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

Forensic Aftercare Facilities and Their Impact on the Releasability of Persons Who Committed Sexual Offenses: A Three Group Comparison

Partly due to a lack of release options for individuals who committed sexual offenses, forensic follow-up treatment has been strengthened latest since 2007. The current study investigates whether the foundation of a professionalized follow-up-treatment has actually improved release options for individuals who committed sexual offenses. Thus, the aim of the present study was to assess the difference in criminogenic needs and recidivism relevant characteristics (e.g., index offense, criminal history, psychiatric diagnoses and risk assessment) between three groups who had been released from forensic psychiatry at different times or under different outpatient follow-up modalities: (1) individuals released prior the foundation of professionalized follow-up-treatment, (2) individuals released after the foundation and received treatment, and (3) individuals released after the foundation but not receiving this special treatment. It was found that with the availability of professionalized forensic followup treatment, persons with higher scores in common risk assessment tools and a longer duration of implacement had been released. Indeed, this indicates an increased risk tolerance among decision makers. However, it was not those who were released after the foundation of the professionalized forensic follow-up treatment but without this specific treatment who showed the lowest initial risk, but those who were released prior to the foundation. Results are discussed in terms of possible explanations and methodological issues.

Madison to Manipal: A narrative review of modified assertive community treatment programs

BACKGROUND

Assertive community treatment (ACT) is a multidisciplinary, team-based approach providing comprehensive individualized care for the patients with various mental illness, has been adapted variably across the world in terms of patient-staff ratio, selection of patients, the pattern of service delivery and frequency of contact. We aim to review the extant literature on the modifications of ACT programs for severe mental disorders and their effectiveness.

METHODS

Studies on modified ACT approaches for mental illnesses were searched in multiple databases. We adopted a rapid appraisal approach. The searches were restricted to articles published in English. We appraised the fidelity assessment of the ACT studies wherever available. In addition, we assessed the study quality using a grading tool based on ten practice components of ACT.

RESULTS

We found 23 reports (10 RCTs and 13 non-controlled studies) on modified ACT. The extant literature on modified ACT programs is heterogeneous. The modifications in ACT included changes in patient-to-staff ratio, team composition, service hours, and interventions carried out. Most controlled studies were conducted in high-income settings and had inconsistent outcome, possibly due to the comprehensive nature of the 'usual care.' In contrast, modified ACT services from low and middle-income countries reduced hospitalization rates and improved treatment adherence.

CONCLUSIONS

Modifications in ACT programs were done to cater to specific subpopulation and the changes in program structure to suit the resources and setting. The outcome of modified ACT appears heterogenous, though the findings from low and middle-income countries are promising.

Affordability of Forensic Assertive Community Treatment Programs: A Return-on-Investment Analysis

OBJECTIVE

In this study, the authors assessed return on investment (ROI) associated with a forensic assertive community treatment (FACT) program.

METHODS

A retrospective secondary data analysis of a randomized controlled trial comprising 70 legal-involved patients with severe mental illness was conducted in Rochester, New York. Patients were randomly assigned to receive either FACT or outpatient psychiatric treatment including intensive case management. Unit of service costs associated with psychiatric emergency department visits, psychiatric inpatient days, and days in jail were obtained from records of New York State Medicaid and the Department of Corrections. The total dollar value difference between the two trial arms calculated on a per-patient-per-year (PPPY) basis constituted the return from the FACT intervention. The FACT investment cost was defined by the total additional PPPY cost associated with FACT implementation relative to the control group. ROI was calculated by dividing the return by the investment cost.

RESULTS

The estimated return from FACT was $27,588 PPPY (in 2019 dollars; 95% confidence interval [CI]=$3,262-$51,913), which was driven largely by reductions in psychiatric inpatient days, and the estimated investment cost was $18,440 PPPY (95% CI=$15,215-$21,665), implying an ROI of 1.50 (95% CI=0.35-2.97) for FACT.

CONCLUSIONS

The Rochester FACT program was associated with approximately $1.50 return for every $1 spent on its implementation, even without considering potential returns from other sources, including reductions in acute medical care, crime-related damages, and public safety costs. ROI estimates were highly dependent on context-specific factors, particularly Medicaid reimbursement rates for assertive community treatment and hospital stays.

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.

Dutch Forensic Flexible Assertive Community Treatment: Operating on the Interface Between General Mental Health Care and Forensic Psychiatric Care

In the Netherlands, Forensic Flexible Assertive Community Treatment (ForFACT) is used as a specialized form of outpatient intensive treatment. This outreaching type of treatment is aimed at patients with severe and long lasting psychiatric problems that are at risk of engaging in criminal behavior. In addition, these patients often suffer from addiction and experience problems in different areas of their life (e.g., financial debt, unemployment, or lack of daytime activities). The aim of this exploratory study was to gain more insight into the characteristics of the ForFACT patient population. More knowledge about these patients may enhance the effectiveness of ForFACT and therefore (further) reduce the risk of recidivism. Data on 132 ForFACT patients were gathered by studying electronic patient records, criminal records, and by conducting semi-structured interviews with practitioners and patients. Additionally, as part of a cognitive screening, two screening instruments were conducted to gain insight into intelligence and possible mild cognitive impairments. This article gives a broad description of the ForFACT patient population, including demographic data and context variables, diagnostics, recidivism risk and offense history, and aspects related to care. Furthermore, several recommendations are given to further improve ForFACT. Based on the results it can be concluded that the ForFACT patient population shows a high degree of diversity in complex care needs and responsivity issues. Therefore, this article highlights the necessity for ForFACT to collaborate with other mental health institutions, as well as probation officers, and forensic or criminal justice institutions. Moreover, it is important to continually check the inclusion and exclusion criteria when admitting patients to ForFACT, and to examine whether ForFACT is still the most adequate care for patients or if they need to be referred. In addition, the results emphasize the importance of cognitive screening for forensic outpatients. Finally, this study zooms in on the interface between forensic psychiatric care and general mental health care.

Essential Elements of Forensic Assertive Community Treatment

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Assess characteristics of forensic assertive community treatment programs.

ABSTRACT

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.

The Impact of Housing First on Criminal Justice Outcomes among Homeless People with Mental Illness: A Systematic Review

OBJECTIVE

Housing First is increasingly put forward as an important component of a pragmatic plan to end homelessness. The literature evaluating the impact of Housing First on criminal justice involvement has not yet been systematically examined. The objective of this systematic review is to examine the impact of Housing First on criminal justice outcomes among homeless people with mental illness.

METHOD

Five electronic databases (PsycINFO, MEDLINE, Embase, CINAHL, Web of Science) were searched up until July 2018 for randomised and nonrandomised studies of Housing First among homeless people with a serious mental disorder.

RESULTS

Five studies were included for a total of 7128 participants. Two studies from a randomised controlled trial found no effect of Housing First on arrests compared to treatment as usual. Other studies compared Housing First to other programs or compared configurations of HF and found reductions in criminal justice involvement among Housing First participants.

CONCLUSIONS

This systematic review suggests that Housing First, on average, has little impact on criminal justice involvement. Community services such as Housing First are potentially an important setting to put in place strategies to reduce criminal justice involvement. However, forensic mental health approaches such as risk assessment and management strategies and interventions may need to be integrated into existing services to better address potential underlying individual criminogenic risk factors. Further outcome assessment studies would be necessary.