ACT service recipients may also have diagnostic profiles that include features typically found in other DSM-5 categories (for example, bipolar, depressive, anxiety, and personality disorders, among others).
The symptoms and complications of their mental illnesses have led to serious functioning difficulties in several areas of life, often including work, social relationships, residential independence, money management, and physical health and wellness.
[10] While ACT is more staff-intensive than most other forms of community treatment, it is viewed as a less restrictive option for carefully selected service recipients, compared to custodial or more heavily supervised alternatives; see Olmstead v. L.C.
ACT was first developed during the early 1970s, the heyday of deinstitutionalization, when large numbers of patients were being discharged from state-operated psychiatric hospitals to an underdeveloped, poorly integrated "nonsystem" of community services characterized (in the words of one of the model's founders) by serious "gaps" and "cracks.
"[11][12] The founders were Leonard I. Stein,[13][14][15][16][17][18][19] Mary Ann Test,[2][11][20][21][22][23][24][25] Arnold J. Marx,[26] Deborah J. Allness,[6][27] William H. Knoedler,[6][28][29] and their colleagues[30][31][32][33][34] at the Mendota Mental Health Institute, a state operated psychiatric hospital in Madison, Wisconsin.
[37] The Harbinger program in Grand Rapids, Michigan, is generally recognized as the first replication,[38][39] and a family-initiated early adaptation in Minnesota, known as Sharing Life in the Community when it was founded in 1976, also traces its origins to the Madison model.
[60] There are also major program concentrations in Delaware, Florida, Georgia, Idaho, Illinois,[43][46] Indiana (home of numerous research-based ACT programs[61][62] and the Indiana ACT Center[63]), Michigan,[64][65] Minnesota,[66] Missouri,[67][68][69] New Jersey, New Mexico, New York,[70] North Carolina (home to the UNC Institute for Best Practices), Ohio, Rhode Island, South Carolina,[71][72] South Dakota, Texas, Virginia, Australia,[55][56] Canada,[73][74][75] and the United Kingdom,[76][77][78] among many other places.
[96][97][98] He and his colleagues (especially Robert E. Drake[99][100][101] at Dartmouth Medical School) have attempted to consolidate and harmonize several major currents in this continuously developing area of practice, including: An evidence review conducted by the AcademyHealth[111] policy center in July 2016, examining the impact of housing-related services and supports on the health outcomes of homeless people enrolled in Medicaid, concluded that ACT reduces self-reported psychiatric symptoms, psychiatric hospital stays, and hospital emergency department visits among people with mental illness and substance use diagnoses.
Some clinicians and dual diagnosis specialists have voiced concerns that the model creates a safe environment for increased drug use, resulting in more instances of overdose and even death; they are awaiting an empirical study to confirm these suspicions.
[128] Moser and Bond address coercion and the broader concept of "agency control" (practices in which the treatment team maintains supervisory responsibility over consumers) in a discussion of data from 23 ACT programs.
To ensure the best possible service quality on a routine basis, public regulators and payers would also benefit from having fidelity and outcome monitoring tools more easily administered than those currently available.
The defining characteristics of the ACT approach will remain an attractive framework for services to meet the needs of special populations, such as individuals whose psychiatric symptoms get them into trouble with the criminal justice system,[132][133][134][135][136][137][138][139] refugees from foreign countries who struggle with the added burden of mental illness,[140] and children and adolescents with serious emotional disturbances.
[147][148][149] Ironically, the dissemination of separate evidence-based practices, not all of which are easily integrated with each other, has once again made service coordination a pivotal issue in community mental health — as it was during the latter decades of the 20th century, when ACT was created as an antidote to the "nonsystem" of care.