Assertive Community Treatment
Assertive Community Treatment
Assertive community treatment (ACT) combines multiple types of help—including medication, counseling, education, legal and financial support—provided by community-based, mobile teams to people with severe mental illnesses.
ACT is aimed at older teenagers and adults with a severe mental illness that greatly impacts their ability to care for themselves and function at home and at work. The intensive program is designed to help those with serious, long-term mental illness including, but not limited to, schizophrenia. ACT combines medication, counseling, rehabilitation, education, legal and financial support, and family assistance.
Arnold Marx, MD, Leonard Stein, MD, and Mary Ann Test, Ph.D., pioneered the ACT program in the late 1960s in Madison, Wisconsin, as an alternative to admission to a psychiatric institution. While working at Mendota State Hospital, the trio noticed that patients who got better in the hospital often became sick again when reentering the community. They proposed that a round-the-clock program outside the hospital could provide the same ongoing support and therapy. In 1972, they put their theory to the test and formally launched ACT. Today, the program is offered in certain U.S. states and throughout Canada and England.
Because ACT provides care outside of the doctor’s office, usually in the comfort of the patient’s home, the community-based program is sometimes referred to as a hospital without walls. The cornerstone of each ACT program is a diverse team of nearly a dozen different health care specialists, including doctors, nurses, and counselors. The program provides support and care 24 hours a day, seven days a week, all year long.
Project leaders, called case managers, usually have fewer than 10 patients, which allows for highly individualized care. A patient is considered a client of the ACT team. ACT is different from other community mental health center (CMHC) services. The ACT team comes to the client, while CMHC patients must go to a clinic. Those who participate in ACT receive more personalized attention, and may be in contact with the ACT team daily, as opposed to weekly or monthly. The ACT team provides all necessary care, including substance abuse treatment and rehabilitation. CMHC services often refer clients to an outside specialist.
ACT has three key features: treatment, rehabilitation, and support services.
- Treatment may involve antipsychotic and antidepressant medicines, substance abuse therapy, counseling, and possible admission to a hospital for closer monitoring.
- The rehabilitation arm of the program helps the patient find volunteer work and paid employment and provides support for continuing education. Specialists teach patients new behaviors, such as how to structure schedules and perform daily activities.
- The support services advise patients on how to find legal and financial support, housing, transportation, and other services. Family members are taught how to cope with their loved one’s illness and are provided with education materials. According to the Schizophrenia Patient Outcomes Research Team (PORT) study, funded by the National Institute of Mental Health and the Agency for Health Care Policy and Research, fewer than one in 10 families of persons with schizophrenia receives such education and support.
ACT may also be referred to as the Program of Assertive Community Treatment or PACT. Many organizations use the terms interchangeably. Other names for ACT include community support programs (CSP) and mobile treatment teams (MTT).
ACT may benefit those with schizophrenia, schizoaffective disorder, and bipolar disorder. PORT recommends ACT as an effective treatment for schizophrenia and persons with serious mental illness.
ACT is targeted to persons with very severe mental illness that has led to repeated hospital and emergency room visits, homelessness, or jail time. According to the National Jail Association, about 700,000 persons with mental illness are incarcerated every year. ACT programs have helped such criminal offenders meet their legal obligations while providing medical support and rehabilitation services.
The ACT program has several goals:
- relieve or cure symptoms of the disorder.
- reduce or prevent repeated, severe episodes associated with the disorder.
- enhance the quality of life.
- improve functioning at work and in social settings.
- encourage independence and teach necessary self-care skills.
- reduce the burden of care on a patient’s family by providing education and support.
Studies have shown that ACT and similar programs greatly reduce the number of hospital stays among those with severe mental illness. One study
Antidepressant —A drug used to treat depression.
Antipsychotic —A drug used to treat serious mental disorders that cause hallucinations or delusions.
Bipolar disorder —A mental illness marked by alternating periods of excitement and depression. Also called manic-depressive disorder.
Delusion —A false belief that persists.
Hallucination —Seeing or hearing something that does not really exist.
Substance abuse —Overuse of a drug or alcohol, which leads to addiction.
found that ACT not only reduced overall hospital admissions, it also decreased the length of the hospital stays. ACT has been shown to improve patient functioning and encourage patients to stick to their treatment routines. The benefits are reported to be particularly marked among those with a coexisting mental disorder and substance abuse problem, perhaps because such patients are at higher risk of hospitalization and complications.
Compared to those who are admitted to an institution, ACT clients have fewer symptoms, more positive social interactions, and spend less time unemployed. Experts say anywhere between 20-40% of people with the most severe and persistent mental illnesses would benefit from ACT.
There are a limited number of ACT teams in the United States. As of January 2007, only Delaware, Idaho, Missouri, Rhode Island, Texas, and Wisconsin offered statewide programs. However, 19 other states offered test, or pilot, programs.
Because there are so many specialists on an ACT team, it can be costly. Some argue that the expense is justified, particularly when compared to the cost of an extended hospital stay. According to the National Alliance on Mental Illness, ACT costs each participant between $9,000 and $14,000 a year, while hospital costs for an extended stay can exceed $100,000.
Assertive Community Treatment Association. Suite 102, 810 E. Grand River Avenue, Brighton, MI 48116. Telephone: (810) 227-1859. <http://www.actassociation.org>.
National Alliance on Mental Illness. 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042. Telephone: (703) 524-7600. <http://www.nami.org>.
National Mental Health Information Center. P.O. Box 42557, Washington, DC 20015. Telephone: (800) 789-2647. <http://mentalhealth.samhsa.gov>.
Kelli Miller Stacy