Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Assertive Community Treatment

Information for Practitioners and Clinical Supervisors

What is assertive community treatment?

Assertive community treatment is a team-based approach to delivering comprehensive and flexible treatment, support, and services. Assertive community treatment, or ACT, is for individuals who have the most serious and intractable symptoms of severe mental illness and who, consequently have the greatest difficulty with basic daily activities such as keeping themselves safe, caring for their basic physical needs, or maintaining a safe and affordable place to live. Unemployment, substance abuse, homelessness, and involvement in the criminal justice system are common problems. People who receive ACT services typically have needs that have not been effectively addressed by traditional, less intensive services.

Is ACT different from other approaches to mental health treatment?

An assertive community treatment team is a service delivery system that takes responsibility for providing a customized array of services to keep people out of the hospital and help them attain a life that is not driven by their illness. ACT should not be confused with case management programs that broker services from other agencies or providers. Rather than sending people to other programs for services, the team provides the services people need. If people need a service the team is unable to provide—for example, housing or medical care—the team is responsible for making certain they receive that service.

An ACT team consists of 10 to 12 staff with experience in psychiatry, social work, nursing, substance abuse treatment, and employment support. Members of the team do not have individual caseloads, instead, the team as a whole, is responsible for approximately 100 people. Team members are cross-trained in each other's areas of expertise to the maximum extent feasible. Assessment and treatment planning are done collaboratively and team members work in close consultation with each other to deliver an integrated array of treatment, support and rehabilitation services that is customized for each person. Team members are generalists, that is, they are not limited to providing services only in their area of expertise. A nurse, for instance, might assist an individual in negotiating a lease or an employment specialist may call to check on lost food stamps.

The majority of services a team provides are delivered in vivo, that is, team members work with individuals in their homes, work settings, or other places in the community where support might be needed. Sometimes this means working with members of the community such as property owners or employers to educate them about mental illness and advocate for people's rights.

There is no predetermined set of services. The team is responsible for delivering any service or support people need to live in the community and reach the goals they have set for recovery. There are also no arbitrary time limits on ACT services. Interventions are carried out as long as they are useful and nothing more beneficial is available. Even if a person is hospitalized or arrested, the team continues to be the fixed point of responsibility for assuring that the person's needs are met.

Services are available 24 hours a day, 7 days a week. Team members may interact with a person with acute needs multiple times a day. As the individual stabilizes, contacts decrease.

This team approach is facilitated by daily team meetings in which the team is briefly updated on each individual. Activities for the day are organized and team members are available to one another throughout the day to provide consultation or assistance. This close monitoring allows the team to quickly adjust the nature and intensity of services in response to individuals’ changing needs.

Assertive Community Treatment

• Individualized, comprehensive and flexible treatment, support and rehabilitation services
• Team members are direct providers of services
• Majority of contacts with consumers are in community settings
• Team is the fixed point of responsibility for services
• Services are provided on a time–unlimited basis

What do other mental health professionals think about assertive community treatment?

Assertive community treatment may be very different from what some practitioners were exposed to in their professional training and may challenge the way they have become accustomed to thinking about people who are diagnosed with a severe mental illness and the services they need. The switch to working in community settings and being a member of a collaborative team can be uncomfortable initially for some people. However, working with an ACT team can also be very satisfying. Members of ACT teams find that having a long-term relationship with the people they serve gives them a chance to know them as people. Many practitioners also find it rewarding to be able to work with individuals long enough to see positive changes. And, when things don't go well, teammates can provide support and practical assistance.

What is expected of members of assertive community treatment teams?

It takes pragmatism, initiative, “street smarts,” and a “can do” attitude to be a successful member of an assertive community treatment team.

In working with their teammates, practitioners are expected to:

• communicate their professional assessment of people's needs and suggest treatment strategies based upon their professional knowledge
• teach team mates as much as possible about their area of expertise
• ask other team members questions and learn as much as possible about their areas of expertise
• pitch in and help when needed, even if it means doing something that draws on their life experience rather than professional expertise (for example, helping someone move furniture into a new apartment)
• be innovative and creative
• focus on problem solving

In working with people who receive services from the team, team members are expected to:

• communicate hope and optimism
• treat people with dignity and respect
• actively involve consumers in decisions about their treatment and services
• help people attain the goals they set
• focus on people’s abilities
• advocate for people's rights
• provide practical, hands-on, side-by-side support
• become familiar and comfortable with different cultures
• work with people’s natural support systems

What evidence is there that assertive community treatment works?

One of the things that makes assertive community treatment somewhat unique is that it has been extensively tested, not just in university research settings as is sometimes the case with mental health research, but in real world settings. Studies that have compared ACT to case management services consistently find that individuals who receive ACT are less likely to be hospitalized and more likely to have stable housing than individuals who receive case management. Studies of consumer and family member satisfaction with care suggest that ACT is more satisfactory than case management.

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