Forensic Assertive Community Treatment Research Articles

Substance Use in Forensic Assertive Community Treatment: Development and Implementation of a Pilot Project for Internees in Belgium

Substance use is a significant factor associated with new arrests, detentions and compulsory admissions for patients in forensic assertive community teams (FACT). To enhance community tenure for forensic patients and facilitate their sustainable integration into society, a treatment that offers a community-based alternative to admission following substance use was developed. In this paper, the development of the project, FENIX + is described along with the reporting of a pilot study of all included patients during 12 months (N = 24). Recidivism risk and community integration were assessed utilizing the Short-Term Risk Assessment and Treatability (START) as well as the Measurements in Addiction for Triage and Evaluation (MATE) scales. The included patients avoided 60% of admissions, exhibited positive changes in their desire for assistance, and successfully reduced their risk of recidivism. By accessing the community-based alternative, they were able to delay admissions effectively. These promising results suggest that a community-based treatment could benefit patients at risk of reoffending following substance use.

The Sequential Intercept Model and Forensic Assertive Community Treatment (FACT) for People with Serious Mental Illness: Implications for Social Work Practice

In the United States, adults with serious mental illness are overrepresented in the criminal justice system. The sequential intercept model is a novel framework that identifies three major stages where interventions for this population can best be utilized: pretrial diversion, post-plea alternative to incarceration (ATI), and community reentry from jail and prison. This paper begins with a review of the literature that supports the application of Forensic Assertive Community Treatment (FACT) across these three stages. This paper will also draw on the influences of therapeutic jurisprudence, which holds that the courts can be used to both advance public safety and enhance access to mental health services for justice involved people with serious mental illness. 
 The literature has suggested that patients receiving FACT services have been found to have lower rates of psychiatric hospitalization and criminal justice recidivism in comparison to those who received traditional mental health services. This paper will touch on cutting edge practices to reduce psychiatric hospitalization and criminal justice recidivism rates among people with mental illness that are currently in use. In particular, programs involving law enforcement integration such as ACT-PI teams, co-response teams, and crisis intervention training will be explored. This paper will focus on applications and limitations of FACT across the various stages of the sequential intercept model, with a particular focus of using FACT as a way to reduce racial and gender disparities within the criminal justice system among people with serious mental illness. In light of the broad support the literature highlights for FACT when applied earlier within the criminal justice system, social work practice efforts should accordingly focus on expansion of early access to FACT services. In particular, criminal justice policy efforts should be expanded with respect to utilization of these services at the pretrial diversion and ATI stages, where they are historically underutilized.

Barriers and facilitators of access and utilization of mental health services among forensic service users along the care pathway

BackgroundThe verdict of Not Criminally Responsible on account of a Mental Disorder (NCRMD) is increasingly used to access specialized mental health services in Canada and elsewhere. This situation highlights the importance of ensuring timely access to services in the community to prevent violence and justice involvement. The objective of the present study is to identify individual and contextual barriers and facilitators of access to mental health services during the period preceding an offense leading to a verdict of NCRMD.MethodsThe sample includes 753 people found NCRMD in Québec, Canada. All episodes of mental health hospitalizations and service use before the index offense were identified using provincial administrative health data, for an average period of 4.5 years. Access was conceptualized as a function of the possibility of seeking, reaching and receiving appropriate health care services, based on Lévesque and colleagues patient-centred model of access to care.Generalized linear models were computed to identify the individual and contextual predictors of: (1) seeking mental healthcare (at least one contact with any type of services for mental health reasons); (2) reaching psychiatric care (at least one contact with a psychiatrist); (3) receiving psychiatric care, operationalized as (3a) continuity and (3b) intensity. Factors associated with volume of emergency mental health services were examined as exploratory analysis.ResultsGeographical considerations were highly important in determining who reached, and who received specialized mental health care – above and beyond individual factors related to need. Those who lived outside of major urban centres were 2.6 times as likely to reach psychiatric services as those who lived in major urban centres, and made greater use of emergency mental health services by 2.1 times. Living with family decreased the odds of seeking mental healthcare by half and the intensity of psychiatric care received, even when adjusting for level of need.ConclusionsFindings support efforts to engage with the family of service users and highlights the importance of providing resources to make family-centred services sustainable for health practitioners. Health policies should also focus on the implementation of outreach programs, such as Forensic Assertive Community Treatment teams as part of prevention initiatives.

Mental health and criminal justice: bridging two worlds

PurposeThe purpose of this study was to describe programs that aim at programs to divert people with a mental condition from the criminal justice system to mental health services are being initiated, but reporting is limited and fragmented. This study described programs that aim at diverting persons with mental health conditions out of criminal justice systems to community mental health services, with the intention to inform research and practice.Design/methodology/approachA scoping review was used to map and synthesise diversion programs. Ten online data bases were searched. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was used to direct the selection of sources. Research and evaluation publications and grey literature published from 2010 to 2021 in English language were included.FindingsEight distinct diversion programs were identified across 24 countries or territories covering five phases of the criminal justice process. Diversion programs included crisis intervention teams, the electronic linkage system, mobile crisis units, the criminal justice liaison program, problem-solving courts, the abstinence-based program, the community equivalence program and the forensic assertive community treatment program. Although distinct programs have the potential to form a system of diversion across the continuum of the criminal justice process, only two territories moved in that direction. Diversion programs reported overwhelmingly originated from high-income countries.Practical implicationsStigma that labels people with mental health conditions as violent and dangerous need to be addressed. It is important to place diversion systems on national policy agendas and advocate for evidence-based interventions.Originality/valueThe study provides a blueprint on diversion systems to set a research agenda and develop a road map, tailored towards local contexts.

Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review.

Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures.Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale.Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50–75%. The severity of SUD tended to increase initially and to stabilize afterwards.Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.

Effectiveness of Forensic Assertive Community Treatment on Forensic and Health Outcomes: A Systematic Review and Meta-Analysis

Given the increasing literature on forensic assertive community treatment (FACT), we conducted a systematic review and meta-analysis to explore the effectiveness of FACT among justice-involved individuals with severe mental illness. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Sixteen studies were included in the systematic review, six of which were included in the meta-analyses for a total of 1,246 participants. Mixed results regarding health-related outcomes were found. The pre-post FACT analysis and comparison with control groups did not yield significant results other than increased outpatient service use. Results on forensic outcomes were more compelling. Both the narrative review and the meta-analysis highlighted that FACT programs may improve justice outcomes such as the number of days spent in jail. More high quality and multisite randomized controlled trials are needed to consolidate findings. Further research is needed to examine other psychosocial factors related to FACT program success.

Essential Elements of Forensic Assertive Community Treatment.

After participating in this activity, learners should be better able to:• Assess characteristics of forensic assertive community treatment programs. Forensic assertive community treatment (FACT) has emerged internationally as an intervention strategy for people with serious mental disorders who are involved with the criminal justice system. Studies to date have shown marked variability, however, in FACT program design and operation. Based upon a literature review and relevant experience, the authors present their perspective on the essential elements of FACT. Given that FACT is an adaptation of the evidence-based assertive community treatment (ACT) model, it is recommended that FACT programs maintain a high-fidelity ACT component. FACT programs should also have both mental health and criminal justice admission criteria because service recipients are involved in both service systems. For optimal effectiveness, FACT team clinicians must partner with criminal justice agencies that provide community-based supervision to their patients. Prospective FACT enrollees should receive a clear explanation of the program, including how their respective mental health and criminal justice service providers will work collaboratively with them to prevent incarceration. FACT programs should also use risk/need assessment to inform treatment planning, evidence-based mental health and community correctional practices to promote both wellness and public safety, and shared training to promote effective collaboration. Additional elements to consider include housing, medical care, and transitional services. These elements are presented and discussed, including a rationale and evidence to support each component. The article concludes with introduction of a FACT fidelity scale, the Rochester Forensic Assertive Community Treatment Scale (R-FACTS). By operationalizing essential FACT elements, the R-FACTS is designed to support FACT program development, implementation, and dissemination in a more consistent and measurable manner.

Societal Reentry of Prison Inmates With Mental Illness: Obstacles, Programs, and Best Practices.

Societal reentry from prison presents a wide array of extreme challenges to inmates attempting to reintegrate with society. This process is significantly more daunting for inmates suffering from mental illness for several reasons. This paper examines the reentry process for inmates with mental illness. Three sample reentry programs (Forensic Assertive Community Treatment, Critical Time Intervention, and Thresholds' Prison Aftercare Program) that were developed for inmates with mental illness are discussed along with research testifying to the effectiveness of these programs. Finally, components that would comprise an ideal prison reentry program for mentally ill inmates are outlined, which include a three-phase structure and a focus on preparing both inmates and communities for the reentry process.

A comprehensive literature review of Forensic Assertive Community Treatment (FACT): Directions for practice, policy and research

Forensic assertive community treatment (FACT) is an adaptation of Assertive Community Treatment (ACT), a widely-studied evidence-based model for mental health services delivery. ACT has been demonstrated to reduce psychiatric hospitalizations and improve community tenure, however, research on the adaptations needed to target criminogenic risks and needs and reduce recidivism for individuals living with serious mental illnesses who are justice involved is in its nascent stages. This literature review was undertaken to establish the current state of research on the FACT model. An analysis was conducted of 47 peer-reviewed research articles and book chapters to identify themes in FACT eligibility criteria, staffing and competencies, models, sustainability, and outcomes of FACT. The paper provides an overview of the research to-date on FACT and offers recommendations for practice, policy, and research. At this stage, research is needed to better understand for whom does FACT work, under what circumstances, and with what outcomes.

14. VIOLENCE IN SCHIZOPHRENIA: PREVALENCE, MEASUREMENT, PREDICTION AND PREVENTION

Overall : Most patients with schizophrenia and bipolar disorders (severe mental illness, SMI) are not violent in their lifetimes, however, a minority of patients are violent at some points in the course of their illness. As the illness appears relatively early in life, and typically runs a chronic course, the number of violent incidents caused by patients can be considerable in some cases. Due to the stigma toward SMI, the media often emphasize reporting of these incidents, which fuel the stigma even more. Although violent behavior is a common cause of concern for patients, their families and clinicians, it is not often discussed in scientific meetings. The purpose of this symposium is to bring this relatively neglected, but very important topic into the spotlight in SIRS, in order to summarize the latest evidence for clinicians and researchers, and to foster new work on reducing these risks of violence.Dr. Weiser will present an overview of the prevalence of violent behavior in patients with SMI, and will present a population-based, case-control study from Israel, showing increased rates of violent crime in patients with SMI, particularly in female patients and patients who abuse drugs. Secondary analyses will show increased rates of violent behaviour in siblings of patients as well.Dr. Fazel will present a systematic review on the prognostic (or predictive) accuracy of structured ways to assess violence risk in patients with severe mental illness, and present new work on a scalable and potentially useful predictive model of violent behaviour based on 75,000 patients in Sweden.Dr. Nijman will present a model based on patient, ward and staff variables focused on the causes and triggers of aggressive behavior on (locked) psychiatric wards. Based on this model, a number of preventive measures can be formulated. At the patient level, the administration of anti-psychotic medication is used to reduce the negative cognitive schemes and delusional thoughts that are depicted in the center of the model. A more novel intervention at the patient level may be the additional administration of nutritional supplements with (among others) high levels of omega 3 fatty acids. The results of two Dutch studies on this topic will be briefly presented in the lecture, among which a RCT on the effects of the use of nutritional supplements on aggressiveness. On the staff level, the use of short-term (daily) risks assessments by the ward nursing staff, among others by means of the six item BrØset Violence Checklist (BVC), has been found to reduce aggressiveness as well as the use of coercive measures on psychiatric wards in two cluster randomized RCTs. On the ward level, studies indicate that aggression on psychiatric wards can be reduced by preventing overcrowding on psychiatric wards, and by providing more space and privacy to the patients.Dr. Torrey will present data on rates of re-arrest in patients with SMI, showing that the average five-year re-arrest rate is approximately 40% for those released from psychiatric hospitals and 60% for those released from jails or prisons, and will present comparison data from other countries. He will then present data on the effect of extended conditional release, Forensic Assertive Community Treatment (FACT) teams, and Psychiatric Security Review Boards on re-arrest rates.

14.4 FOLLOW-UP TREATMENT FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS WHO HAVE COMMITTED MAJOR CRIMES

BackgroundFor individuals who have a psychiatric disorder and have committed a major crime, the rate of re-offending is twice as high in the US compared to nine other countries for which there is comparable data. For such individuals the average five-year rearrest rate is approximately 40% for those released from psychiatric hospitals and 60% for those released from jails or prisons. The use of treatment modalities such as extended conditional release, Forensic Assertive Community Treatment (FACT) teams, and Psychiatric Security Review Boards can reduce the rearrest rate from 40–60% to 10% or less.MethodsAll 50 states were surveyed to assess how they were doing in providing follow-up treatment for such individuals.ResultsSixteen states were found to be making a moderate effort to provide follow-up treatment, and another 13 states are making a minimal effort. However, the other 21 states, 42% of the total, are making virtually no effort, lending to an unnecessarily high rate of re-offending.DiscussionUsing proven treatment approaches the re-arrest rate of individuals with serious mental illness can be reduced from 40–60% to 10% or less.

Kriminalitetsprofiler i en dansk retspsykiatrisk population – udfordringer for psykiatriens kriminalitetsforebyggende opgave?

English title: Typologies of crime committed by mentally disordered offenders: A challenge to the statutory task in hospital psychiatry of preventing recidivism to criminal actsThe aim of the study is to identify and describe a number of characteristics among a selected sample of mentally disordered offenders referred to a specialized forensic assertive community treatment team in Copenhagen (n=181). Looking at a number of variables, the study identifies a heavily burdened patient population in terms of social marginalization, serious mental illness, and criminal acts. Having identified a huge variety and number of typologies of criminal acts, we argue that the task of preventing recidivism to new crime not clear among mental health professionals. Furthermore, it proves difficult to prevent crime when the typologies of crime are diverse and widespread. It is one thing is to prevent violent crimes closely related to an actual psychotic mental state and quite another to prevent drug crimes or property crimes not so obviously related to a mental disorder. The article concludes that we need to increase our knowledge and awareness of risk and protective factors specifically related to criminal recidivism and improve cooperation between hospital psychiatry, social services and probation services.

Criminal Thinking, Psychiatric Symptoms, and Recovery Attitudes Among Community Mental Health Patients: An Examination of Program Placement

Research suggests it is important to consider criminogenic needs among individuals with severe mental illness. This study aimed to determine the severity of criminal thinking in community-based clinical samples, understand the association between criminal thinking and psychiatric and criminal justice outcomes, and compare these associations between consumers enrolled in Assertive Community Treatment (ACT) and Forensic Assertive Community Treatment (FACT) programs. Participants ( N = 234) were male and female consumers enrolled in ACT and FACT programs in five states. Results revealed no significant differences in criminal thinking when comparing participants by program type or history of criminal justice involvement. There were significant positive relations between general criminal thinking and psychiatric symptomatology and the number of lifetime arrests, a negative association between recovery attitudes and general criminal thinking, and ACT participants reported a greater number of lifetime psychiatric hospitalizations than FACT participants. Result implications are discussed with specific reference to treatment programming.

Mental health courts and forensic assertive community treatment teams as correctional diversion programs.

Problem-solving courts (PSCs) developed as a means of mandating treatment and judicial supervision of certain types of court participants. PSCs have rapidly expanded in number and type over several decades. Mental health courts (MHCs) are a type of PSC that arose in response to the growing number of persons with mental illness within the criminal justice system. Their primary role is to divert individuals with mental illness from incarceration into psychiatric treatment and to reduce recidivism while improving psychosocial functioning of participants. Although different in history, philosophy, and program structure, forensic assertive community treatment (FACT) programs serve a similar goal of reducing recidivism and improving functioning in persons with mental illness who are involved with the criminal justice system. FACTs may be used as a standalone diversion option or be linked with a MHC as a form of intensive treatment and monitoring. Suggestions for future research and evaluation of these programs are offered.

Forensic Assertive Community Treatment in a Continuum of Care for Male Internees in Belgium: Results After 33 Months.

Non-forensic or regular assertive community treatment (ACT) has positive effects on non-forensic outcomes but has poor effects on forensic outcome measures. In this study, we examined non-forensic and forensic outcome measures of a forensic adaptation of ACT (ForACT) within a continuum of care for internees. Data were collected retrospectively from files of 70 participants in the ForACT group who had been released from a forensic hospital. The control group comprised internees who had left prison and entered community-based care (n = 56). The ForACT group demonstrated significantly better outcomes on forensic measures, such as arrests and incarcerations, and had better community tenure. However, this group showed high hospitalization rates. The findings indicate that this type of community-based care can be beneficial for such internees; however, internees continue to experience difficulties reintegrating into society.

A Randomized Controlled Trial of the Rochester Forensic Assertive Community Treatment Model.

Forensic assertive community treatment (FACT) is an adaptation of the assertive community treatment model and is designed to serve justice-involved adults with serious mental illness. This study compared the effectiveness of a standardized FACT model and enhanced treatment as usual in reducing jail and hospital use and in promoting engagement in outpatient mental health services. Seventy adults with psychotic disorders who were arrested for misdemeanor crimes and who were eligible for conditional discharge were recruited from the Monroe County, New York, court system. Participants were randomly assigned to receive either FACT (N=35) or enhanced treatment as usual (N=35) for one year. Criminal justice and mental health service utilization outcomes were measured by using state and county databases. Forty-nine participants (70%) completed the full one-year intervention period. Nineteen (27%) were removed early by judicial order, one was removed by county health authorities, and one died of a medical illness. Intent-to-treat analysis for all 70 participants showed that those receiving the FACT intervention had fewer mean±SD convictions (.4±.7 versus .9±1.3, p=.023), fewer mean days in jail (21.5±25.9 versus 43.5±59.2, p=.025), fewer mean days in the hospital (4.4±15.1 versus 23.8±64.2, p=.025), and more mean days in outpatient mental health treatment (305.5±92.1 versus 169.4±139.6, p<.001) compared with participants who received treatment as usual. The Rochester FACT model was associated with fewer convictions for new crimes, less time in jail and hospitals, and more time in outpatient treatment among justice-involved adults with psychotic disorders compared with treatment as usual.

Forensic Assertive Community Treatment: Recidivism, hospitalization, and the role of housing and support

ABSTRACTWhile Assertive Community Treatment (ACT) is considered an evidence-based service model, there is limited evidence regarding the effectiveness of an adaptation of the model, Forensic Assertive Community Treatment (FACT), for persons with serious mental illness who also have significant criminal justice system involvement. Using a multimethod approach, this article combines quantitative and qualitative data to review baseline information and nine-month follow-up recidivism, hospitalization, and housing outcomes for individuals enrolled in a FACT program. Findings suggest substance use, housing, and FACT team members’ support played an important role in clients’ prison reentry experiences.

Forensic Assertive Community Treatment: A Review of the Literature.

An extensive body of literature provides evidence supporting the effectiveness of assertive community treatment (ACT) with regard to non-forensic outcome measures, such as number of hospital admissions and length of stay. However, research findings on the effectiveness of ACT for forensic outcome measures, such as rearrests or detentions, is much less clear. The present review, therefore, focuses on the application of ACT in forensic populations, combining key elements of ACT with elements of forensic rehabilitation models. Specifically, a review of the literature was conducted using a systematic methodology in an attempt to combine evidence-based elements of 40years of research on regular ACT with elements of forensic rehabilitation models. Results reveal limited yet promising evidence in support of the effectiveness of forensic ACT for forensic outcome measures. Implications for future research and clinical practice are discussed.

Results of forensic assertive community treatment in Belgium after 33 months

IntroductionForensic adaptations of assertive community treatment (ACT) remain understudied in Europe, whereas promising results emerge from the United States. There is a need for research into the effectiveness of ForACT outside the United States, as Europe differs greatly in terms of organisation of mental health and judicial system.ObjectiveInvestigating effectiveness of forensic adaptations of ACT in the area of Flanders, Belgium. Outcome measures are divided into forensic, like arrests or incarcerations, and non-forensic, like admissions and length of stay.AimsInvestigating effectiveness of ForACT on forensic and non-forensic outcome measures as well as factors related to outcome. A third outcome is community tenure, which is the actual number of days divided by the potential number of days spent in the community.MethodsA controlled cohort study was designed over with first results at 33 months. The experimental group consists of a new ForACT team in the area of Flanders, Belgium (n = 70). Patients are admitted from prison, psychiatric hospitals or other community-based care. The control group consists of mentally ill offenders in community-based treatment after release from prison (n = 56).ResultsResults on forensic measures and community tenure are promising in favour of the ForACT team. In contrast, clients are often, though shortly, readmitted into psychiatric residential care. Substance use emerges as the main reason for admissions.ConclusionsA local forensic adaptation of ACT reveals promising results on forensic outcome measures, yet suffers a large number of admissions.Disclosure of interestThe authors have not supplied their declaration of competing interest.

New Frontiers for Conditional Release: Applying Lessons Learned from Other Offenders with Mental Illness.

There is relatively little research in the literature on insanity acquittees as compared with the large number of studies focused on the supervision and treatment of probationers and parolees with mental illness. Ideally, the latter literature could be successfully applied to insanity acquittees discharged from an inpatient hospital on "conditional release." This article describes the challenges faced by persons on conditional release as well as the gaps in extant conditional release literature. Then, five evidence-based models for the supervision and/or treatment of probationers and parolees with mental illness are applied to a theoretical conditionally released population (mental health courts, forensic assertive community treatment teams, the risk-need-responsivity model, informed supervision practices, and HOPE probation). Benefits and limitations are noted, and recommendations for such crossover are given. Copyright © 2016 John Wiley & Sons, Ltd.