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

TO THE EDITOR: We read with interest and some concern the article by Bonfine et al. (1). The authors suggested that service development for justice-involved individuals with serious mental illness has been driven largely by the “criminalization hypothesis,” which attributes overrepresentation of people with mental illness in the criminal justice system to inadequate access to mental health treatment. As a result, according to the authors, current interventions have failed to prevent criminal recidivism because they fail to address factors other than mental illness that contribute to justice involvement. The authors then proclaim that “a new approach” is needed that addresses these factors, including criminogenic risk factors, and that utilizes cross-system collaboration. They further suggest that the sequential intercept model could help achieve such outcomes.

In discussing current services, the authors refer to forensic assertive community treatment (FACT) as a “first-generation” intervention (i.e., one that seeks to prevent criminal justice involvement among people with mental illness by treating their mental illness). This characterization is inconsistent with the work our research group and others have published on FACT over the past 20 years.

The first national survey of FACT programs was published in 2004, and it characterized these early programs as “developing integrated mental health and criminal justice service systems” (2). Our prototype model in Rochester, New York, featured multipoint service integration involving health care, criminal justice, and social service systems (3). We subsequently incorporated strategies for addressing criminogenic risk factors, an idea published in Psychiatric Services in 2007 as part of a conceptual framework to guide model development (4). These principles of addressing criminogenic needs and cross-system collaboration eventually received validation in 2017 through a randomized controlled trial funded by the National Institute of Mental Health. In that study, FACT was associated with significant reductions in criminal convictions and time spent in jails and hospitals, along with significantly improved engagement in community-based care (5). These principles have since been adopted nationally by the Substance Abuse and Mental Health Services Administration (SAMHSA) as cornerstones of FACT (6).

Some people continue to view FACT as simply diverting justice-involved individuals into standard assertive community treatment teams. One could likewise view diversion into standard mental health services as the essence of the sequential intercept model, which has emphasized “intercepting” patients from the criminal justice system. However, such characterizations reflect a basic lack of understanding of these strategies. The prevailing view of FACT is evident in SAMHSA’s position paper, which was developed through a national consensus process, 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-generation” terminology in the future will be more mindful of the current state of play regarding services for justice-involved people with severe mental illness in community settings.