Forensic and Nonforensic Clients in Assertive Community Treatment: A Longitudinal Study

This article presents findings from a large statewide administrative database of ACT teams’ enrollment and outcome data. Recidivism rates were high among individuals with recent forensic histories, with 33% rearrested or incarcerated within one year of enrollment. Although rates may have been significantly higher had these individuals been receiving less intensive treatments, their high risk of recidivism is noteworthy. Indeed, ACT clients with a forensic history at enrollment, compared with those without a forensic history, had higher rates of arrest or incarceration even after three years of ACT services. Arrest or incarceration was the only outcome that did not significantly improve over time, even after we corrected for baseline characteristics. This finding is consistent with a compelling body of literature that indicates that criminal history is among the strongest predictors of forensic recidivism (28).

ACT clients with a recent forensic history were more likely to be discharged from ACT within the first year of enrollment, which may raise concerns that ACT teams were not able to engage these clients as effectively as those without a forensic history. This finding persisted after we controlled for baseline characteristics and consequently cannot be fully explained by the higher rates of substance abuse and homelessness observed in this population. However, when we excluded ACT discharges resulting from incarceration, the clients with a recent forensic history were no longer significantly different from nonforensic clients on this engagement outcome. These findings suggest that ACT teams can engage forensic clients as well as nonforensic clients and that recidivism is a primary barrier to ongoing access to ACT services for the forensic population.

ACT was initially designed to reduce rates and duration of psychiatric hospitalization for individuals with severe mental illness. Hospitalization rates were equally high in the first year of ACT (40%–42%) for forensic and nonforensic clients alike and decreased similarly for all groups over time, with no significant differences among groups at any time point. This suggests that any impact of ACT on hospitalization is the same for forensic clients and nonforensic clients on this primary ACT outcome.

Rates of homelessness decreased significantly for all groups of ACT clients over time, and by the end of the three-year study period, the rate of homelessness for the forensic groups was not significantly different from that of the nonforensic group. This finding suggests that ACT may have been effective in increasing housing stability among individuals with severe mental illness, including those with forensic involvement. Individuals with a recent forensic history had higher rates of homelessness at baseline and in the first year with ACT (27% versus 9%). This effect persisted after analyses controlled for baseline characteristics, but it was no longer significant after year 2 with ACT. Indeed, homelessness is the single outcome on which there was a significantly greater improvement for forensic clients than for nonforensic clients. These findings underscore the need for housing services for this population and suggest that ACT services can support positive housing outcomes for the forensic population.

ACT clients with forensic histories, particularly those with active and recent correctional system involvement, have multiple risk factors for poor outcomes. Forensic clients admitted to ACT teams had higher rates of active substance use and recent homelessness, more lifetime hospitalizations, and lower rates of high school graduation or equivalent education than individuals admitted to ACT without a forensic history. In this study, forensic clients were particularly vulnerable to adverse outcomes in the first year of ACT, including arrest or incarceration, homelessness, and early discharge from ACT, even with controls for baseline characteristics. Consequently, it may be valuable to incorporate clinical approaches that focus attention on this vulnerable period, including identifying and addressing modifiable risk factors and targeting recidivism.

One clinical approach may be to adapt critical time intervention (CTI) strategies for ACT. CTI is an evidence-based model of homelessness prevention for clients with severe mental illness that focuses on the vulnerable transition period from institutional settings to the community (29,30). Draine and Herman (31) have been evaluating the feasibility of extending CTI into correctional settings. CTI supports engagement by having CTI workers establish relationships with clients during their institutional stays. Indeed, various FACT programs described in the literature, including the Thresholds FACT team and Project Link, both of which won American Psychiatric Association Gold Awards, begin to work with clients while they are still incarcerated to develop an alliance with them before their release, which is a vulnerable transition period (32,33). The question of whether CTI could be incorporated into ACT is worthy of investigation.

Two modifiable risk factors, substance abuse and homelessness, were associated with increased recidivism and homelessness at follow-up. The integrated model of care delivered by ACT teams can support identification and mitigation of these modifiable risks. ACT teams have substance abuse specialists on staff, and integrated services for substance use disorders are components of high-fidelity ACT teams.

ACT clinical and program models for delivering housing services and supports are less well specified; for example, there are no ACT fidelity items dedicated to housing, although several items focus on integrated treatment for co-occurring mental disorders and substance use disorders (34). One approach to incorporating housing services is the Housing First model (35). This specialized ACT program engages individuals with severe mental illness by focusing on what clients typically identify as their first priority (housing) through the provision of independent, permanent housing without prerequisites. This contrasts with more traditional models that require individuals first to demonstrate psychiatric stability, abstinence from drugs and alcohol, and “housing readiness” by progressing through a series of supervised short-term living arrangements. The high baseline levels of homelessness in the forensic population, the multiple risk factors for poor outcomes, and the marked improvement in housing outcomes observed in this study suggest that this is an important area for future research.

It is important to note that this study examined outcomes for ACT clients on the basis of time since last arrest or incarceration at enrollment, with the assumption that those with a more recent history are at higher risk. We did not examine degree of recidivism within the forensic cohorts at baseline. Therefore, the recent forensic cohort represented individuals who were first-time offenders and individuals who were highly recidivistic. The remote cohort was a similarly diverse group, because inclusion was based on only six months without an incarceration. Examination of ACT outcomes for forensically involved clients in regard to their degree or their pattern or type of recidivism is an area for future study.

Our study had several limitations. First, we did not have a comparison group to examine outcomes compared with treatment as usual (for example, outpatient treatment at a community mental health center). Consequently, we cannot on the basis of this study comment on whether ACT was more helpful for clients than standard care. Although clients on ACT teams had attenuating risks of homelessness and hospitalization over time, we cannot rule out the possibility that this finding represents regression to the mean. In addition, the highest-risk clients may have been discharged from ACT teams at higher rates, whereas those who remained on the team may have been less vulnerable to adverse outcomes. Second, our data were derived from state administrative data reported by treating clinicians. Criminal justice databases may have been a more reliable source for arrest or incarceration data. However, because of the frequency and in vivo nature of ACT services, it is likely that ACT staff members are more aware than treatment providers in other settings about adverse outcomes such as episodes of homelessness, arrest or incarceration, and hospitalization. Finally, our risk of spurious associations was increased given the multiple comparisons. To minimize type I error we used Tukey’s method and a more conservative level of significance for comparing enrollment characteristics.

This study offers several important findings. First, there was significant risk of arrest or incarceration among clients with forensic histories on ACT teams and a significant risk of homelessness and early discharge from ACT among those with a recent history of criminal justice involvement. This finding underscores the need for ACT teams to incorporate interventions targeted at improving forensic outcomes in this population. Doing so will require clinical interventions to mitigate modifiable risk factors such as homelessness and substance abuse. Alternatively, systems with sufficient numbers of forensically involved patients in need of ACT services might consider the recommendation of Morrissey and colleagues (10) to develop a clinical model for FACT that incorporates interventions designed to target criminal behaviors and jail recidivism. Second, there were no significant differences in rates of psychiatric hospitalization between forensic and nonforensic clients on ACT teams, suggesting that ACT is no less effective for this population with respect to reducing the frequency of psychiatric hospitalizations. Finally, although rates of psychiatric hospitalization, homelessness, and ACT discharge declined over time for all clients, the initial year of ACT enrollment was a particularly vulnerable period for ACT clients, especially for clients with a recent forensic history. This finding highlights the importance of developing strategies to improve engagement and reduce adverse outcomes in the first year of ACT.

This work was supported by the New York State Office of Mental Health, the New York State Psychiatric Institute, the Columbia University Psychiatric Residency Program, and Bristol-Myers Squibb Foundation. Dr. Finnerty’s time on this project was supported by the New York State Office of Mental Health; she is the principal investigator on the ACT Transitions grant from Bristol-Myers Squibb Foundation. Dr. Manuel’s time was supported by the Bristol-Myers Squibb Foundation. The authors thank Veronica Hackethal, M.D., for assistance in manuscript preparation.

Dr. Appelbaum reports an equity interest in COVR, Inc., for violence prediction software. The other authors report no competing interests.