CLINICAL HANDBOOK OF SCHIZOPHRENIA

334 V. SYSTEMS OF CAREvices compared to usual services are mostly satisfied, and satisfaction with ACT servicesis similar for individuals of different backgrounds.Nevertheless, it is worth noting that some critics of the ACT model argue that ACTprograms are coercive or paternalistic, and that they are not based on client choice. Thebasis of this criticism derives mostly from anecdotes and theoretical arguments ratherthan empirical studies. Recent studies have attempted to examine systematically the useof coercion by outpatient teams (including ACT), both from practitioner and client perspectives.From the few existing studies examining this issue, it appears that at least asmall percentage of clients served by an ACT team are formally coerced (e.g., legally committedto receive treatment) by the team at some time. However, these studies noted thatclients more frequently encountered informal coercion throughout treatment, such asthreats of commitment and making services or resources (e.g., money, housing) contingenton treatment compliance or abstinence from drugs or alcohol. A recent study of clients’perceptions of ACT indicated that whereas clients were positive about their ACTexperience overall, some negative experiences included conflicts with staff about medicationsand money management, and promotion of authoritative rather than collaborativepractices.One large-scale survey that examined interventions used by ACT teams to influenceclient behavior found that case managers reported using techniques spanning a range oftactics from low levels of coercion (e.g., merely ignoring a behavior) to high levels of coercion(e.g., committing a client to the hospital against their will). Verbal persuasion waswidely reported, whereas the more coercive interventions were reported for less than10% of clients. Case managers used more influencing tactics with clients who had moreextensive hospitalization histories, more symptoms, more arrests, more recent substanceuse, and who reported a weaker sense of alliance with staff. The results of an ACT clientsatisfaction survey suggested that clients were least satisfied on dimensions related to clientchoice. Moreover, complaints about ACT services are more frequent in ACT programswith low model fidelity.Characteristics of both the ACT model (e.g., use of assertive engagement and highfrequency of community-based contacts) and clients targeted for ACT services (e.g., difficultto engage in less intensive services) may heighten the potential for more coercion andless collaboration in the treatment process. Each day, ACT teams confront many thornyconflicts between clients’ expressed preferences and what team members feel are the bestinterests of clients. Ideally, client choice is promoted, and coercion is used minimally andwith discretion. By helping clients avoid hospitalization (including involuntary commitments),ACT enables them to live more normal lives and in this respect increases clientchoice. Moreover, ACT teams often expand the range of opportunities for clients with respectto where they can live, whether or not they can find work, and whether they havean income. Again, the extent to which ACT teams truly promote client choice may be relatedto their degree of fidelity to the model, as well as practitioner training and skillfulness,and agency-level culture and processes. Research in the use of coercive tactics ofACT teams and other mental health services continues to develop.RECOMMENDATIONS FOR ACT PRACTICEProviding ACT services first requires a strong structural framework to support the specificrequirements of the model. Several basic steps to follow when implementing ACT orany EBP have been published. The steps include making systematic efforts to identify andto build consensus among key stakeholders in a community, locating appropriate funding