Exploring Illness Experiences in a Mental Health Court: Crime, Meds, and Neurochemical Selves

Background:  With roughly 14% of the criminal justice population having a mental health diagnosis, mental health courts (MHCs) have become common legal methods for diverting offenders with serious mental illness from jails and prisons.  As a normatively treatment-focused criminal justice intervention, MHCs deploy common Western forms of psychiatric practices, wherein a biomedical and psychoanalytic understanding of mental illness takes primacy and psychopharmacological and psychotherapeutic interventions are utilized. Underlying this court-based model of mental health treatment is an implicit belief about the pathological nature of defendants and an inextricable link of this pathology to the causation of their criminal justice involvement. Existing research on mental health courts has not attempted to understand the significance of this model for defendants, its underlying assumptions about criminality, or the meaning assigned to treatment modalities by defendants. Employing an “illness experience” framework by Arthur Kleinmen (1988), this study examines the narratives of defendants in a mental health court, how they make sense of their illness and criminal past in relation to mandated treatment, and the subjective meanings they ascribe to court-sanctioned psychiatric technologies, such as medication. In general, it seeks to better understand illness experiences in the context of court-based interventions that center on treating diagnoses as a primary way of alleviating criminality.

Methods: Thirty-one defendants with serious mental illnesses from a mental health court were recruited to participate in in-depth interviews. These interviews focused primarily on the defendants’ thoughts and experiences regarding their mental health court participation and their illness experience in the context of mandated treatment and extensive criminal justice involvement. A thematic analysis was used to analyze the in-depth interviews. Primarily interested in the perceptions and experiences of the participants in mental health court, transcripts were coded for salient themes related to addiction, criminal history, current treatment regimen, and experiences with mental illness.

Results: The sample was 67% African-American, 48% male, 58% Bipolar Disorder, with a mean age of 43, and average time in the court was 13.8 months.  Thematic results indicate that mental health court structures and frames illness experiences through mobilization of psychiatric knowledge and linkages to common mental-health treatments.  By emphasizing medication adherence, the court facilitates a process of narrative reconstruction whereby participants are able to make sense of their past crimes and reconfigure their identities as chemically imbalanced sick patients with a biological disease. Stable medication adherence provides clarity of criminality and gives way to the emergence of an iatrogenic identity. Consequently, defendants symbolically redraw the lines between normality and abnormality. Illustrative quotes from defendants highlight these narrative elements.

Conclusions:  MHCs span traditional boundaries between criminal justice and mental health systems, providing a unique position from which the traditional narratives of mental illness are imbricated with criminality.  These courts activate processes and practices of medicalization in unique ways, partly due to the latent threats of penalization.  This study provides evidence for how illness experiences are reshaped through mental health courts and how participants come to understand the significance of their conditions and their life of crime and incarceration.