Keeping mentally ill out of jail and in treatment—model shown to work in breakthrough study

People with severe mental illness are more than four times more likely to be arrested than other adults and account for nearly 20% of today's U.S. prison population. Behind bars, they often wait months to receive appropriate treatment, if any, studies show.

To tackle this growing national concern, varied approaches have been tried and tested in cities across the country, but results have been mixed at best.

Now, an intervention born in Rochester, N.Y., has been shown for the first time to reduce the population's criminal convictions, jail time and hospitalizations by roughly 50 percent. Additionally, the model—which hinges on active collaboration and shared problem-solving between mental health and criminal justice systems—has proven to keep mentally ill individuals in treatment twice as long as the study's comparison program.

In a three-year, randomized-control study conducted by clinical researchers at the University of Rochester Medical Center's Department of Psychiatry, the Rochester Forensic Assertive Community Treatment model (R-FACT) withstood rigorous examination and now holds promise for cities across the United States. The peer-reviewed study, supported by a grant from the National Institute of Mental Health, was published online today in Psychiatric Services, a journal of the American Psychiatric Association.

"Our research suggests that it's possible to prevent criminal recidivism among people with even the most severe mental illnesses and substantial criminal histories."  says study principal investigator, J. Steven Lamberti, M.D., a professor of Psychiatry in URMC's Department of Psychiatry.  "We found that by combining the expertise of mental health and criminal justice professionals in a certain way, we can promote both individual health and public safety."

Co-investigator, Robert L. Weisman, D.O., professor of Psychiatry and forensic psychiatrist on the URMC study team, notes that R-FACT "promotes patient engagement in treatment and community tenure through collaboration with criminal justice partners. Such efforts will likely have large beneficial downstream effects for this population."

With the continued support of his Psychiatry Department chair and senior author Eric Caine, MD, and an equally dedicated team of colleagues, Lamberti has relentlessly devoted nearly 25 years to finding a way to keep mentally ill individuals from languishing in prisons—a trend that coincides with the downsizing of U.S. psychiatric hospitals in the 1980s.The Rochester Psychiatric Center (RPC), for example, once housed as many as 3,000 patients, but serves only about 100 today.

For many years, Lamberti believed the solution to the high rate of incarceration among the mentally ill (often involving the same individuals with repeated incarcerations in Rochester's Monroe County Jail) was simply to provide better mental health treatment  With county funding in 1995, he assembled what was then considered the "gold standard" of community mental health treatment—an assertive community treatment (ACT) team composed of culturally diverse psychiatric clinicians, social workers, and s case managers who made "house calls" across the Rochester area.

Many other American cities, he would learn, developed similar outreach programs—which were later shown in studies to be effective at reducing hospitalizations, but not criminal involvement. In fact, to Lamberti's dismay, ACT teams' close monitoring of offenders and timelier reporting of criminal infractions to the justice system actually resulted in higher recidivism rates.

It was a talk given by a criminologist at a national conference that caused Lamberti to channel his energies in a new direction. His attention turned toward understanding the multiple and unique "criminogenic risk factors" of mentally ill individuals, such as antisocial personality, criminal thinking, social support for crime, and substance abuse—coupled with psychiatric issues like psychosis, paranoia, cognitive impairment and trauma—and how this combination makes people more vulnerable and less responsive to standard correctional intervention.  

"If we want to fix the problem, we have to understand it," says Lamberti.  "People with severe mental illness have much higher rates of criminogenic risk factors, along with other issues that affect how they relate to others.  The key to preventing recidivism is to engage these individuals in specific interventions that target the things driving their involvement with the criminal justice system." 

But engaging individuals in treatment—especially those resistant or fearful of it—is the hardest part, says Lamberti.

After several years of research, trial-and error, multiple studies and focus groups, what evolved under Lamberti's direction was the Rochester FACT prototype which uses legal leverage to engage individuals in mental health treatment that systematically targets their criminogenic risk factors.

Getting judges, lawyers, probation officers, and other criminal justice professionals to "buy-in" to the program is key, Lamberti says.

"Legal leverage isn't about making threats to force compliance, or simply reporting infractions," says Lamberti. "It's about the appropriate, respectful use of legal authority to guide people toward engagement. It also requires getting mental health and criminal justice professionals to problem-solve together, and to consider therapeutic alternatives to punishment.  Our clients are  men and women who feel demoralized and discouraged, they are at their very lowest point, and they need more rewards than sanctions."

Rochester City Court judge (7th Judicial District) Hon. Jack Elliott, one of two judges who participated in the study, says the key elements that made the program work were the intensive level of communication between him and the R-FACT team members, the program's comprehensive approach, and the fact that individuals could be seen immediately by a mental health provider upon court recommendation.

"Prior to that, so many people had to wait six weeks or more for an appointment," says Elliott, who now presides over the Monroe County Mental Health Court and the Rochester Drug Treatment Court. "That's what they were used to. But with FACT, they're in treatment within a week.  The treatment provider was always there in court and they had a feeling that someone was actually looking out for them. I would meet with the treatment team before and after the court appearance and get straight information about how each person was doing. If they were doing well, I could reinforce that, give them praise, and if they were screwing up, I could really address them in a very factual way. I could hone in on it. But the big thing was getting them immediate access to the right treatment."

Elliott, who was a public defender for several years before becoming a city court judge, says it will take a high level of trust and understanding between mental health and criminal justice systems for the program to be transplanted elsewhere successfully. Lamberti and his colleagues worked diligently with the Rochester court system for several years to develop that level of rapport.

"We have a totally different lingo," Elliott says. "It took some time for them to get used to how the court system works, and vice versa. Mental health is very touchy-feely, and this is a court and you have to be accountable. I take a different tone in here. Which is why I think it works. Steve calls it therapeutic jurisprudence. It does come down to the judge in many cases. I don't think what I do is all that special. Treat people decently, give them a chance, find humor when I can and try to be understanding. You have to get a judge who's willing to do that. But with this type of work, I feel like you can really make a difference in changing people's lives."