Assertive community treatment

Assertive community treatment, or ACT, is a form of total in-community care for people with serious, long-term mental illness.

Definition
The defining characteristics of ACT include:
 * a clear focus on those participants (clients) who require the most help from the care delivery system;
 * an explicit mission to prevent homelessness and unnecessary hospitalization, as well as to promote the participants' independence, rehabilitation, and recovery;
 * a primary emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial treatment setting to the "real world";
 * a participant-to-staff ratio that is low enough to allow the ACT "core services team" to perform virtually all of the necessary treatment, rehabilitation, 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 professionals;
 * a comprehensive approach to assessment and service planning by the interdisciplinary ACT team, which typically includes a psychiatrist and one or more nurses, social workers, substance abuse specialists, vocational rehabilitation counselors, and peer recovery specialists (individuals who have had personal, successful experience with the recovery process);
 * a willingness on the part of the ACT team to take ultimate professional responsibility for the participants' well-being in all areas of community functioning, including most especially the "nitty-gritty" aspects of everyday life;
 * a conscious effort to help participants avoid crisis situations in the first place or, if that proves impossible, to resolve their crises -- at any time, day or night -- without going back to the hospital; and
 * a promise to work with people on a time-unlimited basis, whether or not they can make measurable progress toward recovery, as long as they continue to demonstrate the need for this intensive level of professional help.

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 by serious "gaps" and "cracks." The founders of the approach were Leonard I. Stein, M.D.,    Mary Ann Test, Ph.D.,      Arnold J. Marx, M.D., Deborah J. Allness, M.S.W., William H. Knoedler, M.D.,   and their colleagues     at the Mendota Mental Health Institute, a state hospital in Madison, Wisconsin. Also known in the literature as the Training in Community Living (TCL) project, the Program of Assertive Community Treatment (PACT), or simply the "Madison model," this innovation seemed radical at the time but has since evolved into one of the most influential service delivery approaches in the history of community mental health. The original Madison project received the American Psychiatric Association's prestigious Gold Award in 1974. After conceiving the model as a strategy to prevent hospitalization in a relatively heterogeneous group of prospective state hospital patients, the PACT team turned its attention in the late 1970s and '80s to a more narrowly defined group of young adults with early-stage schizophrenia.

ACT as an evidence-based practice
Because of its long track record of success with high-priority service recipients in a wide variety of geographical and organizational settings -- as demonstrated by a large and growing body of rigorous outcome evaluation studies -- ACT has been recognized by the United States federal government's Substance Abuse and Mental Health Services Administration (SAMHSA),  the Robert Wood Johnson Foundation, the National Alliance on Mental Illness (NAMI), and the Commission on Accreditation of Rehabilitation Facilities (CARF), among other recognized arbiters, as an evidence-based practice  worthy of widespread dissemination. It should also be pointed out, however, that some critics -- notably Tomi Gomory, Ph.D., at Florida State University -- have argued that ACT is inherently "coercive" and that the research claiming to support it is scientifically invalid; Test and Stein have replied to this critique, and Gomory, in turn, has answered their reply.

Dissemination of ACT
Since the late 1970s, the ACT approach has been replicated or adapted widely. The Harbinger program in Grand Rapids, Michigan, is generally recognized as the first replication, and a family-initiated adaptation in Minnesota also traces its origins to the Madison model. In 1978, the Bridge program at the Thresholds psychosocial rehabilitation center in Chicago, Illinois, became the first big-city adaptation of ACT and the first program to focus on the most frequently hospitalized portion of the mental health consumer population. In the 1980s and '90s, Thresholds further adapted the approach to serve deaf people with mental illness, homeless people with mental illness, people experiencing psychiatric crises, and people with mental illness who had been inappropriately jailed. In British Columbia, an experimental assertive outreach program based on the Thresholds model was established in 1988 and later expanded to additional sites. Outside of North America, one of the first research-based adaptations was an assertive outreach program in Australia.

Other replications or adaptations of the ACT approach can be found throughout the English-speaking world. In Wisconsin, the original Madison model was adapted by its founders for the realities of a sparsely populated rural environment. There are also major program concentrations in Delaware, Florida, Georgia, Idaho, Illinois, Indiana (home of numerous research-based ACT programs  and the Indiana ACT Center ), Michigan (home of approximately 100 teams  and a professional organization called the Assertive Community Treatment Association ), Minnesota, Missouri (home of an exemplary program for homeless people with co-occurring mental illness and chemical dependence   ), New Jersey, New Mexico, New York, North Carolina, Rhode Island, South Carolina, South Dakota, Texas, Virginia, Australia,  Canada,   and the United Kingdom,   among other places. An important issue for planners is to determine the number of ACT or "ACT-like" programs a particular geographical area needs.

Research on ACT
ACT and its variations are among the most widely and intensively studied intervention approaches in community mental health. The original Madison studies by Stein and Test and their colleagues are classics in the field. Another major contributor to the ACT literature has been Gary Bond, Ph.D., who completed several studies at Thresholds in Chicago before establishing the ACT Center of Indiana at Indiana University-Purdue University at Indianapolis. Bond has been particularly influential in the development of fidelity measurement scales for ACT    and other evidence-based practices. He and his colleagues (especially Robert E. Drake, M.D., Ph.D.,    at Dartmouth Medical School) have attempted to consolidate and harmonize several major currents in this continuously developing area of practice -- for example, the different "styles" of service delivery exemplified by PACT in Madison, Thresholds in Chicago, the Dartmouth/New Hampshire model of integrated dual disorders treatment, and other influential programs; the various modifications of the original ACT approach over the years to maximize its effectiveness with particular service delivery challenges, such as helping consumers to recover from co-occurring psychiatric and substance use disorders or to obtain and retain competitive jobs through a rehabilitation approach called supported employment; and the increasingly well-organized efforts to help consumers take charge of their own illness management and recovery processes.

Although most of the early PACT replicates and adaptations were funded by grants from federal, state/provincial, or local mental health authorities, there has been a growing tendency to fund these services through Medicaid and other publicly supported health insurance plans. Medicaid funding has been used for ACT services throughout the United States, starting in the late 1980s, when Allness left PACT to head Wisconsin's state mental health agency and led the development of ACT operational standards. Since then, U.S. and Canadian standards have been developed, and many states and provinces have used them in the development of ACT services for individuals with psychiatric disabilities who would otherwise be dependent on more costly, less effective alternatives. Although Medicaid has turned out to be a mixed blessing -- it can be difficult to demonstrate a person's eligibility for this insurance program or to find supplemental funding for necessary services that it will not cover -- Medicaid reimbursement has led to a long-overdue expansion of ACT in previously unserved or underserved jurisdictions.

Future of ACT
An important area for future program design and evaluation work is the use of ACT in concert with other established interventions, such as integrated dual disorders treatment, supported employment, family psychoeducation approaches for concerned relatives,  and dialectical behavior therapy (DBT) for persons with borderline personality disorder. In general, the promulgation of separate evidence-based practices, not all of which are easily coordinated with each other, has once again made service integration an important issue for community mental health service delivery -- as it was in the last century, interestingly, when ACT was born; some issues just will not go away.