Assertive community treatment

1. Introduction

Version followed: the US ACT model as now specified by the Tool for Measurement of ACT (TMACT, Version 1.0, Revision 3, 2018; Monroe-DeVita, Moser & Teague) for team structure and fidelity standards, with day-to-day team procedures taken from the SAMHSA/CMHS Implementing Evidence-Based Practices Project: ACT Workbook (draft, 2003; eds. Phillips & Burns), which is largely adapted from Allness & Knoedler's PACT Manual (NAMI, 1999). Where these differ, the difference is named. Variants such as UK assertive outreach and Dutch Flexible ACT (FACT) are not covered [uncertain].

Assertive community treatment (ACT) is a service delivery model, not a single psychotherapy. A transdisciplinary team of about 10–12 staff takes on around 100 adults with severe and persistent mental illness and the greatest functional difficulties. It acts as their fixed point of responsibility, delivering nearly all treatment, rehabilitation and practical support itself, mostly in the person's home and community, around the clock and with no fixed end date [source: ACT Workbook 2003, pp. 4–5, 8–16; TMACT Summary Scale]. The model was developed in 1972 at Mendota Mental Health Institute in Madison, Wisconsin. Mary Ann Test, Arnold Marx and Leonard Stein concluded that hospital-based work could not stop "revolving-door" readmission. They first ran a pilot "community treatment group", which then became the NIMH-funded Training in Community Living programme and later PACT/ACT [source: Dixon 2000; PACT History and Influence 2021].

How change is thought to happen. The founders held that people who could not be discharged signalled a failure of the hospital, not of the patient. Their targets were people with limited problem-solving skills, strong dependency needs, or symptoms that worsen under stress. Change comes from hospital-level staff bringing treatment and coping-skills help into the person's home, work and neighbourhood, and from staying involved for as long as needed [source: Dixon 2000]. The Workbook frames the primary goal as recovery through community treatment and habilitation [source: ACT Workbook 2003, pp. 8–12]. The idea that skills are best learned where they will be used is implied by these sources but not stated in them as a principle [uncertain]. In early studies, gains eroded when services were withdrawn after 12 months. That is why ACT rejects arbitrary time limits [source: Dixon 2000].

This guide is written for a clinician joining or working with an ACT team, such as a team psychologist or therapist, team leader, nurse or specialist, or a referring therapist. The model is not proprietary and no single licence is required. In the US, however, state mental health authorities and payers usually certify ACT teams and require periodic fidelity review (DACTS or TMACT) before services can be billed as ACT [uncertain: state rules]. The TMACT authors say a real fidelity evaluation needs the full protocol and appendices, not the summary scale [source: TMACT Summary Scale; TMACT Part I]. The Workbook recommends mentor or consultant support during the first year [source: ACT Workbook 2003].

2. Framework

ACT has no session count. The "dose" is set at team level. The TMACT standard is an average of at least 3 face-to-face contacts and at least 2 hours of face-to-face contact per client per week, with at least 75% of contacts in the community. Each client should see at least 3 different staff members within 4 weeks [source: TMACT Summary Scale CP1, CP3, CP4, OS2]. Intensity varies with need and is "not time-limited or sequenced" [source: Dixon 2000]. The course still has a recognisable sequence.

Team format (prerequisites for every phase) [source: TMACT Summary Scale OS, CT, ST; ACT Workbook 2003, pp. 4–5, 13–16]

Ratio of 10 or fewer clients per clinical staff member. A 100-client team has 10 or more FTE direct clinical staff. Clients are not given individual caseloads.
Core team: a full-time team leader who also practises; a psychiatric care provider (at least 0.8 FTE per 100 clients); at least 2.85 FTE registered nurses per 100 clients; and a full-time program assistant.
Specialists, each at least 1.0 FTE: co-occurring disorders specialist, employment specialist, peer specialist.
The 2003 Workbook names team leader, psychiatrist, RN, vocational specialist and substance abuse specialist. The peer specialist and the empirically supported psychotherapy standard are TMACT-era additions.
The team meets daily, 5 days a week, with full attendance. It is responsible for crisis response 24/7 and is involved in at least 90% of psychiatric admissions and discharges.

Phase A – Referral, screening and gradual admission

Goal: enrol people in the priority population. These are people with severe and persistent mental illness plus matching functional deficits. Diagnosis alone does not qualify [source: PACT History and Influence 2021; TMACT OS6].
The team controls its own admissions. It recruits actively from non-traditional sources such as shelters, jails and emergency departments, and fills open slots [source: TMACT OS6–OS7].
No more than about 4 new admissions in any month, so that engagement and assessment are not rushed [source: TMACT OS8].
Move on when the person is accepted and has had a first contact.

Phase B – Engagement (starts before admission and never ends)

Goal: build a working relationship by helping with what the person wants now.
Contact with family and other supporters and program visits can happen before admission. Introductions to other team members are staged. For someone who is very psychotic, one trusted staff member may lead at first and others join as trust grows [source: ACT Workbook 2003, pp. 38–40].
Engagement is sustained by visible progress on the person's own goals [source: ACT Workbook 2003].

Phase C – Immediate needs and comprehensive assessment (about the first 30 days)

Address urgent needs such as housing, money, medication and food first, and assess while doing so.
Physical health interview within 72 hours of admission. Psychiatric history, family assessment and the other domain assessments within about 30 days. Each piece is assigned to a named discipline. Urgent findings go to the team leader at once [source: ACT Workbook 2003, pp. 33–34, 40–44, Table 3.2].
Move on when the assessment is compiled and reviewed with the people who contributed to it.

Phase D – Person-centred treatment planning

The team pools information. The plan names specific actions, who does them, and on which days and times. The person reviews it and agreement is reached [source: ACT Workbook 2003, pp. 34–39].
TMACT requires the person's own goals, strengths used in the plan, regular planning meetings, participants the person chooses, and interventions across life domains [source: TMACT PP1–PP4].
Plans are reviewed at least every 6 months and revised at once when needs increase [source: ACT Workbook 2003, p. 49].

Phase E – Ongoing in vivo service delivery (open-ended)

The plan is turned into a Weekly Consumer Schedule. The daily team meeting turns those schedules into each day's staff assignments [source: ACT Workbook 2003, pp. 37–39, 50–55; TMACT Protocol Part II OS4].
Services are reduced only after a plan review with the person, for example after symptoms remit or after successful work integration [source: ACT Workbook 2003, p. 50].

Phase F – Transition to less intensive services (when criteria are met)

At every plan review, assess whether the person still needs ACT. Use explicit criteria that any team member could apply consistently.
Prepare over a period that fits the person, often 3–6 months. Monitor after transition, sometimes for up to about 3 months. Guarantee fast readmission [source: TMACT Protocol Part II OS9].
Criteria about the move itself are in §4.25. Overall, at least 95% of clients should be retained over 12 months [source: TMACT OS10].

3. Guiding principles

[source: ACT Workbook 2003, pp. 8–16, 30–31, 49; TMACT Summary Scale; Dixon 2000. Practical meanings are synthesis unless tagged.]

Fixed point of responsibility. If something in the person's life is not working, it is the team's job to fix it or make sure it is fixed. You do not refer the person elsewhere and close the case.
Team approach and shared caseload. Every staff member knows every client, and you will see people you are not "assigned" to. Do not hoard clients.
Transdisciplinary, not multidisciplinary. Assess, plan and deliver together. Cross-train, and do what is needed within your licence rather than defending professional turf [source: Workbook p. 15].
Small caseload. About 1:10. Protect this when the team grows, because larger caseloads pull staff back to office-based habits [source: Workbook pp. 4–5].
In vivo services. Meet in homes, shops, workplaces and shelters. The office is the exception (at least 75% of contacts in the community).
Time-unlimited services. Never discharge because of an arbitrary time limit or missed appointments. Step down only on explicit, individualised criteria [source: Dixon 2000; TMACT OS9; UNC protocol].
Flexible, individualised intensity. Contact can range from several times a day to weekly, adjusted daily in the team meeting.
24/7 crisis responsibility. The team, not a generic crisis line, is the first responder and is willing to go out in person.
Comprehensive, directly provided services. Psychiatry, rehabilitation, substance use treatment, employment, housing support and wellness management are delivered by the team itself rather than brokered (90% or more of those who need each service get it from the team) [source: TMACT CP7–CP8, EP1–EP3].
Assertive engagement. Keep reaching out persistently and creatively. One team member put it as "We just would not give up hope." [source: Workbook p. 58].
The person's goals drive the work. In plan reviews, ask whether the team is "working on the consumer's goal or our goals?" [source: Workbook p. 49].
When progress stalls, look at the team first. The Workbook's review question is "What is the team (not the consumer) doing wrong?" [source: Workbook p. 49].
Strengths-based, person-centred, self-determination. Help the person see their choices, honour everyday choices, teach independent skills, and match oversight to need, with the least oversight that is safe [source: TMACT PP1–PP4].
Recovery orientation. Aim for a life in the community, with work, a home and relationships, not only symptom control [source: Workbook pp. 8–12; TMACT EP5, EP8].
Evidence-based practices are built in. Integrated co-occurring disorders treatment, supported employment, wellness management and recovery, family psychoeducation and empirically supported psychotherapy are part of ACT, not add-ons [source: TMACT EP1–EP8].
Avoid unnecessary hospitalisation, and be involved when it happens. Help the person stay in the community. If admission is needed, the team takes part in the admission and the discharge [source: Workbook p. 39; TMACT OS11].
Least intrusive engagement first. Treat limit-setting and legal levers as last resorts. Rising use of them can be a sign of a demoralised team [source: Manuel et al. 2013; UNC protocol 2021].
Fidelity matters. Teams that follow the model most closely tend to get better outcomes. Measure fidelity and act on the results [source: Workbook pp. 8–12; PACT History 2021].

4. Intervention inventory

In ACT the interventions are team procedures and service components, delivered in vivo by whoever on the shared team is best placed to do them. Steps are paraphrased from the sources named in each item. Step detail beyond the sources is marked [synthesis]. All example language is illustrative unless it is a short cited quote.

4.1 Screening and gradual admission

Purpose / when: At referral, to make sure the team's scarce, costly capacity goes to the priority population [source: TMACT OS6–OS8; PACT History 2021].
Steps:
1. Apply written admission criteria: a severe and persistent mental illness and serious functional impairment. Typical signs are high use of hospital or crisis services, unstable housing, and failure to engage with standard services.
2. The team, not an outside gatekeeper, decides on admission.
3. Recruit actively from places where the target group actually is, such as shelters, jails, emergency departments and inpatient units. Teach referrers what ACT is.
4. Keep admissions to about 4 or fewer per month, and keep the census near capacity.
Example language (illustrative): To a referrer: "We take people who are struggling to stay out of hospital or keep housing despite usual services. Tell me about their last year, not just their diagnosis."
Watch for: Admitting people mainly to relieve other services. Admitting a burst of clients at once, which overloads engagement. Admission based on diagnosis alone.

4.2 Pre-admission engagement and staged introductions

Purpose / when: From referral onward, to begin a relationship before formal enrolment, especially with people who have been poorly served and avoid services [source: ACT Workbook 2003, pp. 17–18, 38–40].
Steps:
1. Meet the person where they are: on the ward, at the shelter or at home. Meet supporters too, with consent.
2. Lead with practical help the person values.
3. Introduce other team members gradually. If the person is very psychotic or mistrustful, one trusted contact leads at first and others are added as trust grows.
4. Keep early visits brief and few if the person needs that. The Workbook's case "Harold" was allowed to adjust slowly [source: Workbook p. 57].
5. Make clear what the team is not there to do. In the "Lucy" case, staff made clear they were "not there to admit her to the hospital" [source: Workbook p. 58].
Example language (illustrative): "I'm from a team that helps people with the things they want to sort out: money, housing, whatever matters to you. Can I bring you some groceries on Thursday?"
Watch for: Engagement is working when the person accepts or keeps a contact, names something they want, or tolerates a second staff member. Too many new faces too fast leads to withdrawal.

4.3 Assertive engagement mechanisms (motivational and limit-setting)

Purpose / when: Throughout care, to keep people engaged who are ambivalent, avoidant or impaired in insight. TMACT credits teams that use both motivational and limit-setting approaches and have a systematic way to identify, measure and adjust engagement strategies [source: TMACT CP2].
Steps:
1. Default to the least intrusive strategies. In a survey of 34 New York ACT teams, the most used were positive inducements (calling or visiting people who refuse, food at groups, transit passes) and verbal guidance (pointing out harmful behaviour and its likely consequences) [source: Manuel et al. 2013].
2. Use medication monitoring, such as watching people take medication or giving injections at home, only as agreed in the plan.
3. Use money management (representative payee, spending plans), conditional involvement (making help depend on behaviour), hospitalisation, and reports to authorities (assisted outpatient treatment, guardianship) only after less intrusive options. Discuss them openly as a team and record them. Manuel et al. found these were used less often, and conditional involvement was used least [source: Manuel et al. 2013].
4. Review each client's engagement strategy in planning: what is being tried, whether it works, and what to change [source: TMACT CP2].
Example language (illustrative): "You've said you want to keep this flat. Last time the rent went unpaid, you nearly lost it. What would help this month, and how could we help without taking over?"
Watch for: Risk: intrusive levers can erode the person's own decision-making and satisfaction. In the survey, more intrusive practice was associated with a demoralised team climate and with stigmatising staff beliefs [source: Manuel et al. 2013]. If your team's use of payeeship, conditional help or commitment is rising, treat it as a team problem to examine, not only a client problem [synthesis].

4.4 Structured outreach protocol for disengaged or missing clients

Purpose / when: When a client stops engaging or cannot be found. The protocol ensures every reasonable route has been tried before discharge is considered. Version: Powers & McDonnell 2021, adapted from Case Western Center for Evidence-Based Practices [source: UNC ACT Assertive Engagement & Outreach Protocol].
Steps (located but not engaging):
1. Record the last in-person contact and possible reasons for disengagement.
2. Re-explore the person's own perspective and goals.
3. Meet basic needs: benefits, budgeting, groceries, medication delivery, housing problems, medical appointments.
4. Respect the person's preferences for place, transport, technology (text, email) and time of contact.
5. If substance use is involved, offer harm reduction (for example naloxone or syringe services), rides to co-occurring disorders or self-help groups, and match the approach to the person's stage of change.
6. Make sure at least 3 different team members have tried, including the team leader and the peer specialist. Try joint visits, and join the person in an activity they choose.
7. Re-explain each staff member's role and how each can help with the person's goals. Consider cultural factors.
8. With a valid release, contact natural and formal supports: emergency contact, guardian or payee, landlord, previous provider, probation, employer, medical provider. Log every contact.
9. Check whether the team itself has been cancelling appointments.
10. Use MI, peer support, an integrated dual-disorder approach and groups. Assess legal options (emergency admission, guardianship or payeeship, criminal-justice involvement) only as a last resort.
Steps (cannot be located):
1. Phone 3–4 times a week. Also text, write letters and email.
2. Send messages built around the person's interests or past requests, such as an activity they enjoy.
3. Have 3 or more different staff search the person's home and usual places.
4. Check shelters, food pantries, police, jails, hospitals, nursing homes and rehabilitation units.
5. Log the date, the staff member and the outcome of every attempt.
Example language (illustrative): Text: "Hi, it's Sam from the team. No pressure, we just miss seeing you. Still up for the fishing trip you mentioned? Reply anytime."
Watch for: The protocol sets no total outreach duration [uncertain]. It warns against discharge driven by missed appointments or fixed time limits. Its "creative messaging" examples must stay truthful: never use a false pretext to make contact [synthesis, ethical caution].

4.5 Comprehensive assessment

Purpose / when: The first ~30 days after admission. Repeat parts of it when circumstances change [source: ACT Workbook 2003, pp. 33–34, 40–44, Tables 3.1–3.2].
Steps:
1. Start at the first meeting and assess while helping with immediate needs. Do not run a separate intake interview first.
2. Assign each domain to the relevant specialist, with a deadline. Domains include physical health interview (within 72 h), psychiatric history (within 30 days), substance use, vocational, family (within 30 days, defining the family's role with consent), social development (leisure interests, social skills, relationships), housing, daily living, finances and legal.
3. Approach personal topics sensitively. Substance use information may take several interviews to collect [source: Workbook p. 43].
4. Look for patterns. Build a psychosocial timeline: a chronological map of symptoms, treatment episodes, hospitalisations and life events [source: Workbook p. 34, pp. 46–48].
5. Report urgent findings, such as medical problems or safety risk, to the team leader at once.
6. Review the compiled assessment with the people who contributed to it, then take it to the initial planning meeting.
Example language (illustrative): "Can we sketch out the last ten years together, when things went well and when they got hard? It helps us see what has worked for you before."
Watch for: The timeline should reveal relapse triggers, such as stressors, anniversaries and stopping medication, and past helpers. Those feed the crisis plan and proactive contacts (§4.8, §4.11).

4.6 Person-centred, strengths-based treatment planning

Purpose / when: After the initial assessment, at least every 6 months, and immediately when needs increase [source: ACT Workbook 2003, pp. 34–39, 49; TMACT PP1–PP4].
Steps:
1. Gather the person's own early ideas about goals before the meeting.
2. Hold a planning meeting with participants the person chooses.
3. Write the person's goals in their words. Identify strengths and use them as means.
4. Plan interventions across life domains: housing, work and education, health, substance use, relationships, leisure.
5. For each intervention, name what will be done, by whom, on which days and at what times.
6. Review the plan with the person until they agree with it.
7. Support the person to direct their own plan as far as they can.
8. At review, ask whether the team is working on the person's goals or its own, and what the team may be doing wrong [source: Workbook p. 49].
Example language (illustrative): "If this next six months went really well, what would be different? Which bits do you want us alongside you for, and which do you want to do yourself?"
Watch for: Plans written in clinical goals only (for example "medication compliance"). Plans with no named staff or times. Strengths listed but not used.

4.7 Weekly consumer schedule and daily team schedule

Purpose / when: To turn the plan into actual contacts [source: ACT Workbook 2003, pp. 37–39, 50–52; TMACT Protocol Part II OS4].
Steps:
1. Translate each plan intervention into recurring weekly contacts on that person's Weekly Consumer Schedule. Traditionally this is a 5×8 card kept in pencil, or a monthly calendar.
2. Build the Daily Team Schedule from all clients' weekly schedules. Add non-recurring appointments and crisis follow-up. Block staff time for documentation and other tasks.
3. Use client initials only on shared schedules for confidentiality.
4. Make each person's schedule shareable with them, as TMACT requires for full credit.
Example language (illustrative): "Here's your week: Tuesday Priya comes for shopping, Wednesday the nurse visits, Friday is the job search with Marco. Anything you want moved?"
Watch for: Schedules that do not match the plan. Contacts that "float" without a named staff member.

4.8 Daily team meeting

Purpose / when: Every weekday, attended by all staff on shift. It is the engine of the shared caseload [source: TMACT OS3–OS4 and Protocol Part II OS4; ACT Workbook 2003, pp. 37–39, 55].
Steps (the six TMACT functions):
1. Briefly review every client, using the communication log. Report contacts from the last 24 hours in behavioural terms.
2. Record each person's status daily in a consistent format, building a monthly log of services provided, not provided and missed.
3. Base the day's staff assignments on the clients' weekly schedules.
4. Turn emerging needs, such as a crisis, an unplanned appointment or an admission, into specific scheduled contacts.
5. Schedule proactive contacts to head off crises, for example near anniversaries or when early warning signs appear.
6. Hold staff accountable by checking scheduled contacts against reported ones.
7. Solve quick problems in the meeting and move complex cases to a separate meeting.
Example language (illustrative): "J.R.: seen yesterday 2 pm, ate, took meds, talked about moving out. Not sleeping two nights, which was his early sign last spring. Can we add an evening check today?"
Watch for: The Workbook says a focused team can review about 100 people in roughly 45 minutes [source: p. 55]. Reading the log aloud without discussion, skipping clients, or very long or very short reports earn partial or no fidelity credit.

4.9 Shared caseload and cross-training

Purpose / when: Continuously, so that care does not collapse when one worker is away, and so the person benefits from several skill sets [source: ACT Workbook 2003, pp. 13–16; TMACT OS2].
Steps:
1. Rotate contacts so that at least 3 different staff see each person within 4 weeks.
2. Assess, plan and implement treatment jointly.
3. Specialists model and teach their methods to colleagues. For example, the co-occurring disorders specialist shows MI, and the employment specialist shows job development.
4. Respect licensure limits, such as prescribing and nursing tasks.
5. Smaller "mini-teams" may carry administrative assignments, but never act as private caseloads.
Example language (illustrative): To a client: "You'll see a few of us. We all know your plan, so you won't have to repeat your story."
Watch for: Staff referring to "my clients". Clients who will only see one person over the long term (sometimes needed early on, see §4.2).

4.10 In vivo, community-based contact

Purpose / when: The default setting for all services, with at least 75% of face-to-face contacts in the community [source: TMACT CP1; ACT Workbook 2003; Dixon 2000].
Steps:
1. Deliver help where the skill or problem occurs: the person's kitchen, the supermarket, the job site, the benefits office.
2. Work side by side rather than giving advice from a distance.
3. Use the visit to observe functioning, mental state, the home environment and medication.
4. Plan travel and safety for home visits, including lone-worker procedures [synthesis].
Example language (illustrative): "Rather than talk about budgeting in the office, shall we do this week's shop together and work it out as we go?"
Watch for: A drift back to office or clinic appointments, which is a common fidelity slide.

4.11 Crisis responsibility and individualised crisis plans

Purpose / when: 24/7. The team is the first-line crisis responder and is willing to respond in person [source: TMACT CP6; ACT Workbook 2003, Appendix B, pp. 33, 52–53].
Steps:
1. For each person, write an individualised crisis plan. It should cover early warning signs (from the timeline), what helps, whom to contact, preferences about hospital, and how to reach the team after hours [content of plan: synthesis; TMACT requires the plan to exist].
2. Staff an on-call rota with team members who know the clients. A plan to set one up does not earn TMACT credit; it must be in place.
3. Respond to a crisis by phone or in person. Add unscheduled visits to the Daily Team Schedule and review them at the next meeting.
4. Schedule proactive contacts when early signs appear (§4.8).
5. For suicide or self-harm risk, follow your service's standard structured risk assessment and safety planning. Include lethal-means counselling (safe storage or removal, agreed with the person and their supports) and same-day team review [synthesis, standard practice].
Example language (illustrative): "This card has our 24-hour number. If the voices get loud like they did in March, call us first. One of us who knows you will pick up."
Watch for: Crises handled by outside services without the team's knowledge. Crisis plans that sit in the file and are never reviewed with the person.

4.12 Involvement in hospital admission and discharge

Purpose / when: Whenever psychiatric admission is being considered or happens. The team should be involved in at least 90% of admissions and discharges [source: TMACT OS11; ACT Workbook 2003, pp. 16, 39].
Steps:
1. Try community alternatives first: more frequent visits, medication review, a crisis plan, staying with a supporter [alternatives: synthesis].
2. If admission is needed, the team arranges it or takes part in the decision.
3. Keep visiting during the stay.
4. Plan the discharge with the inpatient unit and step up contact in the first days home.
Example language (illustrative): "We'll keep coming while you're on the ward, and we'll be at your discharge meeting so we can plan the first week back together."
Watch for: Admissions the team only hears about afterwards. Discharges with no team contact in the first 24–48 hours [synthesis].

4.13 Psychiatric care and medication support

Purpose / when: For everyone who needs psychiatric care. At least 90% of those who need it get it from the team [source: TMACT CP7, CT3–CT7; ACT Workbook 2003, pp. 30, 33, 57].
Psychiatric provider's roles: Assesses each person at least monthly (TMACT). The 2003 Workbook's example plan has visits every 4–6 weeks, which is a version difference. Offers brief therapy. Makes medication decisions jointly with the person. Monitors medical problems. Liaises with hospitals and makes home visits. Shares clinical oversight with the team leader, educates staff, attends meetings, works closely with the nurses and backs up after-hours cover.
Nurses' roles: Medication management and support for adherence, medical monitoring, coordination of physical health care, health promotion, and staff education [source: TMACT CT7].
Steps:
1. Discuss side effects and preferences openly, and decide together.
2. Agree on a support method with the person: delivering medication, packing pill organisers, observing doses, or giving injections at home, as in the Workbook's "Harold" case [source: Workbook p. 57].
3. Review adherence and side effects in the daily meeting.
4. Raise problems with the prescriber quickly. No dosing guidance is given here.
Example language (illustrative): "What's the worst thing about this medication for you? Let's take that to Dr Lee on Thursday and see what the options are."
Watch for: Medication support that slides into surveillance the person did not agree to (§4.3). Unaddressed side effects as the hidden reason for non-adherence.

4.14 Stress and symptom management

Purpose / when: When stress or symptoms threaten functioning, and when change is planned (a move, a new job) [source: ACT Workbook 2003, pp. 28–31, 33].
Steps:
1. Identify the person's stressors, including positive events, daily hassles, and states such as fatigue or hunger that increase vulnerability.
2. Help the person recognise their own signs of stress.
3. Anticipate upcoming stressors and plan to avoid them or rehearse them.
4. Break changes into "bite-size" steps. The Workbook's example is short visits to a new flat before a first overnight stay [source: Workbook p. 30].
5. Reduce hassles, for example by avoiding rush-hour travel to a new job [source: Workbook pp. 30–31].
6. Teach and practise coping strategies, such as relaxation or quiet music on headphones, and mobilise support.
Example language (illustrative): "Moving is good news, but even good changes are stressful. Shall we do a couple of daytime visits to the new place before you sleep there?"
Watch for: Early warning signs reported in the daily meeting. Changes rushed because of external deadlines.

4.15 Wellness management and recovery (IMR, WRAP)

Purpose / when: For everyone who needs self-management skills. TMACT expects formal approaches such as Illness Management and Recovery (IMR) or the Wellness Recovery Action Plan (WRAP), delivered by the team to at least 90% of those who need them [source: TMACT EP3, ST8].
Steps:
1. Choose the curriculum.
2. Deliver it individually or in groups, often with the peer specialist.
3. Link the person's relapse-prevention plan to their crisis plan (§4.11) [synthesis].
Example language (illustrative): "Would you like to put together your own plan for staying well, in your words, so we follow what you want if things get rough?"
Watch for: Curriculum content belongs to IMR and WRAP; see their own manuals [uncertain].

4.16 Integrated treatment for co-occurring substance use

Purpose / when: For everyone with co-occurring substance use, treated alongside psychiatric symptoms by the team, not referred out [source: TMACT ST1–ST3, EP1, EP4; ACT Workbook 2003, pp. 30, 33, 43].
Steps:
1. Assess substance use and its interaction with symptoms.
2. Determine the person's stage of change for each substance or behaviour.
3. Match the intervention to the stage: motivational outreach and MI for people who are not ready, CBT and relapse prevention for people who are.
4. Support harm reduction.
5. In the Workbook's example plan, one-to-one MI is offered three times weekly, plus a weekly dual-diagnosis group [source: Workbook p. 33].
6. The co-occurring disorders specialist models these methods, cross-trains staff and attends daily and planning meetings.
Example language (illustrative): "I'm not here to make you stop. I'm curious what the drinking does for you, and what it costs you."
Watch for: Abstinence demanded as a condition of help, which runs against EP4's harm-reduction stance. Use the outreach protocol's harm-reduction items for people who are not engaged (§4.4).

4.17 Supported employment and education

Purpose / when: For anyone who wants work or study. The person's wish is the only eligibility criterion [source: TMACT ST4–ST6, EP2, EP5; ACT Workbook 2003, pp. 30–31].
Steps:
1. The employment specialist builds an ongoing counselling relationship.
2. Aim for competitive jobs.
3. Assess on the job rather than through prolonged pre-vocational testing.
4. Find individualised placements.
5. Phase work entry and reduce support gradually.
6. Offer ongoing in-work support and benefits counselling.
7. Use hassle reduction, such as working out travel times.
Example language (illustrative): "What kind of work would you actually like? Let's look at a couple of places this week. You don't need to be 'ready' first."
Watch for: Staff deciding the person is "not ready". Lost benefits caused by missing benefits counselling.

4.18 Supportive housing

Purpose / when: For homelessness or housing instability, and to sustain tenancies [source: TMACT EP8; ACT Workbook 2003, pp. 30, 33].
Steps:
1. Help the person choose housing.
2. Help them access it: applications, locating safe and affordable housing.
3. Respect their privacy.
4. Make sure tenancy rights are guaranteed regardless of treatment progress.
5. Support the tenancy with in vivo help, such as the weekly apartment maintenance checks in the Workbook's example plan, agreed with the person.
6. Stage moves in small steps (§4.14).
Example language (illustrative): "Where would you like to live? Let's go and see two places, and I'll help with the forms."
Watch for: Housing that is conditional on treatment compliance, which does not meet EP8.

4.19 Psychiatric rehabilitation and skills training in daily living

Purpose / when: For deficits in meal planning, budgeting, shopping, laundry, hygiene and transport. At least 90% of those who need it get it from the team, through deliberate skills training [source: TMACT CP8; ACT Workbook 2003, pp. 31, 33, 50–51].
Steps:
1. Identify the specific task.
2. Work side by side in the real setting, such as weekly grocery trips or twice-weekly laundry help in the Workbook's "Paula" example.
3. Teach the steps, then gradually fade staff involvement as the person masters them [fading: synthesis consistent with TMACT PP4].
Example language (illustrative): "This week I'll do the list with you. Next week you write it and I'll just come along."
Watch for: Staff doing for the person indefinitely. TMACT PP4 asks teams to teach independence and match oversight to need.

4.20 Engagement and psychoeducation with natural supports

Purpose / when: For families and other natural supports, with the person's consent. TMACT expects at least 90% of clients to have natural supports contacted at least monthly [source: TMACT CP5, EP6; ACT Workbook 2003, pp. 44, 58].
Steps:
1. Complete the family assessment within about 30 days, defining the family's role with consent.
2. Educate supports about the illness and treatment.
3. Teach problem-solving.
4. Connect them to support groups.
5. Clarify the division of labour. In the Workbook's "Lucy" case, the daughter was reluctant until the team made clear it would handle clinical care.
Example language (illustrative): To a relative: "You don't have to be her nurse. That's our job. What would help you most is knowing who to call and what the warning signs look like."
Watch for: Contact with supports that the person has not consented to, outside legal emergency exceptions [synthesis].

4.21 Empirically supported psychotherapy

Purpose / when: For people who would benefit from a structured individual or group therapy, such as CBT for psychosis or trauma-focused work. TMACT credits deliberate, evidence-based therapy delivered at an appropriate rate, ideally by a licensed therapist on the team [source: TMACT EP7].
Steps:
1. Identify a target problem and an evidence-based approach for it.
2. Deliver the therapy flexibly, in the home or community if needed [specific therapies and adaptations: synthesis].
3. Record it in the plan and schedule it like any other intervention.
Example language (illustrative): "Would you like to meet weekly to work on the voices directly, looking at what they say and how you respond?"
Watch for: "Supportive chats" counted as therapy. TMACT's protocol defines what counts [uncertain: Part II EP7 text not read].

4.22 Peer specialist services

Purpose / when: Throughout care. At least 1.0 FTE certified peer specialist, or equivalent lived experience and training [source: TMACT ST7–ST8].
Steps:
1. The peer specialist coaches clients on recovery.
2. They teach wellness and recovery strategies.
3. They participate fully in the team, including daily meetings.
4. They model recovery-oriented language and cross-train colleagues.
5. They take part in outreach to disengaged clients (§4.4).
Example language (illustrative): Peer: "I've been in hospital too, and I know what it's like when the team keeps showing up. Can I tell you what helped me decide to give them a chance?"
Watch for: Peers used only as drivers or for clerical tasks, without their recovery-coaching role.

4.23 Social and recreational development

Purpose / when: For isolation and lack of meaningful activity [source: ACT Workbook 2003, pp. 44, 57].
Steps:
1. Assess leisure interests, social skills and relationships.
2. Help the person build activities and connections in the community. In the "Harold" case, the team matched him with another client for weekly tennis, which lasted for years.
Example language (illustrative): "You mentioned you used to play chess. There's a club on Tuesdays. Want to go and watch together first?"
Watch for: Activities that stay team-run forever rather than becoming part of the person's own network [synthesis].

4.24 Practical help and advocacy

Purpose / when: For benefits, finances, legal problems and access to services. This is often the first thing the person values [source: ACT Workbook 2003, p. 27; UNC Outreach Protocol].
Steps:
1. Accompany the person to offices.
2. Help with forms and budgets.
3. Advocate with landlords, agencies and courts, with consent.
4. If a representative payee is involved, follow the cautions in §4.3.
Example language (illustrative): "Let's go to the benefits office together on Monday. I'll bring the letters; you do the talking and I'll back you up."
Watch for: Advocacy that speaks for the person when they could speak for themselves.

4.25 Transition to less intensive services and expedited readmission

Purpose / when: When the person has reached sustained gains [source: TMACT Protocol Part II OS9; Dixon 2000; ACT Workbook 2003, p. 50].
Steps:
1. Assess at every plan review whether the person still needs ACT.
2. Use explicit criteria that any team member could apply. Look at use of fewer or less intensive services and improved functioning in housing, medication use, crisis use, substance use, daily living skills and community integration. Criteria based only on medication adherence or hospitalisations are weak.
3. Plan an individualised, gradual transition, often 3–6 months. Options include an internal transition group, trial periods with the new service, and handover meetings with the receiving provider. The receiving service may be standard community mental health care or a clubhouse [Dixon 2000].
4. Monitor after the transfer, varying by need, sometimes for up to about 3 months, with home visits if needed.
5. Guarantee fast readmission without the waitlist, for example through reserved slots or briefly exceeding capacity. The person need not meet entry criteria again.
Example language (illustrative): "You've had your own flat and your job for over a year without a crisis. How would you feel about trying a lighter service, with us still in the background and a quick way back if you need it?"
Watch for: Transition driven by waitlist pressure. Abrupt handovers. People who fear losing the team and destabilise as transition nears. If so, slow the transition down; do not abandon it [synthesis].

4.26 Fidelity monitoring as a team practice

Purpose / when: At least yearly, and at start-up [source: TMACT Part I; ACT Workbook 2003, Appendix C].
Steps:
1. Arrange an external or self-assessment with the DACTS or the TMACT (47 items across 6 subscales, each rated 1–5). TMACT reviews include observing a daily team meeting, interviewing each role, and reviewing schedules, logs and charts.
2. Turn low-scoring items into an action plan, with mentor or consultant support.
Example language (illustrative): "Our lowest scores were community contacts and natural supports. Let's set a target for each and review monthly."
Watch for: Ratings reflect what the team actually does now, not plans. A planned on-call system earns no crisis credit [source: TMACT Part I p. 7].

5. Handling problems

Source-based guidance is tagged with its source. Everything tagged [synthesis] is this guide's own clinical guidance, not from the ACT sources.

Client will not engage or avoids the team

Treat avoidance as expected in a group that has been poorly served by services [source: ACT Workbook 2003, pp. 17–18].
Return to practical help on the person's own terms. Reduce the number of new faces, keep visits short, and keep showing up [source: Workbook pp. 40, 57–58].
Work through the UNC/Case Western outreach checklist (§4.4) before any talk of discharge. Make sure at least 3 staff, including the peer specialist and team leader, have tried.
Ask "What is the team doing wrong?" [source: Workbook p. 49]. Check for staff cancellations [source: UNC protocol].
Never discharge for missed appointments alone [source: UNC protocol; Dixon 2000].

Client cannot be found

Follow §4.4 Part 3.
If there is concern for the person's safety, such as a serious relapse, suicide risk or a medical condition, escalate the same day. Request a welfare check under your local legal framework, document it, and inform the team leader [synthesis].

Resistance to medication or non-adherence

Explore side effects and the meaning the medication has for the person. Make decisions jointly with the prescriber [source: TMACT CT4].
Offer practical supports such as delivery, organisers or home administration, as the person agrees [source: Workbook p. 57].
Keep working on the person's other goals whatever their medication choice, so that engagement does not hinge on medication [synthesis].
Remember that criteria focused only on adherence are a weak marker of progress [source: TMACT OS9].

Drift toward coercion

Climb the intrusiveness ladder only with team discussion. The order runs from inducements and verbal guidance, through monitoring, money management and conditional help, to hospitalisation and legal measures [source: Manuel et al. 2013].
Record the reason for each intrusive step and plan when to step it back down [synthesis].
If intrusive practice is rising, review team climate (exhaustion, depersonalisation, role conflict) and staff attitudes. These were associated with more intrusive practice [source: Manuel et al. 2013].
Know your jurisdiction's law on involuntary treatment, guardianship and outpatient orders. ACT staff do not have powers beyond what that law gives them [synthesis].

Ruptures with a particular staff member

Use the shared caseload. Another staff member can carry contacts while the rupture is discussed in the team, and the original worker can repair it later if the person wishes [synthesis].
Name the rupture with the person: acknowledge the team's part, ask what would make contact acceptable, and let the person choose who visits for now [synthesis].

Overwhelm or decompensation

Increase contact frequency through the daily meeting.
Use the individual crisis plan and proactive contacts [source: TMACT OS4, CP6].
Postpone non-urgent changes such as moves and new jobs, or break them into smaller steps [source: Workbook pp. 30–31].
Involve the team in any admission and discharge [source: TMACT OS11].

Suicide or self-harm risk

Assess with your service's standard structured approach and update the safety and crisis plan with the person.
Do lethal-means counselling: safe storage or removal, involving supports with consent.
Increase visits, and review risk at the next daily meeting or sooner. The team's 24/7 role means after-hours staff must know the plan [synthesis, standard practice].

Substance use undermining progress

Re-assess the person's stage of change and match the intervention to it. Move away from confrontation and toward MI and harm reduction [source: TMACT EP4; UNC protocol].
Do not withdraw housing or support as a sanction [source: TMACT EP8; synthesis on sanctions].

Family is reluctant or burnt out

Clarify that the team carries the clinical load. Offer education, problem-solving and support groups [source: Workbook p. 58; TMACT EP6].

Dependency on the team, or fear of transition

Fade staff involvement in skills as the person masters them (§4.19).
Introduce the idea of step-down as a sign of success early, use trial periods, and guarantee readmission [source: TMACT OS9; framing: synthesis].

Team-level problems

Fidelity drift as caseloads grow or office habits return: protect the 1:10 ratio and audit the share of community contacts [source: Workbook pp. 4–5; TMACT CP1].
Professional turf conflicts: explicit cross-training and shared assessment [source: Workbook p. 15].
Slow or unfocused daily meetings: use a set format and a time limit (about 45 minutes for 100 clients) [source: Workbook p. 55].
Burnout: rotate on-call fairly, review difficult cases in a separate meeting, give regular supervision through the team leader, and celebrate gains [synthesis; supervision role: TMACT CT2].

Boundaries and safety in home-based work

Feeding someone, giving lifts, holding their money and visiting where they live all blur boundaries. Agree each of these in the plan, with a clear rationale, and review it as a team [synthesis].
Follow lone-worker procedures and assess risk before visits. Use paired visits when risk is raised [synthesis].
Honest messaging only: an outreach message must never use a false pretext [synthesis].

Cultural mismatch

The outreach protocol asks teams to consider cultural factors when engagement fails [source: UNC protocol].
Ask about the person's cultural and faith resources, include chosen community supports in planning, and match staff where possible [synthesis].

Sources

Sources:

SAMHSA Assertive Community Treatment (ACT) Evidence-Based Practices KIT, product page. The KIT booklets themselves are not drawn on here [uncertain].
Implementing Evidence-Based Practices Project: Assertive Community Treatment Workbook (draft, 2003; eds. Phillips & Burns), hosted by Washington HCA. Read to about p. 58; later chapters on service components were not read [uncertain].
[TMACT Summary Scale, Version 1.0 rev. 3 (2018), Oregon Health Authority](https://www.oregon.gov/oha/HSD/AMH/Reporting Reqs/TMACT-Summary-Scale.pdf)
TMACT Protocol Part I: Introduction (Moser, Monroe-DeVita & Teague), Delaware DSAMH
TMACT Protocol Part II: Itemized Data Collection Forms, Delaware DSAMH. Only the OS4 and OS9 detail was read.
ACT Assertive Engagement & Outreach Protocol (Powers & McDonnell 2021), UNC Institute for Best Practices
Dixon L. (2000) Assertive Community Treatment: Twenty-Five Years of Gold. Psychiatric Services 51:759–765
Manuel J.I. et al. (2013) Use of intervention strategies by ACT teams to promote patients' engagement. Psychiatric Services
PACT History and Influence (2021), UW–Green Bay Behavioral Health Training Partnership