The acceptability of assertive community treatment

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The acceptability of assertive community treatment

• Dr Helen Killaspy
• Senior lecturer and honorary consultant in
  rehabilitation psychiatry
• University College London
• Camden Islington NHS Foundation Trust
• h.killaspy_at_medsch.ucl.ac.uk

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What is assertive community treatment?

• Maximum case load 10-12 per FT worker
• Extended hours
• In vivo contact
• Assertive engagement
• No drop-out policy
• Team based approach
• Regular and frequent team meetings - daily plans
• Use skills of team rather than outside agencies
• Family/carer support and liaison
• Own beds, responsible for admissions/discharges
• Dartmouth ACT Scale. Teague et al., 1998, Am J
  of Orthopsychiatry, 68, 216-232

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Evidence re. ACT in US and Australia

• Stein, L. I. Test, M. A. (1980) Alternatives to
  mental hospital treatment. Archives
• of General Psychiatry, 37, 392 - 397.
• Hoult, J. (1986) Community care of the acutely
  mentally ill. British Journal of Psychiatry,
• 149, 137-144.
• Hambridge, J. A. Rosen, A. (1994) Assertive
  community treatment for the seriously
• mentally ill in suburban Sydney A programme
  description and evaluation. Australian and
• New Zealand Journal of Psychiatry, 28,
  438-445.Hambridge Rosen, 1994
• Issakidis, C., Sanderson, K., Teeson, M., et al
  (1999) Intensive case management in
• Australia a randomized controlled trial. Acta
  Psychiatrica Scandinavica, 99, 360-367.
• Marshall Lockwood (1998) Marshall Lockwood
  (1998) Assertive community treatment for
• people with severe mental disorders. Cochrane
  Schizophrenia Group, Cochrane database of
• systematic reviews. 1, 2003

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Evidence re. ACT in US/Australia

• less likely to be lost to follow up
• less likely to be admitted and shorter admissions
  
• improved employment, accommodation stability and
  satisfaction with services
• no greater risk of adverse events
• no advantage over standard care in terms of
  improvement in symptoms or social functioning

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Evidence re. ACT in Europe

• Holloway, F. Carson, J. (1998) Intensive case
  management for the severely mentally
• ill. Controlled Trial. British Journal of
  Psychiatry, 172, 19-22.
• Thornicroft, G., Wykes, T., Holloway, F., et al
  (1998) From efficacy to effectiveness in
• community mental health services. PRiSM Psychosis
  Study 10. British Journal of
• Psychiatry, 173, 423-427.
• Burns, T., Creed, F., Fahy, T., et al (1999)
  Intensive versus standard case management
• for severe psychotic illness A randomised trial.
  Lancet, 353, 2185-9.
• Killaspy, H., Bebbington, P., Blizard, R., et al
  (2006) The REACT study Randomised
• evaluation of assertive community treatment in
  north London. British Medical Journal,
• 332, 815-820.
• Sytema, S., Wunderink, L., Bloemers, W. et al
  (2007) Assertive community treatment
• in the Netherlands a randomized controlled
  trial. Acta Psychiatrica Scandinavica, 116,
• 105-112

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Evidence re. ACT in Europe

• Increased contact/engagement
• Greater client satisfaction
• No advantage over standard care in terms of
  inpatient service use
• No advantage over standard care in terms of
  improvement in symptoms or social functioning
• Not (more) cost effective

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Concerns about coercion and ACT

• Assertive approach is, by definition, coercive
• Designed to regulate and normalise service users
  behaviour
• Paternalistic
• Service can limit access to e.g. housing and
  finances
• Some countries have legal measures to ensure
  treatment adherence e.g. outpatient commitment,
  community treatment orders,
• ACT requires bending the will of an unwilling
  participant
• Underhand and insidious befriending focussing
  on practical issues but with aim of increasing
  treatment adherence

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Is there evidence of coercive practices in ACT?

• Angell, B., Mahoney, C. A., Martinez, N. I.
  (2006). Promoting treatment
• adherence in assertive community treatment.
  Social Service Review, 80, 485
• 526
• Qualitative study in 1 urban and 1 rural ACT team
  in Madison, Wisconsin
• 45 client-staff contacts observed
• Very little use of coercive approaches e.g.
  outpatient commitment, financial control
• Evidence of wide range of collaborative
  approaches that promoted psychoeducation and
  engagement

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• Davidson, G. and Campbell, J. (2007). An
  examination of the use of coercion
• by assertive outreach and community mental health
  teams in
• Northern Ireland, British Journal of Social Work,
  37, 537-555.
• Service users perceived coercion reduced more
  for ACT than CMHT clients
• Fewer coercive strategies used by ACT than CMHT
  staff
• Killaspy, H., Bebbington, P., Blizard, R., et al
  (2006) The REACT study
• Randomised evaluation of assertive community
  treatment in north London.
• British Medical Journal, 332, 815-820.
• ACT clients ratings of intrusiveness of service
  were lower than CMHT clients, despite having
  three times the number of contacts and most in
  vivo
• Less coercive approaches reported than CMHT staff
  in qualitative study

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Implementation of ACT

• UK National service framework for mental health
  5 years on (Dept. Health, 2005)
• 263 ACT teams (target 220)
• 168 Crisis Resolution Teams (target 335)
• 41 Early Intervention Services (target 50)
• Netherlands, Spain, Sweden, Italy, Germany
• Tobago, Trinidad, Sri Lanka

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Qualitative study of content of care delivered
to participants in the REACT study

• Staff felt ACT model more appropriate than CMHT
  case management for working with hard to engage
  clients
• Model popular with staff, particularly due to the
  support provided by the team approach and
  flexibility of small case loads
• Clients better engaged and more satisfied with
  service, probably due to specific style of
  working
• Collaborative
• Respectful
• Common ground
• Focus on practical issues
• Informal support to families/carers

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Priebe, S., Watts, J., Chase, M et al. Processes
of disengagement and engagement in assertive
outreach patients qualitative study. British
Journal of Psychiatry, 2005, 187, 438-443

• Service users reported that a poor therapeutic
  relationship was most important factor associated
  with disengagement from ACT
• Engagement was promoted where there was not a
  focus on medication and where service users felt
  they were in an authentic partnership and being
  listened to

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• Does engagement matter?

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Catty, J. (2004). The vehicle of success.
Theoretical and empirical perspectives on the
therapeutic alliance in psychotherapy and
psychiatry. Psychology and psychotherapy Theory,
Research and Practice, 77, 255-272

• Therapeutic alliance is one of the most powerful
  predictors of outcome in psychotherapy
• Outcomes include social functioning, global
  improvement, drug use
• Meta-analyses suggest around 25 of outcome can
  be attributed to therapeutic alliance
• Construct of therapeutic alliance comprises
  affective bonds and collaboration
• Similar to Rogers (1951) core conditions for
  therapeutic success
• empathy unconditional positive regard and
  congruence

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Is therapeutic alliance in psychotherapy the same
thing as engagement in psychiatric practice?

• Obvious differences in how clients present to
  psychotherapists vs psychiatrists
• Engagement can mean medication adherence
  appointment keeping not dropping out of contact
  collaboration in treatment plan

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McCabe, R. Priebe, S. (In Press). The
therapeutic relationship in the treatment of
severe mental illness a review of methods and
findings. International Journal of Social
Psychiatry.

• Paucity of literature on therapeutic alliance in
  schizophrenia
• Most measures used to assess therapeutic alliance
  developed for psychotherapy clients
• Measures generally assess single relationship
• Associations found with medication adherence
  satisfaction self-rated symptoms and social
  functioning quality of life inpatient service
  use (increased or decreased)
• No convincing evidence that increased engagement
  is associated with improved outcomes for ACT
  service users, even after 3 years

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But.

• Association between therapeutic alliance and
  outcome doesnt necessarily mean therapeutic
  alliance is the active ingredient. It may
  simply be a vehicle for delivery of interventions
  that are effective.

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Burns T, Catty J, Dash M. et al. (2007).
Intensive case management and hospitalisation
explaining the inconsistent findings. A
Systematic Review and Meta-Regression. BMJ,
335,336-40

• Fidelity to the team structure and organisation
  aspect of ACT does explain much of the variation
  in outcomes
• Whether the team was primary therapist for its
  clients was based off the hospital campus met
  daily shared responsibility for caseloads was
  available 24 hours had a team leader who was
  also a case manager offered time-unlimited
  services

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Wright, C, Brugha, T, Burns, T et al. Assertive
outreach in England a national study of service
organisation conformity to model fidelity.
British Journal of Psychiatry, In press

• 222 teams surveyed in 2002-3
• Wide range of model fidelity
• Only 12 were operating with high model fidelity
• Many of the missing components of the ACT model
  (operates 24 hours a day meets daily team
  manager has case load primary therapist for
  clients) were those associated with greater
  efficacy (Burns et al, 2007)
• Average case load of 5 clients
• Average service user contact 2 hours per week
• Minimal provision of specialist psychosocial
  interventions (2/3 had OT, very few had
  psychologist)
• Only half had a psychiatrist hence medication was
  not prescribed or reviewed by the team
• Few had substance misuse or vocational
  rehabilitation specialist on staff
• Rebadged community rehabilitation teams, which
  made up 20 of ACT teams had good model fidelity,
  better than newly formed teams

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Sustainability of ACT

• Carpenter, J., Luce, A. Wooff, D. (2008).
  Assertive outreach in the
• North East and Yorkshire. Final report
  
• Detailed surveys of all ACT teams in North East
  England
• in 2002/3 (n30) and 2005/6 (n34)
• Teams didnt change in staffing or model fidelity
  over time
• gt 50 no psychiatrist, gt 60 no occupational
  therapist, gt 80 no psychologist at both time
  points
• No change in missing components
• Schneider et al. Assertive outreach policy and
  reality,
• Psych. Bulletin, 2006, 30,89-94
• Teams continued to work with target population

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Conclusions

• ACT is acceptable to staff
• ACT is more acceptable to service users than
  standard care
• Concerns about it being coercive may be unfounded
• Popular, sustainable and widely implemented
• Embodies recovery based practice

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The ACT vehicle

• Team approach
• In vivo working
• Extended hours
• Full clinical responsibility
• Manager has clinical case load
• Time unlimited service
• Appropriately staffed

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