Forensic Assertive Community Treatment: An Emerging Model of Service Delivery

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DESCRIPTION (provided by applicant): LONG-TERM OBJECTIVE: To develop Forensic Assertive Community Treatment (FACT) as an adaptation of the Assertive Community Treatment (ACT) model for adults with psychotic disorders in the criminal justice system. The goal of this application is to prepare the FACT model for rigorous evaluation in an R01 study. SPECIFIC AIMS: 1) To standardize one form of legal leverage - judicial monitoring - as a critical component of FACT by developing a legal leverage intervention manual and fidelity scale. 2) To establish the feasibility and promise of FACT intervention by conducting a pilot randomized controlled study of ACT plus judicial monitoring versus enhanced treatment as usual (TAU) in a cohort of high-risk adults with psychotic disorders. RESEARCH DESIGN and METHODS: Since the primary distinction between FACT and ACT involves the use of legal leverage in the former, we propose three phases of research to prepare the FACT model for rigorous testing. Phase 1 will consist of defining and standardizing the legal leverage component. We will develop a legal leverage intervention manual by gathering broad input from FACT program focus groups in three different cities, from national experts, and from local stakeholders. The legal leverage manual will be written to provide judges and ACT team leaders with practical guidelines about how to collaborate in using legal authority to promote treatment adherence and prevent criminal recidivism. We will subsequently develop a fidelity scale and rater manual based on the legal leverage intervention process. Phase 2 will consist of integrating and refining the legal leverage component. We will conduct a small-scale feasibility study to examine the feasibility of integrating legal leverage in the form of judicial monitoring into a standard ACT team (thus forming a FACT team). Then we will refine the legal leverage manual by obtaining feedback about its usability from the judges and the clinicians involved in the feasibility study. Finally, we will gather preliminary experience with the fidelity scale to determine the need for modification. Phase 3 will consist of establishing the feasibility and promise of FACT through pilot testing. The FACT model (ACT + legal leverage in the form of judicial monitoring) will be compared to enhanced TAU (close outpatient follow-up without judicial monitoring). Seventy adults with psychotic disorders in the Monroe County Jail who are convicted of a misdemeanor will be randomly assigned to each treatment group and followed for 12 months. Primary outcomes will include criminal justice and mental health service utilization rates, treatment adherence, psychiatric symptoms, substance abuse, and homelessness. Service utilization outcomes will be tracked using established mental health and criminal justice databases. Intent-to-treat analyses will be performed, controlling for subjects' baseline risk of criminal recidivism with established criminal risk assessment tools.