Community Mental Health Journal

, Volume 48, Issue 5, pp 652–661 | Cite as

Implementation of Assertive Community Treatment in Australia: Model Fidelity, Patient Characteristics and Staff Experiences

  • Carol HarveyEmail author
  • Helen Killaspy
  • Salvatore Martino
  • Sonia Johnson
Original Paper


The impact of variable implementation of the Assertive Community Treatment (ACT) model on patient outcomes is increasingly recognised. We conducted the first study of four established Australian ACT teams, examining team composition, processes and model fidelity, using previously validated questionnaires. Demographic and clinical details of patients and their own experiences of ACT were gathered from staff. Associations between burnout and work experiences were examined. All teams were ACT-like (mean DACTS score = 3.7, SD = 0.3) with few significant patient differences between teams, except diagnosis (schizophrenia 61–93%, co-morbid substance abuse 16–33%) and proportion living alone (23–72%). Clinicians were fairly satisfied, but inter-team differences in staffing profile and experience emerged and one team scored highly on emotional exhaustion. Increased burnout was associated with greater stress due to taking a team approach. Inter-team differences suggested that attention to effective team working and leadership, as well as model fidelity, may be warranted.


Assertive community treatment Community mental health services Severe mental illness Schizophrenia Staff burnout Team working 



The authors thank all the MSTT team leaders and clinicians who participated in this study.


  1. Ash, D., Brown, P., Burvill, P., Davies, J., Hughson, B., Meadows, G., et al. (2007). Mental health services in the Australian states and territories. In G. Meadows, B. Singh, & M. Grigg (Eds.), Mental health in Australia: Collaborative community practice (2nd ed., pp. 99–131). South Melbourne: Oxford University Press.Google Scholar
  2. Australian Bureau of Statistics. (2003a). Regional population growth Australia and New Zealand, 20012002 (Publication). Retrieved July 10, 2007, from
  3. Australian Bureau of Statistics. (2003b). 2001 census: Socio-economic indices for areas. Canberra: Australian Bureau of Statistics.Google Scholar
  4. Billings, J., Johnson, S., Bebbington, P., Greaves, A., Priebe, S., Muijen, M., et al. (2003). Assertive outreach teams in London: Staff experiences and perceptions. Pan-London Assertive Outreach Study, part 2. British Journal of Psychiatry, 183, 139–147.PubMedCrossRefGoogle Scholar
  5. Bond, G. R. (1990). Intensive case management. Hospital & Community Psychiatry, 41(8), 927–928.Google Scholar
  6. Bond, G., Drake, R. E., Mueser, K. T., & Becker, D. R. (1997). An update on supported employment for people with severe mental illness. Psychiatric Services, 48(3), 335–346.PubMedGoogle Scholar
  7. Burns, T., Catty, J., Dash, M., Roberts, C., Lockwood, A., & Marshall, M. (2007). Use of intensive case management to reduce time in hospital in people with severe mental illness: Systematic review and meta-regression. British Medical Journal, 335(7615), 336–342.PubMedCrossRefGoogle Scholar
  8. Burns, T., Creed, F., Fahy, T., Thompson, S., Tryrer, P., & White, I. (1999). Intensive versus standard case management for severe psychotic illness: A randomised trial. Lancet, 353(9171), 2185–2189.PubMedCrossRefGoogle Scholar
  9. Catty, J., Burns, T., Knapp, M., Watt, H., Wright, C., Henderson, J., et al. (2002). Home treatment for mental health problems: A systematic review. Psychological Medicine, 32, 383–401.PubMedCrossRefGoogle Scholar
  10. Corrigan, P. W., Steiner, L., McCracken, S. G., Blaser, B., & Barr, M. (2001). Strategies for disseminating evidence-based practices to staff who treat people with serious mental illness. Psychiatric Services, 52(12), 1598–1606.PubMedCrossRefGoogle Scholar
  11. Drake, R., Mueser, K., & McHugo, G. (1986). Clinician ratings scales: Alcohol Use Scale (AUS), Drug Use Scale (DUS) and Substance Abuse Treatment Scale (SATS). In L. Sederer & B. Dickey (Eds.), Outcomes assessment in clinical practice. Baltimore: Williams and Wilkins.Google Scholar
  12. Fiander, M., Burns, T., McHugo, G. J., & Drake, R. E. (2003). Assertive community treatment across the Atlantic: Comparison of model fidelity in the UK and USA. British Journal of Psychiatry, 182, 248–254.PubMedCrossRefGoogle Scholar
  13. Hambridge, J. A., & Rosen, A. (1994). Assertive community treatment for the seriously mentally ill in suburban Sydney: A programme description and evaluation. Australian and New Zealand Journal of Psychiatry, 28, 438–445.PubMedCrossRefGoogle Scholar
  14. Harvey, C., Killaspy, H., Martino, S., White, S., Priebe, S., Wright, C., et al. (2011). A comparison of the implementation of Assertive Community Treatment in Melbourne, Australia and London, England. Epidemiologia Psichiatria Sociale, 20(2), 151–161.CrossRefGoogle Scholar
  15. Health and Community Services. (1994). Victoria’s Mental Health Service. The framework for service delivery. Melbourne: Psychiatric Services division, Victoria.Google Scholar
  16. Hoult, J. (1986). Community care of the acutely mentally ill. British Journal of Psychiatry, 149, 137–144.PubMedCrossRefGoogle Scholar
  17. Human Services Victoria. (1995). Mobile support and treatment services. Guidelines for service provision. Melbourne: Psychiatric Services Branch.Google Scholar
  18. Issakidis, C., Sanderson, K., Teeson, M., Johnson, S., & Buhrich, N. (1999). Intensive case management in Australia: A randomized controlled trial. Acta Psychiatrica Scandinavica, 99, 360–367.PubMedCrossRefGoogle Scholar
  19. Joy, C. B., Adams, C. E., & Rice, K. (2002). Crisis intervention for people with severe mental illness (Cochrane review). In The Cochrane Library (Issue 3). Oxford, Update Software.Google Scholar
  20. Killaspy, H., Bebbington, P., Blizard, R., Johnson, S., Nolan, F., Pilling, S., et al. (2006). The REACT study: Randomised evaluation of assertive community treatment in north London. British Medical Journal, 332(7545), 815–820.PubMedCrossRefGoogle Scholar
  21. Killaspy, H., Johnson, S., Pierce, B., Bebbington, P., Pilling, S., Nolan, F., et al. (2009). Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial. Social Psychiatry and Psychiatric Epidemiology, 44(7), 532–540.PubMedCrossRefGoogle Scholar
  22. King, R. (2006). Intensive case management: a critical re-appraisal of the scientific evidence for effectiveness. Administration Policy Mental Health and Mental Heath Services Research, 33(5), 529–535.CrossRefGoogle Scholar
  23. Kirsh, B., Cockburn, L., & Gewurtz, R. (2005). Best practice in occupational therapy: Program characteristics that influence vocational outcomes for people with serious mental illnesses. Canadian Journal of Occupational Therapy, 72(5), 265–279.Google Scholar
  24. Marshall, M., Bond, G., Stein, L. I., Shepherd, G., McGrew, J., Hoult, J., et al. (1999). PRiSM psychosis study. Design limitations, questionable conclusions. British Journal of Psychiatry, 175, 501–503.PubMedCrossRefGoogle Scholar
  25. Marshall, M., & Lockwood, A. (1998). Assertive community treatment for people with severe mental disorders (Review) (Publication no. CD001089. doi: 10.1002/14651858). Retrieved November 4, 2005, from John Wiley & Sons Ltd.
  26. Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). The Maslach Burnout Inventory (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.Google Scholar
  27. McGrew, J. H., Bond, G. R., Dietzen, L., & Salyers, M. (1994). Measuring the fidelity of implementation of a mental health program model. Journal of Consulting and Clinical Psychology, 62(4), 670–678.PubMedCrossRefGoogle Scholar
  28. McHugo, G. J., Drake, R. E., Whitley, R., Bond, G. R., Campbell, K., Rapp, C. A., et al. (2007). Fidelity outcomes in the national implementing evidence-based practices project. Psychiatric Services, 58(10), 1279–1284.PubMedCrossRefGoogle Scholar
  29. Priebe, S., Fakhoury, W., Watts, J., Bebbington, P., Burns, T., Johnson, S., et al. (2003). Assertive outreach teams in London: Patient characteristics and outcomes. Pan-London Assertive Outreach Study, part 3. British Journal of Psychiatry, 183, 148–154.PubMedCrossRefGoogle Scholar
  30. Prosser, D., Johnson, S., Kuipers, E., Szmukler, G., Bebbington, P., & Thornicroft, G. (1997). Perceived sources of work stress and satisfaction among hospital and community mental health staff, and their relation to mental health, burnout and job satisfaction. Journal of Psychosom Research, 43(1), 51–59.CrossRefGoogle Scholar
  31. Rosen, A., Mueser, K., & Teesson, M. (2007). Assertive community treatment-issues from scientific and clinical literature with implications for practice. Journal of Rehabilitation Research and Development, 44(6), 813–825.PubMedCrossRefGoogle Scholar
  32. Salyers, M. P., Bond, G. R., Teague, G. B., Cox, J. F., Smith, M. E., Hicks, M. L., et al. (2003). Is it ACT yet? Real-world examples of evaluating the degree of implementation for assertive community treatment. Journal of Behavioral Health Services and Research, 30(3), 304–320.PubMedCrossRefGoogle Scholar
  33. SPSS. (2009). SPSS for Windows, Version 19. Chicago: SPSS Inc.Google Scholar
  34. Stein, L. I., & Test, M. A. (1980). Alternatives to mental hospital treatment. Archives of General Psychiatry, 37, 392–397.PubMedCrossRefGoogle Scholar
  35. Sytema, S., Wunderink, L., Bloemers, W., Roorda, L., & Wiersma, D. (2007). Assertive community treatment in the Netherlands: A randomized controlled trial. Acta Psychiatrica Scandinavica, 116(2), 105–112.PubMedCrossRefGoogle Scholar
  36. Teague, G., Bond, G., & Drake, R. (1998). Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry, 68(2), 216–232.PubMedCrossRefGoogle Scholar
  37. Thornicroft, G., Wykes, T., Holloway, F., Johnson, S., & Szmukler, G. (1998). From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study 10. British Journal of Psychiatry, 173, 423–427.PubMedCrossRefGoogle Scholar
  38. Victorian Government. (1986). Mental Health Act 1986. Melbourne: Department of Human Services.Google Scholar
  39. Weiss, D. J., Dawis, R. V., England, G. W., & Lofquist, L. H. (1967). Manual for the Minnesota Satisfaction Questionnaire. Minnesota Studies in Vocational Rehabilitation: XXII. Minneapolis: University of Minnesota, Industrial Relations Center Work Adjustment Project.Google Scholar
  40. Winter, J., & Caslyn, R. (2000). The Dartmouth Assertive Community Treatment Scale (DACTS): A generalizability study. Evaluation Review, 24(2), 319–337.PubMedCrossRefGoogle Scholar
  41. Wright, C., Burns, T., James, P., Billings, J., Johnson, S., Muijen, M., et al. (2003). Assertive outreach teams in London: Models of operation. Pan-London Assertive Outreach Study, part 1. British Journal of Psychiatry, 183, 132–138.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Carol Harvey
    • 1
    Email author
  • Helen Killaspy
    • 2
  • Salvatore Martino
    • 3
    • 4
  • Sonia Johnson
    • 5
  1. 1.Department of PsychiatryThe University of Melbourne & North Western Mental Health, Psychosocial Research CentreCoburgAustralia
  2. 2.Department of Mental Health SciencesUniversity College London and Camden and Islington NHS Foundation Trust, Royal Free HospitalLondonUK
  3. 3.South West Area Mental Health ServiceMelbourneAustralia
  4. 4.Glen IrisAustralia
  5. 5.Research Department of Mental Health SciencesUniversity College London and Camden and Islington NHS Foundation Trust, Charles Bell HouseLondonUK

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