An outpatient treatment program to reduce recidivism and promote recovery among justice-involved adults with a serious mental illness.
Blueprints: Promising
J. Steven Lamberti, M.D.
University of Rochester Medical Center, Department of Psychiatry
Strong Ties Clinic
2613 West Henrietta Road
Rochester, NY 14623
Email: steve_lamberti@urmc.rochester.edu
Training and Technical Assistance:
Community Forensic Interventions, LLC
www.Commfit.org
J. Steven Lamberti, M.D. / Robert L. Weisman, D.O.
University of Rochester Medical Center, Department of Psychiatry
The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.
The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.
R-FACT consists of four components, including 1) high-fidelity assertive community treatment provided by a team of criminal justice-savvy staff, 2) identification and targeting of criminogenic risk factors, 3) use of legal authority to promote engagement in necessary interventions (i.e., legal leverage), and 4) mental health/criminal justice collaboration to promote effective problem solving. In the R-FACT model, legal leverage can be provided by a judge, a probation officer, or a parole officer, depending on the collaborating criminal justice agency. In Lamberti et al. (2017), a single judge provided judicial oversight, which included weekly meetings between R-FACT clinicians, the judge and representatives from the public defender and district attorney offices to discuss problems and agree upon intervention strategies prior to any court appearances. Weekly court appearances were initially required, and the frequency of subsequent meetings was determined by the judge in collaboration with a clinical team liaison and attorneys.
Primary Evidence Base for Certification
Study 1
Lamberti et al. (2017) found that compared to the control group, offenders in the treatment group had, on average, significantly fewer:
In terms of risk & protective factors, at the posttest, treatment offenders (compared to control) had, on average, significantly:
Primary Evidence Base for Certification
The one study Blueprints has reviewed (Study 1) meets Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). The study was done by the developer.
Study 1
Lamberti et al. (2017) conducted a randomized control trial in which 70 offenders with a diagnosis of severe mental illness were randomly assigned to the intervention or enhanced treatment as usual. Data were collected at baseline and after a one-year intervention period. Outcomes included recidivism rates and use of psychiatric hospital and outpatient mental health services. All participants (treatment and control) entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity.
Study 1
Lamberti, J. S., Weisman, R. L., Cerulli, C., Williams, G. C., Jacobowitz, D. B., Mueser, K. T., . . . Cain, E. D. (2017). A randomized controlled trial of the Rochester Forensic Assertive Community Treatment model. Psychiatric Services, 68(10), 1016-1024.
Individual: Antisocial/aggressive behavior, Substance use
Peer: Interaction with antisocial peers
Family: Family conflict/violence
Individual: Coping Skills, Prosocial involvement
Peer: Interaction with prosocial peers
*
Risk/Protective Factor was significantly impacted by the program
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
The participants in Study 1 (Lamberti et al., 2017) were predominantly male and African American.
Community Forensic Interventions, LLC (www.Commfit.org) provides training and technical assistance services that are tailored to meet community needs, whether starting a new FACT program or optimizing an existing one. For locales interested in starting a new FACT program using the Rochester model, training is provided through a combination of on-site interactive workshops and teleconference meetings. All training activities are enhanced through the use of printed and video-based materials.
Depending upon local needs, the training curriculum generally consists of three live trainings over a 12-month period. The trainings include a two-day "kick-off" training, followed by two additional day-long trainings at 6 and 12 months. In addition, regular teleconferences are held to promote skill acquisition and to address implementation barriers as they arise. Training covers key elements of program development, implementation, operation and evaluation. Training topics include:
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
On average, a 12-month training contract costs $80,000 plus applicable taxes. Training is provided by Drs. J. Steven Lamberti and Robert L. Weisman. The training contract covers all aspects of training and technical assistance, including:
Included in the training contract.
Included in the training contract.
R-FACT is an adaptation of the assertive community treatment (ACT) model. The space needs are the same for R-FACT as for a standard ACT team (i.e. shared office space for approximately 10 staff members).
None.
R-FACT is an adaptation of the assertive community treatment (ACT) model. The staffing requirements and operational costs are the same for R-FACT as for a standard ACT team. (For specific staffing requirements, see Act Program Guidelines 2007, Section 4.7.1.) These costs are offset by program revenues, assuming that ACT is a billable service in municipalities seeking to initiate R-FACT.
Participation of agency administrators and other senior stakeholders is required during each of the three training visits.
No information is available
The training curriculum includes instruction in use of the Rochester Forensic Assertive Community Treatment Scale (R-FACTS) to monitor intervention fidelity. R-FACTS fidelity assessment requires approximately ½ day, with additional time required for preparation beforehand and for report writing afterwards.
A fidelity review is included at the end of the training process (i.e. at month 12).
No information is available
No information is available
The R-FACT model teaches ACT team members new skills related to identifying and addressing risk factors for criminal recidivism, including how to collaborate most effectively with criminal justice service providers. As such, R-FACT teams operate within existing administrative and billing structures for standard ACT teams. Beyond training costs, the R-FACT model is designed to introduce no new costs or expenses.
No information is available
J. Steven Lamberti, M.D. / Robert L. Weisman, D.O.University of Rochester Medical Center, Department of PsychiatryStrong Ties Clinic2613 West Henrietta RoadRochester, NY 14623steve_lamberti@urmc.rochester.edu
An outpatient treatment program to reduce recidivism and promote recovery among justice-involved adults with a serious mental illness.
Adult offenders diagnosed with a psychotic disorder.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
The participants in Study 1 (Lamberti et al., 2017) were predominantly male and African American.
Justice-involved adults diagnosed with severe mental illness are more likely to recidivate, due to having higher rates of criminogenic risk factors including psychosis, substance use, and unemployment. In addition, many individuals with severe mental illness are unwilling or unable to accept treatment interventions, which further increases the likelihood of criminal justice system involvement.
Individual: Antisocial/aggressive behavior, Substance use
Peer: Interaction with antisocial peers
Family: Family conflict/violence
Individual: Coping Skills, Prosocial involvement
Peer: Interaction with prosocial peers
*Risk/Protective Factor was significantly impacted by the program
The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.
The Rochester Forensic Assertive Community Treatment (R-FACT) model is an adaptation of assertive community treatment (ACT), developed to prevent psychiatric hospitalization and promote housing stability. However, ACT alone has not been shown to reduce recidivism. R-FACT adapts the ACT model by targeting criminogenic risk factors, utilizing legal authority to promote engagement, and emphasizing mental health and criminal justice collaboration to promote effective problem solving. These elements distinguish R-FACT from ACT and from other FACT-type interventions. By targeting the drivers of crime and emphasizing shared problem solving, R-FACT represents a criminologically-informed hybrid that combines practices from the fields of mental health and community corrections.
R-FACT consists of four components, including 1) high-fidelity assertive community treatment provided by a team of criminal justice-savvy staff, 2) identification and targeting of criminogenic risk factors, 3) use of legal authority to promote engagement in necessary interventions (i.e., legal leverage), and 4) mental health/criminal justice collaboration to promote effective problem solving. In the R-FACT model, legal leverage can be provided by a judge, a probation officer, or a parole officer, depending on the collaborating criminal justice agency. In Lamberti et al. (2017), a single judge provided judicial oversight, which included weekly meetings between R-FACT clinicians, the judge and representatives from the public defender and district attorney offices to discuss problems and agree upon intervention strategies prior to any court appearances. Weekly court appearances were initially required, and the frequency of subsequent meetings was determined by the judge in collaboration with a clinical team liaison and attorneys.
R-FACT design and operation are based upon two conceptual foundations. The first is a conceptual model (see Lamberti, 2007) that uses legal leverage to engage justice-involved individuals in treatments and services that target criminogenic risk factors. The second is a conceptual framework to promote effective mental health and criminal justice collaboration (Lamberti, 2016). Collaboration is structured based on a six-step framework that includes engagement, assessment, planning and treatment, monitoring, problem solving, and transition to less intensive services.
Primary Evidence Base for Certification
The one study Blueprints has reviewed (Study 1) meets Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). The study was done by the developer.
Study 1
Lamberti et al. (2017) conducted a randomized control trial in which 70 offenders with a diagnosis of severe mental illness were randomly assigned to the intervention or enhanced treatment as usual. Data were collected at baseline and after a one-year intervention period. Outcomes included recidivism rates and use of psychiatric hospital and outpatient mental health services. All participants (treatment and control) entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity.
Primary Evidence Base for Certification
Study 1
Lamberti et al. (2017) found that compared to the control group, offenders in the treatment group had significantly fewer convictions for new crimes and spent significantly fewer days in jail (on average) at posttest. In terms of risk and protective factors, offenders in R-FACT treatment were also engaged in outpatient treatment for significantly longer periods of time, and they spent significantly fewer days in the hospital, on average.
Primary Evidence Base for Certification
Study 1
Lamberti et al. (2017) found that compared to the control group, offenders in the treatment group had, on average, significantly fewer:
In terms of risk & protective factors, at the posttest, treatment offenders (compared to control) had, on average, significantly:
One study meets Blueprints standards for high-quality methods with strong evidence of program impact (i.e., "certified" by Blueprints): Study 1 (Lamberti et al., 2017). The study sample included misdemeanor offenders aged 18 and over who were on probation and had a diagnosed psychotic disorder.
The study took place in an academic medical center for clinical interventions and a criminal court for judicial hearings in Monroe County, New York, and compared the treatment group to a treatment-as-usual control group.
Blueprints: Promising
J. Steven Lamberti, M.D.
University of Rochester Medical Center, Department of Psychiatry
Strong Ties Clinic
2613 West Henrietta Road
Rochester, NY 14623
Email: steve_lamberti@urmc.rochester.edu
Training and Technical Assistance:
Community Forensic Interventions, LLC
www.Commfit.org
Lamberti, J. S. (2007). Understanding and preventing criminal recidivism among adults with psychotic disorders. Psychiatric Services, 58, 773-781.
Lamberti, J. S. (2016). Preventing criminal recidivism through mental health and criminal justice collaboration. Psychiatric Services, 67, 1206-1212.
Certified Lamberti, J. S., Weisman, R. L., Cerulli, C., Williams, G. C., Jacobowitz, D. B., Mueser, K. T., . . . Cain, E. D. (2017). A randomized controlled trial of the Rochester Forensic Assertive Community Treatment model. Psychiatric Services, 68(10), 1016-1024.
Summary
Lamberti et al. (2017) found that compared to control, at posttest offenders in the treatment group had significantly fewer convictions for new crimes and spent significantly fewer days in jail (on average). In terms of risk and protective factors, offenders in R-FACT treatment were also engaged in outpatient treatment for significantly longer periods of time, and they spent significantly fewer days in the hospital, on average.
Lamberti et al. (2017) found that compared to the control group, offenders in the treatment group had, on average, significantly fewer:
In terms of risk & protective factors, at the posttest, treatment offenders (compared to control) had, on average, significantly:
Evaluation Methodology
Design:
Recruitment: The study took place in Monroe County, New York, at an academic medical center for clinical interventions and a criminal court for judicial hearings. Individuals involved in probation, parole, mental health court, assisted outpatient treatment, or other forms of legal leverage at the time of recruitment were excluded to enable comparison of leveraged (treatment) and nonleveraged (control) groups. Individuals facing felony charges were also excluded, but those with prior felony convictions were eligible for enrollment. A total of 232 offenders on probation were assessed for eligibility. Study inclusion criteria were ages 18 and older, presence of a DSM-IV-TR psychotic disorder, ability to speak English, adequate capacity to consent to research, recent conviction on a misdemeanor charge, and eligibility for a conditional discharge. All participants entered the study under a conditional discharge status, whereby their pre-enrollment sentences were suspended pending successful compliance with legal stipulations that included accepting mental health treatment and avoiding further criminal activity. Of those who expressed interest in the study, 104 did not meet eligibility and 58 declined to participate. The most common reason for not meeting study inclusion criteria was lack of a DSM-IVTR diagnosis of a psychotic disorder including schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, major depression with psychotic features or psychotic disorder NOS. Recruitment occurred in 3 phases: 1) potential study participants were first identified with assistance from the public defender's office; 2) those who expressed interest after pleading guilty and accepting a conditional discharge subsequently met with a research team to provide informed consent in the presence of their defense attorneys; and 3) consenting individuals were randomized to conditions.
Assignment: Seventy offenders were randomly assigned to the treatment (n=35) or control (n=35) group by using computer-generated assignment cards within a courtroom setting. The control group received enhanced treatment as usual, which included outpatient mental health treatment from teams that included a psychiatrist or nurse practitioner for pharmacotherapy, a licensed clinical social worker for supportive therapy, and a case manager. All control group participants were given intake appointments at the medical center within five business days of randomization as a service enhancement to ensure comparable access to care.
Assessments and Attrition: Administrative records were used to assess outcomes. Of the 70 participants assigned to condition, 49 completed the protocol but 69 were included in the posttest analysis (one treatment participant died so records were not available). Thus, attrition from pre- to posttest was low (1%).
Sample Characteristics:
Participants were predominantly male, African American, never married, and unemployed, and nearly half had not graduated from high school. The most common diagnosis was schizophrenia, and 70% of participants self-reported having a co-occurring substance use disorder. On average, participants spent over two months in jail during the year before enrollment and had over 16 lifetime arrests.
Measures:
The study used two sources of administrative records to measure recidivism:
In addition, mental health service data were obtained from the Monroe County mental health service database, which is a countywide system that spans all publicly funded mental health agencies in the county. These records provided information on psychiatric hospitalization, emergency room, and outpatient service use.
Analysis:
A Poisson regression model was used to detect changes in jail time, the primary outcome measure, by condition. For all other outcomes, because each measure could be viewed as a count, negative binomial regression models were used. Scores from the Level of Service Inventory-Revised, collected as a baseline measure of risk of reoffending, were included as a covariate. The 54-item inventory covers criminal history and nine other content domains predictive of recidivism.
Intent-to-Treat: The authors conducted intent-to-treat analyses using data from 69 study participants (there was missing data for the one deceased participant).
Outcomes
Implementation Fidelity: An assessment of fidelity was used approximately six and 15 months after study initiation, with scores indicating high fidelity to treatment (4.69 and 4.61 out of 5.0, respectively). As for dosage, forty-nine participants (70%) received services for one full year.
Baseline Equivalence: Baseline data included age, gender, race-ethnicity, marital status, highest level of education, employment status, primary diagnosis, days homeless, lifetime arrests, lifetime convictions, hospital days, jail days, lifetime jail days (sentenced), and lifetime months of probation (sentenced). In addition, researchers (who were not blind to condition), collected baseline measures to assess symptoms, insight into need for treatment, medication adherence, severity of addiction, motivation for treatment, and involvement in violence as a victim or perpetrator. There were no significant differences between study groups in any of these demographic, criminal history or baseline assessments.
Differential Attrition: Attrition was minimal (1%).
Posttest: Compared to control at posttest, offenders in the treatment group had significantly fewer convictions and spent significantly fewer days in jail (on average). No significant differences were observed between the groups, however, in mean numbers of arrests or incarcerations. In terms of risk and protective factors, on average, offenders in treatment also received more days in outpatient mental health treatment and fewer days in the hospital, but there were no differences between groups in average number of emergency room visits. Of note, one R-FACT group subject had 50 emergency room visits, more than all other R-FACT group subjects combined. When this outlier was removed from analysis, the R-FACT group had significantly fewer emergency room visits compared to the control group.
Long-Term: Not conducted.