The term assertive community treatment which is normally referred to in its short as ACT refers an intensive as well as a highly integrated approach through which community mental health service is delivered. This program which has its prime focus on those clients who show symptoms that require assistance through the service delivery system; it therefore serves people whose symptoms on mental health illness basically result into severe functional difficulties that are bound to interfere with their capability to attain a sensible recovery goal in a wide range of core areas in life including work, living independently, and having friends among others. The prime characteristic of ACT involves the promotion of the client’s rehabilitation, independence, and recovery while avoiding the homelessness as well as any unnecessary hospitalization. This approach has its primary emphasis targeting the promotion of home visits, out of the office intervention, and an elimination of hospital based artificial rehabilitation while promoting treatment in the real world within a natural setting.
Analyzing ACT
Apparently, this concept does not have its basics shallowly rooted on any recent discovery as it has its history dating back to the 1970s at the dawn of deinstitutionalization. This was a time when a huge number of patients who had overwhelmed the rate at which the available health care institutions could serve them. These patients were therefore discharged from the psychiatric state-operated hospitals and put under an underdeveloped and poorly integrated community based service which was basically characterized by solemn cracks and gaps within the nonsystematic approach. According to Phillips (2001), this approach to health care evolved from the works of Marx Arnold, Mary Ann Test, and Leonard Stein towards the end of the 1960s. This approach has however been widely adopted across the globe and more particularly in Canada, England, and United States.
It is acclaimed that the ACT approach to health care evolved from the innovative idea that these scholars had introduced at the state hospital in Madison and Wisconsin. These ideas were delivered through innovative programs that had been designed to curb the frequent door to door recurrent hospitalization of people who were undergoing severe mental illnesses. According to Wasmer, et al., (1999), the prime idea was to render mental treatment away from the hospital into an open community-based setting where an intensive psychopharmacologic care could be administered to patients who would require a hospital care. This case would be delivered in a twenty-four-seven response to crisis, an assertive engagement, and an effortless assistance for the patients involved helping them improve their living skills within the community (Wasmer et al., 1999).
Although the rate at which this approach was being adapted in the US mental health system was taking a gradual course particularly in the 1980s and the 1990s, it had its remarkable effects across the continent as it assumed a more faster pace at which it was adopted in other countries including England, Canada, Sweden and Australia. As has been explained by Wasmer et al. (1999), the slow pace at which ACT diffused in the US was particularly due to the high cost that was imposed on each member as well as due to the government politics particularly regarding the conflicting government bodies on the beneficial resources which the government derived from the ACT programs. The prime beneficiaries of the community-based healthcare integrated program would be the state hospitals in that it saved the cost at which service delivery was rendered to the clients who would otherwise be flocking into the state hospital for admission in the acute as well as the reception care unit. The federal government was however bound to fund for all the healthcare delivery services and as such, different government units were conflicting on which unit would pay for the program and who would benefit from these programs. The implementation of the program was left to the federal government which was equally obliged to cater for any other spill over cost including housing, Medicaid, local welfare and other public welfare costs for the consumers that may have been hospitalized within the state facility. The adoption of the ACT-based healthcare to other community thus started to prove challenging in that it was likely to render a shift in cost from the state to the local program, the county of the federal government (Wasmer et al., 1999).
The ACT program would basically involve a total team approach in which the staff involved would typically work with the participants involved under the keen supervision of a qualified health professional who would serve as a team leader to deliver mental health care services to the people. Apparently, such staff was supposed to willingly engage in a people centered responsibilities in order to enhance the wellbeing of all the areas that were related to the community functioning particularly on all the aspects of everyday life. Such responsibilities would involve home visits carried out by a low participant-to-staff ratio with one psychiatrist, one or more nurses, substance abuse specialists, social workers, occupational therapists, certified pear counselors as well as vocational rehabilitation experts. Such staff was expected to provide virtually all the required services including treatment, rehabilitation and community support in a more comprehensive manner (Ridgely et al., 2001).
Although the prime objective for this program was to avoid crisis within the state health facilities, the availability of healthcare professions at the grassroots level would on the other hand deliver health intervention at a readily available level where it could easily be availed to the clients at any required time, day or night in order to avoid any unnecessary hospitalization. ACT is therefore viewed as a sensitive approach which is medically monitored but non-residential service within the mental healthcare array which has been made more intensive than any of the highly intensified community based healthcare services. However, on the other hand it is less intensive than the medically monitored healthcare services that are residential based. It therefore entails a promise for the healthcare participants to work with people at the grassroots level without time limit for as long as they would demonstrate any continued need for the highly integrated as well as intensified professional medical help (Hughes, 1999).
According to Morrissey and Piper (2005), it is apparent that ACT has had a remarkable level of success as it has been widely replicated throughout the continent. The harbinger program which is located at the Grand Rapids in Michigan has been considered as the foremost replication. It is also considered as the first family-initiated program which has the traces of its origin from the Madison model. ACT thus has had a wide range of dissemination prevailing all over the world. As been evidenced by the various ACT programs that have prevailed in various parts of the continent, these programs have been adapting unique and innovative modifications while basing their prime foundation on the Madison model of ACT (Morrissey & Piper, 2005).
The 1978 Bridge program which was established at the thresholds of the Chicago psychological rehabilitation centre became the first ACT program to particularly focus on the established most frequently hospitalized area of the mental healthcare consumer populace. At the dawn of 1980s and 1990s, Thresholds expanded the type of clients that received the ACT-based mental healthcare to include deaf people with mental health problems; inappropriately jailed people with mental illnesses; and homeless people with mental illness together with people who were experiencing psychiatric crises (Morrissey & Piper, 2005). While the Threshold continued to be adapted as the new ACT model after the Madison model, the 1988 assertive outreach program which was purely based on this new model was founded in the British Colombia but was later expanded to other additional sites. The assertive outreach program in the northern part of America and in Australia has been identified as one of the first research-based programs in the region (Early, 1996).
Although the progress of this program had initially proven to be challenging given the many loopholes which stood on the way, its adoption led to the program by NAMI which made ACT to become a national priority. This led to the creation of a technical assistance centre through which efforts to render metal healthcare would be coordinated across the state while on the other hand lobbying for the reimbursement of the Medicaid. The evidence based practices has become one of the most successful contributors of the wellbeing of ACT. Apparently, the evidence based approach to ACT has become one of the most desirable practices as it includes the Schizophrenia team recommendations on patient outcome research. It also forms part of the six toolkits that are being implemented in the Dartmouth evidence based project (Phillips, 2001).
The concept of ACT is therefore strong and it actually diffuses faster than the practices instilled in it. Although programs may have cropped up in the claim that they are just like the ACT, they cannot replicate ACT’s essential staffing structure. As a way of ensuring genuine programs, fidelity rating scales have been adapted in order to show any significant difference between genuine ACT programs from among the various case management programs. Consequently, high fidelity scores with better outcomes have been witnessed. Apparently, the significant effectiveness of the ACT program has been established through more that fifty five controlled studies conducted both in the US and beyond. From among the recent studies that have been carried out in the US, ACT has proven to be the most effective program in reducing the usage, frequency as well as the number of days that one spends in the hospital. It is important to note that ACT has not proven to be effective in reducing the symptoms as well as the times in which one gets arrested in jail (Wasmer, et al, 1999).
This has equally proven to be ineffective in improving social adjustment, quality or substance abuse. As has been explained by Morrissey & Piper (2005), ACT has only proven to be effective in reducing hospitalization for cases related to psychiatric ailments and enhancing housing stability particularly when compared with other forms of case management. A randomized study which was carried out in the US in 2001 showed that 17 trials reduced psychiatric hospital use by 74% compared to six trials by use of other forms of case management which did not show any changes. A further seven trials using ACT showed a 44% improvement in the reduction of psychiatric symptoms while a consistent nine trials using other methods of case management showed a 56% change within the first trial but the subsequent trials did not show any changes (Morrissey & Piper, 2005).
In addition, seven trials using ACT showed a 58% increase in raising the quality of life for the study population; while other methods of case management showed a 42% improvement after five trials. However, other methods of case management have proven to be more effective in improving social adjustment, reducing substance use, and reducing cases of arrest than the ACT. From the randomized control trials carried out in 2001, other methods of case management improved the degree of social adjustment by 77% proven within 10 trials while ACT reduced this by 23% proven within three trials. The other methods of case management reduced substance use by 67% proven after four trials whereas two trials using ACT showed that it reduced substance use only by 33%. Also, other methods reduced arrest cases by 70% as proven through seven trials while ACT only reduced this by 20% as proven by the two trials conducted (Morrissey & Piper, 2005).
It is true that a number of modifications have been rendered to programs which have been diffusing from the original ACT programs in Madison to other parts of the US as well as other countries like England and Australia. However, a number of ACT-like programs have ultimately cropped up which basically focus on keeping individuals with severe mental illnesses out of prisons and jails. Apparently, FACT has been one of the most prominent ACT programs which have been developed particularly focusing on keeping people with long histories of imprisonment out of jail. Although most of the consumers of this program had been dependent on incarceration, protection from arrest as well as the transfer to a number of criminal justice agencies in order to access their freedom, FACT has on the contrary been utilized with the central aim of developing an incorporated and supervised residential based treatment for consumers of high-risk substances particularly those with recurrent substance use disorders (Phillips, 2001).
According to Early (1996), a total of twenty six programs were located in twelve different states among a forensic population within a criminal justice setting. In order to implement the FACT program, a total of five distinct kinds of program settings were identified in order to serve individuals with severe mental illnesses but having varying degrees of criminal justice offenses. The criminal offenders that were allowed to participate in this program were identified as having widely ranging cases of felonies from nonviolent to severe misdemeanors and violent offenses (Early, 1996).
Although the respondents to the program included those that had been declared by the court system as not being guilty on reason of their mental instability or insanity, the FACT program largely accepted consumers that had been referred from the forensic psychiatric units in the state hospital who had been acquitted of crime and were going through intensive treatment before being taken for prison re-entry program. The participants of the FACT program had initially portrayed extended periods of imprisonment as they would be taken through the prison re-entry program so often following their repeated misconducts. Those who had completed a one year period of participation within the FACT program showed a significant reduction in hospitalization days, jail days and also in the number of arrests that they faced (Early, 1996).
Conclusion
In conclusion, it can be argued that ACT has become one of the most effective out of the hospital community based programs in handling mental related ailments. This program reduces the length of time as well as the frequency of hospitalization for individuals suffering from mental illness. It also reduces symptoms while improving the quality of life for the participants as it has been made available for them any time irrespective of whether it is during night or daytime. The high benefit of this program is that it can be employed in an institutional setting particularly in a forensic program within a jail setting as has been proven in the program that was implemented in the California jail setting to reduce the number of arrests, jail days, and hospitalization days for criminal offenders suffering from severe mental illnesses
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