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A ssertive C ommunity T reatment Training

A ssertive C ommunity T reatment Training

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A ssertive C ommunity T reatment Training

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  1. Assertive CommunityTreatmentTraining ACT Center of Indiana 2007

  2. Getting Started… • Introductions • Amount of time on team? • Lost? • Two truths & a lie • Overview of Training Manual • Other housekeeping Items?

  3. Training Overview • Evidence Based Practices (EBP’s) • Introduction to ACT • ACT Philosophy • ACT Structure • ACT Skills

  4. ACT Center • Technical Assistance Center • A Collaborative Effort • Trainers, Researchers, and Evaluators from diverse backgrounds (some family and consumers) • Advocates for Evidenced-Based Practices and developing other practices that work

  5. Training Overview • Evidence Based Practices (EBP’s) • Definition • Examples • IntroductiontoACT • ACTPhilosophy • ACTStructure • ACTSkills

  6. What is an Evidence-Based Practice? • Intervention with a body of evidence: • rigorous research studies • specified target population • specified client outcomes • Specific implementation criteria (treatment manual/fidelity scale) • A track record showing that the practice can be implemented in different settings

  7. What are the EBPs (so far)? Assertive community treatment (ACT) Integrated dual disorders treatment (IDDT) Illness management and recovery (IMR) Family psychoeducation Supported employment Medication management http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp

  8. Training Overview • EvidenceBasedPractices(EBP’s) • Introduction to ACT • ACT Philosophy • ACT Structure • ACT Skills

  9. Introduction to ACT • HistoryofACT • Who does ACT serve? • What is ACT? • ACT Research

  10. Quiz Time!

  11. Initial Development (Stein & Test, 1980) • Developed during 1970s • Revolving Door • “Hospital without Walls” • Experimentally demonstrated its effectiveness

  12. Introduction to ACT • History of ACT • WhodoesACTserve? • What is ACT? • ACT Research

  13. Quiz Time!

  14. Typical Admission Categories • Frequent psychiatric admissions • Frequent use of emergency rooms • Homeless or unstable housing • Treatment nonadherence • Dual diagnosis (SMI + substance abuse) • Legal problems • Discharge from long-term hospital

  15. IntroductiontoACT • History of ACT • Who does ACT serve? • WhatisACT? • A platform • What ACT is not • Basic Principles • ACT Research

  16. ACT is a Way of Organizing Services… As a model, ACT is an effective way to deliver structured, intensive services to meet the multiple, individualized needs of consumers as they increase their involvement in the community in roles that they define as important and meaningful.

  17. Quiz Time!

  18. What ACT is NOT • A sub team of a larger team with mixed caseloads of ACT and non-ACT clients • Individual caseloads • Responsibilities outside ACT • Traditional psychiatry role (i.e., med checks, occasional interactions with team members) • Brokered services • Day treatment • Case management for persons in group homes • Traditional MH team (i.e., weekly meetings, limited backup, informalinformation sharing)

  19. Basic Principles of ACT • Multidisciplinary team approach/shared caseload • Integration of all services • Low client-staff ratios • Intensive, yet flexible level of service • Locus of contact in the community • Assertive outreach • Ready access in times of crisis • No arbitrary time limits on services

  20. IntroductiontoACT • History of ACT • Who does ACT serve? • What is ACT? • ACT Research • Effectiveness • Perceptions

  21. Quiz Time!

  22. ACT Effectiveness Across 25+ Studies • Large impact on: • Hospital use – 61% reduction in days • Housing • Retention in treatment • Moderate impact on: • Symptoms • Quality of life

  23. ACT Effectiveness • Weak impact on: • Employment • Substance use • Jail and legal problems • Social adjustment

  24. Future Research & Practice of ACT • Integrating other EBPs on ACT Teams • Expanding recovery-focus • Examining effectiveness for special populations

  25. When Is ACT Cost-Effective?Latimer (1999) • Depends on Who Is Served • ACT saves money when serving heavy users of psychiatric hospitals (>50 hospital days in prior year) • And How It’s Implemented • ACT saves money if program shows fidelity to model

  26. Perceptions: Typical criticisms • Paternalistic • Non-empowering • Coercive • Overuse of legal sanctions • Over medicalized focus/staffing • Too much emphasis/reliance on drugs • Deficit model • Survival focus, not growth oriented

  27. What Clients Like Least(McGrew et al., 1997)

  28. Perceptions & Fidelity:Team Fidelity = Client ComplaintsOr Higher Client Satisfaction (McGrew et al., 2001)

  29. Perceptions: Client Satisfaction Bond et al. (2001) review 8 controlled studies ACT vs. comparison groups on client satisfaction 7 studies ACT more satisfied 1 study  no difference in satisfaction

  30. Helping relationship 21% Attributes of staff 20% Availability of staff 18% Nonspecific help 17% Someone to talk to 14% Recreation 11% Problem-solving 9% What Clients Like Best (McGrew et al., 1997. N=165) Home visits 6% Medical care 4% Intensity of service 4% Money management 4% Housing 3% Shared caseloads 3% Transportation 2%

  31. Training Overview • EvidenceBasedPractices (EBP’s) • IntroductiontoACT • ACT Philosophy • ACTStructure • ACTSkills

  32. ACT Philosophy • Recovery • Cultural Competency • Expectations • Stress Vulnerability Model

  33. Recovery:SAMHSA* Consensus Statement “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.” *SAMHSA: Substance Abuse and Mental Health Services Administration www.samhsa.gov/

  34. 10 Fundamental Componentsof Recovery(SAMHSA) • Self-direction • Individualized and person-centered • Empowerment • Holistic • Non-linear

  35. 10 Components of Recovery(cont’d) • Strengths-based • Peer support • Respect • Responsibility • Hope

  36. Evaluating our Beliefs About Consumers’ Ability to Recover • What are our fears about change? • Combating what we’ve already been taught/learned. • Moving beyond “compliance”, “stability” and/or “maintenance” • What personality characteristics do we bring to the consumer/staff relationship that may have an impact? • Looking at and navigating through agency and team practices, climate, expectations, and dynamics.

  37. ACT Philosophy • Recovery • Cultural Competency • Expectations • Stress Vulnerability Model

  38. Cultural Competence(NAMI Multicultural Action Center) • Culture: a person’s beliefs, norms, values, and language • Culture influences • Perception of and experience with MI • Help seeking behavior • Service utilization • Service effectiveness • Cultural competence is the ability to work effectively and sensitively within various cultural contexts

  39. Western Individually oriented interpersonal moral code Personal freedom of choice and individual responsibility (independence) Family psychopathology Non-Western Duty-based interpersonal moral code (group-oriented) Responsibilities to kin (inter-dependence) Family as therapeutic asset Cultural Issues (Value Systems)(Barrio, 2000; Lefley, 1996)

  40. Cultural Conceptions of Mental Illness (Milstein et al. 1994) • African & European Americans: mental failure or chemical imbalance • Hispanics: emotional problem as a continuum • Asian Americans: supernatural intervention, imbalance between positive & negative energy

  41. Service Utilization(Mental Health United States, 1987, cited in Lefley, 1996)

  42. Elements of CulturalCompetence (Davis, 2007) • Attitudes of Respect • Beliefs • Knowledge and Skills • Language and Communication • Community Analysis • Valuing Diversity • Cultural Self-Assessment

  43. Where is Cultural Competence Needed Most?(Davis, 2007) • Agency Vision & Mission • Organizational Values • Organizational Policies • Clinical Standards & Guidelines for Service • Hiring Patterns & Staffing • Clinical Supervision • Formal Education • Continuing Education

  44. Cultural Competence Resources • NAMI Multicultural Action Center • http://www.nami.org/Template.cfm?section=multicultural_support • Cultural competence online • http://www.culturalcompetence2.com/ • Cultural Competence Standards in Managed Care Mental Health Services: Four Underserved/ Underrepresented Racial/Ethnic Groups • http://mentalhealth.samhsa.gov/publications/allpubs/SMA00-3457/default.asp • National Center for Cultural Competence • http://www11.georgetown.edu/research/gucchd/nccc/

  45. ACT Philosophy • Recovery • Cultural Competency • Expectations • Video • Discussion • Stress Vulnerability Model

  46. ACT Philosophy • Recovery • Cultural Competency • Expectations • Stress Vulnerability Model

  47. Stress-Vulnerability Model Biological Factors Psychiatric Symptoms Vulnerability Stress Impairment

  48. Implications for Assessment & Intervention • Address multiple entry points • Provide practical assistance so impairment will not contribute to stress • Reduce exposure to stress • Reduce sensitivity to stress • Increase factors that make it easier to cope with stress (innate and developed strengths) • Reduce psychiatric symptoms