Extended Interview: Psychiatrist Explains Assertive Community Treatment
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SUSAN DENTZER: Project Link has been in existence now since 1995, and just recently you looked at all of the patients who have been treated under the program. What did you find?
J. STEVEN LAMBERTI: We found that Project Link cut involvement in the criminal justice system in half — about half as many arrests, half as many incarcerations. And we found even a more dramatic effect with hospitalizations and emergency room stays.
We also found less substance abuse, which we think is driving a lot of the problems, and we found increased functioning. Now, I have to say that this research is early. We didn’t have a control group, so our findings are preliminary. So we’re doing a follow-up study that we’re going to be presenting this week in Ottawa where we looked at every patient that’s ever been through Project Link, and we confirmed the original results, that we cut the criminal justice involvement in half, and had even more dramatic results with reducing hospital stays and emergency room stays.
But we were also interested in finding who didn’t do well in Project Link. So we were looking at those factors that predicted not only success but failure.
SUSAN DENTZER: And what did you find there?
J. STEVEN LAMBERTI: We found that a lot of the factors that lead people with severe mental illness to getting into trouble with the criminal justice system are the same factors that lead other people to getting in trouble with the criminal justice system. These are established crime risk factors that are well known in the criminology literature — things like substance abuse, anti-social personality, having family problems, not being engaged in work or school. Those factors played quite a part.
SUSAN DENTZER: So that for people who were seriously mentally ill, but also had a lot of family issues or what-have-you, that would tend to have them not do as well in the Project Link environment?
J. STEVEN LAMBERTI: Yes, in a sense they have double trouble. Within Project Link we’ve probably seen all of our patients have problems with school, and problems with work, and most of them have problems with family, but there are different extremes.
We found that the most strong predictor was a strong criminal history, because many people with schizophrenia, they get in trouble with the law simply because they’re in the wrong place at the wrong time, or they get arrested for some type of petty charge. But there are some individuals who had antisocial personality traits before they developed psychotic disorders, and we found that those individuals with the strongest criminal histories, that was most predictive of continued criminal history.
SUSAN DENTZER: So one very simplistic way to say this is Project Link can’t deal with every situation that you come across.
J. STEVEN LAMBERTI: That’s absolutely correct. We’re trying to take a bite out of the problem, but we definitely can’t handle the whole problem. You know, when Rob [Robert Weisman, the director of Project Link] and I talk about people with mental illness who get involved with violent acts, we really don’t think of it as a mental health issue. It really is a public health issue. So we’ve been working to get outside of the mental health system, to partner with the criminal justice system so that perhaps the whole will be greater than the sum of the parts.
Accessible care and legal leverage
SUSAN DENTZER: Is the country thinking in this direction, or are you alone on this?
J. STEVEN LAMBERTI: I think there's a lot of misunderstanding about mental illness. I think that it's hard to imagine anything that's more stigmatizing than when a violent act is committed by a mentally ill person. But the reality is that there are solutions. We just need to find them.
We did do a survey where we looked at the rest of the country. We looked at assertive community treatment programs that were treating only people involved in the criminal justice system. They were partnering with the criminal justice system, and they were getting their referrals primarily from jails and courts. And we found there were 15 other programs that were doing something pretty similar to what we're doing.
We published that just a couple of years ago, and by the time that paper hit the press, I believe that about half of those programs had closed because of financial problems.
SUSAN DENTZER: That's 15 out of a country of 300 million people, 50 states, 15 programs of which half were dead by the time you...
J. STEVEN LAMBERTI: That's all we found. So it can be a case where the glass is half full or half empty. We can say it's not enough, those programs should have kept going, but I tend to be an optimist and I'd like to say that it shows that we're onto something. I'd like to think that we invented the wheel here in Rochester, but I don't think we did. I think other people have discovered that if you combine competent accessible care with legal leverage, then you have something that can help some of the most difficult patients. Maybe not all patients, but a lot of them.
So other places in the country are starting to do things that are similar to us. We're just the first that have written about it and perhaps the first to have studied it.
SUSAN DENTZER: What is legal leverage?
J. STEVEN LAMBERTI: Well, legal leverage is using court authority to promote adherence. It's using the authority of a judge to help a patient engage in treatments. Now, you can think of legal leverage having two pieces. One is the judge's authority, but the other piece is how we use that authority, and that's the piece we need to learn about.
If that authority is used in a way where we're working with difficult patients but we're treating them with respect, we're giving them choice, we're giving them options, we're giving them empathy, that has the best chance of promoting internal motivation, because it's an old adage, but a man convinced against his will is of the same opinion still.
So in order to really have lasting change, we need to facilitate that internal drive. So there are ways to use legal leverage that I think can promote autonomy and can promote recovery. Unfortunately, there are examples of the literature where the authority was used without those interpersonal elements that are important to all of us.
In those cases legal leverage wasn't effective. So now we have a mess in the literature--with some programs, some papers saying legal leverage works, and others saying it doesn't work. But if you cut through, then I think what's missing is you have to have accessible competent care. You can't just leverage people into treatment as usual. That's clinically and ethically questionable, because we know these folks have special needs. And when you use leverage, it has to be done in a way that's going to be maximally effective, and we're still trying to figure out exactly what the best way is.
An opportunity to learn
SUSAN DENTZER: Now, when you read about the case in Virginia with Cho having been found to be a danger to himself, hospitalized at least very briefly, referred to a judge who ordered him into mandatory treatment, and it turned out that nothing happened, what did you think?
J. STEVEN LAMBERTI: I think there are opportunities here. This is a painful lesson for all of us, but I think we can learn from it. I think that we can learn when it comes to legal leverage, we have to think about how it's being applied.
In Virginia, the state commitment laws use the same criteria of imminent dangerousness as for hospitalization. So unless somebody is holding the smoking gun, it's sometimes hard to commit them into treatment.
SUSAN DENTZER: What do you mean? Expand on that.
J. STEVEN LAMBERTI: Well, when somebody is committed, you have to decide how dangerous do they need to be before they can be committed. I'm talking about a person with serious mental illness. Where are you going to draw the line?
And the states draw the line in different places. So this is another example of where we're still trying to figure out how early do you intervene. If you intervene too early, you're really impacting a person's civil rights. But if you intervene too late, then it's disastrous.
So we're trying to find that happy medium. So that's one issue. And then the other issue is when you do mandate somebody to treatment, what treatment are you giving them? There's been very little discussion. It's as if this country's thinking is that commitment alone is enough--and to have commitment without accessible competent care, it's just not going to work. Things can break down, and may have broken down in this case.
SUSAN DENTZER: And clearly in this case there was at least uncertainty, if not just complete lack of specificity about whose job it was to provide the treatment. I mean, Cho was saddled with the responsibility of getting treatment, but it was not clear who had to provide it to him.
J. STEVEN LAMBERTI: Patients can fall through the cracks. The mental health system and the criminal justice system, they have different traditions, different languages. They often don't talk well to each other. And what we're beginning to learn is that if we can work together, we can accomplish something that neither of us can accomplish alone.
SUSAN DENTZER: As I asked Rob[ert Weismna] this same question, I'd like to ask it to you as well. What would you hope to see out of the reports coming forward at the federal level and at the state level that bears on these questions? What should the nation do, moving forward?
J. STEVEN LAMBERTI: I hope it generates political will to look more closely at potential solutions. Project Link is one, and there are others -- to take a look at what individuals need, individuals who are severely mentally ill and at risk for harming themselves or others.
I think we need to look closely at potential solutions. I think we need to develop those solutions. We need to test them to establish their effectiveness.
A challenge with Project Link is that we've yet to manualize or standardize it. We're still early in our research where we're trying to decide what are the key components, how do you define and test those, and ultimately, how can we put together a road map so that other communities can follow what we've done in Rochester?
Evaluating Project Link
SUSAN DENTZER: And I'd like to come back just one more time and talk about the study that you did and the results you'll be presenting. [...] You didn't have a control group, but you obviously had some kind of a comparison.
So what did you find when you looked at all the patients who have been treated through Project Link, and looked at the results of the programs?
J. STEVEN LAMBERTI: Well, we compared the history of those patients in the years before they joined Project Link, and we compared it to the years after Project Link. So we didn't have a comparison group, but we used each patient as their own comparison. And what we found was that on average, once patients entered Project Link, they had a real reduction in the number of arrests -- six arrests less per person. That was the average both for violent and nonviolent crimes.
We also found reductions in the amount of time that they spent in the hospital, and improvement in terms of how they were functioning in the community, and reductions in terms of how much substance abuse they were using.
So is it conclusive? No. But is it encouraging? Yes.
SUSAN DENTZER: And then if you could also just give me a short description of the number of patients now who have come through the program, and then, to the degree you have it, roughly speaking, what their various diagnoses have been?
J. STEVEN LAMBERTI: Project Link is a small project. In the time that we've been operating, we've had about 130 patients come through the project. The most common diagnosis by far is schizophrenia. If you look at schizophrenia or a related illness called schizoaffective disorder, that explains about two-thirds of the patients diagnostically.
We also found a large category -- maybe 20 percent -- that were very hard to diagnose. We used a diagnosis that psychiatrists call psychosis NOS, which means psychosis not otherwise specified, which is a fancy way of saying we don't really know because when somebody is so involved in drug abuse, and they've had such a traumatic start in life, and they're having some psychotic symptoms, it's hard to know exactly what the cause is. All you know is that there are psychotic symptoms, and as you know, those have been reported by a significant percentage of all people in jails and prisons.
SUSAN DENTZER: Now again, one is reluctant to diagnose somebody like Cho on a long-distance ex post facto basis, but given what you've read or heard about him, what would you have guessed was going on with him?
J. STEVEN LAMBERTI: I don't think you can make a diagnosis without being able to do a careful evaluation. But it seems like there are three possibilities. One is an agitated depression, somebody who is depressed and angry.
A second possibility is something that we call a personality disorder, where somebody has a lack of empathy for others, a sense of entitlement, and a tendency towards aggression.
A third possibility are psychotic disorders like schizophrenia where somebody is out of touch with reality, and may have a delusional sense of persecution.
SUSAN DENTZER: And based on what you saw with his video, which is the main way we've all come to know him -- to the degree we have come to know him at all; any thoughts?
J. STEVEN LAMBERTI: I think it's very hard to make a diagnosis on the basis of a five-second YouTube video clip. I think what we can really learn regardless of diagnosis is how we can stop people like him from falling through the cracks.
There is technology that's developing, and I think we can do better in the future. It's an opportunity for us to learn in a very difficult way.