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Supported Employment in Assertive Community Treatment

Assertive community treatment (ACT) programs, which are described in depth in more detail in Chapter 7, often include a vocational component. This strategy combines vocational rehabilitation services with other treatment services provided by the ACT team. In this model, one of the ACT team members is a vocational specialist although, as is common in ACT, all team members contribute to employment outcomes. Using an individualized placement approach, the service is based on the belief that employment is both an outcome and a treatment. A basic assumption is that a complex relationship exists between symptoms and vocational functioning thus the ACT model of treatment views work as a critical competing process to symptoms (Russert & Frey, 1991, p. 342). In

Assertive Community Treatment and Case Management

The Need for Continuity of Care 193 Awareness of the Need for Care Coordination at the National Level 196 Case Management 196 The Case Manager 198 Models of Case Management 199 Expanded Broker Model 199 Rehabilitation Model 200 Strengths Model 200 Full Support Model (Assertive Community Treatment) Model 200 The Story of Micky 201 Evaluating Case Management 203 The Development of Assertive Community Treatment 204 Evaluating Training for Community Living 206 Evolution into ACT 206 When Is a Program Actually ACT 207 Do Effective Case Management Programs Share Similar Characteristics 208 Assertive Community Treatment An Evidence-Based Practice 208 Critical Ingredients of ACT 211 Service Outcomes of ACT 211 Reviews of ACT Research 211 ACT as an Early Intervention Strategy 212 ACT and Persons in the Criminal Justice Psychiatric rehabilitation (PsyR) responds to the variety of needs of persons with serious and persistent mental illness. Given the multifaceted nature of the disabilities...

Assertive Community Treatment An Evidence Based Practice

Assertive community treatment is one of the most widely utilized evidence-based practices (EBP). As this chapter has pointed out, ACT has many positive characteristics for both the consumer and the service delivery system. Essentially, comprehensive services including medication, counseling, case management, rehabilitation, substance abuse services, and other specialized supports are provided to the consumer in the environments of his or her choice. CONTROVERSIAL ISSUE Is Assertive Community Treatment Too Assertive An evidence-based practice, assertive community treatment (ACT), has consistently proven effective at reducing hospital utilization and increasing housing stability (Bond et al., 2001 Marshall & Lockwood, 2004). The fact that staff members actively seek out individuals in the community to ensure that they are receiving the services they need is considered an important ingredient in the success of this strategy. This assertive approach on the part of staff has several...

The Experience of Hospitalization

In recent years these figures have improved in terms of the proportion of individuals who relapse. For example, the 1-year relapse rates have decreased from a range of 20 to 40 to a range of 15 to 23 for individuals being treated with antipsychotic medication (Leucht et al., 2003). Klinkenberg and Calsyn (1996) reviewed research on predictors of recidivism among individuals with severe and persistent mental illnesses. They found that those individuals receiving aftercare (post-hospital care) and assertive community treatment (see Chapter 7) in addition to their medication experienced lower rates of rehospitalization.

Evolution of Research

Standing, since the late 1960's personality and social psychologists have been entangled in the person-situation debate, a controversy over whether the presumed stability in behavior might be based more on illusion than reality. While doubts about the existence of traits were already raised in the middle of the twentieth century, the work of Walter Mischel was instrumental in bringing the controversy into the forefront of academic psychology. In reviewing a voluminous body of literature, Mischel showed in 1968 thatvirtu-ally all so-called trait measures, except intelligence, change substantially over time and even more dramatically across situations. Traits such as honesty, assertiveness, or attitudes toward authority typically showed reliability across situations of .20 to .30. This means that if the correlation of behavior presumably reflecting a trait in two different situations is .30, less than one-tenth (.30 x .30 .09, or 9 percent) of the variability in the behavior can be...

Psychosocial Treatments

In addition to pharmacological treatments, the other broad category of treatment for severe and persistent mental illnesses is psychosocial treatment. Psychosocial treatments are approaches that attempt to effect change through the manipulation of social or psychological factors. Psychosocial interventions have been found to be very important in the care of persons with these disorders and are discussed throughout this text. Specific models that employ psychosocial strategies include some types of day programs, assertive community treatment, supported employment, and family psy-choeducation. (These approaches are all described in detail in subsequent chapters of this book.) Also the various forms of psychotherapies are psychosocial interventions.

Environmental Modifications

The adoption of evidence-based practices (EBPs) by psychiatric rehabilitation, a relatively new development, is already having profound effects on the field. These changes both offer the promise of improved services and raise issues about the future of PsyR. EBPs produce specific outcomes by maintaining high fidelity (similarity) to a specific service model. For example, research tells us that high-fidelity assertive community treatment (ACT) programs reduce hospital utilization rates. If a service planner wishes to reduce the number of state-funded hospital beds, which tend to be very expensive, an effective solution would be to develop ACT programs. Of course, to ensure that hospital utilization rates were reduced, those programs would need to have fairly high fidelity with the EBP ACT model.

The Need for Continuity of Care

Just as with other fields, many of the innovations in psychiatric rehabilitation have emerged from seemingly casual observations and the initiatives of regular staff members doing what comes naturally. The following description of the discovery of what would emerge as the assertive community treatment model, describes such an event.

Reviews of ACT Research

The most comprehensive, rigorous, and up-to-date assessment of assertive community research was carried out by the Cochrane reviews, which looked separately at experimental, random assignment studies of assertive community treatment and case management (Marshall & Lockwood, 2004). According to Marshall and Lockwood, ACT has been demonstrated to be an effective way of caring for and providing rehabilitation to persons with severe and persistent mental illness living in the community. People in ACT are twice as likely as those in other types of services to maintain contact with their treatment providers. ACT also drastically reduces the use of inpatient hospital care, sometimes by as much as 20 of the hospitalization days compared with other approaches. Many consumers of ACT are satisfied with the care.

ACT and Persons in the Criminal Justice System

In the past several years, the principles of ACT have been applied to serve persons with severe and persistent mental illness involved in the criminal justice system. Examples of two nationally recognized models are the Thresholds Jail Program in Chicago, Illinois, and Project Link in Rochester, New York (Lambert et al., 2001 Lamberti & Weisman, 2004). Both of these programs use ACT to engage clients through assertive outreach in clinical, residential, and social services. The Thresholds Jail Program is a collaboration between Chicago's largest PsyR provider and one of the nation's largest jail systems, Cook County, Illinois. These programs coordinate with the many components of the criminal justice system, and provide services 24 hours per day. Use of ACT to engage offenders who are severely mentally ill is a strategy that is becoming increasingly more common. Both Thresholds Jail Project and Project Link have (1) demonstrated decreased arrest and incarceration rates, (2)...

ACT Comes of Age as a Program and a Professional Specialty

In addition to being an EBP, the field of assertive community treatment is a specialty program that has come of age with its own professional association, Assertive Community Treatment Association (ACTA). On its website (http www.ACTassociation.org), one can learn about ACTA annual conferences, training, and program standards. In the United States, special training and technical assistance centers are sponsored by state mental health agencies (e.g., ACT Center of Indiana and the Bridgeway Training & Technical Assistance Center, Elizabeth, New Jersey). Some version of ACT services are funded in dozens of U.S. states, Europe, Australia, and New Zealand.

Organization Of Teams For Community Mental Health Care Possible Models

The introduction of CMHTs has had a number of consequences for the practice and management structure of psychiatry, mostly beneficial. CMHTs cannot work effectively without a relatively democratic management structure, as it is essential that the team members share their skills. The team leaders may or may not be senior psychiatrists. Tyrer 24 listed the features that together facilitate the effective working of CMHTs skill sharing coordination flexible hours of working development of good liaison assertive but flexible outreach rapid response to impending crises access to an out-of-hours service responsibility for hospital beds and development of referral criteria.

Role in Victimization

One example of this can be demonstrated in the area of victimized women and children. Halfway houses and safe houses are established in an attempt to both protect and retrain battered women and children. Efforts are made to teach them how to change their perceptions and give them new feelings of potency and control. The goal is to teach them that they can have an effect on their environment and have the power to administer successful positive change. For many women, assertiveness training, martial arts classes, and seminars on how to make a strong positive statement with their self-presentation (such as their choice of clothes) become matters of survival.

The Crisis Resolution Function

Generic CMHT plus assertive outreach team a) Each sector has both CMHT and an assertive outreach team b) Each sector has CMHT assertive outreach team covers several sectors 4. CMHT plus assertive outreach plus crisis team 5. Generic CMHTs with specialist crisis and or assertive outreach functions within them

Outcomes of the Supported Housing Approach

As mentioned earlier, supported housing is a relatively recent residential service strategy that is still being refined. A 1997 literature review on supported housing by Ogilvie concluded that there are still too few outcome studies on supported housing to draw firm conclusions about the efficacy of the approach. A more recent review of the supported housing literature by Debra Rog (2004) found that the evidence on supported housing is still insufficient. Rog identified, for example, only five studies that used rigorous scientific designs. Her review found convincing evidence that supported housing residents were less likely to become homeless, less likely to be hospitalized, and fared better than similar residents in other settings. The findings of three studies (Dickey et al., 1996 Dickey, Latimer, Powers, Gonzalez, & Goldfinger, 1997 Goldfinger et al., 1999 ) suggest that housing stability is increased by providing supports rather than by a specific program model. Similarly,...

Therapeutic Relationships

Psychotherapists have recognized that many patients have difficulty with changing their patterns of living because of anxiety or lack of skill and experience in behaving differently. Behavioral therapy techniques are especially useful in such cases. In cases of anxiety, the patient can be taught to relax through relaxation training exercises. The patient gradually imagines performing new, difficult behaviors while relaxing. Eventually, the patient learns to stay relaxed while performing these behaviors with the psychotherapist and other people. This process is called desensitization, and it was originally developed to treat persons with extreme fears of particular objects or situations, termed phobias. New behavior is sometimes taught through modeling techniques in which examples of the behavior are first demonstrated by others. Behavioral psychotherapists have also shown the importance of rewarding small approximations to the new behavior that is the goal. This shaping technique...

Are Peer Providers as Effective as Other Providers

Several studies found that programs that utilized peer providers were no better or worse in terms of outcomes. Solomon and Draine (1995) compared a peer partnership case management program with a traditional nonpeer case management program. They found that after 2 years both programs were associated with improvements in the lives of the consumers served. There were no significant differences in outcomes of the two types of programs in terms of symptoms, social adjustment, and quality of life. This study was later replicated in a peer-operated agency that operated two assertive community treatment teams, one of which employed peer providers and one that did not. A 2-year comparison also resulted in no significant differences in clinical or social outcomes or in retention

Sources for Further Study

Davis, Martha, Elizabeth Eshelman, and Matthew McKay. The Relaxation and Stress Reduction Workbook. 5th ed. Oakland, Calif. New Harbinger, 2000. An overview of techniques used to reduce stress. Sections include body awareness, progressive relaxation, visualization, biofeedback, coping skills training, job stress management, and assertiveness training.

Stateofthe Art Psychiatric Rehabilitation Day Programming

Treatment and rehabilitation in segregated facility-based settings and now has better ways to provide services. Newer models such as assertive community treatment, supported employment, and supported housing meet the individual needs of persons by design. These new services start by considering the preferences of the individual (e.g., what kind of job is desired, what kind of housing), are offered in the environments in which the individual wants to live, work, and socialize, and are less stigmatizing than attending a mental health clinic or program. In addition, services such as assertive community treatment and supported employment are evidence-based practices, which means they produce dependable results if they are carried out properly.

Ethical Vignettes In Rehabilitation

Eric is a 29-year-old man with a history of many psychiatric hospitalizations. He has been referred to a number of PsyR programs in the past, but has been difficult to engage. Eric's symptoms typically include restlessness, confusion, and paranoia, and while he seems to respond well to antipsychotic medications, he frequently refuses to take them. Following a hospital discharge, Eric returns home to live with his mother and is assigned to an assertive community treatment program in which a team of staff provides services for Eric at his home. Eric is reluctant to talk with the team members when they visit and more often than not, despite pleas from his mother, refuses to take medication. The team decides to implement the following plan Eric's mother, who is the payee for his monthly disability check, will give him a weekly allowance of spending money if he complies with the following conditions (1) taking his medication as prescribed twice a day, and (2) talking with the team members...

Are Peer Delivered Services Better than Other Services

Another group of studies found that peer-delivered services produced some superior outcomes when compared to services offered solely by nonconsumer providers. Programs that utilized peer providers resulted in a reduction in the use of hospital and crisis services when compared to traditional programs (Clarke et al., 2000 Edmunson, Bedell, Archer & Gordon, 1982 Klein, Cnaan, & Whitecraft 1998). Clarke and colleagues (2000) compared an assertive community treatment (ACT) team that included peer providers with a traditional ACT team without peer providers and found that individuals served by the team with peer providers had both fewer hospitalizations and fewer instances of using crisis services. Klein and colleagues (1998) compared consumers who received both intensive case management and peer-provided social supports with a group who only received case management services. Like the Clarke et al. study (2000), the peer-enhanced group had fewer hospitalizations and used crisis...

The Future of ACT and Case Management Approaches

It is not surprising that the use of case management strategies for the community treatment of severe mental illness has steadily increased. Case management has obvious economic and quality-of-life advantages. Although case management, particularly ACT, can be more expensive than traditional community-based services, it is considerably cheaper than psychiatric hospitalization. Planners on the state and national level see increasing evidence that employing case management strategies reduces hospital usage. Numerous states have adopted case management strategies in an effort to reduce hospitalizations and close some of their state hospitals (see Chapter 14). These new strategies have also proven to be effective for reaching those consumers who have fallen through the cracks in the system. Whether because of their illness, underlying personality issues, past experiences that have alienated them from the system, or any number of other reasons, a large number of consumers are unconnected...

Cognitive Behavioral Therapies for PTSD

Kilpatrick et al.'s (1982) program and subsequent programs consist of education the acquisition of coping skills and the application of coping skills, including deep muscle relaxation, breathing control, communication skills and assertiveness training, covert modeling (imagery based modeling), thought stopping, and guided-self dialogue consisting of identifying one's internal dialogue and generating and substituting positive ones. Assertiveness Training Assertiveness training is a skill-building intervention sometimes used in conjunction with other therapies. It is intended to be a coping skill that helps reduce arousal in tense or otherwise arousing situations that a PTSD sufferer may have otherwise avoided or overreacted to. It may also be viewed as a solid adjunct for helping a patient develop a stronger sense of self-efficacy and self-control. However, it is not considered a therapy or treatment in and of itself and is not considered a vital...

Evidence Based Practices

A number of important steps must be carried out to establish an EBP. Most EBPs started from a service innovation. Such innovations (e.g., assertive community treatment Chapter 7 , supported employment Chapter 9 ) typically come about through the trial-and-error efforts of dedicated professionals trying to improve services. After an innovation shows promise, the next step is to carefully and objectively define the service including carefully explaining just how the service is performed, who performs it, for how long, and so forth. The definition of the service becomes the service model that will subsequently be field tested. Robert E. Drake, M.D., Ph.D., is the Andrew Thomson Professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School. He is also the director of the New Hampshire-Dartmouth Psychiatric Research Center. Dr. Drake has been a long-term contributor to the psychiatric rehabilitation knowledge base through his work developing and evaluating...

Models of Case Management

Full support model (assertive community treatment). The full support model is given the most attention. Currently, it is most commonly referred to as assertive community treatment (ACT) or program of assertive community treatment (PACT). ACT is an evidence-based practice.

Individual Level Strategies

Self-help consumer groups could host sessions in which persons teach and train each other to access health care systems by sharing experiences and resources. Here, consumers could share their own experiences regarding what works and what doesn't. Sessions on how to be assertive and stand up for one's rights should be helpful. Having access to information on consumer legal rights could be shared within the context of these groups. (A more detailed discussion of how to implement a support group is provided in chapter 7.)

Attributional Style Questionnaire

Subjects involved in testing are told to imagine themselves in the situations and to determine what they believe would be the major cause of the situation if it were to happen to them. After subjects complete the test, their performance is rated according to stability versus instability, globality versus specificity, and externality versus internality. An example of stable, global, internal perceptions would be a feeling of stupidity for one's failure an unstable, specific, and external perception might consider luck to be the cause of the same situation. The questionnaire has been used by some industries and corporations to identify people who may not be appropriate for certain positions requiring assertiveness and a well-developed ability to handle stress. The same questionnaire has also been used to identify individuals who may be at high risk for developing psychosomatic disorders so that early intervention can be implemented.

Treatment of Avoidant Personality Disorder

Individual psychotherapy, group psychotherapy and behavioral techniques may all be useful. Group therapy may assist in dealing with social anxiety. Behavioral techniques, such as assertiveness training and systematic desensitization, may help the patient to overcome anxiety and shyness.

Beyond Self Help Categories of Peer Provided Services

We will look closely at each of these categories in the following subsections, as well as some illustrative examples of peer-delivered service programs. Note that the types of PsyR services and supports that these programs provide are quite varied. Persons who have severe mental illnesses are involved in the implementation of the full range of PsyR models described in this textbook, including employment services, residential programs, case management, and assertive community treatment.

The Implications Of Dual Diagnosis For Community Mental Health Services

The literature on dual diagnosis services in the USA indicates a number of central principles common to many services. In order to minimize barriers to obtaining treatments and maximize continuity of care, treatment for severe mental illness and that for addictions are closely integrated, with both delivered by the same team. Training and supervision are provided so that individual workers have some skill and confidence in the management both of psychotic illnesses and of addictions. Community dual diagnosis services often adopt the main principles of assertive outreach teams, with small case-loads, a team approach, and intensive attention to engaging clients. In the initial phase of treatment, there may in fact be very little active work on the substance abuse, with efforts directed primarily towards establishing a relationship with clients and persuading them to accept contact with services. Addiction techniques, such as motivational interviewing education about the effects of...

Elements of the Evidence Based Practice Integrated Dual Disorder Treatment

Assertive outreach Actively seeking out clients in their own environments, assertive outreach is an element of many of the EBPs. Given the propensity of individuals with either mental illness or substance abuse disorders to drop out of treatment, assertive outreach is often necessary to maintain contact.

The Effectiveness of Day Programs

The more recent research has focused on achieving specific outcomes and has examined clubhouse programs. For example, a comparison of outcomes achieved by assertive community treatment programs (see Chapter 7) and clubhouse programs conducted by Stein, Barry, Van Dien, Hollingsworth, and Sweeney (1999) found strong similarities on measures of vocational activity, social relationships, social networks, and community integration. Similarly, Macias (2001) reported on a long-term experimental comparison of the employment results of a program of assertive community treatment (PACT) team (see Chapter 7) and an ICCD-certified clubhouse in Worcester, Massachusetts. Not surprisingly, the PACT team, considering its assertive outreach component, was clearly superior in retaining consumers in the program in contrast to the completely voluntary nature of the clubhouse. PACT was also superior with regard to the proportion of people who achieved employment, although this difference diminished with...

Research On Coping And Adjustment Among African Americans

Belgrave and Washington (1986) found among adolescents with sickle cell disease that an assertive coping style was linked to their ability to manage painful episodes. Adolescents reported less disruption in activities of daily living when having a painful episode if they had an assertive coping style. This assertive coping style is an active, problem-focused way of dealing with painful sickle cell disease episodes. Adolescents in our study who were able to make requests and to inform others of their needs within the home, school, peer, and community domains fared better.

When Is a Program Actually ACT

How do you know an ACT program when you see it A validated and widely used fidelity scale is the Dartmouth Assertive Community Treatment Scale (DACTS Teague, Bond & Drake, 1998). Fidelity, as introduced in Chapter 1, is about faithfulness to a particular treatment or rehabilitation model. DACTS has been used to assess fidelity of programs to the ACT model (Bond et al., 2001). Ten Principles of Assertive Community Treatment 2. Rather than brokering services, all treatment and rehabilitation services are provided directly by the assertive community treatment team. 10. The team is assertive in engaging individuals in treatment and monitoring their progress. Source Based on Phillips et al., 2001.

Strengths Model

In this model, the case manager acts as a mentor who assists the client in problem solving and resource development (Hodge & Draine, 1993). Unlike many traditional approaches, the strengths and interests of the individual are the primary emphasis. Rather than emphasizing problems such as a lack of punctuality or poor personal appearance, interventions are focused on helping persons use their strengths to succeed in natural environments of their choice and their places within that environment known as niches. Through both assertive outreach to the individual as well as to gain support and resources, the case manager facilitates the person's pursuit of interests and opportunities of his or her choice in the community. Thus, the individual has both the reasons and the motivation to arrive on time and make a good personal appearance.

Evolution into ACT

Training in Community Living has evolved into assertive community treatment. Over the years, principles for the implementation of ACT have been established and its critical ingredients have been established. These have been outlined by Phillips et al. (2001) and Bond, Drake, Mueser, and Latimer (2001). ACT employs a multidisciplinary team approach with the capacity to provide services 24 hours per day, 7 days a week when needed. The team approach ensures that someone with knowledge of each individual receiving services is always available if needed. In addition, caseload sizes are kept small (approximate ratio of one ACT team member to 10 consumers). So a multidisciplinary team of six would serve a caseload of 60. All treatment and rehabilitation services are provided by the team including a part-time psychiatrist, nurse, case manager, substance abuse counselor, vocational specialist, and sometimes a peer consumer provider. The team meets four or five times a week and is led by a team...

Behaviour therapy

Behaviour therapy incorporates applications derived from learning theory (classical and operant conditioning) and employs them to the treatment of persistent, maladaptive, learned habits. Among behaviour therapy techniques are systematic desensitisation, assertiveness and social skills training, behaviour analysis, relaxation training (e.g. autogenic and progressive muscle relaxation, biofeedback) habit-reversal training and imagery. The aim of these techniques is to progressively diminish maladaptive behavioural responses by repeatedly inhibiting the anxiety by means of competing responses (Wolpe, 1980). A behaviour analysis is conducted where the clinician collects information about the relationship between stimuli and behavioural responses in order to understand the role of anxiety. Imagery with skin disease patients is employed in order to help them cope with anxiety relating to their condition. Imagery is a useful technique for helping the patient to visualise the feared...

Peer Employees

On the other hand, some agencies have designated peer employee positions that are meant to be an adjunct to professionally provided services. For example, an assertive community treatment team that consists primarily of professionals with degrees and credentials may include two peer employees who serve as community resource aides. Positions that are specifically developed for peer providers have been given a number of labels including peer counselor, peer advocate, peer specialist, and consumer case manager (Solomon, 2004). Peer employees have been referred to at times as prosumers. Manos (1993) stated that

History of NAMI

As of 2006, NAMI and its state chapters were playing an important role in a number of important public mental health system issues, such as the promotion and dissemination of the assertive community treatment (ACT) model throughout the United States (see Chapter 7 of this text and http www.nami.org). NAMI and its chapters are very supportive of ACT, sometimes known as PACT (programs of assertive community treatment).