What Is Assertive Community Treatment ?

text by James Farquhar MD psychiatrist - July 1998

Assertive Community Treatment is a way to organize some mental health services to help severely mentally ill people to attain stable, satisfying lives with dignity and respect.

Across North America, hospitals continue to cut down the numbers of mentally ill persons who can stay in a hospital psychiatric ward at any one time. In-hospital psychiatric care is seen as too expensive, in a time when hospital budgets are being cut across the board. But the number of mentally ill persons remains the same.

Many of them are stuck in a cycle of wandering away from their appointments and medications, then getting ill again and needing hospitalization -- in a system that can't offer them much hospitalization any more.

For these persons, being ill usually means drifting into a world of fear and dread. Just trying to think becomes an effort, as thoughts criss-cross the mind like a dozen jet planes out of control. Their lives feel like plots for the X-files. Their strange experiences may include hearing voices that criticize every move they make. The voices may tell them to leap off an escalator or do something else "crazy".

They may drift away from "treatment" for all sorts of reasons. Maybe they are just terrified of taking the bus to their appointment. Maybe their illness makes it hard for them to trust the mental health system. Maybe they blow all their money on alcohol or marijuana, and then they can't afford their medications.

When "treatment" always means coming to an office for an appointment, then these drift-away people just don't get treatment. They may become homeless, they may end up in jail for minor crimes, they may just show up sick again in an emergency room. Or their voices may really kill them -- suicide.

About 10 to 20 per cent of persons with severe mental illness are hard to help for just these reasons. They are often called "revolving-door patients" because they are in and out of the hospital so often.

The ill persons are not the only ones suffering. Their families -- mothers, fathers, brothers, sisters, and children -- often go through agony. They never know what to expect in the ill person's behavior: beauty or the beast? Families feel helpless when the ill person becomes destructive. Families get fed up giving them long arguments over simple things like bathing to prevent stinking. An ill person may make them pay $50 for a taxi ride "home" to mom and dad because they couldn't remember how to use the bus.

Every time they drift away from treatment and medication, every time they have a breakdown, they lose a little more of their concentration, their memory, and the finer points of getting along with others.

And every time they have a breakdown, there is a costly hospitalization -- paid for by dollars that are also needed by others who do stick with their treatment.

Assertive Community Treatment (ACT) can help these persons get out of the revolving door, and stay out of hospital most of the time.

The ACT approach keeps the ill person in contact with help, by visiting him at home, very often. This could mean a visit every day, if that's what's needed to keep him well.

Since this task would burn out one single mental health worker, the ACT work is done by a team of 8 to 12 staff persons. Commonly they are nurses, social workers, or persons with bachelors' or masters' level education in psychology or social sciences. Usually, a psychiatrist takes part in the team about half-time, taking responsibility for about 60 to 100 clients helped by the team.

The ill person's life improves just by having several new supportive, reliable people in his life. Many ill persons have no relationships at all before ACT steps in.

The visits may emphasize taking the medication in front of the ACT visitor. This is not police work. Most persons "drift away" from medications because they forget, because they are not organized enough, because they lose track of what they do from hour to hour, or because they need reminding of the good that the medications do.

With the supportive relationship, ACT also focuses on helping the person organize his life so that it is worth living -- to him.

The ACT team makes an individual treatment plan for each ill person. For some, this may mean helping him deal with his landlord, find a new place to live, shop sensibly for food, hook up with a job or a daytime activity, or go to the dentist so his toothache won't throw him into a rage.

Commonly, the ill person needs the ACT team to manage his money from social security or welfare, to avoid a needless hospitalization for lack of food and a place to stay. The person still gets 100 per cent of his money, but parceled out once or twice a week, with the rent paid at the beginning of the month.

ACT work is intensive and expensive. Most people who work in the mental health care system have to take care of 50 to 100 mentally ill persons, the kind who do come to appointments. On an ACT team the ratio is usually more like one mental health worker to 8 or 10 patients or clients. This reflects the bigger needs and complexity of the revolving-door patients.

ACT may be expensive, but commonly it leads to a lower over-all expense for the mental health care system, per client, than "life without ACT." A single day in hospital is as expensive as a month or more of ACT. Research shows that ACT is never more expensive than the best alternatives.

Thus everyone wins with Assertive Community Treatment. The mental health system wins because far fewer hospital beds are needed. The families win because their mentally ill member is rarely ill any more.

The ill person wins big, because he tastes a sweet, stable life for the first time in years, in which he can build friendships and life plans without seeing them crumble into ruins.

That's Assertive Community Treatment.

than "revolving-door treatment" even with the best alternative