April 04, 2012
Assertive Community Treatment: Efficacy of Therapy
With the creation of Assertive Community Treatment (ACT), many benefited from this new and evidence-based approach to community mental health. ACT provides a much different and progressive type of service than an inpatient facility; it offers community-based, at home care for clients with severe and persistent mental illness. Through ACT, social workers provide mental health care to clients both in the office and in the community. During the hours of 9:00 AM to 11:30 AM, ACT teams travel to the homes of 7-12 clients each day to provide at home care. During this visit, social worker observes clients take AM medications and observes the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance; the whole visit lasts approximately 10-15 minutes. In the afternoon, staff involves clients in different support groups such as co-occurring groups, shopping groups, and walking groups. Staff also uses afternoons to see clients in the office and assist clients with miscellaneous appointments and needs.
Although ACT provides clients with unique and necessary services, research studies show that while ACT does prevent hospitalizations, the program does not significantly increase quality of life or reduce symptoms. Although clients benefit from not being hospitalized unless absolutely necessary, this is more of a fiscal improvement than a mental health improvement. Client care should be more focused on symptom reduction and quality of life if it is truly client based. This lends to the question, if ACT is truly an evidence-based approach to improving mental health, what can be done to improve this service so that clients receive the best possible care?
Mental health care has greatly improved over the past few decades, but has recently reached a point where social workers follow the norm of practices rather than using more progressive, evidence-based practices (Mechanic 2008). Although the main focus of these programs is “recovery, community integration, and making services consumer and family centered”, client’s lives are not significantly improved by programs like ACT.
For example, in a study of the ACT program in Japan, clinicians found that clients in the program had decreased hospitalizations but no symptom reduction. These findings are similar to data collected in the United States. However, in Japan, clients were given a quality of life interview (QOLI) at 2 weeks and then again 12 months later. Through this survey, Horiuchi et al. (2006) found that clients in ACT in Japan had increased quality of life but that they had decreased family contacts which were a predictor of rehospitalization. In the study, “it was assumed that satisfaction with family relationships indicates an unmet need for care among this population”. Clearly, more research must be conducted to determine the connection between quality of life and family contacts.
One of the major benefits, but also potential pitfalls of ACT, is that ACT policies are much looser than in other organizations (Powell, Garrow, Woodford & Perron). Social workers are able to make street-level decisions about how often clients are seen, what services or resources clients may be offered, and what type of therapy to use during interventions. This amount of freedom may seem like a huge bonus to working in an ACT setting, but it may be the reason that the program does not increase quality of life and symptom reduction. If social workers are able to have that much freedom, they may not be choosing evidence-based therapies when working with clients, or they may not have the proper certifications to be qualified for different types of interventions. This creates an unequal dynamic among staff members as some staff may use different techniques than others.
Although it was previously believed that clients with severe and persistent mental illnesses, like schizophrenia, would not benefit from therapy, researchers have recently challenged these assumptions. It seems that once a client is stabilized, therapy is beneficial in increasing medication compliance for longer periods of time, and therapy increases quality of life (Zygmunt, Olfson, Boyer, & Mechanic). Much research has been conducted on individual types of therapy and how they may be implemented by ACT, but no single researcher has compared the major types of therapy and found a perfect solution as to which, if any, to implement into the ACT model.
One important component to increased quality of life lies in medication adherence, because clients who refuse medications experience distressing symptoms. Zygmunt et al. reviewed literature about the necessity of medication adherence for clients with schizophrenia, stating that 50% of those diagnosed with schizophrenia will stop taking medications within a year after first discharge (2002). Once clients have stopped taking medications, they will experience increased risk of relapse (3.7% greater than compliant clients), and symptoms can negatively impact quality of life. Researchers then researched psychosocial techniques and therapies for improving medication compliance. Zygmunt el al. did find that programs such as ACT were more effective, as was motivational interviewing, because each focused on behavioral training. Findings suggest that clients will be more compliant when given concrete instructions and problem-solving strategies. Behavioral training was effective because clients were provided direct feedback for compliance.
Based on the results of the study, it seems evident that evidence-based practices such as CBT and DBT might be paired with the ACT model to increase quality of life and reduce symptoms because both types of therapy are rooted in behavior. Pinninti et al. (2010) have researched the benefits and difficulties of utilizing CBT in an ACT program. First and foremost researchers maintain that medication compliance is critical for ACT clients, but that CBT and training can improve client’s functioning and reduce symptoms because it provides skills training and helps clients improve coping skills for dealing with their mental illness. Pinninti et al. believes that “the improvement in functioning included interventions, such as helping clients make appropriate life decisions, improving social and leisure skills, and dealing with barriers to employment”. However, data suggests that CBT in an ACT setting does not seem to be beneficial for clients who are being treated for substance use. Contrary to Zygmunt et al. (2002), Pinninti et al. (2010) found that there was no correlation between CBT and medication compliance. They also did not find a correlation between CBT and hospitalizations, but this may be due to already reduced rate of hospitalizations because of the ACT model.
Another potential behavioral model that might be beneficial in an ACT program is DBT. While DBT is primarily utilized for clients with Borderline Personality Disorder (BPD), any clients who suffer from emotional dysregulation may also benefit from this type of therapy. While ACT focuses primarily on Axis I conditions, in recent years, data suggests that 26% of clients have a co-morbid personality disorder (Burroughs et al. 2012). Furthermore, “ACT programs appear to lack a theoretical framework for addressing the behavioral concerns typically associated with clients who are diagnosed with personality disorders”. Although Burroughs et al. discuss the lack of framework for clients with personality disorders; it also reflects the more general lack of framework which is associated with ACT in regard to symptom reduction and quality of life. Researchers suggest that using DBT in an ACT program can be beneficial to clients because this type of therapy helps clients regulate emotions, impulsivity, and parasuicidal behavior. It also would be easy to implement into the structure of the program because staff are available 24/7 as is also required by DBT training. Also, staff is already used to seeing clients with increased needs, and would be able to reinforce the client’s skills training when they are providing services to the client in the community. Not only that, but “ACT has the staffing infrastructure necessary to implement DBT with an average ration of staff to clients of 10:1”.
Although it seems as though there are many benefits to implementing the DBT model, there are some serious considerations as well. Problems include the cost and time commitment of becoming certified to practice DBT. For ACT to implement DBT, all staff would need to be trained, and the training is quite expensive at $2400 per person for a 7-day training seminar (Burroughs 2012). Another concern is that there is a high rate of turnover for ACT employees, so the county would need to pay to certify every new employee. Overall, the cost-benefit ratio makes agencies second guess implementing this type of intervention.
The final type of therapy suggested by Zygmunt et al. is motivational interviewing (MI). While this was originally created for clients who use substances, the techniques can be adapted to other Axis I diagnoses as well (Miller 2012). The theory behind motivational interviewing is that clients are stuck in a pattern in which change is difficult and they often do not see a need to change. Clients may also not view themselves as having a problem, which is quite common among schizophrenics, and is often the reason that clients stop taking medications. Based on this, the premise of motivational interviewing is for the client to recognize the reasons for and importance of change. An importance difference between this type of therapy and others is that there is no certification required to use MI. Also, the resources are free on the website, and there are online training modules that staff can use to become proficient. The only potential pitfall of MI is that because there is no certification, staff may be practicing the technique without proficiency.
It is also worth mentioning, that similar to MI, small scale efforts to improve client’s quality of life and symptom reduction can also be implemented. For example, Lang et al. (1999) found that the more engaged clients were involved in creating their treatment plan, and had higher quality of life. The reason for this is that clients sometimes values differed from that of the psychiatrist in the surveys. Clients found pride in smaller scale improvements that clinicians did not notice as much.
In research conducted by Zygmunt et al., researchers found that behavioral therapies and motivational interviewing proved to be effective ways of reducing client’s symptoms and improving quality of life. Within behavioral therapies are DBT and CBT. It seems thus reasonable that if ACT were to implement an evidence-based therapy model, it be CBT, DBT, or MI, as these are also considered in some circles to be three of the five most utilized forms of treatment (Adlaf 2012). Due to the exceedingly high cost and the large amount of training in DBT, this can be ruled out as a formal treatment method. However, some of the skills associated with it, such as validation and emotional regulation, can be used. Also, because the data on CBT suggests that it does not help as consistently when paired with ACT, and also because it has not proven to be helpful with substance users, it should be ruled out as well.Overall, motivational interviewing appears to be the best approach to working with clients in ACT settings. Both substance users and clients with other axis I diagnosis can benefit from the skills training in MI. MI is also a better option because it is easier for clinicians to become proficient in MI than for other therapies, and also it has no costs nor special certification.
ACTA (2012). ACT model. Assertive Community Treatment Association. http://www.actassociation.org/. Retrieved March 1, 2012.
Adlaf, A. (2012). Syllabus. Interpersonal Practice with Adults.
Burroughs, T., & Somerville, J. (2012). Utilization of evidence based dialectical behavioral therapy in assertive community treatment: Examining feasibility and challenges. Community Mental Health.
Horiuchi, K., Nisihio, M., Oshima, I., Ito, J., Matsuoka, H., & Tsukada, K. (2006). The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses. Clinical Practice Epidemiology Mental Health, 2, 18.
Lang, M. A., Davidson, L., Bailey, P., Levine, M. S. (1999). Clinicians’ and clients’ perspectives on the impact of assertive community treatment. Psychiatry Services, 50, 10: 1331-40.
Mechanic, D. (2008). In mental health and social policy: Beyond managed care. Pearson Education, Inc: pp.xi-xvi.
Miller, B. (2011). MI basics. Motivational Interviewing. www.motivationalinterview.org. Retrieved March 10, 2012.
Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health., 46, 4, 337-41.
Powell, Garrow, Woodford & Perron: Policy Making Opportunities for Direct Practitioners in Mental Health and Addiction Services. Mental Health Policy. Retrieved March 1, 2012.
Zygmunt, A., Olfon, M., Boyer C., & Mechanic, D.(2002) Interventions to improve medication adherence in schizophrenia. Am J Psychiatry, 159, 10. 1653-64.
Analysis of Treatment Modalities
Cognitive Behavioral Therapy
Of all the different types of therapies, I entered the class with the most previous knowledge about CBT in comparison to the other types. Although I knew about the premise of CBT, I did not actually know the steps and activities associated with the therapy. I really enjoyed the worksheets and the information about how to progress in therapy. Such as, identifying negative thought patterns or then using the 10 most common negative thought patterns to help client’s self-identify. This is followed by analyzing the negative thought and restructuring the cognitive schema. I think this is also an easy therapy to explain to clients because of examples such as the two different reactions to the dog (picture) and the question: can you make yourself feel a certain type of emotion and how (through thinking). I think it’s important for client’s to relate to the therapy this way, and it’s easy to see how CBT will work.
I think CBT also takes away some of the stigma of mental illness because it is less focused on symptoms, and more focused on cognition. Clients can feel empowered as they recognize how they think and how thinking this way affects their mood and behavior. It does require a lot of effort on the part of the client because of the weekly homework assignments, but I think that most clients will find it beneficial and take the time to work on their thought processes. Also, CBT can be tailored for different disorders (depression, specific phobias, Obsessive Compulsive Disorder, etc.). CBT can also work for clients of any cultures because it focuses on client’s maladaptive cognitions, and usually the client has insight about what his/her illogical thoughts are. Because of this, CBT can be utilized to help clients work through feelings of cultural topics such as prejudice and discrimination, but it can help clients work through any other life problems as well.
My only concern, and the reason that I might not be able to use CBT very often, is because of the population I work with. At ACT, most of my clients have severe and persistent mental illness and often have low cognitive functioning. For CBT to work, a client needs to have good insight, and most of my client have very poor insight about their mental illness. For clients who are more stable and insightful, I can try to use CBT. Although, a second concern is the time frame. Many of the activities and conversations about schema require a substantial amount of time (probably at least 30 minutes per session), and at ACT, I only see clients in 15 minute increments.
However, next semester I may be able to do individual therapy in longer sessions, so perhaps I will try CBT with clients who have more insight. This may be especially good for ACT clients who are not always compliant with taking their medications, because it can help them dissect their thoughts about their medications and analyze if these negative thoughts about their medications are true. One of the greatest criticisms of ACT programs is that while they do reduce costs because they deter hospitalizations, they do not help improve symptoms or increase quality of life. Perhaps implementing CBT with medication management would help clients even more.
Another reason that this treatment modality could benefit these clients is that many of my clients have a history of trauma and have experienced abuse. Clients who have been abused view the world through a very skewed lens, and cognitive restructuring would be one of the best ways to aid this population. The set-back of this (although it would likely be a set-back for any modality) is that clients will need to face their trauma head-on. And from the experiences that I have had with clients, many do not want to discuss their trauma, let alone analyze it and spend more time thinking about it. But I think that this could be a key in helping many clients.
Dialectical Behavioral Therapy
Entering class, I had some basic knowledge about DBT, such as that it is used for clients with Borderline Personality disorder and was created by Marsha Linehan, but I did not know much about the specifics. For example, I one of the most beneficial aspects of DBT is that it can also be used for clients who have difficulty with emotional regulation problems and interpersonal problems. Because of this aspect, DBT would be a good technique for some clients with severe and persistent mental illness because they have do not have strong social networks and many would like to make friends and be closer to others. However, like CBT, DBT requires a great deal of insight into the client’s mental illness, behaviors, and thought patterns. Because of this, it may be a challenge to help my clients with emotional regulation problems.
The technique that seems the most powerful of DBT is validation. Clients who struggle with BPD or emotional regulation problems have often been invalidated by parents and those around them from an early age. Clients have created maladaptive ways of coping with stress because they were told that their original ways were inappropriate in some way. In other types of therapy, clinicians may question client’s thought and behavior patterns without recognizing how these actions help clients in some way. That is why DBT is so unique. It is a therapy style in which clinicians truly listen to client’s and help them feel worthy and not put-down. Already, at field, I have tried this and found great success. I work with a client who has paranoid schizophrenia and trouble regulating emotion. His affect at baseline is extremely labile. I have taken the approach to validate his treatment concerns (he is on an ATO), and tell him that it isn’t fair that he must be seen by ACT but that I know he can do a better job taking care of himself to be relieved of his ATO. When I validate his concerns, he often opens up and speaks to me more and calms down. This is a big difference from his usual screaming about “unconstitutional” services.
Although there are many positive aspects of DBT, one of the difficulties is that the clinician must be willing to be available 24/7 per the treatment contract. With agencies, like ACT, this may be difficult, because while there is someone on call at all times, the person is not always the same. Another problem with DBT in an ACT setting is that clinicians must be trained in DBT and also provide weekly individual therapy and group therapy. This all requires a lot of time that ACT staff may not always have from week to week. ACT currently runs a co-occurring substance use group, so creating a DBT group may be possible, but it would be difficult to have enough time for individual therapy sessions for all clients. Next semester, my supervisor told me that I will be able to conduct therapy sessions with 2-3 clients, and perhaps I will be able to try some DBT techniques, but I will not have the resources to conduct therapy according to an actual DBT model.
I do not think that DBT necessarily needs to be modified for different cultures because of the aspect of validation. DBT hopes to consider the client’s perspective and understand where the client is coming from regardless of race, religion, ability, age, etc. The only aspect that may be different from culture to culture might be the way that emotion is expressed and what is acceptable might be different among different groups. Because of this, having an understanding of the population and their views on expressed emotion is necessary when working with clients.
This briefer intervention might be more useful in an ACT setting than the other types of therapy simply because clients generally are not looking for long-term, if any, therapy. Clients are used to seeing caseworkers anywhere from 1-6 times each week, so this type of therapy, which has less worksheets and homework might be better implemented. Also, the majority of the concerns that clients with severe and persistent mental illness have are either about psychosocial education relating to medication management or interpersonal problems. Thus, this type of therapy could greatly benefit clients who want to work on their relationships with others.
However, the problem with Interpersonal therapy is that it is structured more for clients struggling with depression. So, while the focus on interpersonal conflict is good for ACT settings, the structure and ideas behind it which are based in depression may not be the best, since most clients have schizophrenia or bipolar disorder. Another similar problem is that Interpersonal Therapy is only beneficial to use with clients with mild to moderate symptoms. So, perhaps this type of therapy could be used for clients who are down to 1-2 days per week and those with good insight into their mental illness. Then again, clients who are seen so infrequently generally do not wish to seek therapy or other services because they do not think they ‘need’ ACT services anymore.
Some of the beneficial aspects of this type of treatment include the implementation of treatment goals, the structure, and the functions of the ‘sick role’. First, it is important for clients to create goals for treatment, so that there is a focus for each session. When spending extra time with clients, I have tried to implement this aspect so that there is a focus for the conversation with a measurable outcome. However, I have found that it is very difficult for clients to set goals for longer sessions because, while they would love to talk to me, they do not want ‘therapy’. They would prefer that the time is unstructured and referred to as “extra time with staff”. Another problem with using this type of therapy with clients with severe and persistent mental illness is that while they would like their quality of life to improve, they often cannot identify what steps need to be taken for improvement. Even when I suggest goals or ways to form goals, they do not see a need to make any lifestyle changes.
With Interpersonal Therapy, I also like that there is emphasis on the sick role because many clients do not want to view themselves as ill or mentally ill. Clients want to feel like they have full control over their lives and do not need to take a step back from responsibilities. Allowing clients to understand that this is an illness similar to a physical illness can be very powerful in removing the shame from obtaining treatment or from not being able to do things as well or as frequently as before. Also, I appreciate the structure of Interpersonal Therapy because it gives an itinerary of sorts for the sessions, which is helpful in maintaining evidence-based practices.
Cultural diversity needs to be taken into account for this type of therapy because clients of different ethnic groups may view interpersonal relations (the roles in different relationships and ways of communicating) differently from cultural to cultural. Confronting someone may be acceptable in some cultures and not in others. When working with an African American client who is having difficulty with a friend of twenty years, she has a mentality that friends are for life and even though this ‘friend’ treats her extremely poorly and takes advantage of her, that it is wrong to cut her out of her life.
The goal of psychodynamic therapy is to make the unconscious conscious by asking questions like, “where did you learn to think that way?”. This can be powerful because it allows clients to release some of the guilt and shame they might feel by identifying the source of this belief or behavior. It may help clients make connections between their present actions and how these are learned from parents, family, or friends. Already I have been able to utilize this powerful question in working with a client who feels a lot of guilt. When I asked him, where do you think you learned to feel that way? He became tearful and quiet and said he did not want to speak anymore. Although the conversation did not continue at that point, it was a breakthrough and has led to many good conversations in the last few weeks because it allowed him to think about where these ideas and personal narrative come from.
Another important aspect of psychodynamic therapy is that it explores how the past shapes people today. Clients are able to discuss the pains and joys of their life and make connection about how their past is affecting their present in order to change the cycle for a better future. This can be somewhat difficult to utilize in a way that leads towards a better future because clients can get caught in problem saturation. If clients have no guidance with discussing the past, they will tell many stories about the pains of their lives. However, making the links from how the past relates to current behavior and how it can alter the future is very powerful. Once again though, clients need insight for this to truly work.
Clients must have insight into their mental illness and be able to self-reflect, and oftentimes this is not the case. But it can be utilized with the clients who are seen 1-2 times a week and have more insight. While a traditional psychodynamic therapy model may benefit some clients, the brief psychodynamic psychotherapy would be better for an ACT setting because clients are generally not interested in long-term therapy, and clients may not be in the program for many years, which is often the length of time required for traditional psychotherapy. Another problem with this type of treatment is that, similar to Interpersonal Therapy, this is utilized more for clients with depression and anxiety.
Some of the aspects that I like include the roles of the id, ego, and superego, and the descriptions of the defense mechanisms. The visual depictions of the trio that make the personality would be beneficial for clients who are more visually oriented. It may also be beneficial for clients to imagine the id, ego, and superego in order to identify what plays a role in their decision making. Teaching clients about the defense mechanisms would benefit clients because it would help them identify how they cope with stress and problems in order to analyze their ways of dealing with the world and see if it is helpful or harmful.
Of all the types of therapy that were discussed in class, Motivational Interviewing is the most utilized treatment modality at ACT in Ypsilanti. I do not know if this is the case for all teams or simply because we have a large percentage of substance users and run a pre-contemplation co-occurring group that also utilized motivational interviewing. Also, I conducted research on treatment modalities in ACT settings for another course (Mental Health Policy) and found that Motivational Interviewing seems to be the most beneficial type of treatment to use in ACT settings. CBT was a close second but produced similar results to ACT itself as an evidence-based practice and did not show greater results when paired with ACT.
One of the reasons that Motivational Interviewing is so effective is that the client is at the center of recovery. The client has the choice to heal rather than receiving advice from the therapist. The therapist and client have a balanced relationship where the two are equals, rather than the therapist being on a pedestal and telling the client what needs to be accomplished. This type of therapy seem similar to solution-focused therapy and goal-focused therapy based on the therapeutic alliance and the idea that the client is the expert on him/her self and has the answers, and the therapist used OCEAN techniques to help the client attain self-actualization.
The OCEAN techniques are useful and clear techniques for the therapist to use, especially empathy and affirmations (similar to validation in DBT) and reflective listening. While reflective listening is definitely a skill that needs practice, I do not know how effective it is for clients with severe and persistent mental illness. I have attempted these techniques with clients, and reflective listening is quite difficult, because often clients just give a brief response and sit in silence. Even waiting them out does not phase them! They have so much going on in their minds that sitting in silence is not uncomfortable.
Motivational Interviewing is also especially useful in ACT settings because of the high rate of co-occurrence of substance use. Because this treatment modality is structured to be utilized with this population it can serve a double purpose at ACT. Motivational Interviewing is also beneficial because it can be easily modified for group settings and does not require a certain amount of time per visit with a client to be effective. The only problem that is more of a ‘user error’ is keeping the emphasis on positive behaviors and goals. I have been getting tangled in reflections and affirmations and have not made as much ground work with actually moving towards any type of change or resolution when I use this modality with clients. But with more training, this may be the most beneficial treatment for ACT clients.