Flexible Assertive Community Treatment

Abstract

Background: Carraig Mor Psychiatric Intensive care unit has developed a Flexible Assertive Community Treatment (FACT) approach for mental health service users with complex needs. The aim of FACT is to reduce readmissions and increase voluntary engagement with mental health services through increased levels of outpatient care. FACT combines two approaches within one multidisciplinary team: Individual case management: A more intensive flexible approach for patients at times of need. FACT is a versatile and comprehensive model with continuity of care as its cornerstone; as service user’s needs fluctuate they remain under the care of the same team who adapt their approach to meet changing needs (Drukker, Visser, Sytema, & van Os, 2013) Rationale: One of the essential components of the FACT approach is the ability to confidently make decisions around risk. This is often under difficult circumstances and sometimes will involve using incomplete, conflicting and unconfirmed information. Historically, this has led to mental health practitioners becoming risk averse resulting in extended involuntary admissions due to perceived risk. This is especially true in case management where physical or sexual violence has to be considered. These factors can cause decision making to become paralysed. Such fears can become a significant barrier to recovery, denying service users opportunities to reach their full potential. Structured Professional Judgment: The Carraig Mor FACT team utilise a structured professional judgment (SPJ) approach to aid decision making. SPJ provides a transparent structure that gives explicit instructions and recommendations for the process of identifying risk factors and protective factors unique to the individual service users. It further allows the combining and understanding of this information to aid decision making by means of risk formulation and scenario planning. Decision Making: Formulation is the process of making sense of the complex interactions between different sources of information, including from clinical interview, scales and collateral reports, while identifying potential causation. Examples of this approach include the HCR-20 & RSVP. Risk formulation describes how and why people make decisions to engage in violence, and seeks to understand the various factors that influence their decision making. In practice, risk formulation examines protective factors and destabilising factors unique to the individual service user to inform decision making and individual care planning. Scenario planning is a process of developing several possible futures and individual care or safety plans to meet the potential needs of these hypothetical situations. Conclusion: Labelling and stigma are not confined to diagnosis of mental illness; service users with complex presentations which include histories of violence or sexual offending are often perceived to be dangerous outside the context of the violent event. Risk formulation allows mental health practitioners to make decisions based around service user needs without becoming fixated upon previous offending. Furthermore, it allows for the identification and implementation of protective factors which support the service user to continue through the care pathway unimpeded by stigma and to reach their full potential of personal recovery.