Assertive community treatment
Assertive community treatment (ACT) is an intensive and highly integrated approach for Community mental health service delivery. ACT programs serve outpatients whose symptoms of mental illness lead to serious functioning difficulties in several major areas of life, often including work, social relationships, residential independence, money management, and physical health and wellness.
The defining characteristics of ACT include:
- a focus on participants (also known as members, consumers, clients, or patients) who require the most help from the service delivery system;
- an explicit mission to promote the participants' independence, rehabilitation, and recovery, and in so doing to prevent homelessness, unnecessary hospitalization, and other negative outcomes;
- an emphasis on home visits and other in vivo (out of the office) interventions, eliminating the need to transfer newly learned skills from an artificial rehabilitation or treatment setting to the "real world";
- a participant-to-staff ratio that is low enough to allow the ACT "core services team" to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or "farm out" most of the work to other service providers;
- a "total team" or "whole team" approach to intervention, in which all of the staff work with all of the participants under the supervision and active participation of a mental health professional, who serves as the team's leader;
- an interdisciplinary program of assessment, service planning, and intervention that typically involves—in addition to the team leader—a psychiatrist and one or more case managers or service coordinators, social workers, nurses, occupational therapists, substance use specialists, vocational rehabilitation specialists, and peer support specialists (individuals who have had personal, successful experience with the recovery process); Additionally, Since the Obama era, in many ACT programs have become Housing First Models.
- a willingness on the part of the team to take ultimate professional responsibility for the participants' well-being in all areas of community functioning, including most especially the "nitty-gritty" aspects of everyday life;
- a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of day or night to keep crises from leading to negative outcomes; and
- a promise to work with people on a time-unlimited basis, as long as they continue to demonstrate the need for this intensive level of professional help.
In the array of standard mental health service types, ACT is considered a "medically monitored non-residential service" (Level 4), making it more intensive than "high-intensity community-based services" (Level 3) but less intensive than "medically monitored residential services" (Level 5), as measured by the widely accepted LOCUS utilization management tool.
ACT was first developed during the early 1970s, the heyday of deinstitutionalization, when large numbers of patients were being discharged from state-operated psychiatric hospitals to an underdeveloped, poorly integrated "nonsystem" of community services characterized (in the words of one of the model's founders) by serious "gaps" and "cracks." The founders were Leonard I. Stein, Mary Ann Test, Arnold J. Marx, Deborah J. Allness, William H. Knoedler, and their colleagues at the Mendota Mental Health Institute, a state psychiatric hospital in Madison, Wisconsin. Also known in the literature as the Training in Community Living project, the Program of Assertive Community Treatment (PACT), or simply the "Madison model," this innovation seemed radical at the time but has since evolved into one of the most influential service delivery approaches in the history of community mental health. The original Madison project received the American Psychiatric Association's prestigious Gold Award in 1974. After conceiving the model as a strategy to prevent hospitalization in a relatively heterogeneous sample of prospective state hospital patients, the PACT team turned its attention in the early 1980s to a more narrowly defined target group of young adults with early-stage schizophrenia.
Dissemination of the original model
Since the late 1970s, the ACT approach has been replicated or adapted widely. The Harbinger program in Grand Rapids, Michigan, is generally recognized as the first replication, and a family-initiated early adaptation in Minnesota, known as Sharing Life in the Community when it was founded in 1976, also traces its origins to the Madison model.
Starting in 1978, Jerry Dincin, Thomas F. Witheridge, and their colleagues developed the Bridge assertive outreach program at the Thresholds psychiatric rehabilitation center in Chicago, Illinois—the first big-city adaptation of ACT and the first such program to focus on the most frequently hospitalized segment of the mental health consumer population. In the 1980s and '90s, Thresholds further adapted the approach to serve deaf people with mental illness, homeless people with mental illness, people experiencing psychiatric crises, and people with mental illness who are caught up in the criminal justice system.
In British Columbia, an experimental assertive outreach program based on the Thresholds model was established in 1988 and later expanded to additional sites. Outside of North America, one of the first research-based adaptations was an assertive outreach program in Australia. Other replications or adaptations of the ACT approach can be found throughout the English-speaking world and elsewhere. In Wisconsin, the original Madison model was adapted by its founders for the realities of a sparsely populated rural environment. The Veterans Health Administration has adapted the ACT model for use at multiple sites throughout the United States. There are also major program concentrations in Delaware, Florida, Georgia, Idaho, Illinois, Indiana (home of numerous research-based ACT programs and the Indiana ACT Center), Michigan, Minnesota, Missouri, New Jersey, New Mexico, New York, North Carolina, Ohio, Rhode Island, South Carolina, South Dakota, Texas, Virginia, Australia, Canada, and the United Kingdom, among many other places.
In 1998, the National Alliance on Mental Illness (NAMI) published the first manualization of the ACT model, written by two of its original developers, Allness and Knoedler. From 1998 to 2004, NAMI operated an ACT technical assistance center, dedicated to advocacy and training to make the model more widely available, with funding from the U.S. federal government's Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the Department of Health and Human Services.
Although most of the early PACT replicates and adaptations were funded by grants from federal, state/provincial, or local mental health authorities, there has been a growing tendency to fund these services through Medicaid and other publicly supported health insurance plans. Medicaid funding has been used for ACT services throughout the United States, starting in the late 1980s, when Allness left PACT to head Wisconsin's state mental health agency and led the development of ACT operational standards. Since then, U.S. and Canadian standards have been developed, and many states and provinces have used them in the development of ACT services for individuals with psychiatric disabilities who would otherwise be dependent on more costly, less effective alternatives. Even though Medicaid has turned out to be a mixed blessing—it can be difficult to demonstrate a person's eligibility for this insurance program, to meet its documentation and claim requirements, or to find supplemental funding for necessary services it will not cover—Medicaid reimbursement has led to a long-overdue expansion of ACT in previously unserved or underserved jurisdictions.
Public mental health system planners have attempted to resolve the implementation problems associated with replicating the original Madison approach in sparsely populated rural areas or with low-incidence special populations in urban areas. A related issue for planners is to determine the number of ACT or "ACT-like" programs a particular geographical area needs and can support. Some promising areas for further development are identified below in the section on the future of ACT.
ACT and its variations are among the most widely and intensively studied intervention approaches in community mental health. The original Madison studies by Stein and Test and their colleagues are classics in the field. Another major contributor to the ACT literature is Gary Bond, who completed several studies at Thresholds in Chicago and later developed a major psychiatric rehabilitation research and training program at Indiana University-Purdue University at Indianapolis. Bond has been particularly influential in the development of fidelity measurement scales for ACT and other evidence-based practices. He and his colleagues (especially Robert E. Drake at Dartmouth Medical School) have attempted to consolidate and harmonize several major currents in this continuously developing area of practice, including:
- the different "styles" of service delivery exemplified by PACT in Madison, Thresholds in Chicago, the Dartmouth model of integrated dual disorders treatment, and other pioneering programs;
- the various modifications of the original ACT approach over the years to maximize its effectiveness with particular service delivery challenges, such as helping consumers to recover from co-occurring psychiatric and substance use disorders or to choose, get, and keep competitive jobs through a rehabilitation approach called supported employment; and
- the increasingly well-organized efforts to help consumers take charge of their own wellness management and recovery.
An evidence review conducted by the AcademyHealth policy center in July 2016, examining the impact of housing-related services and supports on the health outcomes of homeless people enrolled in Medicaid, concluded that ACT reduces self-reported psychiatric symptoms, psychiatric hospital stays, and hospital emergency department visits among people with mental illness and substance use diagnoses.
Acclaim and criticism
Because of its long track record of success with high-priority service recipients in a wide variety of geographical and organizational settings—as demonstrated by a large and growing body of rigorous outcome evaluation studies—ACT has been recognized by SAMHSA, NAMI, and the Commission on Accreditation of Rehabilitation Facilities, among other recognized arbiters, as an evidence-based practice worthy of widespread dissemination.
However, the acclaim for assertive community treatment and related service approaches is not universal. For example, Patricia Spindel and Jo Anne Nugent have argued that the main difficulty with the Program of Assertive Community Treatment (PACT) model and some other case management approaches is that there has been no critical analysis of how personally empowering (as opposed to socially controlling) such programs are. These authors have argued that PACT does not meet the criteria for being an empowerment approach for "working with disadvantaged, labelled, and stigmatized people." Furthermore, they assert, PACT does not have a philosophical base that stresses true individual empowerment. There is much literature, they say, questioning the way in which human services are delivered, but this literature is not considered in evaluations of the PACT approach. Spindle and Nugent conclude that "PACT may be little more than a means of transporting the social control and biomedical functions of the hospital or the institution to the community. For a community mental health system which says that it wants a more progressive approach, PACT simply does not fit the bill." Other concerns have arisen out of the harm reduction/Housing First portion of the model as implemented currently. Some clinicians and Dual Diagnosis specialists voice concerns that the model creates a safe environment for increased drug use resulting in more instances of overdoses and even death and are awaiting an empirical study to back these observational concerns.
Tomi Gomory at Florida State University has also been critical of PACT. He has written: "Advocates of Programs of Assertive Community Treatment (PACT) make numerous claims for this intensive intervention program, including reduced hospitalization, overall cost, and clinical symptomatology, and increased client satisfaction, and vocational and social functioning. However, a reanalysis of the controlled experimental research finds no empirical support for any of these claims." Gomory has asserted that the chief characteristics of PACT are "intensity, assertiveness, or aggressiveness, which may better be identified as coercion. For example, reduced hospitalization in ACT is simply accomplished by having an administrative decision rule not to admit ACT patients into the hospital regardless of symptomatic behavior (the patients are kept and treated in the community) while patients in routine treatment are hospitalized regularly. When this rule is not present the research shows no reduced hospitalization by ACT compared to routine treatment." Madison psychiatrist Ronald J. Diamond has provided support to that position: "The development of Programs for Assertive Community Treatment (PACT), assertive community treatment (ACT) teams and a variety of similar mobile, continuous treatment programs has made it possible to coerce a wide range of behaviors in the community." Gomory has also argued that it is mainly professional enthusiasm for the medical model that is driving an expanded use of PACT, rather than any clear benefit to clients who receive the service.
In a Psychiatric Services scholarly journal exchange, Test and Stein have replied to Gomory's assertions that PACT is inherently coercive and that the research claiming to support it is scientifically invalid, and Gomory, in turn, has answered their reply. Moser and Bond address coercion and the broader concept of "agency control" (practices in which the treatment team maintains supervisory responsibility over consumers) in a discussion of data from 23 ACT programs. Their review shows that "agency control" varies greatly among different programs; it may be particularly high with patients diagnosed in the schizophrenia spectrum who also have active substance use issues. A widely distributed book co-authored by Gomory has called the public's attention to various treatment failures allegedly caused by therapies described in the book as "coercive," including PACT.
The cost-effectiveness of ACT was relatively easy to demonstrate in the early days, when psychiatric hospital beds were more heavily used than they are now. In the years to come, service planners will have to justify the comparatively high cost of ACT through the continued use of careful admission criteria and rigorous outcome evaluation.
The defining characteristics of the ACT approach will remain an attractive framework for services to meet the needs of special populations, such as individuals whose psychiatric symptoms get them into trouble with the criminal justice system, refugees from foreign countries who struggle with the added burden of mental illness, and children and adolescents with serious emotional disturbances. One major piece of unfinished business in the mental health field is the discovery that people with serious mental illnesses die an average of 25 years earlier than the general public, often from disorders that are inherently preventable or treatable; this public health disaster is a critical issue for ACT providers and the people they serve.
Another important area for future program design and evaluation is the use of ACT in combination with other established interventions, such as integrated dual disorder treatment for people with co-occurring mental health and substance use diagnoses, supported employment programs, education for concerned family members, and dialectical behavior therapy for individuals diagnosed with borderline personality disorder. Ironically, the dissemination of separate evidence-based practices, not all of which are easily integrated with each other, has once again made service coordination a pivotal issue in community mental health—as it was during the latter part of the 20th century, when ACT was created as an antidote to the "nonsystem" of care.
- Dixon, L. (2000). Assertive community treatment: Twenty-five years of gold. Psychiatric Services, 51, 759-765.
- Test, M. A., & Stein, L. I. (1976). Practical guidelines for the community treatment of markedly impaired patients. Community Mental Health Journal, 12, 72-82.
- Kent, A., & Burns, T. (1996). Setting up an assertive community treatment service. Advances in Psychiatric Treatment, 2, 143-150.
- Cupitt, C. (2009). Reaching Out: The Psychology of Assertive Outreach, 46. Abingdon-on-Thames, UK: Routledge.
- For a definitive analysis of the essential components of the ACT approach, see: Linkins, K., Tunkelrott, T., Dybdal, K., & Robinson, G. (2000, April 28). Assertive community treatment literature review. Report prepared for Health Care Financing Administration & Substance Abuse and Mental Health Services Administration. Falls Church, VA: The Lewin Group. .
- Allness, D. J., & Knoedler, W. H. (2003). A manual for ACT start-up: Based on the PACT model of community treatment for persons with severe and persistent mental illnesses. Arlington, VA: National Alliance on Mental Illness.
- Witheridge, T. F. (1991). The "active ingredients" of assertive outreach. In N. L. Cohen (Ed.), Psychiatric outreach to the mentally ill (pp. 47-64). San Francisco: Jossey-Bass. (New Directions for Mental Health Services, no. 52.)
- McGrew, J. H., & Bond, G. R. (1995). Critical ingredients of assertive community treatment: Judgments of the experts. Journal of Mental Health Administration, 22, 113-125.
- Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive community treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141-159.
- American Association of Community Psychiatrists (2000). Level of Care Utilization System for Psychiatric and Addiction Services, Adult Version 2000. Erie, PA: Deerfield Behavioral Health. Available online at: www.locusonline.com Archived January 11, 2016, at the Wayback Machine.
- Test, M. A. (1979). Continuity of care in community treatment. New Directions for Mental Health Services, no. 2. San Francisco: Jossey-Bass, 15-23.
- V.A. Mental Health Intensive Case Management training in Tucson, Arizona (2002); Mary Ann Test describes the history of the ACT model. https://www.youtube.com/watch?v=Y_S0GeO3Iws
- New York State ACT Institute at Pathways to Housing (2005); Sam Tsemberis Interviews Len Stein about Assertive Community Treatment. https://www.youtube.com/watch?reload=9&v=683yoITWZxc#action=share
- Stein, L. I., & Test, M. A. (Eds.). Alternatives to mental hospital treatment. New York: Plenum Press, 1978.
- Stein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37, 392-397.
- Weisbrod, B. A., Test, M. A., & Stein, L. I. (1980). Alternative to mental hospital treatment. II. Economic benefit-cost analysis. Archives of General Psychiatry, 37, 400-405.
- Test, M. A., & Stein, L. I. (1980). Alternative to mental hospital treatment. III. Social cost. Archives of General Psychiatry, 37, 409-412.
- Stein, L. I., & Santos, A. B. (1998). Assertive community treatment of persons with severe mental illness. New York & London: W. W. Norton
- Stein, L. I., & Test, M. A. (Eds.) (1985). The Training in Community Living model: A decade of experience. New Directions for Mental Health Services, no. 26. San Francisco: Jossey-Bass.
- Test, M. A. (1992). Training in Community Living. In R. P. Liberman (Ed.), Handbook of Psychiatric Rehabilitation. New York: Macmillan, 153-170.
- Test, M. A. (1981). Effective community treatment of the chronically mentally ill: What is necessary? Journal of Social Issues, 37, 71-86.
- Test., M. A., Knoedler, W., Allness, D., & Burke, S. S. (1992). Training in Community Living (TCL) model: Two decades of research. Outlook, a publication of the National Association of State Mental Health Program Directors Research Institute, 2, July–August–September issue, 5-8.
- Test, M. A., & Stein, L. I. (1977). Use of special living arrangements: A model for decision-making. Hospital and Community Psychiatry, 28, 608-610.
- Test, M. A., & Berlin, S. B. (1981). Issues of special concern to chronically mentally ill women. Professional Psychology, 12, 136-145.
- Test, M. A., Wallisch, L. S., Allness, D. J., & Ripp, K. (1989). Substance use in young adults with schizophrenic disorders. Schizophrenia Bulletin, 15, 465-476.
- Marx, A. J., Test, M. A., & Stein, L. I. (1973). Extrohospital management of severe mental illness. Feasibility and effects of social functioning. Archives of General Psychiatry, 29, 505-511.
- Allness, D. J., Knoedler, W. H., & Test, M.A. (1985). The dissemination and impact of a model program in process, 1972-1984. In L. I. Stein & M. A. Test (Eds.), The Training in Community Living Model: A Decade of Experience. New Directions for Mental Health Services, no. 26. San Francisco: Jossey-Bass.
- Knoedler, W. H. (1989). The continuous treatment team model: Role of the psychiatrist. Psychiatric Annals, 19, 35-40.
- Knoedler, W. H. (1979). How the training in community living program helps patients work. New Directions for Mental Health Services, no. 2. San Francisco: Jossey-Bass, 57-66.
- Brekke, J. S., & Test, M. A. (1987). An empirical analysis of services delivered in a model community support program. Journal of Psychosocial Rehabilitation, 10, 51-61.
- Brekke, J. S., Test, M. A. (1992). A model for measuring the implementation of community support programs: Results from three sites. Community Mental Health Journal, 28, 227-247.
- Cohen, L. J., Test, M. A., & Brown, R. L. (1990). Suicide and schizophrenia: Data from a prospective community treatment study. American Journal of Psychiatry, 147, 602-607.
- Russert, M. G. & Frey, J. L. (1991). The PACT vocational model: A step into the future. Psychosocial Rehabilitation Journal, 14, 127-134.
- Ahrens, C. S., Frey, J. L., & Senn Burke, S. C. (1999). An individualized job engagement approach for persons with severe mental illness. Journal of Applied Rehabilitation Counseling, October/November/December issue.
- Gold award: A community treatment program. Mendota Mental Health Institute, Madison, Wisconsin (1974). Hospital and Community Psychiatry, 25, 669-672.
- Test, M. A., Knoedler, W. H., & Allness, D. J. (1985). The long-term treatment of young schizophrenics in a community support program. In L. I. Stein & M. A. Test (Eds.), The Training in Community Living Model: A Decade of Experience. (New Directions for Mental Health Services, no. 26.) San Francisco: Jossey-Bass, 1985.
- Deci, A. B., Santos, A. B., Hiott, D. W., Schoenwald, S., & Dias, J. K. (1995). Dissemination of assertive community treatment programs. Psychiatric Services, 46, 676-678.
- Mowbray, C. T., Collins, M. E., Plum, T. B., Masterton, T., & Mulder, R. (1997). Harbinger I: The development and evaluation of the first PACT replication. Administration and Policy in Mental Health and Mental Health Services Research, 25, 105-123.
- Mowbray, C. T., Plum, T. B., & Masterton, T. (1997). Harbinger II: Deployment and evolution of assertive community treatment in Michigan. Administration and Policy in Mental Health and Mental Health Services Research, 25, 125-139.
- The program subsequently developed into a larger agency, Mental Health Resources; http://www.mhresources.org
- ACT innovations at Thresholds (http://www.thresholds.org) were led by Jerry Dincin, Thomas F. Witheridge, Daniel J. Wasmer, Debra Pavick, John Mayes, Karen Kozlowski Graham, and others.
- Witheridge, T. F., Dincin, J., & Appleby, L. (1982). Working with the most frequent recidivists: A total team approach to assertive resource management. Psychosocial Rehabilitation Journal, 5, 9-11.
- Witheridge, T. F., & Dincin, J. (1985). The Bridge: An assertive outreach program in an urban setting. In L. I. Stein & M. A. Test (Eds.), The Training in Community Living model: A decade of experience (pp. 65-76). San Francisco: Jossey-Bass. (New Directions for Mental Health Services, no. 26.)
- Witheridge, T. F. (1989). The assertive community treatment worker: An emerging role and its implications for professional training. Hospital and Community Psychiatry, 40, 620-624.
- McGrew, J. H., & Bond, G. R. (1997). The association between program characteristics and service delivery in assertive community treatment. Administration and Policy in Mental Health, 25, 175-189.
- For information about Thresholds and its Bridge assertive outreach programs, go to: http://www.thresholds.org/.
- Stein, L. I., & Test, M. A. (1985), Editors' notes. In L. I. Stein, L. I., & Test, M. A. (Eds.), The Training in Community Living model: A decade of experience (pp. 1-5). San Francisco: Jossey-Bass. (New Directions for Mental Health Services, no. 26.)
- Witheridge, T. F. (1990). Assertive community treatment: A strategy for helping persons with severe mental illness to avoid rehospitalization. In N. L. Cohen (Ed.), Psychiatry takes to the streets: Outreach and crisis intervention for the mentally ill (pp. 80-106). New York: Guilford Press.
- Witheridge, T. (1994). The "active ingredients" of a program that works. In A. B. Critchfield (Ed.), Psychosocial rehabilitation for persons who are deaf and mentally ill: Breakout III—new traditions (pp. 113-121). Columbia, South Carolina: South Carolina Department of Mental Health.
- Slagg, N. B., Lyons, J., Cook, J. A., Wasmer, D. J., Witheridge, T. F., & Dincin, J. (1994). A profile of clients served by a mobile outreach program for homeless mentally ill persons. Hospital and Community Psychiatry, 45, 1139-1141.
- Bond, G. R., Witheridge, T. F., Wasmer, D., Dincin, J., McRae, S. A., Mayes, J., & Ward, R. S. (1989). A comparison of two crisis housing alternatives to psychiatric hospitalization. Hospital and Community Psychiatry, 40, 177-183.
- Gold Award: Helping mentally ill people break the cycle of jail and homelessness. The Thresholds State, County Collaborative Jail Linkage Project, Chicago (2001). Psychiatric Services, 52, 1380-1382.
- Higenbottam, J. A., Etches, B., Shewfelt, Y., & Alberti, M. (1992). Riverview/Fraser Valley assertive outreach program. In R. B. Deber & G. G. Thompson (Eds.), Restructuring Canada's health services system: How do we get there from here? Proceedings of the Fourth Canadian Conference on Health Economics, August 27–29, 1990, University of Toronto. Toronto: University of Toronto Press, 185-190.
- Hoult, J., Reynolds, I., Charbonneau-Powis, M., Coles, P., & Briggs, J. (1981). A controlled study of psychiatric hospital versus community treatment - the effect on relatives. Australian and New Zealand Journal of Psychiatry, 15, 323-328.
- Hoult, J., Reynolds, I., Charbonneau-Powis, M., Weekes, P., & Briggs, J. (1983). Psychiatric hospital versus community treatment: The results of a randomised trial. Australian and New Zealand Journal of Psychiatry, 17, 160-167.
- Hoult, J. (1987). Replicating the Mendota model in Australia. Hospital and Community Psychiatry, 38, 565.
- Field, G., Allness, D., & Knoedler, W. H. (1980). Application of the Training in Community Living program to rural areas. Journal of Community Psychology, 8, 9-15.
- Diamond, R. J., & Van Dyke, D. (1985). Rural community support programs: The experience in three Wisconsin counties. In L. I. Stein & M. A. Test (Eds.), The Training in Community Living Model: A decade of experience (pp. 49 – 63). (New Directions for Mental Health Services, no. 26.)
- Rosenheck, R. A., & Neale, M. S. (1998). Cost-effectiveness of intensive psychiatric community care for high users of inpatient services. Archives of General Psychiatry, 55, 459-466.
- Bond, G. R., Miller, L. D., Krumwied, R. D., & Ward, R. S. (1988). Assertive case management in three CMHCs: A controlled study. Hospital and Community Psychiatry, 39, 411 – 418.
- McDonel, E. C., Bond, G. R., Salyers, M., Fekete, D., Chen, A., McGrew, J. H., & Miller, L. (1997). Implementing assertive community treatment programs in rural settings. Journal of Administration and Policy in Mental Health and Mental Health Services Research, 25, 153-173.
- For information about the Indiana ACT Center, go to: https://labs.science.iupui.edu/act.
- According to the state's Department of Community Health, Michigan ACT teams served 6,487 people in fiscal 2004; for more information, go to: http://www.michigan.gov/mdch/0,1607,7-132-2941_4868_38495_38496_38504-130083--,00.html.
- For a description of Michigan's statewide ACT program development initiative, see: Plum, T. B., & Lawther, S. (1992). How Michigan established a highly effective statewide community-based program for persons with serious and persistent mental illness. Outlook, a publication of the National Association of State Mental Health Program Directors Research Institute, 2, July–August–September issue, 2-5.
- In Minnesota, ACT became a Medicaid-funded service in 2005; now there are more than two dozen teams, serving both urban and rural parts of the state. For information go to: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_058151
- Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., Trusty, M. L., Gerber, F., Smith, R., Tempelhoff, B., & Ahmad, L.(1997). An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatric Services, 48, 497-503.
- Morse, G. A., Calsyn, R. J., Miller, J., Rosenberg, P., West, L., & Gilliland, J. (1996). Outreach to homeless mentally ill people: Conceptual and clinical considerations. Community Mental Health Journal, 32, 261-274.
- Morse, G., Calsyn, R. J., Allen, G., Tempelhoff, B., & Smith, R. (1992). Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hospital and Community Psychiatry, 43, 1005-1010.
- For information about ACT programs in New York go to: https://my.omh.ny.gov/analytics/saw.dll?PortalPages
- Gold, P. B., Meisler, N., Santos, A. B., Carnemolla, M. A, Williams, O. H., & Keleher, J. (2005). Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness. Schizophrenia Bulletin, 32, 378-395.
- Gold, P. B., Meisler, N., Santos, A. B., Keleher, J., Becker, D. R., Knoedler, W. H., Carnemolla, M. A., Williams, O. H., Toscvano, R., & Stormer, G. (2003). The Program of Assertive Community Treatment: Implementation and dissemination of an evidence-based model of community-based care for persons with severe and persistent mental illness. Cognitive and Behavioral Practice, 10, 290-303.
- Wasylenki, D. A., Goering, P. N., Lemire, D., Lindsey, S., & Lancee, W. (1993). The Hostel Outreach Program: Assertive case management for homeless mentally ill persons. Hospital and Community Psychiatry, 44, 848-853.
- Lafave, H. G., de Souza, H. R., & Gerber, G. J. (1996). Assertive community treatment of severe mental illness: A Canadian experience. Psychiatric Services, 47, 757-759.
- Tibbo, P., Joffe, K., Chue, P., Metelitsa, A., & Wright, E. (2001). Global Assessment of Functioning following assertive community treatment in Edmonton, Alberta: A longitudinal study. Canadian Journal of Psychiatry, 46, 131-137.
- Marshall, M., & Creed, F. (2000). Assertive community treatment - is it the future of community care in the UK? International Review of Psychiatry, 12, 191-196.
- Burns, T., & Firn, M. (2002). Assertive outreach in mental health: A manual for practitioners. New York: Oxford University Press.
- Fiander, M., Burns, T., McHugo, G. J., & Drake, R. E. (2003). Assertive community treatment across the Atlantic: Comparison of model fidelity in the UK and USA. British Journal of Psychiatry, 182, 248-254.
- For guidance on current United States ACT standards and practices, the SAMHSA website is a good place to begin: http://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345
- Lachance, K. R., & Santos, A. B. (1995). Modifying the PACT model: Preserving critical elements. Psychiatric Services, 46, 601-604.
- Cuddeback, G. S., Morrissey, J. P., & Meyer, P. S. (2006). How many assertive community treatment teams do we need? Psychiatric Services, 57, 1803-1806.
- Mueser, K. T., Bond, G. R., Drake, R. E., & Resnick, S. G. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24, 37-74.
- Stein, L. I., & Test, M. A. (Eds.). Alternatives to mental hospital treatment. New York: Plenum Press, 1978.
- Stein, L. I., & Test, M. A. (1976). Retraining hospital staff for work in a community program in Wisconsin. Hospital and Community Psychiatry, 27, 266-268.
- Test, M. A., & Stein, L. I. (1977). Special living arrangements: A model for decision-making. Hospital and Community Psychiatry, 28, 608-610.
- Bond, G. R., Witheridge, T. F., Setze, P. J., & Dincin, J. (1985). Preventing rehospitalization of clients in a psychosocial rehabilitation program. Hospital and Community Psychiatry, 36, 993-995.
- Bond, G. R., Witheridge, T. F., Dincin, J., Wasmer, D., Webb, J., & de Graaf-Kaser, R. (1990). Assertive community treatment for frequent users of psychiatric hospitals in a large city: A controlled study. American Journal of Community Psychology, 18, 865-891.
- Bond, along with Mike McKasson, Michelle Salyers, and John McGrew, founded the ACT Center of Indiana, a technical assistance and training center for ACT and other evidence-based practices. For information on the ACT Center of Indiana, go to: https://labs.science.iupui.edu/act .
- For a brief overview of ACT by Bond, go to: https://web.archive.org/web/20060925204549/http://www.bhrm.org/guidelines/ACTguide.pdf
- Bond led the development of the most widely used fidelity instrument for ACT, the Dartmouth Assertive Community Treatment Scale (DACTS), also known as the Assertive Community Treatment Fidelity Scale. For the complete scale and the protocol for its administration, go to the evidence-based practices pages on the SAMHSA website: http://store.samhsa.gov/shin/content//SMA08-4345/EvaluatingYourProgram-ACT.pdf
- McGrew, J. H., Bond, G. R. Dietzen, L., & Salyers, M. (1994). Measuring the fidelity of implementation of a mental health program model. Journal of Consulting and Clinical Psychology, 62, 670-678.
- Teague, G. B., Bond, G. R., & Drake, R. E. (1998). Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry, 68, 216-232.
- Salyers, M. P., Bond, G. R., Teague, G. B., Cox, J. F., Smith, M. E., Hicks, M. L., & Koop, J. I. (2003). Is it ACT yet? Real-world examples of evaluating the degree of implementation for assertive community treatment. Journal of Behavioral Health Services & Research, 30, 304-320.
- Bond, G. R., & Salyers, M. P. (2004). Prediction of outcome from the Dartmouth assertive community treatment fidelity scale. CNS Spectrums, 9, 937-942.
- Bond, G. R., Evans, L., Salyers, M. P., Williams, J., & Kim, H. K. (2000). Measurement of fidelity in psychiatric rehabilitation. Mental Health Services Research, 2, 75-87.
- Bond, G. R., Campbell, K., Evans, L. J., Gervey, R., Pascaris, A., Tice, S., Del Bene, D., & Revell, G. (2002). A scale to measure quality of supported employment for persons with severe mental illness. Journal of Vocational Rehabilitation, 17, 239-250.
- Mueser, K. T., Fox, L., Bond, G. R., Salyers, M. P., Yamamoto, K., & Williams, J. (2003). Integrated Dual Disorders Treatment Fidelity Scale. In K. T. Mueser, D. L. Noordsy, R. E. Drake, & L. Fox (Eds.), Integrated treatment for dual disorders: A guide to effective practice (pp. 337-359). New York: Guilford Publications.
- Minkoff, K. & Drake, R. E. (Eds.) (1991). Dual diagnosis of major mental illness and substance disorder. New Directions for Mental Health Services, no. 50, 95-107. San Francisco: Jossey-Bass.
- Torrey, W. C., Drake, R. E., Dixon, L., Burns, B. J., Rush, A. J., Clark, R. E., & Klatzker, D. (2001). Implementing evidence-based practices for persons with severe mental illnesses. Psychiatric Services, 52, 45-50.
- Becker, D. R., & Drake, R. E. (2003). A working life for people with severe mental illness. New York: Oxford University Press.
- Drake, R. E., Becker, D. R., & Bond, G. R. (2003). Recent research on vocational rehabilitation for persons with severe mental illness. Current Opinion in Psychiatry, 16, 451-455.
- McHugo, G. J., Drake, R. E., Teague, G. B., Xie, H. Y. (1999). Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services, 50, 818-824.
- Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Treatment of substance abuse in patients with severe mental illness: A review of recent research. Schizophrenia Bulletin, 24, 589-608.
- Bond, G. R., Becker, D. R., Drake, R. E., Rapp, C. A., Meisler, N., Lehman, A. F., Bell, M. D., & Blyler, C. R. (2001). Implementing supported employment as an evidence-based practice. Psychiatric Services, 52, 313-322.
- The SAMSHA toolkit for the evidence-based practice known as illness management and recovery can be found at: https://store.samhsa.gov/shin/content/SMA09-4463/PractitionerGuidesandHandouts.pdf.
- Drake, R. E., Wilkness, S. M., Frounfelker, R. L., Whitley, R., Zipple, A. M., McHugo, G. J., & Bond, G. R. (2009). Public-academic partnerships: The Thresholds-Dartmouth partnership and research on shared decision making. Psychiatric Services, 60, 142-144.
- Olfson, M. (1990). Assertive community treatment: An evaluation of the experimental evidence. Hospital and Community Psychiatry, 41, 634-641.
- Mueser, K. T., Bond, G. R., Drake, R. E., & Resnick, S. G. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24, 37-74.
- U.S. Department of Health and Human Services (1999). Mental health: A report of the Surgeon General — Chapter 4: Adults and mental health. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
- For SAMHSA's "KIT" on the ACT approach, go to: http://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345
- See: http://www.nami.org/Learn-More/Mental-Health-Conditions/Schizophrenia/Treatment
- See: http://www.carf.org/Programs/BH/
- See: http://store.samhsa.gov/list/series?name=Evidence-Based-Practices-KITs
- Mueser, K. T., Torrey, W. C., Lynde, D., Singer, P., & Drake, R. E. (2003). Implementing evidence-based practices for people with severe mental illness. Behavior Modification, 27, 387-411.
- Spindel, P., & Nugent, J. A. (2001). The trouble with PACT: Questioning the increasing use of assertive community treatment teams in community mental health. Toronto: Humber College of Applied Arts and Technology, http://akmhcweb.org/Articles/pact.htm.
- Gomory, T. (1998). Coercion Justified? — Evaluating the Training In Community Living Model — A Conceptual and Empirical Critique, Ph.D. dissertation, Social Welfare, University of California at Berkeley.
- Gomory, T. (2002). The origins of coercion in “Assertive Community Treatment” (ACT): A review of early publications from the “Special Treatment Unit” (STU) of Mendota State Hospital. Ethical Human Sciences and Services, 4, 3-16.
- Kirk, S. A., Gomory, T., & Cohen, D. (2013). Mad science: Psychiatric coercion, diagnosis, and drugs. Rutgers, NJ: Transaction Publishers.
- Gomory, Tomi. "Programs of Assertive Community Treatment (PACT): A critical review".
- Diamond, R. J. (1996). Coercion and tenacious treatment in the community. In D.L. Dennis & J. Monahan (Eds.), Coercion and aggressive community treatment.(pp. 51-72). New York: Plenum Press.
- Test, M. A., & Stein, L. I. (2001). Letters: A critique of the effectiveness of assertive community treatment. Psychiatric Services, 52, 1396-1397
- Gomory, T. (2002). Effectiveness of assertive community treatment. Psychiatric Services, 53, 103
- Moser, L. L., & Bond, G. R. (2009). Scope of agency control: Assertive community treatment teams' supervision of consumers. Psychiatric Services, 60, 922-928.
- U.S. Department of Health and Human Services (1999). Mental health: A report of the Surgeon General. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Mental Health. See Chapter 4, Service Delivery, Assertive Community Treatment.
- Weisman, R. L., Lamberti, J. S., & Price, N. (2004). Integrating criminal justice, community healthcare, and support services for adults with severe mental disorders. Psychiatric Quarterly, 75, 71-85.
- Lamberti, J.S., Weisman, R.L., & Faden, D.I. (2004). Forensic assertive community treatment: Preventing incarceration of adults with severe mental illness. Psychiatric Services, 55, 1285-1293.
- Lamberti, J. S., & Weisman, R. L. (2010). Forensic assertive community treatment: Origins, current practice, and future directions. In H. Dlugacz (Ed.), Reentry planning for offenders with mental disorders (1st ed., pp. 121-145). Kingston, New Jersey: Civic Research Institute.
- Lamberti, J. S., Deem, A., Weisman, R. L., LaDuke, C. (2011). The role of probation in forensic assertive community treatment. Psychiatric Services, 62, 418-421.
- McCoy, M. L., Roberts, D. L., Hanrahan, P., Clay, R., & Luchins, D. J. (2004). Jail linkage assertive community treatment services for individuals with mental illnesses. Psychiatric Rehabilitation Journal, 27, 243-250.
- Morrissey, J., Meyer, P., & Cuddeback, G. (2007). Extending assertive community treatment to criminal justice settings: Origins, current evidence, and future directions. Community Mental Health Journal, 43, 527-544.
- Cuddeback, G. S., Morrissey, J. P., & Cusack, K. J. (2008). How many forensic assertive community treatment teams do we need? Psychiatric Services, 59, 205-208.
- Cuddeback, G. S., & Morrissey, J. P. (2011). Program planning and staff competencies for forensic assertive community treatment: ACT-eligible versus FACT-eligible consumers. Journal of the American Psychiatric Nurses Association, 17, 90-97.
- Chow, W., Law, S., & Andermann, L. (2009). ACT tailored for ethnocultural communities of metropolitan Toronto. Psychiatric Services, 60, 847.
- Lamb, C. E. (2009). Alternatives to admission for children and adolescents: Providing intensive mental healthcare services at home and in communities: What works? Current Opinion in Psychiatry, 22, 345-350.
- Parks, J., Pollack, D., Bartels, S., & Mauer, B. (2005). Integrating behavioral health and primary care services: Opportunities and challenges for state mental health authorities. Alexandria, VA: National Association of State Mental Health Program Directors.
- Colton, C. W., & Manderscheid, R. W. (April 2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease (serial online). Available from: URL: https://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.
- Weinstein, L.C., Henwood, B.F., Cody, J. W., Jordan, M., & Lelar, R. (2011). Transforming assertive community treatment into an integrated care system: The role of nursing and primary care partnerships. Journal of the American Psychiatric Nurses Association, 17, 64-71.
- McFarlane, W. R., Stastny, P., & Deakins, S. (1992). Family-aided assertive community treatment: A comprehensive rehabilitation and intensive case management approach for persons with schizophrenic disorders. New Directions for Mental Health Services, 53, 43-54.
- Dixon, L., McFarlane, W. R., Lefley, H., Lucksted, A., Cohen, M., Falloon, I., Mueser, K., Miklowitz, D., Solomon, P., & Sondheimer, D. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services, 52, 903-910.
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
- For information on DBT, go to: https://behavioraltech.org.
- For an overview of issues associated with the treatment of personality disorders, see: Links, P. S. (1998). Developing effective services for patients with personality disorders. Canadian Journal of Psychiatry, 43, 251-259. Issues associated with the use of ACT for persons with the borderline personality disorder diagnosis are discussed in Horvitz-Lennon, M., Reynolds, S., Wolbert, R., & Witheridge, T. F. (2009), The role of assertive community treatment in the treatment of people with borderline personality disorder, American Journal of Psychiatric Rehabilitation, 12, 261-277.