This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryWorkbook for Clinical & Practical SupervisorsACT Service components 59Chapter 4
Objectives Identify areas where cross training is needed. Learn more about assertive community treatment services. Overview The services delivered by ACT teams should not be thought of as discrete, disconnected services but rather as parts of an integrated intervention. Services provided by teams target problems and address objectives in multiple areas of a consumer’s life (see Figure 4.1 next page). Figure 4.1—ACT Service ComponentsMedication Support Educate about medications Psychosocial Treatment Community Living Skills Health Promotion Family Involvement Housing Assistance Employment *See seperate Implementation Resource Kits specific to these services for more information, as described briefly in Appendices D - I of this workbook. Medication Support Not all people diagnosed with a psychiatric disorder benefit to the same extent
from medications and some people will decide they do not want to take medications.
If a person decides not to take medications, the team continues to work with
him or her in other areas. It may be helpful to talk with people who are considering
discontinuing medications about previous experiences when they stopped taking
medications and plan with them ahead of time what they would like to have happen
should their symptoms get worse. If people experience an exacerbation of symptoms
when not taking medications, team members can work with them to assess out the
relationship between not taking medications and experiencing acute psychiatric
symptoms and also, to weigh the relative costs of taking medications versus
Educate about medications Order medications from pharmacy Deliver medications to clients
Organize medications Monitor medical compliance and side effects Use of medications Psychosocial treatment Managing illness
Crisis intervention – 24/7 availability
In responding to these needs, the team might:
Around the clock availability of the ACT team allows a quick response to a crisis. Knowledge that the team will see or talk with a consumer whenever necessary is very reassuring to the consumers and family members. Crisis visits are more frequent in the early stages of involvement in ACT. Once it is clear that such support is truly forthcoming, the number of crises usually diminishes and can often be handled by telephone. Dual disorders treatment When a consumer is suspected or known to have a substance abuse or dependency disorder, one of the team’s substance abuse specialists is assigned to work with the person. The substance abuse specialist has primary responsibility for assessing the person’s substance use disorder and planning treatment. The substance abuse specialist collaborates extensively with other members of the team in carrying out these interventions. The use of outside providers for substance abuse treatment is highly selective. An instance where an outside provider might be used is for detoxification or when residential services are warranted. When outside services are used, the team refers consumers to those programs that are adapted specifically to consumers with dual disorders.
Care coordination (e.g., hospital with community) You may be able to address problems that lead to hospitalization by increasing the number of contacts you are having with a person, but there will still be times when hospitalization is necessary. You are going to try to do that before a problem becomes a crisis. You are also going to keep the consumer’s community resources in place if you can -- for instance, keep their housing. Acute psychiatric hospitalization. Although the team has the ability to quickly respond to changes in a consumer’s status, there will still be times when inpatient care is appropriate. When a consumer is admitted to an inpatient setting, the team’s role is to make the transition from outpatient to inpatient status, and back again, as smooth as possible and to facilitate collaboration between the team and the inpatient staff.
The PACT Manual suggests that short-term psychiatric inpatient treatment may be appropriate for people who:
According to The PACT Manual, longer term hospitalization is appropriate for consumers who have such severe symptoms and accompanying poor functioning that they are often at risk of harm to others or themselves or cannot carry out basic survival tasks (e.g., nutrition, shelter, clothing, healthcare, protections from harm) despite very intense daily team efforts and repeated short-term psychiatric hospitalizations over an extended period of time. When inpatient care is needed, the assertive community treatment team collaborates with inpatient staff to facilitate rapid development of a treatment plan and provide continuity in treatment to the greatest extent possible. Admission to the unit. There will be times when consumers will seek emergency admissions on their own or they may be taken to the hospital by family or emergency personnel (i.e., EMS, police), but in most cases the assertive community treatment team will usually initiate inpatient admissions. When the team is involved in the admission process, team members can provide emotional support to the consumer and share information with the inpatient staff that facilitates their understanding of the consumer’s history, current status, and create a smoother transition between outpatient and inpatient care. It is difficult to admit consumers unless funding for the hospitalization is assured ahead of time, though in true emergencies hospitalization will proceed even if this is not guaranteed. Where the consumer has insurance (e.g., Medicare or Medicaid, funding may not be a problem, though increasingly payors require preadmission and concurrent review). Where preadmission assessment is required, staff usually must present information and negotiate with a screening or gatekeeper agency that has authority to provide funding. When this agency is closely managing local funding and using very tight criteria for hospitalization, this negotiation can be a difficult process demanding patience and skill. After the funding for the admission has been approved, a team member calls the attending psychiatrist of the inpatient unit to request admission and explains the details of the case. The team member also informs a nurse on the unit. When the inpatient unit has approved the admission, a team member accompanies the consumer to the unit, helps him or her through the admission process, assists the inpatient staff in establishing communication with the consumer, and settles the consumer into the unit. This team member should bring a copy of the current treatment plan and a list of current medications with their dosages and side effects. Key tasks during hospitalization. The team stays actively involved with consumers who are hospitalized. Someone on the team who has worked closely with the consumer visits the consumer at least once a day (assuming geography permits). These visits are to assess the consumer’s status and progress, implement parts of the treatment plan (with the agreement of the inpatient staff), make recommendations to the inpatient staff, and provide support and advocacy for the consumers. There are a number of practical ‘rules of conduct’ the team follows in working with hospitalized consumers and the inpatient staff:
The team psychiatrist should regularly (i.e., once or twice a week) confer with the inpatient psychiatrist to relay his or her, and other team members’ observations and recommendations. Most inpatient units organize their collective observations and formulate treatment plans for consumers in staffing meetings. Usually, an initial staffing is held within the first few days of admission, with others scheduled as needed or at regular intervals thereafter. The consumer often attends part of the meeting. Team staff should respectfully but assertively ask to be involved in these meetings, starting with the first one soon after admission. Inpatient staff are usually quite receptive to this involvement and will learn to plan and rely on it. Most consumers will usually remain continuously on the inpatient unit over the first one to two days of admission to allow for assessment and treatment of presenting symptoms. Thereafter, it is useful for most consumers (unless suicidal or very easily distressed) to continue to be involved with their life and treatment in the community, even on a daily basis. When not clinically counter-indicated, passes for consumers to go on visits into the community might be part of the overall treatment plan that is developed with the inpatient staff. Passes allow consumers to stay involved in normal activities (i.e., handling tasks like paying bills or retuning to work); in social and supportive relationships (e.g., visit with family and friends, contact with the team); and in personally satisfying activities (e.g., going for a walk, shopping while in the hospital). Overnight or weekend passes provide a method for the consumer and team to assess consumer improvement and readiness for discharge. Discharge planning and return to the community. Some consumers will only be hospitalized for a short time and will need very little change in the treatment plan guiding the assertive community treatment team’s interventions in anticipation of discharge. In other cases, markedly different interventions may be needed at discharge. Passes can be used to test new interventions prior to consumer discharge. Long-term hospitalization. A few consumers will require long-term (i.e., 3 months of more) hospitalization. These admissions are usually involuntary and preceded by an appropriate legal process. Continuity of care (i.e., continued team participation) is as important for these consumers as for consumers hospitalized on acute units. The team usually initiates the legal or other proceedings leading to the commitment, usually after an extended period of unsuccessful treatment in the community. Relying heavily on the strength of its teaming capacity, team members approach the consumer hospitalized long-term with the same commitment, energy, and community orientation as they do any other consumer; at the same time they support and assist the inpatient staff to provide optimal treatment. This means visiting the consumer at least weekly to assess progress and status, developing treatment plans in collaboration with the inpatient staff, attending regular staffing, and involving the consumer in regular treatment and rehabilitations activities in the community as part of the treatment plan (i.e., work, socialization, etc). Discharge planning should be underway long before discharge. Outpatient treatment and rehabilitation activities should have been an ongoing part of the treatment plan and are increased in intensity as the consumer moves closer to discharge. In fact, readiness is determined by the consumer’s ability to handle increased expectations in the community. Necessary resources (particularly housing) may have to be secured and the consumer introduced to them (e.g., overnights, extended visits). The outpatient plan is usually an intense and structured one and anticipates the need for at least once-per-day contacts, including supervision and assistance in the area of medications, self-care and care of residence, finances, socialization and support, and daily productive activity. Community Living Skills The goals of community living skills are to (The PACT Manual, pp. 93):
Housekeeping If consumers need help organizing and planning housekeeping tasks, team members might work with them on defining a list of tasks. It is worth the effort to discuss how often the task will be done. For example, does making the bed mean every morning, some time during the day, more often than not, or when the mood strikes. Does washing dishes mean when there are not any more clean ones, before going to bed, or immediately after meals. Does it include drying and putting them away? This is particularly important because multiple people are working with the consumer and the plan needs to be consistent to avoid confusion. Whatever decisions are made, the team will need to make certain that the consumer has basic information (i.e., what day does the trash get picked up, what dumpster does it get put in) and that he or she has the needed equipment/tools (trash bags, dish soap, broom). Money management The assertive community treatment program has the capacity to directly handle consumer funds to promptly pay monthly bills and distribute cash (e.g., for groceries, laundry, spending) in amounts determined by each person’s budget. The purpose of this system is to assist consumers in money management and to provide the consumer with frequent access to cash when budgeting or financial management is a problem. For example, if a consumer’s monthly spending money is gone in the first week of the month and no more is available for that month, the consumer suffers high stress, which is counterproductive to his or her treatment. The team works with the consumer to come up with a plan to allocate the spending money. The team holds the spending money and takes responsibility to set up smaller amounts of money that the consumer receives more frequently (e.g., daily, three times a week). The program may manage consumer services money and individual consumer funds including disability benefit payments such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI) under the supervision of a payee or financial guardian. Consumer services money. Consumer services money comes from funds allocated in the program budget to provide direct financial grants or loans to consumers when disability benefits have not started, a benefits check is delayed, or the first check from a new job is insufficient to cover expenses. Lack of immediate financial resources keeps many persons on inpatient units longer than their psychiatric treatment requires and contributes to homelessness among person with severe and persistent mental illness. Consumer services money can also be used for emergencies, rent, security deposits, food, clothing, recreation, and transportation costs. Individual consumer funds. Individual consumer funds consist of entitlements (e.g., SSI, SSDI, VA pensions and benefits) consumer wages, grants, and family supports. When a consumer has a protective payee appointed by Social Security or a financial guardian designated by the court, the team works with the consumer and the financial guardian or protective payee to make sure ‘the beneficiary’s day-to-day needs are met’ and that records are kept showing how the money was used. The team leader and the program assistant may manage and operate a system (in compliance with Social Security requirements) to:
Social relationships and leisure activities [adapted from The PACT Manual (pp. 101-104)]
Social competence and social skills. According to The PACT
Manual, the nature and quality of a consumer’s social and sexual relationships
prior to onset of illness such as, social involvement with friends from adolescence
through early adulthood, whether the consumer dated, had relationships, or married
is often correlated with social competence. Consumers who achieved milestones
before becoming ill will generally be more socially competent than those who
did not since they have been exposed to these adult life experiences. This is
what being socially competent means – to meet adult Social skills, on the other hand, refer to the abilities needed for effective interpersonal performance. Consumers with severe mental illness often lack social skills because of the symptoms of mental illness, the iatrogenic effects of institutionalization, insufficient learning opportunities and appropriate role models during childhood and adolescences. The difference between social competence and social skills is best portrayed by the following two consumer examples: Example 1 – Jerome had developed social skills before the onset of mental illness when he was 20 years old and attending a community college. He was a good student, played sports, and had friendships in high school. His mental illness is episodic with almost complete recovery between episodes. He has been able to reestablish his relationships because treatment was provided immediately to lessen symptoms and continuously to minimize and prevent recurrent acute episodes. The team provides treatment and support to Jerome during episodes and the periods of recovery after the episodes. The team then provides rehabilitation services long term to help him to reestablish or renegotiate the relationships that have been disrupted by these episodes as well as to initiate new friendships and social relationships. For example, the team met with Jerome and his longtime friends and roommate to provide support for Jerome to talk about and resolve issues that resulted between them during the last episode. The team provided both ongoing supportive therapy and side-by-side assistance to help reinvolve Jerome in existing relationships and to pursue leisure-time activities. This treatment and rehabilitation process is continuous as Jerome experience fluctuations in his symptoms. Example 2 – Marcia has few social skills. Her only interpersonal relationships are with her family. The onset of her mental illness occurred gradually in her middle to late teens, disrupting her normal social development and producing impairments in social functioning. She has had great difficulty in making a full recovery between episodes because of persistent symptoms and functional difficulties. Additionally, it was traumatic for her and her family when acute episodes disrupted her participation in high school formative relationships; normal family functioning also was altered because of her symptoms and impairments and because of her involvement in mental health services (Psychiatric hospitals can be frightening and stigmatizing places for young people and their families). Marcia experiences significant social anxiety, is withdrawn, and has idiosyncratic characteristics in her dress (e.g., at all times wearing a red bandanna over her hair). She needs significant long-term help from the team to improve her social competence and skills, pursue and establish a social niche with one or two relationships with others (e.g., other people, consumers, volunteers, and family) and participate consistently in leisure-time activities. The team provides a combination of social stimulation and involvement for Marcia through one-to-one activities with staff (e.g., social recreation contacts) and groups (e.g. social recreation activities) to pursue consistent and regular leisure-time activities. The team also provides gradual teaching of social skills (e.g., ‘small talk,’ assertiveness) to increase her social competence and comfort. Goals of social, interpersonal relationships, and leisure-time services. Services for social and interpersonal relationships and leisure-time enjoyment include:
Features of social, interpersonal relationships, and leisure-time services. Active provision of social activities and interpersonal support. The team helps consumers develop, restore, and maintain social and interpersonal relationships, to engage in social and leisure-time activities, and to increase their social network by first providing social and interpersonal support to consumers. The team works out how to establish an understanding and trusting relationship with each consumer and then provides it. Each team member plans an important role for each consumer as an unwavering social support and a role model who maintains the appropriate balance between professional interpersonal boundaries and adequate compassionate support. This modeling occurs in all contacts between consumers and team members. Moratorium and support during recovery. The team helps consumers in social and interpersonal relationships over time in a gradual step-by-step fashion. Continuous services in this area allow consumers the time to restore social functioning. Consumers may delay having to function in some social situations until they feel better, and they are provided adequate support and assistance to practice in real-life social situations as opportunities arise. Reconciliation and renegotiation of relationships. The team
evaluated with each consumer what relationships in his or her life have been
affected or disrupted by mental illness and develops and implements strategies
or interventions with the consumer to reconcile or renegotiate these relationships.
The stigma that goes with mental illness as well as the lack of help from traditional
service providers in this area often prevents consumers from directly dealing
with disruptions in Through problem-solving, role-playing, and modeling, the consumer make goals and plans approaches for reconciliation or renegotiating relationships. Intervention also may include team members working with the consumer and the friend or family member in an intermediary role or supporting the consumer in meeting with the individual to either get closure or reestablish the relationship on mutual terms. It is a tragedy when consumers have been separated from parents, brothers, sisters, and even children because of their mental illness. It also is a serious shortcoming when metal health providers assume that a family wants nothing to do with a consumer without making an effort to find out if this is really the case. Restoring balance in relationships. Helping consumers restore a sense of personal well being can be difficult because mental illness has rendered them so vulnerable and highly dependent on relationships and services just to survive. The asymmetrical quality of helping relationships, especially if help is provided in a patronizing or authoritarian manner, can cause consumers to feel controlled and demoralized. To help consumers make their relationships more symmetrical, the team directly assists consumer to move from the primarily receiving position in relationships to that of an equal participant (e.g., giving and taking). This is accomplished through cognitive-behavioral approaches including assertiveness training and all one to-one rehabilitation services provided by team members (e.g., redirecting a question to the consumer that the landlord directed to the team member; drawing the consumer into a social conversations; practicing before an interaction with an employer how the consumer prefers to respond to anticipated feedback; assisting a consumer to shop for a present to have something to take to a parent’s birthday party). Health Promotion Preventative health education The team also needs to monitor whether a consumer is getting proper rest. As with changes in hygiene, changes in sleeping patterns can also indicate a change in symptoms. Alternately, difficulty going to sleep, as well as difficulty staying awake, may indicate the need for an adjustment in the consumer’s medication regimen. Along with encouraging good basic health practices, the team also provides education on the prevention of certain communicable diseases including HIV and sexually transmitted diseases. This education is particularly important for consumers engaged in high-risk behaviors. Psychiatric medications and medications prescribed for physical illnesses can interact in ways that alter the effects of the medication or lead to serious health problems. Consumers need to be educated about the medications they are taking and possible interactions. It may also be advisable for the team psychiatrist to communicate directly with medical providers (with the consumer’s permission) in order to work out the best medications to safely address both the consumer’s mental health and physical health needs. Medical screening Schedule health maintenance visits Liaison for acute medical care Reproductive counseling When a pregnancy (planned or not planned) occurs, team involvement is usually very important. The team must adapt the consumer’s psychiatric treatment so that it meets the needs of the pregnancy and delivery; they ensure the provision of prenatal care and maintain communication with hospital staff both during and after delivery. Family Involvement Families provide significant amounts of care and support to their relatives with severe and persistent mental illness. Family member roles can become distorted. For example a mother’s role may have become intertwined with that of nurse or social worker. When a family member has a severe and persistent mental illness, it can be difficult for a family to just be a family. Many consumers have little or no contact with their family and may say they have none. This may be due to moving away or family termination of contact. Further, many consumers have children. Their ability to parent can be compromised by their mental illness. Women consumers, as their opportunities for community living and relationships expand, become pregnant and have children, with perhaps as many as one-third giving birth by age 30. The team delivers a range of services to help consumers fulfill their parenting role responsibilities. Collaboration with families At the point of admission, the assertive community treatment team involves the consumer and family members in a collaboration to free the family of some of the provider roles they have taken on. Initiation of the collaboration process involves:
Family meetings can occur at the consumer’s residence, the family home, or the assertive community treatment office. Family meetings usually involve the consumer but he or she can choose not to attend. The psychiatrist participates in most meetings with family members and is readily available to assist them with crises and other problem-causing situations. Lessening Consumers’ Overreliance on Family First, team members take over many of the practical functions (e.g., shopping, laundry, money management, mediation administration) that family members perform and then help the consumer to carry out these tasks on his or her own. Second, since teams can easily increase the intensity of the contacts they have with the consumer, they can even provide intensive support to help consumers gradually move out of the family home into their own residences. Crisis management Assistance to Consumers with Children
All activities involve the participation of partners and other individuals in the consumer’s support network. The team also supports consumers in fulfilling parenting responsibilities and coordinating services for the child. Though the team’s primary obligation is to the consumers, the team works with consumers to help them meet parenting roles and responsibilities. The team does not directly provide physical or psychological care for children, but assists consumers and their families to plan for and obtain necessary services (e.g., parenting training, child care, respite care) for them. Team members help consumers relate to the systems (e.g., schools, social services, mental health professions) that provide services to children by being available to meet with the agencies, consumers, and children, reviewing agency recommendations with consumers and establishing plans to carry them out. Over time, staff often function as extended family and friend to consumers and their children. Another role of the assertive community treatment team is maintaining the mother-child relationship. A single woman with severe and persistent mental illness often has difficulty effectively and safely raising her child. Even with intensive assistance by the team, other family members, and social services agencies, mothers are sometimes forced to surrender this responsibility to others (e.g., family members, foster parents, adoptive parents). Sometimes this happens voluntarily; at other times, in spite of her protests, the mother is forced by the court to relinquish custody. This is a painful situation for the consumer who suffers a great loss and a blow to self-esteem and confidence. Though the welfare of the child is primary, the team supports the mother’s desire and need to maintain a connection with her child and to continue in some way to participate in parenting. Where this is not harmful to the child and is potentially to his or her benefit, the team advocates with the court and social services for the consumers continued contact and helps establish a visitation plan, which may include supervised visits with team members, family members, or social services staff. When the consumer is doing poorly or not adhering to the treatment, the team is responsible to report this to social services, which my lead to suspension of visits. Some consumers learn to ask staff or others to help with their child during rough times, even to the point of suggesting themselves more limited contact with their children until they feel better. Psychoeducation and family support Actively engage family members in the consumer’s recovery
Housing Assistance Many consumers have very limited incomes (e.g., SSI, SSDI, wages from part-time work). Consumer services funds from the assertive community treatment program budget are often needed to cover many of the upfront costs for housing (i.e., security deposits, first month’s rent, etc). In addition to the financial barriers to obtaining safe affordable housing that people encounter, some people served by the assertive community treatment program will run into difficulty because they have a poor rental history with multiple evictions, poor credit, or criminal records. It is very important for team members to get to know people in the community who own or manage low cost and subsidized housing and to introduce them to the program. People may be willing to take risks on consumers with marginal rental/credit histories if they know that the program is providing support around payment of rent and monitoring upkeep of the residence. Find suitable shelter
Team members schedule regular appointments with each consumer to plan and look for a place to live. Consumers are involved in each step of the process including:
Support housing once established
The team may want to discourage situations where more than 2 or 3 consumers share a dwelling as several consumers living together may take on the attributes of a group home rather than independent housing. Safety. Despite your most creative and diligent efforts to help consumers obtain safe housing, some consumers will live in housing that is in questionable repair or in areas in which there is a relatively high level of crime. When it comes to the safety of the property, your team will need to be prepared to help consumers hold property owners to meeting at least minimum legal standards for safe housing. That is, gas should not leak from appliances, electric wiring should not be exposed, toilets should flush, floors should not have holes in them, faucets should turn on and off, etc. Municipal authorities may be able to assist you, if needed, in pressuring property owners to bring housing up to code. There will be instances in which consumers will be living in housing in areas in which there is an abundance of drug activity and other types of crime. Consumers can be easy prey for people who are looking for a place to sell drugs or someone to carry drugs for them. They may also be easy marks for people who would hustle them out of their money or personal property. A secure, locked building and regular phone or face-to-face support and coaching might assist the consumer in not permitting entry to those who might take advantage of him or her. Your local law enforcement agency can also provide tips in crime prevention strategies. You will want to take advantage of this training and work with consumers on developing and practicing specific things they can do to protect themselves and their property. The more difficult situation is when the consumer is using drugs and has contact with people who are selling drugs. In such instances, part of the substance use treatment plan might include a change in residence or involving the person in alternative activities. Neighbors. Sometimes neighbors may be anxious about living in close proximity to someone with a severe mental illness. This may have nothing to do with anything that the consumer does. It may simply come from the neighbor’s stereotyped misperceptions about people with mental illness. It may be helpful for the consumer to make an effort to meet some of his or her neighbors and even possibly put the fact that he or she has an illness in the open as a way of educating people about what people with mental illness are really like. The consumer might also choose to have a neighbor or two meet members of the team and give them information about how to contact the team. Help purchase and repair household items. Consumers may need assistance with purchasing household items at a reasonable price. They may also need some instruction for simple repairs (unclogging a sink) or how to get help if the power goes out or telephone is disconnected. Develop relationships with landlords. An ongoing relationship with landlords is essential not only to obtain housing originally, but to trouble shoot problems (e.g., safety issues above, failure to pay rent). Employment The team’s employment specialists are responsible for providing the majority of employment services. They are also responsible for directing and teaching other team members to participate in carrying out individual consumer employment plans. Persons with severe mental illnesses rarely lose jobs because they do not have the skills for the job. More often, jobs are lost because metal illness and related symptoms and behavior effect job performance. For this reason, the assessment process includes a careful review, not only of the consumer’s education and past work experience, but also of the specific behaviors or other issues that have been problematic on the job. Provide support in finding work The team promotes consumer interest and motivation to work by:
Direct Placement in Competitive Jobs. Job sites are developed individually for each consumer based on the specifications identified in the vocational assessment (e.g., consumer preferences and skills, type of job, environmental adaptations, availability of ongoing work supports). To make an appropriate job and consumer match, the employment specialist, with other team members, uses the want ads, friends, personal contacts, and the yellow pages to locate jobs and meet employers. In fact, the employment specialist may go as far as proposing to an employer a job which fits both a particular consumer’s needs and goals, and with those of the work setting. Appendix H is a set of Job Support Checklists called “Planning for Success.” It offers several lists of questions with many tips on getting and keeping a job. Liaison with and education of employers Job coach Supported employment
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