Author : Martin L. Korn, MD

Introduction

Since deinstitutionalization was initiated in the 1950s, there has been ongoing concern about our ability to care for the most seriously mentally ill. As part of this process, state and long-term hospitals were closed. This movement was driven by the introduction of new pharmacologic treatments. However, the multifaceted and complex psychosocial needs of these individuals now living in the community were not adequately addressed. Efforts at adequate rehabilitation were often partially effective, if at all. This failure in policy has been attributed to multiple factors, including underfunding, new challenges including rampant substance abuse, and high rates of noncompliance with medications and programs. The Assertive Community Treatment or ACT program was initiated in the 1970s in Wisconsin by a mental health team that included Arnold Marx MD, Leonard Stein, MD, and Mary Ann Test, PhD as a means of addressing these difficulties in a proactive and comprehensive manner. A symposium at the American Psychiatric Association 156th Annual Meeting discussed the nature of the ACT programs and discussed future directions.

Principles of the ACT Program

There have been approximately 25 randomized controlled trials demonstrating the clinical and cost effectiveness of the ACT program.[1] A consumer-centered perspective is part of the ACT program in order to help the client achieve goals that are meaningful and important to the client. This is in contrast to programs that are based on the structure of the institutions, such as homeless shelters. Consumer goals often relate to vocational achievement, adequate housing, and establishing fulfilling interpersonal relationships. However, programs often deal with these goals in a secondary manner, if at all.

There are several criteria that are considered central to the ACT program:

1. Targeted services to the severely mentally ill;
2. Direct service through the treatment team rather than through outside clinicians and services;
3. Small staff ratio of approximately 1 staff person to 10 clients;
4. Shared team responsibilities so that each client is treated by multiple staff members;
5. Comprehensive and flexible services;
6. Treatment and services administered primarily outside the clinic setting;
7. No time limit on services;
8. Individualized treatment and support;
9. Service delivery 24 hours a day, 7 days per week; and
10. Addressing the individual's strengths and needs.

Working With Forensic MICA Clients

Michelle Des Roches, MSW, discussed Project Renewal's Parole Support and Treatment Program in New York City.[2] This program is designed to help mentally ill chemical abusing (MICA) clients newly released from jail. Close cooperation with the parole board is required, and the services are mandated for the individual. Often, individuals with psychiatric disorders who are released from incarceration are given a 2- to 4-week supply of medications and are frequently given no follow-up clinic visits. Sixty-two percent of individuals who are released from jail will be rearrested within 3 years, and those with mental illness are the most vulnerable. The program has enrolled 55 individuals in the past 10 months. They are primarily minority and 50% have medical problems. The types of crimes committed include murder, arson, theft, assault, and substance abuse-related crimes.

Although several of the programmatic elements are derived from the ACT format, because of the special needs of the clientele, there are significant variances. The program is designed to help the individual to overcome obstacles in the community that make reintegration difficult. In contrast to the ACT model, there are limits as to length of the time that the team may work with the program, depending on the length and conditions of parole. The average length is 12 to 18 months. Temporary housing is also available to the team.

There are several survival skills that are learned in prison that are very maladaptive in the community at large. For example, the incarcerated individual is taught to distrust inmates as well as jail personnel. Intimidation of others and fighting for one's respect is essential to maintaining one's role in a potentially punishing and severe hierarchy. Stigma against mental illness is especially strong in prisons, and the afflicted inmate often attempts to hide difficulties. Once released into the community, it is the role of the team to help the individual to learn to substitute the now maladaptive behaviors with those more suited to life on the outside. Splitting of the team by the client is frequent, and it is very important to act as a coordinated team to decrease this behavior. Groups are utilized to develop support and help to foster constructive community cooperation. The former inmate is often fearful of connecting to the family after a long absence, and the family also may have significant concerns about the individual's behavior. The program is having some success with this difficult population, with decreases in rearrest rates and better integration into the community.

Homeless Clients

Ann Hackman, MD,[3] discussed an initiative being conducted at the University of Maryland. The program has been in existence for 13 years. Approximately 25% to 35% of the homeless population is considered to have serious mental disorders, and the program is designed for these individuals. For the first 3 years of the program, a research evaluation program was conducted to compare the efficacy of the ACT model with usual services provided by the community.[4] A total of 152 homeless individuals with severe and persistent mental illness were randomized to the ACT team or treatment as usual. Subjects in the ACT team required significantly fewer psychiatric inpatient days, less emergency room visits, and utilized more outpatient visits compared with controls. Those in the ACT team were also domiciled in community residences for a significantly greater period of time. The ACT program was also cost-effective since the ACT team relied on less expensive outpatient treatment alternatives.[5] The ACT services cost in this program was $242 per day of stable housing compared with $415 per day in controls. The efficiency ratio was 0.58 in favor of the ACT program.

The program currently services 160 clients and approximately 60% are male. Two thirds have a history of homelessness and 50% are currently homeless or in an unstable living environment. Since many of the homeless are not available for treatment due to their shifting social environment, stress has been placed on an aggressive outreach initiative. Small teams have been utilized in preference to the larger shared team approach of many other ACT teams. This was done in order to provide more consistency to the homeless client. It has been helpful if the psychiatrist goes into the field with the team. Attempts are made to transition clients to other services when suitable. Four phases of the program were outlined:

1. Engagement. In this phase, the individual is often off of medications and stress is placed on developing a trusting relationship. Since the recalcitrant homeless individual may live in makeshift housing such as boxes or tents, the team goes to meet the homeless at that site. Medications are offered but not required.
   
2. Stabilization. The client is assisted in developing daily living and social skills. They may be assisted with doing laundry, cooking, finding housing, and obtaining employment, among other activities.
   
3. Ongoing Treatment. Active treatment is carried out in order to help the individual maximize and maintain treatment gains.
   
4. Discharge & Transition. Transition to less intensive services is attempted if the individual is able to handle this transition.
   

Other research has also documented the effectiveness of the ACT model with the homeless. Morse and colleagues[6] compared homeless clients assigned to "brokered" case management with those enrolled in the ACT teams. In the case management model, the case manager helps to coordinate care with multiple agencies. This model was compared with the direct ACT model and the ACT model with additional support from community workers. A total of 165 subjects participated, and 135 of these were followed for a period of 18 months. Compared with the case management services, both of the ACT programs resulted in a greater number of service contacts, greater utilization of resources such as entitlements, decreased thought disorder severity, and increased client satisfaction. Clients randomized to the ACT team alone were in stable housing a significantly longer period of time compared with either of the other modalities.

Housing First Model

The Pathways to Housing program is based on the premise that housing a homeless individual should be the first step in the rehabilitation process. Discussed by Sam Tsemberis, PhD,[7] the program combines ACT principles along with the housing initiative. Clients are offered housing without requirement of a period of sobriety for MICA clients or psychiatric services for the mentally ill. The ACT team provides supportive social and clinical programs for these now domiciled individuals. The process is consumer driven in that homeless individuals rate housing needs as one of their primary concerns and desires. Currently, 6 ACT teams in the New York area serve approximately 450 people. Vocational training and opportunities are stressed. Housing is provided through a variety of realtors, and tenants are asked to pay 30% of their income or entitlements. Pathways provides the landlord with guaranteed regular payment of rent. The extensive support services to the client helps to reassure the landlord that the client's difficulties will be addressed quickly.
Several studies have been carried out on the program, and the effectiveness of the model has been demonstrated.[8] In a study of 225 homeless individuals carried out over 36 months, the Pathways program was shown to dramatically decrease the rate of homelessness from an initial 50% to near zero. A control group offering treatment as usual decreased the rate to 22%. Although alcohol use declined, there was no significant decrease in the rate of drug use. Psychiatric difficulties and polysubstance abuse, however, were not related to the ability to maintain the client in adequate housing with the extensive support services provided. The motivation to address problems often increased with provision of housing.

ACT in New York State: Implementing Evidence-Based Practices

New York State has begun an initiative to establish several ACT programs in conformity with evidence-based practices. Doug Ruderman, MSW,[9] from the NY State Office of Mental Health, reported on this initiative. New York will be establishing 71 programs by the end of 2003. The programs will be state licensed and funding will provided through Medicaid.
Although there is a considerable amount of research supporting the rationale for "best practice" implementation of social and psychopharmacologic interventions, these data-supported interventions are often not followed consistently.[10] The Schizophrenia Patient Outcomes Research Team (PORT) assessed the interventions provided for 719 individuals with schizophrenia in 2 states.[11] The programs assessed included inpatient programs and continuing day outpatient programs in both rural and urban settings. The conformance rate between the programs and current treatment recommendations was usually below 50%. Some of these interventions include self-management training, family psychoeducation, supportive employment, and integrated substance abuse treatment.
In order to maximize the effectiveness of interventions in New York State, the state will help to disseminate the best-practice guidelines. These guidelines will be incorporated into licensing protocols. The Dartmouth Community Treatment (DACT) program guidelines are being utilized to assess the programs and provide information concerning best practices interventions to the ACT teams. In order to disseminate these guidelines and information, there will be a commitment to training. A "kick-off" meeting will introduce the concepts to the teams and the basic philosophy will be introduced. A basic training kit developed by the Dartmouth group will be distributed. A consultant will monitor the progress of the team. In order for new teams to learn the basic principles in the field, "shadow training" will be utilized. In this process, new teams will follow clinicians from established teams. A monthly newsletter will be disseminated to update the teams on evolving information. Data from several programs will be collected, and this information will be utilized to assess the quality of care and improve the treatment process in an ongoing manner. With these methods, a collaborative effort will be established between the Office of Mental Health and the ACT teams and an evolving system of quality of care will be implemented.

Comments and Summary

Ronald Diamond, MD[12] discussed the current state of the ACT model and the evolution of the conceptual system. Although clearly an effective system of care, there are several aspects of the program as well as the implementation that may be critiqued. Despite the stated goal of a consumer-centered system of care, ACT teams have been criticized as being overly paternalistic. Is it overly directive, for example to very actively guide the client toward treatment that may not be desired? The Pathways to Housing program provides immediate fulfillment of a basic residence need and does not require substance abuse or mental health participation. Active attempts are made after this to engage the client in treatment. This is at variance with other ACT programs that may guide clients more actively.
Other issues that should be considered are the need for outside services that may not be available through the team. Traditionally, services are provided through the ACT team, but a combination of the 2 may be more effective. The ACT team is considered to be a long-term program, available to the client "for life." However, transition to other programs may be delayed due to this very long-term perspective. The use of peer counseling has also been controversial. Although often considered very helpful to the team and broadening the perspective, issues of confidentiality and boundaries must be considered.[13]
Although evidence-based practices are helpful in increasing the quality of programs, they may not take into account local needs and variations due to the uniform standards. Therefore, fidelity to structure may diminish the creativity process required to help the ACT system of care to evolve. Fidelity must be counterbalanced with plasticity and innovation. The ACT model should therefore be considered an evolving process rather than simply an effective program.

References

1. Herinckx HA, Kinney RF, Clarke GN, Paulson RI. Assertive community treatment versus usual care in engaging and retaining clients with severe mental illness. Psychiatr Serv. 1997;48:1297-1306.
2. Des Roches M. Adapting the assertive community treatment model to work with forensic MICA population in supported apartments. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, CA. Abstract S78A.
3. Hackman AL. Assertive community treatment with homeless individuals. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. Abstract S78B.
4. Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry. 1997;54:1038-1043.
5. Lehman AF, Dixon L, Hoch JS, Deforge B, Kernan E, Frank R. Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness. Br J Psychiatry. 1999;174:346-352.
6. Morse GA, Calsyn RJ, Klinkenberg WD, et al. An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatr Serv. 1997;48:497-503.
7. Tsemberis S. Pathways to housing: from streets to homes: housing people with dual diagnosis directly from the streets. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. Abstract S78C.
8. Tsemberis S, Eisenberg RF. Pathways to housing: supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatr Serv. 2000;51:487-493.
9. Rosenberg L, Ruderman D. Assertive community treatment in New York: a platform for implementing evidence-based practices. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. Abstract S78D.
10. Drake RE, Goldman HH, Leff HS, et al. Implementing evidence-based practices in routine mental health service settings. Psychiatr Serv. 2001;52:179-182.
11. Lehman AF, Steinwachs DM. Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) client survey. Schizophr Bull. 1998;24:11-20; discussion 20-32.
12. Diamond R. Is this an act or an ACT? Approaches to assertive community treatment. Program and abstracts of the American Psychiatric Association 156th Annual Meeting; May 17-22, 2003; San Francisco, California. Abstract S78.
13. Dixon L, Hackman A, Lehman A. Consumers as staff in assertive community treatment programs. Adm Policy Ment Health. 1997;25:199-208.