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.

ACT is a highly normalized service. The stigma attached in attending a mental health center or a psychiatrist's office is eliminated, although some argue that having one or more professionals arriving at your home or job might be somewhat stigmatizing and intrusive. At the same time supports are provided on an as-needed basis to help the consumer achieve success in different settings such as school, work, and the community. Although ACT is a fairly high-cost community-based service, this increased cost is more than offset by the reduction in hospital utilization that is achieved. In fact, some states have employed ACT to help reduce the census of state psychiatric hospitals allowing for reductions in the number of needed hospital beds and the closing of some hospitals.

ACT employs a multidisciplinary team approach with the capacity to provide around-the-clock support. The team approach ensures around-the-clock availability of someone with knowledge of each individual receiving services. In addition, caseload sizes are kept small (approximate ratio of one ACT team member to 10 consumers) and support is provided to consumers as long as it is needed.

Randomized controlled clinical trials have consistently demonstrated that ACT is effective at reducing the number of hospital days (time spent in the hospital). ACT programs have also demonstrated an increase in housing stability for their clients. Results on improved quality of life and increased client satisfaction with services have been mixed. Some high-fidelity programs that are very faithful to the ACT model (see description of fidelity in Chapter 1 and earlier in this chapter) have achieved these outcomes, others have not.

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 important benefits. Frequent staff member visits may help remedy the lack of insight experienced by some individuals with severe mental illness. Xavier Amador, in his book I Am Not Sick: I Don't Need Help (Amador & Johanson, 2000), sees this lack of awareness as "anosognosia" a term referring to impaired awareness or ignorance of illness. This was discussed in Chapter 2 of this text. In short, the ill individual is unaware of the symptoms or presence of the illness. It is not uncommon for a floridly psychotic individual to state that he feels fine, has no problems and no illness. In these circumstances, left unchecked, the individual typically continues to deteriorate until hospitalization is necessary. Assertive outreach may also help to identify problems before they become full-blown crises. For example, a problem with the landlord may be dealt with in a timely fashion before it gets blown out of proportion and ends in eviction.

While the benefits of an assertive approach are obvious, an increasing number of consumers and professionals have raised concerns about the coercive effects this can have on individuals (e.g., Ahern & Fisher, 2001; Diamond, 1995). Because of the strong emphasis on medication compliance in some ACT services, some have questioned whether ACT is a "medical model" program rather than psychiatric rehabilitation. In addition, some individuals have complained that ACT is intrusive and occasionally coercive (Ahern & Fisher, 2001). The implication is that the principles of consumer choice and empow erment so strongly held by psychiatric rehabilitation are less emphasized in medical model programs. Ahern and Fisher consider ACT so coercive that they devised an alternate form of case management they call PACE (Personal Assistance in Community Existence). Diamond points out that assertive outreach falls along the same continuum as court-ordered treatment, which he sees as highly coercive and paternalistic. The point is very simple. An individual who, without requesting it, is frequently visited by a team of professionals who ask prying questions may reasonably feel coerced.

Diamond (1995) is correct; this issue is similar to court-ordered treatment and outpatient commitment. When, if ever, should the principles of choice and respect for the individual be violated in an effort to help? Should society be paternalistic and intrusive when an individual is not aware that he or she is putting himself or herself or others at risk?

What is the evidence that ACT is too assertive or even intrusive? Bond et al. (2001) in their study reported that only 11% of the consumers enrolled in ACT found it to be intrusive, confining, or fostering dependency. Rosenheck and Neale in two reports (Neale & Rosenheck, 2000; Rosenheck & Neale, 2001 (a,b)) studied 40 ACT teams serving more than 1,500 consumers within the Veterans Administration system to determine the extent to which "limit-setting" coercive interventions were offered. Coercive interventions included assigning a representative payee (someone other than the consumer to manage his or her money), contingent withholding of services or supports until a desired behavior was established, invocation of external authorities such as parole or probation officers, and enforced "voluntary" or involuntary hospitalization. These coercive interventions were used with 10% of the ACT consumers. The coercive interventions tended to be used with individuals who had a more difficult course of their illness and recovery and were actually associated with poorer outcomes. Thus, there is some evidence showing that for a small minority of consumers ACT is viewed as a coercive approach.

BOX 7.2

The research and writing of Gary Bond, Ph.D., Chancellor's Professor of Psychology at Indiana University-Purdue University Indianapolis, has contributed to the field of psychiatric rehabilitation since 1979. Since entering the field as director of research at Thresholds, a large PsyR agency in Chicago, he has worked to understand how services can be more effective and to train professionals to work in the field.

When he went to Thresholds for the first time, Dr. Bond found that the practical and egalitarian orientation appealed to him, as did the real-world relevance of the research questions. Does psychiatric rehabilitation help people get jobs? Does it help them to live independently? His interest in the answers to such questions has a personal side as well. Inspired by his sister's determination in coping with symptoms of schizophrenia, Dr. Bond is convinced that people with psychiatric disabilities can and should achieve full community integration.

Dr. Bond's research has focused on evidence-based practices, including studies of supported employment, assertive community treatment, and assessment of fidelity of implementation of evidence-based practices. Gary Bond's work is some of the most frequently cited research in the psychiatric rehabilitation literature.

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