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 leader who is also a "front-line" practicing clinician. The entire team serves each individual. ACT teams provide the following services:
• Case management and coordination of services, primarily by direct provision of the services
• Psychiatric services, provided by an M.D. or nurse practitioner, including evaluation, prescribing medication, and monitoring symptoms and side effects
• All needed counseling and psychotherapy services
• Housing support services to help the individual maintain a stable residence
• Employment and rehabilitation services, similar to supported employment (see Chapter 9)
For consumers with addiction diagnoses, substance abuse counseling that is fully integrated with mental health services, using a stages of change or recovery model, is included (Bond et al., 2001). This treatment technique is covered in greater detail in Chapter 8.
As discussed earlier, all services are provided to consumers in the community, rather than at clinics. None of the services are arbitrarily time limited. All services are provided assertively; that is, individuals who do not respond or may initially refuse treatment are repeatedly contacted and offered the service. Service recipients are met or contacted wherever they can be found: at their homes, public places, and even in the streets. In ACT, there is no fixed length of stay and generally a "no close" policy—consumers can be served as long as they wish to be. Services are offered intensively, if needed, with contact between staff and clients averaging four times weekly, but at least 2 hours per week. As mentioned, supports are provided around the clock, including the availability of 24-hour crisis intervention. Generally, ACT teams control, in part or whole, the screening and evaluation for any needed psychiatric hospitalizations. They participate on hospital treatment teams, and facilitate discharge planning. In jurisdictions where permitted by law, ACT teams will collaborate with probation and parole officials. In addition, in some places, when someone is involuntarily committed to outpatient services, they are often enrolled in ACT.
An additional feature of many ACT programs is the inclusion of peer providers. Peer providers are persons who are themselves recovering from mental illness who serve as team members. Peer providers have been found to be as effective in some ways as nonpeer providers. Added to teams, they bring unique strengths and sometimes produce better outcomes (Craig, Doherty, Jamieson-Craig, Boocock, & Godfried, 2004). The addition of a consumer or peer to an ACT or case management team successfully engages more consumers. Clients randomly assigned to teams with peer case managers were more engaged with treatment and had lower rates of nonattendance at appointments. They also had higher levels of participation in structured social activities and significantly fewer unmet needs in the domains of daytime activity, social activity, finances, transportation, and access to benefits. Employing peer providers also contributes to improved client engagement with services and improved outcomes in some areas.
The features and ingredients of ACT are summarized in ten principles stated by Phillips et al. (2001) and presented in Table 7.2.
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