Assertive Community Treatment of Persons with Severe Mental Illness. By Leonard I. Stein & Alberto B. Santos. New York & London: W. W. Norton & Co. 1998. 274 pp. $19.95 (pb). ISBN 0-393-70258-8

This book is published at an opportune time in the UK. Colleagues in the USA may be surprised to hear that few in this country had heard of assertive community treatment or its acronym, ACT, before 1990. It has been used in Wisconsin, where it was developed, since 1974, and it was the impressive results of randomised controlled trials in Wisconsin and later, in Australia, by Hoult et al, that made both research workers and clinicians in the UK interested, and later, quite excited. Now, a quarter of a century after its introduction, its originators, who include Leonard Stein himself, would feel proud that the world has finally approved ACT as “a service delivery vehicle or system designed to furnish the latest, most effective and efficient treatments, rehabilitation and support services conveniently as an integrated package”. What better at this stage than to play Wisconsin's Pomp and Circumstance to a world audience, complete with the 119 pages of ACT assessment and treatment plans from Dane County in Wisconsin, the home of the original recipe? ?

This is all valuable, but not entirely for the reasons that the authors intend. They are writing for either acolytes of ACT or those wishing to be converted and in the process of setting up programmes of their own. In enthusiastic and sometimes adulatory tones they describe the essentials of ACT and the patient-based philosophy underlying it — to help patients with severe mental illness live successfully in the community with a good quality of life.

By far the best section is the account of the functions of the work in a good ACT team — where the essential elements of sharing skills and genuine team working are graphically described from practical experience — and emphasising the need for all such teams to be flexible and opportunistic in their management of the combatants under their care. ‘Combatant’ may seem a strange word, but perpetually challenging the system of care for the most disabled of psychiatric patients is still much more common than the harmonious care plans that sit at the heart of government policies for those with mental illness. The need for lateral thinking and creativity in teams on the ground contrasts greatly with the uncritical promulgation of the core features that are presented as a prerequisite for success, including case-loads of between 8 and 12 (no more, no less), 24-hour cover, and (only) part-time psychiatric input using a parallel hierarchy, without which no team can say it practises true ACT. These are clearly not essential, as the authors present examples of the success of ACT in settings outside the UK, including our own service in Paddington and North Kensington, in which none of these features were present.

Much is made of the results of controlled trials that show superiority of ACT over conventional treatment in the UK settings in particular. There is no comment about the apparent lesser efficacy of ACT (and its counterpart, intensive case management) in the UK and elsewhere. However, the authors indicate why ACT is so effective in the USA in the early pages of this book. They note that there is a “fragmented non-system of public mental health care in the United States” in which services are “uncoordinated and non-collaborative, where service users are denied services, excluded from services, or never apply for them in the first place”. When this is treatment as usual it is not surprising that any form of coordinated and committed care would come out to be superior.

This book is certainly worth reading. It gives the longitudinal history of an experiment in community care that has been undoubtedly successful and has influenced the world. However, it also reveals, almost unwittingly, that the essential requirements of success are not cookbook ingredients, but the right mix of skills, true collaboration between professionals, and good communication and coordination. The members of many community mental health teams in this country would be surprised on reading this book to find out that they are practising assertive community treatment but without the prerequisites that its instigators regard as essential. Perhaps this should be the true test of the success of this approach; it is fundamentally the philosophy that matters and what constitutes its outer clothes is really immaterial.