Mary Ann Test (UW-Madison School of Social Work) helped create ACT. This is the first comprehensive national study of ACT fidelity and implementation.
When Mary Ann Test, PhD, a long-time professor at the UW-Madison School of Social Work, and colleagues from the Mendota Mental Health Institute gathered sometime in the late 1970s for a regular staff debrief, morale was low. Despite their hard work treating people with serious mental illness, the successes they saw were brief. All too often when clients were released into the community they ended back in need of hospitalization. One of the staff members even said something to the effect of, “Maybe we should close this damn ward down,” according to Test. So Dr. Test, along with Dr. Arnold Marx and Dr. Leonard Stein, reassessed their treatment protocols and began discussions about what would eventually become known as Assertive Community Treatment (ACT) and in the process revolutionized approaches to the treatment of people with severe mental illness.
After starting in Madison in the late 1970s and early 80s, ACT today is recognized as a successful treatment option for people with significant psychiatric conditions such as schizophrenia, schizoaffective disorder, and bipolar disorder throughout the country and the world. Now, another professor with the UW-Madison School of Social Work is taking up the first comprehensive nation-wide research study of ACT fidelity and implementation.
Lynette Studer, PhD, Clinical Assistant Professor of Social Work has worked with ACT on every level – from clinician and team leader, to state program director, to consultant. She is part of a new nearly $500,000 grant-funded project with partners at the University of North Carolina Center for Excellence in Community Mental Health to research the availability of ACT and the fidelity to which programs meet the ACT model throughout the United States. The research project is called, “Establishing the Current State of Assertive Community Treatment (ACT) Implementation in the U.S.,” funded by the Laura and John Arnold Foundation.
According to Dr. Studer, every state implements ACT differently and there has not been a national survey to really understand how these programs differ, what outcomes they get, and how they are structurally funded.
In working with clients on everything from recovery planning to implementation for their daily lives, ACT is “helping the client dream about what they want to do and then actually implementing a plan to get to that spot,” Studer said.
This research study will help assess the connection of implementing ACT and positive outcomes as well as how adherence to a full ACT model (i.e. fidelity) plays a role in ensuring successful transitions in everyday life.
“We anticipate it will be beneficial for both ACT team members as well as policy people,” Studer said. “It would have been beneficial to me to have something like that when working for the State of Minnesota, to be like ‘who does this well? I want to learn how to do this well and get positive outcomes.’”
Assertive Community Treatment teams usually include social workers, psychiatrists, nurses, and a range of specialists in peer services, substance abuse, employment, housing, and psychiatric rehabilitation – all providing highly specialized and individualized care to clients.
Through dozens of randomized controlled trials, ACT has shown a decrease in hospitalization, a decrease in family burden, and individuals served are more likely to find housing and less likely to be jailed when compared to other treatment options. As Mary Ann Test said, ACT is simply the result of people having the courage to “do things differently when the status quo isn’t working.”
Assertive Community Treatment appears to work better when the model is followed closely. If not, results can vary, but up until now the full extent of this variance has not been investigated.
“It’s an expensive care model. If you get the right type of client in it can be a neutral expense or may actually save the system some money, but if you don’t do it well it can be a costly program without positive outcomes,” Studer said.
The research project will consist of two phases. Studer will take the lead on the first phase – a systemic surveying and interviewing of key stakeholders in each state responsible for policy of implementation and sustenance of ACT services. The second phase will investigate ACT fidelity and the relationship between program and client outcomes.
While past research indicates positive outcomes for clients in an ACT model, implementation of ACT across the states can vary for a number of reasons – including organizational structure, legislative barriers, and fiscal reimbursement of services. According to Studer and past research, “the closer that you are to full [ACT] model the better your outcomes are likely to be.”
But like with any treatment program, if not done fully, or if leaders cut corners, there can be unintended consequences. “If it’s not done well with a certain amount of recovery-based philosophy and a team leader/supervisor and psychiatrist who buy into self-determinization and the rights of the clients, the intended outcomes of people living fuller, rewarding lives can be impacted,” Studer said.
Studer is uniquely positioned to help assess implementation of Assertive Community Treatment throughout the country and aid states and systems struggling to implement it well. Her entire career has focused on helping people with serious mental illness, inspiring and teaching students how to do so, and implementing evidence-based programs.
Her field placement as an BSW student at UW-Madison was at Mendota Mental Health Institute where she “fell in love with working with people with serious mental illness and their families,” and working to help them improve their lives. Upon graduating with her MSW, she immediately got a job as a social worker on the ACT team in Green County (Monroe) Wisconsin, and within two years was a team leader for the first rural adaptation of ACT, which was started in 1982. That ACT team became known nationally as a high-fidelity rural ACT program and was a training program that other states shadowed. “Nationally I became involved with consultation because teams would come to learn what we were doing,” Studer said.
Studer became the State Program Director of the Adult Mental Health Division for the State of Minnesota in 2013 where she was state policy analyst for Assertive Community Treatment and the State Administrator for the implementation of Evidence-based Practices. She completed her PhD in Social Welfare from UW-Madison in 2015 and has been a Clinical Assistant Professor in the school since August 2017, where she teaches three classes each semester in subjects ranging from advanced practice skills in mental health to macro policy/social work policy – among others.
“I think this research will inform my teaching because it is hot off the press mental health policy implementation. States will look at this be like, ‘ok, we will give money to this because we do want these outcomes for our system and clients,’” she said.
“I’m excited. This research project feeds the researcher part of me,” Studer explains. “This (Assertive Community Treatment) is such a huge part of my professional life.”
What drives Studer is the same thing that drove Mary Ann Test and her colleagues at the time – improving the care for individuals with serious mental illness.
“Working with clients and figuring out how to make the system better so more people have access to ACT is one of the most fulfilling things I’ve done,” Studer said. “Ultimately we want people to have better access to high quality services so they can recover and live lives that are full of hope.”
 Mary Ann Test, “History of ACT Model (Assertive Community Treatment).”