Is assertive community treatment coercive?

Background: Assertive community treatment (ACT) has become one of the cornerstones of care for people with serious mental illnesses. ACT is usually conceptualized as incorporating a multidisciplinary team approach, active and persistent attempts to engage clients, direct provision of comprehensive health and social care, and in-vivo and out-of-hours working. In addition, the service is ongoing, not time-limited, and has a low practitioner-to-client ratio (usually 1:10). However, ACT is not without its critics, many of them focused on the use of "coercive" techniques with ACT patients 12. At one end of the spectrum are those opponents of ACT who contend, "ACT is largely a euphemistic label for coercion." Despite substantial interest in the coercive aspects of ACT, no studies have focused specifically on understanding the phenomenology of the use and experience of leverage in ACT. Methods: Staff and patients of 4 ACT teams in Manhattan were recruited to participate in focus groups exploring their experiences with and opinions about the use of leverage in ACT. A total of 21 patients and 24 staff members participated with group size ranging from 10 to 12 members. Results: With only one exception, patients said uniformly that they did not believe that their ACT team was coercive or went too far in pressuring them to comply with treatment. ACT staff seemed more aware of the dangers of engaging in coercive behavior. Hence, they indicated a need to "keep each other in check." Conclusion: This preliminary series of focus groups with patients and staff members of ACT programs revealed little evidence from either set of participants of significant use of leverage or perceptions of coercion. Instead both patients and staff reported that supporting patients and building relationships with them were the preferred mechanisms for promoting treatment goals. This study suggests that ACT is not an intrinsically coercive model for the delivery of mental health services