Stephanie Rhoades, Judge, Anchorage Mental Health Court

Interviews

Stephanie Rhoades, Judge, Anchorage Mental Health Court

Stephanie Rhoades, Judge, Anchorage Mental Health Court

Judge Stephanie Rhoades has presided over the Anchorage Mental Health Court—the first mental health court in Alaska—since it was created in 1998. 

What motivated you to start a mental health court in Anchorage?
I think I was motivated by the same things that others have been motivated by, those who were at the beginning of all of this. I had a family member who has a mental disorder, and I started seeing a lot of people in criminal misdemeanors who were cycling through the system and who simply did not understand their probation conditions or what they were doing in jail. I saw police arresting people in order to get them help. I felt there had to be a better solution.

What are some of the most important ethical issues raised by mental health courts?
I think one of the main ethical issues is the use of coercion to motivate people to engage in mental health treatment. Coercion is inherent in the criminal justice bail and sentencing practice, and you use coercion in the regular district court, but I think the big ethical questions arise when you have someone charged with a crime who really shouldn’t have been, someone who was criminalized because of the symptoms of their mental disorder and not because they have any criminal intent. There’s also a second group of people who have a mental disorder but also have some degree of criminal intent. In these cases it makes more sense to use coercion, but these defendants still require different accommodations because of their disorder.

I think overall you need to really be ethical when it comes to how rigorous of a plan an individual is required to follow, and how much you expect from him or her. Each defendant has an individual criminal history but also an individual diagnostic profile and a different set of needs, and so you have to be ethical in matching up a person’s exposure in a criminal case and the price of that particular criminal action. A person shouldn’t be asked to do something more onerous than they would otherwise be asked to do for the offense that they’ve committed. I find prosecutors all the time asking for sanctions for behaviors that a person never would even be monitored for in the regular district court here—for the use of substances, for example, or not taking medications. It’s an ethical conundrum if what you’re going to do is give a defendant the advantage of greater linkage and greater services but at the same time scrutinize that defendant more because they’ve received the benefit of those things.

Have you learned of or heard of any mental health court practices that are cause for concern?
If you don’t have treatments to divert people to, then you really can’t operate a successful program. A mental health court is in and of itself a therapeutic intervention but it’s only one component of what needs to be an overall multidisciplinary approach, and if you have treatment that’s inappropriate or not a good match, then it’s a set up for the person to fail.

I think generally I worry about courts that are creating their own treatment components that can only be accessed through the court. My philosophy about this court has been that we will only link people to services that already exist in the community, based on their diagnosis. So there are people we turn away because there are not any appropriate treatment services.

And I think that the use of sanctions for people who aren’t taking medication is problematic. The truth is that compliance rates with medications are very low among the average population, and we don’t put people in jail for not taking their asthma meds every day, even though the cost to society is that they may have more emergency room visits. I think that there is a stigma involved in judges using jail as a consequence when clients either decide to go off their medications or aren’t taking them regularly, and I think that we need to look very carefully within ourselves about whether we are treating people with mental disorders differently than we treat other people with chronic medical disorders who aren’t complying with their regimes. I think that there are many checks a judge needs to keep on him or herself as a result of some of the biases we all hold about mental illness.

How in your court do you address some of these issues?
First of all, the court was not implemented until after a very lengthy planning process involving multiple stakeholders. And it was not started with federal money but state money, because we really wanted to make sure that if the court was successful it would continue and that we wouldn’t run out of federal money.

The second thing is that once we planned out a model, we wrote up the policies and procedures so that everyone would know how cases get processed and what the goals of each team member are and what ethical canons each player is going to follow. It’s also important to make sure that you basically address the philosophy of incentives and sanctions. In our policies and procedures we specifically say that jail will be used only after attempts have been made to troubleshoot the treatment plan, to see whether or not there’s something that can be changed. We spell out that the project is a decriminalization and not a recriminalization project.

So it’s important to be very clear about your philosophy and make sure that you have included prosecutors, defense attorneys, the court system, and treatment providers in the written policies and procedures, and that everyone agrees to follow them. You need a prosecutor, for example, to agree that they’re not going to file additional charges for violating conditions of release if people violate bail or probation conditions. Things like that.

I think it’s also crucial to do a lot of training for your people, local trainings to teach people about basic mental disorders, medications and side effects, what a psychiatric assessment is, what a neuro-psychiatric assessment is, what kind of treatment is available in your community, why individuals with one diagnosis get hooked up with one place and individuals with another diagnosis get hooked up with another place, and what the funding mechanisms are for these things. You also need a judge who’s trained so that he or she can provide an atmosphere where there’s a lot of stigma-busting and education going on about mental disorders. For example, if a defendant starts telling the judge that he or she’s been hearing voices recently, it’s important for the judge to say for the entire room’s benefit that this is a symptom of the defendant’s disorder, which is a brain disorder and so is treatable, and that the defendant will be okay if he or she keeps working with the treatment. The judge should be working to normalize the disorders and reduce the fear that people tend to have about people with mental disorders, creating a situation that is sympathetic and helpful and motivating and engaging for everyone.

It’s also important, in terms of treatment planning, to look at all the life domain areas. First and foremost we look at housing. We make sure that the individual knows where they’re going to go for their medical treatment because a lot of these folks have medical conditions that are pretty significant, too. We make sure that they have some kind of day activities that create something for them to do with themselves that’s worthwhile. It’s important to just generally promote healthy positive lifestyles where people then end up in a place where they have things to lose. What we know about the criminal justice system is that the more an individual has to lose, the less likely they are to commit crimes.

What are some of the toughest challenges you face when presiding over a mental health court?
I think the toughest challenge is just the lack of resources. Most specifically housing, and treatment for severe co-occurring disorders. Even with high-level coordination, people end up not getting their meds in jail for five days. And that can be as simple as someone’s fax not going through.

And my final frustration in presiding over a mental health court is quite frankly in my own jurisdiction therapeutic courts really are not supported by my judicial colleagues. I think that in terms of sustaining these types of courts, the judges need to become supportive of them and regard them as every bit as important and worthy as any other court hearing on a regular court calendar. And judges tend to not receive respect for some reason for doing this type of work, among their own colleagues, and I think that’s a real policy problem from the top down. The Conference of Chief Justices has passed the problem-solving court resolution but I’m not sure how well that has filtered down to individual states and individual courts.

Overall, what would you say is most positive about mental health courts? What’s working? What kind of successes have you seen in your court?
So many of the individuals who end up recycling through the criminal justice system are disenfranchised. These folks are people who have lost all their natural supports. They don’t have advocates any longer, they don’t have family members to take them in, and they’ve burnt all their bridges with treatment and everyone else. They’re the tough customers, and their lifestyles are really dissonant with the medical model of mental health and substance abuse treatment delivery. They tend to be more likely than not homeless, co-occurring disordered, without money. They don’t show up for appointments, and they often have complicating medical issues. On top of all that they often have a criminal history that makes them look in many ways worse than they are to the treatment system. So I think that the resource of a boundary-spanner and a linker, the case coordinator who can actually take the individual and hook them up with services appropriate to their condition is a tremendous resource. And what I’ve found is that the treatment system is far more likely to serve an individual who’s being monitored in the mental health court.

The outcome of all this is that people do engage in services, and then when they have their next mental health crisis, instead of defaulting to the police on the street they default to the treatment system. They know that they can resort to them in crisis and not be turned away.

What I see is definitely far more treatment engagement and a higher functioning individual. Also, when someone decompensates some amount we know about it, and then perhaps we expedite a court hearing and look at what’s going on and get a person back up before they end up having to be hospitalized or incarcerated.
 
Do you have any success stories you would like to share?

I think for me the successes have been the individuals who most everybody except for me thought were completely and totally incapable of change. There is one man who recently graduated. He was homeless, he had multiple medical disorders, he was a smoker, he was living in camps here in the wintertime, and he had a guardian but had a tremendously difficult time accepting the fact that he was required to have a guardian. He refused to stay in any kind of housing. And he didn’t actually succeed in his treatment plan the first three cases that he had, but what I noticed was he kept coming back to the court, to the case coordinator here, whenever he got in trouble with his guardian or whatever, and that he perceived us to be of assistance to him in dealing with the system. He finally came back on a fourth case and we took him again, and at this point he was recycling between the hospital emergency room and the psychiatric hospital and jail. He was at extremely high risk of death, and he was costing the city a lot of money. Finally he ended up having a conversation with me where I asked him if he would try going to an assisted living facility for just a week and told him that if it didn’t work out after a week we would look at something else. And he did it for a week and finally he just decided that he liked living indoors and that things were going to be okay there, and staff worked with him, treatment worked with him, and now he’s very successful. His medical and mental health conditions have completely stabilized.

And I think that what this tells me is to never give up. Don’t give up on anybody because there may be a time in anyone’s life where they are ready, and readiness for change is so critical because you could meet a person four times during their life or even during the course of a couple of years, and if they’re not ready it’s not going to happen. But if you exclude them when they are ready then you’ve excluded the possibility that a person can completely recover. And to me that has been just one of the most fulfilling aspects of being a mental health court judge, and just of my job in general.

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