Mental Health Matters: Assertive Community Treatment

The history of psychiatric treatment is a grim one, filled with incidents of abuse and individuals held for years against their will. Before the advent of psychiatric hospitals, where there was a belief that mental illness could be treated, psychiatric patients were basically warehoused in asylums. Even the early treatment provided in hospitals would be considered inhumane by modern standards, with patients often being controlled through sedation and physical restraints.

As better medications were developed and as people advocated for the humane treatment of psychiatric patients, there developed a movement in the 1950s and 1960s to deinstitutionalize patients and instead care for them in the community. Caring for patients in the community means they live at home, work to the best of their abilities and retain all their liberties. The process of deinstitutionalization continued until the 1980s.

Despite improved attitudes about mental illness and more effective medications with fewer side effects, there remains a segment of the population that has great difficulty being treated in the community. These patients often have multiple hospitalizations each year, become homeless or end up in prisons (where psychiatric treatment is questionable at best).

Mental health professionals saw the strain on patients and the community caused by chronic instability. Frequent hospitalizations are expensive and disrupt the patient’s ability to work and maintain relationships. Homelessness leads to a syndrome of difficulties, including poor physical health and more frequent exposure to violence.

In the 1970s in Wisconsin, there developed a response called Assertive Community Treatment (ACT) where multidisciplinary teams of professionals sought to provide a more intensive level of care to prevent hospitalization, homelessness and incarceration.

These teams have a psychiatrist or other mental health prescriber, a registered nurse, a peer specialist, a specialist in dual diagnosis (both mental illness and substance abuse) and case managers. Often referred to as hospitals without walls, these teams operate 24 hours a day, 365 days a year. Staff on the teams tend to know every patient served, make house calls, assist with medication compliance and help patients access therapy and health care services.

About 15 years ago, I worked on an ACT team in another state and still consider it one of the most profound experiences I have had. On an ACT team, things can feel like an outpatient clinic one minute and an emergency room the next. Because patients are seen frequently (from weekly to two or three times a day), staff get to know them well and develop a true sense of caring.

The team I worked on consisted of a psychiatrist, three registered nurses and multiple master's and bachelor's-level professionals, all taking care of 100 patients with chronic and persistent mental illness. The majority of the clients had schizophrenia and, because of their symptoms, had difficulty taking their medication regularly or maintaining stable housing without our assistance, which included financial assistance.

All the patients were receiving Social Security disability payments, which were usually quite small because they had not been able to work. Lack of money, combined with psychiatric symptoms which often alienated family, meant our patients were truly vulnerable. Some had been homeless, many had been abused and taken advantage of. Because of the ACT team, they were able to live independently and with dignity. Some maintained enough recovery that they could work part-time.

Because I know firsthand the important work done by ACT teams, I was pleased to hear that in 2023, the state of South Carolina decided to allow Medicaid funding for Assertive Community Treatment. My research shows that the teams tend to be run through the community mental health centers and that the term “Intensive Community Treatment” is used instead of Assertive Community Treatment.

If you or a loved one suffers from a chronic and persistent mental illness with repeated hospitalizations, I encourage you to contact your community mental health center and inquire about Assertive Community Treatment or Intensive Community Treatment.

Nora Sinclair is a licensed professional counselor and a nationally certified counselor based in Lexington, S.C.