CLINICAL HANDBOOK OF SCHIZOPHRENIA

332 V. SYSTEMS OF CAREfor ACT have incorporated major EBPs, such as illness self-management, medicationguidelines, supported employment, integrated treatment for dual disorders, and familypsychoeducation. One great advantage is that ACT is completely compatible with theseEBPs; in fact, preliminary work in conceptualizing and developing several of these practicesfirst occurred within the context of ACT teams.Implementing ACT ServicesClear program guidelines, as established by practice manuals, state standards, or otherformalized means, help to define the structural foundation of an ACT team. Publishedstandards prescribe the qualifications of practitioners who should be hired, how manyclients the team should take on, and how often to provide services. Studies of ACT implementationefforts have shown that these types of structural program elements are morereadily put into place than are process-oriented program elements, such as individualizationof services. It is critical to include the key structural elements that define ACT services,but to serve clients best (particularly to facilitate recovery rather than maintenance),key clinical elements must be included in the process of delivering ACT. Crucialclinical practices include assessment, treatment planning, and clinical supervision. Theseclinical elements are discussed in more detail in the final section of the chapter.Target PopulationThere is now broad consensus that it is neither practical nor necessary to provide ACTprograms universally to all clients with SMI. Instead, ACT is typically reserved for a relativelysmall minority of clients who have not benefited from usual outpatient services.Most ACT programs target individuals with SMI who do not respond well to less intensivecare modalities (e.g., who fail to keep office appointments) and are frequent users ofemergency psychiatric services, especially inpatient care. ACT teams have been conceptualizedin several ways with respect to admission criteria. The first is to facilitate the dischargeof long-term inpatients, a strategy that has gained renewed currency with the closingand downsizing of state and provincial hospitals. A second conceptualization is toemploy ACT as an alternative to admission for acutely ill patients—so-called “deflection”programs. Similarly, ACT teams have also been used as an alternative to arrest andincarceration for persons with SMI and a long history of criminal justice system involvement.The third and most common use is to maintain unstable, long-term clients (sometimes referredto as “revolving-door” clients) in the community. Some programs specialize furtherin outreach to clients with a dual diagnosis of mental illness and substance use disorderswho are homeless, or to those entangled with the criminal justice system. It is estimatedthat in a well-functioning mental health system, approximately 15–20% of clients withSMI would benefit from ACT services. If the service system is deficient, more ACT teamsmay be required to fill service gaps. In less populated areas, the percentage of SMI clientswho fit ACT admission criteria may be even lower.Contraindications for UseEvidence from both research and clinical practice suggests that ACT is very flexibleacross a wide range of clients. Its effectiveness has been reported for clients from manydifferent cultural backgrounds. Experience suggests that ACT teams are well suited forboth young adults and older adults. Differences in gender, education, and other backgroundcharacteristics have not been reported as factors limiting the effectiveness of ACT.