June 5, 2014 | PRA Work | Joanna Ahlatis The GAINS Center interviewed Ann-Marie Louison and Bradley Jacobs, co-directors of the Adult Behavioral Health Programs at CASES in NYC, about Forensic Assertive Community Treatment (FACT). Mr. Jacobs oversees the Nathaniel ACT Alternatives To Incarceration (ATI) program, Manhattan ACT, and a supported housing and diversion program for individuals convicted of misdemeanor crimes. Ms. Louison joined CASES in 1999 to start the alternatives to incarceration programs for adults with serious mental illness. She currently oversees the launch of two large programs offering ATI and alternatives to detention (ATD) services and the Nathaniel Clinic. GAINS: Who should be eligible for Forensic Assertive Community Treatment (FACT)? AML & BJ: FACT is a model that should ideally be reserved for individuals who meet clinical eligibility for standard ACT treatment, because they have a serious mental illness that results in significant functional impairment. The additional factor for consideration with FACT is that the individual also has a criminal justice history or status. FACT is ideally suited to those individuals that need intensive outpatient treatment delivered by a mobile treatment team because they have clear histories of not succeeding in traditional mental health treatment. The FACT participant also needs services that integrate criminal justice practice to facilitate both mental health recovery and reductions in the elevated risks and behaviors that are associated with criminal justice involvement. Put very simply, when we think about FACT we are thinking about individuals with high mental health needs, probably co-occurring substance use disorder, and also high needs related to the risk of continued criminal justice involvement. GAINS: How does a FACT team differ from an ACT team? AML & BJ: The FACT team combines everything that is wonderful and effective about ACT: multidisciplinary team, low clinical staff to participant ratios, community locus, collaboration with support systems, assertive outreach, 24/7 availability, and continuous primary treatment responsibility. FACT teams are also different than ACT teams in some fundamental ways. FACT has an explicit approach to address a participant’s involvement, current or historical, in the criminal justice system. FACT staff generally have a better appreciation of the workings of the criminal justice system and how to collaborate with criminal justice personnel. FACT also directly partners with the criminal justice system and this can involve adding a probation officer to the team or having specially designated clinical staff that manage collaboration with the criminal justice system, whether it’s a mental health court, judges in regular courtrooms, or probation and parole officers. This partnership explicitly establishes FACT as an intervention that supports both behavioral health and also public safety outcomes as key to the functioning and role of the team. GAINS: How does Risk/Needs/Responsivity factor into FACT? AML & BJ: The Risk/Needs/Responsivity (RNR) model for offender assessment and rehabilitation is a very helpful approach for FACT. RNR provides the evidence base to support FACT to reduce the criminal recidivism of its participants. RNR says first assess risk with more intensive efforts used for high-risk individuals; second, identify those factors – the criminogenic needs – that put a participant at risk; and finally, adapt treatment and respond according to the individual’s mental status, learning style, motivation and strengths. The challenge for FACT is how to assess for these needs using valid and reliable risk and need assessments. Once FACT has identified the criminogenic needs of its participants, teams have to make decisions about how to deliver services and interventions that are effective for needs related to criminal history, antisocial/criminal thinking, antisocial associates, and antisocial personality pattern. RNR highlights the need for FACT to extend services beyond evidence-based, recovery-oriented mental health treatment. FACT teams need to know who their participants are in terms of their risk for recidivism, and ultimately have to integrate effective practices to reduce risk and support their participants to stay in the community free from further offending. GAINS: What kinds of clinical interventions are required for criminogenic needs? AML & BJ: FACT teams – in addition to providing psychiatry; health integration; integrated treatment to address co-occurring substance use; housing procurement; psychoeducation to restore and strengthen family and social relationships; vocational services to support participation in school and employment; and direct assistance to support individuals to participate in self-help, social clubs, and culturally preferred and supportive community resources – also have to address criminal history and the dynamic factors of antisocial personality pattern, antisocial cognition, and antisocial associates. Teams are also implementing the use of structured cognitive behavioral therapy (CBT) approaches focused on recidivism reduction, such as: Reasoning and Rehabilitation 2 for Youth and Adults with Mental Health Problems, Moral Reconation Therapy, and Thinking for a Change. These interventions purposefully target the acquisition of skills, new methods of thinking, and improved problem solving to reduce recidivism. In the absence of structured CBT, the effective implementation of integrated dual disorder treatment in FACT will support reductions in substance use – a high criminogenic need for many FACT participants. GAINS: Are there any words of advice you would offer to a community looking to start a FACT team? AML & BJ: FACT, like ACT, should be targeted for the high need individual with serious mental illness who clinically needs the services of a mobile multidisciplinary treatment team. Additionally, a FACT-eligible population has criminal justice characteristics that also require specific approaches in addition to evidence-based mental health treatment. Therefore, FACT is not a service model for all individuals with serious mental illness involved in the criminal justice system. Communities should ensure there are enough individuals in their locality that meet these criteria when considering the question “should we start a FACT team?”. FACT is still an evolving model. Before you proceed, speak to others who run these programs across the country they can help inform you about whether the FACT model is right for your community. Thank you for your insightful remarks, Ann-Marie and Bradley!