Assertive community treatment (ACT) is an intensive and highly integrated approach for community mental health service delivery.Dixon, L. (2000). Assertive community treatment: Twenty-five years of gold. Psychiatric Services, 51, 759-765. ACT teams serve individuals who have been diagnosed with serious and persistent forms of mental illness, predominantly but not exclusively the schizophrenia spectrum disorders. ACT service recipients may also have diagnostic profiles that include features typically found in other DSM-5 categories (for example, bipolar, depressive, anxiety, and personality disorders, among others). Many have histories of frequent psychiatric hospitalization, substance abuse, victimization and trauma, arrests and incarceration, homelessness, and additional significant challenges. The symptoms and complications of their mental illnesses have led to serious functioning difficulties in several areas of life, often including work, social relationships, residential independence, money management, and physical health and wellness. By the time they start receiving ACT services, they are likely to have experienced failure, discrimination, and stigmatization, and their hope for the future is likely to be quite low.
Definition The defining characteristics of ACT include: a focus on participants (also known as members, consumers, clients, or patients) who require the most help from the service delivery system; an explicit mission to promote the participants' independence, rehabilitation, community integration, and recovery, and in so doing to prevent homelessness, unnecessary hospitalization, and other negative outcomes; an emphasis on home visits and other in vivo (out of the office) interventions, eliminating the need to transfer newly learned skills from an artificial rehabilitation or treatment setting to the "real world"Test, M. A., & Stein, L. I. (1976). Practical guidelines for the community treatment of markedly impaired patients. Community Mental Health Journal, 12, 72-82. — indeed, this simple feature of the model has had a profound impact on psychiatric rehabilitation in general, because it shifts the burden of “fitting in” from service recipients to service providers, who now find it more difficult to prescribe, and thus to control, the characteristics of the intervention setting; a participant-to-staff ratio that is low enough to allow the ACT "core services team"Kent, A., & Burns, T. (1996). Setting up an assertive community treatment service. Advances in Psychiatric Treatment, 2, 143-150. to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or "farm out" most of the work to other service providers; a "total team" or "whole team" approach to intervention,Cupitt, C. (2009). Reaching Out: The Psychology of Assertive Outreach, 46. Abingdon-on-Thames, UK: Routledge. in which all of the staff work with all of the participants, under the supervision and with the active participation of a mental health professional, who serves as the team's leader; an interdisciplinary program of continuous assessment, service planning, and intervention that typically involves — in addition to the team leader — a psychiatrist, social workers, nurses, occupational therapists, co-occurring disorder specialists, vocational rehabilitation specialists, and peer support specialists (individuals who have had personal, successful experience with the recovery process); a willingness to be a “one stop” intervention that takes ultimate professional responsibility for the participants' well-being in all areas of community functioning — including most especially the "nitty-gritty" aspects of everyday life — by providing a comprehensive array of services for every participant and ensuring clear staff-to-staff communication, through such measures as daily team meetings to review the previous 24-hour (or weekend) period and to plan for the coming days and weeks; a conscious effort to help people avoid crisis situations in the first place through careful planning, frequent communication, and flexible staff deployment, or — if the current plan isn't working — to revise it and intervene rapidly and assertively, with the goal of preventing hospitalizations (when possible), loss of housing, and other negative outcomes; and a commitment to work with people on a time-unlimited basis, as long as they still demonstrate the need for this intensive level of professional help, but also to help them move on when they are ready.For a definitive analysis of the essential components of the ACT approach, see: Linkins, K., Tunkelrott, T., Dybdal, K., & Robinson, G. (2000, April 28). Assertive community treatment literature review. Report prepared for Health Care Financing Administration & Substance Abuse and Mental Health Services Administration. Falls Church, VA: The Lewin Group. .Allness, D. J., & Knoedler, W. H. (2003). A manual for ACT start-up: Based on the PACT model of community treatment for persons with severe and persistent mental illnesses. Arlington, VA: National Alliance on Mental Illness.Witheridge, T. F. (1991). The "active ingredients" of assertive outreach. In N. L. Cohen (Ed.), Psychiatric outreach to the mentally ill (pp. 47-64). San Francisco: Jossey-Bass. (New Directions for Mental Health Services, no. 52.)McGrew, J. H., & Bond, G. R. (1995). Critical ingredients of assertive community treatment: Judgments of the experts. Journal of Mental Health Administration, 22, 113-125.Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive community treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141-159.
In the array of standard mental health service types, ACT is considered a "medically monitored non-residential service" (Level 4), making it more intensive than "high-intensity community-based services" (Level 3) but less intensive than "medically monitored residential services" (Level 5), as measured by the widely accepted LOCUS utilization management tool.American Association of Community Psychiatrists (2000). Level of Care Utilization System for Psychiatric and Addiction Services, Adult Version 2000. Erie, PA: Deerfield Behavioral Health. Available online at: www.locusonline.com . While ACT is more staff-intensive than most other forms of community treatment, it is viewed as a less restrictive option for carefully selected service recipients, compared to custodial or more heavily supervised alternatives; see Olmstead v. L.C. In general, appropriate candidates are those for whom less intensive approaches have proven unsuccessful or insufficient.
Early developments ACT was first developed during the early 1970s, the heyday of deinstitutionalization, when large numbers of patients were being discharged from state-operated psychiatric hospitals to an underdeveloped, poorly integrated "nonsystem" of community services characterized (in the words of one of the model's founders) by serious "gaps" and "cracks."Test, M. A. (1979). Continuity of care in community treatment. New Directions for Mental Health Services, no. 2. San Francisco: Jossey-Bass, 15-23.V.A. Mental Health Intensive Case Management training in Tucson, Arizona (2002); Mary Ann Test describes the history of the ACT model. https://www.youtube.com/watch?v=Y_S0GeO3Iws The founders were Leonard I. Stein,New York State ACT Institute at Pathways to Housing (2005); Sam Tsemberis Interviews Len Stein about Assertive Community Treatment. https://www.youtube.com/watch?reload=9&v=683yoITWZxc#action=shareStein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37, 392-397.Weisbrod, B. A., Test, M. A., & Stein, L. I. (1980). Alternative to mental hospital treatment. II. Economic benefit-cost analysis. Archives of General Psychiatry, 37, 400-405.Test, M. A., & Stein, L. I. (1980). Alternative to mental hospital treatment. III. Social cost. Archives of General Psychiatry, 37, 409-412.Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe mental illness.