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May 01, 2015

Silver Linings Bench Book

By Judge Patrice Lewis

At a time when specialized dockets are often seen as conflicting with time standards and case flow management demands, a consolidated mental health court docket may be an effective step in the right direction. Limited judicial resources and the need to increase overall productivity often cause those deciding to create a mental health docket to say no. However, our experience would suggest that consolidating all competency, criminal responsibility, and mental health presentence evaluation cases on one docket serves to help the court and the Department of Health and Mental Hygiene provide efficient and effective services to our community at large and those in need for improved services and outcomes. To paraphrase Pat Solitano from Silver Linings Playbook, if life is a film, by helping our defendants implement a court-approved, mental-health-driven, self-improvement course, each community could develop its own Silver Linings Bench Book of available and accessible mental health and co-occurring services and have a judge supervise compliance on a consolidated criminal docket. Let me explain.

Our Maryland General Assembly tightened some language concerning defendants, competency evaluations, and the need to promptly move those found incompetent out of our local detention centers and into the state hospitals to restore competency. This resulted in a judge being designated in each of our district courts to review the current state hospital census for our district and to manage current competency hearings. Honestly, when I agreed to the assignment, I had no idea what that meant in terms of numbers, but I was confident I had the skill set to handle it. Fortunately, the State’s Attorney’s Office assigned a senior supervising attorney to the docket and the Office of the Public Defender assigned the deputy public defender. Parole and Probation assigned an agent with extensive experience, as did Pre-Trial Release. In other words, our team was so savvy, we thought we could knock out the work in no time and agreed to review files once a month.

What resulted is what is now known as the Mental Health Court for Prince George’s County, MD, District Court #5. We meet every Tuesday and Thursday and have a psychologist under contract for the Department of Health and Mental Hygiene who performs all our orders for competency, criminal responsibility, and presentence evaluations. He is an integral part of the team and has performed approximately 275 evaluations per year, for both our circuit and district courts combined. While the majority of these evaluations are for the district court, the benefit for the circuit court is that the case has largely been triaged before indictment and that gives the Coordinating Judge for Criminal Operations in Circuit Court, Michael P. Whalen, greater insight into how the case can best be assigned for case management purposes. To put it most succinctly, it allows for more efficient docketing of cases that have particularized issues and/or probable dispositions.

As our caseload expanded, the Mental Health Court team also expanded and now includes three case workers, a licensed clinical social worker, and a Mental Health Court coordinator.

By way of background, Prince George’s County is the immediate eastern suburb to Washington, D.C. Our community has a population of nearly 900,000. We were originally a rural community, but as the tobacco farms were sold off and developed, we became what is described as the wealthiest predominantly African American community in the country, with a per-capita income of $32,254, a median household income of $73,568, and approximately 8.7 percent of our community living below the poverty level. We are the home to the flagship campus of the University of Maryland, College Park; Bowie State University; Prince George’s Community College; and numerous satellite campuses for Howard University, the Johns Hopkins University, and others. Many residents are first- or second-generation college educated. Yet we still have many blue-collar workers. We reflect a community of immigrants, with about 20 percent of our members being foreign born and 20 percent of our households speaking a language other than English. Prince George’s County offers even those of limited means affordable housing, which includes approximately 100,000 apartment units. We are a true reflection of a 21st century American urban community (according to the U.S. Census Bureau).

I offer this as background because our court sees quite a mix of people. However, the common denominator in Mental Health Court is they are people. Old, young, highly educated, or less educated, mental illness is an equal opportunity affliction. In fact, in our first year of operation, the average defendant was 42 years old. I originally found this quite surprising. Yet the longer I worked with this group, the more I questioned my surprise. You see, in almost all mental disorders, what we are witnessing is the inability of the person to adapt to the demands of daily life. Haven’t we all heard of the midlife crisis? It is arguable that mental illness is just a midlife crisis, but supersized.

The Centers for Disease Control and Prevention defines mental illnesses as:

disorders generally characterized by dysregulation of mood, thought, and/or behavior, as recognized by the Diagnostic and Statistical Manual, 5th edition, of the American Psychiatric Association (DSM-V). Mood disorders are among the most pervasive of all mental disorders and include major depression, in which the individual commonly reports feeling, for a time period of two weeks or more, sad or blue, uninterested in things previously of interest, psychomotor retardation or agitation, and increased or decreased appetite since the depressive episode ensued.

What is fascinating about the definition is that few are excluded. The longer you work in the area, the sooner you realize that mental disorders are not rare. When you approach from the perspective of a judge, you question the percentage of court-involved individuals who qualify as having experienced a mental disorder. Statistically, anywhere from 20 to 30 percent of the general population are predicted to suffer from a mental illness in their lifetime. And the definition suggests it is often triggered by a stressful event, which seems to beg the court’s question: Is everybody a little off around here?

The common characteristic of the cases in Mental Health Court is that a routine event is unfolding but the defendants’ response is irrational, disproportionate, and sometimes nonsensical and seems to occur almost explosively. That is to say, the others present are at a loss that what preceded has triggered the defendant’s response. They are in court because the conduct has crossed the line and at least is perceived as meeting a probable cause standard for criminal charges. Under DSM IV, it was an Axis II diagnosis. The criteria may seem more expansive under DSM V, but, in the end, we do not work with sociopaths, oppositional personality disorders, and the like.

Our Mental Health Court team reviews the charges and considers whether there is a prior diagnosis of a mental disorder. If this exists, the team reviews the history and determines whether there is a treatment plan that could restore the defendant’s good health and support his or her ability to maintain it, with care and treatment. Often, medications are prescribed, with medication compliance a requirement. Additionally, those defendants who are also substance abusers are required to submit to urinalysis to ensure they are free of any street drugs/alcohol, which are contraindicated for defendants on mental health medications.

In our first year, we saw 355 defendants, and have averaged about another 230 annually thereafter. These 230 defendants are new, previously not identified to our Mental Health Court. The question often arises, “Where do they come from?” But as one of the long-experienced Mental Health Court judges and distinguished national speaker Steven Gross of Georgia would say, “they have always been in inventory.”

So once we find them, what do we do with them that differs from what a traditional criminal court would do? The defendant signs a contract to participate in Mental Health Court and signs a release of information form for medical records. We assign the defendant a caseworker whom the defendant must contact once a week, if he or she is not incarcerated. The team reviews past medical records and recent treatment diagnosis and prognosis and helps the defendant plot a course to better health and functionalism. More often than not, the state agrees not to prosecute the charges if the defendant acknowledges his or her illness, accepts the diagnosis, and demonstrates over a period of time an ability to manage his or her mental health without continued court supervision.

Sounds simple enough, but the path to wellness can be a long and winding road, with a few frolics and detours, to say the least. However, what is clear is that most people enjoy the clarity that comes from medications, properly managed; the supportive therapy; and praise for their good efforts. I often describe Mental Health Court as being a lot like parenting: You cannot give up or turn your back. Indeed, it is important to maintain standards, expect them to be met, sanction misconduct, but never give up. It is by being supportive, encouraging, and accessible even in the darkest of times that leads to improvement. In most instances, the demons can be fought back and a better way of life can be achieved. We have witnessed many who have learned to accept their diagnosis, recognize the signs, and self-regulate so as not to deteriorate back to their earlier position of despair and hopelessness. I say that because for each of the past seven years at our morning meeting, where we conference our cases, we not only have taken in new defendants but recognize a successful defendant by stating he or she is being “voted off the island today.” Our vernacular means that while we do not graduate any of our defendants, because our philosophy is that they have a chronic illness that must always be managed, they have clearly demonstrated the ability to go out into the community and successfully manage their own mental health without mandatory reporting. The criminal case may be terminated or placed in an inactive status or the defendant may have to plead guilty and successfully complete probation.

Our Mental Health Court was born out of a consolidated Competency, Not Criminally Responsible Docket. The creation of a consolidated docket allows for the convening of the necessary behavioral health professionals in one courtroom for the community. It is a cost-savings strategy for the state hospital and local service providers because they can have multiple clients/patients on one docket and can reduce transports to multiple courthouses, as well as among multiple courtrooms. The defendants reap the benefit of a more stable lifestyle, frequently without receiving a criminal conviction.

The adversarial nature of the standard criminal courtroom yields to a more collaborative effort to improve the quality of life for the specific defendant and the general community. It does not matter which party prevails but whether Prince George’s County determines that this is an important end and has invested the time, talent, and resources of our Family Services, Mental Health and Disabilities Division, L. Christina Waddler in particular, and numerous other county employees, who over the years have worked to find, fund, and link services to so many. Her knowledge leadership and commitment to enhance services and ensure quality care have been an integral part of whatever successes have been realized by our mental health court. It is critical that a mental health court have community support.

The consolidated docket approach increases the likelihood of integrating the behavioral health service providers’ aftercare plans into court orders of conditions of pretrial release, possible probation terms, and/or alternative diversion strategies with mental health compliance requirements. Managed care requirements increase the defendant’s likelihood of success in the community and decrease public safety concerns. Further, they promote the defendant’s general good health and well-being, which improve a community’s overall standards and peacefulness. Having one courtroom designated for prompt presentment provides for the earliest and best care, better care for those suffering from mental illness, and an efficient use of court time and resources. A consolidated docket is an easy, 21st century response to the changing needs of our courts. It would be an appropriate place for each community to implement a particularized Silver Linings Bench Book.

For further information, please contact our Mental Health Court Coordinator Marilyn Bailey at 301-298-4101 or [email protected].