Towards Assertive Community Care

Assertive Community Treatment (ACT) refers to a loosely related set of principles and practices focused on improving the lot of those identified as "heavy service users", or those people who have historically been difficult to engage in treatment. A burgeoning body of research testifies to the effectiveness of ACT and a bewildering number of acronyms such as PACT, MIT, MCT, TCL and MST have been coined to describe services more or less faithful to ACT principles.This paper describes the key principles of ACT, research on outcomes and ACT programmes, presents a sketch of the Mobile Intensive Treatment Team in Townsville and critiques ACT from an ethical perspective. It proposes that ACT ought to commence from a philosophy of community mental health firmly grounded in respect for people, and ought to be the primary business of community mental health services.

Introduction

ACT may best be conceptualised as a "middle way" of psychiatric service provision, neither passively neglecting the individual with mental illness nor aggressively riding rough shod over his or her human rights to enforce treatment. ACT is a return to the traditional values of sound nursing or human service, founded on respect, human engagement, and which is orientated towards facilitating the right conditions for growth and development. The success or otherwise of ACT is largely dependent on the capacity for individual clinicians to engage in a meaningful helping relationship, to build on the strengths of the individual and community, and to assist in the negotiation of problems of everyday living.

Defining an ACT programme

Public mental health services and mental health professionals may have many faults but a questionable strength is the capacity to create pithy acronyms to name and describe what they do. Assertive community treatment or ACT is a trendy acronym, which can lead to confusion in part because it is synonymous with many other terms and embodied in many mental health programmes. It is a term that encompasses a range of principles and practices, which are more or less synonymous with:

Some have even suggested that clinical case management is synonymous with ACT (Burns, 1997), which is particularly problematic given that ACT is frequently compared and contrasted with variations of clinical case management.

ACT is a form of case management, but the very term ‘case management’ is confusing and various typographies exist to describe variations in types of case management. Diamond and Kantor have referred to the varieties as:

The travel agent model – where the professional sits behind the desk offering advice. This is described by others as the "brokerage model".
The travel companion model where someone goes with you but without any special expertise or training; and
The travel guide model – where a person will not only be there, and do things with you, but also has appropriate training, experience and expertise to know the most scenic routes, how to take short cuts without getting lost, how to reliably avoid the pitfalls and how to arrive safely at the destination.

Australasian mental health case management draws on all these models but has most in common with the travel guide model.

There is considerable variation between ACT programmes and some disagreement on the components that are critical to success. However, most services share the following features:

The history of ACT

The "training in community living program" developed during the 1970s as an alternative to mental hospital treatment, is widely accepted as the first model of assertive community treatment (Dixon, 2000). The programme evolved out of work credited to Arnold Marx, Leonard Stein and Mary Ann Test at the Mendota Mental Health Institute in Madison, Wisconsin. Its aims were similar to the aims of most community mental health teams today, that is, to enhance patient’s community adjustment, decrease time spent in institutions, and ultimately to prevent the development of the chronic patient role. Additionally the program focuses on decreasing patients’ symptomatology and increasing their self-esteem and satisfaction with life. (Gold Award, 2000, p.6). In order to meet these goals substantial human resources were committed to provide whatever assistance people needed in order to live in the community, e.g. assisting with securing accommodation, finding employment, budgeting, shopping, and personal care. Services were provided in two shifts, with one staff member being on call at night, seven days a week. The training in community living programme eventually evolved into the Program of Assertive Community Treatment (PACT), a reasonably standardised service that is popular in the United States today.

Hoult, Reynolds, Charbonneau-Powis, Coles, and Briggs (1981) are credited with being responsible for introducing a variation of ACT to Australia and demonstrating the feasibility of providing assertive treatment by mobile community teams with the back up of crisis services as a viable alternative to in-patient care without significantly increasing care-giver burden. Since then Mobile Intensive Treatment or Support Teams has become part of the mental health service landscape in Australia.

Today ACT as a system of care, whilst not available universally to those who might benefit from it is being promoted as standard practice (Phillips et al., 2001). Burns (2001) suggests that the UK is awash with outreach programmes. In the United States ACT programmes have been implemented in 35 states (Phillips et al., 2001) and the National Alliance for the Mentally Ill (NAMI) aims to have PACT programmes operating in every state by 2002 (Carolla, 1998). Adaptations of ACT have been implemented in Europe and Canada (Phillips et al., 2001), Australia and New Zealand. ACT principles are being employed in the establishment and development of general community mental health teams and services targeting groups such as those with recent onset of illness, concurrent drug related problems and mental illness, the homeless, forensic or hard to engage patients (Burns, 2001).

Benefits of ACT

Assertive Community Treatment is one of the most well evaluated and documented non-pharmaceutical mental health interventions. Many substantial reviews of ACT have been undertaken. The most recent Cochrane Review (Marshall & Lockwood, 2000) concluded that compared to standard community care people allocated to ACT were:

There were no differences between ACT and control treatments on mental state or social functioning (Marshall & Lockwood, 2000).

In contrast the Cochrane Review examining general case management for people with severe mental illness presented some scathing criticisms (Marshall, Gray, Lockwood, & Green, 2000). The review found that case management approximately doubled the rate of hospital admissions with little evidence of improvement in mental state, social functioning or quality of life. It conclude that

Ziguras and Stuart (2000) undertook a meta-analysis of controlled trials examining the effectiveness of case management over 20 years and had a more liberal approach to study inclusion than the Cochrane Review. They examined 44 studies, 9 of which directly compared ACT with clinical case management and 35 compared ACT or clinical case management with usual treatment. Both types of case management were found to:

ACT was found to reduce hospitalisation frequency and length of stay. However, they found that whilst clinical case management increased the frequency of hospitalisation, it decreased the total number of hospital days.

There is little doubt that ACT is helpful in reducing hospitalisation, improving housing stability, and possibly contributes to modest improvements in quality of life and psychiatric symptomatology. However, the research evidence does not elucidate what elements of ACT contribute to improvements or whether or not improvements are sustained over time once ACT services are withdrawn (Mueser, Bond, Drake, & Resnick, 1998). Furthermore, ACT has largely only been examined in the context of discrete, well-resourced teams, often comparing outcomes with poorly resourced services.

Successful ACT programmes described in the literature have also often been implemented as part of well-resourced and planned integrated services. For example Hambridge and Rosen (1994) described a reduction of 62% in bed occupancy by clients referred to a newly developed mobile community management team in suburban Sydney. However, this service was also part of an integrated programme that included supervised residences and residential rehabilitation, a transitional work programme, two community mental health centres with 24 hour mobile crisis services and living skills centres. Such a range of services would be the envy of many regions and beyond the reach of less populace centres. ACT must invariably be adapted to the specific needs of communities, geographic settings and adapted to the presence and availability of additional services. Little research has been undertaken examining how ACT fits in to a wider integrated service.

The United Kingdom has been slower to adopt ACT. Results of a recent random controlled trial of ACT in the UK have been less impressive than elsewhere. Burns et al. (1999) randomly assigned 708 psychotic patients to standard case management (case load 30 to 35) and to intensive case management (case load 10 to 15) at four sites. They reported no significant gains in clinical or social functioning in either group at one or two years, and no significant difference in hospital use between groups (Burns et al., 1999). It appears that simply reducing caseload does not lead to an improvement in outcomes. It might also be that without careful targeting of interventions to those that might benefit the most, clients risk being over-serviced without improvement in outcomes. However, in a later study examining effects of case load size Burns et al. (2000) concluded that "UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions." It matters more what individual case-managers do with their time with clients than how often they see them.

Programme fidelity & the essential ingredients of ACT

Programme fidelity is the term used to describe conformity to prescribed elements and the absence of non-prescribed elements in a programme. Programme fidelity is particularly important in research in order to ensure that one is comparing similar services i.e. apples with apples. There also comes a point when an intervention or programme deviates so much from recognised elements that it can no longer be said to be that entity. There is some evidence that those programmes that are more faithful to the ACT model have superior outcomes (McGrew, Bond, Dietzen, & Salyers, 1994; McHugo, Drake, Teague, & Xie, 1999; Teague, Bond, & Drake, 1998). The Dartmouth Assertive Community Treatment Scale (Teague et al., 1998) includes the following factors which are indicative of high fidelity in an ACT team:-

Structure and Human Resources:

Organisational boundaries:

Nature of services:

Most programmes that would claim to be ACT services deviate from these specifications in some way. Burns, Fioritti, Holloway, Malm, and Rossler (2001) suggest that a significant influence of national culture is evident both in the acceptability of case management and in approaches to researching and undertaking it. This is also likely to be the case across Australasia. Experts disagree on the relative importance of different components (see: McGrew & Bond, 1995; Schaedle & Epstein, 2000). For example, twenty-four hour care by a dedicated team may be an expensive luxury and duplication of service when alternative crisis services are available. In early implementations of ACT avoidance of office or clinic visits was pursued pedantically, however avoidance of office visits may be better thought of as an outcome of assertive outreach, rather than an end in itself. The need to have one team member as a co-ordinator and a team approach are often considered important structural elements of ACT programmes (McGrew & Bond, 1995).

Targeting and triage

One general principle of ACT is that the service is targeted to those who might most benefit from it. From it’s conception ACT has targeted those perceived as being "heavy service users" or those with the most intractable symptoms of severe illness and the greatest level of functional impairment. Kent, Fogarty, and Yellowlees (1995) describe the heavy service user as the 10 to 30 percent of patients who use 50 to 80 percent of resources. Abbott et al. (1997) undertook a literature review and engaged a panel of "experts" to arrive at 13 factors, which characterised the heavy service user and qualified them for involvement in a Mobile Intensive Treatment Team (MITT) service. The Townsville MIT team utilises the instrument and a comprehensive referral for screening potential participants in the programme. The Mobile Intensive Team Screening Instrument

MITT ENTRY CRITERIA

To be considered eligible for MITT services all mandatory criteria must be met and a score of at least 16 out of 35 points needs to be attained. Abbott et al. (1997) suggested that the tool might be used as an exit-screening instrument e.g. when scores fall below 16 consideration is given to discharging the person from the service, although the instrument has not been used in this way.

Discharge from ACT

Discharge from ACT is not an issue that has been examined in sufficient detail to specify rigid criteria. In practice, a fair amount of clinical judgement based on amongst other things, the nature and type of supports available to the person, a knowledge of the natural history of the person’s illness, stability of insight and symptoms, compliance with aftercare, and the person’s wishes, determine the need for discharge.

A number of people grow beyond the need for ACT, and for others the need is ongoing. Most are likely to require some type of follow-up from mental health services and a lengthy period of shared follow-up with a new case-manager is useful. Abrupt withdrawal of ACT often amounts to an abrupt withdrawal of a key form of stabilising support which can act as a buffer to life’s stresses.

In the absence of further details this vignette might raise many questions about client dependence on MITT services, the failure to facilitate natural supports, the quality of rehabilitation provided and of planned after care. However, in my view it best illustrates the provision of ACT as a human undertaking and the importance of supportive relationships in maintaining well-being. Klinkenberg and Calsyn (1996) describe community support, receipt of aftercare and system responsiveness as the key mediating factors leading to nonrecidivism in vulnerable mentally ill populations. Certainly ACT increases the certainty of aftercare and ought to act to bolster community support for the person and where needed act as a surrogate to natural supports. ACT ought to be responsive not only to gross changes in mental health status, but to the changing and emerging needs of the person on a day to day basis. Indeed, these factors ought to be central concerns of a mental health system, not just a dedicated team.

The Mobile Intensive Treatment Team in Townsville

The Mobile Intensive Treatment Team in Townsville was set up in 1998 with federal funding to provide assertive community treatment to those within the Townsville and Thuringowa Metropolitan areas (population approximately 135,000). It also had a mandate to case manage people under Project 300, a scheme that targeted resources to assist people who had been hospitalised for long periods to be integrated and treated in the community. Originally the MIT team was a stand-alone service but in 2001 the team was relocated with other community health services and made operationally responsible to a team leader for all adult community mental health services.

At the time of writing the MIT team in Townsville consisted of a Clinical Nurse Consultant, Clinical Psychologist, Social Worker, Occupational Therapist, a part time administrative officer with shared duties and a consultant psychiatrist working approximately 0.2 FTE for MITT. The hours of operation are 8-5 Monday to Friday. Referrals are received from within adult mental health services, and have included zonal inpatient rehabilitation units in Kirwan and Charters Towers, the acute inpatient unit and the general case management teams. The team is currently responsible for providing care and treatment to approximately 30 people.

Most clients have a diagnosis of a psychotic disorder although several have a diagnosis of bipolar affective disorder or a primary personality disorder. Most have some other confounding co-morbidity such as an acquired brain injury, intellectual handicap, substance use disorder, or borderline personality traits. A forensic history is common. The majority also had few supportive relationships, had frequent or lengthy hospital admissions, and had unstable accommodation on referral.

Unique contextual factors

Townsville is a multicultural town with a relatively young population. It has the largest urban concentration of Aboriginal and Torres Straight Islanders outside of Darwin. It is located in the tropics and as such certain health practices such as maintaining personal hygiene and rubbish disposal are important to maintain personal and public health. Those on pensions are entitled to subsidised or public housing, cheaper public transport, educational subsidies, childcare subsidies, medication subsidies and free dental treatment. However, a complicated bureaucracy administers the welfare system and many people find it hard to access entitlements. Intravenous amphetamine use is common. Homelessness is a problem in Townsville. It can take up to 5 years to access public housing and accessing private rental accommodation is expensive and difficult. People may be permanently "blacklisted" because of non-compliance with tenancy agreements. Consequently many people live in caravan parks, boarding houses, or on the streets. There is no professionally supported or supervised accommodation for people with mental illness outside of the rehabilitation units. A large number of non-government organizations are publicly funded to provide various support services.

Fidelity to ACT model in Townsville

Deviation from ACT model in Townsville

Outcomes and Evaluation

Specific desirable outcomes are negotiated with each client throughout involvement with the MIT team. Measures such as the Health of the Nation Outcome Scale (HoNOS), Life Skills Profile (LSP) and Global Assessment of Functioning (GAF) are collated regularly for all clients at least 3 monthly. Other measures such as the Positive and Negative Syndrome Scale (PANSS) are used as required. The majority of clients have shown clinically significant improvements in functioning (LSP improvement of >16) and the frequency or length of hospitalisation for acute reasons has diminished. One client has "dropped out" of the service over the last twelve months (left town), 3 were readmitted to residential rehabilitation largely due to the lack of extended hours face-to-face support, and another is presently incarcerated after committing arson. Five have been discharged to other services for follow-up.

A survey of clients, family members and non-government organizations was undertaken using semi-structured interviews and thematic analysis early in 2001. This indicated a high degree of satisfaction with the services provided, particularly relative to other services. Clients commented on their satisfaction with the availability of their case manager and how the case manager would offer assistance with activities of daily living such as shopping. Families and non-government organizations commented positively about the quick response to their concerns from MIT and how they were confident that the person would be followed up.

The work of the case manager in an ACT team

The success of an ACT programme is dependent on the right mix of people and skills.What case managers actually do with clients has not been investigated in great detail (see: Bjorkman & Hansson, 2000). There is considerable support for psychiatrists, nurses and social workers being on ACT teams, but also increasing support for vocational and substance abuse experts being available for consultation, if not as full team members. Often people have complex medical needs and nurses are well suited to bridging roles that are required. In the United States it appears that providing most clinical services from within the team is a priority. In part this is due to substance abusing clients having poorer outcomes regardless of intervention (Havassy, Shopshire, & Quigley, 2000), and evidence that brokerage of services is related to decreased satisfaction with service (Huxley & Warner, 1992). Of paramount importance is that ACT workers are suitably experienced and skilled to provide a full range of mental health services.

What ACT case managers actually do with clients is dependent on what needs to be done, thus people are likely to assume numerous roles in relation to the person. Unlike other form of clinical case management the boundaries of involvement tend to be loose rather than tight. The following case example illustrates some of the interventions that might be provided:

Case Example Omitted - Contact Richard if you would like a copy of the full paper.

The above provides just a small sample of roles that may be assumed by an ACT case manager, none of which are particularly unique. Case managers require a depth of knowledge about medical treatments, and well-developed problem solving and counselling skills. It also often requires skills in appraising risk so a degree of experience in mental health services is needed. Unlike programme specifications, the particular mix of roles that may be assumed by case managers will be unique for each individual.

Ethical problems associated with ACT

A cursory review of the literature relating to ACT might suggest that the holy grail of mental health services has been found. That is, a way of configuring mental health service provision, which achieves good outcomes, is mostly acceptable to families and consumers, and reduces hospitalization. However, it is possible that an ACT services can be ethically bankrupt, whilst being faithful to prescribed standards. At the very least the nature of ACT work is a profoundly ethical undertaking and clear conflicts often arise between beneficence and autonomy, between beneficence and nonmaleficence, and between nonmaleficence to the individual and to the community (Stovall, 2001).

Many of the ethical problems arising in ACT are common to mental health care generally but are particularly problematic in ACT due to the persistent and intrusive nature of outreach. ACT has its routes in institutional hospital care in which staff were a permanent and visible part of every aspect of people’s lives. ACT was conceived of originally as "a hospital without walls" and has many elements of institutional care despite such care having lost favour in recent years. At the very least it is considerably more intrusive than office or clinic based approaches in which people may exercise the choice not to attend appointments, to disengage from services and can at least enjoy the relative sanctuary of places free from the surveillance of mental health professionals. Control over medication and money are often of central concern to people with chronic mental illness and when problems arise in these areas the result can be incarceration, hospitalization or homelessness (Stovall, 2001).

ACT can and sometimes does impinge on the personal autonomy of clients. The Program of Assertive Community Treatment (PACT) in the United States has met with some considerable opposition from anti-psychiatry groups. Concerns centre around PACT as a coercive vehicle to enforce medication compliance, particularly when combined with involuntary outpatient commitment. Support Coalition International (2001) likens PACT to a Trojan horse: "This wraparound" service, as it's sometimes called, looks pretty on the outside, but inside you can find a lot of "medication militia" hiding out". ACT teams usually have a biomedical bias in which medication compliance and symptom monitoring are frequently seen to be a cornerstone of treatment and can give rise to a paternalistic approach to care (Spindel & Nugent, 2001). When a biomedical conceptualisation of problems becomes the sole focus or when carried to extreme the benevolent paternalism of psychiatry can become malevolent. Even when treatment appears to be negotiated rather than enforced, the voluntariness of treatment must be acknowledged as shaky when the power to enforce treatment involuntarily rests with mental health services. Coercive strategies to enforce compliance are always ethically problematic.

It is a undeniable that psychiatry has a social control function (Lakeman & Curzon, 1997) which in relation to people receiving ACT services creates tensions between the team’s allegiance to the person, their family and to wider society. One often unacknowledged goal of psychiatric treatment is to minimise the risks posed to society by the person’s behaviour. Those referred to ACT are more likely to have a forensic history, be homeless, impoverished, unemployed and on the margins of society. Extreme caution must be exercised to ensure that ACT doesn’t further subjugate already marginalised groups. Solomon, Draine, and Meyerson (1994) suggest that case management may easily deteriorate into providing monitoring rather than rehabilitative services and thus may facilitate reincarceration. It has been suggested that limit setting is a feature of ACT which sets it apart from other programmes (Neale & Rosenheck, 2000) yet clearly this must be balanced with the provision of care. Health professionals must balance these conflicting demands and interests in their day-to-day work. They also have a duty to address the wider social justice issues which lead to marginalisation of people in the first place; to attempt to create a mental health "care" system (Lakeman, 1998) rather than merely providing a service which is palliative to a sick society.

A further significant ethical problem arises from the exclusive nature of ACT and it’s relationship with other services. A considerable number of people who might benefit from ACT are denied the service because of stringent entry criteria. To some extent ACT as it is located within many services is the ambulance at the bottom of the cliff and can reflect "too much to late". If an ACT approach is implemented earlier many problems might be avoided or become less entrenched. ACT embodies many of the principles, which ought to be a feature of wider community mental health services, for example, a commitment to stick with people for as long as is needed and to do what is needed.

The ethical problems inherent in ACT are not insurmountable. Szmukler (1999) suggests that "...approaches to resolving ethical problems include increasing patient involvement in their care, clarifying the grounds for 'paternalistic' interventions, and re-examining grounds for acting to reduce the risk of harm to others". In practice the resolution of ethical problems must commence from a sensitivity to situations as problematic (Lakeman, 1999). Christensen (1995, p.1217) identifies further virtues that ought to influence our ethical reasoning: Compassion which "... impels us to stand with our clients and take seriously the reality of their pain and confusion." Humility which "... reminds us of our humanness as persons and our fallibility as health care providers." Fidelity which "... inclines us to not easily abandon those whom we have forged commitments to help. Fidelity serves to remind us that clients have a claim on us that endures even when they refuse the treatment we offer." The experiences of implementing ACT over 30 years, and the ethical problems inherent in it can provide some lessons to assist in the development of a unifying philosophy of community mental health.

Towards assertive community care

Whilst not a new phenomenon, many mental health services have a "Spin them out when they stop spinning out" response to people with long term and relatively enduring problems of mental health, that is only dealing with the person in an acute phase of illness rather than having a longer term rehabilitation focus. The goal has become to get the person "off the books" as soon as possible. The word "care" has been lost from the lexicon of many services, and notion of "continuing care" has become highly unfashionable. "General case management teams" often become disgruntled with being unable to provide what they know might be helpful and a negative consequence is an increased emphasis on gate keeping and boundary enforcement rather than provision of care or therapy. ACT provides a broad philosophy of practice that ought to be adopted by all community mental health services, which can counter these disturbing and negative trends.

ACT, like community mental health services is in a state of evolution. Historically, it has its roots in ensuring treatment but over time the best examples of ACT have evolved into systems of care which go well beyond merely providing medical treatment. To use a Buddhist metaphor it reflects a middle way of psychiatric services and is a "skillful" activity in both the technical and ethical sense. Programme specifications are not ends in themselves, but assist in mandating the conditions for ACT to take place.

Assertiveness precludes a passive neglect of people with mental illness. It means not allowing a person to fall through the cracks and knowing when to act and when to stand by. This is not something, which is easily prescribed and requires skills in engagement, negotiation, knowledge of good mental health practices and ethical sensitivity. Neither should ACT be aggressive and ride rough shod over people’s human rights in the enforcement of treatment. Stovall (2001) points out that establishing long term relationships based on respect fosters collaboration and minimises the utilisation of coercive approaches.

Community in ACT is both the location of care and is also acknowledged as the source of natural support and sustenance for the person. ACT should aim to develop the capacity of families and communities to provide care and if necessary to provide that care from within the ACT service for as long as is needed.

Treatment in ACT not only entails medical treatment for mental illness but involves care in the broader sense. It involves building on the strengths of the individual and the community to assist in the negotiation of problems of everyday living. As with all good mental health care the focus should be on growth and attempting to facilitate the right conditions for growth to occur so that the person and his or her family are best able to negotiate everyday living themselves. Having clear treatment goals which are negotiated with the person provide a context for interactions with the team.

ACT in the manner described above is by no means a new concept and harks back to principles of good nursing and human service. It is or ought to be founded on respect for people. ACT represents a set of ideals and an orientation to working which should form the heart of all mental health service delivery.

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