CLINICAL HANDBOOK OF SCHIZOPHRENIA

33. Assertive Community Treatment 331hospital or office settings, as they reduce the challenges that arise when transferring skillstaught in the hospital or clinic to real-world settings. In addition, assessment in realworldsettings is more valid than office-based assessment, because practitioners can observebehavior directly rather than depend on client self-report. Home visits also facilitatemedication delivery, problem solving, crisis intervention, and networking.• Medication management. Effective use of medications is a top priority for ACT,necessitating careful diagnosis and assessment of target symptoms, well-reasoned choicesof medications, appropriate dosing and duration of therapy, and management of sideeffects, in accordance with evidence-based practice (EBP) guidelines. ACT teams oftendeliver medications to clients, tailoring this assistance to the unique needs (and, to thegreatest extent possible, the preferences) of the client, thus increasing appropriate use ofmedications.• Focus on everyday problems in living. ACT teams focus on assisting clients in awide range of ordinary daily activities and chores, depending on a client’s most pressingneeds (e.g., securing housing, keeping appointments, cashing checks, and shopping). BecauseACT teams facilitate increased independence among clients, they also help clientslearn to develop skills and supports in natural settings.• Rapid access. ACT teams differ sharply from most social services in that they respondquickly to client emergencies, even when they occur after regular business hours.From the first conceptualization of this model, the goal for this program element has been24-hour coverage. In a proactive ACT team that communicates well, staff members oftenfind ways to anticipate and respond to potential problem situations, which helps to preventcrises from erupting. ACT teams involved in client admissions to and dischargesfrom hospitals facilitate continuity of care.• Assertive outreach. In targeting a more challenging clinical population, includingclients who are unlikely to seek out help on their own and may be resistant to help whenit is offered, ACT teams must develop strategies to engage reluctant clients, both in theinitial stages of assessment and after enrollment. ACT teams are persistent in their offerof help; for example, they do not disenroll clients who miss appointments. Outreach effortsshould focus on relationship building by establishing rapport in a manner that enhancesclient motivation to engage with the team, even if mental health issues are not immediatelyaddressed. Initial outreach should include offers of tangible assistance, especiallywith regard to finances and housing. Some ACT teams have a client assistance fund topay for emergency expenses, a helpful engagement tool that allows teams to be flexibleand responsive to client needs.• Individualized services. Treatments and supports are individualized to accommodatethe needs and preferences of each client. Truly individualized services foster a personallymeaningful recovery process that may be neglected in other treatment settings.Because of their broad knowledge of community resources and the wherewithal to accessthem, ACT teams often increase available options beyond what clients would otherwisehave (e.g., increased access to housing).• Time-unlimited services. In most ACT programs, rather than “graduating” fromthe program when their situation stabilizes, clients continue to receive ACT assistance ona long-term basis. This allows for the development of stable, trusting therapeutic relationships.This principle follows from studies suggesting that clients regress when terminatedfrom intensive, short-term programs. As discussed below, there is growing evidence thatthis principle should be modified for clients who show substantial improvement.As noted earlier, ACT is regarded to be an organizational framework for deliveringservices rather than a specific clinical intervention itself. Increasingly, practice guidelines