IN REPLY: As admirers of their work, we thank Drs. Lamberti and Weisman for their comments on our article. We agree that the evolution of forensic assertive community treatment (FACT) they describe is exactly the type of community-based, multi-pronged, comprehensive service approach needed to address the high rates of justice involvement among people with serious mental illness. We also agree that the FACT service delivery model as described by the Substance Abuse and Mental Health Services Administration (SAMHSA) is one example of how our proposed vision can be put into action

Bonfine, Natalie

Munetz, Mark R

Wilson, Amy Blank

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involvement. The authors then proclaim that “a new ap-proach” is needed that addresses these factors, includingcriminogenic risk factors, and that utilizes cross-system col-laboration. They further suggest that the sequential interceptmodel could help achieve such outcomes.In discussing current services, the authors refer to forensicassertive community treatment (FACT) as a “first-generation”intervention (i.e., one that seeks to prevent criminal justiceinvolvement among people with mental illness by treatingtheir mental illness). This characterization is inconsistentwith the work our research group and others have publishedon FACT over the past 20 years.The first national survey of FACT programs was pub-lished in 2004, and it characterized these early programs as“developing integrated mental health and criminal justiceservice systems” (2). Our prototypemodel in Rochester, NewYork, featured multipoint service integration involving healthcare, criminal justice, and social service systems (3). Wesubsequently incorporated strategies for addressing crim-inogenic risk factors, an idea published in Psychiatric Servicesin 2007 as part of a conceptual framework to guide modeldevelopment (4). These principles of addressing criminogenicneeds and cross-system collaboration eventually received val-idation in 2017 through a randomized controlled trial funded bythe National Institute of Mental Health. In that study, FACTwas associated with significant reductions in criminal convic-tions and time spent in jails and hospitals, along with signifi-cantly improved engagement in community-based care (5).These principles have since been adopted nationally by theSubstance Abuse and Mental Health Services Administration(SAMHSA) as cornerstones of FACT (6).Some people continue to view FACT as simply divertingjustice-involved individuals into standard assertive communitytreatment teams. One could likewise view diversion into stan-dard mental health services as the essence of the sequentialintercept model, which has emphasized “intercepting” patientsfrom the criminal justice system. However, such characteriza-tions reflect a basic lack of understanding of these strategies.The prevailing view of FACT is evident in SAMHSA’s positionpaper, which was developed through a national consensus pro-cess, and highlights addressing criminogenic needs and cross-system collaboration as core elements of this approach (6).It is our hope that those who choose to use “first-gener-ation” terminology in the future will be more mindful of thecurrent state of play regarding services for justice-involvedpeople with severe mental illness in community settings.REFERENCES1. Bonfine N, Wilson AB, Munetz MR: Meeting the needs of justice-involved people with serious mental illness within community be-havioral health systems. Psychiatr Serv 2020; 71:355–3632. Lamberti JS, Weisman R, Faden DI: Forensic assertive communitytreatment: preventing incarceration of adults with severe mentalillness. Psychiatr Serv 2004; 55:1285–12933. Weisman RL, Lamberti JS, Price N: Integrating criminal justice,community healthcare, and support services for adults with severemental disorders. Psychiatr Q 2004; 75:71–854. Lamberti JS: Understanding and preventing criminal recidivismamong adults with psychotic disorders. Psychiatr Serv 2007; 58:773–7815. Lamberti JS, Weisman RL, Cerulli C, et al: A randomized controlledtrial of the Rochester forensic assertive community treatment model.Psychiatr Serv 2017; 68:1016–10246. Forensic Assertive Community Treatment (FACT): A Service De-livery Model for Individuals With Serious Mental Illness InvolvedWith the Criminal Justice System. Pub no PEP19-FACT-BR. Rockville,MD, Substance Abuse andMental Health Services Administration. https://store.samhsa.gov/product/Forensic-Assertive-Community-Treatment-FACT-A-Service-Delivery-Model-for-Individuals-With-Serious-Mental-Illness-Involved-With-the-Criminal-Justice-System/PEP19-FACT-BRJ. Steven Lamberti, M.D.Robert L. Weisman, D.O.Department of Psychiatry, University of Rochester Medical Center, Rochester,New York.Psychiatric Services 2020; 71:875–876; doi: 10.1176/appi.ps.71801Meeting the Needs of Justice-InvolvedPeople With Serious Mental Illness: In ReplyIN REPLY: As admirers of their work, we thank Drs. LambertiandWeisman for their comments on our article (1).We agreethat the evolution of forensic assertive community treat-ment (FACT) they describe is exactly the type of community-based, multipronged, comprehensive service approach neededto address the high rates of justice involvement among peoplewith serious mental illness. We also agree that the FACT ser-vice delivery model as described by the Substance Abuse andMental Health Services Administration (SAMHSA) is one ex-ample of how our proposed vision can be put into action.The evidence for the effectiveness of the FACT modelthat Drs. Lamberti and Weisman have developed is prom-ising. That said, we have a couple points of clarification.Neither our critique of the criminalization hypothesis norour discussion of the research that has consistently shownthat mental illness is not a strong predictor of criminal jus-tice involvement is new (2, 3). With the recent adaptationsthat have been made to standardize FACT, the authors ap-pear to agree with us on the basic premise of our article,which is that we need to expand existing community-basedmental health services to include new approaches to address-ing involvement of forensically involved people with seriousmental illness. For us, that is the call to action.To that end, we note that while the emerging research onFACT is promising, there is much yet to be learned abouthow FACT works best, for whom, and under what circum-stances (4). It could well be that much of the mixed findingsof prior research is related to the high degree of variabilityfound in the structure and operating procedures of FACTteams across the country (4, 5). The recent SAMHSA guide-lines mentioned by Drs. Lamberti and Weisman offer pro-grams sound direction on how to standardize FACTprograms. However, more research is needed before the ev-idence for this standardized FACT model’s impact on re-cidivism is clear (6). We also have far to go to ensure thedissemination and uptake of this standardized version of876 ps.psychiatryonline.org Psychiatric Services 71:8, August 2020LETTERSFACT. As it stands now, FACT programs are an expensiveresource with limited availability, and local demand for suchspecialized services can outpace the community’s ability toprovide them (5).FACT is a program that straddles the border of special-ized forensic services and what we hope will be mainstreamcriminogenically informed community mental health ser-vices. On the basis of the available evidence, we consider thestandardized FACT program to be one key component of thecontinuum of community-based services that is needed tocreate the “intercept 0” we describe in the article. But, likemost of the services on this continuum, there are manyquestions that remain about how best to use FACT to in-tervene as early as possible in the trajectory of criminaljustice system involvement for people with serious mentalillness. We are heartened by the commitment that Drs.Lamberti andWeisman demonstrate toward our shared goaland look forward to working with them and others to findthe answers.REFERENCES1. Bonfine N, Wilson AB, Munetz MR: Meeting the needs of justice-involved people with serious mental illness within community be-havioral health systems. Psychiatr Serv 2020; 71:355–3632. Bonta J, Law M, Hanson K: The prediction of criminal and violentrecidivism among mentally disordered offenders: a meta-analysis.Psychol Bull 1998; 123:123–1423. Bonta J, Blais J, Wilson HA: A theoretically informed meta-analysisof the risk for general and violent recidivism for mentally disor-dered offenders. Aggress Violent Behav 2014; 19:278–2874. Cuddeback GS, Simpson JM, Wu JC: A comprehensive literaturereview of Forensic Assertive Community Treatment (FACT): direc-tions for practice, policy and research. Int J Ment Health 2020.5. Cuddeback GS, Morrissey JP, Cusack KJ: How many forensic as-sertive community treatment teams do we need? Psychiatr Serv2008; 59:205–2086. Chambless DL, Hollon SD: Defining empirically supported thera-pies. J Consult Clin Psychol 1998; 66:7–18Natalie Bonfine, Ph.D.Amy Blank Wilson, Ph.D.Mark R. Munetz, M.D.Psychiatric Services 2020; 71:876–877; doi: 10.1176/appi.ps.71802Psychiatric Services 71:8, August 2020 ps.psychiatryonline.org 877LETTERS

Meeting the Needs of Justice-Involved People With Serious Mental Illness: In Reply

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Meeting the Needs of Justice-Involved People With Serious Mental Illness: In Reply

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