By Dr. Steve Lamberti Professor of Psychiatry at the University of Rochester Medical Center and Dr. Robert Weisman, Associate Professor of Psychiatry at the University of Rochester Medical Center
For 17 years, Rochester's Forensic Assertive Community Treatment (R-FACT) program has been helping people with mental illness get their lives back on track after an arrest or time in jail. Now it is one step closer to being a new evidence-based practice.
By age 32, D. had been arrested a dozen times before he finally got help for his schizoaffective disorder and got well enough to stay out of jail. D. had a history of drug abuse and rarely made it to doctors' appointments. "I had pretty much given up. . . I'd been jailed a bunch of times for stealing and panhandling. . . Nobody could tell me what to do."
D's life took a turn for the worse when he violated an order of protection and contacted a woman with whom he had fathered a child. According to D, "If I couldn't be with my son then there was no reason to live; he was all I had left." Soon after, he was evicted from his brother's home for stealing from his brother. Homeless and experiencing psychosis, Mr. D. was arrested again, this time for harassment. He was offered a choice: either enroll in Rochester's forensic assertive community treatment (R-FACT) program and report to a judge weekly or go to jail and "get abused and go crazy." He accepted R-FACT treatment and it changed his life.
Mr. D.'s story is sadly very common. About 20% of people in jails and prisons in this country have a serious mental illness. Now a new treatment strategy offers hope for preventing unnecessary time in jail or prison. Although programs like Crisis Intervention Teams help identify people with mental illness when they first encounter police, it has been hard to figure out how best to treat individuals once they are diverted from jail or prison and how to keep them out of the justice system for the long haul.
The search for effective treatments to help people who have repeatedly cycled through jails and prisons has led clinicians and researchers to consider the assertive community treatment (ACT) model. ACT has long been recognized as the "gold standard" for individuals who are difficult to engage in care because it provides 24/7 care and services to people in their homes and communities. But ACT was not designed to help people stay out of jail. However, many clinicians and researchers have adapted the ACT model for people with mental illness who were caught in the criminal justice system. These new programs are known as forensic assertive community treatment (FACT) programs.
At least 27 FACT programs exist around the country. They are all based on the ACT model and serve only justice-involved individuals, but they differ in important ways such as how they work with criminal justice agencies and what services they provide. A team of researchers at the University of Rochester surveyed these programs, brought its findings to the National Institute of Mental Health and was awarded a grant to standardize and test forensic assertive community treatment.
The researchers traveled to forensic assertive community treatment programs across the country and conducted focus groups with individuals receiving treatment through FACT, clinicians and criminal justice staff. They also consulted with national experts in the fields of criminology, mental health and addiction treatment. Based on these findings, the research team refined the R-FACT model and subjected it to rigorous testing. They recruited 70 adults with severe mental illness from Rochester's jail and court system and randomly assigned them to receive either R-FACT or usual treatment for 12 months. Preliminary results from this study were recently presented at the National Council for Behavioral Health Conference on May 7th in Washington, D.C. Compared to usual treatment, the R-FACT study group spent less time in jail (averaging 22 days versus 44 days per person) and less in the hospital (averaging 5 days versus 45 days per person). Although usual treatment included case management, the R-FACT group was better engaged in community-based care. Patients in the R-FACT group spent more time receiving outpatient treatment (averaging 336 days versus 190 days per person) and they dropped out of treatment less often.
For D, the R-FACT program was not easy at first. The weekly meetings with judge were hard: "It was like I was in front of the school principal in 8th grade but I was 31 years old!" He didn't trust his care providers. "I was paranoid from not taking my medications and I thought everybody was against me." But D. made a personal connection: one of clinicians had a brother who went to D's high school. He slowly grew to trust his treatment team, including the R-FACT court judge.
Building trust with the judge wasn't easy, says D. "He locked me up for a weekend because I skipped two weeks of drug groups and turned in a dirty urine [sample]. . . but I gave him no choice." He added, "That taste of being in jail again got my attention." D then began regularly attending groups and taking medications, and he found supportive housing with the R-FACT team's assistance. After four months in R-FACT, D shared with the court and his treatment team that he was not going to let his son down. "I'm doing it for him, but R-FACT with the judge did it for me. I needed them to keep me in treatment at first, but now it's me doing the right thing for my boy and me."
The Rochester team has received calls from cities across the United States requesting training in the R-FACT model. To meet this demand, the team approached the University of Rochester's Office of Technology Transfer for help. This partnership led to creation of a training company called Community Forensic Interventions, LLC. If you are interested in training and technical assistance, visit the company's website at www.Commfit.org for more information.
To learn more about R-FACT, listen to NAMI's Ask the Doctor Teleconference featuring Dr. Lamberti and Dr. Weisman.
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