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ACT History and Origins
Presented here are two articles that address the origins and history of the Assertive Community Treatment Model. The first article by Mary Ann Test, one of the founders of ACT, addresses the very origins of the ACT model and speaks to the power of individuals to effect change and of the importance of believing that change within systems is possible. The second article by John P. Freeman, an ACT Association Board member, provides an excellent account of both the origins and history of the ACT model.
The Origins of PACT
as told by
Mary Ann Test
"How did PACT begin?" my student asked. I smiled and thought back to the chilly April evening in 1970 when the underpinnings of PACT (the Program of Assertive Community Treatment) unexpectedly emerged. PACT was conceived in "Building 2" (B-2), a one story aged clapboard structure that served as the research ward of Mendota State Hospital in Madison, Wisconsin. The charge of the unit was to develop and evaluate more effective ways of helping the so-called "treatment failures"-persons with chronic schizophrenia-to leave the hospital and remain in the community.

When I assumed my first post degree job in 1969 as the Associate Director of B-2, the staff was developing and implementing a series of six month long in hospital programs to better "prepare" patients for community living. After each such phase, those patients who appeared ready were discharged to the aftercare system of Dane County, Wisconsin. Then the energetic and egalitarian B-2 staff-professionals and non-professionals alike-would meet to brainstorm about what kind of innovative "preparatory" approach to institute next to achieve greater success. It was at such a planning meeting in April 1970, that, unanticipated, the concepts of PACT originated. Fewer staff than usual came to the meeting, so -as mental health workers will do- rather than focus on the agenda the group began to process why attendance was so low! It was soon revealed that staff morale was very poor. When asked why, staff expressed their intense discouragement over the fact that almost all of the patients whom we "successfully" discharged and carefully linked with the existing aftercare services rotated back to the hospital within weeks or months, usually in a psychotic and dishevelled state. Staff declared, "Our patients work very hard at getting better and getting ready to live in the community, and we work hard to help them. They leave B-2 in pretty good shape, but they always return. Their efforts and ours seem in vain." As the evening progressed, talk gradually got more intense. Finally, staff looked at the unit leaders, Dr. Marx and me, and declared, "We don't want to do another one of these programs where we try to get patients ready for life in the community. Even though they appear 'ready' when we discharge them, they come right back. What good are we doing?"

We directed the discussion toward what kinds of interventions might be more helpful to our patients. Eventually one of the paraprofessionals commented, "You know, the patients that Barb Lontz works with intensively don't come back. Maybe we should all go out and do what Barb does." Barb Lontz was an innovative and spirited social worker on the ward that, among other things, helped clients with discharge planning. Indeed, when time allowed her, Barb did far more than plan discharge. She drove patients to their new residence in the community and then spent countless hours and days providing them with "hands on" support and assistance to help them live in the community. Barb helped clients move in and get sheets on the bed and a telephone installed; she taught clients how to use the local laundromat by doing laundry with them again and again. She instructed them to ride the bus to the mental health center to get medications by going side by side with them as many times as was needed. She worked next to her clients at the sheltered workshop until they felt comfortable. Barb telephoned clients often to problem solve and provide emotional support; she gave clients and their family and/or landperson her home telephone number to call evenings or weekends if a crisis arose. If there was an emergency, she drove out and intervened. As we listed the clients with whom Barb had worked intensively and continuously in this fashion, it was indeed apparent that almost none of them had come back to the hospital!

We talked about why these methods seemed to be effective and someone said, "You know, I think the community, not the hospital, is where our patients need the most help. They adjust to the hospital quite well-sometimes even too well- but life out in the community is hard, and it's especially hard for them. I think that's where we should be spending the majority of our time and effort." Other staff nodded in agreement and gradually voices got louder and suggestions more extreme. Finally, the room filled with excitement when a staff member proclaimed, "We ought to close B-2 down and all go out into the community like Barb and help our clients out there, where they really need support and where it will do the most good!"

The meeting ended in a spirit of incredibly high morale. Fortunately, Arnie Marx, Len Stein, and I had the good sense to pay attention to our staff and to integrate their observations with our own knowledge about the characteristics and needs of persons with severe mental illnesses. Rather remarkably, in a four-hour meeting we and our staff together had decided to change radically our own (and the existing) philosophy of care for persons with severe and persistent mental illness! Instead of having hospitalization as the "main event," the site where patients stabilized and received long term "preparation" for community living, we would make the community the primary locus of treatment. And treatment would consist of long term reaching out to clients to deliver medications and whatever individualized services and supports clients needed to live in the community at a decent quality of life and to reduce stress so that relapse would be minimized.

We soon began experimenting with the new approach, discharging more and more of our patients but at the same time sending staff of all disciplines out into the community day and evening, including weekends, to provide "hands on" assistance. Then we conducted a controlled pilot study, which revealed that even very disabled patients could be discharged and live in the community successfully if they received this kind of intensive, ongoing support from staff.

In 1972 our planning meeting vision became a reality as we closed B-2 and moved our hospital ward staff to the community to work out of a small office in downtown Madison. We reasoned that, if we provided this intensive seven days per week, 24 hours per day kind of outreach support to persons who were not yet hospitalized but were about to be, we could stabilize clients and thereby avoid the majority of hospitalizations, and over time help persons achieve greater satisfaction and ability to function in the community. The results of a major research study led by Len Stein and myself in the 1970s confirmed this hypothesis. Since then over a dozen well controlled studies in other parts of the U.S. and abroad have replicated our findings; PACT is now considered a national model of effective community care.

Reprinted from: The Journal, Volume 9, Issue 1, 1998, Sacramento, California.


ACT History and Origins
Deinstitutionalization

Assertive Community Treatment has spread throughout the US, Canada, UK, Australia and beyond. In fact, it is easy to forget that ACT has not actually been around that long. Nevertheless, its history has been a fascinating one, and if you would like to know more about it please read on. At the end, I have included some references to other works, which provide good accounts of the history and origins of ACT.

Assertive Community Treatment emerged during the era of deinstitutionalisation, when the old psychiatric hospitals emptied, and former residents, many of whom had serious mental health problems were discharged to community settings for which they were ill-prepared and where they received in sufficient support to ensure their needs were met.

By the 1960's hospital care was becoming much more expensive. This was the era of liberation, of the rejection of traditional thinking. A time of social upheaval throughout the Western world had dawned. No longer willing to accept the 'status quo' as had been the case during the post-war consensus years, people took up the cause of minority rights and the disadvantaged and wanted a better deal (Greenley, 1995). The cause of the mentally ill became consistent with these times. A period of change and optimism about a better world converged with a time of rapid progress within psychiatry. The widespread use of antipsychotic drugs had enabled psychiatrists to remove the straightjackets and padded cells of the institutions. The time was ripe for the locus of psychiatric care to shift away from the institutions that had dominated the field for so many years. The Community Mental Health Centres Acts of 1963 outlined a federal commitment to a program of Community Mental Health Centres. These were intended to provide a variety of facilities for partial and short-term hospitalisation, including clinics, halfway houses and day hospitals, in the hope that this would expedite the hospital closure program and the movement towards Deinstiitutionalisation. The plan was a long range one, and the proposed figure of 2,000 centres proved ambitious. By the late 1960's, it was clear that the program was neither feasible nor affordable, resulting in various halfway measures and budget cuts by the federal government. Meanwhile the states, banking on the ability of the newer drugs to maintain chronically ill patients outside the hospital, continued their policy of closing or educing the state hospitals.

The focus moved to rehabilitation rather than cure, with promising attempts to construct interventions based on family interventions and social skills training. By this time, many of the old hospitals were in crisis. Dropping inpatient numbers, a paucity of financial resources and investment in facilities, Erving Goffman's 'Asylums' had provided a damning critique of the shame that many hospital residents were forced to endure. Rosenhan's study, 'On Being Sane in Insane Places' widely read, also caused a crisis in the burgeoning science of diagnosis. Institutional psychiatry was being attacked from all corners. Hospitals remained isolated; wards resembled separate 'fiefdoms'. Disillusioned and impotent staff, short of skills or expertise, and often without the active support of a Responsible Medical Officer, were left to cope with large numbers of very ill people, and generally did so in decaying environments.

By 1975, the hospital population in the USA had plummeted by 80%. Optimistic psychiatrists hopeful about the new range of antipsychotic agents discharged patients, believing that federal dollars were in the process of constructing a network of agencies to provide long-term community care for their former charges. Nevertheless, many patients were still very sick when they were discharged and what these people encountered upon entering 'the community' was not a happy scenario. Often ill equipped to deal with the daily hardships of living outside the hospital, many former residents found even the basics of daily living challenging and stressful. Communities too were unprepared; it was thought that a place to live and an outpatient appointment were sufficient for someone with years of illness and dependent living to survive away from the confines of the institution. Former patients had very limited ability to advocate for themselves, and as well as experiencing stigma and social exclusion were frequently vulnerable to crime. A disparate and uncoordinated network of facilities existed to provide them with meaningful aftercare and support. Multiple service providers, if they existed at all were poor at communicating effectively with each other, genuinely seamless care with an obvious point of contact taking responsibility was hard to detect. High relapse and readmission rates resulted. A new phenomenon, that of the 'revolving door patient' emerged, as a large group of vulnerable people expected to cope with difficult and challenging community settings, failed spectacularly to do so and were repeatedly readmitted.

The Origins of Assertive Community Treatment.

In the late 1960's, The Mendota State Hospital in Madison, Wisconsin was a typical facility with a good staff, a large patient population, and high rates of admission and discharge (Stein and Santos, 1998). In 1969, some years after the Community Mental Health Centres Act had given national impetus to the process of discharging long-stay hospital residents, Dr Leonard Stein and Dr Mary Anne Test came together in the Special Treatment Unit (STU) of the Mendota State Hospital. A psychiatrist by profession, Stein was influenced by the humanistic philosophies of the antipsychiatrists. Dr Test, a psychologist, had substantial research skills and shared Dr Stein's vision of a better world for those who had been marginalised and downtrodden by traditional ways of thinking and working. Antipsychiatric, antibiological and antiestablishment views flourished, and profoundly influenced the early work of the researchers in the STU. Dr Arnold Marx was a third member of the team, and influential in bringing Stein and Test together It was his achievement also to persuade the MMHI authorities to dedicate an entire ward for the implementation of innovative research projects. The STU quickly became a research unit whose primary purpose was to evaluate various psychosocial techniques for the modification of behaviour and the rehabilitation of persons with chronic schizophrenia within the hospital setting. Thus far, the STU provided no philosophical difficulties for the hospital administrators. A variety of novel psychosocial interventions were attempted with residents, assisting the search for alternative and effective treatment approaches for this group of persons. Not all successful, they nevertheless boosted the standing of the MMHI, which already had a reputation for innovative thinking, and advanced clinical practice. The major emphasis of the STU was on research projects with an inpatient group. It was Dr Ludwig's passionate belief that their residents with schizophrenia were far from being a hopeless and helpless group, and research energies and monies were pointed in this direction. When Arnold Ludwig left his position as Director of Research and Training at the Institute in 1970, Leonard Stein succeeded him. Mary Anne Test had gained good experience of working in community settings, and the enthusiasm she had for this work, combined with Leonard Stein's views about the controlling and harmful nature of institutions helped prompt a radical shift in emphasis away from focussing on the hospital. Staff however, were becoming discouraged because in spite of their innovative interventions, patients continued to repeatedly return to hospital shortly thereafter with an exacerbation of symptoms or having experienced a major inability to cope with the everyday stresses of community living. The work that the team had set in place was proving to be successful in the short term, but enduring effectiveness throughout the post-discharge period was beyond reach. In the spring of 1971 one team member, a Social Worker, Barbara Lontz described how she followed up her patients in the community once they had been discharged. Providing an intensive follow up over the critical immediate post-discharge appeared to enhance the patient's ability to adapt and cope with the stresses of living away from the institution. The patients' neighbourhood was essentially the "therapy arena" (Marx, et al, 1973).

Services that existed at this time generally included general medical care, mental health or substance misuse treatment, vocational rehabilitation and housing services. The system was poorly integrated and complex (Drake, 1998). Not surprisingly, those patients with serious mental health problems had great difficulty in negotiating their way around this disparate network of provider agencies. The STU group in Madison believed that the failure of the hospital to effectively skill their patients sufficiently to live in the community was not for the want of effort. A range of initiatives had been tried but with limited success. They came to view the hospital itself as the problem, and formed the simple view that some patients were simply too sick to be treated in hospital (Dixon, 2000). The identification and acceptance of this failure led in turn to the development of a number of community based initiatives. Among these were halfway houses, community psychosocial rehabilitation centres, and semi-sheltered work-living groups such as Fairweather Lodge Evaluation of these programs looked encouraging and the STU group formed the idea that the hospital as the primary locus of treatment and preparation for community living was an unhelpful and increasingly anachronistic concept. They believed that the community was exactly the place where the patient needed help the most, and that it was logical therefore that the community should become the 'therapy arena'. They argued that the community had a number of advantages over the hospital setting in attempting to promote rehabilitation and community tenure. The presence of 'healthy role models' in the community and the expectations of normal behaviour in society, as well as the ready availability of opportunities to generalize skills acquired in vivo could be accessed in the community far more directly than in hospital. These hypotheses underpinned the establishment therefore of a rationale for the creation of a community treatment program that adhered to the following guidelines:
  1. Treatment concentrated primarily on patients' acquiring coping skills necessary to live in the community and enjoy a reasonable quality of life- the acquisition of these skills would take place in the community.
  2. A virtual abstention from rehospitalising any patients being managed in the community.
  3. Work with families and significant others primarily directed towards the goal of breaking pathologically dependent relationships.
  4. Staff relating to patients as responsible individuals and making maximal efforts to expose them to the reinforcements and contingencies of living in society.
  5. A close working relationship with a very wide variety of community facilities- from agencies to individuals- in order to ensure the consistency and continuity of the approach.
  6. A markedly assertive orientation in order to minimize the possibility of patients dropping out of treatment.
                        (Marx et al, 1973)
The results were dramatic. During the five-month research study, the community group experienced massively reduced periods of hospitalisation. There was a preparatory period of a maximum of eight days spent within the research ward before discharge, and largely speaking the accrued figures for time spent in hospital were almost entirely accounted for by this preparatory period. Effectively, hardly any study patients were readmitted, even when apparent crises occurred, and when they were readmitted, they could swiftly be discharged back to their community setting. Furthermore, the patients had not simply been transferred from one institution to another. In fact, what had taken place was that a group of dedicated staff assertively pursued the study group, and worked closely alongside them to help them adjust to their new lives. While some results were startling, others were less dramatic. Measures of psychiatric symptomatology for example were unaffected in the study group, similarly self-esteem remained similar to baseline. Neither of these findings were construed as of major significance by the research team however. They, quite reasonably suggested that self-esteem was likely to remain fairly static over as short a period as five months. Symptomatology was more complex. The team may have initially hoped that symptomatology would reduce, but they accepted that the burdens of community living were stressful to patients, and that, even in spite of the range of treatment which was provided, that the study group would correspondingly benefit little in terms of reduced symptomatology. In spite of this however, it was clear enough, that a number of persons with a range of diagnoses and difficulties who had previously experienced considerable periods of hospitalisation could be helped to live outside the institution. They lived and worked in ordinary settings, and were assisted to normalize their activities as far as possible. In this way, a comprehensive and far-reaching framework was designed in order to ensure the complex and challenging needs of this group of persons could be fully provided with hardly any recourse to the hospital setting. In 1974, the Program won the National Institute for Mental Health Gold Achievement Award, and was described as "an unusual community treatment program", which demonstrated that "patients who would otherwise be treated in mental hospitals can be successfully treated in the community without shifting the burden of care to their families" (Dixon, 2000).

Crucially the team was also able to demonstrate that the model could be economically viable, most directly because the need for inpatient beds was greatly reduced by this kind of community-focussed working (Weisbrod et al, 1980). Over the next few years, the team produced a series of papers outlining benefits of the new 'Training in Community Living' model. It began to receive attention and acclaim, and other ACT programs began to be developed modelling themselves on the innovative work of the STU team in Madison.

Further reading:
  1. Dixon, L., (2000), Assertive Community Treatment: Twenty-Five Years of Gold, Psychiatric Services, 51, 6, 759-765.
  2. Drake, R.E., (1998), Brief History, Current Status, and Future Place of Assertive Community Treatment, American Journal of Orthopsychiatry, 68, 2, 172-175.
  3. Marx, A.J., Test, M.A., Stein, L.I., (1973), Extrohospital Management of Severe Mental Illness, Feasibility and Effects of Social Functioning, Archives of General Psychiatry, 29, 505-511.
  4. Stein, L.I., Santos, A.B., (1998), Assertive Community Treatment for People with Severe Mental Illness, New York, W.W.Norton & Company.
  5. Schulz, R., Greenley, J.R., (eds.), (1995), Innovating in Community Mental Health- International Perspectives, Westport, Connecticut, Praeger.
  6. Thompson, K.S., Griffith, E.E.H., Leaf, P.J., (1990), A Historical Review of the Madison Model of Community Care, Hospital and Community Psychiatry, 41, 6, 625-635.
  7. Weisbrod, B.A., Test, M.A., Stein, L.I., (1980), Alternative to Mental Hospital Treatment II: economic benefit cost-analysis, Archives of General Psychiatry, 37, 400-405.
John Freeman
J.P.Freeman@sheffield.ac.uk
November 2001.

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