“With such a large volume of people moving through our doors, we needed a system, not just a single courtroom.…”
—The Honorable Paul Biebel, Presiding Judge, Criminal Division, Cook County Circuit Court
The Cook County (Illinois) Criminal Justice System is the nation's largest unified court system. Each year it processes and admits more than 100,000 people to the Cook County Department of Corrections (CCDOC), more than 10,000 of whom have serious mental illnesses. Every day more than 1,000 detainees—of whom about 97% are awaiting the disposition of their felony cases—receive psychiatric services at CCDOC. Without clinical interventions, these individuals contribute to the backlog in court case processing and continue to cycle in and out of the jail and prison system.
Although some jurisdictions across the country have one problem-solving courtroom to meet the needs of people with serious mental illness, Cook County's sheer volume of cases would overwhelm a single specialized courtroom. Instead, Cook County's large, complex system required a much broader and systemic approach.
Additionally, Cook County and its partners recognized the challenges inherent in identifying individuals with mental health needs at a single point in time, which minimizes the efficacy of a “mental health courtroom.” For example, drug courts often are able to identify clients based on their charges. In contrast, mental health issues may emerge at any point in case processing, and criminal behavior may or may not be a symptom of a mental health disorder. Therefore, Cook County sought to allow for engagement in a specialized program for people with serious mental illness at any point in court or justice system involvement.
From the beginning, a wide array of high-level officials, treatment providers, and client advocates shared equally in the conceptualization of and planning for the program, including:
chief judge of the Cook County Courts;
presiding judge of the Cook County Courts' Criminal Division;
administrators from Treatment Alternatives for Safe Communities, Inc. (TASC), a not-for-profit organization that provides behavioral health recovery management services for individuals with substance abuse and mental health disorders;
Cook County Adult Probation Department (Mental Health Unit);
Cook County State's Attorney's Office;
Cook County Public Defender's Office;
Cermak Health Services of Cook County, providing mental health services for detainees;
Illinois Department of Human Services' Division of Mental Health (DMH) and Division of Alcoholism and Substance Abuse (DASA);
Chicago Police Department;
Loyola University Chicago;
National Alliance for the Mentally Ill; and
community-based mental health treatment providers.
The Cook County Mental Health Program was implemented in April 2004 with a small federal planning grant and existing resources within Cook County to create a cohesive service system dedicated to the rehabilitation and recovery of offenders with mental illness. From its onset, the program's goal was to create a judicial system informed about therapeutic issues and characterized by equal treatment under the law, whereby equal offenses receive equal criminal processing.
In developing the program, stakeholders had a few primary goals. They aimed to identify eligible individuals early in their court involvement and link them to community-based treatment. They also wanted all criminal courts to have access to relevant information regarding treatment history and the extent to which mental illness might have contributed to criminal behavior. Ideally, judges in all Cook County criminal courtrooms would use the same legal standards to determine guilt or innocence, and sentencing would be informed by an understanding of appropriate therapeutic interventions. They hoped this information ultimately would lead to a reduction in the incidence of arrests, incarcerations, and hospitalizations among program participants with serious mental illness and co-occurring substance use disorders.The program's core components were developed with a primary focus on sustainability and leveraging existing resources. The program's partners intended to develop a prototype for systemic change instead of an approach that relied on one courtroom, which would be limited in its ability to monitor clients' behaviors and to assist them in managing their illnesses. Therefore, identification of needs and appropriate interventions are built in at each stage on the Cook County criminal justice continuum (from arrest and incarceration through termination of community supervision).
Program participants are sentenced to probation with mandatory mental health treatment and other types of behavioral healthcare and social services. Mandated treatment for clients allows the judicial system to leverage the opportunity for stabilizing individuals through treatment and medication management and monitoring their progress. In turn, this theoretically reduces the likelihood of psychiatric and criminal recidivism.
In addition, the program takes advantage of case management strategies and client advocacy through TASC that have proved successful in criminal justice, mental health, and substance abuse systems. These strategies are designed to incorporate an intensive recovery management model, which promotes client responsibility and self-sufficiency by incorporating habilitation services in standard case management plans.
Within the program's structure, individuals can be reassessed and referred to different types and levels of services as they move through the criminal justice and treatment process. This allows for a seamless transition between services, thereby reducing the level of program attrition, and ensures that clients are continuously supported throughout their tenure in the program, including identification, assessment, service planning, clinical interventions, and each of the criminal justice phases.
Appropriate graduated sanctions to address noncompliance and incentives for progress are determined through a collective problem-solving approach that not only involves the client, TASC case managers, probation officers, and judges, but also the Chicago Police Department's Crisis Intervention Team, state's attorneys, public defenders, and DMH- and DASA-funded providers. The team strategy underscores the importance of coordinating decision making with core TASC case management activities. Members of the program team all play a role in monitoring, evaluating, and supporting clients' participation in treatment through a schedule of judicial hearings in which the judge and team have direct, meaningful contacts with individuals.
The program has been supported through a combination of local, state, and federal funds, including a significant contribution of existing resources from each of the criminal justice partners and a grant in 2005 from the Substance Abuse and Mental Health Services Administration's Center for Mental Health Services. The CMHS grant has allowed the program to triple its capacity and build a network of community partners such as Thresholds Psychiatric Rehabilitation Centers (one of the nation's largest nonprofit providers of mental health services).
The program has demonstrated marked success in its first two-plus years. In August 2006, among the 28 participants enrolled in the program for at least 12 months, the average number of arrests per participant decreased from a preparticipation rate of 4 in the year prior to admission to 0.43 in the year after enrollment. This was a reduction of 3.57 arrests per participant, which represents an 89.3% decrease.
Among these 28 participants, the average number of days incarcerated per participant decreased from a preparticipation rate of 124 in the year prior to admission to 26 in the year after enrollment. This was a reduction of 98 days, which represents a 79.0% decrease. (This reflects the per-participant average number of days incarcerated for new crimes, as well as symptomatic regression or noncompliance with treatment. When only new-crime incarceration days are counted, the per-participant average was 8.)
The public cost savings associated with the reduction of incarceration days for these 28 participants was dramatic. The average preparticipation cost of incarceration per participant in the year prior to admission was an estimated $8,680, compared to $1,820 in the year following enrollment. This was a reduction of at least $6,860 per participant ($192,080 total), which represents a 79.0% decrease. (Costs are based on the lowest estimate of $70/day cost of general population; it is assumed that daily costs for the program's population are significantly higher based on special needs and costs of medication.) This estimate does not take into account the potential cost savings associated with arrests and adjudication that the program might have prevented. This estimate also does not take into account the cost savings associated with participants who had been in the program for less than one year but still minimized their contact with the criminal justice system in terms of arrests and incarceration days compared with their preenrollment levels.
The Cook County Mental Health Program's success has depended on fostering new relationships and capitalizing on the existing systemic strengths and partnerships. The program has enabled treatment at all stages of the criminal justice continuum, supported participant engagement and retention in services, intervened swiftly as problems developed, and used a system of graduated responses. The program has effectively seeded a system to reduce subsequent arrests, incarcerations, and hospitalizations of mentally ill offenders sentenced to probation in the Cook County criminal courts. Program partners are committed to the sustainability of the project and have been actively soliciting new funds to ensure the safe and humane treatment of persons with serious mental illness.
The authors thank Maureen McDonnell, Special Projects Program Liaison at TASC, for her contribution to this article.Lisa Braude, PhD, is Director of Research and Policy at Treatment Alternatives for Safe Communities, Inc. (TASC) in Chicago.
Carl Alaimo, PsyD, is Director of Mental Health Services at Cermak Health Services of Cook County (Illinois)