Assertive Community Treatment Clients Research Articles

Understanding Barriers and Facilitators of Primary Care Use Among Assertive Community Treatment Teams Via Qualitative Analysis of Clients and Clinicians.

Individuals with severe mental illness and substance use disorders face complex barriers to achieving physical health. This study aims to explore the barriers and facilitators of primary care access among an Assertive Community Treatment (ACT) team. Semi-structured qualitative interviews were conducted with 14 clients and 7 clinicians from an ACT team at a community mental health center in Connecticut. Data analysis followed a grounded theory approach, with codes and themes emerging iteratively during the interview process. The study identified multifaceted barriers to accessing primary care, including economic challenges, homelessness, and the prioritization of mental health and substance use symptoms over healthcare. The conceptual framework consists of nine dominant themes: clients' attitudes, knowledge, mental health, andmotivations("Client-Level Barriers and Facilitators"); ACTteam-directed care coordination and relationship-building as well as primary care provider communication ("Provider-Level Barriers and Facilitators"); and clients'experiences with medical care andsocioeconomic status("Systemic-Level Barriers and Facilitators"). This research provides valuable insights into the various barriers faced by ACT clients in accessing primary care. Improving primary care access for individuals with severe mental illness and substance use disorders is crucial for reducing health disparities in this vulnerable population.

Impact of OT on Assertive Community Treatment Clients: A Mixed-Methods Study Exploring Occupational Performance & Satisfaction

Abstract Date Presented 04/22/2023 OT has a unique role in community mental health, including assertive community treatment (ACT) teams. This study explored occupational performance and satisfaction among ACT clients to help advance the profession in mental health. Primary Author and Speaker: Ashley N. Fuentes Contributing Authors: Jennifer Gardner

A Qualitative Exploratory Study of Family Inclusion in Assertive Community Treatment: Challenges and Possibilities

The purpose of this study is to understand the unique challenges of Assertive Community Treatment (ACT) service providers to actively include natural supports in treatment. The qualitative approach was guided by the participatory intervention model and tenets of critical realism. Interviews included focus groups of different stakeholders on ACT teams (e.g., case managers) and individual interviews with ACT clients. Through thematic analysis, we identified themes demonstrating how state funding requirements, demands on staff schedules, and psychosocial barriers make it challenging to include clients’ natural supports. We derived two implications which may enhance future possibilities for natural support inclusion: community-based psychoeducation family groups coupled with state funding streams that better support the ACT model.

The Psychometric Properties of the Assertive Community Treatment Transition Readiness Scale (ATR).

Assertive community treatment (ACT) is an evidence-based practice for individuals living with severe mental illnesses. Originally conceptualized as a lifetime service, there is a need for standardized measures to help ACT teams identify clients who are potentially ready for a transition to less intensive services. Here, to address this gap in the literature, the psychometric properties of the Assertive Community Treatment Transition Readiness Scale (ATR) were examined. Data on the ATR were collected from ACT staff from across the country who had experience transitioning ACT clients to less intensive services. Results from an exploratory factor analysis suggested a one-factor solution and that items on the ATR demonstrated excellent internal consistency reliability as well as predictive criterion validity and known-groups validity. The ATR is an easy-to-use, 18-item measure that has the potential, in combination with clinical judgment and practice wisdom, to be a useful tool for identifying ACT clients who could transition to a less intensive level of care.

Impact of psychiatric advance directive facilitation on mental health consumers: empowerment, treatment attitudes and the role of peer support specialists

Background A psychiatric advance directive (PAD) is designed to prevent involuntary mental health interventions by enabling people with serious mental illnesses to plan ahead for their own treatment during a future incapacitating crisis. This study implemented PAD facilitation in assertive community treatment (ACT) teams. Aims We examined ACT clients’ attitudes toward PAD facilitators, satisfaction with PAD facilitation, the short-term impact of PAD completion on subjective sense of empowerment and attitudes toward treatment, and whether the type of PAD facilitator made a difference. Methods Participants were randomly assigned to be offered PAD facilitation by a peer support specialist or non-peer ACT team clinician, and interviewed at baseline (n = 145) and post-facilitation 1–2-month follow-up (n = 116), to assess perceived consumer-directedness of PAD facilitation, empowerment and various treatment attitudes. Mean scores before and after the intervention were compared for PAD-completers, non-completers, and those who completed a PAD with a peer vs. non-peer. The effect of PAD completion was assessed using logistic and linear regression analysis. Results There was no evidence of bias against peer-facilitators. There was a modest positive impact of PAD facilitation on treatment attitudes and empowerment. Conclusions PAD facilitation by peer support specialists and others working in community mental health settings supports recovery.

Assisted outpatient treatment orders and the therapeutic relationship in Assertive Community Treatment: a mixed-methods study

ABSTRACTBackground: A large proportion of clients served by Assertive Community Treatment (ACT) teams in New York City (NYC) are referred through “Assisted Outpatient Treatment” (AOT), which involves civil commitment to outpatient services. Research indicates that clients perceive AOT to be coercive, but it is unclear how this impacts the therapeutic relationships with ACT teams. We used mixed-methods to examine and compare perceptions of the therapeutic relationship and associated factors between ACT clients who were, and were not, referred through AOT.Method: Thirty persons receiving ACT services in NYC (15 AOT, 15 non-AOT) completed qualitative interviews about perceptions of treatment and referral, as well as measures of therapeutic alliance, procedural fairness, experienced coercion, shared decision-making, and self-stigma.Results: Quantitative findings revealed no differences in measures between AOT and non-AOT participants, with the exception being perception of “negative pressures” in the referral process, which was higher in the AOT group. However, qualitative findings were more mixed, with a notable subgroup of AOT-participants endorsing themes of paternalism and coercion in the referral and treatment decision-making process.Discussion: Findings indicate that the impact of AOT-referral on perceptions of ACT services is complex, and that AOT referrals impact treatment relationships in a subset of clients.

Systematic Literature Review of General Health Care Interventions Within Programs of Assertive Community Treatment.

Assertive community treatment (ACT) is one of the few evidence-based practices for adults with severe mental illness. Interest has slowly waned for ACT implementation. Yet ACT remains an appealing services platform to achieve the triple aim of health care reform (improved health outcomes, reduced cost, and improved satisfaction) through integration of primary care and behavioral health services. This review highlights the evidence for ACT to improve general medical outcomes, reduce treatment costs, and increase access to treatment. Using a comprehensive list of relevant search terms, the authors performed a systematic literature database search for articles published through November 2015, resulting in ten articles for inclusion. No studies reported on clinical outcomes of general medical comorbidities or on mortality of ACT clients. Half of the studies reporting utilization (three of six) found a decrease in emergency room usage, and three of four studies identified an increase in outpatient primary care visits. Most studies found no increase in overall medical care costs. Of the few studies reporting on quality of life, most found mild to moderate improvements. To date, rigorous scientific examination of the effect of ACT on the general health of the populations it serves has not been undertaken. Given ACT's similarity to emerging chronic illness medical management models, the approach seems like a natural fit for improving general medical outcomes of persons with severe mental illnesses. More research is needed that investigates the current effect of ACT teams on general medical outcomes, treatment costs, and access to care.

Facilitating Social Integration for People With Severe Mental Illness Served by Assertive Community Treatment

PurposeThis article explores the experience of workers on Assertive Community Treatment (ACT) teams surrounding their efforts to facilitate social integration for their clients. Design and methodsSixteen workers were individually interviewed and eight additional workers participated in two focus groups. FindingsThe formation of caring relationships between worker and client was an important first step towards social integration for ACT clients. Community activities offer opportunities for social interaction. Practice implicationsThe frequency of community based activities should be increased. Social integration should be a targeted focus of service by structurally embedding a social integration specialist onto the ACT model.

Effects of Client Perceptions of Therapeutic Alliance, Empowerment, Attitudes Toward Medication and Insight on Functioning

Background : Limited research is available on how Assertive Community Treatment (ACT) clients’ cognitions, attitudes and behaviours experienced over time during the therapeutic process and recovery, affect functioning. Aims : This prospective study investigated whether changes in 1) clients’ ratings of therapeutic alliance, sense of empowerment over their illness, attitudes toward medication and insight, 2) clinicians’ assessment of medication adherence and 3) delivered services predicted functioning of ACT clients in southern Ontario, Canada. Method : Hierarchical Linear Modelling was used to assess time-varying and invariant predictors of overall functioning, over a two-year follow-up period. Results : The study found that during each 6 month follow-up time period about 90% of clients achieved successful community tenure and overall functioning increased between baseline and year 1 and decreased between baseline and year 2. Clients’ ratings of therapeutic alliance on functioning were moderated by previous lifetime days in hospital, while change in ratings of empowerment was moderated by age and previous lifetime days in hospital. Improved insight and medication adherence predicted functioning. Number of client contacts by ACT staff was not associated with functioning. Conclusions : These findings suggest that changes in client’s cognitions, attitudes and behaviours experienced during the therapeutic process and recovery can predict client functioning.

Everyday Ethics: Voices From the Front Line of Community Psychiatry by Paul Brodwin (review)

Paul Brodwin, Everyday Ethics: Voices From the Front Line of Community Psychiatry. Berkeley: University of California Press, 2012. 248 pp.Brodwin's well-researched book is a must-read for anyone interested in the anthropology of psychiatry, work, health care, or moral decision-making. His aim is to show happens in the backstage of medical settings, which he does well (199). Brodwin's book embeds us in the work teams of Eastside Services in a Midwestern city to reveal the extreme conditions and ethical uncertainty in the lives of people with serious psychiatric disabilities and the people struggling to provide them with care.At Eastside, teams of low-paid, bottom of the ladder clinical workers offered Assertive Community Treatment (ACT) model care to clients with serious psychiatric disabilities, such as schizophrenia, bipolar disorder, and major depression. Many Eastside clients also seemed to struggle with addictions, which is true for about 50 percent of people diagnosed with serious mental illnesses in the public mental health system (Drake et al. 2006). ACT clients, according to Brodwin (and the original model developed in Wisconsin [Stein and Test 1980]) were often deemed to be in need of hands-on care in order to reduce rehospitalizations and enhance their participation in the community. At times, they were recipients of outpatient commitment orders, which are often considered to be a controversial imposition of the state on individual liberties.The ACT model of case management has been well-researched, and at least two good ethnographies of case management for people with serious psychiatric disabilities have been published, including Sue Estroff's (1981) classic, Making It Crazy: An Ethnography of Psychiatric Clients in an American Community, and Jerry Floersch's (2002) Meds, Money, and Manners. These books offer intimate perspectives on case management models from the perspectives of service users (Estroff) and from the perspective of front line staff (Floersch).Brodwin's book builds on the findings of these previous studies and makes an important contribution to the literature because he targets very important issues in care and caregiving, and relentlessly questions the ethical uncertainty of mental health care. He asks: how are decisions made about the care of people with serious psychiatric disabilities, why, by whom, and to what end?The book moves us toward understanding the complex answers to these questions. To help guide his understandings of clinical decisionmaking, Brodwin employs the term everyday ethics, which he has borrowed from Donna Haraway (2013). He describes everyday as a species of situated knowledge that is a partial perspective based on one's own way of organizing the world according to one's own local world-view (173). Interspersed in his ethical vignettes are informative discussions of the ways the mental health care system as-is emerged on a policy level, and the ethics of decision-making that the mental health system forces care providers to manage.The work offers a very humanizing perspective of frontline community psychiatry care providers and their efforts to make incredibly important, challenging, and often demoralizing decisions for their clients with psychiatric disabilities. They do so with a very local perspective, Brodwin argues. Brodwin is most interested in moments of rupture when ethical comments do emerge unexpectedly and people take a moment to reflect upon the social they are playing (202).It seems there are two kinds of frontline care providers playing the game in this book. The seemingly well-educated, all-powerful psychiatrist Dr. Young, who operates on his own set of biomedical logics that a person has a medical disease, needs treatment, and cannot be counted on to take care of themselves until they have proven themselves capable of doing so in a very specific, step-by-step way. …

Assertive Community Treatment (ACT) in a Rural Canadian Community: Client Characteristics, Client Satisfaction, and Service Effectiveness

This study describes an assertive community treatment (ACT) model in a rural Canadian location and examines characteristics of ACT service users, their degree of satisfaction with ACT, and whether their engagement with ACT resulted in reduced reliance on acute psychiatric services and hospital emergency room use. Chart audits were used to collect demographic and clinical participant data, including days of psychiatric admission and emergency room (ER) visits. Twenty-nine ACT clients agreed to participate. The majority of participants (82.8%) were male and had been diagnosed with schizophrenia or a schizoaffective disorder (65.5%). There was a high rate of concurrent substance abuse (75.9%). The average number of readmission days was reduced from 14 to 0 (p < 0.05) following engagement with ACT, and the average number of visits to ER s was reduced from 3 to 1 (p < 0.05). Participants reported overall high satisfaction with ACT services. Study implications for policy and practice are discussed along with future research recommendations.

Clinicians’ Perceptions of Challenges and Strategies of Transition from Assertive Community Treatment to Less Intensive Services

The study aimed to identify clinical strategies and challenges around transition from Assertive Community Treatment (ACT) to less intensive services. Six focus groups were conducted with ACT team leaders (n = 49). Themes were grouped under four intervention-focused domains: (1) client/clinical, (2) family and natural supports, (3) ACT staff and team, and (4) public mental health system. Barriers to transition included beliefs that clients and families would not want to terminate services (due to loss of relationships, fear of failure, preference for ACT model), clinical concerns that transition would not be successful (due to limited client skills, relapse without ACT support), systems challenges (clinic waiting lists, transportation barriers, eligibility restrictions, stigma against ACT clients), and staff ambivalence (loss of relationship with client, impact on caseload). Strategies to support transition included building skills for transition, engaging supports, celebrating success, enhanced coordination with new providers, and integrating and structuring transition in ACT routines.

Distinctive Trajectory Groups of Mental Health Functioning among Assertive Community Treatment Clients: An Application of Growth Mixture Modelling Analysis

Assertive community treatment (ACT) studies that have used conventional, statistical growth modelling methods have not examined different trajectories of outcomes or covariates that could influence different trajectories, even though heterogeneity in outcomes has been established in other research on severe mental illness. The purpose of our study was to examine the general trend in mental health functioning of ACT clients over a 2-year follow-up time period, to discover groups of ACT clients with distinctive longitudinal trajectories of mental health functioning, and to examine if some of the key sociodemographic and illness-related factors influence group membership. A 2-year, prospective, within-subjects study of 216 ACT clients within southern Ontario, collected functional outcome data at baseline and 12 and 24 months using the Colorado Client Assessment Record. Baseline covariates included sex, primary diagnosis, number of comorbidities, hospitalization history, and duration of illness. Growth mixture modelling (GMM) was used to examine trajectories. Clinical staff assessments of ACT clients showed a statistically significant improvement in functioning and 84% achieved successful community tenure. GMM analysis identified 2 classes of ACT clients: class 1 (79.63% of clients) experienced lower and stable overall functioning, and class 2 (20.37%) showed a better baseline functioning score and improvement in the overall functioning over time. Class membership was predicted by the number of comorbidities and diagnosis. Our study suggests general stability in overall functioning for the sampled ACT clients over 2 years, but significant heterogeneity in trajectories of functioning.

Forensic and Nonforensic Clients in Assertive Community Treatment: A Longitudinal Study

OBJECTIVE This study compared rates of arrest and incarceration, psychiatric hospitalization, homelessness, and discharge from assertive community treatment (ACT) programs for forensic and nonforensic clients in New York State and explored associated risk factors. METHODS Data were extracted from the New York State Office of Mental Health's Web-based outcome reporting system. ACT clients admitted between July 1, 2003, and June 30, 2007 (N=4,756), were divided into three groups by their forensic status at enrollment: recent (involvement in the past six months), remote (forensic involvement was more than six months prior), and no history. Client characteristics as of ACT enrollment and outcomes at one, two, and three years were compared over time. RESULTS Clients with forensic histories had a significantly higher ongoing risk of arrest or incarceration, and those with recent criminal justice involvement had a higher risk of homelessness and early discharge from ACT. Psychiatric hospitalization rates did not differ significantly across groups. Rates of all adverse outcomes were highest in the first year for all ACT clients, especially for those with a recent forensic history, and rates of psychiatric hospitalization, homelessness, and discharge declined over time for all clients. For all ACT clients, homelessness and problematic substance abuse at enrollment were significant risk factors for arrest or incarceration and for homelessness on three-year follow-up. CONCLUSIONS Clients with recent forensic histories were vulnerable to an array of adverse outcomes, particularly during their first year of ACT. This finding highlights the need for additional strategies to improve forensic and other outcomes for this high-risk population.

Changes in Antipsychotic Medication in Clients of Assertive Community Treatment in Japan: A One-Year Follow Up

The purpose of the present one-year follow-up study was to describe and investigate the change in the amount of antipsychotic drugs prescribed for ACT (assertive community treatment) clients in Japan. Subjects were 52 clients of ACT from January 2009 to December 2009. Prescription data were collected each month from the time the clients entered into ACT. The results of a Wilcoxon signed-rank test show that the dosage of antipsychotics significantly decreased from 1,131.3 mg to 731.3 mg over the course of the 12 months (Z = -2.505, p = 0.012).

Suicidality in Seriously Mentally Ill Clients of Two Intensive Community Mental Health Programs

The purpose of this study was to evaluate the effect of two intensive community mental health programs on the suicidality of clients with serious mental illness. Eighty individuals with severe and persistent mental illness were enrolled in this randomized controlled study comparing two models of intensive community support: Assertive Community Treatment (ACT) and Intensive Case Management (ICM). Suicidal ideation and behaviours were measured using the Modified Scale for Suicide Ideation. Study clients underwent comprehensive interviews at baseline and were reinterviewed 9 and 18 months later. The Dartmouth Assertive Community Treatment Scale (DACTS) instrument was used to gain more insight into the specific ACT and ICM program structures and characteristics that provide crisis support and suicide intervention. A chart review of 2 randomly chosen months of service looked at the on-call after-hours pager use of ACT program clients. The ACT intervention was effective in reducing suicidal ideation over 18 months. In addition, the prevalence of suicidal ideation was significantly lower at 18 months in ACT clients versus ICM clients. This is the first study to suggest that ACT may confer some additional benefit in terms of reduced suicidality in clients with severe and persistent mental illness.

Pet Ownership as a Meaningful Community Occupation for People With Serious Mental Illness

We determined the proportion of pet owners and non-pet owners with serious mental illness, compared their characteristics and their motivations for owning or not owning a pet, and examined the relationship between pet ownership and engagement in meaningful activity and three dimensions of community integration. Three Assertive Community Treatment (ACT) teams reported on the pet ownership of all service recipients (N = 204). Of these recipients, 60 completed a survey. Nonparametric tests were selected for data analysis. Of 204 ACT clients, 38 (18.6%) were pet owners. Twenty-tour (63.2%) of 38 responding non-pet owners desired to live with a pet. There were significant differences between groups on diagnosis, gender, a global measure of function, meaningful activity, and psychological integration. The key finding supports the hypothesis that pet owners with serious mental illness living in the community demonstrate higher social community integration. Implications for future research and practice are discussed.

Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial

The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants. Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team. CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction. The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.

Contexts of social relationship development among assertive community treatment clients.

This exploratory qualitative study examined contexts and processes of social relationship development as experienced by adults with schizophrenia participating in assertive community treatment (ACT) programs. Semistructured interviews with 20 ACT clients diagnosed with schizophrenia-spectrum disorders and 2 ACT staff members were analyzed using grounded theory analysis methods. Results showed that aside from contacts with family members and providers, participants' interactions with fellow mental health clients tended to dominate social interactions, and that this pattern appeared to be influenced by both the concentration of social opportunities in daily activities of service utilization and the ACT program emphasis upon facilitating relationships between clients. Participants described their relationships with other mental health clients in primarily positive terms, yet several participants expressed dissatisfaction and desired greater integration into mainstream social networks. Implications for mental health service delivery are discussed.

Perceived stigma and community integration among clients of assertive community treatment.

Facilitating the integration of persons with psychiatric disabilities is an important goal of community programs. In addition to limitations such as inadequate housing, poverty, and unemployment, a common barrier to community adjustment identified by people with psychiatric disabilities is their perception of being stigmatized. This study examined the relationships between perceived stigma and community integration in 95 clients of assertive community treatment (ACT) teams, using sequential multiple regression procedures. Findings indicate that despite their physical presence in the community and the intensive support they receive, ACT clients believe other community members will reject them. Moreover, this perception appears to interfere with their sense of belonging, particularly among those who also perceive less social support and who have greater psychosocial skill deficits. In the context of the present study, global self-esteem did not mediate this relationship. In addition to community focused antistigma campaigns, stigma-related issues should also be addressed with ACT clients themselves.