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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Implementation Tips for Mental Health Program Leaders

Part 3. The Assertive Community Treatment Team as a Complex Adaptive System

Charlene Allred, RN, Ph.D.
An ACT team performs various complex activities in response to continuous changes in the status of consumers served by the team. People and other resources are brought together across disciplinary boundaries. On any given day, the situations encountered by the team might range from the routine to the “never been heard of before.” Leaders come to the forefront and recede into the background based upon the needs of consumers and which team members have relevant information, experience, or skills. The team knows that what worked with one consumer may not necessarily work with the next or in a similar situation. Therefore, in working with consumers, the team is constantly organizing and reorganizing its activities.

To be effective the ACT team must be alive—it must be adaptive, flexible, intelligent, reflective, renewing, resilient, and constantly learning. The ACT team is a living system that has an identity that shapes what it sees and does. It is nourished by an abundance of information, and lives and learns within a web of relationships.

The Assertive Community Treatment Team as a Cognitive and Social Process

An ACT team is comprised of individuals from a variety of disciplines. The key challenge for team leaders is helping team members to combine their knowledge in order to develop innovative and efficient strategies to help people with severe and persistent mental illnesses reach their recovery goals.

The ACT team operates as a transdisciplinary team. In a transdisciplinary team, the team members relate to one another in a highly integrated fashion. They make a commitment to teach, learn, and work together across professional boundaries for all aspects of care that affect a consumer’s life in the community. ACT team members are accountable to one another. Together they assess the consumer, develop a comprehensive treatment plan, monitor and review the plan, and support one another in whatever way is necessary to assure the treatment plan is implemented in the most effective way.

In order to come up with creative strategies to help consumers reach their goals, an ACT team engages in knowledge-producing activities. Knowledge is embedded in the expertise of the team’s members and in their interactions. The team members must share this knowledge so that the team functions as a single unit of expertise. An effective team is greater than the sum of its parts. That is, an effective team is more than a collection of well-coordinated, discrete individuals representing different professions.

Two strategies are used to release the knowledge embedded in ACT team members and their interactions. These strategies are:

1. sensemaking
2. self-organization

Sensemaking. Sensemaking is a way to reduce confusion about what might be going on with a consumer. The first thing that the ACT team does when engaging in sensemaking is to gather information. An example of the team trying to make sense of a situation is when the team gathers to review a comprehensive assessment. Together, the team members blend their perspectives or viewpoints in ways that result in a collective or shared understanding of the consumer’s needs. This dynamic interaction of information gathering and perspective blending is what enables the ACT team to envision solutions to complex problems and even new creative possibilities.

Self-organization. Once the team has devised a treatment plan, the team must organize itself to implement the plan. Self-organization emerges from the interactions and patterns of relationships between team members, the consumer, and the community. It refers to the team’s ability to spontaneously change in such a way that a new behavior or process can emerge in response to consumer needs.

Imagine the ACT team as an improvisational jazz ensemble. A jazz ensemble typically has no designated leader but all the members have a similar focus—music making. Through the music, they develop an unspoken connection with one another. Each musician’s contribution to the music is based upon what his/her fellow musicians are doing within the context of a particular piece of music. The fantastic music that emerges could not have been predicted by listening to anyone musician alone nor would it necessarily sound the same the next time these musicians joined.

Like the jazz ensemble, the complex and well-coordinated activities of the ACT team are more than the sum of its individual members. Sometimes the most unusual or unexpected behaviors may drive the team to greatness.

Tools for Sensemaking

The tools that ACT team members need for sensemaking include (but are not necessarily limited to):

• Contributing
• Representing
• Subordinating
• Understanding
• Collaborating
• Learning

The tools of contributing, representing, and subordinating help team members create a system of interrelated activities. That is, all of the team’s activities are related to one another and, at the same time, directed toward helping consumers reach their recovery goals. Nobody is working at cross-purposes—the team operates as a single unit of expertise.

Contributing. Contributing refers to the action(s) taken by a team member. The team member must act with an awareness of how his or her behaviors fit into the “big picture.” To act with awareness then, you first must understand the “big picture.” But sometimes, the big picture is not immediately or exactly clear. Therefore, this means that you must learn to pay attention. Contributing team members pay attention to discrete pieces of information and, in thoughtful ways, notice patterns that emerge over time relative to the consumer, team, or community.

• For example, one day you visit a consumer and notice that there are some dishes of water stacked on the table. While you’re helping the consumer with cleaning up his apartment, you simply wash the dishes and return them to the kitchen cabinet. A few days later, you once again notice dishes of water stacked on the table and once again wash them and return them to the cabinet.

Unbeknownst to you, other team members have observed and did the same thing. No one who observed this behavior mentioned it at the daily team conference. The following week, the consumer is picked up by police in an adjoining state and is experiencing an acute manic episode.

At the next day’s team conference, a team member mentions they observed dishes of water stacked on the table during a visit. You mention a similar observation and so do other team members. A behavior pattern—filling dishes with water and stacking them - begins to emerge, suggesting that, for this particular consumer, this pattern may be an early warning sign of relapse.

Representing. In the above example, each team member took an action—putting the dishes back into the cabinet - and concluded that the “isolated event” was not anything that needed to be reported at the daily team conference.

When team members represent, they construct their actions with a conscious awareness that their actions are part of a system of joint actions—other team members will interact with the consumer and take their own actions based upon the actions of others who have seen the consumer prior to them.

For an ACT team to be successful, its team members must remember that their individual actions are connected to the actions of others. The idea that an action, such as returning dishes to the cabinet, is connected to other team members’ actions was lost in the above example. The team members did not interact with care because they failed to see their own behavior as part of a system of joint actions.

Subordinating. Subordinating means that ACT team members always interrelate their actions with the actions of other team members. They subordinate their individual action to the team’s larger system of joint actions.

Continuing with our example, subordinating would have meant that each individual team member interrelated their actions to the actions of others by reporting the incident and their own actions to the entire team at the daily team conference. Had the team members brought this information forward the team would have been able make sense of the consumer’s behavior and create an action plan that may have thwarted the relapse or at least minimized its severity.

Understanding, Collaborating, Learning. Successful ACT teams generate solutions to complex challenges. Carrying out these solutions represents a well-defined system of interrelated activities among the team members. When team members are tied together by trust they are able to interrelate their activities more easily than when there is suspicion. Through understanding, collaborating, and learning, team members listen, share information, and connect in a manner that builds trust.

One kind of understanding that builds trust is interpersonal understanding. Interpersonal understanding means that team members develop an appreciation of one another’s preferences, concerns, strengths, and weaknesses. Individual personalities, skills, values, work styles, professional and personal experiences, and agendas all affect how the team interacts and the level of trust among team members. Exercises that provide opportunities for team members to share information about these traits can facilitate interpersonal understanding. Set aside time for team members to get to know other team members.

Successful ACT team members cooperate rather than compete with one another. They are able to do so because they have trust in the team process. They trust that fellow team members will work toward team goals rather than individual goals. They trust that each member of the team will complete their tasks successfully either by themselves or involving others with the appropriate expertise.

Collaboration is enhanced when team members:

• Listen;
• Avoid premature judgments;
• Communicate in a way that stresses coordinated action over everyone having to agree all the time;
• Show respect for differences rather than unrestricted candor;
• Contribute in an ongoing way, not just once in a while;
• Share information over and above the minimal amount required by each person to do the job; and
• Think of the team goals rather than personal goals.

Solving complex consumer problems requires that team members continuously learn. Learning within the team emerges from the connections and communications between members and others possessing diverse perspectives and areas of expertise. When team members connect with one another, they share information from many viewpoints and develop a common understanding of the consumer’s strengths, weaknesses, and goals. When the consumer’s goals are understood in a new way, new knowledge is created. In other words, team learning has occurred and this opens new possibilities for team response options and a better future for the consumer.

Team members can encourage learning by being:

• Trustworthy;
• Willing to share information;
• Open and nonjudgmental in their communications;
• Issue oriented rather than personality oriented;
• Willing to discuss mistakes openly;
• Willing to give and receive feedback;
• Comfortable communicating thru a variety of channels including face to face, phone, meetings, written documents, and email, etc.;
• Open to questioning, exploring, experimenting, discovering, and innovating;
• Reflective upon prior experiences including actions and consequences;
• Ready to experience events more richly through a variety of interpretations;
• Willing to ask the tough questions like “What if?”; and
• Receptive to a work environment where responsibilities and priorities are clear but roles are fluid.

Tools for Self-Organizing.

The tools that ACT team members need for self-organization include (but are not necessarily
limited to):

• Decision making
• Creativity

Decision Making. The quality of the ACT team’s decisions is the cornerstone of the team’s overall effectiveness. The decisions represent the ACT team’s response to a consumer problem or goals. The reason that we’ve emphasized the group member skills of contributing, representing, subordinating, understanding, collaborating, and learning is that all of these skills come together as ACT team members participate in the decision-making process. We encourage participation in the decision-making process by all team members.

The scope of participation will be determined by the need or problem to be solved and a team member’s area of expertise. How intensively a team member participates in the decision making process is dependent upon a variety of activities that connect the team member to the decision making process.

The ways that team members can participate in the decision making process include:

• Taking necessary actions to thwart a problem or meet the need (including teaching the consumer the skills to solve the problem or meet the need);
• Engaging in direct and frequent contact with other team members, the consumer, and community as it relates to the identified problem or need;
• Raising issues related to the problem or need;
• Providing information that will help to define, shape, and communicate the problem or need;
• Using reflection, discussion, scenario analysis, and brainstorming to generate a variety of possible solutions to the consumer’s problem or ways to meet a need;
• Imagining potential reactions from the consumer and community in response to each possible solution before the final decision is made;
• Supporting a selected solution while understanding the perfect solution is often impossible; and
• Recognizing that once a solution is implemented, changes may be necessary in the solution chosen, how it is being implemented, or in even how the original problem was defined.

Creativity. Self-organizing occurs when the conversations between ACT team members results in behavior(s) that solve a consumer problem or meet a consumer need. In other words, the team has identified a plan, now they must organize themselves to implement it. Plan implementation is more complex when there are no routines or procedures to guide team member actions and the team must “invent” a procedure for implementing the solution. Hence, if the ACT team is going to be successful, creativity is an essential skill for team members. Creative team members have active, exploratory minds and are inventive, resourceful, imaginative, and even ingenious!

A creative approach to problem solving requires ACT team members to:

• Embrace diversity in viewpoints and relationships;
• Think in terms of relationships, not specific roles;
• Form weak ties with a variety of individuals rather than strong ties to just a few—social pressure to conform with the status quo will be less;
• Notice connections, patterns, subtle changes, or emerging events;
• Use timelines, maps, models, or visual images to notice connections or relationships between seemingly small events;
• Be imaginative–use artistic representation to visualize things quite differently than the way they appear in the real world;
• Trust intuition and go with your “gut”--facts and reason may reveal themselves at a later point in time;
• Improvise—normally we plan an action and then execute it but sometimes things don’t go as planned and we have to think on our feet or plan as we go along;
• Use existing rules or procedures in new ways or new situations;
• Experiment by figuring out how to make things work with what you have on hand; and
• Be tolerant of uncertainty or ambiguity—the tension it creates is a vital source of creative energy.

The Role of the ACT Team Leader

The ACT team leader facilitates the team’s sensemaking and self-organization actions by recognizing that relationships are everything. The ACT team functions as a single unit of expertise, and an indivisible, dynamic whole because team members’ actions are highly interrelated.

The role of the ACT team leader is to support the development and growth of crucial relationships by making sure that team members are diverse in their expertise, constant recipients of information, and well-connected to others. Relationship building tools available to the ACT team leader include (but are not necessarily limited to):

• Meaning Creation
• Designing

Meaning Creation. When the ACT team “loses meaning” they are unable to comprehend or make sense out of what is going on with a consumer. If this goes on for a long time, the consumer may be at risk. Leaders create meaning by helping the ACT team members to make sense out of consumers’ behaviors. The result is that team members have a common or shared understanding of the situation. Hence, the leader’s goal is to help minimize confusion so that the team can come up with a solution to the consumer’s problem(s) or a way of helping the consumer meet goals.

The ACT team leader can help the team members create meaning by:

• Accepting that the world is unpredictable and giving up trying to plan for and control everything;
• Talking less and listening more;
• Maintaining a unified vision that blends different viewpoints and at the same time manages conflict;
• Building trust and seeking individuals who are able to be attentive, alert, honest, and caring;
• Building a culture that supports open communication, questioning, exploring, and learning;
• Seeking diversity in team members experiences and knowledge;
• Building trust within the ACT team related to team orientation and technical competence—ACT team members must know that their fellow team members are working toward team goals rather than personal goals and that they have the competencies to complete the tasks that are critical to the consumer’s well-being;
• Seeking team members with “T-shaped skills”—these are persons who are expert in a specific area with an equally deep understanding of how their expertise relates to the expertise of other team members;
• Developing “A-shaped skills”—effective leaders have the ability to combine the insights of different team members (who actually represent different areas of expertise) in ways that produce a new understanding of a complex situation;
• Encouraging informal leadership—as the number of informal leaders on a team increases, team member ownership of the team process and team cohesion increase;
• Encouraging rich, personal interactions among team members in the form of direct (face to face), and frequent (daily), contact through informal channels;
• Recognizing that the team is not a society for historical preservation and rewarding team members for discarding the obsolete and unlearning “old ways”; and
• Focusing on real-time learning—or learning as the team is acting.

Designing. Once the ACT team is up and running, it is by no means a finished work! The team is constantly “becoming” because it is always in communication with its own members, the consumer, and the community. As the team, consumer, and community interact, they “adjust” to one another whereby they are changed or made different in some way because of the interactions. These interactions are crucial to team effectiveness because they contain vital information that enables the team, consumer, and community to adapt to the situation at hand. Therefore, a successful relationship between the team, consumer, and community can only happen if they work from sources of information that are rich and varied. In other words, information is the life force behind an effective team.

Designing is a tool that an ACT team leader can use to make sure the team, consumer, and community are supplied with a continuous flow of information. The goal of designing is to create sets of relationships among people who are different from each other, where each represents a source of critical information for team sensemaking and self-organization. Successful design strategies include (but may not necessarily be limited to):

• Building a variety of connections between people that have a rich capacity for information exchange so that people can work together to identify goals and develop action alternatives;
• Including more of a variety of people in the decision making process;
• Seeking diversity among the team because individuals with heterogeneous backgrounds tend to take in more and see significant patterns and relationships more quickly than a group of individuals with homogeneous backgrounds;
• Teaching team members what other team members are doing by encouraging overlapping roles and knowledge sets because under pressured or novel conditions, even if the team disintegrates the roles will remain alive in people’s mind;
• Avoiding over commitment to existing ways of doing things;
• Remembering that creativity exists on the boundary between order and disorder; and
• Maintaining an attitude of wisdom by avoiding over cautiousness or over confidence.

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