Ohio Coordinating Center for ACT “ACT + __________”: Forensic Assertive Community Treatment

1. Ohio Coordinating Center for ACT “ACT + __________”: Forensic Assertive Community Treatment

2. Ohio Coordinating Center for ACT InterAct for Change 3805 Edwards Road, Suite 500 Cincinnati, Ohio 45209 513-458-6733 jramos@ohioactcenter.org

3. Welcome Thanks Introductions Outline: What is the problem? What are the solutions? (FACT is one…) What is FACT? How do I start a FACT Team? What are existing FACT Teams doing?

4. Do you know the lingo? (GAME)

5. Why focus on Reentry/Diversion? High numbers incarcerated People with mental illness and co-occurring disorders are significantly over-represented in the criminal justice system

6. National statistics: correctional population (Bureau of Justice Statistics, 2003)

7. National statistics: correctional population (Gains 2002) • 11,400,000/ yr. booked into jails • 12,500,000/yr. booked into jails (Karberg 2004) • 621,000 any given day (jail) • 1920-1980:100/100,000, since 1980: 400/100,00 • Combined rate of prison and jail: 700/100,000

8. National statistics: MI in CJ (Council of State Governments 2002) • 700,000: the number of adults entering jail with active symptoms of an SMI • 3-5 times: statistical likelihood that a person with an SMI will be incarcerated relative to individual without a SMI. • 15-16%:percent of individuals in prison and jail with a SMI • 2.8-5%: Rate of SMI in general population

9. National statistics: MI in CJ (Cuddeback et al 2005) • Individual with SMI (in a given year): • 1.5 times more likely to be jailed than hospitalized (psychiatric) • 8 times more likely to be incarcerated than hospitalized in state psychiatric hospital

10. National statistics: reentry • 4,916,480: the number of people on probation or parole in 2004. (Bureau of Justice) • Over 7,000,000 people are released annually from local correctional facilities (Re-entry policy council)

11. National: "Mental Health Problems of Prison and Jail Inmates" BJS(2006) • Local jail inmates • 54 percent of symptoms of mania, • 30 percent major depression and • 24 percent psychotic disorder, such as delusions or hallucinations. • State prisoners • 43 percent of had symptoms of mania, • 23 percent major depression and • 15 percent psychotic disorder. • Federal prisoners • 35 percent of had symptoms of mania, • 16 percent major depression and • 10 percent psychotic disorder.

12. National statistics:

13. National Statistics: Prison Recidivism (BJS) (re-arrest) • Mirror the national

14. National Statistics: prison recidivism: 1994 (BJS) Rearrest within 3 years • 67.5% of prisoners released in 1994 were re-arrested within 3 years • The re-arrest rate for property offenders, drug offenders, and public-order offenders • 73.8% for property offenders • 66.7% for drug offenders • 62.2% for public-order offenders • The re-arrest rate for violent offenders • 61.7%

15. National Statistics: prison recidivism (BJS) Reconviction within 3 years • Overall 46.9% • - violent offenders 39.9%, • - property offenders 53.4% • - public-order offenders 42.0% • - drug offenders 47.0% Returned to prison within 3 years • The 1994 recidivism study: 51.8%

16. Ohio statistics: Prison • Mirror the national • 52%: the recidivism rate for the SMI population (Parole). • 20% of SMD population develop new charges • 32% return to prison on technical violations SOURCE= ODRC

17. What is creating the problem? Q: Is the problem lack of access to MH TX and/or poor efficacy? • Prisons have become hospitals • Inpt. commitment hard to get • Not engaged/engaged well • Criminalization of Behavior • Fisher at al (2002): • 2 groups of SMI: • 47% had no previous hospitalization • 53% had HX of hospitalizations: (1-40) • 41% had contact with CJ in past 12 months A: Appears to be: both access and efficacy

18. The Challenge • What can criminal justice do differently? • What can the MH/SA/Housing/Health treatment systems do differently? • What can legislators/ funders/ policy folks do? • How can they work together differently? Reponses: Federal/ State/ Local

19. Addressing the Problem:Federal Responses The President’s New Freedom Commission on Mental Health “The Commission recommends widely adopting adult criminal justice and juvenile justice diversion and re-entry strategies to avoid the unnecessary criminalization and extended incarceration on non-violent adult and juvenile offenders with mental illnesses.”

20. Addressing the Problem:Federal Responses • Legislative Activity – The Mentally Ill Offender Treatment and Crime Reduction Act (S.B. 1194) • SAMHSA • Targeted capacity expansion grants • GAINS/TAPA technical assistance center • 1 800 311- 4246 • http://gainscenter.samhsa.gov

21. Addressing the Problem:State Responses • Council of State Governments Criminal Justice/Mental Health Consensus Project • www.consensusproject.org • State Flexibility with Federal Programs – Bazelon Center Reports (benefits/housing/ accessing services) • Prisons • Ohio- RTUs • New York-Inmate Observation Program • Oregon-DOC Co-occurring Disorders Program • Indiana – Therapeutic Communities

22. Addressing the Problem: Local Response • Jails • CBT work • Forensic PATH Partnerships • Post-Booking Diversion Programs • Community Reentry • APIC Model • Jails – Brad H. Settlement in NY • Forensic Assertive Community Treatment Teams

23. Addressing the problem: Local Responses • Law Enforcement • Police Dispatcher Training • Police-Based Specialized Responses • Police Response – CIT • Police-Mental Health Partnership Response • Courts • Mental Health Courts • Drug Courts • MH systems • FACT • Forensic PATH • Specialized clinical interventions: CBT

24. Addressing the Problem:Ohio Responses • Services: • ODRC Prison: RTU/ Staff Training • Community: CIT/ MH Courts/ FACT • Collaborative: • Kitchen Cabinet • Justice Stratton: ACMIC • ODRC

25. Addressing the Problem: OhioODRC • ODRC structure: • Who is MI? (C1) • Prison TX: RTU/MH TX • Reentry: com link/TX team (flowchart) • Packet (flowchart) • Process • Content

26. Addressing the Problem:ODRC :Community efforts Citizen circles CORE ACMIC: benefits/housing/accessing services/ collaboration/ employment Benefits pilot Employment FACT

27. One solution is (“FACT”):Forensic Assertive Community Treatment ACT FOR “FORENSIC POPULATIONS” • Evidenced- based for MH (Access and efficacy) • Hospital/ engagement/ housing/ communication • Emerging Best Practice • 2 themes: • Comprehensive and Collaborative • Goals and Roles

28. One solution is (“FACT”):Forensic Assertive Community Treatment • ACT+ Forensic/CJ specific: • Personnel/ Collaboration • Skills/Knowledge/Competencies • Resources (& Services) • Clear Goals/Roles • Population(s)

29. What is ACT? ACT +____________ Resource: ACT Training Binder/ OCCA/ ACT Training Brochure/ 5122-29-29

30. ACT (Assertive Community Treatment) is: • Multidisciplinary team, working together, who • strive to meet all psychosocial TX needs, of • clients not engaged in traditional CM; in order to • maximize opportunities for recovery.

31. What is ACT? Who is the multidisciplinary TX Team? • Psychiatrist • Team Leader • Nurse • Substance Abuse Team Member • Employment Specialist • Independently Licensed Therapist • Mental Health Professionals • Peer Specialist

32. What is ACT? • How does the team work together? ACT teamwork elements: • Individual (Shared Caseload approach) • Specialist/Generalist Model • Critical for teamwork= “everyone is a CM” • Structural (Meetings): • Team Meetings • Daily/ TX Planning /Clinical Supervision Group • Clinical (Core Processes): • Continuous collaboration: • Assess—Plan—Serve—Eval

33. What is ACT? • How does ACT strive to provide all needed services? • Intensive/frequent contacts • Assertive outreach/engagement • Focus on symptom management and everyday problems in living • Ready access in times of crisis • Essential other engagement • Comprehensive: Team is the single point of clinical responsibility

34. What is ACT? • Who are the clients not engaged? • Top 10% • Co-occurring disorders • DX: top 4 • Engaged by other systems/institutions • Revolving door/Hospital/Crisis • Not engaged but demonstrate high service need: • Functional impairment

35. What is ACT? • How is ACT recovery focused? • Holistic approach • Incorporates client as active part of treatment team • Addresses fragmentation of MH system • Provides choice • It is effective: • An Evidenced- Based Practice: • Evidence from 25+ years of research establishing the model’s effectiveness • Uniformity of model and practice ensures consistent positive outcomes

36. What is the evidence for effectiveness of ACT?(Why should we do it?)

37. ACT: The Most Widely Researched Model of Case Management • Bedell, J. R., Cohen, N. L., & Sullivan, A. (2000). Case management: The current best practices and the next generation of innovation. Community Mental Health Journal, 36, 179-194. • Latimer, E. (1999). Economic impacts of assertive community treatment: A review of the literature. Canadian Journal of Psychiatry, 44, 443-454. • Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive community treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141-159. • Bond, G. R., McGrew, J. H., & Fekete, D. M. (1995). Assertive outreach for frequent users of psychiatric hospitals: A meta-analysis. Journal of Mental Health Administration, 22, 4-16. • Bond, G. R., Pensec, M., Dietzen, L., McCafferty, D., Giemza, R., & Sipple, H. W. (1991). Intensive case management for frequent users of psychiatric hospitals in a large city: A comparison of team and individual caseloads. Psychosocial Rehabilitation Journal, 15(1), 90-98. • Boyer, S. L., & Bond, G. R. (1999). Does assertive community treatment reduce burnout? A comparison with traditional case management. Mental Health Services Research, 1, 31-45.

38. Summary of ACT Outcomes (Bond et al. meta-analysis: 25 controlled studies) • Lower use of inpatient services • Better quality of life • More independent living/stability • Better substance abuse outcomes (when a substance abuse component is included) • Higher rates of competitive employment (when supported employment component is included) • Greater consumer and family member satisfaction • Higher rates of treatment retention

39. The Evidence: ACT • An EBP: • Model/ Positive, Predictable Results/ Reproducible/ Fidelity Scale • The ACT Literature shows that: • A high fidelity team, as measured by DACTS, produce predictable, positive results. • These are the 4 parts of an EBP!

40. The Evidence: FACT • If ACT is good then FACT should help: • Housing/ hospital/ engagement/ satisfaction/ coordination/work/SA TX • Elements which appear to help recidivism (Clark1999; Steadman 2005; SAMHSA 2004; Veysey 1997) • Emerging Best Practice • The evidence is being collected (sort of) to: • Clearly articulate model • ID the predictable positive results • Develop the fidelity tool Resources: FACT Bibliography/ Misc. Forensic Articles/OCCA

41. What is Forensic ACT? • Literature/Emerging Expert Consensus: • Divergent Models • Essential Elements • 2 themes: • Goals and Roles • Comprehensive and Collaborative • ACT + CJ SPECIFIC__

42. What is Forensic ACT? • ACT + __________ • Keep the EBP Model of ACT • Some ACT Model questions for FACT: • LOS • Outside resource use • General Adaptations: • Intercept point/Population: • Reentry or Diversion • Adaptations: • With/without CJ team member • Resource options: • With/Without residential

43. The Evidence: FACT • Lambertti, J. (2004). New approaches to preventing incarceration of severely mentally ill adults. Psychiatric Times, 21(3). • Lambertti, J. S., Weisman, R., & Faden, D. I. (2004). Forensic Assertive Community Treatment: preventing incarceration of adults with severe mental illness. Psychiatric Services, 55, 1285-1293. • Lurigio, A. J., Fallon, J. R., & Dincin, J. (2000). Helping the mentally ill in jails adjust to community life: a description of a post release ACT program and its clients. International Journal of Offender Therapy and Comparative Criminology, 44(5), 532-548. • McCoy, M., Roberts, D., Hanrahan, P., Clay, R. & Luchins, D. (2004). Jail linkage assertive community treatment services for individuals with mental illness. Psychiatric Rehabilitation Journal, 27(3), 243-250.

44. The Evidence: FACT: Cost Effectiveness and Capacity Cuddeback, Morrissey and Cusack (in press 2007) • Cost effectiveness: MH and CJ $ • Recidivism (hosp/crisis/CJ) • Argue that up to 60% of their SMI population have access to ACT (relative to about 20% without CJ) (this is higher than in OH- where we believe up to 10%) • AT least 3 x (up to 5x) as many ACT Teams when CJ involvement considered as additional eligibility criterion

45. What is Forensic ACT?Emerging Literature/Consensus • FACT indicators of success (Lamberti, 2004) • Outcomes goals include specific CJ goals • Specific forensic population • Clear roles for MH and CJ • Strive for Treatment and support vs. coercive extension of supervision 2 themes: • Goals and Roles • Comprehensive and Collaborative • Essential Elements

46. What is Forensic ACT? Essential elements ACT + __________ • ACT: • MH services • + Forensic/CJ specific: • 1. Team Personnel/ Collaboration • 2. Skills/Knowledge/Competencies • 3. Resources (& Services) • 4. Goals (& Roles) • 5. Population

47. What is Forensic ACT? Essential elements- Discussion ACT Fidelity ACT + __________ • ACT Model/Fidelity Questions: • LOS • Outside Resources

48. What is Forensic ACT? Comprehensive and Collaborative • 1. ACT + Team Personnel/ Collaboration: • CJ on team • CJ linked • Designated • Communication plan Resources: FACT Articles/Select Resource List/ FACT Presentations/Example Contact List

49. What is Forensic ACT? Comprehensive and Collaborative • 2. ACT + Skills/ Knowledge/Competencies What are the CJ specific clinical skills/knowledge? Examples: • CJ knowledge of system/process • Stages of change/ Motivational interviewing • CBT/ Thinking errors • Cultural competency • Integrated treatment • Staff safety Resources: Massaro/ Rotter/ OCCA Lists: SO info and Misc. Resources/ OCCA

50. What is Forensic ACT? Comprehensive and Collaborative 3. ACT + Resources ( &Services)which appear to help reduce recidivism through engagement (Lamberti 1997&2004; Clark1999; Steadman 2005; SAMHSA 2004; Veysey 1997) • ACT Services • Housing • Work • Benefits • Money • Transitional Resources • Rep Payee Outside resources? Resources: ACT Model/ Personnel on team/OCCA