Assertive Community Treatment Programs

Charles Rainey, MD, JD

     In this article, we will look at what an Assertive Community Treatment (ACT) program is in general and in ethical

     terms and then discuss the implementation of a specific program in Rochester, New York, that won the 1999 APA

     Gold Achievement award.

     These programs are important because of the increasing number of mentally ill persons found in the criminal justice

     system. This population was stable for 60 years, but in the 1980s it began to increase exponentially. The United

     States is second only to Russia and Uganda in the number of citizens imprisoned per capita. The incidence of

     mentally ill persons in jail is 3 to 4 times that of the general population. The increased number of mentally ill persons

     in the criminal justice system may result from a variety of factors, including public sentiment and legal decisions

     requiring deinstitutionalizing of the chronically mental ill; restructuring of civil commitment laws that make it difficult

     to obtain a civil commitment; and inaccessibility of mental health services in the community. The project discussed

     here examines another reason:that there may be gaps in the coverage, resources, and services of the criminal justice,

     mental health, and the social service systems.

     What is an ACT System/Team?

     ACT is an intervention that is carried out in vivo. It is not done in an office or clinic but is taken into the community

     where the patient is. The team assumes full clinical responsibility for the patient, looking after their medication and

     therapy needs as well as their financial (eg, payeeship); housing; legal (representation and/or probation or parole);

     and substance abuse issues. ACT team members are available for rapid, invasive responses. They also have a

     long-term allegiance to the patient resulting from a low staff-to-client ratio and the focus on the most seriously and

     persistently mentally ill persons. The model was originally developed in Madison, Wisconsin.[1]

     As it was designed, the program should decrease the number and length of hospital stays and increase client

     satisfaction, but the impact on cost may be equivocal and until recently, there was no evidence of the effects on

     reincarceration.

     Dr. Jeffrey G. Stovall, Assistant Professor at the University of Massachusetts and a director of outpatient services,

     recently looked at programs from an ethical perspective.[2] He found the programs to be invasive; for example, the

     client may have to take medication in front of a team member every day. Since the program has a partial allegiance

     to the community, the patient may be hospitalized if necessary to prevent harm to the community. Because of the

     intensive nature of the service, patient activity is subject to more frequent and intensive policing. He also asked,

     "What is ethical treatment?" and "Do ACT programs violate any ethical standards? Are they coercive?" As

     discussed during the presentation, everyone is subject to limits as they grow up and develop in a communal society.

     Perhaps the limits placed on ACT clients are just part of the limits they must endure to live in that community. In

     response, Dr. Stovall quoted Judge Bazelon: "How real is the premise of individual autonomy for a confused person

     set adrift in a hostile environment?"

     Dr. Stovall also expressed concern about loyalty in the ACT program, where the team member has allegiance to

     both the patient and the community. In an office practice, the allegiance is solely to the patient. Regarding the

     voluntary or coercive nature of ACT services, Dr. Stovall posed an ethical question: "Do we use ACT because other

     services (such as housing, employment, treatment, societal attention) don't exist for these patients?" He found that,

     above all, patients wanted to be treated with respect. As an alternative to the Georgetown mantra of autonomy,

     nonmalfeasance, beneficence, and justice, Dr. Stovall proposed one of compassion, humility, and fidelity for members

     and clients of ACT programs.

     Project LINK

     Based in Monroe County, New York, one particular ACT program won the 1999 APA Gold Achievement Award.[3]

     The program was based on a 1993 survey done at the University of Rochester, New York. This study reviewed 126

     people who had had multiple arrests from 1990 ensured outpatient treatment. The second model reviewed was the

     ACT model, which focused on high-risk patients; used a mobile, multidisciplinary treatment team, had an assertive

     treatment philosophy; and was effective in engaging patients in treatment. However, studies did not show an effect

     in the number of arrests.[4]

     To address the Monroe Jail survey, 2 faculty from the University of Rochester developed Project LINK. The project

     consists of a mobile treatment team, mentally ill chemical abuser (MICA) residence, criminal justice system

     integration, and community partnership. The mobile treatment team comprises a psychiatrist; a nurse practitioner;

     and to ensure cultural sensitivity for the project's clients, 5 culturally diverse caseworkers drawn from the community

     partners of Project LINK. This team focuses on the 40 most serious cases and is available 24 hours a day. The

     MICA treatment residence consists of 10 apartments in a complex with 3 clients per unit. Staff is present 24 hours a

     day and has an increased presence in the evening, which is when the clients have fewer outside activities. Numerous

     group sessions and recreational activities are provided by in-house staff as well as by outside organizations. The

     Project LINK community is structured on a 4-level privilege-based system. The project is integrated into the criminal

     justice system through its connection with the Monroe County Jail clinic, which serves 1000 clients. This simplifies

     the team members' access to the jail and clients when they are incarcerated. Surveys and education of members of

     the judiciary have lead to the development of a de novo mental health court with judges versed in the issues of the

     mentally ill. Project LINK members have also developed a close working relationship with the probation and parole

     departments and ultimately an alternative to incarceration program.

     Project LINK's admission criteria for its 40 most serious cases are: age older than 18 years, diagnosis of a psychotic

     disorder, and prior criminal justice system involvement. Although not an admission criterion, substance abuse is

     common. The project is financed by diversionary funds from the closing of the state hospitals and a grant from the

     Robert Wood Johnson Foundation. Community buy-in was obtained by directors of community mental health groups.

     The Project has been operating since 1996, and the average length of treatment is 24 months.

     To date, the project has treated 71 clients, of whom 56% or 79% were male. Thirty-nine (55%) had a diagnosis of

     schizophrenia; 15 (21%) had psychosis NOS; 9 (13%) had schizoaffective disorder; 6 (8%) had bipolar disorder; and

     2 (3%) had other disorders. Sixty-three patients (89%) had a comorbid diagnosis of substance abuse, and 66 (93%)

     were unemployed at the time of intake. Looking at outcomes, substance abuse was significantly improved at the time

     of discharge, as measured by the MCAS (before 2.2, after 3.3; P > .001; n = 44) and the Substance Abuse

     Treatment Scale (SATS) (before 2.3, after 4.8; P > .001; n = 44). The clients showed a decreased total number of

     hospital days during the 1-year period after treatment compared with the 1-year period before treatment (16 and 100

     days, respectively; n = 41). A decline in jail days has also been shown (100 and 45 days, respectively; n = 45). The

     cost per jail-day was $77. There was no prospective randomization of clients. The cost per patient for the year

     before entry into the program, which includes housing, treatment, and jail, was an average of $73,878. For the year

     after entry into the program, the cost per patient was $34,360.

     Project LINK is a demonstration of an ACT program that shows improvements in the traditional outcomes measures

     of decreasing the number of hospital days, the number of jail days, and cost in providing assertive treatment in the

     community. The success of this project was attributed to the cultural sensitivity of the mobile treatment, availability

     of 24-hour community services, integration into the criminal justice system, and buy in from community mental health

     groups. Project LINK gives hope that the increasing number of mentally ill persons who enter into the criminal

     justice system can be served, and both these people and the community can benefit by the provision of intensive

     outpatient services.

     Mandated Outpatient Treatment

     Another trial that was a part of the APA's Council on Psychiatry and Law Presentation[5] studied the use of

     mandated outpatient treatment in the Chicago area. Illinois has allowed outpatient commitment for about 20 years,

     but use was relatively infrequent and when used, lag time for readmission was significant. The mental health system

     involved has 3 state hospitals, 80 community centers, and 3 overlapping networks with a total of 700 beds, including

     those in the forensic programs. In this project, a partnership was formed among the state's attorney's office,

     psychiatric treatment providers, and the mental health advocacy groups. They started by developing a simple,

     clear-cut scenario under which a person would be expeditiously readmitted. The initial criteria required the patient to

     currently be an inpatient at a state hospital for treatment of a severe mental illness, violence or threat of violence to

     self or others, a history of treatment noncompliance, a clear course of decline over multiple admissions, at least a

     180-day treatment commitment history, and a desire by the patient to return to the community. In addition,

     participation in the plan must be voluntary on the part of both the patient and the treatment provider. During the first

     18 months of this project, 15 people have participated. Nine were males, and 6 were females. Thirteen patients came

     from treatment providers who were part of the project, and 2 came from outside providers. Examination of the

     1-year periods before and after participation revealed the following. The average number of inpatient admissions

     was 3.7 in the year before entry into the program and declined to 0.8 in the year after entry. Likewise, the total

     number of hospital days declined from 41 in the year before to only 15 in the year after entry. Similar to the results

     of Project LINK, the number of jail admissions declined from 3 in the year before to 0 in the year after entry into the

     program. No information was presented on the comparative costs of this program. Work is now being done on

     additional scenarios to allow admission into to the program with less clear-cut indications, including a treatment

     diversion program where a person would be voluntarily admitted and not hospitalized but rather discharged to the

     program. If they violated a term of their discharge, they could be rapidly pulled in and the deferred evaluation done.

     The partnership has fostered new understanding and cooperation among the parties. For example, the community

     groups compiled a database of mentally ill persons to share with the Chicago police to improve the relationship

     between the groups and prevent unnecessary entry of the mentally ill into the criminal justice system.

     These two projects show that hope is increasing for the treatment of mentally ill persons without their being involved

     in the criminal justice system. There are second-generation studies that further this hope, as does the APA's

     Resource on Outpatient Treatment.

     References

        1.Thompson KS, Griffith EE, Lenf PJ. A historical review of the Madison Model Community Care. Hospital

          and Community Psychiatry.1990;41:625-634.

        2.Stovall JG. Ethical dilemmas in assertive community treatment. Program and abstracts of the 52nd Annual

          Institute on Psychiatric Services, American Psychiatric Association Meeting; October 25-29, 2000;

          Philadelphia, Pennsylvania. Abstract: Innovative Program 17.

        3.Lamberti JS. Project LINK : preventing incarceration of adults with severe mental illness. Program and

          abstracts of the 52nd Annual Institute on Psychiatric Services, American Psychiatric Association Meeting;

          October 25-29, 2000; Philadelphia, Pennsylvania. Abstract: Innovative Program 16.

        4.Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community care for severe mental illness: a review

          of research on case management. Schizophr Bull. 1998;24:37-74.

        5.Simpatico T. Mandatory outpatient treatment: background, pilot data and recommendations. Program and

          abstracts of the 52nd Annual Institute on Psychiatric Services, American Psychiatric Association Meeting;

          October 25-29, 2000; Philadelphia, Pennsylvania. Abstract: Innovative Program 54.