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September 10, 2012

Assertive Community Treatment: Beneficial for Taxpayers or Clients?

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.

Posted by desolada at September 10, 2012 08:37 PM


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