Mental Health and Justice on the Last Frontier: A Conversation about the Anchorage Mental Health Court
Judge Stephanie L. Rhoades, who helped found and has presided over the Anchorage Mental Health Court since 1998, and Kathi R. Trawver, associate professor of the School of Social Work at the University of Alaska, Anchorage, discuss the court's origins, accomplishments and lessons. They co-authored "Homesteading a Pioneering Mental Health Court: A Judicial Perspective from the Last Frontier" for American Behavioral Scientist.
The following is a transcript of the podcast:
ROBERT V. WOLF: Hi, I'm Rob Wolf, Director of Communications at the Center for Court Innovation, and welcome to New Thinking, the podcast where we interview justice reformers and innovators. Today I have on the phone two experts who are well versed in the intersection of mental health and justice. They are Judge Stephanie L. Rhoades, who has presided over the Anchorage Mental Health Court since the court was created in 1998, and Kathi R. Trawver, associate professor of the School of Social Work at the University of Alaska, Anchorage. I know you're both very busy, so I really want to thank you for taking the time to talk today.
JUDGE RHOADES: Thank you, Robert.
ROB WOLF: I thought we could focus on the article you both recently co-authored in American Behavioral Scientist, where you draw some lessons from the experience of the Anchorage Mental Health Court. The article is Homesteading A Pioneering Mental Health Court: a Judicial Perspective from the Last Frontier. And I'll put a link to it on the podcast page, although I think people need to be a journal subscriber to actually download it. You note in the article that there are about 300 mental health courts in the U.S. today, but back in 1998 there were only a handful and Judge Rhoades actually created the Anchorage court without ever seeing a model in action. So Judge Rhoades, can you describe some of the motivations—and I know there were some personal ones and professional ones—that led you and a special commission to explore creating one of the first mental health courts in the country.
JUDGE RHOADES: I will. Some of the motivation was exactly what are the motivations for all the courts that are developed, which are the over representation of people with mental disorders in corrections, basically. And the frustration of judges who would sentence folks on low-level misdemeanor offenses, and they were committed largely because people are disordered, homeless, they've got other challenges, and the sentences really don't have an impact because these folks go out the back door of the jail the same way they come in the front doors. And so nothing's really changed and there was a kind of a harmonious convergence of the Department of Corrections in Alaska getting some technical assistance nationally to form a Criminal Justice Assessment Commission, which was a policy-level group to think about how to reduce the number of people in jail.
So one of the issues that they explored was the over representation of people with mental disorders. Meanwhile, in my personal life, I have a brother who has both intellectual disability and some mental health issues. And I recognize that, you know, if anything like this had happened to him and he'd gotten arrested, that he would have certain needs that nobody in the system was ever going to be able to fulfill. And that is basically what got me thinking about a mental health court, which is a way to have people be helpful to individuals who were going through the criminal justice system, to hook them up with treatment and other resources that would, hopefully, address the underlying issues that brought them before the court, and to prevent them from returning.
WOLF: The Anchorage Mental Health Court, one of the many things that's interesting about it is that it was the first problem-solving court in Alaska. And to my knowledge, most of the time that states have created a mental health court, they're usually already familiar with linking defendants to services through their work with drug courts. I'm wondering how you presented the concept to other court players, and prosecutors, and defenders, without having, you know, a drug court to point to or some other kind of problem-solving court to point to as an example.
JUDGE RHOADES: Well, I’ll take that one on, Robert. It's Judge Rhoades here. You know, there's a great saying up here in Alaska: “We don't do it like they do it outside.” And we were, in fact, I think the last state to get a drug court, which is sort of funny.
You know drug courts were top down planned courts. They were federally funded, the start-ups were federally funded, and the way the mental health court started here, basically, was more of a ground floor response by people who were experiencing this frustration. I think the deal here is that, generally speaking, our prosecutors have more understanding that—and more sympathy, perhaps—for people who have mental health disorders, who get caught up in the system, than they do for people who have addiction disorders.
I think there's still quite a bit of thinking about drug and alcohol addictions that basically these are voluntary and that all you have to do is just say no, but I think the prosecutors definitely got the fact that there are some people who have mental disorders who just are, you know, really—you can't punish the disorder out of them.
WOLF: I imagine that you, with your personal connections with your brother, had a greater credibility to present the need for this kind of court.
RHOADES: Frankly, Robert, I never divulged to anybody that I had a brother. It's a small town here and he lives here, so that really wasn't something that anybody knew about me. I think what was really helpful was judicial leadership. You know, when a judge calls somebody and says ‘let's have a meeting,’ they show up. That didn't happen when I was a lawyer. It didn't happen when I was, you know, in any other profession and so judges tend to have this really wonderful opportunity to convene people, to get stakeholders together.
WOLF: Professor Trawver, maybe you can put mental health courts in context. With the rate of mental illness so high among the justice-involved population, why are mental health courts significant?
PROFESSOR TRAWVER: Good question. I guess I can preface my answer by saying that I think, along with other folks, that we don't really believe, necessarily, that mental health courts are the only answer or the best answer, but still a really significant contribution to the continuum of potential diversion opportunities, and I think that they are important in several ways.
First, I think they offer an improved court-based process for individuals. Second, there's strong evidence that mental health courts improve access to treatment, even—funny—even when treatment is already available. So they're already actually entitled to it, but they seem to still improve access. And I guess the third—another thing that's significant about mental health courts is that there's a strong developing evidence base that mental health courts result in reduced rates of recidivism. And finally with the development and expansion of mental health courts, I think they’ve raised awareness about the intersection of mental health and criminal justice involvement. So for example, in the Anchorage Mental Health Court, all the nursing students who go through UAA are required to come to watch the mental health court during their psychiatric rotation.
WOLF: One of the key goals at the outset for the Anchorage Mental Health Court, as you describe in your article, was to try, to some extent, to decriminalize mental illness and get the mentally ill out of the justice system. Judge Rhoades, why is decriminalization so hard to achieve, and have you been disappointed or frustrated that you haven't been able to move further in that direction?
RHOADES: The premise was that we believed mental illnesses basically were the direct cause of criminal justice involvement, and really it turns out that it's very few people for whom that's true. It appears now, from more recent research, that mental illness is a reason why people can't necessarily change as easily as other people. Really they are just as susceptible, and perhaps more susceptible, to what we call criminogenic risks and needs. Anti-social behaviors, anti-social personality patterns, anti-social thinking, anti-social associates, you know, being close associates with people who aren't law abiding. Having poor family or marital relationships, not having education or work opportunities, not having pro-social leisure and recreation, and substance abuse. I think that, unfortunately, people with mental illness tend to experience these factors perhaps more than other people.
You know, for example, substance abuse is very highly associated with people who have mental illness. These factors are things that we really did not dig down into and look at when we first started the court, and now that we are informed by some of this information, we have begun to actually measure these things on validated instruments to see where people are experiencing high, medium, or low risks and needs in these areas that predict recidivism. By doing that, we can be more effective in terms of how and what we are linking people up with, so that they can actually, you know, reduce their recidivism.
WOLF: I think there are probably many unique things about Alaska, and I wonder if, in particular, relating to the population you're working with, are there unique challenges regarding the mentally ill?
TRAWVER: There's a long list. First is just geographic challenges. If you sort of think about how huge Alaska is, and many people live off the road system in rural areas and in conditions that I am pretty sure that most New Yorkers would consider Third World conditions. Social problems—Alaska has the distinction of ranking very high among states in a lot of contributing social problems. For instance, we're number one in our rate of adult drug use, number two in alcohol consumption, number two in rates of suicide across the board, very high rates of trauma and family violence, and that's disproportionately true among Alaska natives.
Third, I would say access to behavioral health services is a major problem in Alaska. So we do have some innovations in terms of tele-behavioral health which is interesting and used by a lot of paraprofessionals, behavioral health aids in remote and rural areas, and housing is just a major barrier in many communities, and there's still a great deal of stigma and nimbyism, particularly in some of the larger communities.
RHOADES: I only want to add one other thing about what makes Alaska's court different. We take a very broad diagnostic group, much broader than, I think, most other courts. because we are serving people who have any mental health disorder, and co-occurring substance abuse disorders, so long as they can be linked and matched with services in the community, that means for us that we have to become competent at linking and monitoring people in the intellectual disabilities community as well as the mentally ill community, as well as the substance abuse community. And Alaska experiences very high rate of traumatic brain injury and fetal alcohol spectrum disorder, which are very difficult disorders to link with treatments.
WOLF: What are the takeaways? What lessons, Judge Rhoades, do you have for other judges? And Professor Trawver, what do you think, from your perspective, are the take-aways from the Anchorage Mental Health Court?
TRAWVER: I have some things I would say about Judge Rhoades. I view her as a true pioneer. Even though she made it sound really simple when she was talking about how she started the court, I know that she struggled and actually sacrificed a great deal professionally to create the Anchorage Court.
JUDGE RHOADES: It is true that it was a long road getting started, but my advice to other courts would be a couple things. One is you really have to get an education about different diagnoses and what the behaviors are that go along with those, so that you can understand the perspective of each of the people that come before the court. Judges really need to learn how to talk candidly to people about mental illness and about other kinds of disabilities because you know it's really important to note that they have strengths and challenges, and that they can do really well. And I think the other part of it is that in terms of the structure of any court, what I would give as advice is that like any project, you've got to have a mission, you've got to have policies and procedures that are clearly stated and enforced, and understood by everybody, most especially the participants, and you really have to go back and every time that there is a decision to make, because there are many decisions to make that pose ethical dilemmas, every one of those decisions should really hearken back to whatever your stated mission is.
These courts really have been put together without much research to guide them. So it's very easy, under circumstances like that, to get off the reservation, especially from a very paternalistic point of, you know, let me do good for you, I'll put you in jail these five days because you didn't take your medications. Well, that's not meeting your mission if your mission is decriminalization, or reducing the number of days they spend in jail.
WOLF: Well thank you very much for both of you sharing your experience and knowledge. I've been speaking with Judge Stephanie L. Rhoades, who have presided over the Anchorage Mental Health Court since the court's very beginning in 1998, and I've also been speaking with Kathi R. Trawver, who's an associate professor of the School of Social Work at the University of Alaska, Anchorage. So thank you both very much.
RHOADES: Thank you, Robert.
TRAWVER: Thank you, Robert.
WOLF: And for folks who are interested in learning more about the Anchorage Mental Health Court, you can read the article that they co-authored, that is in the American Behavioral Scientist. It's called Homesteading A Pioneering Mental Health Court: A Judicial Perspective from the Last Frontier. And there will be a link to it on our podcast page at our website, www.courtinnovation.org. I'm Rob Wolf, Director of Communications at the Center for Court Innovation. Thanks very much for listening.
(March 2014)