The Basics of Assertive Community Treatment

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Assertive community treatment (ACT) is a form of community-based mental health care for individuals experiencing a serious mental illness that interferes with their ability to live in the community, attend appointments with professionals in clinics and hospitals, and manage mental health symptoms.

If you or someone you know has been referred to an assertive community treatment program, you may be wondering whether this is the best option and what it will entail. Rest assured that ACT is an evidence-based practice that has been studied for several decades, and has likely been offered to you for specific reasons.

Definition of ACT

The simple definition of assertive community treatment is an intensive, integrated approach to community mental health service delivery. What this means is that mental health services are provided in a community setting (rather than a more restrictive residential or hospital setting) to people experiencing serious mental illness.

The mission of ACT is to help people become independent and integrate into the community as they experience recovery.

Secondary goals include reducing homelessness and unnecessary hospital stays. In this way, ACT offers treatment in the "real world" and the team of professionals provides help using a "whole team" approach.

Many people suffer from symptoms of mental illness that impact their ability to function in daily life and that land them in the hospital emergency department seeking services. The goal of ACT is to reduce this reliance on hospitals by providing round-the-clock services to the people who need it most. In this way, assertive community treatment could be expected to help to reduce preventable outcomes of mental illness, such as homelessness and substance abuse.

History

How did assertive community treatment get its start? Go back to the 1970s and a picture will quickly emerge of a shift away from institutionalization of patients with severe mental illness. At the same time, community services were poorly set up to help these people who were no longer living in institutional settings.

The founders of ACT were Leonard I. Stein, Mary Ann Test, Arnold J. Marx, Deborah J. Allness, William H. Knoedler and other colleagues at Mendota Mental Health Insitute in Madison, Wisconsin (a state psychiatric hospital).

As unusual as it sounds, at the time that assertive community treatment first came into being, it was considered a radical approach. Since that time, however, it has become one of the most important delivery methods for specific populations of those with mental illness.

What's more, the National Alliance on Mental Illness (NAMI) has been on board, publishing a manual for ACT in 1998 and operating a training and advocacy center from 1998 to 2004.

Who Assertive Community Treatment Serves

If you or a family member has been assigned ACT services, you might wonder why you were chosen to receive this type of service. Below is a list of the most common reasons a person will be offered assertive community treatment services:

  • persons with severe symptoms of mental illness
  • people with significant thought disorders such as schizophrenia
  • young adults experiencing early-stage schizophrenia
  • people with stigmatized mental illnesses
  • persons with high rates of substance abuse
  • people with a significant history of trauma
  • those with frequent hospital stays
  • people experiencing homelessness due to mental illness
  • persons with overlapping physical and mental illnesses (for instance, hard-of-hearing individuals with a mental illness)
  • persons experiencing psychiatric crises
  • people with mental illness in the criminal justice system
  • refugees with mental illness
  • people unlikely to attend appointments at hospitals or clinics
  • people who have not responded well to traditional outpatient care

ACT Locations

Assertive community treatment has been implemented in countries such as the United States, Canada, Australia, and the United Kingdom. For example, specifically in the United States, ACT was implemented across the country by the Department of Veterans Affairs.

Services are not provided in a clinic, but rather in the patient's home, in community locations (such as a coffee shop, restaurant, or public park), in homeless shelters, or wherever is most appropriate and convenient for the person using the service.

Characteristics

If you are about to enter assertive community treatment, you are probably unsure of what to expect. Most ACT programs have similar structures, so the following may give you some guidance on what the program will offer.

  • Your treatment plan will be centered around your own personal strengths, needs, and desires for the future
  • ACT is offered long-term but not unlimited; the goal is to eventually transition you to other services or for you to maintain what you have learned on your own
  • The focus of ACT is on community integration and getting you back to living a normal life
  • ACT follows a holistic approach to treatment, meaning that all areas of your life are targets for improvement
  • ACT usually has a ratio of about 10:1, meaning that for every 10 clients there will be one team member assigned
  • Most clients have multiple contacts with team members each week
  • ACT is offered 24 hours a day, 7 days a week to ensure that you always have the help you need
  • An ACT team generally includes a psychiatrist, social workers, nurses, occupational therapists, peer support specialists, and more
  • ACT is a considered a medically monitored non-residential service, which is two steps down from the highest level of service (medically managed residential service)
  • Team members will develop long-term relationships with you regardless of whether you become homeless or find yourself incarcerated
  • When you are doing better, you will be transitioned out of the ACT program

Services Provided by ACT

What are the specific services that you can expect to receive from the ACT team? The following is a list of some of the primary services that assertive community treatment offers:

  • initial and ongoing assessments
  • psychiatric services such as coping with psychotic episodes or crises
  • substance abuse services
  • help with employment and housing
  • education for family members and you about your mental illness
  • treatment planning and monitoring
  • accompanying you to medical appointments and dentist appointments
  • representation at court hearings
  • help with finances (such as managing money and paying bills)
  • helping you to grow confident with housekeeping, shopping, cooking, and transportation
  • employment support such as finding and keeping a job
  • help to order and manage medications

The Benefits

Overall, research evidence on assertive community treatment has been positive with some caveats. A 2016 evidence review showed that ACT reduced self-reported psychiatric symptoms, hospital stays, and emergency department visits among people with mental illness and substance abuse.

In general, from the dozens of randomized controlled trials that have been conducted, it can be concluded that ACT is more effective than standard services in reducing hospital use, but findings for other outcomes are less clear.

While studies have shown improvements in housing, symptom management, and quality of life for ACT, these findings were most evident for people who tended to return to hospitals often.

It has been noted that ACT may be most helpful in communities that do not have well coordinated mental health care systems, which result in overuse of hospitals by those with serious mental illness.

For example, ACT may show better outcomes in the United States than in the United Kingdom, because the former has a poorly coordinated system for mental health care that results in more hospital stays, while the latter has a well-coordinated system that already includes many aspects of ACT in its standard care.

Other research has shown ACT to be more effective than standard care in reducing the risk of hospital stays and incarceration, specifically in poor inner-city neighborhoods, and reducing alcohol use or incarceration among those with antisocial personality disorder.

Furthermore, among the homeless, it has been shown that ACT results in more satisfaction with care and more stable housing situations than standard care. This is easy to understand when you consider the ACT model—homeless individuals meet service providers where it is convenient for them are more likely to benefit from services than those who must travel to receive help.

Finally, in a Cochrane review of 38 clinical trials from the United States, Canada, Europe, and Australia, it was shown that ACT was more effective than standard care in lowering the time spent in hospitals and improving social functioning and independent living. At the same time, mental health and quality of life were not shown to improve more than when standard care was offered.

Overall, the research evidence suggests that ACT is most helpful for people with serious mental illness as a method to keep them out of the hospital and in the community.

Criticism of ACT

Overall, there have been some criticisms of the ACT program. One is that ACT is simply a system of coercion in which hospitals deny admission to patients based on their enrollment in the ACT program.

At the same time, isn't staying in the community the goal of all mental health initiatives? In this way, it seems that regardless of whether the tactics are coercive, if patients can be treated in the community where they live, tracked through prison and homeless shelters, and offered 24/7 care at their convenience, then the benefits may be worth the drawbacks.

A Word From Verywell

If you have been assigned to receive assertive community treatment services, you may feel nervous about what to expect or what sort of support you will receive. Know that your team will be available to answer questions and offer support to you long-term in the community at locations that serve you best. As a person living with serious mental illness, ACT is an effective long-term support that should serve you well.

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