Forensic Assertive Community Treatment (FACT) for internees : effectivity on forensic and non-forensic outcome and substance use as a factor related to outcome

This thesis presents a research project investigating the feasibility and effectiveness of community-based care for individuals found Not Guilty by Reason of Insanity (NGRI)—referred to as “internees” in Belgium. The impetus for this research stemmed from the observation that in 2014 community-based psychiatric services were virtually inaccessible to this population in Belgium. Despite some subsequent efforts to expand such care, services remained limited and fragmented. Consequently, internees often faced prolonged residential treatment pathways with significant wait times. These waits were frequently spent in prison facilities, where individuals awaited potential admission to secure psychiatric institutions. As a result, hundreds of internees spent extended periods incarcerated without access to appropriate psychiatric care. Still in 2025, over 1000 internees await an admission into a forensic psychiatric hospital in prison. This lack of community-based care also had adverse consequences for the duration of residential treatment. Many internees were returned to prison during psychiatric hospitalization due to noncompliance with treatment. Compared to international models—mostly developed in the United States—Belgium’s community-based forensic psychiatric services were markedly underutilized and underdeveloped. In contrast, non-forensic or regular community-based care had been well studied and shown to be effective on a range of clinical outcomes. Notably, these non-forensic models proved ineffective when applied to populations with complex forensic needs. This contrast inspired the hypothesis that integrating the robust evidence base of community-based psychiatric care with insights from forensic rehabilitation theories could yield effective community-based treatment for forensic populations. Developing a functional and effective community-based alternative could reduce lengths of stay in forensic psychiatric hospitals and prevent unnecessary returns to prison from these hospitals due to noncompliance to treatment. It may also allow for direct release from prisons into community settings, an approach rarely implemented in Belgium, where most internees are currently transferred to forensic hospitals. Given the ambitious goals of such an initiative, we selected Assertive Community Treatment (ACT)—an evidence-based, high-intensity care model developed in the 1980s in the United States in response to large-scale deinstitutionalization—as the foundation for our intervention. ACT has demonstrated effectiveness for non-forensic populations on non-forensic outcomes. We hypothesized that a forensic adaptation of ACT, termed Forensic Assertive Community Treatment (FACT), could retain these benefits while also positively impacting forensic outcomes, such as reductions in rearrest and reincarceration. Additionally, we sought to identify the factors influencing outcomes within a FACT model. Our study followed a four-stage methodology. First, we conducted a literature review to determine what a forensic adaptation of ACT would entail. We identified core components associated with successful non-forensic outcomes and aligned these with principles from established forensic rehabilitation frameworks (Chapter 2). Second, we analyzed data from a FACT team operating in a care continuum in Leuven, Belgium, focusing on forensic outcomes and associated predictors (Chapter 3). Given the strong association between substance use in the context of a substance use disorder and forensic outcomes—both in our data and the broader literature—we conducted a targeted review on how FACT teams address substance use disorders (Chapter 4). Finally, we piloted a community-based alternative to inpatient admission following substance use and assessed its effectiveness (Chapter 5). Our findings revealed six foundational components of ACT with a positive relation to non-forensic outcome that can be used as a basis for FACT: an embedded psychiatrist, home-based care, low caseloads, integrated dual-diagnosis treatment, vocational services, and 24/7 availability. To this, we added two key elements derived from forensic rehabilitation theories: a hybrid staffing model and the use of structured risk assessments during follow-up decision-making. Together, these eight components form the conceptual framework of FACT (Chapter 1). Our data from the Leuven team demonstrated promising results: internees enrolled from a forensic psychiatric hospital in FACT were six times less likely to be re-arrested and nearly 14 times less likely to be re-incarcerated compared to controls (Chapter 3). Community tenure was also significantly higher among FACT participants, indicating good community integration. However, short-term admissions remained frequent, largely driven by substance use—a factor consistently linked to poorer outcomes across all outcome measures. In response, we developed and evaluated a pilot intervention that offered a community-based alternative to hospitalization following substance use in the context of a substance use disorder. This approach reduced the rate of hospital admissions while preserving community integration, suggesting that targeted adaptations within the FACT model can further enhance its effectiveness. In conclusion, the FACT framework that we followed has demonstrated effectiveness in improving forensic outcomes when implemented according to eight core components drawn from both non-forensic ACT and forensic rehabilitation frameworks. Its success is further enhanced when integrated within a continuum of care in collaboration with residential partners and is developed into a full evidence-based model. Substance use in the context of a substance use disorders emerged as the primary factor influencing outcomes and should therefore be a central consideration in determining patients’ appropriate points of entry into the continuum of care. So, we propose FACT as a viable solution to address the current gap in community-based care for internees in Belgium. This model holds promise for reducing the rate of rehospitalizations, shortening lengths of stay in forensic psychiatric facilities, and decreasing the number of internees currently residing in Belgian prisons.