September / October 2000 Table
In this Article
Challenging scope of practice
by Lucy Ann Kubina
Integral to mental health reform in Ontario has been the funding of close to 60 Assertive Community Treatment (ACT) teams across the province. ACT (also known as Programs for Assertive Community Treatment or PACT) teams are mandated to provide long-term, innovative and highly flexible service to people with severe and persistent mental illnesses. These individuals may also be homeless, abusing substances, have involvement with the criminal justice system, and make frequent use of emergency systems and/or hospitals.
ACT is a psychiatric intervention that has been widely disseminated and researched since its development in Madison, Wisconsin. ACT teams are multidisciplinary, and provide highly individualized treatment and rehabilitation and support services 24 hours a day, 365 days a year (Ontario Ministry of Health, 1999).
Key tenets of ACT are assertive outreach, and providing services in the consumer's own environment, for as long as may be required. The ACT model is especially designed to engage consumers who, for a variety of reasons, have not connected with traditional office-based mental health services. Occupational therapists are included in the Ministry of Health's list of individuals qualified to provide ACT services. This article, based on the author's own experience, will examine some of the challenges of practising as a member of an Assertive Community Treatment team.
One of the foremost challenges for occupational therapists providing ACT services lies in the domain of risk-taking. Risk taking occurs on several levels in ACT. The risk of an expanded non-traditional role (generic and discipline-specific), the risk of delivering services in non-traditional fashion and in unusual situations (shelters, rooming houses, park benches), the risk of upholding client wishes, values and beliefs in a model that has been criticized for its emphasis on medication and symptom management (Spindel, Nugent, 1999).
From the outset, all ACT team members share generic case management roles. These include medication management, symptom management, crisis intervention, housing support, financial management, and substance abuse counselling. Discipline specific roles encompass areas of professional expertise, which, for occupational therapists lie in the area of assessment of occupational performance, and enabling the performance of self-care, productivity and leisure occupations. The nature of ACT requires that at any given moment, the occupational therapist must have the ability to provide generic or specialized services, wearing two hats, interchangeably, in order to meet the client's immediate service requirement. The occupational therapist's capacity to absorb such role fluctuations without experiencing a sense of loss of professional identity may be contingent on the therapist's stage of professional development (Kasar & Muscari, 2000), and the availability of professional support systems. More often than not, occupational therapists practising on ACT teams do so without the support and structure of traditional occupational therapy departments. As is frequently the case in community practice, therapists working in ACT establish their own support network (Stefaniak, 1998). These support networks can range from face-to-face meetings, telephone consultation, to e-mail discussion groups.
Risk taking also occurs on a personal level as all ACT team members share in covering day, evening, weekend and on-call shifts. Prior to the advent of ACT teams, mental health occupational therapists employed in the public sector typically worked within an office-based schedule, i.e., Monday to Friday,"9 to5". ACT services are designed to be available when a client may require them, which is typically outside of traditional office or clinic hours. In order to work on an ACT team, an occupational therapist must be prepared to personally accommodate an irregular work schedule. This can, at times, entail personal sacrifice.
The environment of practice of an ACT team engenders risk taking in the area of clinical reasoning and problem-solving. Team members must frequently "think outside the box" when collaborating in the provision of service delivery (Westmorland, 1999). With a mandate to reach out to persons who may be socially isolated, homeless, engaging in at-risk behaviors such as active drug use and prostitution, or residing in hostile environments, team members are called upon to consider creative ways to build trust and mutual respect. For occupational therapists, this entails the acquisition of a larger set of skills in engagement and rapport-building with individuals who frequently perceive the psychiatric system as harmful and who may not consider themselves as needing mental health services (Cohen, 1989). Occupational therapists who espouse the principles of collaboration and mutuality in their practice are likely to take greater risks in developing creative and innovative methods to engage with these individuals.
Challenging scope of practice
As has been noted, the expanded scope of practice inherent in ACT provides ample opportunity for developing a larger set of skills. Training is usually provided to team members during the orientation phases of employment, and can range from case-based learning, peer consultation, formal educational sessions to on-the-job learning (Gehrs, Read & Wasylenki, 1999). The extensive nature of such training reflects the transdisciplinary model of ACT; for the occupational therapist, this training, though a steep learning curve, gradually flattens as knowledge is integrated into practice.
Lastly, occupational therapists on ACT teams are provided with the opportunity to advocate in numerous ways on behalf of their clients. This advocacy may take place inside or outside the ACT team. Occupational therapists may be advocating on clients' behalf to external sources such as housing providers, lawyers, social assistance benefits workers, and probation officers. They may also work with the consumer to enable him/her to advocate for his/herself. In some instances they may be called on to advocate for the removal of barriers to client-centred services, such as lengthy and bureaucratic housing intake applications, or government cutbacks to social assistance benefits.
They may also be called on to advocate for the client to the ACT team. This may occur if the ACT team targets goals of intervention that are unrelated to the client's stated goals, wishes and beliefs. The "overprofessionalized" structure of ACT service delivery, warn the critics of the ACT model, can lead to client disempowerment (Spindel & Nugent, 1999). This author would argue that occupational therapists have an important role to play as advocates of a client-centred and client-empowerment approach to ACT.
Further advocacy is required to ensure that targeted outcomes of ACT are occupation-focused. ACT teams are set up to follow fidelity criteria, and these criteria are in place to ensure that outcomes of ACT services reflect consistent, timely and responsive service delivery. Current outcomes being studied in randomized clinical trials of ACT in Ontario relate to general aspects of client satisfaction, length of community tenure, caregiver burden, quality of life and program fidelity measures. The area of occupation-centred outcomes in ACT is beginning to be explored. For example, a recent study carried out at Queen's University examined the daily time use of clients receiving ACT services (McLean, 1999; Krupa, McLean, Eastabrook, Baksh & Mcleod, 2000). The study supported the need to attend to the activity patterns of persons with severe psychiatric disabilities in the community and suggested that occupational therapists are in an ideal position to facilitate the development of ACT services that promote occupational well-being. The recent expansion of teams across Ontario can be a golden opportunity for occupational therapists to advocate and collaborate in the development of occupation-focused outcomes and interventions.
As a model of care, assertive community treatment is becoming firmly established in Ontario and is spreading to other Canadian provinces. It is now in place in the provinces of Alberta and Quebec and is developing in British Columbia. In this writer's view, there is a clear congruence between the ACT and occupational therapy philosophy. Both aim to be client-centered. Both encourage innovative and creative approaches to mental health care. Both ask that occupational therapists be mindful of the pitfalls of a medicalized model of care, and strive to listen to what clients with severe psychiatric disabilities tell us they really need. While the reality of these clients' life circumstances can limit the effectiveness of traditional office-based interventions, ACT offers the hope that they will indeed receive the services they require, and that these services will be delivered in a manner congruent with their values and beliefs.
The author thanks occupational therapists Laura Humphrey and Terry Krupa for their contribution to this article.
Cohen, M.B. (1989). Social work practice with homeless mentally ill people: Engaging the client. Social Work, 505-509.
Gehrs, M., Read, N., & Wasylenki, D. (1999). Implementing assertive community treatment in a general hospital setting: Service redesign for individuals with serious mental illness. Canadian Psychiatric Association, Bulletin, 31, 112-115.
Gomory, T. (1999). Programs of Assertive Community Treatment (PACT): A critical review. Ethical Human Sciences and Services Journal: An International Journal of Critical Inquiry, 1, 431-437.
Kasar, J., & Muscari, M.E. (1999). A conceptual model for the development of professional behaviours in occupational therapists. Canadian Journal of Occupational Therapists, 67, 42-50.
Krupa, T., & Clark, C.C. (1995). Occupational therapists as case managers: Responding to current approaches to community mental health service delivery. Canadian Journal of Occupational Therapy, 62, 16-22.
Krupa, T., McLean, H., Eastabrook, S., Baksh, L.A., & McLeod, A. (2000). Daily Time Use of Clients of Assertive Community Treatment. Presentation to the Annual General Meeting of the International Association of Psychosocial Rehabilitation Services, Washington, D.C.
Lysack, C.L., Stadnick, R., Paterson, M., McLeod, K., & Krefting,L. (1995). Professional expertise of occupational therapists in community practice: Results of an Ontario survey. Canadian Journal of Occupational Therapy, 62, 138-147.
McLean, H. (1999). The relationship between the vocational component of ACT programs and client productivity levels. Unpublished Master's thesis. Kingston, Ontario: Queen's University.
Ontario Ministry of Health. (1998). Standards for Assertive Community Treatment Teams.
Spindel, P., & Nugent, J. A. (July, 2000). The trouble with PACT: Questioning the increasing use of Assertive Community Treatment teams in community mental health. Retrieved July 11, 2000 from the World Wide Web: http:// www.madnation.org/pacttrouble.htm.
Stefaniak, K. (1998). One new grad's experience in community based practice. CAOT National Newsletter, 15 (4), 13-14.
Westmorland, M. (1998). Case Management: Is the time right? CAOT National Newsletter, 15 (6), 1-3.
Westmorland, M. (1999). Risk-taking: An antidote to diffidence. Canadian Journal of Occupational Therapy, 66, 214-219.
Lucy Ann Kubina O.T. ( C), formerly of the CONTACT team at St. Michael's
Hospital, Toronto, is now with the Royal Ottawa Hospital, 1145 Carling,
Ottawa, ON K1Z 7K4. She can be reached at firstname.lastname@example.org.
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