Offending Behaviour and Mental Illness: Characteristics of a Mental Health Court Liaison Service

Offending Behaviour and Mental Illness: Characteristics of a Mental Health Court Liaison Service John Sharples and Terry J. Lewin Centre for Mental Health Studies, Newcastle, Australia Russell J. Hinton Regional Forensic Psychiatric Services, Auckland, New Zealand Ketrina A. Sly Centre for Mental Health Studies, Newcastle, Australia Gregory W. Coles Office of the Director of Public Prosecutions, Newcastle, Australia Patrick J. Johnston and Vaughan J. Carr Centre for Mental Health Studies, Newcastle, Australia T his paper begins with a brief review of recent literature about relationships between offending behaviour and mental illness, classifying studies by the settings within which they occurred. The establishment and role of a mental health court liaison (MHCL) service is then described, together with findings from a 3-year service audit, including an examination of relationships between clients characteristics and offence profiles, and comparisons with regional offence data. During the audit period, 971 clients (767 males, 204 females) were referred to the service, comprising 1139 service episodes, 35.5% of which involved a comorbid substance use diagnosis. The pattern of offences for MHCL clients was reasonably similar to the regional offence data, except that among MHCL clients there were proportionately more offences against justice procedures (e.g., breaches of apprehended violence orders [AVOs]) and fewer driving offences and other offences. Additionally, male MHCL clients had proportionately more malicious damage and robbery offences and lower rates of offensive behaviour and drug offences. A range of service and research issues is also discussed. Overall, the new service appears to have forged more effective links between the mental health and criminal justice systems. Mental illness and crime are two of the major social, political and financial issues of our time. Research into the prevalence of crime associated with mental illness has traditionally focused on community epidemiological samples, with a particular focus on violent behaviour. Studies of subgroups within the criminal justice and health services areas have also been undertaken. The Correspondence to: Terry J. Lewin, Centre for Mental Health Studies, University of Newcastle, Callaghan, NSW 2308, Australia. Email: Terry.Lewin@hunter.health.nsw.gov.au 300 PSYCHIATRY, PSYCHOLOGY AND LAW VOLUME 10 NUMBER 2 2003 pp. 300 315

MENTAL HEALTH COURT LIAISON SERVICE generalisability of these findings is limited, partially by predetermined sample characteristics, such as socioeconomic, geographic and service provision differences (Coid, Kahtan, Cook, Gault, & Jarman, 2001; Hodgins, Mednick, Brennan, Schulsinger, & Engberg, 1996), as well as by the diversity of mental illness found among clients of particular services. Mental health and welfare policy changes may have also contributed to changes in prison populations, with increased rates of mental illness in correctional facilities being observed to coincide with a rise in homeless psychiatric patients, through deinstitutionalisation (Chaiklin, 2001). Changes within the justice system, such as the dramatic increase in the use of apprehended violence orders (AVOs; Hickey & Cumines, 1999), and the associated potential for greater numbers of AVO breaches, illustrate the ways in which societal and judicial views about less serious offending behaviour can impact on populations with mental illness. People with a mental illness have previously been reported to be much more likely to be arrested for a breach of the peace or offences against public order (Robertson, Pearson, & Gibb, 1996). Consequently, where possible, studies that attempt to characterise offending behaviour among people with a mental illness should also seek to elucidate important contributing factors, as well as the potential implications for health and welfare outcomes and treatments. Studies Undertaken Within Selected Populations Community Studies of Offending Behaviour and Mental Illness Epidemiological research, largely focusing on violent crime, suggests that psychiatric hospitalisation is significantly associated with the likelihood of having a criminal conviction (Hodgins et al., 1996; Arboleda-Flórez, 1998; Brennan, Mednick, & Hodgins, 2000). Higher rates of offending have been associated with alcoholinduced psychoses, schizophrenia with comorbid alcohol abuse (Tiihonen, Isohanni, Rasanen, Koiranen, & Moring, 1997), psychoactive substance abuse and illness acuity (Modestin, 1998). In general, schizophrenia and mood disorders with psychotic features have been linked with an elevated risk of violent offending (Tiihonen et al., 1997; Modestin, 1998; Angermeyer, 2000; Eronen, Angermeyer, & Schulze, 1998), whereas organic disorders have been associated with a higher risk of driving and property offences (Tiihonen et al., 1997). Gender differences have been consistently reported, including elevated rates of violent crime among males (Tiihonen et al., 1997), with a two-and-a-half to four-fold increase in the risk of offending among males with a major mental disorder (Hodgins, 1992). On the other hand, a lower prevalence of offending behaviour has been reported for unipolar depression and males with high anxiety, although sociodemographic factors are important predictors, with elevated rates of offending among younger patients from lower socioeconomic backgrounds (Modestin, Thiel, & Erni, 2002). Studies Within Correctional Facilities Studies undertaken in correctional facilities report varying but consistently elevated rates of mental illness compared to community samples (Hodgins et al., 1996). A UK male prison sample reported rates of 1% for schizophrenia, 0.4% for affective psychoses, 23% for current substance abuse and 10% for severe personality disorders (Gunn, Maden, & Swinton, 1991). A Canadian penitentiary sample reported increased prevalence rates for schizophrenia (seven-fold), major depression (twofold) and bipolar disorder (four-fold), compared to a community sample (Hodgins & Cote, 1990). In a recent New Zealand prison sample, 1-month prevalence rates for schizophrenia of 3.4% for males remanded and 2.2% for those sentenced were found, compared to current community rates for schizophrenia of 0.1% and a lifetime rate of 0.3% (Brinded, Simpson, Laidlaw, Fairley, & Malcolm, 2001). Similarly, an Australian study of convictions in the High Court found that a quarter of those convicted had previous psychiatric service contacts, typically involving personality disorder and substance misuse (Wallace, Mullen, Burgess, Palmer, Ruschena, & Browne, 1998). Studies Among Psychiatric Populations In a small community sample of patients with chronic mental illness, early onset substance use was the single best predictor of violence, with use before the age of 15 being the strongest risk factor (Fulwiler, Grossman, Forbes, & Ruthazer, 1997). However, while substance abuse may increase symptom severity, it is strongly associated with violence irrespective of mental illness (Fulwiler et al., 301

J. SHARPLES, T.J. LEWIN, R.J. HINTON, K.A. SLY, G.W. COLES, P.J. JOHNSTON AND V.J. CARR 1997). Both age and gender also influence offending behaviour irrespective of mental health issues, with males being generally more likely to exhibit violent behaviours (Modestin et al., 2002; Stueve & Link, 1998). Crime rates tend to decline with age (Modestin et al., 2002), males and females aged 20 29 being more likely to have a conviction (Wallace et al., 1998). Moreover, people who commence their offending at an early age tend to become more specialised in the type of offences they commit over time (Piquero, Paternoster, Mazerolle, Brame, & Dean, 1999; Mazerolle, Brame, Paternoster, Piquero, & Dean, 2000). While offending directly attributable to mental illness accounts for only a small proportion of all crime (Modestin, 1998; Wallace et al., 1998), offending risk among psychiatric populations is greater than that of the general population for particular offence categories, such as homicide and serious violence (Wallace et al., 1998). A limitation of psychiatric population studies is selection bias. For example, in the Wallace et al. (1998) case register sample, service utilisation did not directly equate to a psychiatric diagnosis and might potentially represent a skewed sample of disorders. Many studies may not adequately take into account diversion into mental health care. There is also the unknown extent to which this population is more likely to be apprehended, charged and convicted compared to the general population (Wallace et al., 1998). Studies of Dismissed Charges Under the Mental Health Act Utilisation of the Mental Health Act (1990) was examined in a New South Wales (NSW) study, providing an indication of the prevalence of mental illness identified among those facing criminal charges (Freeman, 1998). Only a very small proportion (0.3%) of all criminal charges finalised for less serious offences in the NSW local courts in 1996 were dismissed under Section 32 or 33 of the Mental Health Act (1990). Females were overrepresented amongst such dismissals, while assaults and theft accounted for over half of the charges dismissed, followed by breaches of court orders (14%) and offences against good order (15%). Substance abuse was often noted as an additional complication, as the Mental Health Act (1990) does not automatically consider someone under the influence of drugs to be mentally ill. Additionally, for serious offences, only a very small proportion of all offenders in the NSW higher courts were found not guilty due to mental illness, although the proportion of offenders who become mentally ill while in prison and require a forensic transfer needs to be considered (Freeman, 1998). Studies of Diversional Processes The process of diversion may influence the treatment outcomes of mentally ill offenders and have substantial criminal justice and mental health service implications. Robertson et al. (1996) examined the process of diversion among seven London police stations. Only a small proportion of people arrested (1.4%) were found to be acutely ill and entry into the criminal justice system was strongly associated with violence at the time of arrest. Petty offending such as failure to appear in court, resulting in a court warrant, was another factor identified, as petty offences involved frequent contact (often without the benefit of care), which increased with inadequate housing and unemployment. Robertson et al. (1996) also examined a group identified by court liaison psychiatrists and found up to 90% had received previous psychiatric treatment. Differences in regard to offending were apparent, with public order offences being less likely and violent offences more likely, compared to the police sample. Differences in patterns of offending highlight the importance of the referral source, as particular samples may represent offenders with very different characteristics and treatment needs. Moreover, police might not always detect mental illness. While court liaison services reduce the likelihood of this occurring, findings suggest that repeat offenders with minor offences are being charged due to prior court appearances and not diverted into psychiatric care (Robertson et al., 1996). Court Liaison and Diversional Services The demand for court liaison services is evident. However, there is a paucity of research evaluating the effectiveness of these services. Differing modes of operation exist with regard to referral, treatment and diversion, as well as inherent difficulties in evaluating treatment outcomes in a multidisciplinary setting. Services range from traditional diversion, involving psychiatric hospitalisation as an immediate alternative to imprisonment, to court liaison services operating within the criminal justice system, providing assistance not only to those facing imprisonment but to those requiring advice, treatment and support (Draine & Solomon, 302

MENTAL HEALTH COURT LIAISON SERVICE 1999). The number of services has steadily increased, coinciding with identified high rates of mental illness in correctional facilities and a move away from traditional diversion. Minor repeat offenders previously lost to the system are increasingly able to benefit from support and treatment, as are offenders facing serious convictions. These services are heavily reliant on referral to work effectively, especially since the typical offender will have already come into contact with a number of agencies including police, probation officers, and prosecution and defence solicitors (Turnbull & Beese, 2000). Turnbull and Beese (2000) surveyed nurses from six services across England and Wales and found all services reported operational changes since commencement, indicating the need for continued development. Difficulties in relation to conflicting professional approaches, priorities and boundaries were noted, although generally close links with probation were reported. It was crucial for nurses to be able to work effectively as a sole health professional in an unfamiliar environment, among competing professional groups and without the support of a structured health environment. However, surprisingly only one nurse reported receiving training in preparation for the position (Turnbull & Beese, 2000). In making service comparisons, referral, location, situational employment factors relating to the court liaison officer and many other professional relationships all influence how any particular service operates. Studies characterising particular services across several countries have reported similar client characteristics. For example, clients of a New Zealand-based service are described as mostly male, with a mean age of 30.3 years, mainly single or separated, on sickness benefits or unemployed, and mostly facing serious charges (Barnes, Hudson, & Roberts, 2000). A UK-based service reports similar characteristics, with clients being described as mostly male, having a mean age of 33.1 years, and being involved in a range of offences including public order, property and driving offences, violence, sexual offences and arson (Purchase, McCallum, & Kennedy, 1996). Referrals to these services came mainly from police and legal counsel, and the majority had previous criminal justice and mental health service contact, with those requiring hospitalisation generally being known to the service and more likely to have had previous psychiatric admissions (Barnes et al., 2000; Purchase et al., 1996). In the New Zealand sample, police referrals were more likely to be hospitalised, while legal counsel referrals usually related to issues of dangerousness (Barnes et al., 2000). Those who were hospitalised were older, with diagnoses of schizophrenia, bipolar affective disorder or unspecified psychoses, compared to diagnoses of major depression, substance abuse or dependency and antisocial personality disorder among those remaining in the criminal justice system (Barnes et al., 2000). In the UK sample, schizophrenia was the most common diagnosis, followed by major affective disorder, organic mental illness, neurotic disorders and learning difficulties; offenders diagnosed with schizophrenia were also more likely to be hospitalised (Purchase et al., 1996). Moderate to high levels of substance abuse or intoxication at the time of the offence were also observed (Purchase et al., 1996; Barnes et al., 2000). To establish the extent of mental disorder that existing court liaison schemes in the UK fail to identify, Brabbins and Travers (1994) interviewed police detainees prior to their first appearance in a magistrates court. Low rates of mental illness were found but high levels of drug and alcohol abuse were noted, raising concerns that this group may be neglected (Brabbins & Travers, 1994). In evaluating their service, Purchase et al. (1996) identified the need for improved follow-up care plans and community supervision, as none of the clients with previous service contact was receiving ongoing care and only a few received intermittent care. Complexities in evaluating service effectiveness and its relationship to health and judicial outcomes, improved follow-up care and reduced recidivism have been identified in the literature. These highlight the need for a thorough initial characterisation of each service, including the diversity of mental illness and offending behaviour evident amongst clients of the service, patterns of service contact and engagement and the identification of subgroups requiring specific attention. Establishment and Role of the Newcastle Mental Health Court Liaison (MHCL) Service A perception emerged among local magistrates, probation officers, psychiatric staff and others that people with mental health problems who became involved with the criminal justice system were 303

J. SHARPLES, T.J. LEWIN, R.J. HINTON, K.A. SLY, G.W. COLES, P.J. JOHNSTON AND V.J. CARR not being effectively managed. Consequently, in August 1997, a Mental Health Court Liaison (MHCL) Service pilot project began at the Newcastle court complex. It was the first of its kind in New South Wales. The new service formed cooperative links between the mental health and criminal justice systems. It provided a reliable exchange of information and, where necessary, assistance and advocacy for offenders already being treated by the mental health service. Further, the availability of a mental health clinician ensured timely mental health assessments and practical management options for persons appearing before the court who had no prior or recent contact with the mental health services. The MHCL service consists of a full-time clinical nurse consultant (JS) and an administrative officer, both based at a psychiatric hospital that is adjacent to the Newcastle court complex. Staff specialists from Hunter Mental Health and trainee psychiatrists provide medical back-up. Clients are usually referred to the MHCL service by the Legal Aid duty solicitor, representing an individual in custody facing a non-indictable charge. The likelihood of current mental health problems is usually indicated by police reports and by the person s general demeanour. Frequently there is a history of prior contact with mental health services and/or drug and alcohol services. Typically, the MHCL service is contacted by pager or telephone, with clients in custody being seen within the hour. After initial assessment by the nurse consultant, a management plan is formulated. If the person appears to be mentally ill under the Mental Health Act (1990), an immediate transfer to hospital for further assessment is arranged. More frequently, negotiations between the solicitor and the bench result in the granting of bail to allow further assessment and/or treatment in the community, after which the court will be informed of the outcome. Because the MHCL service is part of the overall local community mental health system, it also receives referrals and requests for advice directly from other units within the mental health service and from elsewhere. These referrals often concern mental health service clients who have outstanding matters before the court. Consequently, the MHCL service also provides a community forensic role, which complements its court assessment function. Purpose of this Paper The purpose of this paper is three-fold: (a) to document the establishment and role of the Newcastle MHCL Service and to describe the characteristics of the clients referred to the service during its initial period of operation and their patterns of contact (audit period: 1998 2000); (b) to examine relationships between client characteristics and offence profiles and identify other distinguishing features of the clients seen by the service (e.g., by comparisons with regional offence data); and (c) to identify issues that may be worthy of further clinical and research attention, both within the current service and elsewhere. Method Service Audit The service audit period was from 1998 to 2000, which comprised the first 3 full years of operation of the Newcastle MHCL Service. Records for all clients referred to the service on or after January 1, 1998, and discharged on or before December 31, 2000, were included in the audit. During this period there were 971 clients (767 males, 204 females). We use the term service episode to refer to each discrete period of client contact with the MHCL service, which was usually associated with a separate set of criminal charges (from any previous service episodes) and typically lasted 1 to 2 months. Episode length was defined as the number of days between the first service contact for that episode and the MHCL service discharge date. There were 1139 service episodes during the audit period (905 by males, 234 by females), of which 958 (84.1%) were classified as an initial episode (i.e., first period of contact with the MHCL service) and 181 (15.9%) as a subsequent episode. For each service episode, we coded basic sociodemographic information (e.g., gender, age, country of birth, cultural background, marital and employment status), clinical characteristics (e.g., ICD-10 diagnoses), service episode details (e.g., contact and discharge dates, referral source, discharge destination) and charge details (e.g., offences, times committed/charged). Outcome data will be examined in a subsequent paper. Classification of Criminal Charges All criminal charges associated with each service episode were coded into the 19 offence categories used by the NSW Bureau of Crime 304

MENTAL HEALTH COURT LIAISON SERVICE Statistics and Research (see Doak, Fitzgerald & Ramsay, 2003, Appendix 1). For convenience, these offence categories were also grouped into three overall offence types, namely: (a) offences against people homicide, assault, sexual offences (e.g., sexual assault, acts of indecency), abduction and kidnapping, robbery, and other offences against the person; (b) offences against property theft, demanding money with menaces, extortion/blackmail, arson and malicious damage to property; and (c) offences against public order drug offences (e.g., possession, cultivation and dealing), offensive behaviour (e.g., offensive conduct or language), prostitution, betting and gaming offences, weapons offences, offences against justice procedures (e.g., breaches of AVOs, bail conditions and other judicial orders), driving offences (including driving while above the prescribed concentration of alcohol) and other offences. Initially, service episodes were classified in terms of the presence or absence of particular offence types (e.g., offences against people, property or public order). Comparisons with regional offence data were then made, based on detailed analyses of individual offence categories, with all offences treated as separate instances. For example, five counts of malicious damage by a particular individual was recorded as five offences of that type. Regional Offence Data State and regional breakdowns of all reported incidents of crime during the index period (1998 2000) were obtained from the NSW Bureau of Crime Statistics and Research. Components within this database were then filtered and aggregated to facilitate more direct comparisons with the MHCL service data. Because we were interested primarily in criminal charges (as opposed to criminal incidents) and in age and gender distributions, records that were not associated with an identified person were excluded (e.g., reports relating to insurance claims or stolen vehicles and those where either age or gender was unknown). In the extracted database, repeated offences by the same person were not identifiable but contributed to the overall offence count. Two indices were calculated for each of the 19 offence categories: annual population offence rates per 100,000 and relative offence distributions. These indices were derived for all combinations of region (NSW or Hunter), gender and age group (10 19 years, 20 29 years, 30 39 years, 40 49 years, 50 years and over, and all persons aged 10 years and over). The population gender and age distributions used in these calculations were for June 1999 (Australian Bureau of Statistics, 1999, Cat No. 3235.1), the midpoint of the audit period. The second index was simply the percentage of total offences that fell within each offence category, which was also calculated for each region by gender and age grouping. Finally, the resulting male and female offence profiles for the Hunter region were re-weighted by the corresponding age distributions within the MHCL service data to obtain the expected percentage for each offence category. Arguably, this approach should provide comparable estimates to drawing an MHCL service age and gender matched sample from all offenders in the local area during the index period. We have not reported offence profiles for NSW as these were extremely similar to those for the Hunter region, which may reflect the fact that the Hunter has a comparable urban-rural mix and comprises approximately 9% of the state s population. Data Analysis For simple statistical comparisons involving categorical outcome variables, Chi-square (c 2 ) analyses were conducted (with Fisher s exact tests as required). Logistic regressions were also used to identify significant predictors of the likelihood of having been charged with offences against people, property or public order, with Odds Ratios (OR) being the preferred metric for reporting the magnitude of effects. Both univariate and multivariate logistic regressions were conducted, with the latter comprising three-step hierarchical analyses in which offence status was the outcome variable and sociodemographic (Step 1), referral source (Step 2) and diagnosis-related variables (Step 3) were the predictors. As a partial control for the number of statistical tests, the threshold for statistical significance was set at p <.01. Results Characteristics of the MHCL Service Clients Table 1 presents a breakdown of the 1139 service episodes during the audit period with respect to their associated client characteristics. The prototypical service episode was by a male (79.5%), aged 20 39 years (71.2%), who was Australian-born 305

J. SHARPLES, T.J. LEWIN, R.J. HINTON, K.A. SLY, G.W. COLES, P.J. JOHNSTON AND V.J. CARR (94.7%), from a non-aboriginal background (96.7%) and who was currently single (73.1%). The majority of service episodes were by persons in receipt of welfare benefits, either through unemployment (68.9%) or disability (19.3%). Most referrals were from the criminal justice system (60.0%) or inpatient mental health units (24.0%). Several categories of ICD-10 (World Health Organization, 1994) primary diagnoses were identified, with drug and alcohol problems (23.4%) and psychotic disorders (19.0%) being the most frequent. Comorbid drug and alcohol problems were noted in an additional 12.1% of presentations, such that over one-third of all service episodes (35.5%) were by persons with a drug or alcohol problem. Approximately one-sixth (16.3%) of presentations did not have a current psychiatric diagnosis, although aspects of their current legal circumstances or other situational factors were often noted as stressors. Charge profiles associated with the current service episode are also presented in Table 1. Table 1 Characteristics of the MHCL Service Clients: Breakdown of the 1139 Service Episodes During the Audit Period by Clients Characteristics (at that Time) 971 Clients (767 Males, 204 Females) Characteristic a % of Service Episodes Characteristic a % of Service Episodes Gender Referral source Males 79.5 Criminal justice system 60.0 Females 20.5 Inpatient MH units 24.0 Community health or MH 10.2 Age (years) Family, friends or self 4.3 10 19 10.6 Other 1.6 20 29 42.8 30 39 28.4 Primary diagnosis (ICD-10) 40 49 12.8 Adjustment disorder 8.5 50 5.5 Bipolar disorder 5.9 Depression 10.1 Country of birth Drug and alcohol disorder 23.4 Australia 94.7 Psychotic disorder 19.0 Elsewhere 5.3 Personality disorder 7.8 Other diagnosis 9.0 Culture No diagnosis (other than legal circumstances) 16.3 Aboriginal or TSI 3.3 Additional comorbid drug and alcohol disorder 12.1 Non-Aboriginal 96.7 Charge profiles b Marital status Offences against people Single 73.1 No offences 70.4 Married/de facto 14.7 One or more 29.6 Separated/divorced 11.2 Offences against property No offences 68.8 Employment status One or more 31.2 Employed (full- or part-time) 7.0 Offences against public order Unemployed 68.9 No offences 59.1 Pension or disability benefit 19.3 One or more 40.9 Other (e.g., student, home duties) 4.7 Overall No offences c 15.5 One or more 84.5 Note: a TSI = Torres Strait Islander, MH = Mental Health Service. b Charges associated with the current service episode, classified as offences against people (e.g., homicide, assault, sexual offences, abduction, robbery), offences against property (e.g., theft, extortion, arson, malicious damage) or offences against public order (e.g., drug offences, offensive behaviour, prostitution, gaming offences, against justice procedures, driving offences). c Includes clients who were primarily seeking advice, those who had AVOs sought against them, and those presenting as a consequence of earlier charges (i.e., where there was no new charge associated with the current service episode). 306

MENTAL HEALTH COURT LIAISON SERVICE Offences against people were recorded for 29.6% of service episodes, within which the mean number of offences (per service episode) was 1.20 (SD = 0.65). Likewise, for 31.2% of service episodes at least one property-related charge was recorded, within which the mean number of offences was 1.69 (SD = 3.45). The corresponding values for offences against public order were: 40.9% of episodes and 1.39 offences per offender (SD = 1.08). Overall, 15.5% of MHCL service episodes were coded as no offences. These were clients who were primarily seeking advice, or who had AVOs sought against them, or who were presenting as a consequence of earlier charges or associated issues. Among current offenders, the mean number of offences per service episode (across all offence types) was 1.72 (SD = 2.44). Service Contacts The mean service episode length was 41.33 days (SD = 44.89), with 12.5% of episodes lasting more than 2 months. Figure 1 presents a breakdown of service episodes by audit year. Overall, the number of service episodes per year increased by approximately 75%, from 268 in 1998 to 471 in 2000. However, the rate of presentation of new clients to the service appears to have reached a plateau (258 service episodes with new clients in 1998, 357 in 1999, and 343 in 2000). Consequently, service demands are growing primarily because of re-presentations by previous clients (10 service episodes with previous clients in 1998, 43 in 1999, and 128 in 2000). In the last year of the service audit, over one-quarter of the service episodes (27.2%) were by clients previously seen by the MHCL service. Comparisons between initial and subsequent service episodes revealed a significant association with ICD-10 primary diagnosis (c 2 = 55.82, p <.001), due largely to higher rates (7) of psychotic disorders (16.6% vs. 31.5%) and personality disorders (6.3% vs. 16.0%) among clients re-presenting to the service. Relationships Between Client Characteristics and Overall Charge Profiles A series of three-step hierarchical logistic regression analyses was conducted to identify client characteristics that were associated with the likelihood of having been charged with particular offences. The Figure 1 Service episodes by audit year (1998 2000) 1139 service episodes (234 by females, 905 by males). 307

J. SHARPLES, T.J. LEWIN, R.J. HINTON, K.A. SLY, G.W. COLES, P.J. JOHNSTON AND V.J. CARR binary outcome variables in these analyses were the absence (0) or presence (1) of offences against people, property or public order. Sociodemographic predictor variables were included at Step 1 (gender, age, marital status, employment status), referral source information at Step 2, and diagnosis-related variables at Step 3 (primary diagnosis, drug and alcohol comorbidity). Univariate logistic regression analyses were also conducted to help describe the simple patterns of association between individual predictor and outcome variables (i.e., outside of the chosen hierarchy, but using a common OR metric). Table 2 summarises the statistically significant findings from the logistic regression analyses. As shown in Table 2, offences against people were less likely to be reported by clients referred from inpatient mental health units than those referred by the criminal justice system (21.2% vs. 32.5%, OR = 0.55, p <.001). Clients with a primary diagnosis of bipolar disorder were also less likely to have been charged with offences against people (13.4%), however, this effect was nonsignificant in the multivariate analysis, after controlling for referral source (since 70% of clients with bipolar disorder were referred from mental health services). Offences against property were less likely among older age groups (i.e., those aged 30 or above) and those referred from inpatient mental health services (see Table 2). On the other hand, clients with a primary diagnosis of drug and alcohol disorder were the most likely subgroup (38.3%) to have been charged with a propertyrelated offence; however, this association was nonsignificant when other factors (such as age) were controlled. Finally, there were no significant predictor variables in the multivariate analysis of offences against public order (see Table 2). In the corresponding univariate analyses, there was some evidence that female clients and those with a psychotic disorder were less likely to have been charged with offences against public order, while those with a primary diagnosis of drug and alcohol disorder were the most likely subgroup (51.9%) to have been charged with such offences. Comparisons with Regional Offence Data and Examination of Offence Category Profiles Regional annual offence rates per 100,000 and relative offence distributions are reported in Table 3 for males and females, based on averaged Hunter region offence data for 1998 to 2000. For the typical year, there were over 10,000 offences per 100,000 males and less than 2200 offences per 100,000 females. If offenders averaged 1.72 charges each (i.e., the aggregate rate in the MHCL data set), this would correspond to annual offending rates of 5.8% for males and 1.3% for females. Despite clear gender differences in overall regional offence rates, in broad terms, relative offence distributions were similar for males and females (see Table 3). For both genders, three offence categories accounted for over two-thirds of all offences (i.e., theft, driving offences and assault), with a further three offence categories (i.e., drug offences, offences against justice procedures and malicious damage to property) bringing the cumulative percentage to between 85% and 90% of total offences. Table 4 reports offence category profiles associated with MHCL service episodes during the audit period. For male and female clients, there were four offence categories that each comprised more than 10% of total charges (i.e., theft, assault, offences against justice procedures and driving offences). Moreover, the overall ratio of male to female offences observed in the MHCL data (1:0.22) was very similar to that found in the regional data set (1:0.21). Table 4 also reports the expected percentages for each offence category, which were obtained by re-weighting age breakdowns of the regional offence profiles (see Table 3) by the age distributions for each gender within the MHCL data. As shown in Table 4, male clients of the MHCL service had proportionately lower than expected rates of driving offences, drug offences and other offences against public order than typical male offenders within the region. However, they had a higher proportion of offences against justice procedures (18.62% vs. 7.16%), offences involving malicious damage to property (8.94% vs. 5.31%) and robbery offences (3.25% vs. 0.84%). Female clients of the MHCL service were also proportionately less likely to have been charged with driving offences and other offences against public order, and proportionately more likely to have been charged with offences against justice procedures (14.77% vs. 4.73%; see Table 4). Characteristics of Offenders Against Justice Procedures In view of the disproportionately high rates of offences against justice procedures among both male and female clients of the MHCL service, and 308

MENTAL HEALTH COURT LIAISON SERVICE Table 2 Predictors of the Likelihood of Having Been Charged with Offences Against People, Property or Public Order a Statistically Significant Offences Against People Offences Against Property Offences Against Public Order Predictor Variables % Off. U M OR (99%CI) % Off. U M OR (99%CI) % Off. U M OR (99%CI) Gender Males 43.1 1.00 Females 32.5 * 0.68 (0.45, 1.03) Age (years) 10 19 45.0 1.00 20 29 34.3 30 39 28.2 ** 0.46 (0.25, 0.84) 40 49 22.1 ** 0.31 (0.15, 0.64) 50 17.7 ** 0.23 (0.08, 0.65) Referral source Criminal justice system 32.5 1.00 34.8 1.00 Inpatient MH units 21.2 ** ** 0.55 (0.35, 0.86) 23.8 * * 0.61 (0.40, 0.94) Community health or MH 29.3 27.6 Family, friends or self 26.5 32.7 Primary diagnosis (ICD-10) Adjustment disorder 38.1 24.7 46.4 Bipolar disorder 13.4 ** 0.39 (0.14, 1.10) 32.8 32.8 Depression 31.3 27.8 35.7 Drug and alcohol disorder 27.4 38.3 * 1.58 (0.91, 2.76) 51.9 ** 1.46 (0.88, 2.44) Psychotic disorder 32.4 30.1 28.2 ** 0.56 (0.31, 1.01) Personality disorder 23.6 32.6 42.7 Other diagnosis 30.1 28.2 41.7 No diagnosis 32.3 1.00 28.0 1.00 41.9 1.00 Note: a N = 1139 service episodes. Tabled values show the percentage of each subgroup reporting each offence type (% Off.), the significance of the (Chi-square like) Wald statistics from the corresponding univariate (U) and multivariate (M) logistic regression analyses (* p <.01, ** p <.001), and the Odds Ratios (OR) and associated 99% confidence intervals (99%CI) from the multivariate analyses. The reference subgroup for each predictor variable is indicated by an OR of 1.0. Results are reported for predictor variables that were statistically significant in either the univariate or multivariate analyses. 309

J. SHARPLES, T.J. LEWIN, R.J. HINTON, K.A. SLY, G.W. COLES, P.J. JOHNSTON AND V.J. CARR Table 3 Regional Offence Profiles by Gender: Annual Offence Rates per 100,000 and Relative Offence Distributions, Using Averaged Hunter Region Offence Data for 1998 2000 a Offence Category Males Females Annual Offence Rates Percentage of Annual Offence Rates Percentage of per 100,000 Total Offences per 100,000 Total Offences Offences against people Homicide 10.10 0.10 2.81 0.13 Assault 1432.63 14.28 295.61 13.74 Sexual offences 234.52 2.34 6.41 0.30 Abduction and kidnapping 6.96 0.07 0.67 0.03 Robbery 93.78 0.93 20.70 0.96 Other offences against the person 36.86 0.37 4.81 0.22 Offences against property Theft 2591.42 25.83 737.49 34.27 Demand money with menaces 10.92 0.11 1.60 0.07 Extortion, blackmail 0.14 0.00 0.13 0.01 Arson 22.80 0.23 3.21 0.15 Malicious damage to property 593.66 5.92 104.99 4.88 Offences against public order Drug offences 633.93 6.32 151.75 7.05 Offensive behaviour 239.84 2.39 44.62 2.07 Prostitution offences 8.74 0.09 11.75 0.55 Betting and gaming offences 0.27 0.00 0.00 0.00 Weapons offences 196.98 1.96 15.63 0.73 Against justice procedures 671.20 6.69 103.26 4.80 Driving offences 2703.36 26.94 506.40 23.53 Other offences 545.61 5.44 140.39 6.52 Total 10,033.72 2152.23 Note: a Based on offence data supplied by the NSW Bureau of Crime Statistics and Research for persons aged 10 years and over, excluding reported crimes that were not associated with an identified person (e.g., insurance related reports, and where either age or gender was unknown). Rates per 100,000 were calculated by comparing all offences in each category (not persons) against regional demographic data as of June, 1999 (Australian Bureau of Statistics, 1999). the absence of significant predictors of being charged with offences against public order (see Table 2), we undertook supplementary logistic regression analyses to try to identify the characteristics of offenders against justice procedures. The three-step hierarchy of predictors described earlier was used once again, with marital status and referral source emerging as significant predictors of the likelihood of having been charged with offences against justice procedures. Approximately onefifth (20.9%) of single clients reported that they had been charged with offences against justice procedures, compared with 27.4% of those who were married (or in de facto relationships), and 31.5% of those who were separated or divorced. Relative to the reference group of single persons (OR = 1.00), those who were separated or divorced were significantly more likely to have been charged with offences against justice procedures (OR = 2.17; 99%CI: 1.21, 3.92; p <.001). Consistently with the earlier analyses, referrals from inpatient mental health units were less likely than those referred from the criminal justice system (16.1% vs. 26.2%) to have been charged with offences against justice procedures (OR = 0.57; 99%CI: 0.35, 0.94; p <.01). Discussion Client Characteristics and Contacts In broad terms, the sociodemographic and clinical characteristics of the clients presenting to the Newcastle MHCL Service during the 3-year audit period were similar to those reported by other court liaison and diversional services. Comparable 310

MENTAL HEALTH COURT LIAISON SERVICE Table 4 Offence Category Profiles by Gender Associated with MHCL Service Episodes from 1998 2000: Number of Charges in Each Offence Category, Percentage of Total Charges During Period and Comparisons with Regional Offence Data a Offence Category Males Females Charges Percentage Expected Charges Percentage Expected Associated with of Total Percentage Associated with of Total Percentage Service Episodes Charges (From Regional Service Episodes Charges (From Regional from 1998 2000 Offence Data) from 1998 2000 Offence Data) Offences against people Homicide 7 0.52 0.11 5 1.68 0.14 Assault 245 18.09 14.91 51 17.11 13.47 Sexual offences 31 2.29 2.32 0 0.00 0.28 Abduction and kidnapping 4 0.30 0.08 1 0.34 0.04 Robbery 44 3.25 ** 0.84 5 1.68 0.73 Other offences against the person 8 0.59 0.39 4 1.34 0.23 Offences against property Theft 337 24.89 23.91 124 41.61 33.20 Demand money with menaces 2 0.15 0.10 0 0.00 0.06 Extortion, blackmail 0 0.00 0.00 0 0.00 0.01 Arson 3 0.22 0.18 0 0.00 0.13 Malicious damage to property 121 8.94 ** 5.31 13 4.36 4.47 Offences against public order Drug offences 51 3.77 ** 6.64 13 4.36 7.40 Offensive behaviour 12 0.88 * 2.25 2 0.67 1.74 Prostitution offences 1 0.07 0.09 0 0.00 0.61 Betting and gaming offences 0 0.00 0.00 0 0.00 0.00 Weapons offences 39 2.88 2.03 2 0.67 0.75 Against justice procedures 252 18.62 ** 7.16 44 14.77 ** 4.73 Driving offences 172 12.70 ** 28.67 32 10.73 ** 25.78 Other offences 25 1.85 ** 5.02 2 0.67 ** 6.24 Total 1352 298 Note: a Age breakdowns of the regional offence profiles in Table 3 were re-weighted by the age distributions within the MHCL service data to calculate the expected percentages reported here. Chi-square (and Fisher s exact Chisquare) tests were used to determine statistical significance, assuming overall sample sizes were equal to the number of service episodes for each gender (* p <.01, ** p <.001). 311

J. SHARPLES, T.J. LEWIN, R.J. HINTON, K.A. SLY, G.W. COLES, P.J. JOHNSTON AND V.J. CARR gender and age distributions were found to samples drawn from diversional programs in other countries (e.g., Purchase et al., 1996; Barnes et al., 2000), with a preponderance of males aged in their 20s and 30s. Most of the clients were also single and receiving unemployment or other welfare benefits, which is consistent with Barnes et al. s (2000) recent New Zealand study. The finding that drug or alcohol problems were associated with over one-third of MHCL service episodes is also consistent with several previous studies that have identified high rates of comorbid substance abuse among offenders (e.g., Purchase et al., 1996; Tiihonen et al., 1997; Modestin, 1998; Wallace et al., 1998; Barnes et al., 2000). Most of the MHCL service clients had a primary psychiatric diagnosis at the time of presentation (83.7% of service episodes), which attests to the appropriateness of their referral, their overall level of disability and their need for clinical management. It also serves as a reminder that people with a psychiatric history are also more likely to be victims of crime, and the risk of victimisation significantly increases with a history of substance use, severe and persistent mental illness and homelessness (Hiday, Swartz, Swanston, Borum, & Wagner, 1999; Marley & Buila, 2001). Based on the pattern of service episodes (see Figure 1), there is clearly a sufficient demand to justify the existence of the Newcastle MHCL Service. While the service has reached a plateau of approximately seven new clients per week, there appears to be a steady increase in workload as a consequence of re-presentations by previous clients, who currently comprise one-quarter (27.2%) of the service episodes and among whom there appear to be higher rates of psychotic and personality disorders. The location of the service within the broader community mental health system is both advantageous and indicative of the need to provide more than a court assessment function, with 40.0% of referrals being from outside the criminal justice system and approximately one-sixth (15.5%) being primarily for advice (including advice about AVOs sought against the client). However, the service s growth, and its ongoing ability to meet the needs of clients and other stakeholders, should be viewed against the backdrop of the increasingly sophisticated requirements of the health and judicial systems. These include: increased demands for documentation, including all assessments undertaken, referrals arranged and specific treatments or clinical programs provided; evidence of ongoing care plans; and the monitoring of outcomes achieved and resources used. One possible index of these changing service demands is the increase in mean service episode length from 31.94 days (SD = 40.63) in 1998 to 53.27 days (SD = 52.36) in 2000. The literature reviewed earlier demonstrates how difficult it is to directly compare studies of offending behaviour and mental illness, because of the wide variety of study settings and methods (e.g., community samples versus those drawn from correctional facilities, psychiatric populations or diversional programs). In relation to the current study, it is particularly important to note that most clients had been charged with non-indictable offences that were scheduled for hearing in the local (magistrates) court. Indeed, among MHCL service clients, the top five offence categories were: theft (461 charges); assault (296 charges); offences against justice procedures (296 charges); driving offences (204 charges); and malicious damage to property (134 charges; see Table 4). There were similar overall rates of offences against people and property (29.6% and 31.2% of service episodes, respectively), with a larger proportion of service episodes (40.9%) involving offences against public order. Almost half of the charges of the latter type (296/647, 45.7%) related to offences against justice procedures. Elsewhere, Robertson et al. s (1996) study of police station detainees found that more than half had been arrested for some type of public disorder or other non-notifiable offence and that repeat offenders who commit less serious crimes may be at higher risk of circulating in and out of the criminal justice system without the benefit of care. Based on the relative offence category profiles in Table 4, the Newcastle MHCL Service appears to provide a proportionately high level of support to offenders against justice procedures, at least partially addressing the mental health care concerns raised by Robertson et al. (1996). Other Distinguishing Features Two analysis strategies were adopted to try to identify other distinguishing features of the MHCL service clients: an internal analysis of relationships between client characteristics and overall charge profiles (using logistic regression analyses) and comparisons with Hunter region relative offence distributions for the audit period. The former primarily revealed referral source and age effects (see Table 2), while the latter generally 312

MENTAL HEALTH COURT LIAISON SERVICE demonstrated similar patterns of offences between MHCL clients and Hunter offenders as a whole (see Table 4), with a few notable exceptions, which are discussed below. With regard to referral source effects, clients referred from inpatient mental health units were significantly less likely to have been charged with offences against people or property. Lower rates of property offences were also observed among older age groups, which is generally consistent with other studies showing declining crime rates with age (e.g., Wallace et al., 1998; Modestin et al., 2002). Within the MHCL sample, primary ICD- 10 diagnosis was not significantly associated with the type of charge, after referral source and sociodemographic factors were taken into account. A diagnosis of drug and alcohol disorder was the only diagnosis having a significant univariate (but not a multivariate) association with an increased likelihood of offending (against property and public order; see Table 2). Within the regional and the MHCL service data sets there were approximately 4 5 offences by males for every offence by a female. Compared to the relative offence distributions reported for all Hunter offenders (see Table 3), the key exceptions noted in the MHCL data were as follows: for both male and female clients of the MHCL service, there were proportionately more offences against justice procedures and fewer driving offences and other offences ; for male clients only, there were proportionately more malicious damage and robbery offences and lower rates of offensive behaviour and drug offences (e.g., possession and dealing offences; see Table 4). The observed lower rates of driving and drug offences among MHCL clients probably reflects their relative socioeconomic disadvantage and the fact that they are more likely to be drug users than drug dealers. Proportionate increases in male offences with an aggressive element, such as robbery and malicious damage, are generally consistent with the elevated rates of violent crime that have been reported among males with a major mental illness (e.g., Hodgins, 1992; Tiihonen et al., 1997). The higher proportion of offences against justice procedures found among the MHCL sample was probably due, in large part, to breaches of AVOs, which comprised half of the offences in that category (146/296, 49.3%). In addition to the above, supplementary logistic regressions revealed significant associations between marital status, referral source and the likelihood of having been charged with offences against justice procedures. While clients referred from inpatient mental health units were, once again, less likely to have been charged with such offences, those who were separated or divorced were more likely to have offended in this way, such as breaching AVOs taken out against them. More generally, there has been a steady increase in NSW in both the number and proportion of AVO applications per year that relate to domestic violence (Hickey & Cumines, 1999). Specific interventions may need to be provided to assist those with mental illness who are perceived to have a propensity for violence (and comorbid substance abuse) and relationship problems. We also need to develop a broader range of interventions for relationship-focused aggression (e.g., Fals-Stewart, Kashdan, O Farrell, & Birchler, 2002). Since MHCL clients referred from inpatient mental health units were generally less likely to have been charged with offences against people, property or justice procedures, the obvious question that arises is: Why were those clients without current offences actually referred to the service? There were 76 referrals from inpatient mental health units during the audit period that were not associated with any current offences, of which half related primarily to advice about AVOs, including 35 service episodes relating to AVOs sought against the client and three in which the client was seeking an AVO. Whether or not such referrals represent an effective intervention (e.g., reducing the likelihood of subsequent problems, AVO breaches or other offences) is not yet known, but is clearly a question worth answering. Limitations The service audit reported in this paper is primarily descriptive in nature and relates to a single community-based mental health court liaison service established in a regional city in NSW, Australia. Consequently, it cannot directly address many of the specific research questions that arise about relationships between offending behaviour and mental illness. It should also be emphasised that this is largely a study of offenders who have been caught and who have been subsequently referred to a publicly-funded mental health service. Consequently, this study may reveal as much about who gets caught, charged and referred, as it does about patterns of community offending. Moreover, most 313