Abstract
Assertive community treatment (ACT) refers to a highly specific model of service delivery for people with severe mental illness. The original ACT program was developed in Wisconsin in the early 1970s by Leonard Stein, Mary Ann Test and others, and has subsequently been much refined, replicated, and modified in the USA and elsewhere, including Australia.
This useful book, cowritten by one of the originators of ACT, brings together in one volume for the first time a comprehensive overview of ACT. It is directed toward a wide audience and intended to be useable as a manual providing sufficient information to start an ACT program from scratch, including necessary paperwork.
The authors begin with a very brief, historical overview of the management of people with severe mental illness and place the development of ACT within its historical context in the USA. They go on to explain in depth their treatment approach, from conceptual framework to specific interventions, describing in detail how an ACT team works on a day-to-day basis. Various modifications of the original model are described for special populations including homeless persons and those in rural settings. There are chapters on the research base of ACT and on financing mechanisms, and, finally over 100 pages of model forms in the appendix.
The authors mount a case for ACT for people with severe mental illness with proselytising enthusiasm. The ACT model is contrasted favourably with traditional hospital-based and office-based services, including intensive case management. One of ACT's key differences from the latter, which is a model widely implemented in Australia under various guises, is the extent to which ACT teams provide direct clinical services, including drug and alcohol services and vocational rehabilitation services, rather than brokering services from other agencies.
The authors assert that ACT is the most empirically studied of all community mental health programs, and describe more than a dozen controlled trials worldwide including that of Hoult and Reynolds (1983) in Sydney. The main demonstrated benefits of ACT include improved mental health, role functioning and quality of life, decreased time in hospital, reduced hospital costs, increased adherence to medication regimens, and increased residential stability.
The characteristics of the targeted clinical population are described with minimal medical terminology. The authors liken severe and persistent mental illnesses to many medical illnesses such as diabetes, coronary artery disease and asthma, which are chronic, incurable and which have stable and unstable phases. Their key argument is that the frequency, severity and duration of the unstable phase of such illnesses is directly related to the quality of treatment during the stable phase. Continuous care is thus a key strategy of ACT. This is accomplished (i) through providing a broad approach, with most services provided directly by the ACT team; (ii) by providing a fixed point of responsibility for all services, including those brokered from other agencies; (iii) by careful monitoring, particularly with respect to early warning signs; and (iv) by setting no time limits on the duration of service provision.
Chapters on team composition and function, treatment principles and daily program operation contain much practical advice which could be applied well outside the ACT model, and are written with refreshing candour. The final chapter on ACT financing and administration discusses several important administrative principles which are deemed essential to the successful development of ACT programs. Aspects of public policy and financial support are discussed largely with reference to the situation in the USA and may be of less relevance to Australia and New Zealand. The authors conclude with a conspicuous warning about the dangers of contracting with the private sector to care for public sector patients.
This book is well written, tightly argued and easy to read. It contains much practical wisdom relevant to any intensive case-management program. Though discussion at various points on the historical development and proclivities of health systems in the USA may be of only passing interest to many readers, it provides a useful reminder of the struggle to provide humane services to this group of severely disabled patients. This book would be a useful addition to the library of any service providing or intending to set up any form of intensive case management program and should be recommended reading for senior clinicians and managers of such programs.