Skip to main content
SearchLoginLogin or Signup

Explaining Similarities and Variations in Program Structures and Professional Roles in Midwestern Mental Health Courts

Published onNov 01, 2016
Explaining Similarities and Variations in Program Structures and Professional Roles in Midwestern Mental Health Courts


For nearly twenty years, legal and mental health professionals have created mental health courts (MHCs) for responding to the increasing numbers of criminally involved people with severe mental illnesses (PSMI) who are entering the criminal justice system. This article presents findings from qualitative analysis of survey and ethnographic data collected at nine MHCs established in a Midwestern state between 2004 and 2008, exploring how professionals who operated the MHCs organized the programs and conducted roles at the work sites. Findings revealed that professionals established very similar models of mental health court organization at each of the nine sites. The data supported three forms of institutional isomorphism—coercive, mimetic, and normative—that occurred as professionals introduced MHC programs in various jurisdictions. However, the data also revealed some variances of structure, professional belief, and practice when comparing the MHCs. Some of these variations are explained by local organizational cultures, while others are due to organizational dependence on available resources.


For nearly twenty years, legal and mental health professionals have been creating mental health courts (MHCs) to respond to the increasing numbers of criminally involved people with severe mental illness (PSMI) who are entering the criminal justice system. Operating at the preand post-adjudication stages of the criminal justice process, MHCs were first established in 1997 in Broward County, Florida (Goldkamp & Irons-Guynn, 2000). Based  on the principle of therapeutic jurisprudence, in which legal actors strive for therapeutic outcomes for individuals affected with schizophrenia, bipolar disorder, major depression and other serious psychiatric disorders (Hora, Schma, & Rosenthal, 1999), MHCs were modeled after drug treatment courts and proliferated throughout the first decade of the 21st century. Such courts grew in number from a reported four operational programs in late 1997 to more than 300 by 2014 (Council of State Governments, 2014).

Early research on MHCs included studies of the inception and organization of specific programs (e.g., Goldkamp & Irons-Guynn, 2000; Fisler, 2005). Researchers have distinguished the first generation MHCs, which arose in roughly the first five years of MHCs’ operations, from the second-generation MHCs, which were implemented in 2002 and thereafter (Redlich et al., 2005). Several studies have investigated the impact of MHCs on the judicial system, community, and participants. Findings have shown that MHCs appear to reduce the likelihood (Sarteschi, Vaughn, & Kim, 2011) and severity of future criminal activity, at least during the year following participation (Moore & Hiday, 2006). MHCs also appear to enhance the quality of life for participants (Sarteschi, 2009) and to increase use of services (Boothroyd et al., 2003).

Work roles connecting criminal justice and mental health systems and teamwork among different kinds of MHC professionals have also been studied. Steadman (1992) identified critical boundary-spanning work roles that connect the mental health and criminal justice systems. Goss (2008) emphasized the importance of teamwork between local mental health and criminal justice professionals, as well as support from client advocates, in their effort to implement an MHC in rural Georgia. Gallagher et al. (2011) interviewed professionals working in 11 Ohio MHCs and found that they understood their own roles in relation to the different roles of other MHC workers, and that those roles coalesced around the issue of client needs.

The growth of MHCs in the United States is well documented, and the establishment of the earliest MHCs has been investigated. However, no previous studies have applied social science perspectives on organizations and professions in order to explain precisely how MHCs have been launched and spread by professionals within a single state, or how the programs within one state compare to each other in structure and professional roles. From the spring of 2010 through the spring of 2012, we conducted research at all MHC sites in one Midwestern state. Our research design made it possible to investigate how an MHC program was first established by influential professionals in one county and how the establishment of additional MHCs by other professionals followed in other counties within that state.

In this paper, we present findings from analyses of survey and ethnographic data collected at nine MHCs in one Midwestern state, exploring how professionals who operated the MHCs organized the programs and conducted their work roles at each of the sites. DiMaggio and Powell (1983) identified processes of institutional isomorphism to explain how bureaucratic organizations become similar to one another due to institutional pressures for legitimacy within a single field or group of organizations. Professionals in organizations are important to institutional isomorphism. In conducting this study, we recognized that almost all work occupations involved in operating the Midwestern MHC programs—including judges, attorneys, probation officers, social workers, and psychologists—have been defined as “professional” in previous academic research. The early trait approach in the sociology of professions differentiated professional occupations (e.g., doctor, judge, and lawyer) from non-professional ones (Pavalko, 1988), while later researchers studied professionals in terms of their power over clients in institutions (e.g., Freidson, 1970), and feminist researchers identified the “caring professions,” such as social worker, probation officer, and nurse (Abbot & Wallace, 1990). In studying the workers in Midwestern MHCs, we recognized that almost   all worked in professional occupations as defined in previous research, and thus institutional isomorphism was relevant to the analysis.

We investigated the processes of isomorphism, using data from surveys, interviews, and observations of the nine MHCs, and explored similarities and differences in the various program structures and professional roles. Findings revealed that the organizational structures and professional roles of the programs were very similar across the nine sites, despite important variations. We explained similarities and differences by referring to concepts from previous research on organizations and professions, which we present below.

Theoretical background

Meyer and Rowan (1977) introduced a new institutional approach by arguing that institutional rules function as myths that are then adopted into structures by organizations in pursuit of legitimacy. A homogenizing process referred to as isomorphism acts as a constraining mechanism that causes an organization to resemble others confronting a similar set of environmental conditions. The authors also note that formal organizational structures could represent ceremonial attempts at legitimacy that are decoupled from the actual practices of workers in the organization (Meyer & Rowan, 1977). DiMaggio and Powell (1983) described the “organizational field” as a set of organizations that comprise a recognized aggregate within a larger institution, such as criminal justice programs within a state. Similarity occurs among organizations because, as a field emerges, powerful forces make the organizations homogenous bureaucratically and in other ways. Both professionals and the state are the “great rationalizers” (DiMaggio & Powell, 1983, p. 147) and will often deal with constraints in ways that are very similar in terms of culture, structure, and output. DiMaggio and Powell (1983) discussed two types of isomorphism: competitive and institutional. Competitive isomorphism describes how organizations become similar due to the experience of the same market forces within a shared environment; institutional isomorphism describes how certain organizations must also compete for political and institutional legitimacy.

Three kinds of institutional isomorphism (coercive, mimetic, and normative) impel organizations to resemble one another. Coercive isomorphism occurs when organizations respond similarly to pressures exerted by other organizations and by cultural expectations. Mimetic isomorphism occurs when organizations are uncertain about their structure and operations and respond by following the models established by other organizations. Lastly, normative isomorphism occurs through a process of professionalization, whereby members of an occupation ascertain how and where they work (DiMaggio & Powell, 1983).

The neoinstitutional perspective challenged prevailing rationalist organizational perspectives that failed to account for normative and cultural pressures on organizations (Pedersen & Dobbin, 2006). Another  important challenge to hyper-rationalist perspectives in organizational studies arises from the perspective of organizational culture (Pedersen & Dobbin, 2006), which can be considered as a pattern of basic assumptions shared  by a given group that is coping with external pressures and maintaining internal stability. Such assumptions have worked well enough over time to be viewed as valid by group members and are taught to new members as the response to problems (Schein, 1990). Organizations are groupings of people that form purposely to achieve particular goals (Ritzer, 2013) and ascribe  to a culture that is comprised of the shared experiences of its members. Smaller groupings within an organization might also form a subculture that could be in harmony or in conflict with the organizational culture (Schein, 1990). Although no standard organizational culture can be applied across disciplines, researchers with this perspective view culture as a positive factor that creates stability and consistency within an organization (Prue & Devine, 2012). The organizational cultural perspective also recognizes the importance of an organization’s founders, as they establish the initial organizational culture, which may remain relatively unchanged over time (Robbins & Judge, 2008).

The neoinstitutionalist and organizational culture perspectives have significantly influenced the field of organizational studies but have promoted seemingly contradictory ideas (Pedersen & Dobbin, 2006). Neoinstitutionalists focus on organizations becoming isomorphic over time due to external pressures, whereas organizational culture researchers focus on the internal development of organizational cultures and the shared identity among their members. Nonetheless, Pedersen and Dobbin (2006) suggested that the two perspectives are compatible because both processes can happen simultaneously within and among organizations. Organizations face external pressures in seeking legitimacy, which leads to isomorphism, whereas organizations strive internally to form identities and solidarity among members.

When analyzing qualitative data collected for the purpose of the statewide study of mental health courts, we recognized both processes in comparing Midwestern MHCs. Coercive, mimetic, and normative isomorphic processes were apparent, while some significant differences among MHCs were a matter of specific beliefs and practices of the professionals—the organizational culture of an MHC. However, we noted that internal organizational culture will overlap with other levels of culture. We also recognized that contextual elements, such as the availability of resources (Pfeffer & Salancik, 1978), may affect how MHCs are organized; yet isomorphism and culture are the focus of this paper.

Criminal justice and mental health organizations

Most of the prior research on criminal justice or mental health organizations relevant to the theoretical approach in this paper consists of neoinstitutional analysis of law enforcement agencies. The initial use of this analysis was presented by Mastrofski, Ritti, and Hoffmaster (1987), who studied police enforcement of a new DUI law and found that larger departments fit   a “loosely-coupled model,” where street-level practice was only loosely related to bureaucratic directives regarding the new law, while institutional isomorphic processes of legitimacy and professional norms explained why the small police departments were more likely to enforce it. The researcher John P. Crank then initiated a series of papers, usually with co-authors, analyzing police organizations primarily by utilizing Meyer and Rowan’s (1977) neoinstitutional theory (Crank & Langworthy, 1992; Crank, 1994; Crank & Rehm, 1994).

A number of other researchers applied neoinstitutional theory to the police, considering the three types of  institutional  isomorphism  defined by DiMaggio and Powell (1983). Using survey data from 160 police departments, Giblin (2006) found that the contingency factor of size and the institutional factor of normative isomorphism were significant in predicting the adoption of crime analysis units. Using field research and survey methods, Willis, Mastrofski, and Weisburd (2007) concluded that a neoinstitutional model of organization better explained three police agencies’ adoption of the COMPSTAT management system than a technical/rational model. Giblin and Burruss (2009) conducted factor analyses to develop a model for large-scale measurement of institutional isomorphic processes among police organizations nationwide. As they did not align with the other pressures, they removed coercive constructs, and normative constructs were divided into publications and professionalization. This model was supported when applied to data from over 400 police agencies regarding the adoption of community policing (Burruss & Giblin, 2014).

There have been far fewer neoinstitutional studies of other kinds of criminal justice organizations, but the theory has been applied to state prisons (McGarrel, 1993), community corrections (McCorkle & Crank,  1996), and private prisons (Ogle, 1999). Hagan, Hewitt, and Alwin (1979) contended that neoinstitutional ideas better explained how probation became a subsystem of the criminal courts than Marxist or Durkheimian explanations. The creation of the probation profession and new adjudication practices are largely ceremonial in approach while purportedly serving the goals of individualized treatment. The researchers developed a model for quantitative analysis of sentencing in a Washington state criminal court jurisdiction and found that judges’ sentencing was more influenced by prosecutor recommendations than those of probation officers (Hagan, Hewitt, & Alwin, 1979).

Relatively few studies of criminal justice organizations have focused specifically on organizational or workplace culture, although police occupational culture has been well-researched. Reuss-Ianni (1983) described a schism between street cop culture and management cop culture at two New York City Police Department sites. Christensen and Crank (2001) conducted ethnographic research at a sheriff’s office in a nonurban setting, finding some differences but broad similarities with cultural themes found across urban police departments. Kim et al. (2013) utilized an organizational culture measure in a statewide survey of law enforcement agencies in Texas, finding the measure was significant in predicting positive attitudes toward working with parole agencies. From a neoinstitutional perspective, Katz (2001) found that pressures to achieve legitimacy for a new gang unit came not only from outside the police department, but also from officers within the department via their beliefs regarding professionalism and practices at their agency. He argued the latter finding suggested the importance of police culture at the department, but did not specify this as a specific workplace culture, despite it being an internal pressure (Katz, 2001). A number of scholars have recognized and researched the distinct occupational culture of the police (e.g., Manning, 1989; Chan, 1997). There are overlapping cultural systems when workers at a site are members of a distinct occupational culture and formalized professional organizations, while also members of their workplace with its organizational culture. This was an important point for our research at MHCs, where different kinds of professionals with their own respective occupational cultures regularly work together.

Neoinstitutional studies of mental health organizations are not as numerous as those of law enforcement organizations, but a few of these studies have found isomorphism. Peyrot (1991) found isomorphism and decoupling of technical practice from the administrative process in drug abuse treatment units connected to the justice system in Los Angeles. D’Aunno, Sutton, and Price (1991) also investigated drug abuse treatment units, finding isomorphism among new units formed in mental health agencies in which traditional treatment was provided while conflicting 12-step ideals were stated. But contrary to neoinstitutional theory, Shen and Snowden (2014) concluded that late adopters of deinstitutionalization policy were motivated by technical efficiency rather than by the desire to seek legitimacy. There are relatively few studies of mental health organizations considering workplace culture. Glisson (2002) delineated the importance of organizational culture in providing effective mental health treatment for children. Jones and Kelly (2014) explored workplace culture of eldercare workers in relation to their view toward whistle blowing.

Scheid and Greenberg (2007) reviewed numerous sociological studies   of mental health care that impacted organizational theory, yet they focused on institutional theory that emphasizes conflict and change in reaction to a changing environment, rather than neoinstitutional theory. However, in describing potential areas of conflict for professionals in mental health care, their comments are of particular interest here. They noted that different kinds of professionals often work in one mental health organization, creating the potential for inter-professional conflict. But organizations can reduce conflict if various professionals can resolve differences cordially and have autonomy in doing so, rather than by having disputes resolved bureaucratically with limits to autonomy. As we will see, professional work in Midwestern MHCs is characterized by cordial relationships among different professionals from two institutional backgrounds who generally take a team approach to decisions and practice.


The research presented in this paper was part of a larger, state-funded study aimed at describing, comparing, and contrasting all operational mental health court (MHC) programs in the state of Midwestern. The research questions of the larger study relevant to the current investigation are

  1. How did the programs begin?

  2. In what ways are the programs similar?

  3. In what ways are the programs different?

For this paper, we analyzed data on how each operational program was organized, initiated, and operated by the various professionals involved. We conducted surveys, interviews, and field observations at each of the nine MHC programs, explored how the programs began, and examined program structures and professional roles. The larger research began with a state-wide survey of all Midwestern court jurisdictions, which identified the nine MHCs currently in operation in the state. All had been established for at least one year. Each of the nine MHC programs was located in one of eight counties in the state: Collins, Ferry, Gabriel, Gilmour, Hackett, Manzanera, Lynne, and Waters (one program in Bevan City and one in the suburb of Tandy).1

At each of the nine sites, a professional involved in running the MHC completed a survey in the spring of 2010. The survey contained both openand closed-ended questions, and covered several areas of information: the history of the program; program structure in terms of personnel, adjudication, and mental health services; program resources and funding; and participant demographics. These data were used to profile each site and were analyzed with Qualrus, a qualitative analysis software program.

After the survey, representatives from each of the nine sites permitted focus group interviews of all MHC staff and observations of staff meetings and court calls. During a series of site visits to each MHC between May 2010 and February 2012, we conducted focus group and individual interviews with the professionals who operated the MHC programs, and we observed staff meetings and court operations. After being invited by several professionals, we also observed meetings of a professional organization that was formed in 2009 for the purpose of promoting mental health courts in the state.

At each MHC, we conducted one-hour focus group interviews with workers, including judges, attorneys, probation officers, social workers, program coordinators, psychologists, and nurses. One of the MHC coordinators requested that two groups be scheduled on separate dates so that all of the MHC personnel could be included. Thus, 10 focus group interviews with 81 participants were conducted at the nine MHC sites between June 2010 and April of 2011. The interviewer asked a set of open-ended questions at each focus group in order to launch an informative conversation with participants.

Focus group interview questions asked about the beginnings of the MHC, current program operations, problematic issues, relationships among MHC professionals, and relationships with program participants, law enforcement agents, and community service providers. Conducting focus groups in a work setting might make workers hesitant to express critical opinions in the presence of co-workers and supervisors (Liamputtong, 2011). However, we believed that this was not an issue for three reasons. First, we triangulated the data through observations and follow-up individual interviews and did not find contradictions to the descriptions of work roles and teamwork found in the group interviews. Second, among the various professionals who participated at each site, there were relatively few hierarchical supervisor-worker relationships. Third, questions focused on how the professionals conducted their work rather than their personal opinions (although personal opinions were shared at times during the groups).

A strength of the focus group method is that data are gathered from a group of individuals interacting with each other rather  than simply  with the interviewer (Wilkinson, 1998). This feature was particularly valuable for researching how the professionals worked together. We also conducted fourteen individual follow-up interviews with key professionals, including judges, program coordinators, mental health workers, and a probation officer, in order to clarify and delve into processes observed in the field and discussed in the focus group interviews. The interviewer constructed a specific set of open-ended questions for each individual interview, but, as with the focus groups, the open-ended questions were asked to initiate a conversation that fully explored issues of interest. Transcripts of the focus group and individual interviews were prepared and then uploaded into the Qualrus software program.

Additional site visits were made to each of the nine MHCs in order to conduct field observations of MHC operations, including staff meetings (in which new referrals and participants’ cases were discussed by MHC team members) and court calls (in which program participants were scheduled  to appear individually before the judge in open court). At least one full court observation (staff meeting and court call) was conducted at each of the nine MHC sites. Eight of the sites allowed more than one observation, and six sites were observed three or more times. Written notes were taken during each meeting and courtroom observation in order to provide details on how the MHC team members worked together and operated the court program. We also took notes at six bi-monthly meetings of the professional organization held in various locations over an eighteen month period.

The researcher writing field notes constructed narratives for each observation, which described how the professionals worked with one another and fulfilled their professional roles in staff meetings and court hearings; how each court docket transpired; and how each professional meeting was conducted. At appropriate times during observations, the researcher made open jottings (Emerson, Fretz, & Shaw, 1995) that focused on the activities of workers and court participants and the settings in which they interacted.

Shortly after observing a court call or staff meeting, the researcher read through jottings and added more field notes to provide details and clarification for thick description (Warren & Karner, 2010). Eventually, these notes were incorporated into a single narrative for each observation, which included vivid description, dialogue through indirect and direct quotation, and full characterization of workers and participants, while avoiding summary and evaluative wording (Emerson, Fretz, & Shaw, 1995). The same process was followed with field notes from each observation of the professional organization meetings. All observations were typed into documents that were then uploaded into Qualrus and combined with the survey data and interview transcripts.

The pooling of the survey, interview, and observational data into Qualrus allowed for qualitative content analysis and method triangulation of the various data sources (Patton, 1999). In order to utilize the software to compare across programs, we coded for sites, structures, and roles, among other categories. Codes for similarities among the programs utilized a conceptual framework drawn from institutional isomorphism (i.e., modeling, funding). As analysis progressed, categories were detailed, and links between them were identified. We recognized that some differences found when comparing the MHCs could be explained by workplace culture. Overall, the analysis identified consistent and contrasting themes regarding how MHC court operations were initiated, how they were structured, and how MHC professionals fulfilled work roles and collaborated as a team.


Beginnings of Midwestern MHC programs

All nine Midwestern MHC programs had been in operation for at least     a year and a half at the time of the survey. The idea to begin an MHC program typically arose due to information gathered at meetings and conferences and from professional literature. For example, in 1998, local National Alliance for the Mentally Ill (NAMI) advocates began contacting health and criminal justice officials in Ferry County about a specialized court program after attending a national NAMI conference. To design the program, which finally began in 2004, NAMI and the local state’s attorney relied on professional and research literature on MHCs, as well as meetings with local mental health and criminal justice professionals and representatives of community organizations. Waters County judges learned about MHCs that were being developed elsewhere by attending conferences and reading the judicial literature. The non-profit agency Treatment Alternatives for Safer Communities (TASC), already involved in the drug court, obtained a federal grant to begin the Bevan City program in 2005. NAMI representatives met regularly with Waters County court officials and TASC for planning the new program. The Tandy MHC in suburban Waters County was established four years later than the Bevan MHC and was modeled after the Bevan City program with TASC involvement, but was a much smaller program (six participants vs. 55 in Bevan City). Criminal justice officials in Lynne County began discussing the possibility of beginning a program in 2003 after the Chief Judge learned of MHCs and asked local mental health officials to conduct a study, which found over-representation of people with severe mental illness (PSMI) in the jail population. The Chief Judge formed a coordinating council with another judge and local mental health providers that spent 18 months planning and developing resources for the MHC program.

All of the remaining programs were established by the end of 2008. In Gabriel County, local NAMI members had been part of a task force that had been meeting with criminal justice officials for over five years regarding police contacts with PSMI. NAMI representatives approached the chief judge in the jurisdiction about beginning an MHC. Founders of the program attended a GAINS conference in California, gathered literature (Council of State Governments, 2007) on essential elements of an MHC, and visited the Lynne County MHC program before establishing their own program. Judges from Collins County learned of MHCs at a statewide circuit court judge meeting before initiating one of their own. There, a task force organized of mental health and criminal justice leaders met regularly for two years, and also utilized the literature on essential elements of an MHC. The Hackett County program was created after a judge recognized a need for the jurisdiction to deal differently with specific mentally ill individuals, began discussing an MHC with local professionals, and took them to visit the Lynne County MHC. The Gilmour County MHC began after a member of a local mental health funding board contacted the probation department and suggested the establishment of an MHC. The eventual program was also modeled after the Lynne County MHC, and NAMI representatives trained the MHC workers on families of PSMI.

As revealed by these cases, a few individual professionals in each county, usually judges assisted by mental health leaders, began MHC programs after learning about them through professional networks and/or government and professional literature, and in four cases, after visiting existing MHCs elsewhere in the state. NAMI was a key organizational influence in four counties: in Ferry and Gabriel Counties, NAMI members were a driving force in beginning programs; in Waters County, members were part of planning the MHC; and in Gilmour County, members provided training to workers. A mental health funding board influenced the beginning of the Gilmour County MHC. Five of the programs received federal funds to begin operations. Founders initiated MHCs despite limited county resources and their own inexperience in running an MHC program. They aimed for program operations to follow professionally recognized practices. Below, the similarities of these Midwestern MHCs are presented.

Typical model of Midwestern MHC programs

Although program sizes ranged widely (from 5 to 102 participants at time of the survey), the nine programs were remarkably similar in terms of their structure. The typical model of these Midwestern MHCs included specific professional work roles for the judge, state’s attorney, public defender, probation officer, social/mental health worker, and program administrator. All of the programs centered on periodic court hearings before a judge who engaged clients on an individual level, and a program coordinator who organized work activities such as taking referrals and convening meetings. Each program had assistant state’s attorneys (ASAs) and public defenders, who generally worked together rather than as adversaries, and a monitoring team comprised of at least one probation officer and one mental health worker, who supervised participants and communicated with each other between hearings. Furthermore, the programs all had some type of staff meeting connected to each hearing during which mental health and criminal justice professionals would discuss referrals and participants and decide how best to work with them.

Redlich et al. (2006) identified six characteristics that operationally define an MHC, and these were present in all nine Midwestern programs. All had separate dockets for criminal defendants with mental illness. Each program worked toward diverting participants from incarceration to community mental health treatment. Mental health treatment was mandated as a requirement for participation in each program. As mentioned above, participation in treatment was supervised via periodic court hearings and direct supervision in the community. Workers in the programs—specifically, the judge during hearings and probation officers and mental health workers between hearings—offered praise and encouragement to participants for adherence to program guidelines and meted out sanctions for noncompliance. Finally, all of the Midwestern MHCs were voluntary in that eligible defendants could choose whether to participate.

Roles involved with monitoring offenders between court hearings—namely, social workers, probation officers, and even public defenders at some sites—often shared work activities, whereas other roles were more narrowly construed in terms of which activities accomplished the work of the court for specific case management purposes. The role of the judges varied little from site to site, and work tasks, including interactions with participants, were strictly defined by legal authority. The judges in each of the nine MHC programs played the same key role. All programs held participant hearings before a judge, who structured the program around the continual monitoring and evaluation of each participant’s mental health treatment and adherence to probation conditions. These hearings provided an accounting of each client’s treatment compliance and progress in the MHC program.

Important decisions were made at the staff meetings that were held before the participants appeared in front of the judge. Nevertheless, in every program observed, the hearing involved a judge in a robe at the bench who reviewed the participant’s progress and acknowledged which behaviors were praiseworthy and which were unacceptable. Probation officers, social workers, and public defenders would stand just behind participants when they appeared before judges, and these MHC staff members would report on the participant’s progress. The judge would then extend praise, encouragement, or admonishment, depending on whether the reports were positive or negative. This communication by the judge to the participant relied on the power of legal enforcement, which could potentially, in any given hearing, change the program participant’s legal status.

Although each judge in the MHC programs exercised legal power, each did so in a manner that involved personally knowing the program clients in order to provide moral support and encouragement aimed at influencing them to continue their treatment and abide by probation conditions. In addition, the hearings were the only times during which judges had contact with participants, which enabled participants to make their appearance before the judge at critical moments in their program participation. The emotional support of judges combined with their power of legal enforcement on display at hearings was a fundamental and organizational component of each MHC program studied.

Similar to the judges’ roles, the roles of ASAs were very consistent among the MHCs. In each of the nine programs, the ASA was gatekeeper. ASAs screened referrals and evaluated the details of cases against prospective clients, often including the opinions of arresting officers and victims with a concern for public safety. During the referral process, the ASAs would either give their approval and the potential participant would continue through  the referral process, or the case would be rejected by the ASAs and the defendant would not be accepted into the MHC program. The ASAs discussed new referrals with others on the MHC team and considered their opinions. Nonetheless, before the client could enter an MHC program, a referral had to be accepted by the state’s attorney’s office, which was accomplished through the representation of the ASA on the MHC team.

ASAs were involved during court calls in the processing of cases, enabling defendants to enter the MHC program, and in other situations in which participants had violated the terms of probation or been arrested for another crime. ASAs also monitored participants’ progress, tracking participants’ cases during staff meetings and court calls. Nevertheless, they did not engage in a high level of direct contact with participants. Several ASAs noted the inappropriateness of being heavily involved with participants through direct contact. Thus, the boundaries of the ASA-client relationship were rigidly defined and maintained.

Public defenders were important role players at all sites, although at a couple of sites a small number of MHC participants were represented by private defense attorneys. In some cases, private attorneys turned their client over to the public defender. The public defenders at two sites were adversarial in approach compared to defenders at the other sites, a variation between the MHCs that will be explained below.

Probation officers and mental health workers, such as case managers, therapists, and nurses, served monitoring roles, because they were responsible for the regular supervision of participants in the time between MHC appearances. Although staff composition varied, all nine MHCs had at least one probation representative and one or more mental health workers (social workers, psychologists, nurses) who cooperated and shared responsibility for the regular monitoring of participants. The probation officers focused on meeting criminal justice monitoring objectives, while the social workers and psychologists focused on meeting clients’ service and treatment needs.

Before MHCs were introduced in the United States, Steadman (1992) had utilized the concept of boundary spanners, drawn from the literature on organizations, to describe the important role of players who work in diversion programs at the intersection of the criminal justice and mental health systems. Boundary spanners were present in the administrative roles of the Midwestern MHCs, but not all of these roles could be described as boundary spanners because of the variety of their professional backgrounds, which is also detailed below when discussing variations across sites.

Variations in Midwestern MHCs

The MHCs were part of a statewide organizational field of programs and were scattered across the state in a variety of urban, suburban, and mixed rural/suburban areas, with different population sizes, resources, and government structures. MHCs in high-population areas had larger staffs and larger numbers of participants. These programs spent less time in staff meetings for each participant, and judges worked at a faster pace during hearings. Median annual household incomes for the eight counties, according to the 2010 U.S. Census, ranged from $10,000 below to $20,000 above the state median, greatly affecting the tax base supporting government and social services. This may explain why the two most affluent counties—Ferry and Manzanera—were able to staff their MHC programs entirely with government personnel, rather than collaborating with an external agency. In Manzanera County, the second most affluent county, pretrial services officers were part of the MHC staff, unlike any of the other programs. Some variations were a matter of the specific conditions in a county. For example, the Bevan City MHC does not accept misdemeanor cases because the main criminal courthouse heard only felony cases, and that was where the MHC was housed. When the program in Tandy began, it also mirrored the Bevan City program and allowed only felony cases.

All of the Midwestern MHCs accepted offenders with mental illness charged with felony violations; the two programs in Waters County accepted only felony cases, while the rest accepted both misdemeanors and felonies. The Ferry County MHC had only a pre-adjudication model. Four MHCs utilized both pre- and post-adjudication models, and the remaining four programs utilized only post-adjudication. Four MHCs accepted persons charged with violent offenses on a case-by-case basis, while the remaining five programs did not accept any offenders with violent charges. Programs varied  in terms of how often they held MHC hearings, ranging from twice weekly  to twice monthly. The average length of participation for all but one MHC was one to two years; the Gilmour County MHC reported only a six-month to one-year average length of participation. All of these programs progressively decreased the level of court supervision by lessening the required frequency of probation visits and court appearances.

Redlich et al. (2005) identified two generations of MHC development nationwide using a sample of eight MHCs begun during the 1990s, and another seven MHCs begun after 2002. Second-generation MHCs were more likely to accept persons charged with felony or violent offenses, employ post-plea adjudication models, use jail as a sanction, and utilize court personnel or probation for supervision (Redlich et al., 2005). Midwestern MHCs reflect the second-generation trends (Redlich et al., 2005) toward hearing felony cases, utilizing post-adjudication models, and utilizing jail as a sanction for noncompliance, but not the trend toward relying on court personnel supervision models. Only one program—the Gilmour County MHC—did not utilize jail  as a sanction for participants. Only three of the nine MHCs relied primarily on court personnel or probation officers for monitoring and supervision of participants, but these programs had mental health workers external to the court attend staff meetings. The remaining six programs relied on a combination of court personnel and community or county mental health workers external to the court for monitoring and supervision of participants.

Professional role variation

The various professional roles displayed much similarity across sites, but there were variations among them. All of the judges regularly deferred to the judgment of clinicians and probation officers in determining how best to deal with a participant during the hearings, but judges in some MHCs took charge more than others in leading staff meetings and court calls. For instance, staff meetings in the Bevan City MHC, which had a men’s and women’s court call, were led by judges who took the initiative and ran quick meetings that involved less discussion time than in some other MHCs. These judges held MHC hearings between regular dockets that were larger than those at other courts. By contrast, the judge in the Gilmour County MHC was casual in discussions of participants with other MHC staff members. Here, the discussion and process of the hearing was led primarily by the case managers with input from probation officers, and the judge provided guidance as needed. The Gilmour MHC judge worked in a courthouse that was much smaller and had much less criminal justice/court activity overall, allowing for a more leisurely pace during the hearing.

The nine MHC programs varied in the number and composition of role players engaged in monitoring the participants. Although staff composition varied, all nine MHCs had at least one probation representative and one or more mental health workers (social workers, psychologists, nurses) who cooperated and shared responsibility for the regular monitoring of participants. In several of the programs, one or two specific mental health service providers worked with the MHC to such an extent that their employees were regular members of the MHC team, attended all staff meetings and court calls, and spent much if not all of their time serving MHC participants. Other mental health workers were employees of the court or county government, such as the court psychologist in Gabriel County or the clinical social worker in Ferry County, who was employed by the county health department.

Several significant variations in MHC practices can be attributed to the organizational culture of the worksite. When the Midwestern MHC professionals interacted with one another and participants, they engaged in the specific workplace culture (Volti, 2008) of their programs. One explanation of the variation in MHC practices across sites is that founders were important in establishing beliefs and practices for the organizations. For example, several professionals in the Gilmour County MHC—the only one not to use jail as a sanction—noted that they believed jail was inappropriate for participants. In an individual interview, the Gilmour program coordinator explained that she and other founders decided, when beginning the MHC, that the illnesses of participants would be exacerbated in jail in ways that undermined program adherence. Professionals in all other MHCs believed that jail was sometimes an appropriate sanction but should be utilized sparingly.

Public defenders: Variation in use of adversarial and non-adversarial roles

Public defenders were essential personnel in all nine MHC programs studied; however, the performance of their roles varied among the programs. In the research literature on specialty court programs, such professionals typically assume a non-adversarial posture (e.g., Miller & Johnson, 2009; Nolan, 2001), which differs from their traditional adversarial role in criminal courts. Under the adversarial approach, an ASA brings charges against a defendant, while a defense attorney, representing the defendant’s interests, argues against the state’s case and for the rights of the defendant. ASAs and public defenders in specialty court programs are described in the research as setting aside their traditional adversarial roles in order to work together as members of the program team and to advocate for the behavioral healthcare interests of participants. Although the non-adversarial characterization was generally true for the nine MHC programs observed, it was only partially true for a couple of them. In court observations, two of the public defenders adopted a somewhat adversarial approach during staff meetings as the team decided how to sanction participants who had not fully complied with program rules.

The public defender in the Lynne County MHC, Joanie, was a decades-long veteran of the criminal justice system. Joanie supervised the other public defenders in Lynne County but served MHC participants as a regular member of the staff. During the staff meetings, when a participant’s case was being discussed, the public defender was often observed arguing against a solution being considered by the judge, clinicians, administrator, and the ASA. Sometimes as a result, a less severe punishment was meted out for a rule violation. Joanie played the adversarial role in several discussions of how to sanction program participants, always on the side of a less punitive resolution. In addition, in discussions about participants who had violated program rules or who might have committed a criminal offense, she limited the amount of information that was shared with the judge and the ASA.

Peggy, the public defender in the Ferry County MHC, also took an adversarial stance, and described a high level of concern about keeping information that was considered harmful to clients from the judge and the ASA. The Ferry MHC, however, was a pre-plea program, which was generally not the case in the other MHC programs studied. Because the state had not formally dealt with charges in a pre-plea program, Peggy and several co-workers were concerned that negative information might eventually affect the adjudication of a participant’s case. Therefore in the Ferry MHC, Peggy worked to prevent the sharing of such negative information, especially about new program applicants. This tactic is described in the following interview excerpt:

Peggy: I am very particular about [information sharing]. If we’re all in staffing and it’s all-open communication I have … it’s fine, but [the Ferry MHC judge] is not included on our emails and shouldn’t be. We’ve developed a system where [others on the MHC team] got the evaluations. They can’t go to her until someone is going to be accepted into the program. She should not have that information ever, until someone’s accepted into the program.

Interviewer: So a lot of your role is to control information, it sounds like.

Peggy: I’m an anal-retentive gatekeeper of information. Of how it gets controlled, because there’s certain [information] that should not be given without all parties present and that’s just, legally it shouldn’t be there … whether it’s a wellness court or not, there’s due process rights involved.

Professionals running the Ferry County MHC believed that information sharing among MHC staff should be limited to prevent violation of clients’ rights. As the earliest-established program, it had a pre-plea adjudication model common to first-generation MHCs (Redlich et al., 2005). Additionally, when founders were planning the MHC, the local NAMI chapter had stressed to criminal justice officials the importance of protecting privacy rights of persons with mental illness. In limiting information sharing with the judge, in contrast to the non-adversarial design of other MHCs, the public defender plays an adversarial role. In other Midwestern MHCs, staff required that participants sign a general release of information so that all MHC team members can freely discuss their activities and progress. The public defenders, probation officers, and mental health workers in the other MHCs regularly shared both positive and negative information on the clients with the judge and the ASA, and described a team approach in making decisions on how to reward and sanction participants, which required that all team members have this information.

Public defenders were also observed playing a role in case management for some participants in several of the MHCs observed. Some public defenders collaborated with the mental health workers and probation officers on the MHC team, such as helping a participant obtain supportive services that did not necessarily focus on legal concerns. In such situations, public defenders joined other MHC staff in assisting participants in their day-to-day lives. This reflected the value of flexibility shared among professionals at some MHCs, which we will return to later.

Program coordinators as boundary spanners

We also found variation across sites when comparing program coordinator work roles. In Waters County, the director of treatment programs, Phil, held the administrative role in the two MHCs. He worked for drug courts  and MHCs at several locations, including his county’s two MHCs observed  for this study. Phil worked in the ASA’s Office and performed administrative functions for the specialty courts, including screening for the criminal background of referrals on behalf of the state’s attorney. Although working in the criminal justice system, Phil had a mental health background and thus fit the role of boundary spanner, as he detailed below:

Phil: My background is clinical. I worked in behavioral health care for my entire career before coming here a little over seven years ago. When the position that I’m in now came open, then the idea was to have somebody fill that position with a clinical background so that the state’s attorney’s office would have more of a clinical input into some of these alternative programs. I started out with primarily drug cases. Drug diversion was the first thing that I was involved in. I had some involvement with the court, I still have some involvement with the drug court system in the county … uh, and then when the mental health court was in the process of being implemented, the thought was that given my clinical mental health background that it would make sense for me to have the position as coordinator.

Administrative roles in the other MHCs were not based in the state’s attorney’s office. Each jurisdiction had both a court administrator’s office and a probation department. Four program coordinator positions were placed in the probation department, while the remaining three were out of the court administrator’s office. In seven of the programs, the program coordinator role regularly attended all staff meetings and court calls, provided input on participant cases, and also served an administrative function, such as organizing staff meetings or finding funds for program operations. On the other hand, the Lynne County specialty courts administrator had a background as a prosecutor, not as a mental health specialist, and did not meet the criteria to be a boundary spanner (Steadman, 1992). But both the Collins MHC coordinator and the Gabriel coordinator could be considered boundary spanners due to years of prior experience in mental health.

The program manager in Ferry County did not work directly with MHC participants, having direct contact with potential participants only after they had been referred to the program and initiated the program application process. The Ferry County program manager supervised a drug court program in addition to MHC, both of which were relatively large programs. This role was purely administrative and did not involve boundary spanning. The program manager had no input into how cases were handled after a participant began the program and did not attend MHC staff meetings.

Inter-professional norms and organizational-institutional reactivity

The concept of boundary spanner (Steadman, 1992) points to the overlap between criminal justice and mental health professional disciplines that grew in the post-deinstitutionalization era. Mental health courts are arenas where professionals from the two backgrounds, boundary-spanners or not, regularly trade professional norms regarding how to work with populations of criminality and mental illness. During work observations for this study, professionals displayed very little conflict relative to the open cooperation they engaged in during staff meetings and court calls, arenas where they regularly shared beliefs and practices drawn from both disciplines. Workers of both backgrounds openly discussed MHC referrals and participants who had particular mental health diagnoses combined with specific criminal charges and levels of offense, as well as particular social contextual factors (i.e. race, age, means, etc.). When decisions were made in staff meetings regarding these individuals, discussions were generally marked by consensus building.

Eisenstein and Jacob (1977) studied criminal courts as “workgroups,” analyzing three municipal courts. The researchers found that if the members of a courtroom workgroup only occasionally worked together, work was more formal and adversarial than that of workgroups who were regularly in court together. The professionals that we observed in this study displayed familiarity, informality, and humor during staff meetings, albeit this was slightly less true of meetings at the large programs in Waters and Ferry Counties. We observed opinion sharing from the various professional roles, and occasional disagreements, but decisions were typically made without rancor. Instead, decisions were made via consensus reached by professionals in their respective roles, agreeing to a plan of action. Each professional displayed a level of autonomy in sharing opinions, and decisions were made as a team. As Scheid and Greenberg (2007) suggested regarding inter-professional work, conflict was minimized among the professionals because decisions were made as a team, rather than through a bureaucratic hierarchy. The professionals displayed a combined criminal justice/mental health understanding of each case during these discussions. Thus, each professional occupation has its own culture. Further, in MHCs and other arenas, an inter-professional occupational culture is developing among mental health and criminal justice professionals engaged in work together.

Professionals in the Midwestern state also displayed teamwork and sharing of disciplinary backgrounds through their formation of a statewide organization to promote the utilization of best practices in MHCs in the state. Over a series of meetings, we observed the formation and reporting of committees aiming to define criteria for state MHCs and to pursue tax-exempt status for the new organization. The appropriateness of the utilization of MHCs and the necessity of best practices were beliefs regularly shared among professionals at these meetings. This was an example of “organizational-institutional reactivity” (Crank & Langworthy, 1992) in which organizations react to coercive processes by taking part in the shaping of myths. During our research, only one group of professionals—the judge, psychologists, public defender, and program coordinator during their focus group interview in Gabriel County—expressed doubts about the appropriateness of MHC as a solution for the problem of PSMI in criminal justice settings.

The various MHCs were shaped by external pressures, including federal grants and literature, NAMI, and professional norms such as therapeutic jurisprudence ideals held by judges. Professional organizations promoted MHC practice through conferences and literature, an example of overlap between coercive and normative pressures. Although few studies had documented the effectiveness of MHCs by 2004, and despite varying contextual factors  at the different sites, professionals established nine MHCs in the Midwestern state over a four-year period and were now meeting together every two months to promote their use.

The value of flexibility

Probation officers focused on meeting criminal justice monitoring objectives, while social workers and psychologists focused on meeting participants’ service and treatment needs. Nonetheless, probation and mental health workers in Collins, Ferry, Hackett, and Lynne MHCs characterized the sharing of responsibilities and teamwork as playing a critical role in meeting participants’ service, treatment, and monitoring needs. Even public defenders were observed at two of the sites assisting with case management. The value of flexibility and the sharing of work roles are part of the professional workplace culture of these four programs and were displayed in their approach to client case management.

At each of these sites, professionals emphasized ideals of flexibility during interviews and openly displayed sharing of work roles during observations. The value of flexibility in problem-solving courts is celebrated in academic literature (e.g., Miller & Johnson, 2009); thus, the professional enthusiasm may be an example of institutional-organizational reactivity (Crank & Langworthy, 1992), in which professionals engaged in myth-making through their approach to work, although we cannot directly trace the origin of the value from the external environment. Midwestern MHC professionals understand flexibility in two different ways. First, professionals in the programs in Collins, Ferry, Hackett, and Lynne counties emphasized the notion of being flexible in all aspects of program operations so that each client’s needs are met. They related the importance of getting to know each participant, … so their approaches to client motivation and sanctioning were individually tailored so as to be most effective. In the following interview excerpt, Ben, … a probation officer from the Hackett County MHC, and Kelly, the public defender, described how the program is customized to best meet the needs of each participant:

Ben: The one thing about this team that I know or see is that it’s completely driven by the individual. It’s not driven by rules or guidelines or anything like that—it’s driven by the individual’s needs. Which, to me, is what really makes this so unique and works so well is that it’s all about the individual and what their needs are. And this team, their whole purpose is to meet the needs of that person.

Kelly: And that starts from the beginning, when someone gets identified as a potential participant. That can come from police officers in the field that have participated in crisis intervention training. That can come from the probation officer who has worked with this person in the past, or has some other knowledge from working with family members throughout the community. It can come from a judge at first appearances when they are first brought to answer to the charges. It’s recognition from the public defender’s office, the state’s attorney’s office, or any other member of the team that brings them into this and from there, then like you saw today, we discuss this person, and those attributes that are unique to them. And then the case plan is developed and we all decide if this person is appropriate, and what we can do for this individual.

Flexibility was also understood as a matter of professional roles. Some respondents recognized their professional roles as flexible, while others, such as the judge and the ASA, did not. At most sites, probation officers and clinical social workers—and at some sites public defenders and nurses—spoke about being willing to share duties and perform tasks that were outside of their job description. These professionals spoke of doing “whatever is needed” to best work with participants, which might include monitoring, counseling, case management, and transportation regardless of whether one’s role is within criminal justice or mental health. Professionals also spoke of “teamwork” as a concept that required them to adopt various roles in doing work activities. Sara, the program coordinator of Lynne County, described the willingness  of MHC staff to share work activities. Similarly, Gene, a probation officer, followed up with an example of teamwork:

Sara: And sometimes there are different functions … I think … in traditional programs where, well, this role does this—like maybe transport to inpatient treatment or something like that. But that’s not how this team works. It’s who has the available time at 9:00 on Monday to take somebody, and it’s whoever is available to do it. So [the probation officer] may do it, staff from [the community mental health agency] may do it. It’s very fluid and working together about what can be in the best interest of the clients.

Gene: Just as an example of how the different components seem to work together at times: we had an individual last week who we had talked about at staffing [for whom] we were looking for a treatment facility. And our dual diagnosis person, she contacted the treatment center, and she sent an email to the team stating that we needed a court order to allow the agency to go into the jail. Immediately, the PD [public defender] … contacted the team asking to do the [creation of document releasing the individual from jail]. She made contact with the state’s attorney [stating] that the judge emailed her back [writing] that he would sign off. So it’s kind of a team effort in many areas throughout the day that we don’t even think about. It’s kind of automatic now.


Coercive, mimetic, and normative isomorphism were relevant in explaining similarities among the Midwestern MHC programs. Coercive isomorphism describes how organizations become similar to one another because of pressures from the organizations upon which they depend or from common cultural pressures. Several coercive pressures affected all of the MHC programs. The federal government through the Bureau of Justice Assistance and the Council of State Governments made grants available and disseminated literature. Midwestern legislature passed a law authorizing jurisdictions to create MHCs but disallowed the participation of offenders charged with certain crimes, such as sex offenses. Advocates from NAMI persuaded officials to begin programs and assisted with the planning.

Coercive isomorphism includes resource dependence. The MHCs required the involvement of mental health professionals, but there was variation in their availability. Thus, coercive pressures created different groupings of  isomorphism among mental health personnel. The programs in Ferry and Manzanera Counties were in the most affluent areas of the nine programs with the highest per capita household incomes. Both of these MHCs were able to rely on well-funded county health departments for personnel and were staffed entirely by employees of the county government. Hackett, Gilmour, and Lynne Counties were among the least wealthy and their MHCs relied upon local community mental health agencies to staff their programs. The programs in Gabriel, Collins, and Waters counties were in areas of moderate income. The Gabriel and Collins county programs relied on a combination of government-employed mental health workers and those from outside agencies. The two Waters County programs had TASC mental health workers who monitored MHC clients and brokered services with external agencies. Here we do not investigate whether or not MHC participants and referrals can be said to experience justice by geography (Feld and Schaeffer, 2010), in which their interests are differentially represented due to different contextual elements, but future research on MHCs should consider issues of context. Does the limited time on each case for MHCs in urban environments lead to poorer outcomes for urban defendants compared to rural defendants? Do MHCs utilizing community mental health centers work more or less effectively with PSMI offenders than MHCs entirely staffed by government agencies? These are important questions to explore.

Professionals engaged in mimetic processes when modeling programs after what they had read in the literature, discussed at conferences, or observed in newly established programs. Most of the MHC designs followed some type of established model. The MHCs in Waters, Gilmour, and Manzanera counties, for example, were modeled after their respective drug courts. Four counties reported modeling their court after other Midwestern MHCs. Professionals in Collins and Gabriel counties referred to the “Essential Elements of a Mental Health Court” published by the Council of State Governments Justice Center (2007).

Professionals also described normative processes within their own professions. Several judges reported having learned about the programs from other judges and recognized that they could introduce the programs for certain individuals in their own jurisdictions. Judges also described professional conferences as another arena wherein ideas about MHCs were communicated. Mental health professionals described communicating with their colleagues in other counties on how they could work with new court programs to provide services to criminally involved PSMI.

We found evidence in our research of all three forms of institutional isomorphism, supporting the neoinstitutional theory as formulated by DiMaggio and Powell (1983). On the other hand, we did not find evidence of a loose coupling of street-level practices to the stated goals and policies of the MHC programs, contrary to the neoinstitutional theory of Meyer and Rowan (1977). Although MHC organizations revealed organizational-institutional reactivity (Crank & Langworthy, 1992) in that professionals enthusiastically spread the myths of MHC effectiveness, these same professionals also attempted to match the policies, practices, and designs for the programs as communicated by federal and state literature as well as their own officially-produced documents. This may have been due to the uniqueness of MHCs   as organizations. They were relatively small organizations within criminal courts and have some members from external organizations. The judge is technically the authority in an MHC, but in practice did not rule through bureaucratic directive. Instead, the judge typically deferred to the judgment of mental health workers, and decisions were made collectively by the team of professionals. But in doing so, they paid close attention to following organizational policies, laws, and best practices.

Several variations found when comparing these Midwestern MHCs can be explained as a matter of the specific workplace culture at each site. Founders enacted unique practices relative to other MHCs based around workplace beliefs shared among local professionals. For example, on beginning the Gilmour County MHC, founders determined that MHC participants should not ever be jailed as a sanction due to it being viewed as an inappropriate practice for persons with severe mental illness. In the Ferry County MHC, the public defender and other professionals believed in limiting the sharing of information, a practice begun when the program was first established with a pre-adjudication structure. These findings suggested other important questions that future research should explore: Should jail ever be utilized in mental health court programs as it exacerbates mental illness symptomology? If jail can be utilized, under what conditions is the use of jail appropriate? Is the free sharing of information on MHC cases the best approach? Or is the Ferry County professionals’ concern with protecting rights of defendants not being recognized enough in other jurisdictions?


In this paper, we recognized three forms of institutional isomorphism— coercive, mimetic, and normative—that occurred as MHC programs were introduced and spread in a Midwestern state from 2004 to 2008. MHC program designs followed government-approved guidelines, developed resources, and incorporated contacts with other necessary organizations. Professionals organizing the programs referred to other models such as existing drug courts or other established MHCs. Founders also had to abide by professional norms in operating programs such as those suggested by therapeutic jurisprudence and evidence-based practices. DiMaggio and Powell (1983) conceded that the three types of isomorphism are not always empirically distinct, and that real-world cases often include elements of more than one type. The categories, though, served as an analytical tool for explaining how organizations in a field come to resemble one another, and our analysis displayed examples of all three forms that are true to DiMaggio and Powell’s conceptualization.

Isomorphic processes were identified in the current study, but we also recognized cultural elements present in organizations. Professionals who work in MHCs share specific ideas on how to work with participants in the program. At MHC sites, criminal justice and mental health professionals have developed their own workplace culture (Volti, 2008) resulting from the intermingling of mental health and criminal justice professional practices and ideas. The values and beliefs held by professionals in some MHCs, as in Ferry County and Gilmour County, were not held by professionals in others.

Researchers applying the neoinstitutional and organizational culture perspectives argue against purely rationalist understandings of organizations. They underscore how the pursuit of political and social legitimacy as well as values and beliefs specific to an organization’s members are important factors affecting organizations and work beyond simple market competition and the development of the most efficient methods or best practices. An important takeaway from our research was that mental health and criminal justice professionals operate programs for offenders who have mental illness in a way that is recognized by both as appropriate to divert offenders from incarceration and into treatment.

The programs all displayed commonly held ideals drawn from therapeutic jurisprudence and mental health disciplines, but there were also significant differences. Professionals varied in their understanding and performance of work roles in the programs. Future research should consider whether the most prevalent MHC program structures are, in reality, the best for program outcomes and for dealing with the problem of PSMI who are placed in jails and prisons. Researchers should also compare differences in program design and professional role performance to determine which designs and practices are most supportive of positive outcomes and social justice for PSMI.


Abbott, P., & Wallace, C. (1990). The sociology of the caring professions: An introduction. In P. Abbott and C. Wallace (Eds). The sociology of the caring professions. New York: The Falmer Press.

Boothroyd, R.A., Poythress, N.G., McGaha, A., & Petrila, J. (2003). The Broward mental health court: Process, outcomes, and service utilization. International Journal of Law & Psychiatry, 26, 55-71.

Burruss, G.W., & Giblin, M.J. (2014). Modeling isomorphism on policing innovation: The role of institutional pressures in adopting community-oriented policing. Crime & Delinquency, 60(3), 331-355. Chan, J. (1997). Changing police culture: Policing in a multi-cultural society. Cambridge, MA: Cambridge University Press.

Christensen, W., & Crank, J.P. (2001). Police work and culture in a non-urban setting: An ethnographic analysis. Police Quarterly, 4(1), 69-98.

Council of State Governments. (2007). Improving responses to people with mental illness: The essential elements of a mental health court. Washington, D.C.: Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice.

Council of State Governments. (2014). Mental health courts. Retrieved July 8, 2014, from

Crank, J.P. (1994). Watchman and community: Myth and institutionalization in policing. Law and Society Review, 28(2), 325-352.

Crank, J.P., & Langworthy, R. (1992). An institutional perspective of policing. The Journal of Criminal Law and Criminology, 83(2), 338-363.

Crank, J.P., & Rehm, L.R. (1994). Reciprocity between organizations and institutional environments: A study of Operation Valkyrie. Journal of Criminal Justice, 22(5), 393-406.

DiMaggio, P. J. & Powell, W.W. (1983). The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review, 48(2), 147-160.

D’Aunno, T., Sutton, R.I., & Price, R.H. (1991). Isomorphism and external support in conflicting institutional environments: A study of drug abuse treatment units. Academy of Management Journal, 34(3), 636661.

Eisenstein, J., & Jacob, H. (1977). Felony justice: An organizational analysis of criminal courts. Boston: Little, Brown, and Co.

Emerson, R., Fretz, R., & Shaw, L. (1995). Writing ethnographic fieldnotes. Chicago: University of Chicago Press.

Feld, B.C., & Schaefer, S. (2010). The right to counsel in juvenile court: Law reform to deliver legal services and reduce justice by geography. Criminology and Public Policy, 9(2), 327-356.

Fisler, C. (2005). Building trust and managing risk: A look at a felony mental health court. Psychology, Public Policy, and Law, 11, 587-604.

Freidson, E. (1970). Profession of medicine: A study of the sociology of applied knowledge. Chicago: University of Chicago Press.

Gallagher, M., Skubby, D., Bonfine, N., Munetz, M.R., & Teller, J.L.S. (2011). Recognition and understanding of goals and roles: The key internal features of mental health court  teams. International Journal of Law and Psychiatry, 34, 406-413.

Giblin, M.J. (2006). Structural elaboration and institutional isomorphism: The case of crime analysis units. Policing: An International Journal of Police Strategies & Management, 29(4), 643-664.

Giblin, M.J., & Burruss, G.W. (2009). Developing a measurement model of institutional pressures in policing. Policing: An International Journal of Police Strategies & Management, 32(2), 351-376.

Glisson, C. (2002). The organizational context of children’s mental health services. Clinical Child and Family Psychology Review, 5(4), 233-253.

Goldkamp, J.S., & Irons-Guynn, C. (2000). Emerging judicial strategies for the mentally ill in the criminal caseload: Mental health courts in Fort Lauderdale, Seattle, San Bernardino, and Anchorage (Publication no. 182504). Washington, DC: US Department of Justice, Office of Justice Programs.

Goss, S.S. (2008). Mental health court programs in rural and nonaffluent jurisdictions. Criminal Justice Review, 33, 405-413.

Hagan, J., Hewitt, J.D., & Alwin, D.F. (1979). Ceremonial justice: Crime and punishment in a loosely coupled system. Social Forces, 58(2), 506527.

Hora, P.F., Schma, W.G., & Rosenthal, J.T.A. (1999). Therapeutic jurisprudence and the drug treatment court movement: Revolutionizing the criminal justice system’s response to drug abuse and crime in America. Notre Dame Law Review, 74(2), 439538.

Jones, A., & Kelly, D. (2014). Whistle-blowing and workplace culture in older peoples’ care: Qualitative insights from the healthcare and social care workforce. Sociology of Health & Illness, 36(7), 986-1002.

Katz, C.M. (2001). The establishment of a police gang unit: An examination of organizational and environmental factors. Criminology, 39(1), 3773.

Kim, B., Gerber, J., Beto, D.R., & Lambert, E.G. (2013). Predictors of law enforcement agencies’ perceptions of partnerships with parole agencies. Police Quarterly, 16(2), 245-269.

Liamputtong, P. (2011). Focus group methodology: Principles and practice. Thousand Oaks, CA: SAGE Publications, Ltd.

McCorkle, R., & Crank, J.P. (1996). Meet the new boss: Institutional change and loose coupling in parole and probation. American Journal of Criminal Justice, 21(1), 1-25.

McGarrell, E.F. (1993). Institutional theory and the stability of a conflict model of the incarceration rate. Justice Quarterly, 10(1), 7-28.

Manning, P. (1989). Occupational culture. In W.G. Bayley (Ed.), The encyclopedia of police science. New York: Garfield.

Mastrofski, S.D., Ritti, R.R., & Hoffmaster, D. (1987). Organizational determinants of police discretion: The case of drinking-driving. Journal of Criminal Justice, 15, 387-402.

Meyer, J.W., & Rowan, B. (1977). Institutionalized organizations: Formal structure as myth and ceremony. American Journal of Sociology, 83(2), 340-363.

Miller, J. & Johnson, D.C. (2009). Problem-solving courts: A measure of justice. New York: Rowman and Littlefield Publishers, Inc.

Moore, M.E. & Hiday, V.A. (2006). Mental health court outcomes: A comparison of re-arrest and re-arrest severity between mental health court and traditional court participants. Law & Human Behavior, 30, 659-674.

Nolan, J.L. (2001). Reinventing justice: The American drug court movement. Princeton, NJ: Princeton University Press.

Ogle, R.S. (1999). Prison privatization: An environmental catch-22. Justice Quarterly, 16(3), 579-600.

Patton, M.Q. (1999). Enhancing the quality and credibility of qualitative analysis. Health Services Research, 34(5), 1189-1208.

Pavalko, R.M. (1988). The sociology of occupations and professions. Itasca, IL: F.E. Peacock Publishers.

Pedersen, J.S., & Dobbin, F. (2006). In search of identity and legitimation: Bridging organizational culture and neoinstitutionalism. American Behavioral Scientist, 49, 897-907.

Peyrot, M. (1991). Institutional and organizational dynamics in communitybased drug abuse treatment. Social Problems, 38(1), 20-33.

Pfeffer, J., & Salancik, G.R. (1978). The external control of organizations: A resource dependency perspective. New York: Harper and Row.

Prue, D., & Devine, K. (2012). Isomorphism and organizational culture. AlterNative: An International Journal of Indigenous Peoples, 8, 253263.

Redlich, A.D., Steadman, H.J., Monahan, J., Petrila, J., & Griffin, P.A. (2005). The second generation of mental health courts. Psychology, Public Policy, and Law, 11(4), 527-538.

Redlich, A.D., Steadman, H.J., Monahan, J., Robbins, P.C., & Petrila, J. (2006). Patterns of practice in mental health courts: A national survey. Law and Human Behavior, 30(3), 347-362.

Reuss-Ianni, E. (1983). The two cultures of policing: Street cops and management cops. New Brunswick, NJ: Transaction Books.

Ritzer, G. (2013). Introduction to sociology. Thousand Oaks, CA: Sage. Robbins, S.P., & Judge, T.A. (2008). Organizational behavior (13th ed.). Upper Saddle River, NJ: Prentice Hall.

Sarteschi, C.M. (2009). Assessing the effectiveness of mental health courts: A meta-analysis of clinical and recidivism outcomes (Doctoral dissertation). Retrieved from

Sarteschi, C.M., Vaughn, M.G., & Kim, K. (2011). Assessing the effectiveness of mental health courts: A quantitative review. Journal of Criminal Justice, 39, 12-20.

Scheid, T.L., & Greenberg, G. (2007). An organizational analysis of mental health care. In W.R. Avison, J.D. McLeod, & B.A. Pescosolido (Eds.), Mental health, social mirror. New York: Springer.

Schein, E.H. (1990). Organizational culture. American Psychologist, 45, 109-119.

Shen, G.C. & Snowden, L.R. (2014). Institutionalization of deinstitutionalization: A cross-national analysis of mental health system reform. International Journal of Mental Health Systems, 8, 4769.

Steadman, H.J. (1992). Boundary spanners: A key component for the effective interactions of the justice and mental health systems. Law and Human Behavior, 16, 75-87.

Volti, R. (2008). An introduction to the sociology of work and occupations. Thousand Oaks, CA: Pine Forge Press.

Warren, C.A.B., & Karner, T.X. (2010). Discovering qualitative methods: Field research, interviews, and analysis, (2nd ed.). New York: Oxford University Press.

Wilkinson, S. (1998). Focus group methodology: A review. International Journal of Social Research Methodology, 1(3), 181-203.

Willis, J.J., Mastrofski, S.D., & Weisburd, D. (2007). Making sense of COMPSTAT: A theory-based analysis of organizational change in three police departments. Law & Society Review, 41(1), 147-188. 


Monte D. Staton is an Assistant Professor in the Department of Criminal Justice and Criminology at Ball State University. He was awarded a Master of Arts in Sociology with a specialty in Criminology and Deviance from Bowling Green State University in 1998. Staton next worked for eight years in Chicago as a counselor in rehabilitation programs for persons with mental illness.   In 2006 he began attending Loyola University Chicago, where he earned his Ph.D. in Sociology.

Arthur J. Lurigio, a psychologist, is Senior Associate Dean for Faculty      in the College of Arts and Sciences, and a Professor of Criminal Justice and Criminology and of Psychology at Loyola University Chicago. In 2003, Dr. Lurigio was named a faculty scholar, one of the highest honors bestowed on senior faculty at Loyola University Chicago. In recognition of his continued scholar productivity, he was named, in 2013, a Master Researcher in the College of Arts and Sciences at Loyola University Chicago.

No comments here
Why not start the discussion?