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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Workbook for Clinical & Practical Supervisors
Principles of Assertive Community Treatment
Chapter 1
Objectives
Familiarize staff and Advisory Group members with the assertive
community
treatment model.
This chapter explains the history of ACT, the outcomes associated with this
model, key components, how assertive community treatment compares to case management,
and characteristics of the population who receive ACT services.
Team members will also need to know specific information about the particular
program in which they will be working, such as:
- admission criteria for consumers;
- criteria upon which the program’s fidelity to the assertive community
treatment model will be assessed;
- outcomes upon which the success of the program will be assessed.
Staff and Advisory Group members will understand the potential
benefits of assertive community treatment.
Studies that have explored what makes a difference in whether or not practitioners
adopt a new treatment approach have found that practitioners are more likely
to adopt a practice if it addresses an area in which they feel they need to
improve. With assertive community treatment, it may not be so much a matter
of an individual practitioner needing to improve, but of radically addressing
the way services are organized and delivered. Encourage team members to share
experiences where the traditional service delivery system has been inadequate
and help them identify aspects of assertive community treatment that address
those inadequacies.
Begin to build a ‘team’
The ultimate purpose of this chapter is to have staff begin to think and act
like a team. A critical component of a well-functioning team is open communication.
Working through this chapter creates an opportunity to learn about how team
members communicate in a team environment. You will want to have team members
discuss their responses to the questions in this workbook in a group format.
Some people have difficultly speaking up in a group. This might be because they
are somewhat timid or soft-spoken by nature. Others may feel professionally
intimidated by those with more experience or higher degrees. Conversely, some
team members will be very self-confident and outspoken and will need to learn
to listen openly to what others have to say. One of the leader’s roles
is to encourage individuals who are more withdrawn to express their views and
make sure that more vocal team members give others an opportunity to speak.
There will be an opportunity to assess anxiety that team members may feel about
working on an assertive community treatment team.
Introduce cross training
This chapter introduces cross training by having people begin to think about
the professional knowledge and expertise they have and how it could be of value
to other team members.
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Complementary Activities
Identify communication styles
There are a number of exercises that identify differences in the ways people
communicate and work. Often these exercises involve a brief quiz or questionnaire
that result in the person being identified as some particular ‘type’
of communicator or worker. If you do not have an exercise like this on hand,
check with your Human Resources Officer. If you are still unable to locate an
exercise of this nature, the Myer-Briggs Type Indicator is used for this purpose
but requires a person trained in interpretation of it. A number of adaptations
of this are available.
The idea behind having your team do an exercise of this nature is to help team
members understand their innate differences and to give them a vocabulary for
talking about those differences. Ideally, the exercise will include tips on
how people with different tendencies can communicate or work more effectively
with other ‘types.’ This can also function as an icebreaker.
Have team members take responsibility for presenting materials
to the team
One strategy for using this workbook is to have individuals read the materials
and come to a team meeting prepared to respond to the discussion questions.
Another option is to divide this workbook into sections, then have the team
divide into groups with each group taking responsibility for different sections.
Ask each group to plan a presentation of the materials for the larger group.
When they have finished, discuss the review questions together.
Write a mission statement or team motto
Part of being familiar with the assertive community treatment model and working
as a team is being clear about goals. You might have the group develop a brief
mission statement or come up with a one-line motto. Depending on the interests
of the group, they might also create a team logo.
Learn about consumers’ and family members’ perspectives
on mental health services
We encourage you to invite a group of 3 to 5 people who have been recipients
of mental health services and people who have family members who have been diagnosed
with a severe mental illness to participate in a panel discussion. These might
include members of the team’s Advisory Group, consumers working on the
team, or people identified through local consumer or family groups.
Ask panelists who have experienced mental illness to be prepared to discuss
the effect of their illness on them as a person. Also ask them to share experiences
they had with the mental health system that were helpful and those that were
not helpful.
Ask family members participating in the panel to discuss the experience of finding
out their family member had a mental illness and how their family member’s
illness has affected the family. Also, ask them to talk about experiences they
have had with the mental health system that were helpful and not helpful.
Have each panelist in turn tell his or her story and then ask the panelists
if they would be willing to entertain questions from the team?
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Principles of Assertive Community Treatment
- Assertive community treatment is a service delivery model, not a case management
program.
- The primary goal of assertive community treatment is recovery through community
treatment and habilitation.
- ACT is characterized by a:
• in vivo services
• time unlimited services
• flexible service delivery
• 24/7 crisis availability
• in vivo services
• time unlimited services
• flexible service delivery
• 24/7 crisis availability
- ACT is for people with the most challenging and persistent problems.
- Programs that adhere most closely to the ACT model are more likely to get
the
best outcomes.
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How did ACT change the way services are delivered?
Assertive community treatment (ACT) began when several mental health
professionals at the Mendota Mental Health Institute in Madison, Wisconsin realized
that many people diagnosed with a severe mental illness were being discharged
from inpatient care in stable condition only to return shortly thereafter. At
best, revolving door hospitalizations were accepted as inevitable. At worst,
people diagnosed with severe mental illness who did not fair well under the
existing system of care were labeled as ‘noncompliant,’ ‘treatment
resistant,’ or ‘unmotivated,’ and their needs
went unmet.
Rather than finding fault with the people who were not benefiting from existing
mental health services, the originators of assertive community treatment, Drs.
Arnold Marx, Leonard Stein, and Mary Ann Test, took a different approach. They
looked at the way mental health services were delivered and created a way to
change care so that people diagnosed with a severe mental illness could become
integral members of the community.
What they found was that:
- following discharge, the variety and intensity of services to support individuals
in their lives outside the hospital decreased dramatically
- services were invariably clinic-based, and admission criteria and rules
about continuing to receive services varied
- regardless of an individual’s needs, many programs were available
only for a limited period and were of no assistance once a person was discharged
- services were structured in a way that assumed individuals progressed steadily
from more to less structured services without consideration for individual
differences in the course of recovery
- if a service was not available, no one was responsible for insuring that
individuals got the help they needed
- even when a considerable amount of time was spent in the hospital teaching
people the skills they needed to live in the community, these skills did not
generalize to community living
- problems with shifting skills into the community were exacerbated by the
fact that many people diagnosed with a severe mental illness were particularly
vulnerable to the stress associated with change and new experiences.
The originators responded by designing a service delivery model in which a
team of professionals assumed responsibility for providing the specific mix
of services each individual needed at the appropriate frequency and intensity
and for as long as necessary, and in which team members were available 24 hours
a day, 7 days a week. Services were provided in vivo, that is, services were
provided in the community in places and situations where problems arise rather
than in an office or clinic settings. Interventions were integrated through
collaboration among team members. The individual’s response was carefully
monitored so that the team could quickly adjust interventions to meet changing
needs. Rather than brokering services from other providers, team members provided
an array of treatment and habilitation support themselves.
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What are the benefits of assertive community treatment?
Since the original assertive community treatment (ACT) program began in Madison
nearly 30 years ago, programs have been implemented in 35 states and in Canada,
England, Sweden, Australia, and Holland. As assertive community treatment spread,
researchers carefully studied its effectiveness. Reviews of assertive community
treatment research consistently conclude that, compared with other treatments
under controlled conditions (e.g., brokered case management, clinical case management),
assertive community treatment leads to a greater reduction in psychiatric hospitalization
and a higher level of housing stability. Research also shows that, compared
to other treatments, assertive community treatment has the same or better effect
on quality of life, symptoms, and social functioning. In addition, consumers
and family members report greater satisfaction.
While studies consistently show that assertive community treatment is associated
with many beneficial outcomes, the Patient Outcomes Research Team (PORT) made
up of researchers from the University of Maryland and Johns Hopkins University
found that people who might benefit from assertive community treatment often
do not receive this intervention. Those findings ultimately lead to the Implementing
Evidence-Based Practices Project and the development of materials to help mental
health systems implement assertive community treatment programs and other interventions
known to be effective for adults diagnosed with serious and persistent mental
illness.
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What are the ‘active ingredients’ of ACT?
One of the unique features of assertive community treatment is that
the important characteristics of this intervention have been delineated. The
characteristics of assertive community treatment have been translated into program
standards to help make certain that programs attempting to replicate assertive
community treatment are adhering to the model. An instrument called the Dartmouth
Assertive Community Treatment Scale (DACTS) is available to help teams assess
how closely their program is following the Assertive Community Treatment model
(See Appendix C). Your team leader will tell you about how your program will
use this instrument.
The following briefly describes some of the basic characteristics of assertive
community treatment:
Team approach – practitioners with various professional
training and general life skills work closely together to blend their knowledge
and skills.
Small caseload – a team consists of 10 to 12 staff
that serve approximately 100 consumers. This results in a staff to consumer
ratio of approximately 1 to 10.
Shared caseload – practitioners do not have individual
caseloads; rather the team as a whole is responsible for assuring each consumer
is receiving the services he or she needs to live in the community and reach
his or her personal goals.
Fixed point of responsibility – rather than sending
consumers to a variety of providers for services, the team itself provides the
services each consumer needs. If using another provider cannot be avoided (e.g.,
medical care), the team is responsible for making certain that the consumer
receives the services he or she needs.
In vivo services – services are delivered in the places
and contexts where they are needed
Time unlimited services – a service is provided as
long as needed, not on the basis of predetermined timelines
Flexible service delivery – the team meets daily to
discuss how each consumer is doing. The team can quickly adjust the services
they are providing to be responsive to changes in consumers’ needs.
24/7 Crisis services – services are available 24 hours
a day, 7 days a week. Team members often find, however, that they can anticipate
and head off crises.
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How is assertive community treatment different from
case management?
In an article published in 2001 in the journal Disease Management and
Health Outcomes, Bond, Drake, Mueser, and Latimer, leading ACT researchers,
compared assertive community treatment with case management models (Table 1.1).
They write:
Case management has been defined as the “coordination, integration,
and allocation of care within limited resources.” ACT is a model of care
that provides treatment and rehabilitation in addition to performing case management
functions. Although we discuss ACT in the context of case management, it should
be noted that ACT is a more comprehensive service model.
The typical goals of case management (e.g., preventing hospitalization,
improving quality of life, improving client functioning), as well as some typical
case management activities (e.g., service planning, assessment, and advocacy)
overlap with those for ACT programs. However, the methods and resources to achieve
these ends differ sharply.
Unlike ACT, traditional case managers usually broker services (i.e., link
consumers to other service providers) rather than intervening directly. Brokered
case managers have individual caseloads, typically averaging about 30 consumers
(sometimes more), and far more circumscribed job duties.
ACT also differs conceptually from intensive case management (ICM). One
important difference is that ICM has no single origin. Consequently, unlike
ACT, ICM has not achieved clear consensus in its essential ingredients. One
frequently-mentioned difference between ACT and ICM is that ICM programs do
not subscribe to the team approach with shared caseloads and daily team meetings,
a difference that has en empirically confirmed in one study.
Table 1.1 A Comparison of Case Management and ACT
Case Management Programs |
ACT Service Delivery Model |
| Caseloads of 30 or more |
Staff to consumer ratio of about 1 to 10 |
| Services ‘brokered’ from other providers |
All services provided directly by team members |
| Case managers have sole responsibility for people assigned to them |
Team members share responsibility for all individuals |
| Change in intensity of services means change in providers |
Type and intensity of services can be varied easily |
| Individuals receive services they need IF the service exists, the person
meets eligibility criteria, and there is space in the program |
Team members provide ANY service a person needs |
| Individuals may be dropped from the caseload if they are ‘noncompliant,’
in jail, or receiving services somewhere else |
Team is responsible for assuring people receive services they need even
if they are difficult to engage, get arrested, or are hospitalized |
| If a case manager quits or goes on vacation, consumers are switched to
someone else or do not receive services |
If a team member goes on vacation or quits, service plans are continued
by other team members who are known to the consumer |
| Team discusses changes in individuals’ status daily and adjusts
treatment as needed |
Team discusses changes in individuals’ status daily and adjusts
treatment as needed |
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How is an ACT team different from other teams?
People from multiple disciplines work together on assertive community
treatment teams, but it is not technically a ‘multidisciplinary team.’
Rather, an assertive community treatment team is what is known as a transdiscdiplinary
team. Table 1.2 on page 19 compares transdisciplinary and multidisciplinary
teams.
One way of thinking about a transdisciplinary team is as a vehicle that blends
the knowledge and skills of professionals from multiple disciplines with the
goals of service users to surpasses the limitations of individual disciplines
and service programs. It even transcends the typical provider-consumer relationship.
Consumers have a decisive voice in what services they receive and the way they
receive them. This model allows providers to deliver a comprehensive and integrated
array of services to individuals who have complex needs.
As a transdisciplinary team, assertive community treatment teams are set up
around a task - keeping individuals out of the hospital and supporting their
recovery from mental illness. This is very different from the way mental health
services are usually set up.
Typically, services are set up in a predetermined hierarchy or configuration.
The service system then tries to fit the tasks that it is given into that configuration.
In contrast, the configuration of ACT services is not predetermined. Instead,
ACT teams start with a task – keeping an individual out of the hospital
and supporting his or her recovery. The team’s resources and services
are then configured to accomplish that task. What this means essentially is
that rather than trying to fit people into a rigid service system, services
are fitted to people’s needs.
Several things can go wrong in the more traditional hierarchal system, especially
when service users have needs that are as complex as the needs of individuals
receiving assertive community treatment services. In traditional service models,
services may be delivered sequentially. For instance, one provider at one agency
treats the person’s mental illness, and after that problem is treated,
the person is sent to a substance abuse treatment program or to a vocational
program. One of the problems with this ‘pass around’ approach is
that many problems are too pressing to wait for attention, and some problems
are of such a protracted nature that the person might never get to the next
provider.
Another problem under the usual care system is to provide parallel services.
For instance, a mental health professional and a substance abuse treatment provider
work with a person at the same time. Ideally, practitioners communicate with
each other, but even so they may duplicate efforts or miss information that
might be relevant to the other provider or work at cross-purposes.
In a transdisciplinary team, team members work together intimately so that
each team member can draw on every other team member’s knowledge, skills,
and observations, and a precise combination of carefully crafted, well-integrated
services.
Open communication is essential to providing integrated services. Assertive
community treatment teams work in shared space to facilitate the informal sharing
of information. They have daily meetings where they talk about what is going
on with each consumer.
It is difficult to have a transdisciplinary team if some service users are
‘yours’ and some are ‘mine.’ That is why members of
assertive community treatment teams do not have individual caseloads. Specific
consumers may be assigned to mini teams for administrative purposes, where a
subgroup of team members works very closely with particular consumers, but the
team as a whole is responsible for the success of every consumer.
In order for a transdisciplinary team to function optimally, cross training
has to occur. This does not mean that every member of the team prescribes medicine
or does physical examinations. Some tasks are governed by licensure and laws.
However, many of the things that team members know that are specific to their
discipline can be taught to people from other disciplines. Those other people
then become extra eyes and ears, can recognize when there is a problem brewing,
help deliver or reinforce interventions, and communicate from a broader perspective
about what is going on with each consumer.
Cross training occurs while doing comprehensive assessments, during treatment
planning, and in daily meetings. On new teams, cross training can be facilitated
by having members of different disciplines work together jointly with consumers.
By observing the types of questions team members from other specialists are
asking and finding out why that information is important, colleagues can begin
to understand each other’s professional perspectives and skills. Teams
can also make opportunities for members from the various disciplines to ‘teach’
their teammates about their discipline.
Working on a transdisciplinary team can be taxing. It requires flexibility
and a willingness to set aside professional turf. On the other hand, working
on a transdisciplinary team can be very rewarding. Many professionals who have
worked in this model find that it is less stressful because other team members
are available to provide expertise and support. They also see the work environment
as being enriched, find that problem solving is easier, and they enjoy opportunities
to learn from other disciplines. Most of all, professionals find it rewarding
to see consumers benefit from a service model that meets their needs and helps
them achieve greater independence.
Table 1.2 COMPARISONS of Team Models
| |
Multidisciplinary |
Interdisciplinary |
Transdisciplinary |
| Assessment |
Separate assessments by team members |
Separate assessments with consultation |
Team members conduct comprehensive assessment together |
| Consumer Participation |
Consumers meet with individual team members |
Consumers meet with team or team representative |
Consumers are active and participating team members |
| Service Plan Development |
Team members develop separate plans for disciplines |
Team members share separate plans with each other |
Team members and consumers develop plans together |
| Service Plan Implementation |
Team members implement part of plan related to their discipline |
Team members implement their section of plan and incorporate other sections
where possible |
The team is jointly responsible for implementing and monitoring the treatment
plan |
| Lines of Communication |
Informal lines |
Periodic case-specific team meetings |
Regular team meetings with ongoing transfers of information, knowledge
and skills shared among team members |
| Guiding Philosophy |
Team member recognizes the importance of contributions from other disciplines |
Team members willing and able to develop, share and be responsible for
providing services that are part of the total service plan |
Team members make a commitment to teach, learn and work together across
disciplinary boundaries in all aspects to implement unified services plan |
| Staff Development |
Independent within each discipline |
Independent within as well as outside of own discipline |
An integral component of working across disciplines and team building |
Woodruff, B. & McGonigel, M (1988). Early intervention
team approaches: The transdisciplinary model. In J.G. Jordon, J.J. Gallagher,
P.L. Hutinger, & M.G. Karnes (Eds). Early childhood special education: Birth
to three. Reston, VA: Council for Exceptional Children cited in Nicholson, D.,
Artz, S., Armitage A., Fagan J., (2000) Working relationships and outcomes in
multidisciplinary collaborative practice settings. 29(1), 39-73
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How does an ACT team relate to other services?
Quality care is delivered by many capable people in mental health and
related systems. It is the case, however, that some consumers need a higher
level of resources and a different approach to service delivery. This is a fact
- not a criticism of the work of individual mental health professionals.
ACT teams may find that other professionals within the mental health system
will be envious of the resources, training, and skills of the team. Teams will
need to build relationships with other providers to assure seamless and coordinated
care. There will be times when, for instance, hospitalization cannot be avoided
or when a consumer who has been stable for an extended period will be ‘stepped
down.’ Team members must work alongside and partner with professionals
in other services to assure consumers receive proper and continuous care.
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Who uses assertive community treatment services?
Based on The PACT Model of Community-Based Treatment for Persons
with Severe and Persistent Mental Illnesses: A Manual for PACT Start-Up,
published by The National Alliance on Mental Illness ACT Technical Assistance
Center. Deborah Allness & Bill Knoedler (NAMI). Copyright 1999, Used with
permission.
Target Population
Assertive community treatment is designed for consumers characterized as those
in the greatest need, estimated to be 20 to 40 percent of persons with severe
and persistent mental illness. Criteria for selection include psychiatric disorders
(schizophrenia and bipolar illness of a minimum), which severely impair functioning
in the community. Impairment is likely in multiple areas (1) inability to perform
practical tasks required for basic functioning in the community; (2) inability
to be consistently employed or carryout homemaker roles; or (3) inability to
maintain a safe living situation. They are also likely to have a history of
high service needs (e.g., repeated hospitalizations, a history of substance
abuse or criminal justice system involvement, substandard housing or homeless).
Some programs will focus exclusively, for example on a criminal justice or homeless
population, this will influence the amount of specialized expertise required
by the full team.
People are not excluded from receiving services because of severity of illness,
disruptiveness in the community or in the hospital, or failure to participate
in or respond to traditional mental health services (e.g., outpatient therapy,
day treatment). During acute episodes, people are often unable to adequately
care for themselves and need intensive services and supports, including hospitalization.
Symptoms may completely remit with effective treatment for the majority of consumers,
but for others symptoms only partially remit and they experience them continuously.
In addition to symptoms, a significant number of people with severe psychiatric
conditions have persistent impairments that are the cause of long-term disability
and poor community functioning. Impairment, may be present months or years before
the onset of recognizable psychiatric symptoms, may worsen during acute symptom
episodes, and tend to persist even after symptom remission. Some impairments
require a long-term, ongoing, and consistent approach to intervention.
Impairment, even more than symptoms, produces enduring challenges in employment,
personal care, and socialization such that living in the community is often
difficult, and in some circumstances impossible without extensive and regular
assistance from others. Many adults with severe and persistent mental illnesses
struggle with day-to-day living tasks such as personal hygiene, cooking, shopping,
and managing money. As a result of the impairments associated with severe and
persistent mental illnesses, individuals are often single, isolated, and have
few non-family relationships and supports. Unemployment or ability to work only
part-time or intermittently is another significant issue. Compounding these
difficulties are the stigma and rejection that persons with severe and persistent
mental illnesses experience from the rest of the community.
As a consequence of problems in daily living, adults with severe and persistent
mental illnesses are typically poor and financially dependent on entitlements
and other benefits (e.g., Supplemental Security Income, Social Security Disability
Insurance, Medicaid, veterans’ benefits) and on family. Many persons with
severe and persistent mental illnesses cannot afford decent housing, therefore
constituting a significant portion of the homeless population in the United
States. Further, poverty along with mental illness makes persons more vulnerable
to arrest and incarceration, mostly for misdemeanor offenses, and to victimization.
Adults with severe and persistent mental illnesses also more often die prematurely
from suicide or physical illness, and they frequently become involved in the
use and abuse of alcohol or other substances.
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Who are ‘consumers in greatest need’?
Assertive community treatment programs serve individuals with the greatest
need. Consumers in greatest need are individuals who have severe symptoms and
impairments that are not effectively remedied by usual treatment or who, for
reasons related to their mental illness, resist or avoid involvement with traditional
mental health services.
Consumers in greatest need include people who:
- have major symptoms that improve only partially or not at all
with medication and other treatments and who, as a result, have severe persistent
or intermittent symptoms that create personal suffering and distress (e.g.,
hallucinating and delusional most hours of the day and, consequently, fearful
and isolated)
- have serious disability resulting from mental and behavioral impairments
(e.g., evictions because of poor care of residence and disruption of neighbors,
job losses secondary to poor concentration and anxiety about co-workers)
- have co-existing substance use disorder, physical illnesses or
disabilities (e.g., diabetes, visual impairment) that aggravate psychiatric
symptoms and impairments and magnify overall service needs
- appear to ‘resist or avoid’ involvement in services
because:
- illness changes their beliefs and perceptions (e.g., delusions and
hallucinations) so that they have difficulty acknowledging that they have
a mental illness and view metal health services as a threat, or as unnecessary
- other symptoms (e.g., disorganization and confusion of thinking), impairments
(e.g., anxiety, social withdrawal, limited attention span), and associated
problems (e.g., substance use, sexual inappropriateness) limit their ability
to meet the participation expectations of standard psychiatric services
- some traditional services designed for persons with severe and persistent
mental illnesses (e.g., day treatment programs, group homes) do not easily
accommodate individual choice and personal preference
- persons diagnosed with severe and persistent mental illness sometimes
view such programs as stigmatizing and limiting, rather than promoting
their opportunity to have normal life experiences (e.g., job, home)
Because they do not wish for, or cannot receive consistent help, many of these
individuals go without services and persistently experience symptoms, impairment,
and are at risk of becoming more refractory to treatment when they do eventually
receive it. Consumers in greatest need often have the poorest quality of life
and create the greatest social and financial costs of persons with severe and
persistent mental illnesses. In particular, these individuals are more likely
to frequently use emergency and inpatient medical and psychiatric services,
to be homeless or live in substandard housing, to be arrested and incarcerated,
or to die prematurely from suicide or physical illness.
Many of these individuals may have already been ordered into treatment involuntarily
(e.g., inpatient commitment, probation, or parole expectations) and consequently
approach their caregivers with anger and resentment. Providing effective services
for these persons requires providers to reach out and:
- make visits in the community, on the street, or in jails, shelters, and
impoverished living situations
- to understand substance use
- to listen, support, and provide assistance, even when individuals may have
trouble following through (e.g., paying bills)
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Review
- Before Assertive Community Treatment what characteristics of mental health
services made it difficult for ‘consumers with the greatest need’
to get the services they needed. What were these problems?
a. Have you ever encountered any of these problems when working
with people diagnosed with a severe mental illness? If so, what happened to
these people?
b. Which aspects of Assertive Community Treatment that might
have made a difference? Explain.
- Why would it be inaccurate to describe ACT as just a case management program?
- What characteristics of Assertive Community Treatment programs help to facilitate
communication between team members?
- What are the characteristics of ‘consumers with the greatest need’?
- As you anticipate working on an ACT team what do you expect to be the most
difficult or challenging aspect of working.
- What do you expect to be the most satisfying aspect of working on an ACT
team
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