The critical ingredients of assertive community treatment.

Abstract

In their paradigm-shifting study, Stein and Test (1) developed and evaluated a community mental health treatment model for people with serious mental illness that became known as assertive community treatment (ACT). Their approach challenged many standard practices and beliefs in psychiatry. Based on earlier work, they had concluded (2) that hospital training programs to prepare patients for community living after discharge were ineffective, and that providing training and support within community settings after discharge was far superior. The principle of in vivo assessment, training and support became a cornerstone of the ACT model. With the locus of contact in the community, ACT used assertive outreach to engage clients who were reluctant to keep appointments at a clinic. Another critical ingredient of the ACT model was a holistic approach to services, helping with illness management, medication management, housing, finances, and anything else critical to an individual's community adjustment. ACT services included assistance in routine practical problems in living, such as shopping and using public transportation. Along with the focus on the client's immediate needs and personal goals, the shift in service delivery to community settings dramatically increased client engagement in and satisfaction with mental health services (3). Drawing on their experience on hospital treatment teams, Stein and Test formulated the ACT model as requiring a multidisciplinary team of mental health professionals, providing intensive, timely, and personalized services, facilitated through frequent team meetings to review treatment plans and services. ACT was also conceived as a direct service model, with clinicians providing most needed services themselves rather than referring to other providers. Another feature of the model with far-reaching influence was integration of services, which has demonstrated advantages over brokered approaches (i.e., referring clients to other programs for many services). ACT teams integrated mental health treatment, housing, rehabilitation, and many other services, and tailored them to the needs and goals of each client. Another core feature of the ACT model was a low client-staff ratio of approximately 10 clients per full-time ACT practitioner. This staffing pattern permitted multiple contacts each week with clients needing intensive support. In addition, teams provided continuous coverage, responding quickly to client emergencies, 24 hours per day, seven days per week. Finally, ACT teams committed to long-term and continuous care. Initially, the model promised lifelong care.