Forensic Assertive Community Treatment: An Emerging Model of Service Delivery

说明(申请人提供)：长期目标：发展法医自主性社区治疗(FACT)，作为刑事司法系统中患有精神障碍的成年人的自主性社区治疗(ACT)模式的改编。该应用程序的目标是为R01研究中的严格评估准备事实模型。具体目标：1)通过编制法律杠杆干预手册和保真度量表，将一种形式的法律杠杆--司法监督--标准化为事实的一个重要组成部分。2)通过在一组患有精神障碍的高危成年人中进行ACT加司法监测与常规强化治疗(TAU)的试验性随机对照研究，确定事实干预的可行性和前景。研究设计和方法：由于事实和ACT之间的主要区别涉及前者中法律杠杆的使用，我们提出了三个阶段的研究，以准备事实模型进行严格检验。第一阶段将包括定义和标准化法律杠杆部分。我们将从三个不同城市的FACT项目焦点小组、国家专家和当地利益相关者那里收集广泛的意见，从而制定一份法律杠杆干预手册。将编写法律杠杆手册，为法官和ACT小组领导人提供关于如何合作利用法律权力促进遵守治疗和防止再次犯罪的实用指导方针。随后，我们将根据法律杠杆干预过程，制定一份保真度标尺和评分员手册。第二阶段将包括整合和完善法律杠杆部分。我们将进行一项小规模的可行性研究，以研究将司法监督形式的法律杠杆纳入一个标准的ACT小组(从而组成一个事实小组)的可行性。然后，我们将通过从参与可行性研究的法官和临床医生那里获得关于其可用性的反馈，来完善法律杠杆手册。最后，我们将收集保真度标尺的初步经验，以确定是否需要修改。第三阶段将包括通过试点测试确定事实的可行性和承诺。事实模式(ACT+司法监督形式的法律杠杆)将与增强型TAU(在没有司法监督的情况下密切门诊随访)进行比较。门罗县监狱中被判有轻罪的70名患有精神障碍的成年人将被随机分配到每个治疗组，并进行12个月的跟踪调查。主要结果将包括刑事司法和精神卫生服务的使用率、治疗依从性、精神症状、药物滥用和无家可归。将使用已建立的精神健康和刑事司法数据库跟踪服务利用结果。将进行意向治疗分析，利用已建立的犯罪风险评估工具控制受试者再次犯罪的基线风险。

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.