Assertive Community Treatment as a Case Study of Outpatient

ComplianceBeth Angell, PhD, MSSW

Rutgers, the State University of New Jersey

Second Curtis J. Berger Symposium on Mental Health and the LawColumbia University Law School

November 20, 2009

ACT Overview• History – “hospital without walls”• Structure

– Multi-disciplinary team (including nurse and psychiatrist) works with all clients

– Small caseloads– Seamless 24/7 coverage– Frequent staff meetings and intra-team coordination

• Process– Combined medical and psychosocial focus; minimal brokerage– Flexible service delivery vehicle for individualizing treatment– In-vivo locus– Assertive outreach; frequent 1:1 client-staff contact– Fixed point of responsibility within system

ACT Dissemination and Adaptation

• Standardization: manuals, fidelity scales• NAMI PACT Across America initiative• Adaptations to fit needs of homeless, justice-involved, and

rural residents• 1999: HCFA encouraged Medicaid program

reimbursement• Increasing interest in time-limited and step-down models,

less intensive community support teams• Move to increase recovery-friendliness; merging with

other EBP’s such as IDDT, Housing First, IMR, supported employment

ACT as an EBP• 25 RCTs• Strongest effects :

– Decreased hospitalization– Increased housing stability/reduced homelessness

• Promising:– Symptom reduction– Enhanced QOL– Family and consumer satisfaction

• Equivocal/no evidence of effectiveness– Social and vocational outcomes– Substance use– Medication adherence– Criminal justice outcomes

• Model fidelity = greater effectiveness

Bond et al., 2001; Coldwell & Bender, 2007; Calsyn et al., 2005

ACT Criticisms

• Intensity is costly• No-discharge policy creates capacity problem and

sends anti-recovery message• What’s the intervention? Black box within the

larger well-defined structure• Assertive outreach element seen as paternalistic

(staff know better than clients what they need)• “Whatever it takes” strategies may border on

coercive in some situations

PACT programs heavily rely on coercion. They are rarely voluntary. Professionals make the decisions and leave little room for consumer choice. People are assigned to PACT teams based on the determination by the mental health system that they need such a team. In fact, the push for outpatient commitment…is often coordinated with a push for PACT teams to carry it out…persons can live in the community, but must remain under close surveillance. They can be rehospitalized if they do not take their medication or even appear to be doing worse. This creates the type of mistrust and breach of civil rights which are bound to undermine recovery.

Fisher & Ahearn, 2000

Translating the guideline [of assertiveness] into everyday clinical routines involves informal practices of surveillance, such as counting the number of beer cans in the trash or asking directly about drug use, prostitution, and drinking…keeping up to date with virtually every aspect of clients’ lives – who they visit, what they eat, where the spend their days – through observation or direct questioning…Case managers find that they are massively controlling their clients, supposedly to guarantee that clients control their own lives.

Brodwin, 2008

How do ACT teams manage adherence problems?

• Survey data• Qualitative process studies

Survey Findings

Studies of adherence strategies reported by ACT providers and teams show:

• Low base rates of “high-end” coercive strategies such as withholding help, sanctioning, restricting freedom

• AOT infrequently used but use of rep payeeship much more common

• Reliance on persuasive techniques and intensive monitoring of adherence

Neale & Rosenheck, 1999; Angell, 2006; Moser, 2009

Process Studies: Description

• Qualitative study of two ACT teams using passive observation and interviewing methods (Angell et al., 2006; Angell & Mahoney, 2007)

• In-progress ethnography of forensic assertive community treatment being conducted by Beth Angell, Amy Watson, and colleagues.

• Focus in both studies upon how ACT providers manage adherence in everyday clinical interactions

Process Study Findings• Social influence processes more akin to personal than

professional therapeutic relationships• Bases of social influence in everyday life:

– Authority– Legitimacy– Identification– Referent power– Norm of reciprocity– Reward/resource power

+ Social deprivation of consumers

Creates opportunity context for relational leverageAngell et al., 2006

Strategies of Relational Leverage

• Structuring adherence/intensive monitoring• Empathic listening and expressions of concern;

emotional appeals• Direct or request clients to comply• Provision of practical supports at engagement phase• Rewarding adherence• Forging mental linkages between client goals/values

and adherence behavior• Working with clients to develop the agency to take

responsibility for their own treatment decisions

Consumer Responses to ACT

• Valuing of client-staff relationships ranks most highly

• Assertive outreach most often seen as an expression of caring and support

• Perceptions of team often expressed in friend-like or even family – like terms

• Concrete assistance is important and prioritized• Intrusive and/or coercive sentiments are rarely

expressedRedko et al., 2004; Chinman et al., 1999; McGrew et al., 2002; McGrew et al., 1996; Appelbaum & Le Melle, 2008; Stanhope & Matejkowski, 2009

Is relational leverage enough?

What does AOT add?

NY AOT evaluation suggests an incremental advantage with respect to level of provider-rated service engagement (% with good or excellent engagement) for clients on a long term AOT order vs. ACT clients with no AOT order. For a minority of consumers, AOT may seen as a “nudge” that ensures initial and ongoing engagement.

AOT length ACT alone ACT + AOT> 6 months 32% 37%

> 12 months 43% 55%

Swartz et al. (2009), New York State Assisted Outpatient Treatment Evaluation, final report.

Nudge…or push?

There are major interpersonal costs in coercion – in moving from a collaborative to a controlling relationship. The need for court-ordered treatment is indicative of a failure of the relationship between the client and the treatment staff, at least for that moment in time. It indicates a major discrepancy between what the client feels he or she needs and what clinical staff feel is needed. It can have a major influence on the treatment relationship, an influence that can last for years after the actual event.

Diamond, 1996

Nudges: Examples from Behavioral Economics

• Email filters that sense and caution the writer to wait 24 hours before sending a “heated” message

• Putting oneself on a casino ban list to curb problem gambling

• Committing a sum of money that will be forfeited if a desired behavioral goal is not met

“The gentle power of libertarian paternalism”

From Push to Nudge?

• AOT may provide the extrinsic “push” needed for initial engagement and management of crises.

• Similar effects may accrue from other forms of leverage (financial, housing, criminal justice)

• How can ACT and similar programs move toward nudges that create incentives for consumers to make responsible care decisions?– Providing goods people become motivated to keep, e.g.,

housing, work– Collaborative mechanisms for managing future crises, e.g.,

advanced directives, joint crisis plans

Contact Information

Beth AngellRutgers School of Social Work536 George St.New Brunswick NJ, 08901angell@ssw.rutgers.edu