CLINICAL HANDBOOK OF SCHIZOPHRENIA

416 VI. SPECIAL POPULATIONS AND PROBLEMSsystem. This became particularly evident during transitions, such as between institutionalsettings (shelters, hospitals, jails, and prisons) and the community, leading researchers toidentify lack of continuity of care as a key weakness in the service delivery system for personswith SMI. Furthermore, many case managers were not, and still are not, trained inthe therapeutic techniques of engagement, motivational interviewing, management oftransference and countertransference, and termination. Without such training, therapeuticalliances are often never made, or once made, they break down irreparably. In 1980,Richard Lamb was an early advocate for this expanded role of case managers (see Referencesand Recommended Readings).In a head-to-head comparison of broker case management and assertive case management,the latter has been shown to be superior for homeless mentally ill persons recruitedfrom emergency rooms and inpatient units. Other studies have looked specificallyat the role of the therapeutic alliance between patient and case manager. Although thedata are inconsistent, the strength of that alliance has in some cases been found to be associatedwith positive clinical outcomes, better life satisfaction, and reduced homelessness.Yet another study has demonstrated that for domiciled patients with schizophreniaand schizoaffective disorder, greater intensity of psychosocial rehabilitative services andgreater continuity of care were associated with greater improvement in social, work, andindependent living domains, and with fewer days of hospitalization. Thus, there is somehard evidence that intensive, continuous case management and rehabilitative services canprevent homelessness in patients with schizophrenia.The two evidence-based case management models we describe below, ACT and thecritical time intervention (CTI), both utilize intensive community-based case managementwith a team approach. The ACT team typically includes a psychiatric practitioner (psychiatrist,nurse practitioner, or physician’s assistant), nurse, and social work supervisor, but mayalso include substance abuse counselors, rehabilitative specialists, or peer counselors. Althoughthere are common elements to the two approaches, we describe their differences.ASSERTIVE COMMUNITY TREATMENTOver the past 15 years, ACT has been adapted for use with homeless individuals withSMI, often with coexisting substance abuse disorders. Key ingredients of ACT include themultidisciplinary team, along with a low number of shared caseloads; a targeted population(SMI, with or without homelessness); 24-hour services; assertive engagement whilemaintaining client choice and privacy; provision of services in the community, and inclusionof family, recipient, and cultural perspectives. The team should comprise individualstrained in social work, psychiatry, nursing, psychosocial rehabilitation, and rehabilitationof persons with substance abuse or mentally ill chemically addicted (MICA) persons.When working with street or sheltered populations, ACT teams must do outreach wherethe homeless gather, including parks, subways, bus stations, bread lines, churches, dropincenters, and shelters. A randomized clinical trial of ACT for homeless mentally ill individualshas shown its effectiveness in improving housing, clinical, and life satisfactionoutcomes.As a long-term intervention with ongoing intensive services and broad treatmentgoals, ACT is an expensive yet, it has been argued, cost-effective and labor-intensive servicethat is suitable for some, but not all, people with persistent SMI. With a greater recognitionof the role of psychiatric rehabilitation and recovery, a reduction in services overtime is not only appropriate but also often desirable to the client who feels increasinglyindependent and empowered to meet his or her own needs. One criticism of ACT hasbeen that some of its strong points, such as its assertive and long-term approach, may fos-