin, it would be helpful to know the following: M1. Your court’s name: M2. City: M3. Province/State/Territory: M4. Country: M5. Zip Code / Postal Code: M6. If you would like a final copy of the report, please provide a contact name in the space below: M7. Is your court a dedicated mental health court? __ Yes

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__ No M8. If you answered yes, please continue with the survey. If you answered no, thank you for your time. M9. How often does your mental health court sit? __ days per week __ days per month

Training M10. Have legal team members of the mental health court received training in mental health services? __ Yes __ No M11. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. M12. How many hours does this training take? __Hours M13. How often is this training offered to your court’s members?

a. Every year b. Every two years c. Every three years d. Data not kept e. Don’t know f. Other (please specify).

M14. Is more training needed? __ Yes __ No M15. Please describe the training needed in the space below.

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M16. Have mental health team members of the mental health court received training in mental health law and/or court procedures? __ Yes __ No M17. If yes, please describe the training in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. M18. How many hours does this training take? __Hours M19. How often is this training offered to your court’s members?

g. Every year h. Every two years i. Every three years j. Data not kept k. Don’t know l. Other (please specify).

M20. Is more training needed? __ Yes __ No M21. Please describe the needed training needed in the space below.

Policies and Procedures M22. Please estimate what proportion (per cent) of the court’s time is spent on the following:

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a. Assessing fitness or competence to stand trial __ %

b. Involuntary inpatient commitment / treatment order

__ %

c. Monitoring offender’s compliance with the court’s directives __ %

d. Developing treatment dispositions

__ %

e. Other (please explain) __ %

M23. Would you recommend changes to improve the quality of information available at mentally disordered offenders’ hearings? __ Yes __ No M24. If yes, please explain in the space below. M25. Please estimate the average time (in days) a mentally ill client spends in jail for the following reasons:

a. Waiting for initial hearing __ days

b. Waiting for fitness or competence assessment

__ days

c. Waiting for treatment plan to be put into place __ days

d. Waiting for a forensic bed

__ days

e. Waiting for an acute care hospital bed __ days

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f. Other (please explain)

__ days M26. Can your court take steps to reduce jail time for mentally ill clients? __ Yes __ No M27. If yes, please explain in the space below. M28. If no, what obstacles exist to reductions in jail time? M29. Does your court require the client to sign a contract or agreement that specifies:

a. The conditions of treatment __ Yes

__ No

b. The consequences of non-compliance __ Yes

__ No M30. What sanctions does your court employ to deal with non-compliance with treatment?

a. More frequent court monitoring

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b. Jail time c. Withdrawing the client from the program d. Fines e. Other (please explain)

M31. What sanctions does your court employ to deal with failure to appear?

Outcomes and Monitoring M32. Does the court have an established a set of outcomes for clients? __ Yes __ No M33. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. M34. Does the court have a method for monitoring client's outcomes? __Yes __ No M35. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document.

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Treatment M36. Does your court have the authority to require community services to provide treatment for the court’s clients? __ Yes __ No M37. Does the court have formal agreements or memoranda of understanding with any service providers? __ Yes __ No M38. If yes, please explain in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. M39. Please estimate the timeliness of mental health treatment services (average time between initial referral for treatment and the first day of treatment) a. Within 24 hours

b. Within 2 days c. Within 7 days c. Other (please specify)

M40. Does your mental health court have on-site psychiatrists, psychologists, or social workers to conduct fitness or competence assessments? __ Yes __ No M41. Does your mental health court have on-site psychiatrists, psychologists, or social workers to assess psychiatric diagnoses? __ Yes __ No

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M42. Does your mental health court have off-site psychiatrists, psychologists, or social workers to provide treatment and follow-up? __ Yes __ No M43. Are case management services provided for clients?

__ Always __ Never __ Sometimes

M44. Please identify the groups for whom coordinating necessary treatment services has been especially challenging.

a. Homeless b. Co-occurring illness c. Newly diagnosed d. Non-compliant with medication e. Non-English speaking clients f. Culturally diverse populations g. Other (please explain)

M45. Please note the services provided to clients (check all that apply):

Risk assessment Medication management Case management services Housing assistance Assistance obtaining financial aid Assistance obtaining medical care Assistance with other benefits Money management Crisis intervention Group therapy Individual therapy Day treatment Referral for other therapy (please specify):

Substance abuse Guardianship Family therapy Acute care hospitalization Long-term care hospitalization Emergency room treatment Safe beds / crisis beds Other (please explain)

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M46. Should any other services be available? __ Yes __ No M47. If yes, please explain in the space below. M48. Please estimate how many mentally ill clients the court dealt with last year

__Number/Last year __Data not kept M49. Do your court’s policies exist in written form? __ Yes __ No M50. If yes, please provide these policies in the space below. Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document. M51. Are these policies comprehensive enough to cover the majority of situations encountered by you as a member of the MHC team? __ Yes __ No M52. If no, please explain how the policies could be improved.

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Funding M53. What is your court’s annual budget? _________$/Year M54. In the tables below, please identify the funds allocated to each category. For categories (a) and (b), note the number of equivalent full time (EFT) positions included and provide a job description for each position (Feel free to cut and paste from the relevant sections of any policy documents to which you have access. Alternatively, you can forward these documents as an attachment to [email protected], or mail them to the address noted at the beginning of this document). Please identify as well the source of funds in the space provided (e.g., Attorney General, Department of Health). a. Professional Salaries and Benefits.

Job Title EFT Total

Salary/Benefits Source of Funds

Judge

Prosecutor/Crown

Prosecutor/Crown’s Job Description Defender/Counsel

Defender/Counsel’s Job Description Social Worker

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Social Worker’s Job Description Diversion Worker

Diversion Worker’s Job Description Mental Health Worker

Mental Health Worker’s Job Description Nurse

Nurse’s Job Description Other (Please explain):

Job Description

b. Administrative/Clerical

Title EFT Total Salary/Benefits

Source of Funds

Court Clerk

Court Clerk’s Job Description Court Monitor

Court Monitor’s Job Description Coordinator

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Coordinator’s Job Description Other (please explain)

Job Description

c. Rent __ $/Year

Source of funds:

d. Utilities

__ $/Year

Source of funds:

e. Equipment/supplies __ $/Year

Source of funds:

f. Parking __ $/Year

Source of funds:

g. Other (please explain) __ $/Year

Source of funds: M55. How would you rate the adequacy of the program’s funding?

a. Poor b. Fair c. Good d. Excellent M56. If rated fair or poor, how would you modify the funding structure of the program to improve its overall effectiveness and/or efficiency?

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Conclusion M57. Finally, what are your court’s key strengths? M58. What are your court’s key weaknesses? M59. How might your court be improved? M60. Please provide any additional comments you think might be helpful. M61. Finally, for follow-up purposes, it would be extremely helpful for us to know: ________________________________ Your name. ________________________________ e-mail address. ________________________________ telephone number.

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Thank you for your participation.

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Appendix XV: Survey cover letter

Survey of Evidence-Based Practices in Diversion Programs for Persons with Serious Mental Illness

Who are in Conflict with the Law

Dear Colleague,

You are invited to take part in this survey, conducted by researchers at the University of Western Ontario and the Lawson Health Research Institute in London, Ontario, Canada, on behalf of the Ontario Ministry of Health and Long-Term Care.

About the survey

The purpose of the survey is to understand how persons with serious mental illness are diverted from the criminal justice system. Our goal is to identify the key elements of successful diversion practices in three categories:

1) Pre-arrest or police diversion; 2) Court diversion programs; 3) Mental Health Courts.

Participation is sought from colleagues in Canada, the United States, Great Britain, Australia and New Zealand. Because of its international scope, we believe this survey will lead to a comprehensive assessment of current diversion practices. Your participation is very important if the survey is to be as inclusive as possible. We would be happy to send a copy of the final report you.

Participation is voluntary, but we hope you will agree to contribute to our understanding of diversion programs. Any information you provide will be administered in accordance with the Privacy Act of Canada. The researchers will maintain all responses as confidential, and no individuals will be identified in published reports.

If you have questions about your rights as a research participant, please contact the University of Western Ontario's Office of Research Ethics ([email protected]) or country code 01-519-661-3036.

Instructions

The survey is available at the Web address noted below. We would appreciate your responding before July 9, 2004. We estimate that the survey will take no longer than 20 minutes to complete (based on previous responses).

There are three ways to access the survey:

1) Through a secure site on the Internet. If you choose to complete the Web-based survey, it must be completed in one sitting; you will not be able to save your responses and complete the survey later. If you do not have time to complete the survey in one session, please choose option 2) or 3) below.

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2) You may download a writable .PDF file from here. If you choose this option, you can save the file to your computer and complete the survey at your leisure. If you are completing the .PDF version, Part A (Police Diversion) begins on page 1, Part B (Court Diversion) begins on page 10, and part C (Mental Health Courts) begins on page 21.

3) Finally, you may also download the survey in Word or WordPerfect formats. If you choose this option you must save the file to your computer and complete the survey at your leisure. If you are completing the Word or WordPerfect versions of the survey: Part A (Police Diversion) begins on page 1, Part B (Court Diversion) begins on page10, and Part C (Mental Health Courts) begins on page 22.

If you choose options 2) or 3), lease make sure to send the completed survey as an attachment to [email protected].

An important note

Some of the survey questions will require you to provide information about program statistics, and about policy and planning. You may wish to consult others in your organization. If the answers to any questions are contained in your agency's documents, please feel free to use the cut and paste function to insert these into the appropriate sections of the survey. Or, if you prefer, you can mail copies of the relevant documents to us in care of:

Dr. Kathleen Hartford 375 South Street, NR A220 London, Ontario, Canada N6A 4G5

E-mail: [email protected] Phone: Country code 01-519-685-8000, ext. 77035 Fax: Country code 01-519-432-7367

If you are completing the Web-based version of the survey, click on the relevant link below:

Police Diversion

Court Diversion

Mental Health Courts

You need only complete the section of the survey that corresponds to the type of diversion with which you are involved.

Thank you.

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