Presentation given by Dr. Beth Angell from Rutgers, the State University of New Jersey.

1. Assertive Community Treatment as a Case Study of Outpatient Compliance Beth Angell, PhD, MSSW Rutgers, the State University of New Jersey Second Curtis J. Berger Symposium on Mental Health and the Law Columbia University Law School November 20, 2009

2. ACT Overview History – “hospital without walls” Structure Multi-disciplinary team (including nurse and psychiatrist) works with all clients Small caseloads Seamless 24/7 coverage Frequent staff meetings and intra-team coordination Process Combined medical and psychosocial focus; minimal brokerage Flexible service delivery vehicle for individualizing treatment In-vivo locus Assertive outreach; frequent 1:1 client-staff contact Fixed point of responsibility within system

3. ACT Dissemination and Adaptation Standardization: manuals, fidelity scales NAMI PACT Across America initiative Adaptations to fit needs of homeless, justice-involved, and rural residents 1999: HCFA encouraged Medicaid program reimbursement Increasing interest in time-limited and step-down models, less intensive community support teams Move to increaserecovery-friendliness; merging with other EBP’s such as IDDT, Housing First, IMR, supported employment

4. ACT as an EBP 25 RCTs Strongest effects : Decreased hospitalization Increased housing stability/reduced homelessness Promising: Symptom reduction Enhanced QOL Family and consumer satisfaction Equivocal/no evidence of effectiveness Social and vocational outcomes Substance use Medication adherence Criminal justice outcomes Model fidelity = greater effectiveness Bond et al., 2001; Coldwell & Bender, 2007; Calsyn et al., 2005

5. ACT Criticisms Intensity is costly No-discharge policy creates capacity problem and sends anti-recovery message What’s the intervention? Black box within the larger well-defined structure Assertive outreach element seen as paternalistic (staff know better than clients what they need) “Whatever it takes” strategies may border on coercive in some situations

6. PACT programs heavily rely on coercion. They are rarely voluntary. Professionals make the decisions and leave little room for consumer choice. People are assigned to PACT teams based on the determination by the mental health system that they need such a team. In fact, the push for outpatient commitment…is often coordinated with a push for PACT teams to carry it out…persons can live in the community, but must remain under close surveillance. They can be rehospitalized if they do not take their medication or even appear to be doing worse. This creates the type of mistrust and breach of civil rights which are bound to undermine recovery.Fisher & Ahearn, 2000

7. Translating the guideline [of assertiveness] into everyday clinical routines involves informal practices of surveillance, such as counting the number of beer cans in the trash or asking directly about drug use, prostitution, and drinking…keeping up to date with virtually every aspect of clients’ lives – who they visit, what they eat, where the spend their days – through observation or direct questioning…Case managers find that they are massively controlling their clients, supposedly to guarantee that clients control their own lives.Brodwin, 2008

8. How do ACT teams manage adherence problems? Survey data Qualitative process studies

9. Survey Findings Studies of adherence strategies reportedby ACT providers and teams show: Low base rates of “high-end” coercive strategies such as withholding help, sanctioning, restricting freedom AOT infrequently used but use of rep payeeship much more common Reliance on persuasive techniques and intensive monitoring of adherence Neale & Rosenheck, 1999; Angell, 2006; Moser, 2009

10. Process Studies: Description Qualitative study of two ACT teams using passive observation and interviewing methods (Angell et al., 2006; Angell & Mahoney, 2007) In-progress ethnography of forensic assertive community treatment being conducted by Beth Angell, Amy Watson, and colleagues. Focus in both studies upon how ACT providers manage adherence in everyday clinical interactions

11. Process Study Findings Social influence processes more akin to personal than professional therapeutic relationships Bases of social influence in everyday life: Authority Legitimacy Identification Referent power Norm of reciprocity Reward/resource power + Social deprivation of consumers Creates opportunity context for relational leverage Angell et al., 2006

13. Strategies of Relational Leverage Structuring adherence/intensive monitoring Empathic listening and expressions of concern; emotional appeals Direct or request clients to comply Provision of practical supports at engagement phase Rewarding adherence Forging mental linkages between client goals/values and adherence behavior Working with clients to develop the agency to take responsibility for their own treatment decisions

14. Consumer Responses to ACT Valuing of client-staff relationships ranks most highly Assertive outreach most often seen as an expression of caring and support Perceptions of team often expressed in friend-like or even family – like terms Concrete assistance is important and prioritized Intrusive and/or coercive sentiments are rarely expressed Redko et al., 2004; Chinman et al., 1999; McGrew et al., 2002; McGrew et al., 1996; Appelbaum & Le Melle, 2008; Stanhope & Matejkowski, 2009

15. Is relational leverage enough?

16. What does AOTadd? NY AOT evaluation suggests an incremental advantage with respect to level of provider-rated service engagement (% with good or excellent engagement) for clients on a long term AOT order vs. ACT clients with no AOT order. For a minority of consumers, AOT may seen as a “nudge” that ensures initial and ongoing engagement. Swartz et al. (2009), New York State Assisted Outpatient Treatment Evaluation, final report.

17. Nudge…or push?There are major interpersonal costs in coercion – in moving from a collaborative to a controlling relationship. The need for court-ordered treatment is indicative of a failure of the relationship between the client and the treatment staff, at least for that moment in time. It indicates a major discrepancy between what the client feels he or she needs and what clinical staff feel is needed. It can have a major influence on the treatment relationship, an influence that can last for years after the actual event.Diamond, 1996

18. Nudges: Examples from Behavioral Economics Email filters that sense and caution the writer to wait 24 hours before sending a “heated” message Putting oneself on a casino ban list to curb problem gambling Committing a sum of money that will be forfeited if a desired behavioral goal is not met “The gentle power of libertarian paternalism”

19. From Push to Nudge? AOT may provide the extrinsic “push” needed for initial engagement and management of crises. Similar effects may accrue from other forms of leverage (financial, housing, criminal justice) How can ACT and similar programs move toward nudges that create incentives for consumers to make responsible care decisions? Providing goods people become motivated to keep, e.g., housing, work Collaborative mechanisms for managing future crises, e.g., advanced directives, joint crisis plans

20. Contact Information Beth Angell Rutgers School of Social Work 536 George St. New Brunswick NJ, 08901 angell@ssw.rutgers.edu