Assertive
Community Treatment influenced current community
mental health care more than any other psychosocial
intervention. During the early years of deinstitutionalization,
when many people with severe and persistent mental
illness (SPMI) failed to achieve stability in the
community and cycled in and out of hospitals, a
variety of community-based interventions evolved.
By far the most carefully defined, well documented,
and successful of these interventions was developed
in Madison, Wisconsin, where a group of clinicians
and researchers established an intensive program
of community care that has since become known as
assertive community treatment.
The
central idea of assertive community treatment was
that a community-based team would provide a full
range of medical, psychosocial, and rehabilitative
services, to prevent hospitalization of clients
by maximizing their skills and supports in the community.
The model assumes that bringing care to the patient
would obviate the problem of missed appointments
and that skills learned in a natural setting, rather
than in the hospital, would be more likely to endure.
Existing
intervention modalities have failed to enable many
individuals with SPMI to live in the community and
to improve their quality of life. Since they are
generally resistant to treatment, they may de-compensate
to the point where they become dangerous to self
and/or others. These individuals endure repeated
cycles of hospitalization, many times involuntarily,
and/or experience homelessness. Furthermore, due
to the shifting of the locus of care from hospital
to the community and the reduced number of days
of treatment in the hospital, many individuals with
severe mental illness are discharged to the community
before they are stabilized and require additional
care. The available, fragmented support mechanisms
are totally inadequate to protect these most severely
ill individuals, to provide a safety net, and help
them navigate and live in the community.
Many
of us know how and why people with SPMI keep falling
through the cracks of the mental health system.
They are mistreated, misdiagnosed, and allowed to
de-compensate to the point where they can become
dangerous to themselves and /or others. These incidents,
that occur time and time again, are painfully traumatic
to them, and cause a continued deterioration in
their ability to recover. Some endured repeated
cycles of hospitalization, many times involuntarily.
We know of individuals who experienced over 20 hospitalizations
during the illness, with increasing frequency each
year.
The
lack of appropriate and continuous care, from the
emergency room intake, to treatment in the hospital,
to finding an "appropriate" residence/program in
the community, together with the lack of proper
legislation, which would ensure treatment to the
gravely disabled, contributes to recidivism. The
treatment at each juncture of the cycle starts anew,
with different mental health workers, different
doctors, different environment, different rules
of behavior, and different treatment approaches.
This fragmentation means that:
-
Consumers
do not develop any long-term relationship
with the people entrusted with their
care.
-
Intake
in emergency rooms becomes impossible
without total and complete deterioration
so that they can be taken in, involuntarily,
under the criminalizing rule of "imminent
danger".
-
Since
previous records or history of prior hospitalizations
are not available, each hospitalization
takes longer than needed, because each
treatment starts anew with the possibility
of a new diagnosis and different medication.
-
The
consumer's severe psychiatric disability
causes rejections by residential providers
and contributes to repeated cycles of
hospitalization.
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What we need are comprehensive, integrated, individualized
services that will be accountable, and take responsibility
for the consumers at all times and wherever they
might be, homeless in the streets, in the hospital,
at home with aging parents, in a supervised residence,
or in an independent apartment.
We
need to change the dynamics of caring for the
most severely mentally ill. And we need to care
for them in the community whenever possible. We
need to ensure that the services received by them
are appropriate, that continuity of care is preserved,
and that system-wide individual case responsibility
is maintained. Our objective is recovery and not
community warehousing.
However,
to fully integrate services to the severely mentally
ill, we must have a treatment model for those
consumers who may be living independently, or
are homeless, have special needs, and are resistant
to treatment in a clinic.
Severe
mental illnesses tend to be chronic and unremitting,
and they render the patients dependent on health
care systems for the rest of their lives. The
sad reality is that there is no central concept
that is governed by those clear needs, but rather
a disjointed array of treatment concepts and facilities
without effective communication between them.
Even more disturbing is the fact that short of
the fortunate few who have a single therapist
or agency that offer a life-long responsibility,
most patients are being shuffled from one place
to another. The result is fragmentation of services
for those whose life has already been shattered
and fragmented by their mental illness. Patients
move in never ending cycles of admissions and
discharge without any coherent, future oriented
plan, resulting in decline and homelessness. In
fact, the only "comprehensive" mental health system
is the dreaded final common pathway for the patients--the
long-term chronic care facility.
The
progress made during inpatient treatment by people
with the most severe and persistent mental illnesses
is too often lost when they leave the hospital.
To avoid repeated returns to hospitals or other
residential treatment facilities, many people
with severe and persistent mental illnesses need
more individual help and support in the community
than traditional community services provide.
Too
many times the usual office-based mental health
system fails people who need help with basic,
everyday activities like caring for themselves,
taking their medication, establishing social relationships,
finding and keeping a job, and a place to live.
With enough of the right kind of individual help,
people with even the most severe mental illnesses
can make significant strides toward recovery.
This intensive support is the heart of the P/ACT
program.
WHO
BENEFITS FROM P/ACT SERVICES?
P/ACT
teams will not serve most people with severe mental
illnesses. With increasingly effective medications,
many people don't need the comprehensive level
of services provided by assertive community treatment
teams. There are many effective psychiatric and
psycho-social rehabilitation approaches, such
as clubhouse programs certified by the International
Center for Clubhouse Development, that serve people
with schizophrenia and other severe disorders.
P/ACT can make a critical difference to consumers
of mental health services who are among those
most disabled and vulnerable.
The
characteristics of the population, which will
benefit most, are individuals who demonstrate
both of the following criteria--children and aging
populations are not included:
Primary
Criteria: Persons diagnosed with severe
and persistent mental illness (SPMI) and have
significant impairment in functionality, and a
long-term history of treatment problems and/or
frequent hospitalizations.
And,
Secondary Criteria: Individuals
who demonstrate one or more of the following:
