Assertive community treatment teams

Killaspy et al present disappointing results from their randomised controlled trial examining the effectiveness of assertive community treatment (ACT). ¹ They found that it did not reduce admissions and bed usage.

However, as Professor Burns' editorial in the same issue points out, this finding should not come as any great surprise to us. ² Assertive community treatment has never really been shown to be effective in reducing admissions in the UK. Professor Burns avers that this is because of community mental health teams (CMHTs) actually being active comparators rather than treatment as usual. I think there is another important reason.

UK assertive outreach teams have always had engagement as their primary focus. This is understandable in view of their client group, a group that has not engaged with traditional CMHTs. Thus, innovative approaches to engagement, such as meeting in less stigmatising settings, have been the hallmark of UK assertive outreach teams, along with providing practical support.

However, the key question is, what happens once the patient is engaged? I believe the focus of the team should then swiftly move towards recovery and social inclusion. The most important characteristics of this would include a strong strengths-based approach and a focus on helping patients back to employment, whether voluntary or paid. Other characteristics would include a clear relapse prevention plan made in collaboration with the patient and a strong network of supported accommodation.

Occupational therapists are invaluable in promoting such approaches in psychiatric care, both in terms of social inclusion and potentially in leading on ‘return to work’ initiatives. ³

Similarly, strong links with the Local Authority are important in ensuring a good network of supported accommodation. This is facilitated by the presence of social workers with such links within the team.

However, it is interesting that in surveys done of assertive outreach team composition, it is the nursing profession that predominates. ⁴ Occupational therapy and social work input remains limited, while psychology input is concerningly rare.

Assertive outreach as an intervention has worked well abroad but needs to be modified to suit the needs of the UK population. The modification required, in my opinion, is a stronger focus on recovery and rehabilitation. This can be facilitated by ensuring that occupational therapists and social workers are an integral part of assertive outreach teams. It intuitively makes sense that a strong recovery approach, clear relapse prevention plans and good supported accommodation that is available for the patient who needs it, should together reduce admissions and bed usage. This is the assertive outreach model that needs to be evaluated in well-designed randomised controlled trials.