CLINICAL HANDBOOK OF SCHIZOPHRENIA

33. Assertive Community Treatment 333Moreover, client background characteristics do not predict satisfaction with ACT services.One of the appealing features of ACT is adaptability for many different types of clientswho do not benefit from conventional services, as discussed earlier. Based on costconsiderations, ACT teams are not recommended for clients who have already attainedhigh levels of self-management of their illness. Based purely on clinical considerations,however, ACT services have been found to be beneficial to clients spanning a wide spectrumof symptom severity and disability.Step-Down ACT ProgramsAs previously discussed, the ACT model was originally conceived of as a time-unlimited service.There is now greater recognition that some clients will likely graduate once they attaintheir recovery goals. Increasingly, program planners have adopted “tiered” case managementsystems in which different levels of case management intensity are aimed at differentlevels of client need. Transferring ACT clients to less intensive case management services appearsto be more successful if the transfers are gradual and individualized. Furthermore, the“step-down” programs to which clients are transferred should follow ACT principles butprovide service at a lesser intensity. There also should be flexibility in movement back andforth between different tiers for such an approach to be maximally effective.EVIDENCE IN SUPPORT OF ACTACT is one of the six practices identified as evidence-based by the National ImplementingEvidence-Based Practices Project. It is one of the most extensively researched models ofcommunity care for people with SMI. The evidence for the effectiveness of ACT is quiteconsistent across numerous reviews that have appeared in the literature. Compared tousual community care, ACT has been found to be more successful in engaging clients intreatment. Additionally, ACT substantially reduces psychiatric hospital use and increaseshousing stability, and moderately improves symptoms and subjective quality of life.Mental health service planners are increasingly attentive to the need to establish programstandards and monitor implementation. Based on the premise that better implementedACT programs have better client outcomes, it becomes critical to develop methodsfor assessing the degree to which programs follow the ACT model. Fidelity is theterm used to denote adherence to the standards of a program model, and a measure usedto assess the degree to which a specific program meets the standards for a program modelis known as a fidelity scale. The best known and most widely used of these fidelity scalesis the Dartmouth ACT Fidelity Scale (DACTS). Several studies have suggested that morecarefully implemented ACT programs have better outcomes, such as reduced number ofhospitalization days, greater retention in service, and higher client satisfaction. These fidelitystudies have further bolstered the argument that ACT is indeed an EBP. Notably, fidelity,as measured by the DACTS, captures mainly the structural components of themodel; current plans to expand and revise this scale to include key clinical processes willallow for fuller assessment of the model.Negative Outcomes from ACTThe ACT literature has been very consistent in suggesting an absence of negative outcomes.Significantly, surveys suggest that a greater number of clients receiving ACT ser-