Assertive Community Treatment: Intervention Fact Sheet
By: the Center for Behavioral Health Services and Criminal Justice Research
The Center for Behavioral Health Services and Criminal Justice Research, a research center funded by the National Institute of Mental Health, studies the effectiveness of behavioral health interventions for people in the criminal justice system that have mental illnesses and/or substance abuse problems. The center assesses the strength and validity of research evidence on interventions designed to engage, treat, and assist theses offenders within the criminal justice system with the goal of increasing their ability to return to full and productive lives in the community. One intervention widely used in mental health settings that is being modified for use with criminal offenders with mental illnesses is Assertive Community Treatment (ACT). This fact sheet summarizes findings from the available research to assess what is currently known and not known about the impacts of ACT. It is designed to help policy makers, practitioners, administrators, and advocates make sense of the evidence as they consider whether to adopt, expand or modify ACT. Fact sheets on the other interventions can be found on the centers website at www.cbhs-cjr.edu.
What is Assertive Community Treatment?
Assertive Community Treatment (ACT) was developed in the late 1960’s in Madison, Wisconsin as an alternative to hospitalization for people with serious mental illnesses. The Program originally titled training in Community Living, was designed as self-contained multi-disciplinary team that moves with clients across space (clients’ natural environments) and time (24/7 availability) to provide psychiatric treatment rehabilitation and social services in an intensive wrap-around package. ACT teams maintain a low client staff ratio (10:1) and share caseloads across team members, individualizing treatment to clients’ changing levels of need and discharging them only when they achieve full clinical and/or functional recovery.
ACT is considered to be the most rigorously tested psychosocial interventions for people with serious mental illnesses. Of the more than 25 randomized controlled ACT trials that have been conducted, three-quarters found that ACT was more effective than usual care in reducing hospitalization and increasing client satisfaction with services. Effectiveness in other outcome domains has been less consistent, however 8 out of 12 studies found improvement in housing stability among those treated in ACT and 7 out of 12 showed improvements in subjective quality of life.
Assertive Community Treatment: Intervention Fact Sheet
Domains in which ACT has demonstrated less success include symptom management, functional outcomes, employment, and substance abuse. Efforts to enhance the ACT platform to deal with these issues directly, such as the development of the Integrated Dual Diagnosis Treatment Model in New Hampshire, have shown considerable success. ACT treatment is expensive, but studies have shown that it is cost effective to the extent that it decreases expenditures for inpatient treatment. In the current mental health policy environment, however, individuals with mental illnesses are currently more likely to be jailed than to be hospitalized. Thus whether ACT is also a useful method for reducing or preventing jail and prison recidivism among offenders with mental illnesses is a critical question.
Is ACT Effective in Improving Criminal Justice Outcomes?
In 2001 review bond and colleagues reported that among the 25 randomized controlled trials conducted on the ACT model, 10 had directly assessed criminal justice outcomes (time in jail or prison). Two of the studies found that ACT reduced time incarcerated; on e study found that it increased time incarcerated, and seven studies found not difference between the ACT and control condition. A subsequent report focusing on specifically upon criminal justice outcomes among homeless individuals at risk for criminal justice involvement likewise found no significant ACT advantages. Taken together, these results suggest that ACT requires modification or augmentation in order to tailor it to the unique needs of offenders and for individuals at risk for criminal justice involvement. Two such adaptations have been tested: forensic ACT teams (referred to as “FACT”) and ACT teams implement3ed in conjunction with mental health courts.
Forensic Assertive Community Treatment
Forensic Assertive Community Treatment (FACT) is an emerging ACT variation that aims to curtail the revolving door pattern of people with mental illnesses into and out of jails and prisons. Although variations among such programs exist, comment elements include:
- Targeting of individuals with criminal justice histories or who are at high risk for criminal justice involvement, with a concomitant goal shift form preventing re-hospitalization to preventing arrest and incarceration.
- Creation of formal and informal linkages to the criminal justice system, including collaboration with judges, probation and parole officers, and police departments.
- More deliberate use of legal leverage to encourage adherence to treatment and curb substance abuse.
- Integration of substance abuse treatment service for most or all clients served.
Does Research Indicate Positive Outcomes for FACT Teams?
Relative to the robust evidence base for non-forensic ACT, the evidence base for FACT is far less developed as of 2002, 16 FACT programs were identified nationwide, but only two of the programs have published quasi-experimental evaluations since that time. Project Link in Rochester, NY, augments FACT treatment with specialized residential services based on the therapeutic community (TC) substance abuse treatment model and involves direct collaboration between the team and the criminal justice system to treatment adherence though the use of sanctions. The Thresholds Jail Linkage Program, in Chicago, IL, likewise incorporates substance abuse treatment principles, but limits collaboration with criminal justice authorities to the role of advocating for clients’ rights, rather than working with parole officers to sanction clients when they fail to adhere. Both programs have demonstrated reductions in arrests and jail days from on year prior to program entry to one-year post-entry follow up. Such findings are promising but require further testing using experimental designs.
ACT Delivered in Conjunction with Mental Health Courts
Under the Mentally Ill Offender criminal Reduction Act, 26 California counties established innovative programs to serve criminally-involved people with mental illnesses. The model implemented and tested in Santa Barbara county was a specialty mental health court (MHC) (a fact sheet on Mental Health courts is available at www.cbhs.cjr.rutgers.edu) in which clients who had been charged at least twice with misdemeanors or felony crimes were assigned to a modified ACT program or to treatment as usual (i.e., less intensive case management and adversarial criminal processing). Clients were admitted either pre-plea or post-adjudication, and disposition decisions were made by the treatment team; however judges provided weekly or bi-weekly court supervision and could provide sanction (jail days) for no adherence. Results of the randomized evaluation showed that individuals treated in the ACT+MHC arm of the study were just as likely to be arrested as the control group and spent a similar number of days in jail. However, the offenses of the ACT+MHC clients tend to be of a less serious nature (e.g., technical violations, sanctions) then the control group, who were more likely to have committed new crimes.
Building the Evidence Base
The weight of the evidence clearly suggests that in order for ACT to effectively improve recidivism rates for criminally-involved consumers, the models must, at a minimum, be modified to target specific risk factors for criminal involvement. Two studies of FACT programs show improved outcomes, but lacked the experimental control to lend confidence in the model as evidence based treatment at this juncture. The randomized study of ACT treatment combined with mental health court supervision shows no measurable advantage over treatment as usual, in that during the first 18 months of the program its participant had similar criminal justice outcomes to their non-treated counterparts.
In a recent review, Morrissey and colleagues suggested a multi-pronged agenda for building the FACT evidence base. They suggested that more consideration be given to the nature of the population of offenders with mental illnesses, who because of their histories may be more “street smart” and thus may need less of the assistance with concrete activities of daily living that have traditionally formed the core of ACT services. Instead, these clients likely require psychosocial interventions that target habitual criminal behavior and serious substance abuse problems, to say nothing of importance of addressing long-time poverty and structural disadvantage. Whether such interventions could be offered in a less comprehensive and intensive service package, such as intensive case management, warrants further exploration. Beyond an increased focus on cross-system collaboration and use of leverage, the details of the optimal structure of a FACT program have yet to be defined, and with out such definition, wide variation in implementation is a certainty. An ethnographic evaluation of FACT for recently released prisoners in Chicago, being conducted by CBHSR investigators Amy Watson and Beth Angell, is intended to help fill gaps in our knowledge about how FACT works on the ground and how and how it is experienced by its clients.
For more information, see: http://www.actassociation.org
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