Psychiatric Bulletin (2000) 24: 359-360. doi: 10.1192/pb.24.9.359
© 2000 The Royal College of Psychiatrists
Psychiatric Bulletin (2000) 24: 359-360
© 2000 The Royal College of Psychiatrists
Assertive Community Treatment of Persons with Severe Mental Illness
By Leonard I. Stein & Alberto B. Santos
Peter Tyrer, Professor of Community Psychiatry
Department of Public Mental Health, Division of Neuroscience and
Psychological Medicine, Imperial College School of Medicine, Paterson Centre,
London W2 1PD
New York & London: W. W. Norton & Co. 1998. 274 pp. £ 19.95
(pb). ISBN 0-393-70258-8
This book is published at an opportune time in the UK. Colleagues in the
USA may be surprised to hear that few in this country had heard of assertive
community treatment or its acronym, ACT, before 1990. It has been used in
Wisconsin, where it was developed, since 1974, and it was the impressive
results of randomised controlled trials in Wisconsin and later, in Australia,
by Hoult et al, that made both research workers and clinicians in the
UK interested, and later, quite excited. Now, a quarter of a century after its
introduction, its originators, who include Leonard Stein himself, would feel
proud that the world has finally approved ACT as "a service delivery
vehicle or system designed to furnish the latest, most effective and efficient
treatments, rehabilitation and support services conveniently as an integrated
package". What better at this stage than to play Wisconsin's Pomp and
Circumstance to a world audience, complete with the 119 pages of ACT
assessment and treatment plans from Dane County in Wisconsin, the home of the
original recipe? ?
This is all valuable, but not entirely for the reasons that the authors
intend. They are writing for either acolytes of ACT or those wishing to be
converted and in the process of setting up programmes of their own. In
enthusiastic and sometimes adulatory tones they describe the essentials of ACT
and the patient-based philosophy underlying it — to help patients with
severe mental illness live successfully in the community with a good quality
of life.
By far the best section is the account of the functions of the work in a
good ACT team — where the essential elements of sharing skills and
genuine team working are graphically described from practical experience
— and emphasising the need for all such teams to be flexible and
opportunistic in their management of the combatants under their care.
‘Combatant’ may seem a strange word, but perpetually challenging
the system of care for the most disabled of psychiatric patients is still much
more common than the harmonious care plans that sit at the heart of government
policies for those with mental illness. The need for lateral thinking and
creativity in teams on the ground contrasts greatly with the uncritical
promulgation of the core features that are presented as a prerequisite for
success, including case-loads of between 8 and 12 (no more, no less), 24-hour
cover, and (only) part-time psychiatric input using a parallel hierarchy,
without which no team can say it practises true ACT. These are clearly not
essential, as the authors present examples of the success of ACT in settings
outside the UK, including our own service in Paddington and North Kensington,
in which none of these features were present.
Much is made of the results of controlled trials that show superiority of
ACT over conventional treatment in the UK settings in particular. There is no
comment about the apparent lesser efficacy of ACT (and its counterpart,
intensive case management) in the UK and elsewhere. However, the authors
indicate why ACT is so effective in the USA in the early pages of this book.
They note that there is a "fragmented non-system of public mental health
care in the United States" in which services are "uncoordinated
and non-collaborative, where service users are denied services, excluded from
services, or never apply for them in the first place". When this is
treatment as usual it is not surprising that any form of coordinated and
committed care would come out to be superior.
This book is certainly worth reading. It gives the longitudinal history of
an experiment in community care that has been undoubtedly successful and has
influenced the world. However, it also reveals, almost unwittingly, that the
essential requirements of success are not cookbook ingredients, but the right
mix of skills, true collaboration between professionals, and good
communication and coordination. The members of many community mental health
teams in this country would be surprised on reading this book to find out that
they are practising assertive community treatment but without the
prerequisites that its instigators regard as essential. Perhaps this should be
the true test of the success of this approach; it is fundamentally the
philosophy that matters and what constitutes its outer clothes is really
immaterial.
