A Court of Refuge

by Ginger

  The barriers to care surrounding mental illness are such that fourteen years ago, the New Freedom Commission on Mental Health determined that nothing short of system transformation would remediate the problems and achieve the mission that President George W. Bush outlined in his executive order establishing the commission in 2002.5 The president’s goal was to establish a mental-healthcare delivery system in the United States that enables adults with serious mental illness and children with serious emotional disturbances to live, work, learn, and fully participate in their communities. This goal has not yet been achieved.

  According to research, one in five Americans, 43.8 million people, experience mental illness in a given year. Despite the prevalence of mental illness, research conducted by the National Institute of Mental Health has found that nearly 60 percent of adults and 50 percent of youth who had such an episode in the year previous to the study did not receive mental health services.6 The consequences of untreated mental illness are profound and costly in human, social, and economic terms. Even with the proliferation of problem-solving mental health and other treatment courts, an estimated four hundred thousand people incarcerated in America’s jails and prisons.7

  Combating this trend, the Broward County Mental Health Court and other mental health courts provide valuable lessons and insights into recovery and the power of community, human connections, and ways to leverage social networks and alliances to provide supports to fill gaps. These bold efforts, however, also highlight the need for our nation’s policymakers to “turn the page” of centuries of stigma and discrimination and advance mental health reforms from a public health perspective—as opposed to a criminal justice perspective—as urged by many national experts, including Arthur C. Evans Jr., the chief executive officer of the American Psychological Association. According to Dr. Evans, “Mental health requires a public health approach, which is more like treating diabetes than a broken leg.” A rational mental health or behavioral health delivery system must be informed about the diverse needs of their communities and as stated by Dr. Evans, “develop strategies to prevent, treat, and rehabilitate individuals with varied and diverse problems including serious mental illness and substance use.”8

  Make no mistake: I enthusiastically support problem-solving courts and work to promote the principles and application of therapeutic jurisprudence in all legal spheres. The goals of problem-solving justice and community restorative justice approaches, in my view, are the future of our legal system. But there is one caveat.

  These court strategies, which look to respond to root causes and the vexing social problems that land on the courthouse steps, are not and were never intended to be a substitute for a comprehensive public health model of mental-health and behavioral-health care in the United States. There is a great deal of work to do from a public health perspective to transform mental-health and behavioral-health care delivery for all Americans. After all, mental health is essential to overall health.

  On July 22, 2002, the New Freedom Commission on Mental Health submitted its final report to the White House.9 In a cover letter drafted by the commission chair, Michael F. Hogan, the commission was pleased to report that after a year of extensive study and review of the research and testimony, the commission had concluded that “recovery from mental illness is now a real possibility. The promise of the New Freedom Initiative—a life in the community for everyone—can be realized. But only if the nation undergoes a fundamental transformation in its approach to healthcare.”10

  In August 2008, Janis Blenden, the in-court clinician, and I were invited to present on the Broward County Mental Health Court at the International Conference on Special Needs Offenders, convened by the International Institute on Special Needs and Policy Research, in Niagara Falls, Canada. The conference focus was on mentally ill offenders and special populations including women, indigenous people, and residents of underdeveloped countries. Conference attendees included four large and diverse delegations of criminal justice and mental health stakeholders from Canada, the United States, the United Kingdom, and Kenya. Although we had not been informed that our session was of particular interest to the delegation members from Kenya, that fact became clear to me as I had an opportunity to sit next to Dr. Manford Meli, a mental health policy consultant, who led the delegation.

  In many countries, a lack of rational and comprehensive mental health policies serves to perpetuate stigma and discrimination of those living with mental illness. The World Health Organization has reported that 40 percent of countries do not have a mental health policy, and 25 percent of countries do not have mental health legislation or a rational national mental health agenda.11 The Broward County Mental Health Court, which was established without government funding or grants, offers a cost-effective, sustainable, innovative strategy for other countries to consider, especially if they are interested in transitioning to a more humane, community-centered approach to mental health care.

  Over lunch, Dr. Meli explained that he had accepted an assignment to participate in the development of comprehensive mental health agenda on behalf of the government of Kenya. He described an array of challenges that intersected with every domain of public health infrastructure in Kenya. These challenges included establishing legislative and disability rights law and social justice policies to mitigate health inequities and to begin to close existing gaps in mental health care. There was no system of mental health care at all in Kenya. Instead, there was only one state hospital to serve the entire nation; the hospital was essentially an overcrowded prison. The inhumane conditions at Mathari Hospital in Nairobi gained international attention for the need for national reform in 2013, when forty patients escaped. The subsequent reporting revealed several shortcomings of Kenya’s budget; mental health care was funded at less than 1 percent of the annual budget.12

  As my lunch conversation with Dr. Meli ended, I realized that the delegation from Kenya may have come to the conference for information, but what they needed was hope.

  As the first speaker took the podium to open the presentation about mental health courts, instead of providing a historical context for the development of this problem-solving court model in the United States, he opened his presentation with comments showing what clearly was intended to express his disapproval of the mental health court model, as he sternly stated, “There is no evidence or data that mental health courts work.” I did not take the speaker’s comment seriously in terms of his presentation of data. I knew that mental health courts, which use a dignity model, are highly effective, as research on Broward County’s Mental Health Court has clearly demonstrated.

  According to Michael L. Perlin, advocates should seize on the ratification of the UN’s Convention on the Rights of Persons with Disabilities (CRPD) to push through the expansion of mental health courts to create an international movement on behalf of persons with mental disabilities. He notes, “Individuals with mental disabilities have been outsiders in the world of international human rights law, with many important global human rights agencies traditionally expressing little to no interest in the plight of this cohort.”13 Perlin argues that with the ratification of the CRPD and with the model of Broward County Mental Health Court and other mental health courts, judges who apply the principles of therapeutic jurisprudence dignity can remediate the inhumane treatment of prisoners with mental illness.14

  Perlin states, “The Convention is the most revolutionary international human rights document ever created that applies to persons with disabilities.”15 I concur with his view that mental health courts that promote dignity have the capacity to mitigate the inhumane treatment of persons with mental disabilities. Dignity is the leading objective of the Broward County Mental Health Court, to redress a number of factors: centuries of false and irrational attitudes surrounding mental illness, institutional bias and stigma against people with mental disabilities, the tragic experiences of Aaron Wynn, and the highly fragmented and under-resourced community-based system of mental health care. Fr
om working in the South Florida State Hospital and as a public guardian, I have witnessed firsthand the marginalization and degradation of my clients. This experience led me to create a court culture of dignity and respect. The application of therapeutic jurisprudence and the aspirational goals of the UN Convention give the court impetus to protect individuals’ constitutional and due process rights and promote human connectedness and trust by providing defendants a voice, validation, and voluntariness.

  This example of human connection enhances the perception of fairness, levels the playing field, and instills hope. This is the profound message of the mental health court, nationally and internationally. As noted in a recent publication that surveyed hundreds of mental health courts in the United States and Australia, “The Broward County MHC’s influence on international practice is manifest. In Australia, jail has not been used as a sanction in any its four MHCs.”16 According to Michelle Edgely, mental health courts are gaining in popularity in the United States and internationally, with more than four hundred mental health courts in the United States and around the world. With a focus on what makes a mental health court work, Edgely examines a number of theoretical aspects of judicial approaches in a problem-solving court and argues that the most effective approach in a mental health court to promote rehabilitation pertains to “building therapeutic alliances.”17 Although Edgely notes that more research is needed to evaluate the effectiveness of mental health courts work as to recidivism and rehabilitation, she notes that “a significant body” of data as to mental health court outcomes both in the United States and Australia provide evidence that these courts are effective at reducing recidivism.18

  My awareness of recent evidence of the effectiveness of mental health courts didn’t prevent me, as I paced up and down the side of the conference room as the first speaker shared his views, from being concerned about the impact of the speaker’s remarks on the audience. Many who had come to this session seeking inspiration and a robust exchange of ideas on how to advocate for social change in underdeveloped regions.

  How do you generate hope?

  That first speaker may well have dashed the Kenya delegation’s perception of finding a solution at the conference within a matter of minutes. I glanced at Dr. Meli. His head was down, and as I scanned the room, I noticed that the audience members were looking at me with doubt. I thought about the desperation of Broward County and the release of the scathing 1994 Broward County grand jury report.19 Of course, data is critically important to guide mental health policy and budget decisions. In the report, Broward County’s inadequate mental health community-based system of care had been adjudged “deplorable.” At times, innovation emerges from desperation, and Broward’s Mental Health Court was an example of an innovation that grew out of the need to “do something.”

  I felt that the members of the Kenya delegation needed to understand the power of hope and that they shouldn’t be deterred to bring their own justice innovations forward, as social justice is a matter of life and death. I got up from the speakers’ table where Janis and I were sitting and began to pace up and down the side of the conference breakout room. I thought about a moment fifteen years before when a chief judge at a criminal justice forum suggested that what I was doing in the Broward County Mental Health Court was “wholly inappropriate.” I remember how hard that comment struck me. For me, as a new judge, those words had delivered a hefty load of doubt. How was I going to restore hope to the members of the delegation? As I waited for the opportunity to deliver my rebuttal, I thought about hope and its inextricable connection to vision.

  I began my speech with the words “Data schmata.” This was not a comment about the importance of data and the need to develop outcome measures or an evidence base of “what works.” It was, instead, my way of reinvigorating hope. I meant it as a reminder that there is a time for action and leadership, particularly when there are vacuums in social policy that impact basic human rights and health, and the need for more data should not become an obstacle to such action. It was my referendum on hope.

  As I spoke, I described the problems that the Broward County community had been experiencing in the criminal justice system when a small group of stakeholders decided to create a task force to search for solutions to the overrepresentation of people arrested with mental health and cognitive disorders in our local jail system. I explained that the mental health court was born out of desperation and as a response to suffering and human rights violations, and I described the transformative case of Aaron Wynn. The court was the physical manifestation of a community’s collective hope that they could find a solution—something—that worked.

  “The court was our ‘something,’” I said.

  The room burst out with applause that was so loud, conference officials who hadn’t heard applause that loud before rushed into the room to see if something was wrong.

  Broward County’s mental health system has never recovered from the financial crisis of 2008 and the decision by the Department of Children and Families to accelerate privatization of the behavioral-health-care system, which occurred several years after the conference. Its result was a notable decrease in the number of mental health services and treatment programs available not only to citizens of Broward County but to the state of Florida. Even as the mental health court continues to adapt to ever-changing mental health policy while working to address the needs of the community, each new challenge leads me back to the speech I gave years before in Canada. As of 2017, the community-based system of mental health care hadn’t yet expanded its service capacity for mental health care, residential care, and housing. Then, as now, I wonder: How will the court fill gaps and limitations in Broward’s community-based mental health care?

  And how were we going to restore hope, not only for the court, but for me?

  CHAPTER 15

  Recovery Is Real

  The story of Kathryn Steeves’s descent into homelessness and mental illness—and her journey back to health—tells a larger story than many might give her credit for. It is a story about loss, certainly; but it is also a story about the strength of human character and our ability to overcome insurmountable odds. Kathryn, middle-aged, watched her marriage fall apart and life with her children become more stressful.

  So, one night she simply walked away, closing and locking the door behind her—a final closure on the life she had once loved. Walking into the darkened street, Kathryn abandoned her life for what she might have thought was forever. And yet, it wasn’t forever.

  The lessons and insights that Kathryn and others have learned about the need for comprehensive care and person-centered psychiatric rehabilitation are relevant, but more important, they are real. The welcoming by a compassionate and supportive system of mental health care is essential for people with mental illness to become resilient, achieve recovery, and live a self-directed life in the community. Because, in the end, recovery isn’t an illusion. Recovery is a part of the human condition and the story of each of our lives.

  When I met Kathryn, her dream was to be reunited with her children. She came to the mental health court after two years of living homeless on the street, a condition prompted by a case of undiagnosed and consequently untreated bipolar disorder that was triggered by the stress of her dissolving marriage. Then her children were taken from her. Filled with despair, Kathryn decided that if she did not have her children, then she did not need her home. She told me that she realized she had lost everything the moment she appeared in mental health court. Somehow she had survived for over two years, without friends, family, reliable shelter, or any means of support.

  The mental health court connected her to a residential treatment service called the Cottages in the Pines. When she arrived, she was introduced to a young and ambitious community case manager, Magadalia Perez, a self-described “fireball.” Kathryn credits Magadalia “with saving her life.”

  Kathryn lived at the Cottages for nearly one year, when she learned that it was time for her to
prepare to leave the program. Kathryn was anxious and excited about her chance to start over. Now more in touch with her feelings after intensive therapeutic work, Kathryn wanted to set herself goals that aligned with her mission in life. When the time came to put pen to paper Magadalia asked Kathryn, “What do you want to be?”

  Kathryn smiled and said, “I want to be you.”

  Kathryn applied to college and was accepted to a degree program in mental health counseling. Then, with Magadalia’s support, she petitioned the family court judge to grant her custody of her children.

  The petition was granted, and Kathryn’s long and arduous journey back to her children was over.

  After twenty years, I’ve come to appreciate that anything can happen on a Thursday. Thursday dockets were always rigorous. The diverse mix of cases includes people who have been discharged from the hospital, new court referrals, and cases that have been continued from the session the day before because the problem-solving required by each case was complex and required more time to negotiate systems and to coordinate care.