When the courthouse leads to the therapist’s office
After almost two decades, Mass. mental health courts still grapple with stigma and care crunch
ACCESSING MENTAL HEALTH support can be difficult under normal conditions, with a workforce shortage worsening long wait times for emergency or routine behavioral health care. But for almost 20 years, the Bay State has had a way to connect some people deeply in need of mental health services to intensive treatment, case management, and housing support.
The catch? They have to be arrested first.
A set of three Boston municipal courts and five district courts hold special sessions of mental health court, or “Recovery with Justice.” They offer a ramp off the usual judicial process for defendants on pre-trial or post-conviction probation with serious mental health issues. If defendants, their attorneys, the district attorney, and the courts sign off, the participants embark on a supervised process of mental health treatment and assistance with job and housing supports, if needed.
They are an attempt – part of a national movement toward such specialty courts – to grapple with overlapping issues of mental health and criminal conduct.
"There's been a whole bevy of studies and articles that show that incarcerating someone with a mental health condition only aggravates the underlying symptoms and the underlying conditions,” said Judge Kathleen Coffey, who founded the Massachusetts mental health courts in 2007 and retired in September after 32 years on the bench. “So, in many respects, when we criminalize mental health by locking people up rather than providing them with the access to treatment and the mental health services that they need, we're turning people into criminals, unnecessarily, unfairly, and a lot of times without due process.”
The mental health courts make a compelling offer: If the participants agree to use it, the system will connect them with long-term and accessible mental health supports often out of reach for people in prison or just trying to navigate the crunched behavioral health landscape. But they are expensive, resource intensive, and serve just a fraction of the people in need of mental health services in and out of the criminal justice system.
Statewide, 1.15 million adults in Massachusetts struggle with mental health issues. Among young people with depression, 57 percent receive no care at all, based on KFF data on Massachusetts mental health outcomes.
Health officials have warned for years that workforce shortages are leading to blockages in accessing intensive mental health care even as the stigmas around seeking treatment wane. And within the criminal justice system, mental health needs abound.
In 2022, Hampden Sheriff Nick Cocchi, the vice president of the Massachusetts Sheriffs Associations, estimated that 75 percent of the inmate population incarcerated in county jails now require addiction and mental health services.
More than 200 defendants are participating in the state mental health courts at any given time, according to Coffey. Defendants in the program must have serious mental illness or co-occurring mental health and substance use disorders, and their condition must be connected to their criminal behavior.
According to an analysis of the program from the courts, 25 percent of mental health court participants are female and 75 percent are male. Forty-seven percent identify as white, 37 percent as Black. Over half have experienced homelessness.
The Recovery with Justice process is something of a middle ground between the controversial practice of involuntary court-mandated mental health care and ignoring mental health factors in the criminal justice process. Massachusetts is one of only three states without assisted outpatient treatment laws, which allow judges to mandate outpatient mental health care, according to the Treatment Advocacy Center, a national nonprofit group that advocates for involuntary commitment laws.
“While mental health courts are critical for people with severe mental illness who commit criminal acts and face prosecution, criminal conduct should never be a prerequisite for receiving effective treatment,” the group wrote in 2015 when discussing the expansion of mental health courts in Tennessee.
The structure of the mental health courts is unusual – a twist on the typical adversarial criminal justice process. Participants agree to a program of at least 90 days of intensive outpatient services, after which they transition to a “stepdown” outpatient program, and then to an integrated primary care practice. The whole process typically takes 12-18 months.
At a sitting of the mental health court in June, visited by Supreme Judicial Court Chief Justice Kimberly Budd, Coffey presided over about a dozen cases. Lawyers and clients offered updates on therapy progress, medication, work training, and housing situations.
One man had missed several required therapy sessions, and prosecutors were mulling returning the case to trial.
“You have to take your medicine and go to therapy,” Coffey urged. If he kept to the program, “this case is going to go away,” she said. “Criminal records aren’t good. They act as barriers.”
He agreed, quietly, and promised to see his therapist that Friday. Outside the courtroom, after the session, his lawyer reiterated the seriousness of abandoning the mental health probation process and finding himself back on the trial track.
Participation in the mental health courts is voluntary, though mental health advocacy organizations often consider the programs with a wary eye.
“Mental health courts are inherently coercive because defendants with mental illnesses agree to treatment with the threat of prosecution hanging over their heads,” according to Mental Health America. At the same time, the organization says, “our support for mental health courts is predicated on the fact that even coerced treatment in the community is almost always better than the manner in which persons with mental illnesses are treated in prisons and jails.”
The Bazelon Center for Mental Health Law notes that mental health courts “do not solve the systemic problems that cause people with mental illnesses to be arrested and incarcerated in disproportionate numbers.” They may also “inadvertently create incentives to arrest people to get them into services” and “lead mental health authorities to prioritize scarce resources to be delivered at a late state, as part of a system that involves coercion.”
The clinicians who work in these courts are employed by Boston Medical Center, not the court system, creating what Coffey calls "a true partnership" among the court, clinicians, probation officers, prosecutors, and defense attorneys.
"The focus in a mental health session is, how can we assist this person to navigate systems, to access treatment, to monitor their treatment, to provide the necessary supports, so that when they complete a period of probation — either pre-trial probation or post dispositional probation — they have a skill set that will enable them not to get rearrested due to mental health concerns," Coffey said.
Participants at the June session assured the judge that they liked their program, that it was a “good journey,” and that they were doing their best to keep up with their programming. But even with a dedicated team, system strains intruded. One probation official explained that her defendant was struggling to access treatment beds when needed.
That is an all-too-familiar problem for Bay State residents generally.
Massachusetts residents seeking mental health care through traditional channels can face wait times exceeding two months for an initial assessment, according to a 2022 report from the Association for Behavioral Healthcare. Patients who seek emergency room care for behavioral health visits encounter long wait times — stuck in emergency rooms without treatment in what is known as “emergency room boarding” for more than a day — due to serious staffing shortages, according to a report from the Health Policy Commission.
The “growing trend” of behavioral health emergency room boarding “is not only harmful for these patients and their families,” HPC Director David Selz said, “but also impacts hospital staff, non-[behavioral health] patients, and emergency medical services across the Commonwealth.”
According to a March 2023 report, 568 inpatient beds were unavailable due to staffing shortages in August 2022, and by the end of the year 666 patients were boarding in acute care emergency departments awaiting inpatient psychiatric placement. The commission launched a program aimed specifically at boosting the behavioral health workforce in 2024.
Having access to immediate and tailored clinical support through the mental health courts can be something of a workaround to access care, for the small number of applicants that meet the strict criteria.
As the state grappled with provider shortages, the past four years have been a period of growth for mental health courts in Boston, which were first backed by private foundation funding and championed by retired Judge Maurice Richardson. Coffey and others looked to models in Florida and New York as they developed the Massachusetts approach, landing on a supervised recovery model and a combination of state and private buy-in.
An expansion of the Recovery with Justice program was funded for four years by a $4 million federal grant awarded in 2020. The Boston Outpatient Assisted Treatment (BOAT) Program supported the Boston Municipal Court and Boston Medical Center partnership until funds ran out in December 2024, though the broader Recovery with Justice program is still funded by the state specialty courts budget line item.
The state's Fiscal Year 2026 budget allocates $7.97 million for the operation of all specialty courts statewide, a line item that covers not only the eight mental health court sessions but also 35 drug courts, six treatment courts for veterans, two homeless courts, and other specialized sessions across Massachusetts.
Like many other parts of state government, the courts are feeling a financial squeeze in the face of looming federal cuts. While state lawmakers increased the Trial Court system budget this year, it fell far short of the extra $30 million court advocates said was needed to address serious staffing shortages and burnout.
The program takes funding and coordination across courts, health centers, prosecutors’ offices, and treatment sites. While it has managed to weather workforce and bed shortages for the past two decades, even its boosters still note the paradox of walling off care behind a courthouse door.
"There's a definite weakness and flaw in our system where people have to get arrested in order to access and have the necessary supports, without question,” Coffey said. “But unfortunately, that's the system that's been in place. To our credit, we're trying to make the courts accountable, accessible, and responsive to the needs of the community that we serve, and certainly individuals with a mental health condition are a very distinct and worthy community."
This article first appeared on CommonWealth Beacon and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
