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Nurses and assertive community treatment teams: A critical combination.
This commentary discusses the critical role that nurses play on ACT teams and ACT as a platform to integrate physical and mental health. It also reviews issues that may affect nursing shortages on ACT teams.
Cuddeback, G., & Shatell, M. (2010). Nurses and assertive community treatment teams: A critical combination. Issues in Mental Health Nursing, 31, 751-752. doi: 10.3109/01612840.2010.518338
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Barriers to implementing evidence-based practices in addiction treatment programs: comparing staff
This qualitative study explores barriers to implementing evidence-based practices (EBPs) in community-based addiction treatment organizations (CBOs) by comparing staff descriptions of barriers for four EBPs: Motivational Interviewing (MI), Adolescent Community Reinforcement Approach (A-CRA), Assertive Community Treatment (ACT), and Cognitive-behavioral Therapy (CBT). The results show that front-line staff describes different types of barriers to implementing each EBP. For MI, the majority of barriers involved staff resistance or organizational setting. For CBT, the majority of barriers were associated with client resistance, and for ACT, the majority of barriers were associated with resources. The authors conclude that addiction programs proposing to use specific EBPs must consider whether they have the organizational capacity, as well as the community capacity, to meet the demands of that practice. EBP dissemination to programs should include explicit strategies to address such barriers.
Amodeo, M., Lundgren, L., Cohen, A., Rose, D., Chassler, D., Beltrame, C., & D’Ippolito, M. (2011). Barriers to implementing evidence-based practices in addiction treatment programs: comparing staff reports on motivational interviewing, adolescent community reinforcement approach, assertive community treatment, and cognitive-behavioral therapy. Evaluation and program planning, 34(4), 382-389
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Integrated primary and mental health care services: An evolving partnership model.
The authors describe how two organizations have partnered together to provide integrated primary and mental health services through two Integrated Health Care (IHC) clinics. This project brings IHC into community settings by using nurse practitioner house calls, group primary care visits and tele-monitoring. Tele-monitoring enhances both the efficiency and effectiveness of physical health care specifically targeted at improving adherence to medication regimes and lifestyle changes and monitoring clinical parameters of physically unstable members with diabetes, obesity, and/or hypertension. These services target high-risk Thresholds clients who are not regularly accessing primary care. This report concludes that primary care outreach has not only helped to connect with hard to reach clients, but it has also further improved the integration of mental health and primary care.
Davis, K., Brigell, E., Christiansen, K., Snyder, M., McDevitt, J., Forman, J., Lloyd Storfjell, J., & Wilkniss, S. (2011). Integrated primary and mental health care services: An evolving partnership model. Psychiatric Rehabilitation Journal, 34(4), 317-320.
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Client perspectives on helpful ingredients of assertive community treatment.
This is the first published article on the helpful ingredients of ACT from the client perspective. This study had ACT clients from six assertive community treatment (ACT) programs describe features they liked best about ACT. Clients mentioned non-specific ingredients most frequently (e.g., relationships with case managers); somewhat less frequently they mentioned ingredients considered by experts as integral to the ACT model (e.g, staff availability, home visits). Although ACT services differ in many ways from traditional counseling or psychotherapy, client-identified best aspects of ACT focused more strongly on features of the helping relationship that have been found to be important for counseling in general.
McGrew, J.H., Wilson, R.G., & Bond, G.R. (1996). Client perspectives on helpful ingredients of assertive community treatment. Psychiatric Rehabilitation Journal, 19(3), 13-21.
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Cognitive-behavioral therapy for schizophrenia: A review
This article describes the role that cognitive behavioral therapy has as an adjunct antipsychotic medication and remediative approaches such as social skills training in the management of residual symptoms of chronic schizophrenia. The article mentions that CBT can be combined with family therapy and assertive community treatment programs to reduce relapse and that ACT could complement the delivery of individual CBT.
Turkington, D., Dudley, R., Warman, D.M., & Beck, A.T. (2004). Cognitive-behavioral therapy for schizophrenia: A review. Journal of Psychiatric Practice, 10 (1), 5-16.
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Psychosocial treatments for schizophrenia
This book chapter provides an overview of schizophrenia and the status of psychosocial treatments for schizophrenia (i.e., therapeutic relationship and supportive therapy; behavior therapy and social learning programs; cognitive behavioral therapy; structured, educational family interventions; vocational rehabilitation; case management and treatment teams). The author includes additional considerations for those with a dual diagnosis (substance use and mental disorders) as well as future directions of other treatments such as cognitive rehabilitation. The authors summarize that multiple psychosocial treatment modalities must be delivered to patients if their multidimensional needs are to be met. They conclude that these treatments are most efficacious when delivered in a continuous, comprehensive, and well-coordinated manner within a service such as assertive community treatment.
Kopelowicz, A., Liberman, R.P., & Zarate, R. (2007). Psychosocial treatments for schizophrenia. In Nathan, P. E., & Gorman, J. M. A guide to treatments that work (pp.243-269). Oxford University Press, USA.
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The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements.
The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. The review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.
Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., Dickinson, D., Goldberg, R. W.,...& Kreyenbuhl, J. (2010). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements.Schizophrenia Bulletin, 36(1), 48-70. doi:10.1093/schbul/sbp115
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Transforming assertive community treatment into an integrated care system: The role of nursing and primary care partnerships
This article argues that ACT is an ideal platform to provide both primary and behavioural health care to those with complex service needs. This article considers the transformation of the ACT mental health care model into an integrated health care delivery system by expanding and explicitly redefining the role of the ACT nurse to include establishing partnerships with primary care providers.
Weinstein, L., Henwood, B., Cody, J., Jordan, M. & Lelar, R. (2011). Transforming assertive community treatment into an integrated care system: The role of nursing and primary care partnerships. Journal of the American Psychiatric Nurses Association, 17, 64-71.
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Providing nursing leadership in a community residential mental health setting.
This article outlines the leadership role that nurses can and should play within community residential mental health services. It argues that people who use mental health services are at a greater risk for physical illness and are among the most vulnerable and marginalized individuals within our society. As the largest professional workforce, nurses have a leadership responsibility to fight stigma and discrimination while providing a high level of care to these individuals. Although there are several barriers to this leadership development (i.e. lack recognition, stigma from other nurses), providing clear definitions and expectations of mental health nurses is important to develop services. For nurse led services to grow there must be a shared understanding of their principles and purpose. Also, a strong focus on recovery, formal training and the recognition of leadership are essential components for these services to progress.
Hughes, F., & Bamford, A. (2011). Providing nursing leadership in a community residential mental health setting. Journal of Psychological Nursing, 49(7), 35-42.
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Reaching out: the psychology of assertive outreach.
This book is a collection of chapters that all aim to examine psychological processes involved in assertive outreach. The introduction provides definitions and the evolution of assertive outreach. “Assertive outreach is a flexible and creative client-centred approach to engaging service users in a practical delivery of a wide range of services to meet the complex health and social needs and wants. It is a strategy that requires service providers to take an active role, working with service users, to secure resources and choices in treatment, rehabilitation, psychosocial support, functional and practical help, and equal priorities. (Joint Statement by SCMH, CMHSD, IMPACT, TULIP, North Birmingham AO Service, Kush Housing Association, The Working Together in London Initiative, 1999). It includes the origins of assertive outreach from Training and Community Living (TCL) to Assertive Community Treatment (ACT) and the Programme for Assertive Community Treatment (PACT), as well as differentiates psychological skills and psychological therapy in assertive outreach. It emphasizes the neglect of psychological therapies within ACT and how this neglect has caused ACT to drift from its original psychosocial philosophy of care and to be perceived to promote the medical model. The first half of the book outlines a psychological approach to the task of assertive outreach, beginning with the primary task of engaging service users. The second half of the book is devoted to the task of delivering psychological therapies.
Cupitt, C. (2010). Reaching out: the psychology of assertive outreach. Routledge.
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NPACT: Enhancing programs of assertive community treatment for the seriously ill.
This two-group community comparison design study examines the impact on psychiatric and physical outcomes through enhancing a standard Program of Assertive Treatment (PACT) with Advanced Practice Psychiatric Mental Health Nurses (APNs) and stabilized consumer peer providers (NPACT). Evaluations were conducted at baseline and at 6 months to assess six outcome variables: psychiatric symptoms, community adjustment, disability, physical symptoms, health promotion orientation, and consumer satisfaction. Significant improvements over time were demonstrated for both groups on all variables. However, treatment effects for NPACT over PACT were demonstrated for psychiatric symptoms, community functioning, and consumer satisfaction. NPACT subjects endorsed more medical problems at baseline than did PACT subjects. This may be due to subjects being more likely to disclose physical health symptoms to nurses. In conclusion, enhancements for PACT using advanced practice nurses and consumer peer providers have the potential to address both health and mental health problems of the seriously mentally ill.
Kane, C.F., & Blank, M.B. (2004). NPACT: Enhancing programs of assertive community treatment for the seriously ill. Community Mental Health Journal, 40 (6), 549-559.
Critical ingredients of assertive community treatment: Judgments of the experts
Reports experts’ opinions on the ideal specifications of the ACT model. Describes two subgroups of experts — those who advocated large multidisciplinary teams (100 or more clients) with day and evening shifts and those who advocated smaller, often generalist, teams (approximately 50 clients).
McGrew, J.H. & Bond, G.R. (1995). Critical ingredients of assertive community treatment: Judgments of the experts. The Journal of Mental Health Administration, 22(2), 113-125.
Treating comorbid substance use disorders in schizophrenia
This literature review examines the pharmacological and psychosocial treatment approaches for people with schizophrenia and comorbid substance use disorder(s) (SUD). The results show that despite the high prevalence of comorbid SUD among people with schizophrenia, there is a considerable shortage of rigorously conducted randomized controlled treatment trials. Although there is some evidence for clozapine, and for the adjunctive use of agents such as naltrexone for comorbid alcohol dependence, the available literature largely comprises case studies, case series, open label studies and retrospective surveys. In terms of psychosocial approaches, there is reasonable consensus that integrated approaches are most appropriate. Regarding specific aspects of care, motivational interviewing, cognitive behavioral therapy, contingency management, and family interventions have an emerging supportive literature. The authors state there is no ‘one size fits all’, and a flexible approach with the ability to apply specific components of care to particular individuals, is required. Group-based therapies and longer-term residential services have an important role for some patients, but further research is required to delineate more clearly which patients will benefit from these strategies. The authors conclude that although there is growing evidence that integrated and well articulated interventions that encompass pharmacological and psychosocial parameters can be beneficial for people with schizophrenia and comorbid SUD, there remains a considerable gap in the literature available to inform evidence-based practice
Lubman, D. I., King, J. A., & Castle, D. J. (2010). Treating comorbid substance use disorders in schizophrenia. International Review of psychiatry, 22(2), 191-201.
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Psychotherapy for schizophrenia in an ACT team context
This case study discusses the treatment of a man diagnosed with schizophrenia with severe social anxiety. CBT approaches were used and treatment was conducted by a psychotherapist within the context of ACT services. CBT and ACT were found to be complementary, and the combination of approaches was found to be effective helping to reduce the client’s social anxiety. However, the client decided after all that he did not want to continue therapy. The authors recommend that clinicians working within ACT teams attempt to incorporate CBT approaches to better address the needs of their clients.
Smith, S.M., & Yanos, P.T. (2009). Psychotherapy for schizophrenia in an ACT team context. Clinical Case Studies, 8(6), 454-462. doi: 10.1177/1534650109352006
Feasibility and usefulness of training assertive community treatment team in CBT
This article evaluated the impact of training one ACT team in CBT techniques. This retrospective study found an ACT team who was trained in CBT would utilize CBT interventions with their clients, even after training. However, CBT interventions did not increase medication adherence or result in reductions in crisis visits and hospitalizations. Staff reported that the training was helpful in helping them better understand clients’ problems, increasing their self-confidence in dealing with clients’ problems, and improving their interventions with clients. However, they also identified several barriers to the use of CBT interventions, and these were: (a) the change in individual caseloads for some team members over time, (b) having to play multiple roles, such as driving, being an advocate, helping with shopping, and being a therapist, and (c) having to deal with crises and unexpected issues and not being able to focus on one problem. Another challenge mentioned was that clients had multiple needs and different team members were addressing different needs and this interfered with the continuity of therapy. The ACT psychiatrist and certified cognitive therapist, trained the rest of the ACT team in CBT techniques. Training consisted of 13 h of didactic and experiential training spread over a 6-month period. The training was based upon an unpublished CBT manual for case managers. The didactic training consisted of introduction to cognitive theory, cognitive case conceptualization, adapting cognitive therapy for SMIs and incorporating techniques into routine practice. The experiential training included learning various techniques, such as Socratic questioning, identifying and enhancing coping skills for positive psychotic symptoms, role-playing, and cost-benefits analysis. In addition to the didactic training, individual supervision was provided as needed and amounted to an hour every 2 weeks during the course of the study period.
Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health Journal, 46, 337-341. doi: 10.1007/s10597-009-9271-y
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