After spending some 15 years developing a local program to move mentally ill inmates out of the criminal justice system and keep them out, two University of Rochester Medical Center psychiatrists are winning national attention.
Rochester Forensic Assertive Community Treatment, the program that neuropsychiatrist Steven Lamberti M.D. and Robert Weisman D.O., a forensic psychiatrist, have spent years developing and nearly four years testing, relies heavily on collaboration between mental health professionals and criminal justice officials.
Still six months away from the completion of a locally run clinical trial funded by the National Institutes of Health, the program, known as R-FACT, has drawn interest from mental health and criminal justice officials in Missouri, Ohio and Pennsylvania.
"There (are) FACT programs all over the country. I think there are 80 in New York," Lamberti said. "What we've done is travel all over and observe to see what works and what doesn't. Ours is the only one that has NIH support."
Thanks to promising early results of the clinical trial that the men have published and lectures they have given, interest in the program is strong and growing, Lamberti said. He describes R-FACT as a step-by-step blueprint for reducing recidivism among mentally troubled offenders.
Lamberti and Weisman are working with officials in St. Louis to set up a FACT program there, and with the support of the UR Office of Technology Transfer, they have started a company, Community Forensic Interventions LLC, to disseminate R-FACT methods.
John Fahner-Vihtelic, deputy director of the UR Office of Technology Transfer, helped set up Community Forensic Interventions. He said it bodes well for the fledgling firm that it is generating interest with almost no publicity and has its first commission.
To get Weisman and Lamberti-accomplished medical professionals but novices as entrepreneurs-started as businessmen, Fahner-Vihtelic connected the psychiatrists to a legal adviser and arranged five sessions with a business consultant.
UR is copyrighting the R-FACT methods Lamberti and Weisman devised, Fahner-Vihtelic said. When the process is completed, the school will sign a licensing agreement with Community Forensic Interventions, which will pay a percentage of fees it collects to the university.
Fahner-Vihtelic expects the company to prosper.
"It fills such a need," he said.
Fahner-Vihtelic is a Vietnam veteran who mentors troubled veterans and in that capacity serves as an interlocutor between veterans in trouble with the law and courts. He is well-acquainted with the gaps between the criminal justice and mental health systems that R-FACT can help fill.
Placement in prisons
Large-scale placement of mentally ill individuals in correctional facilities began in the 1970s, when New York and other states began a program of deinstitutionalization, shutting down mental hospitals where mentally ill individuals had been held involuntarily for years, often in deplorable conditions, said Patricia Marks, a former Monroe County Court judge who until her retirement in 2011 was supervising judge of the county's criminal courts and a force behind the establishment of a local mental health court.
Deinstitutionalization faltered in the second half of the effort: establishment of a network of community support in the form of counseling, halfway houses and group homes to provide support for the mentally ill individuals that deinstitutionalization turned loose.
"The history of deinstitutionalization began with high hopes that modern medications and modern treatments could assure people with serious mental illness a successful life in the community. By 2000, our understanding of how to do that had solidified, but it was too late for many. Times had changed. Resources had not flowed as expected. The array of programs that support people with mental illness in the community were not controlled by policymakers who fully understood mental health," concluded a 2007 report by the Kaiser Commission on Medicaid and the Uninsured, based in Washington, D.C.
Many severely mentally ill individuals become homeless and many commit crimes. With little means of support, some steal. Others in the grip of hallucinations or in thrall to voices only they can hear commit acts of vandalism or wander into unsuspecting people's homes and are arrested for trespassing or burglary, Weisman said.
"The Los Angeles County Jail is now the biggest mental hospital in the world, and that has its parallel in Monroe County," Marks said. "I don't know the current statistics, but when I was supervising judge, I used to hear about it from jail officials all the time."
In Monroe County, the work by Weisman and Lamberti has offered one of the few lifelines to mentally ill inmates caught in the system, as well as some hope of relief to frustrated criminal justice officials, she added.
Some 20 percent of U.S. correctional facility inmates are schizophrenic or bipolar, Lamberti said. Others have lesser personality disorders. Many compound their problems by self-medicating with drugs or alcohol or both. Left untreated with symptoms uncontrolled, often such individuals are repeatedly released, re-arrested and jailed again.
A significant downside of jails serving as mental institutions, Marks added: repeatedly jailing habitually offending mentally ill inmates adds thousands of dollars a day in housing and food costs to the county jail's budget. That budget also is burdened by the thousands of dollars more it takes to pay for the pricey anti-psychotic drugs dispensed in hopes of keeping troubled inmates in line.
The FACT program's methodology largely consists of simple-sounding steps, Fahner-Vihtelic observed. In the end, he said, it's mostly a matter of getting clients to keep appointments with counselors and therapists, take their medications, stay sober and not let their inevitable lapses plunge them into despair.
The key to making such interventions work lies largely in striking the right balance between criminal justice and therapeutic measures, Weisman said. While the program's overall goal is to keep clients out of jail, the threat of jail can be applied judiciously to induce a wavering client to stay in line.
His point is illustrated in a URMC-produced video documenting an actual court appearance of an R-FACT client.
Identified by his first name, Ryan, the 30-year-old client is described as mentally ill with a long history of arrests. An appearance before Judge John Elliott in the Criminal Division of Rochester City Court is preceded by a meeting between a team of clinicians who have been dealing with Ryan and the judge.
The court appearance is coming on at the end of yearlong probationary period during which Ryan is supposed to have stayed off drugs and stayed out of trouble to avoid a return to jail. The team's report is hardly a ringing endorsement.
"It's a toss in the air whether he uses pot or he drinks or he gets intoxicated or he's back on the crack, and he's just kind of all over the place. I think that we're just after one year beginning with this kid," a counselor tells Elliott.
At the hearing, a stern Elliott tells an abashed-looking Ryan that though his non-compliance, as evidenced by more than one positive drug test, should land him back in jail, he will receive another year's conditional discharge.
Striking the right balance between therapy and punishment or the threat of punishment is not always easy. In observing other FACT teams around the country, Lamberti said, he and Weisman found that some ended up serving as informants, whose reports to criminal justice officials on client lapses or probation violations landed their charges back in jail.
Ryan is not yet completely on track, Weisman concedes in the video. But with "tough love" from the court and intensive daily interventions from a clinical team, he has been brought to "at least a point where he is no longer thinking about harming himself and others (and) where he respects the court."
Early results of the R-FACT clinical trial seem to indicate Ryan has a good chance of staying out of jail.
Designed like a clinical drug trial with one group receiving R-FACT services and a control group receiving none, the comparative study has looked at 70 mentally troubled individuals of mixed age and gender, following their progress for one to two years.
Results are in on the first 28 to have cycled through the test.
The mean jail time spent during the clinical trial's duration by the 16 enrolled in R-FACT was 9.7 days, versus 41.4 days of incarceration spent by 12 control group members. Over the same period, the mean days of hospitalization for those in R-FACT was 0.75. That compares with a mean of 6.5 days for the control group.
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