Assertive community treatment

Assertive community treatment (ACT) is an intensive and highly integrated approach for community mental health service delivery. ACT programs serve outpatients whose symptoms of mental illness lead to serious functioning difficulties in several major areas of life, often including work, social relationships, residential independence, money management, and physical health and wellness.

The defining characteristics of ACT include:

In the array of standard mental health service types, ACT is considered a "medically monitored non-residential service" (Level 4), making it more intensive than "high-intensity community-based services" (Level 3) but less intensive than "medically monitored residential services" (Level 5), as measured by the widely accepted LOCUS utilization management instrument.

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 by serious "gaps" and "cracks." The founders of the approach were Leonard I. Stein, Mary Ann Test, Arnold J. Marx, Deborah J. Allness, William H. Knoedler, and their colleagues at the Mendota Mental Health Institute, a state psychiatric hospital in Madison, Wisconsin. Also known in the literature as the Training in Community Living project, the Program of Assertive Community Treatment (PACT), or simply the "Madison model," this innovation seemed radical at the time but has since evolved into one of the most influential service delivery approaches in the history of community mental health. The original Madison project received the American Psychiatric Association's prestigious Gold Award in 1974. After conceiving the model as a strategy to prevent hospitalization in a relatively heterogeneous group of prospective state hospital patients, the PACT team turned its attention in the early 1980s to a more narrowly defined group of young adults with early-stage schizophrenia.

Since the late 1970s, the ACT approach has been replicated or adapted widely. The Harbinger program in Grand Rapids, Michigan, is generally recognized as the first replication, and a family-initiated early adaptation in Minnesota also traces its origins to the Madison model.

Starting in 1978, Jerry Dincin, Thomas F. Witheridge, and their colleagues developed the Bridge program at the Thresholdspsychiatric rehabilitation center in Chicago, Illinois—the first big-city adaptation of ACT and the first ACT program to focus on the most frequently hospitalized segment of the mental health consumer population. In the 1980s and '90s, Thresholds further adapted the approach to serve deaf people with mental illness,homeless people with mental illness, people experiencing psychiatric crises, and people with mental illness who are caught up in the criminal justice system.

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